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At St. Jude, preemptive PGx tests guide prescribing

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Karen Titus

April 2015—St. Jude Children’s Research Hospital, Memphis, brings a razor-sharp focus to its mission: the 78-bed institution cares for children with catastrophic illnesses, including leukemias and lymphomas, solid tumors, hematology disorders (including sickle cell disease), and infectious diseases. It doesn’t have an emergency department. Consistent with its goal of advancing cures, all its patients are enrolled in research protocols.

It makes sense, then, that St. Jude would bring a similarly sharp focus to its laboratory testing, in the form of therapeutic drug monitoring and pharmacogenetics testing.

Dr. Molinelli

Dr. Molinelli

It does so with a twist: Before TDM and genotype results are entered into patients’ medical records, a clinical pharmacist tells clinicians what the results mean. “We don’t release results into the record until the pharmacist has entered an interpretive consultation note for that result,” says Alejandro Molinelli, PhD, director of the clinical pharmacokinetics laboratory at St. Jude.

The laboratory also pages the pharmacist once a result is ready. It’s different from the usual routine, Dr. Molinelli says, “where basically results are posted to the medical record just by themselves, with no interpretive consult. If the ordering physician has a question, they usually call the lab and get any clarification.” At St. Jude, “We’re pushing an interpretation together with the results.”

Among the tests: thiopurine methyltransferase (TPMT), which is critical to managing thiopurine medications used to treat pediatric leukemia; and CYP2D6, which is involved in metabolizing a variety of common medications, including codeine.

“We have a fairly limited number of clinical genotypes that we are testing,” says Dr. Molinelli. These tests are done at reference labs, an approach that works “because we have a manageable number of patients,” he says.

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