Pharmacogenetics personalised medicine: new frontier or nonsense?
Apparently my private health insurance covers pharmacogenetics testing to find the best ADHD medication. What is it, is it legit? What's the company going to do with my cheek swabs? How do doctors feel about me going up to them and say hey internet pharma bro tells me I should be taking this instead of what your years of medical school thinks.
What I can't figure out is how my insurance company benefits from this. I'm not paying extra for this service so I must be the product right? Here's part of the marketing FAQ info from my insurance provider:
Personalized Medicine uses advanced pharmacogenetic testing and pharmacist assistance to find the most effective medication for you.
If you’re starting a new medication for a mental health condition (such as anxiety or depression), chronic pain, attention deficit hyperactivity disorder (ADHD), or neurological conditions – or taking a medication for one of these conditions and it’s not working or causing side effects – Personalized Medicine could help. It’s offered through your extended health care benefits plan, so the cost of the test may be covered. To see the list of drugs tested, click here.
It involves a pharmacogenetic test. This is a type of test that identifies how you may respond to medications. Your test results are only for you and anyone you give consent to share them with, such as your doctor. The test is run by Personalized Prescribing Inc., a Canadian company. Manulife
As it stands, all genetic screening for psychopharmacology is exploratory. There may be some small studies with promising results, but it's all new enough to treat as a novelty for the time being. There will probably be benefits in using it in the future, but I don't think it's around the corner for anything murky at all, including ADHD.
If I'm putting on my crank cap, then I'd hazard that Personalized Prescribing is sharing data with insurers, or even willing to fudge results to give you recommendations that always correspond with the cheapest medication. Assuming there's no outright fraud, it does give insurers yet another standard to appeal to, a la "oh, sorry, we said the pharmacy, provider, and medication was covered, but we need your doctor to tell us your medical information to pay for this, just in case". But that's my perspective from the nation to your south, so maybe your insurers are slightly more trustworthy.
So this is not a specialized area of mine, here are some thoughts though.
There's some indication that the use of fMRI can better match medications to the individual. Even if your experience is "depression" but your brain looks like "bipolar" then it's possible mood stabilizers will work better than traditional antidepressants.
Genetic testing can flag some potential negative side effects: flag a gene that makes it unlikely Med A will work for you, or that you metabolize Med B in a particular way, for example.
There's not a much certainty here as they'd like, and it's certainly biased towards predominantly European genotypes and noting those differences. Idk enough to say if that makes it a bad idea for other populations or what the effectiveness difference might be.
Where does this benefit insurance companies? Possible thoughts
Hypothetically if this works they reduce the amount of trying to juggle your meds around, trying fewer meds that don't work and reducing costs by eliminating the "bad" options up front. Even if that hypothetically directs you to more expensive treatment, on average it should probably reduce the cost of bouncing around. Especially if there's effectiveness with ADHD meds, which I didn't look into specifically, this could be beneficial.
Reducing the cost of hospitalizations from not taking meds due to side effects or low efficacy. I see some indication they think they can predict suicidality. I'm less confident about that. But there may be genetic markers for chronically suicidal people that I'm not aware of, so.... Maybe. With ADHD in theory if you're treated you reduce your "I didn't follow up with the doctor about X so now I am at the ER" sorts of things.
It may be that they're getting a kickback from the companies trying to study the efficacy of the treatment (rather than really studying your genes) even if they're not disclosing that research or kickback to you. Idk the law well enough to know what disclosures are required.
My best guess
If you were struggling with meds, especially ones that might leave you suicidal or at other high risk, it might be worth a shot. If you're worried about taking a new med and the struggles of adjusting it is less worth it, but maybe still. I was so frustrated when adjusting my meds for ADHD I wouldn't say it wouldn't have been worth it.
I'm not super precious about my genes, but I don't fault anyone for feeling that way. How do they protect your genetic results and your identity if you are the only one sharing them with your doc? Does the doc just go back to the company? There's going to be privacy laws in place but stuff gets weird sometimes. I'm not sure the efficacy is high enough that I'd be interested if I weren't seriously struggling to find medication that worked for me.
As an aside I get these sorts of offers from my insurance company for diabetes. There is a benefit in making sure people with chronic conditions take care of themselves. it's just idk if this qualifies.
Genetic testing for predicting response to various pharmaceutical interventions is mostly about gene variants that impact drug metabolism, not necessarily drug response or likelihood of all serious side effects (e.g. drug allergies).
There's evidence that up to 80% of the population carries gene variants that impact drug metabolism, either slowing or accelerating breakdown and elimination of specific kinds of chemicals. Knowing which families of chemicals can result in potential under- or over-dosing is important, but it doesn't necessarily tell you which of the tolerable drugs will be most effective for your particular condition.
There's mixed evidence on whether pharmacogenomics actually helps people with various mental health conditions recover faster or better. The best evidence is that it does help achieve faster improvement in major depressive disorder. This could be because there are so many antidepressants with different mechanisms of action, and skipping trials of the ones with unfavorable metabolic profiles would save a great deal of time. [Personal experience, I've been prescribed most of them at one time or another, with varying results from totally ineffective to debilitating to emergency room visits. I would have a different life if the right one was found on the first or second try.]
For ADHD, the review I referenced didn't seem to show a substantial improvement from pharmacogenomic testing across multiple studies. The available mechanisms of action rely on a handful of drugs that are chemically similar to each other, so there's less scope for eliminating whole drug families that you might respond to unfavorably.
As far as how the insurance company benefits, fewer ineffective or harmful drug trials means fewer doctor visits. Earlier improvement generally means better long-term medical outcomes, especially for bipolar disorder and schizophrenia, where delayed treatment increases the likelihood of recurrent hospitalization. Un- or under-treated ADHD substantially increases risks for all-cause mortality and morbidity, including auto accidents, missed medical diagnoses, violence, etc. It's a good risk mitigation strategy for insurers if it works as advertised.