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Progress and Challenges in Pharmacogenomics

Pharmacogenetics has been widely accepted as a crucial factor of interindividual variation of drug response, and there is increasing information on the potential influences of genetic variation included in the summary of product characteristics of various drugs. Moreover, the 26 current guidelines compiled by the Clinical Pharmacogenetics Implementation Consortium are widely accepted in the community of clinical pharmacologists. However, challenges remain to build further clinical evidence for additional drugs and diverse populations, to develop feasible clinical decision support systems, and to build economic incentives to support broad implementation of clinical pharmacogenetics. Indeed, the level of evidence showing significant clinical benefit for patients treated according to pharmacogenomicsbased guidelines compared with treatmentasusual is decisive for the acceptance of pharmacogenomics as an indispensable factor in health care systems. It is understandable that testing of genes associated with severe adverse events was the first that became mandatory before prescription (e.g., abacavirinduced hypersensitivity being strongly linked to HLAB*57:01). The attempts to better understand the mechanisms of HLAassociated adverse drug reactions, however, are still ongoing. In this special issue on Pharmacogenetics and Pharmacogenomics, Deshpande et al. summarize highly interesting insights on HLArelated immunopharmacogenetics, and novel data are presented by Liu et al. on HLAloci associated with hypersensitivity reactions of pegaspargase in pediatric patients with leukemia. However, as mentioned above, it is all about evidence. Most pharmacogenetic traits are related to genetic variants in drug metabolizing enzymes modulating the bioavailability of drugs. In contrast to hypersensitivity reactions being essentially concentration independent, here, the question is not “yes” or “no.” In most cases, dose recommendations are made based on genotypepredicted phenotypes. Hence, there is much more uncertainty on the true individual metabolic activity, and large randomized clinical trials could provide solid evidence on the benefit of pharmacogeneticsguided therapy. The review of Luzum et al. on “Moving Pharmacogenetics Into Practice: It’s All About the Evidence!” excellently outlines the sometimes variable requirements that are necessary to implement pharmacogeneticsbased information into clinical care. The white paper from WhirlCarrillo et al. provides another advancement in pharmacogenetics evidence, as the Pharmacogenomics Knowledgebase (PharmGKB) describes a novel objective scoring system to provide consistent, reproducible, and transparent assessment of the level of evidence for variantdrug pairs. In some clinical areas, accumulation of many association studies over years of study increases confidence that providers and patients can benefit from pharmacogeneticguided therapy to avoid adverse events and to increase clinical response. This is the case, in particular, in psychiatric diseases. Here, the successful treatment and patient’s adherence is often limited due to inadequate active drug concentrations