Case Report: Performing a Medication Safety Review Assisted by Pharmacogenomics to Explain a Prescribing Cascade Resulting in a Patient Fall
Pharmacotherapy for major depressive disorder (MDD) typically consists of trial-and-error and clinician preference approaches, where patients often fail one or more antidepressants before finding an optimal regimen. Pharmacogenomics (PGx) can assist in prescribing appropriate antidepressants, thereb...
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| Format: | Article |
| Language: | English |
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MDPI AG
2023-01-01
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| Series: | Medicina |
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| Online Access: | https://www.mdpi.com/1648-9144/59/1/118 |
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| author | Joshua Russell Meghan J. Arwood Nicole M. Del Toro-Pagán Nishita S. Amin Michele D. Cambridge Jacques Turgeon Veronique Michaud |
| author_facet | Joshua Russell Meghan J. Arwood Nicole M. Del Toro-Pagán Nishita S. Amin Michele D. Cambridge Jacques Turgeon Veronique Michaud |
| author_sort | Joshua Russell |
| collection | DOAJ |
| description | Pharmacotherapy for major depressive disorder (MDD) typically consists of trial-and-error and clinician preference approaches, where patients often fail one or more antidepressants before finding an optimal regimen. Pharmacogenomics (PGx) can assist in prescribing appropriate antidepressants, thereby reducing the time to MDD remission and occurrence of adverse drug events. Since many antidepressants are metabolized by and/or inhibit cytochrome P450 enzymes (e.g., CYP2C19 or CYP2D6), drug-induced phenoconversion is common in patients on antidepressant combinations. This condition influences the interpretation of a patient’s PGx results, overall risk of ineffective/adverse medication response due to multi-drug interactions, and the recommendations. This complex case describes a patient with MDD, generalized anxiety disorder, and chronic pain who experienced a fall due to excessive sedation following a prescribing cascade of fluoxetine, bupropion, and doxepin. These antidepressants delivered a significant additive sedative effect and interacted with the patient’s hydrocodone, potentially contributing to uncontrolled pain, upward dose titration of hydrocodone, and a higher overall sedative burden. The PGx results and drug-induced phenoconversion described in this case report explain the patient’s excessive sedation and possibly ineffective/toxic antidepressant and opioid treatment. This case report also illustrates how a more timely multi-drug interaction assessment (preferably in conjunction with preemptive PGx testing) may have informed a different prescribing pattern, reduced/avoided a prescribing cascade, and potentially prevented a drug-related fall. |
| first_indexed | 2024-03-09T11:44:39Z |
| format | Article |
| id | doaj.art-9adee2c28e5347ad9d2ecc037ae3313d |
| institution | Directory Open Access Journal |
| issn | 1010-660X 1648-9144 |
| language | English |
| last_indexed | 2024-03-09T11:44:39Z |
| publishDate | 2023-01-01 |
| publisher | MDPI AG |
| record_format | Article |
| series | Medicina |
| spelling | doaj.art-9adee2c28e5347ad9d2ecc037ae3313d2023-11-30T23:24:36ZengMDPI AGMedicina1010-660X1648-91442023-01-0159111810.3390/medicina59010118Case Report: Performing a Medication Safety Review Assisted by Pharmacogenomics to Explain a Prescribing Cascade Resulting in a Patient FallJoshua Russell0Meghan J. Arwood1Nicole M. Del Toro-Pagán2Nishita S. Amin3Michele D. Cambridge4Jacques Turgeon5Veronique Michaud6Tabula Rasa HealthCare, Office of Translational Research and Residency Programs, Moorestown, NJ 08057, USATabula Rasa HealthCare, Precision Pharmacotherapy Research and Development Institute, Orlando, FL 32827, USATabula Rasa HealthCare, Office of Translational Research and Residency Programs, Moorestown, NJ 08057, USATabula Rasa HealthCare, Office of Translational Research and Residency Programs, Moorestown, NJ 08057, USAFranciscan Senior Health and Wellness, Program of All-Inclusive Care for the Elderly (PACE), Indianapolis, IN 46259, USATabula Rasa HealthCare, Precision Pharmacotherapy Research and Development Institute, Orlando, FL 32827, USATabula Rasa HealthCare, Precision Pharmacotherapy Research and Development Institute, Orlando, FL 32827, USAPharmacotherapy for major depressive disorder (MDD) typically consists of trial-and-error and clinician preference approaches, where patients often fail one or more antidepressants before finding an optimal regimen. Pharmacogenomics (PGx) can assist in prescribing appropriate antidepressants, thereby reducing the time to MDD remission and occurrence of adverse drug events. Since many antidepressants are metabolized by and/or inhibit cytochrome P450 enzymes (e.g., CYP2C19 or CYP2D6), drug-induced phenoconversion is common in patients on antidepressant combinations. This condition influences the interpretation of a patient’s PGx results, overall risk of ineffective/adverse medication response due to multi-drug interactions, and the recommendations. This complex case describes a patient with MDD, generalized anxiety disorder, and chronic pain who experienced a fall due to excessive sedation following a prescribing cascade of fluoxetine, bupropion, and doxepin. These antidepressants delivered a significant additive sedative effect and interacted with the patient’s hydrocodone, potentially contributing to uncontrolled pain, upward dose titration of hydrocodone, and a higher overall sedative burden. The PGx results and drug-induced phenoconversion described in this case report explain the patient’s excessive sedation and possibly ineffective/toxic antidepressant and opioid treatment. This case report also illustrates how a more timely multi-drug interaction assessment (preferably in conjunction with preemptive PGx testing) may have informed a different prescribing pattern, reduced/avoided a prescribing cascade, and potentially prevented a drug-related fall.https://www.mdpi.com/1648-9144/59/1/118pharmacogenomicspharmacogeneticsphenoconversionprescribing cascadefallantidepressants |
| spellingShingle | Joshua Russell Meghan J. Arwood Nicole M. Del Toro-Pagán Nishita S. Amin Michele D. Cambridge Jacques Turgeon Veronique Michaud Case Report: Performing a Medication Safety Review Assisted by Pharmacogenomics to Explain a Prescribing Cascade Resulting in a Patient Fall Medicina pharmacogenomics pharmacogenetics phenoconversion prescribing cascade fall antidepressants |
| title | Case Report: Performing a Medication Safety Review Assisted by Pharmacogenomics to Explain a Prescribing Cascade Resulting in a Patient Fall |
| title_full | Case Report: Performing a Medication Safety Review Assisted by Pharmacogenomics to Explain a Prescribing Cascade Resulting in a Patient Fall |
| title_fullStr | Case Report: Performing a Medication Safety Review Assisted by Pharmacogenomics to Explain a Prescribing Cascade Resulting in a Patient Fall |
| title_full_unstemmed | Case Report: Performing a Medication Safety Review Assisted by Pharmacogenomics to Explain a Prescribing Cascade Resulting in a Patient Fall |
| title_short | Case Report: Performing a Medication Safety Review Assisted by Pharmacogenomics to Explain a Prescribing Cascade Resulting in a Patient Fall |
| title_sort | case report performing a medication safety review assisted by pharmacogenomics to explain a prescribing cascade resulting in a patient fall |
| topic | pharmacogenomics pharmacogenetics phenoconversion prescribing cascade fall antidepressants |
| url | https://www.mdpi.com/1648-9144/59/1/118 |
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