Strictly Clinical
  • Anesthetists’ Ethical Responsibility Behind Pharmacogenetics

    To the editor: I am writing regarding the AANA Journal article “A Primer to Pharmacogenetics of Postoperative Pain Management,” published in April 2019. I want to take a moment and reflect on the AANA Scope of Nurse Anesthesia Practice, which states, “Nurse anesthetists are innovative leaders in anesthesia care delivery, integrating progressive critical thinking and ethical judgment.”1 I am honored to be part of a profession of leaders who critically think and ethically judge their actions. I applaud Aroke and Kittelsrud’s introduction of a highly controversial subject as useful science. However, genetic testing as a determinant of medication allowances requires an ethical discussion. The use of a patient’s genomic variation offers the anesthetist a powerful tool.2 However, with power comes responsibility, a global responsibility to patients, and our profession. I think this is an opportunity for anesthetists to lead by example; a chance to show patients and other members of the anesthesia care team to not only review the numbers but always the patient as a whole. Often, reliance on these numbers moves and motivates decisions, which in turn, allow us to silence the voice inside, our gut instinct. I then ask, do you believe your instinct? Who better knows the patient? We see how they respond and react to our questions during that first encounter in the preoperative area. We understand the impact midazolam has on their body as we roll them back to the operating room. We learn how their vital signs have responded to other medications at induction. We are the instruments of best measure; genomic analysis cannot exceed our gut instinct and vigilance. Let us never forget the patient right before us, entrusting us with their life. Let us be cognizant how actions of the nurse anesthetist and nursing as a whole create a culture of integrity in which our discipline is founded. I appreciate the work these authors have introduced, but as nursing leaders, we have an ethical obligation to consider all factors affecting our profession and our patients. Genetic testing should never yield discrimination of any kind. We should not allow any one test to classify allowance of pain relief. Anesthetists are privy to all forms of pain management, therefore entrusted with its use. 

    REFERENCES

    1. Scope of Nurse Anesthesia Practice. American Association of Nurse Anesthetists (AANA). https://www.aana.com/docs/ default-source/practice-aana-com-web-documents-(all)/scope-of-nurse-anesthesiapractice.pdf?sfvrsn=250049b1_2. Updated June, 2013. Accessed July 1, 2019.

    2. Aroke E, Kittelsrud J. A primer to pharmacogenetics of postoperative pain management. AANA J. 2019;87(2):131-137.

    Lisa Ferrand, MSA, CRNA, APRN Hollywood, Florida


    Response: We thank Lisa Ferrand for her interest and comments regarding our article published in April 2019 by the AANA Journal entitled “A Primer to Pharmacogenetics of Postoperative Pain Management.” We appreciate your comments regarding ethical use of genetic information and we believe that the use of genetic results in the clinical setting must be governed by principles of bioethics: autonomy, beneficence, non-maleficence, and justice. We are in the midst of a genetic renaissance as such, and information seems to be moving quite quickly from research to clinical practice most notably since the completion of the Human Genome Project. However, pharmacogenetics itself has roots dating back to 510 BC, when Pythagoras first understood that fava bean ingestion was detrimental to those deficient of G6PD.1 Furthermore, the use of genetic information about drug metabolism has been clinically beneficial to providers since the 1950s when Vogel coined the term pharmacogenetics.2 Thus, we respectfully disagree with your assertion that pharmacogenetic is “a highly controversial subject.” Indeed, CRNAs routinely ask patients about personal and family history of malignant hyperthermia (MH) during preoperative assessment. MH is a pharmacogenetic disorder of the L-type calcium channel and ryanodine receptor that is inherited in an autosomal dominant manner.3 A sophisticated research study is not necessary to prove that knowledge of the genetic nature of MH has made it possible for many MH susceptible individuals to successfully undergo anesthesia. In the era of precision health, there is a change in the clinical paradigm towards preemptive genotyping and incorporation of genetic data into clinical decision making. We agree with your caution that healthcare providers should “not only review the numbers but always the patient as a whole.” Institutions that have implemented preemptive genotyping such as Mayo Clinic, have integrated clinical decision support and pharmacogenetic data into the electronic health record to optimize the delivery of the right drug, at the right dose, to the right patient, at the right time.4 Awareness of some of the nuances of pharmacogenetics is the main focus of our article. For example, when a clinician understands that CYP2D6*5 is a deletion allele,5 then the fact that a patient with a CYP2D6*5/*5 genotype still reports a pain rating of 9/10 after taking codeine for pain control makes clinical sense. This knowledge can also provide more clarity, especially in the situation of a patient who is labeled as a “drug seeker” when genetically they are unable to metabolize many pain medications. Finally, pharmacogenetics is a useful tool which can aide our understanding of physiological processes that produce proteins that transport medications, metabolize medications or site of action of medications. This knowledge can only enhance our practice and help guide our “gut instincts” to a more informed practice. The Genetic Information Nondiscrimination Act (GINA) of 2008 protects individuals against health insurance and employment discrimination based on genetic make-up. As clinicians we should strive to improve the quality of care and patient outcomes. Pharmacogenetics/pharmacogenomics information is simply a single piece of the puzzle, and should not undermine the clinician’s final decision, nor override ethical decision making. Thank you.

    REFERENCES

    1. Nebert DW. Pharmacogenetics and pharmacogenomics: why is this relevant to the clinical geneticist? Clin Genet. 1999;56(4):247-258.

    2. Vogel F. Moderne probleme der Humangenetik. Ergeb Inn Med Kinderheild. 1959;12:52-125.

    3. Rosenberg H, Sambuughin N, Riazi S, Dirksen R. Malignant Hyperthermia Susceptibility In: Adam MP, Ardinger HH, Pagon RA, Wallace SE, eds. GeneReviews. Seattle, WA: University of Washington, Seattle; 2013.

    4. Bielinski SJ, Olson JE, Pathak J, et al. Preemptive Genotyping for Personalized Medicine: Design of the Right Drug, Right Dose, Right Time—Using Genomic Data to Individualize Treatment Protocol. Mayo Clinic proceedings. 2014;89(1):25-33.

    5. Del Tredici AL, Malhotra A, Dedek M, et al. Frequency of CYP2D6 Alleles Including Structural Variants in the United States. Frontiers in Pharmacology. 2018;9.

    Edwin Aroke, PhD, CRNA Birmingham, Alabama

    For a PDF of this article, click here.