Evaluation of CYP2C19 Clinical Decision Support Alerts to Guide P2Y₁₂ Inhibitor Prescribing

Area of Science:

• Pharmacogenomics
• Clinical Informatics
• Cardiology

Background:

• CYP2C19 genetic variants impact clopidogrel efficacy in patients undergoing percutaneous coronary intervention (PCI).
• Personalized P2Y12 inhibitor selection is crucial for optimal antiplatelet therapy post-PCI.

Purpose of the Study:

• To evaluate prescriber response to clinical decision support (CDS) alerts recommending alternative P2Y12 inhibitors based on CYP2C19 genotype.
• To assess the impact of CDS alerts on genotype-guided P2Y12 inhibitor prescribing in patients post-PCI.

Main Methods:

• Retrospective analysis of alert response and P2Y12 inhibitor prescription data from October 2020 to December 2023.
• Evaluation of 362 patients with CYP2C19-clopidogrel CDS alerts post-PCI.
• Comparison of alert acceptance rates between CYP2C19 poor and intermediate metabolizers.

Main Results:

• Alert recommendations were accepted 24.5% of the time, leading to alternative P2Y12 inhibitor use on 22.4% of days post-PCI.
• Alert acceptance was higher for poor metabolizers than intermediate metabolizers (P=0.03).
• Provider clinical judgment was the most common reason for alert override (68%).

Conclusions:

• CYP2C19-guided CDS alerts partially promoted genotype-guided P2Y12 inhibitor prescribing post-PCI.
• Increasing age and concomitant oral anticoagulant use were associated with decreased alert acceptance.
• Further research is needed to understand prescriber override reasons and optimize CDS implementation.