Pharmacogenetics in clinical anaesthesia practice: a scoping review

Genetic variation contributes to interindividual differences in responses to anaesthetic agents, and pharmacogenetics may enable personalised anaesthesia. Anaesthetists increasingly often encounter patients with known polymorphisms that could affect drug pharmacokinetics and pharmacodynamics, and the lack of practice guidelines creates uncertainty about management. This review aimed to evaluate clinical evidence for pharmacogenetics-guided anaesthesia. We performed a systematic search in MEDLINE and EMBASE (January 2005 to October 2025). Two authors independently screened records in Covidence software and selected relevant studies for full-text review. Eligible articles included clinical studies addressing commonly used anaesthetic drugs and pharmacogenetic analyses available in routine clinical laboratories. Of 1,016 screened publications, 54 met inclusion criteria. Most studies focused on genes encoding cytochrome P450 (CYP) enzymes and opioid receptor (OPRM1). The most frequently investigated drugs were propofol, opioids, and ondansetron. Findings were heterogeneous: Studies on CYP2B6 variants and propofol yielded conflicting results, though some data link CYP2B6 polymorphisms to delayed emergence from propofol anaesthesia. The relationship between CYP2D6 phenotype and ondansetron efficacy is inconclusive. Polymorphisms in CYP2D6 and OPRM1 may reduce opioid analgesic efficacy in some genotypes. Only one completed randomised trial evaluated preoperative pharmacogenetic testing and found no improvement in postoperative pain outcomes. Current clinical evidence does not support routine pharmacogenetics-guided drug choice and dosing in anaesthesia. Nevertheless, avoiding specific drugs in certain genotypes may be advisable. Existing guideline recommendations for certain opioids and NSAIDs should be followed when applicable. Further clinical trials and implementation studies are needed to define clinical utility.