UF Health MedMatters

UF Health Physicians Use Genetic Information to Create Individualized Postoperative Pain Management Plans

Some of the most common concerns around pain, for physicians and their patients, occur with orthopaedic surgery and joint replacement surgeries. Pain management can greatly influence a patient’s recovery following surgery, but it’s a complex process that may require a more individualized approach. To aid in this process, a team of University of Florida Health researchers took a closer look at how using a patient’s genetic information may help to inform pain management plans that also seek to minimize the risks associated with use of opioid medications.

Pills spilling out of bottle

Bulk prescriptions of opioids, including hydrocodone, morphine, tramadol and oxycodone, have historically been prescribed to patients to manage postoperative pain, said Justin Deen, MD, an assistant professor and attending physician at the UF Health Orthopaedics and Sports Medicine Institute.

“One of the efforts to minimize the utilization of narcotics has been to leverage other non-narcotic medications, a technique called multimodal pain management,” Deen said. “The idea is to use multiple agents that work through different pain pathways to achieve comparable overall pain control, while minimizing risks associated with any individual therapy.”

In their study of genotype-guided therapy for pain management, UF Health physicians tested patients for variants in a gene called CYP2D6, which is associated with activation of some opioid pain medications.

About 10-20% of patients fall outside the parameters of patients who are normal metabolizers of certain pain medications, including codeine, tramadol and hydrocodone. These patients — whether they be slow or fast metabolizers — may have reduced pain response or be at increased risk for serious side effects with some opioids. They may need to have their medications adjusted to ensure safe and adequate pain control, said Larisa Cavallari, PharmD, BCPS, FCCP, director at UF’s Center for Pharmacogenomics and Precision Medicine and the UF Health Precision Medicine Program.

“Our group looks at how testing a patient’s genotype and prescribing pain medication based on genotype result can influence pain control after surgery,” she said. “There was a lot of interest in gathering evidence for how using information about a patient’s CYP2D6 genotype in a practical patient setting can help better manage pain in a clinical setting.”

Cavallari partnered with Hari Parvataneni, MD, and Chancellor Gray, MD, of the UF Health Orthopaedics and Sports Medicine Institute to study patients scheduled for hip or knee replacements.

Patients in the study provided a cheek swab to determine which version of the gene each patient expressed, which was genetic tested in UF’s pathology lab. The pharmacy team then worked with the orthopaedic surgeons to prescribe pain medication expected to be effective and safe for each patient based on genetic testing results.

“Orthopaedic surgeons are among the highest prescribers of narcotics, along with family practice doctors and dentists, because we tend to perform procedures that may include a high degree of pain,” said Gray, an associate professor of orthopaedics at UF and director of quality for inpatient orthopaedic care at UF Health. “And roughly 15% of patients will still be using narcotics six months or even a year after surgery, so historically this has been a problem that we have been trying to solve.”

“Our group looks at how testing a patient’s genotype and prescribing pain medication based on genotype result can influence pain control after surgery. There was a lot of interest in gathering evidence for how using information about a patient’s CYP2D6 genotype in a practical patient setting can help better manage pain in a clinical setting.” - Larisa Cavallari, PharmD, BCPS, FCCP

During the study, the patients were given results of their genetic test at their preoperative visit, about a week before surgery. This included details on their genetic profile related to the CYP2D6 gene. They were then prescribed an individualized medication regimen for postoperative recovery.

“Patients fell into one of four categories based on their test results,” Gray said. “And based on our clinical experience, we created a guidebook for each category that listed the appropriate medications and dosage requirements.”

Of the 260 patients who participated in the study, CYP2D6 gave researchers the ability to identify 20% who had a high-risk genotype. These patients were prescribed an alternate opioid medication that was expected to be more effective. This treatment in turn led to good pain control, with less opioid consumption by patients over the duration of their recovery.

“As surgeons, the responsibility is on us to be good stewards of our patients overall care,” Gray said. “By using CYP2D6 and these genetic personalized pathways, we have an opportunity to better care for patients who would otherwise be at risk.”

About UF Health Shands Hospital

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University of Florida Health Shands Hospital has been recognized among the nation’s best hospitals in seven adult medical specialties. Overall, UF Health Shands Hospital was recognized as one of the best hospitals in Florida. In addition to being ranked among the nation’s top 50 hospitals in seven specialties, UF Health Shands Hospital also was listed as “high performing” in seven specialties, including abdominal aortic aneurysm repair, colon cancer surgery, COPD, heart failure, lung cancer surgery, neurology & neurosurgery and orthopaedics.