Springer Ashley N, Alicea Leah A, Gafari Yemi, Smith Tayler B, Lynch Sheryl, Breman Amy M, Hodge Jennelle C, Pratt Victoria M, Powell Nicholas R, Kreutz Rolf P, Kobold Daniel P, Eadon Michael T, Tillman Emma M, Shugg Tyler, Skaar Todd C
Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.
Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA.
Clin Pharmacol Ther. 2025 Aug;118(2):470-479. doi: 10.1002/cpt.3698. Epub 2025 May 12.
P2Y inhibitor selection involves numerous factors, including CYP2C19 genetics, since evidence demonstrates reduced clopidogrel efficacy in patients with decreased or no function CYP2C19 variants. In 2020, Indiana University health embedded interruptive clinical decision support (CDS) alerts in the electronic health record (EHR) to recommend alternative P2Y inhibitors for patients with decreased CYP2C19 function who had undergone percutaneous coronary intervention (PCI). The objective of this study was to evaluate prescriber response to these CDS alerts. Utilizing alert response data and P2Y inhibitor prescriptions from October 2020 to December 2023, we evaluated prescriber response for 362 patients who had a mean of 2.2 (SD: 1.7) CYP2C19-clopidogrel alerts fire post-PCI. Alert recommendations were accepted 24.5% ± 36.8% (mean ± SD) of the time. Alternative (i.e., non-clopidogrel) P2Y inhibitors were prescribed for 22.4% ± 36.8% of days during the year following PCI. Alerts were accepted more for CYP2C19 poor metabolizers than for intermediate metabolizers (P = 0.03). Each year after 2020 was associated with a 4.6% increase in the days prescribed alternative P2Y inhibitors. In contrast, increasing age was associated with decreased alert acceptance and decreased percentage of days prescribed alternatives, and concomitant oral anticoagulant use was associated with decreased percentage of days prescribed alternatives. Provider clinical judgment was the most common alert override reason, accounting for 68% of clinician responses. Our findings demonstrate that CYP2C19-clopidogrel CDS alerts promoted genotype-guided P2Y inhibitor prescribing in some cases (~22% of study days). Future research should better determine prescriber reasons for rejecting alert recommendations and establish best implementation practices to complement CDS alerts.
P2Y抑制剂的选择涉及众多因素，包括CYP2C19基因，因为有证据表明，CYP2C19功能降低或缺失的患者使用氯吡格雷的疗效会降低。2020年，印第安纳大学健康中心在电子健康记录（EHR）中嵌入了干预性临床决策支持（CDS）警报，以便为接受经皮冠状动脉介入治疗（PCI）且CYP2C19功能降低的患者推荐替代P2Y抑制剂。本研究的目的是评估处方医生对这些CDS警报的反应。利用2020年10月至2023年12月的警报响应数据和P2Y抑制剂处方，我们评估了362例患者的处方医生反应，这些患者在PCI术后平均有2.2次（标准差：1.7次）CYP2C19 - 氯吡格雷警报触发。警报建议被接受的时间为24.5%±36.8%（平均值±标准差）。在PCI术后的一年中，有22.4%±36.8%的天数开具了替代（即非氯吡格雷）P2Y抑制剂。与中间代谢者相比，CYP2C19慢代谢者对警报的接受度更高（P = 0.０3）。2020年后的每一年，开具替代P2Y抑制剂的天数增加4.6%。相比之下，年龄增加与警报接受度降低以及开具替代药物的天数百分比降低相关，同时使用口服抗凝剂与开具替代药物的天数百分比降低相关。医生的临床判断是最常见的忽略警报原因，占临床医生反应的68%。我们的研究结果表明，CYP2C19 - 氯吡格雷CDS警报在某些情况下（约占研究天数的22%）促进了基因型指导的P2Y抑制剂处方。未来的研究应更好地确定医生拒绝警报建议的原因，并建立最佳实施方法以补充CDS警报。
