Journal of Pain Research (Dec 2024)
Catalyzing Pharmacogenomic Analysis for Informing Pain Treatment (C-PAIN): A Randomized Trial of Preemptive CYP2D6 Genotyping in Cancer Palliative Care
Abstract
Youngwoo Cho,1 Theodore Karrison,2 Matthew M Jack,3 Anish R Choksi,3,4 Randall W Knoebel,3,4 Kiang-Teck J Yeo,1,5 Samuel L Volchenboum,6 Russell Z Szmulewitz,1,7 Everett E Vokes,7 Mark J Ratain,1,3,7 Peter H O’Donnell1,3,7 1Committee on Clinical Pharmacology and Pharmacogenomics, University of Chicago, Chicago, IL, USA; 2Biostatistics, Department of Health Service, University of Chicago, Chicago, IL, USA; 3Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA; 4Department of Pharmacy, University of Chicago Medicine, Chicago, IL, USA; 5Department of Pathology, University of Chicago Medical Center and Biological Sciences, Chicago, IL, USA; 6Department of Pediatrics, University of Chicago, Chicago, IL, USA; 7Section of Hematology/Oncology, Department of Medicine, University of Chicago Medical Center and Biological Sciences, Chicago, IL, USACorrespondence: Peter H O’Donnell, Email [email protected]: Cancer patients frequently suffer from pain, often managed with opioids. However, undertreated pain remains a significant concern. Opioid effectiveness varies due to genetic differences in how individuals metabolize some of these medications. While prior research suggests promise in tailoring opioid prescriptions based on CYP2D6 genetic makeup, its application in cancer pain management remains limited. This study investigates the potential benefits of preemptive CYP2D6 genotyping for cancer patients initiating opioid therapy, focusing on codeine, tramadol, and hydrocodone, whose efficacy is demonstrably impacted by CYP2D6 variations.Methods: This is a randomized, prospective study to evaluate the effects of preemptive pharmacogenomic (PGx) testing on opioid dosing decisions/selections and composite pain score in oncology patients. Patients with metastatic solid tumors for whom near-future opioid therapy is anticipated will be randomized to PGx and control arms, stratified by the presence or absence of bony metastases and history of opioid use. In the PGx arm, patients will be preemptively tested using a panel of pharmacogenomic genetic variants, and providers will receive opioid dosing guidance via an electronic medical record-embedded clinical decision support tool. In the control arm, pain prescribing will occur per standard of care without genotype information.Planned Outcome: The primary study outcome will be composite pain intensity during the first 45 days after an index opioid prescription for codeine, tramadol, or hydrocodone. Safety will be assessed by comparing opioid-related adverse event rates between the two study arms. Secondary outcomes will include rates of hospitalization/emergency room visits, cumulative morphine equivalents received, and type of first opioid prescribed.Keywords: pharmacogenomics, CYP2D6, codeine, tramadol, hydrocodone, genetic testing, pain score
