To the Editor We read with interest the article by Povsic et al1 showing the reluctance of physicians to use CYP2C19 genotyping results to guide antiplatelet therapy within the Randomized Trial to Compare the Safety of Rivaroxaban vs Aspirin in Addition to Either Clopidogrel or Ticagrelor in Acute Coronary Syndrome (GEMINI-ACS-1) study. Their data point out a large knowledge gap in that approximately 50% of investigators did not have a plan to alter therapy in genotype-determined nonresponders despite the study being conducted more than 5 years after the US Food and Drug Administration issued a boxed warning about using clopidogrel in poor metabolizers (PMs) homozygous for CYP2C19 nonfunctional alleles. Among those investigators prestipulating a plan to change, only 48% of PMs were switched to ticagrelor.1 Results from the GEMINI-ACS-1 study demonstrate the limited association of the US Food and Drug Administration warning with clopidogrel prescribing practices and highlight the importance of including specific treatment recommendations and having endorsement by applicable clinical practice guidelines.
Stouffer GA, Lee CR. Logistical Challenges Associated With Implementing Precision Medicine. JAMA Cardiol. 2019;4(12):1300. doi:10.1001/jamacardio.2019.4157
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