Transcript Document

Who Are We?
• Molecular Testing Labs is a cutting-edge molecular and genetics
testing laboratory focused on pharmacogenomics, also called
Personalized Medicine.
• Our primary goal is to provide the physician, healthcare practitioner
and patient with the information necessary to understand how a
patient’s unique gene families interact and impact specific drug
responses.
• Molecular Testing Labs is a CLIA approved (#50D2050397) Molecular
/ Genetic Testing Laboratory.
Our Test Groups
Molecular Testing Labs currently offers molecular pharmacogenomics testing in 6
specific areas:
1. Pain Management Drug Response – tests to help determine the patient’s response to
common pain medications and opioids.
2. Cardiac Risk Factors – tests to determine the genetic risk factors for thrombosis or
prothrombin deficiency. Includes evaluating patient’s response to commonly used
cardiovascular drugs.
3. Psychotropic/Neurotropic Drug Response – tests to help understand the patient’s response
to neuroactive drugs. These drugs include antidepressants, antipsychotics and anxiolytics.
4. Hormone Interaction Response – tests to understand the patient’s response to common
hormone replacement therapies.
5. MTHFR Testing – testing for a gene related to folic acid metabolism, which is related to a
variety of birth defects and neural tube defects.
6. Infectious Disease Testing – molecular-based tests for common infectious organisms,
particularly STDs such as Chlamydia, Gonorrhea, Human Papillomavirus, as well as Hepatitis
viruses.
Cytochrome P450
Cytochrome P450
The cytochrome P450 superfamily (officially abbreviated as CYP) is a large and diverse group of enzymes that catalyze
the oxidation of organic substances. The substances of CYP enzymes include metabolic intermediates such as lipids
and steroidal hormones, as well as xenobiotic substances such as drugs and other toxic chemicals. CYPs are the major
enzymes involved in drug metabolism and bioactivation, accounting for about 75% of the total number of different
metabolic reactions.
The most common reaction catalyzed by cytochromes P450 is a monooxygenase reaction, e.g., insertion of one atom of
oxygen into an organic substrate (RH) while the other oxygen atom is reduced to water:
RH + O2 + NADPH + H+ → ROH + H2O + NADP+
Cytochromes P450 (CYPs) belong to the superfamily of proteins containing a heme cofactor and, therefore,
are hemoproteins. CYPs use a variety of small and large molecules as substrates in enzymatic reactions. Often, they form
part of multi-component electron transfer chains, called P450 containing systems. The letter in P450 represents the word
pigment as these enzymes are red because of their heme group. The number 450 reflects wavelength of the absorption
maximum of the enzyme when it is in the reduced state and complexed with CO.
The cytochrome P450 (CYP450) enzymes are involved in the metabolism and processing many drugs and chemicals in our
body. CYP450 is a large enzyme family mostly found in the liver. Since these enzymes have more than 50 variations, their
activity may vary from person to person. Individual differences of cytochrome P450 activity can mean that certain drugs
aren’t metabolized at all, are metabolized slowly, or are metabolized very quickly. This can lead to adverse drug reactions
or a lack of therapeutic effect under standard therapy conditions.
Pharmacogenomics
Pharmacogenomics (PGx)
Phar-ma-co-ge-no-mics
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Pharmacogenomics - the influence of genetic variation on drug response in patients. The goal of Pharmacogenomics is to develop
optimized drug therapy with respect to the patients' unique drug response.
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Pharmacogenomics is the study of how an individual's genetic inheritance affects the body's response to drugs. It may be possible to
predict therapeutic failures or severe adverse drug reactions in individual patients by testing for important DNA sequence variations or
polymorphisms (genotyping) in key drug-metabolizing enzymes, receptors, transporters, etc. Potentially, test results could be used to
optimize drug choice and/or dose earlier for more effective therapy, avoid serious adverse effects, and decrease medical costs
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The cytochrome P450 superfamily (CYP450) is a large and diverse group of enzymes that are responsible for drug metabolism and drug
biotransformation.
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Molecular Testing Labs’ CYP450 tests provide information on how quickly or slowly the patient will metabolize a certain drug (ex:
warfarin or clopidogrel). This allows one to assess the likely risk of adverse drug reactions, drug toxicity, decreased effectiveness or drug
failure when using a specific drug in one particular individual.
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For each drug test requested, Molecular Testing Labs provides an analysis of the patient’s genetic response to that specific drug,
classifying them as:
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Normal Metabolizers (NM)
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Poor Metabolizers (PM)
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Intermediate Metabolizers (IM)
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Rapid Metabolizers (RM)
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Ultra Rapid Metabolizers (URM)
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Key Point: Each person responds to drug treatments differently.
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Molecular Testing Labs is a strong advocate for this type of genetic testing. We are not alone! The U.S. Department of Health and Human
Services (HHS) and the Food and Drug Administration (FDA) have also released directives and drug label warnings in support of genetic
pharmacological testing.
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http://www.fda.gov/drugs/scienceresearch/researchareas/pharmacogenetics/ucm083378.htm
U.S. Government Support of Personalized
Medicine
This Statement was Provided by the U.S. Department of Health and Human Services:
“The Personalized Health Care Initiative will improve the safety, quality and effectiveness of
healthcare for every patient in the U.S. By using ‘genomics,’ or the identification of genes and
how they relate to drug treatment, personalized healthcare will enable medicine to be
tailored to each person’s needs.
“Healthcare that is proactive, instead of reactive, gives the patient the opportunity to become
more involved in their own wellness. The U.S. Department of Health and Human Services
seeks to advance this Initiative through two guiding principles:
• Provide federal leadership supporting research addressing individual aspects of disease
and disease prevention with the ultimate goal of shaping preventive and diagnostic care
to match each person’s unique genetic characteristics.
• Create a ‘network of networks’ to aggregate anonymous healthcare data to help
researchers establish patterns and identify genetic ‘definitions’ to existing diseases.”
Personalized Medicine
Personalized medicine is a medical model that
proposes the customization of healthcare, with
decisions and practices being tailored to the
individual patient by use of genetic or other
information.
Pain Management
CYP450 2C19, 2C9, 2D6, 3A4, 3A5:
Key Factors in Effective Pain Management
Incidence of Pain
• More than 116 million Americans suffer from acute or
chronic pain each year
• More than 2/3 of all emergency room patients are
present for pain management
Condition
No. Sufferers
Source
Chronic Pain
116 million Americans
(>1.5 billion Worldwide)
Institute of Medicine of The
National Academies
Diabetes
25.8 million Americans
American Diabetes Association
Coronary Heart Disease 16.3 million Americans
American Heart Association
Stroke
7.0 million Americans
American Heart Association
Cancer
11.9 million Americans
American Cancer Society
Source: American Academy of Pain Medicine
State of Pain Management
• Drugs are the “first line” of treatment for most forms of
pain.
• Goal of successful pain management is to effectively
control patient pain without causing excess side effects
from the medication prescribed.
• However, only 58% of those who took prescription
medication received any form of pain relief.
• Less than 41% of patients taking over-the-counter pain
medication reported relief.
Source: Peter D. Hart Research Associates – Americans Talk About Pain: Survey Among Adults Nationwide, Aug. 2003
Dosing Management
The incidence of unintentional (and
preventable) overdose- related
deaths is growing exponentially.
Of all drug-related deaths in the U.S.,
43% are due to pain relief
medication.
80% of all pain management drugs
are prescribed by the general
practitioner or the internist
The CYP2D6 gene metabolizes 25% of all prescribed drugs, such as codeine, tricyclic antidepressants (eg,
nortriptyline), SSRI fluvoxamine, SSNRI venlafaxine, classical antipsychotics (eg, haloperidol), and beta-blockers.
Sources: American Academy of Pain Medicine; CDC; IMS Institute of Healthcare Informatics
Analgesic Related Deaths
The rising death toll is attributed to an increased use of a class of
drugs known as Opioid Pain Relievers.
Sources: CDC; IMS Institute of Healthcare Informatics
Opioids 101
Opioids are a class of narcotic analgesics used to control pain
sensations. These drugs are often indicated for the relief of
chronic, and moderate to severe post-surgical pain, in addition to
recovering cancer patients.
Commonly encountered members of this class include:
• Hydrocodone
• Codeine
• Oxycodone
• Morphine
FACT: Hydrocodone was the most frequently prescribed drug in
the U.S. in 2010, with 131.9 million prescriptions
Sources: IMS Institute of Healthcare Informatics
Opioids – Symptoms
Common side effects and symptoms of opioid toxicity include:
• Dizziness
• Nausea
• Vomiting
• Physical Dependence
• Tolerance
• Sedation/Drowsiness
• Weakness
• Respiratory Depression
Prolonged duration of these symptoms will lead to addiction,
overdose, and death.
Potential Causes
Doctors know approximately 50% of all patients undergoing
pain management will not receive adequate relief at first
dosing and/or are at a higher risk of experiencing adverse,
potentially life threatening events.
Explanations:
• Under/over dosing
• Drug interactions
• Genetic variations
– CYP450 2C19, 2C9, 2D6, 3A4, 3A5
CYP2D6 and 3A4
CYP2D6 and CYP3A4 involvement in the primary oxidative
metabolism of hydrocodone by human liver microsomes.
Hutchinson, et al. – Brit J Clin Pharm, Sep. 2003
Objective: To identify the CYP450 enzymes involved in the
metabolism of hydrocodone to its active metabolites hydromorphone
and norhydrocodone
Conclusions:
• CYP2D6 is almost exclusively responsible for the formation of
hydromorphone.
– CYP2D6 Poor Metabolizers formed significantly less hydromorphone than
Extensive Metabolizers (~1% of normal).
• CYP3A4 is mainly responsible for the formation of
norhydrocodone.
Role of CYP2D6 in Opioids
Utilization of Pharmacogenomics and Therapeutic Drug Monitoring
for Opioid Pain Management
Jannetto, et al. – Pharmacogenomics, Oct. 2009
Objective: To determine whether there is a relation between patient
CYP2D6 genotype and observed response to opioid based analgesic
therapy.
Conclusions:
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54% of the study population were CYP2D6 extensive metabolizers; 41% were intermediate
metabolizers; and 5% were poor metabolizers.
80% of patients exhibiting adverse drug events from opioid therapy had impaired CYP2D6
function (remainder 20% of ADEs were attributed to other drug-drug interactions).
A relationship exists between CYP2D6 genotype and observed opioid pain management
outcomes. Genotyping information for patient CPY2D6 status will enhance analgesic
therapy.
Impact of Combined
Enzyme Inhibition
Effect of inhibition of CYP450 enzymes 2D6 and 3A4 on the pharmacokinetics of
intravenous oxycodone: a randomized, three phase, cross-over, placebocontrolled study
Gronlund, et al. – Clin Drug Investig, Mar. 2011
Objective: To determine whether the inhibition of CYP2D6 alone or along with
CYP3A4 would alter the metabolism of oxycodone.
Conclusions:
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Inhibition of just the CYP2D6 enzyme did not yield any significant change to the plasma
concentration of oxycodone.
However, inhibition of both CYP2D6 and CYP3A4 increased the half-life of oxycodone from 3.8
hrs to 6.6 hrs and increased exposure to the drug 2-fold.
While isolated enzyme function inhibition is insignificant, the combined effect of nonfunctional CYP2D6 and CYP3A4 substantially increases exposure to intravenous oxycodone.
The presence of this mutation, by increasing the half-life of the active drug, clues the provider
he/she should decrease the dose, extend the time between doses, or both when prescribing
this drug, or choose a different drug altogether.
Utility of CYP3A4 & 3A5
Genotyping
Pharmacogenomics as Molecular Autopsy for Forensic Toxicology: Genotyping
Cytochrome P450 3A4* 1B and 3A5* 3 for 25 Fentanyl Cases
Jin, et al. – J Anal Toxicol, Oct. 2005
Objective: To identify the role of CYP3A4 and 3A5 in cases of fatal overdosing of
the opioid, fentanyl.
Conclusions:
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6% of the study cases had the CYP3A4*1B mutation; 92% had the CYP3A5*3 mutation.
Subjects with these mutations had significantly lower concentrations of the opioid
fentanyl than wild type subjects (1.4 ug/L vs. 7.3 ug/L).
Homozygous CYP3A5*3 mutation severely impairs opioid metabolism.
Genotyping of both CYP3A4*1B and CYP3A5*3 can help certify and prevent fentanyl
toxicity.
The presence of this mutation, by increasing the half-life of the active drug, clues the
provider he/she should decrease the dose, extend the time between doses, or both
when prescribing this drug, or choose a different drug altogether.
FDA Relabels Opioids
The FDA had relabeled several prominent opioids to include
pertinent pharmacogenomics information.
Example: OxyContin:
(From OxyContin Package Insert)
Inhibitors of CYP3A4:
Since the CYP3A4 isoenzyme plays a major role in the metabolism of oxycodone, coadministration of drugs that inhibit CYP3A4 activity… may cause decreased clearance of
oxycodone which could lead to an increase in oxycodone plasma concentrations.
Inducers of CYP3A4:
CYP450 inducers… may induce the metabolism of oxycodone and, therefore, may cause
increased clearance of the drug, which could lead to a decrease in oxycodone plasma
concentrations, lack of efficacy, or, possibly, development of abstinence syndrome in a
patient who had developed physical dependence to oxycodone.
Economics of Testing
116 million
people suffering
from pain each
year in U.S.1
X
$250-$500 per
patient for
adverse event
prevention
testing2
=
$29-$58 billion in
total testing
costs each year
in U.S.
The U.S. Government understands the cost of molecular
pharmacological testing and fully reimburses the cost of these tests
through Medicare. The superordinate goal is to save monies on the
overall cost of the treatment by mitigating the cost consequences of
inappropriate dosing and use of pain management drugs.
Source: 1: INMAR: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, 2011;
2: Castro, et. al. “Pharmacogenomics in the Clinic”, American Society of Clinical Oncology, Journal of Oncology Practice, 2006
Dosing Guidelines from
the CPIC
Clinical Pharmacogenetics Implementation Consortium Guidelines
for Codeine Therapy in Context of CYP450 2D6 Genotype
Implications for Codeine
Metabolism
Recommendations for Codeine
Therapy
Ultra rapid metabolizer
Increased formation of
morphine following codeine
administration, leading to
higher risk of toxicity
Avoid codeine use due to potential for
toxicity. Consider alternative analgesics such
as morphine or a nonopioid. Consider
avoiding tramadol.
Extensive metabolizer
Normal morphine formation
15–60 mg every 4 hr as needed for pain (label
recommendation)
Intermediate metabolizer
Reduced morphine formation
Begin with 15–60 mg every 4 hr as needed for
pain. If no response, consider alternative
analgesics such as morphine or a nonopioid.
Monitor tramadol use for response.
Poor metabolizer
Greatly reduced morphine
formation following codeine
administration, leading to
insufficient pain relief
Avoid codeine use due to lack of
efficacy. Consider alternative analgesics such
as morphine or a nonopioid. Consider
avoiding tramadol.
Phenotype
Metabolism of Common
Opioids
Class
Opium alkaloids
Drug
Codeine
Metabolism
10% CYP3A4 (to norcodeine); 5% CYP2D6 (to morphine); 80% UGT2B7
Hydrocodone
CYP2D6 (to hydromorphone) and CYP3A4 (to norhydrocodone); other
minor non-CYP oxidative enzymes; UGTs (CYP-metabolized products)
Oxycodone
CYP2D6 (to oxymorphone) and CYP3A4 (to noroxycodone); CYPmetabolized product(s) by UGTs
Dihydrocodeine
5%-10% CYP2D6 (to dihydromorphine) and CYP3A4 (to
nordihydrocodeine); 85% UGT2B7
Hydromorphone
Hepatic glucuronide conjugation via UGT1A3, UGT2B7;
dihydromorphinone ketone reductase
Phenylheptylamine
Methadone
N-demethylation by CYP3A4
Oripavine derivatives
Buprenorphine
CYP3A4 (65%), CYP2C8 (30%), CYP3A5, CYP3A7, CYP2C9, CYP2C19, and
CYP2C18; CYP-metabolized product(s) further cleared by UGTs
Phenylpiperidines
Fentanyl
Meperidine
Sufentanil
Loperamide
Propoxyphene
N-dealkylation by CYP3A4
CYP3A4, CYP2B6, and CYP2C19
N-dealkylation by CYP3A4
N-demethylation by CYP2B6, CYP2C8, CYP2D6, and CYP3A4
N-demethylation by CYP3A4
Semisynthetic
derivatives
Diphenylpropylamine
derivatives
Source: Kadiev E, Patel V, Rad P, et al. Role of pharmacogenetics in variable response to drugs: focus on opioids. Expert Opin Drug Metab Toxicol. 2008;4(1):77-91
Our Summary
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43% of drug-related deaths in the U.S. are related to pain medication.
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The FDA has issued numerous bulletins and updates to product labels informing
clinicians and the public of these dangers, and how they can be assessed with
genetic testing.
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Dosing algorithms are/soon will be updated to account for genetic guidance.
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A percentage of deaths from opioid abuse is attributable to outright addiction and
abuse, and not directly related to genetically predictable adverse reactions to the
drug. However, Molecular Testing Labs notes a possible correlation between the
individuals addicted to opioids and their genetic susceptibility to their effects.
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The goal of Molecular Testing Labs is to provide physicians and their patients with
insight into their unique response to pain medications in order to decrease the
number of adverse reactions and to better manage their pain medication strategy.
Cardiac Molecular Tests
CYP2C19 and its Relationship to the Cardiac Response
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CYP450 includes a gene (CYP2C19) that codes for numerous liver enzymes involved in the metabolism of toxins,
metabolic intermediates, lipids, sterols and xenobiotic substances such as drugs. These enzymes account for 75% of
the metabolic processes involved in the metabolism and bioactivation of all drugs.
Approximately 15% of all prescribed drugs, including clopidogrel (Plavix), propafenone, omeprazole, sertraline,
citalopram, and diazepam are affected by base pair substitutions in this gene. These mutations affect the speed and
ability of the body to metabolize and utilize these drugs. Detecting these genetic variations helps clinicians predict
how a patient will respond to these types of drugs.
Clopidogrel (Plavix) is a common anticoagulant used to prevent and treat blood clots. Clopidogrel is absorbed in the
intestines and converted into its active form by enzymes in the liver. Genetic studies indicate that some people have
genetic variations that reduce the activity of these critical enzymes. Patients who need clopidogrel but have these
variations are at increased risk of heart attacks, strokes and death from cardiovascular causes compared to those
whose genetic makeup enables them to normally metabolize the drug.
Five phenotypes are identified when using the 2C19 genetic test from Molecular Testing Labs: normal metabolizers
(NM), poor metabolizers (PM), intermediate metabolizers (IM), rapid metabolizers (RM) and ultra rapid metabolizers
(URM).
Patients with reduced function alleles have ~3.5x greater risk for major adverse cardiovascular events – with the
greatest risk for poor metabolizers of CYP2C19.1
People of African and Asian ancestry have a greatly increased prevalence of Poor Metabolizer status of CYP2C19.2
Source: 1 Tabassome Simon, MD Genetic Determinents to Response and Cardiovaascular Events ( English Journal of Medicine 2011 p.300-365 ) 2.Hansten PO ( The top 100
Drug Interactions ) H&H Publicatins 2011
Cardiac Molecular Tests
Factor II and its Relationship to Cardiac Events
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The prothrombin gene G20210A mutation differs from the gene for normal prothrombin
or factor II by a single nucleotide. This point mutation causes the body to produce excess
amounts of prothrombin.
– In individuals with the prothrombin gene mutation, prothrombin levels are higher,
which in turn contributes to the formation of blood clots.
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Individuals who have inherited one copy of the gene mutation (heterozygotes) have a
risk of DVT or PE similar to the risk of individuals who have inherited one copy of the
factor V Leiden gene.
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Individuals who have inherited:
1) two copies of the prothrombin gene mutation (homozygotes), or
2) individuals who have inherited one copy of the prothrombin gene mutation and one
copy of the factor V Leiden (compound heterozygotes) . . .
. . . have a risk of DVT or PE similar to the risk of individuals who have inherited two
copies of the factor V Leiden gene.
Cardiac Molecular Tests
Factor II and its Relationship to Cardiac Events
• The increased risk of venous thrombosis in patients who are
heterozygous for the prothrombin gene polymorphosis is 3X greater
than normal.
• Patients with a previous or current thrombotic event that have the
prothrombin gene polymorphism are at increased risk for a
reoccurence.
Cardiac Molecular Tests
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Factor V and its Relationship to Cardiac Events
Factor V is the most common variant associated with inherited
thrombosis.
Has a high prevalence in the U.S. population (4% - 6% and accounts
for 85% - 95% of activate protein C resistance cases (APCR).
Enhanced risk of venous thrombosis in the presence of the Factor V
variant, with odds of 3% – 8% in heterozygotes and 30% – 40% in
homozygotes.
The risk of thrombosis is greatly increased for patients with
multiple genetic risk factors.
Molecular Testing Labs recommends that the Factor II and Factor
V genetic tests are completed in conjunction with the 2C19 genetic
test.
MTHFR
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MTHFR is an abbreviation for the gene that codes for an enzyme called methyltetrahydrofolate reductase. The
MTHFR enzyme helps the body to manufacture proteins. Two mutations are the most studied: 677 and 1298,
although there are more than 50 known MTHFR variants.
Mutations in the 677T variant is associated with thromboembolic and cardiovascular disease, which can lead to
blood clots, strokes, embolisms, and heart attacks.
Mutations in the 1298C variant are associated with a number of chronic diseases, including fibromyalgia, irritable
bowel syndrome, migraines, and other conditions.
Approximately 30%-40% of the population carries a mutation at position C677T, and 20% of the population carries
a mutation at position C1298T. Individuals with these mutations are at increased risk for thromboembolic and
cardiovascular disease. They are also linked with recurrent miscarriages and neutral tube defects (NTD) in the
children of the women carrying the mutations.
Neural tube defects are common birth defects that result in incomplete development of the spinal cord or brain.
The most common NTDs are anencephaly and spina bifida. Anencephaly results in major portions of the brain and
skull not developing. Spina bifida results in incomplete development of the spine, which causes the spinal cord and
the meninges to poke out of the child’s back.
At least 40 of the MTHFR gene mutations result in elevated levels of homocysteine in the blood (homocystinuria).
Homocystinuria is linked to a wide range of disorders, including nearsightedness, osteoporosis, failure to thrive,
seizures, megaloblastic anemia and movement disorders.
Individuals with both mutations, 677T/1298C are more prone to fibromyalgia, IBS, migraine, and autism. Studies
have found that 98% of autistic children have an MTHFR abnormality.
MTHFR
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Molecular Testing Labs considers the MTHFR genetic test one of the most important to your health. MTHFR is involved in processing
folic acid. Small changes in this chemical process can be associated with any one of the following conditions:
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• Depression
• Anxiety
• Chronic pain
• Chronic fatigue
• Nerve pain
• Migraines
• Elevated homocysteine levels
• Fibromyalgia
• Irritable Bowel Syndrome
• Alzheimer’s
• Bipolar disorder
• Schizophrenia
• Parkinson’s
• Stroke
• Heart Disease
• Multiple miscarriages
• Stillbirths, as well as other congenital anomalies (birth defects)
• Down syndrome
• Autism
Infectious Diseases - HPV
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Molecular Testing Labs provides a test for Human Papillomavirus (HPV) that detects the presence of
thirteen (13) high-risk HPV types (Types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68) and two
low risk types (Types 6 and 11). The test also identifies high-risk HPV types by specific types (Types 16,
18, 31, 33 and 45).
HPV is the most common sexually transmitted virus in the U.S. and is associated with several types of
cancer: cervical, vulvar, vaginal, penile, anal and oropharyngeal.
– Almost every sexually active person will acquire HPV at some point in their lives.
– Each year over 21,000 HPV associated cancers are diagnosed in women.
– Each year over 12,000 HPV associated cancers are diagnosed in men.
High-risk HPV infection accounts for approximately 5% of all cancers worldwide.
Persistent HPV infection can result in precancerous cervical lesions as well as invasive cervical and/or
head and neck cancers. With regular HPV Molecular screening and appropriate follow-up, most
cancer precursors can be identified and treated to interrupt progression to invasive disease.
Some clinicians recommend that women who are non-symptomatic have an HPV Molecular Screening
test as part of their vaginal birth discussion.
Molecular Testing Labs provides HPV screening through a buccal swab technique in the cheek or by
a cervical sample in conjunction with cytology.
MOLECULAR TESTING
LABS
Helping You Help Yourself
Our facility is located in Vancouver, Washington.
For more information, visit our website:
WWW.MOLECULARTESTINGLABS.COM