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Editorials |

Personalized Genetic Prediction: Too Limited, Too Expensive, or Too Soon?

John P.A. Ioannidis, MD
[+] Article and Author Information

From the University of Ioannina, Iaonnina 45110, Greece.


Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: John P.A. Ioannidis, MD, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, University Campus, Ioannina, 45110, Greece; e-mail, jioannid@cc.uoi.gr.


Ann Intern Med. 2009;150(2):139-141. doi:10.7326/0003-4819-150-2-200901200-00012
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Genetic epidemiology has identified many common genetic variants that are associated with common diseases, and the list is growing monthly (12). This success has boosted expectations for personalized genetic prediction. According to these expectations, genetic information can tell people about their risk for various diseases and which medications they should use or avoid. However, 2 articles in this issue (34) suggest that this promise may be exaggerated and premature.

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genetics

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Personalized medicine with self management
Posted on February 1, 2009
Mayer Brezis
Center for Clinical Quality & Safety, Hadassah University Hospital
Conflict of Interest: None Declared

To the Editor:

Eckman et al showed genotyping is not cost-effective in the management of atrial fibrillation with warfarin (1). Whether genotyping reduces hemorrhage risk is based on limited evidence from three small trials. Using genotyping, four of 214 patients had major bleeding, as compared to seven of 215 patients with standard management (a difference not statistically significant).

By contrast, a systematic review of 14 randomized trials using self-management and self-monitoring of anticoagulation with warfarin, showed significant reduction of hemorrhage (2). With self-management, 34 of 1349 patients experienced major bleeding as compared to 55 of 1471 patients with standard management. Thromboembolic events and death were also significantly reduced by nearly 40%.

We recently showed feasibility of patient self-management training prior to hospital discharge, based on a simple educational intervention in an unselected population (J Clin Eval Pract, in press). In the intervention group, during the first three months post-discharge, INR fell within target range in 60% of tests compared to 40% or less in the control group (p<0.001). Patient knowledge and satisfaction were also higher in the intervention group. The material, described on our website (www.hadassah.org.il/departments/quality/coumadin), includes a brochure in four languages, a slide rule with operating instructions, and a kit for the family physician.

Empowerment of patients is effective in the management of chronic conditions (3). Beyond genetic typing, personalized medicine might benefit from considering patient literacy, preferences and participation. Market incentives for "low-tech" communication skills are less immediately apparent than those for "high-tech" genetic testing, but the former may not be less effective.

References

1. Eckman MH, Rosand J, Greenberg SM, Gage BF. Cost-effectiveness of using pharmacogenetic information in warfarin dosing for patients with nonvalvular atrial fibrillation. Ann Intern Med. 2009;150:73-83

2. Heneghan C, Alonso-Coello P, Garcia-Alamino JM, Perera R, Meats E, Glasziou P. Self-monitoring of oral anticoagulation: a systematic review and meta-analysis. Lancet 2006;367:404-11

3. Chodosh J, Morton SC, Mojica W, Maglione M, Suttorp MJ, Hilton L, et al. Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med. 2005;143:427-38.

Conflict of Interest:

None declared

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