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In Response

Iravani, Marc MD; Lee, Lisa K. MD; Cannesson, Maxime MD, PhD

doi: 10.1213/ANE.0000000000002478
Letters to the Editor: Letter to the Editor

Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California,

We are very thankful for Dr Gordon1 for his interest in our article2 and his very insightful comments. In fact, we agree with the prescient points that have been raised in his letter. We are aware of the potential advantages of clinically validated genomic testing in preventing thromboembolism or identifying patients with butyrylcholinesterase deficiency or malignant hyperthermia causal genes, to name a few. As the intricate genotype/phenotype relationship is uncovered, we believe many aspects of our daily practice will be impacted. Dr Gordon1 notes the importance of anesthesia provider’s role in “pushing precision medicine and promoting incorporation of such data into our electronic medical records.” We have emphasized the importance of engaging anesthesiologists in perioperative genomic issues and how the patient’s genomic information will gradually be incorporated in the electronic medical record so that the appropriate alerts are raised whenever there is a potential adverse drug effect based on the patient’s genetic composition. In fact, we share Dr Gordon’s1 enthusiasm in reaping the benefits of our genomic information in the perioperative setting and beyond, in the service of our patient’s safety and well-being.

However, we deliberately chose a cautious tone to our article due to the proliferation of other articles propounding transformative changes in medicine since the sequencing of the human genome more than a decade ago. Although very promising, many questions regarding precision medicine remain unanswered.3 We believe imparting a more realistic vision may serve our profession better from a strategic point of view. Although we are optimistic, we are cognizant of the fact that even the early drug candidates for precision medicine, such as dosing of Warfarin based on genotyping versus traditional dosing, is not well supported.4 While whole genome sequencing would undoubtedly provide a wealth of information about the patient that can be of benefit in selecting the best therapy while avoiding potential adverse drug reactions, promotion of routine whole genome sequencing in our patients as suggested by Dr Gordon1 may not be advantageous for the patient yet. In fact, it may even lead to discovery of incidental findings, which we lack sufficient knowledge to address properly. Genomic information should be treated as any other type of medical information or test: Only ordered if we know the proper action to be taken. Furthermore, issues of discrimination based on patient’s genotype and issues of privacy, among others, should be solved at a societal level before routine whole genome sequencing of our patients is undertaken. Insurance companies who have ostensibly paid for sequencing would likely want some return on their investment. Thus, we argue for targeted testing for the protection of our patients.

Finally, we certainly need not wait for point-of-care testing (POC) technology to use genomic information in the perioperative setting and that was not our intent in the article also. But the fact remains that the majority of our patients are not seen 30 days in advance of surgery. This goal may be more practical in an accountable care organization, where patients receive all their care within a single health care system. Since technology is advancing at a very rapid rate, the use of POC testing in the perioperative period may fill the gap for those patients not seen in advance. POC testing or technology in general will not be the impediment in precision medicine as we have stated. Unraveling the interdependent functioning of our genome and its effect on the outcomes of clinical interest will be a far more formidable challenge for clinical medicine.

Marc Iravani, MDLisa K. Lee, MDMaxime Cannesson, MD, PhDDepartment of Anesthesiology and Perioperative MedicineDavid Geffen School of Medicine at UCLALos Angeles,

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1. Gordon RJStandardized care versus precision medicine: do we really need to wait for point-of-care testing? Anesth Analg. 2017:125:2161.
2. Iravani M, Lee LK, Cannesson MStandardized care versus precision medicine in the perioperative setting: can point-of-care testing help bridge the gap? Anesth Analg. 2017;124:1347–1353.
3. Joyner MJ, Paneth NSeven questions for personalized medicine. JAMA. 2015;314:999–1000.
4. Stergiopoulos K, Brown DLGenotype-guided vs clinical dosing of warfarin and its analogues: meta-analysis of randomized clinical trials. JAMA Intern Med. 2014;174:1330–1338.
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