Download CDS User Scenarios

CDS Scenarios from PREDICT
I. Simvastatin CDS:
Genomic result
Simvastatin sensitivity: Intermediate Myopathy Risk, Minor Allele Heterozygous (C;T) - gene:
SLCO1B1 - gene result: *1/*5
Patient presentation
 62 year old female patient self- referred to see PCP for management of hyperlipidemia
 History of obesity, coronary artery disease, diet controlled diabetes (last HgA1c 6.0), a TIA in
2008 and hyperlipidemia
 In 2010, history of exertional shortness of breath evaluated with a diagnostic coronary
catheterization showing moderate coronary artery disease (50% lesion) in the right circumflex
artery not amenable to intervention. The shortness of breath resolved soon thereafter after the
patient began regular walking.
 At her last physician visit 12 weeks ago, she was diagnosed with hypercholesteremia with a
fasting LDL cholesterol of 160, moderately elevated triglycerides of 357, and an HDL of 60. She
was started on 40 mg simvastatin therapy which minimized her out of pocket costs.
 Today she feels no different than usual. She would like to get off of her medications which she
thinks are causing more harm than good and affect her fixed income budget. She has joint
stiffness when she wakes up in the mornings that have been unchanged for the last year.
 Physical exam is unremarkable except for moderate obesity BMI 31; Weight: 120 kg
 Simvastatin is initiated.
 [Participant is asked to complete the simvastatin prescribing task]
Scenario notes:
The patient has an indication for higher dose statin therapy with the diabetes and history of coronary
artery disease (although this may be clinically silent). Simvastatin is a moderate-potency option at the
lowest out of pocket cost when comparing generics. The FDA guidance from 2011 recommends any new
starts on 80mg. CDS recommendation is relevant as duration of therapy is less than 1 year.
II. Warfarin CDS:
Genomic result
Warfarin sensitivity: Hyper Responder - gene results: VKORC1 A/G; CYP2C9 *2/*2
Patient presentation

Patient presents with paroxysmal atrial fibrillation noted on a 24-hour holter monitor and
brief episodes of shortness of breath. He is admitted to the hospital where he is
successfully converted back to a normal sinus rhythm and he is loaded with amiodarone
for rhythm control.
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6 weeks later, you see the patient in your office and order a monitoring ECG showing
asymptomatic recurrent atrial fibrillation. After calling the EP consulting team who previously
saw the patient, you plan long-term anticoagulation and rate control.
Past Medical History (on Problem list) includes Congestive Heart Failure, Hypertension,
Coronary Artery Disease
The patient has never been on anticoagulation previously
Baseline INR 1.0, Hct 37, Hgb 11.5
Medication List:
o Amiodarone 200mg PO qd
o Asa 81 mg PO qd
o Pravastatin 40mg PO qd
o Lisinopril / HCTZ 20 mg / 12.5 mg PO qd
o Metoprolol SR 12.5mg PO bid
o Furosemide 40 mg PO qd
Height 185.4 cm, Weight 123.8 kg;
[Participant is asked to complete the warfarin prescribing task]
Scenario notes

Based on the patient’s genotype results and Amiodarone use, the recommended starting warfarin
dose is 3 mg/day (formula is below).
Starting Coefficient
(Vanderbilt Specific
Dosing Model)
Age (in decades)
Height (in Cm)
Weight (in Kg)
Inducer?
Amiodarone
VKORC1 AG
CYP2C9 *1/*3
4.999
4.999
7
185.4
123.8
No
Yes
Yes
Yes
Weekly
Daily
-1.967
2.781
1.3618
0
-0.827
-0.816
-0.964
20.86 mg
2.98 mg
Clopidogrel CDS:
Genomic result
Clopidogrel sensitivity: Poor Metabolizer, Reduced Anti-Platelet Effect - gene: CYP2C19 - gene
result: *2/*2
Patient Presentation:
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55 y/o male presents with chest pain.
Referred to cardiologist for a stress test which is positive.
Undergoes elective catheterization 2 days later and receives a drug eluting stent in left anterior
descending artery.
Genotyping is performed at the time of the procedure and the patient is started on a loading dose
of clopidogrel.
Patient was discharged on clopidogrel prior to the release of gene results.
Patient calls the week following discharge and requests a 90-day prescription for clopidogrel.
[Participant is asked to complete the clopidogrel prescribing task]