Key result
Automated CYP2C19 genotype-guided CDS for clopidogrel successfully scales across clinical indications, venues, and providers.
Why the study?
To describe experiences implementing and iterating CYP2C19 genotype-guided clopidogrel pharmacogenetic clinical decision support tools over time within a large health system-wide preemptive pharmacogenomics program.
Multidisciplinary collaboration and iterative strategies facilitate the successful implementation and scaling of CYP2C19 genotype-guided clinical decision support for clopidogrel prescribing.
Supports implementation of automated CYP2C19-guided clopidogrel decisions; extends single-site data but leaves open outcome validation.
PURPOSE: To describe our experiences implementing and iterating CYP2C19 genotype-guided clopidogrel pharmacogenetic clinical decision support (CDS) tools over time in the setting of a large health system-wide, preemptive pharmacogenomics program. SUMMARY: Clopidogrel-treated patients who are genetically predicted cytochrome P450 isozyme 2C19 (CYP2C19) intermediate or poor metabolizers have an increased risk of atherothrombotic events, some of which can be life-threatening. The Clinical Pharmacogenetics Implementation Consortium provides guidance for the use of clopidogrel based on CYP2C19 genotype in patients with cardiovascular and cerebrovascular diseases. Our multidisciplinary team implemented an automated, interruptive alert that fires when clopidogrel is ordered or refilled for biobank participants with structured CYP2C19 intermediate or poor metabolizer genomic indicators in the electronic health record. The implementation began with a narrow cardiovascular indication and setting and was then scaled in 4 primary dimensions: (1) clinical indication; (2) availability across health-system locations; (3) care venue (e.g., inpatient vs outpatient); and (4) provider groups (eg, cardiology and neurology). We iterated our approach over time based on evolving clinical evidence and proactive strategies to optimize CDS maintenance and sustainability. A key facilitator of expansion was socialization of the broader pharmacogenomics initiative among our academic medical center community, accompanied by clinician acceptance of pharmacogenetic alerts in practice. CONCLUSION: A multidisciplinary collaboration is recommended to facilitate the use of CYP2C19 genotype-guided antiplatelet therapy in patients with cardiovascular and cerebrovascular diseases. Evolving clopidogrel pharmacogenetic evidence necessitates thoughtful iteration of implementation efforts and strategies to optimize long-term maintenance and sustainability.
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Aquilante et al. (2024) studied Cardiovascular and cerebrovascular diseases. CYP2C19 genotype-guided clopidogrel pharmacogenetic clinical decision support was evaluated. Implementation of an automated CYP2C19 genotype-guided clinical decision support tool for clopidogrel was successfully scaled across clinical indications, care venues, and provider groups.
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