NICE launches second consultation on genetic testing to guide treatment after a stroke
People could be offered a genetic test in the immediate period after having a stroke to help identify the most suitable treatment to reduce their risk of further strokes.
A second consultation on recommendations that clinicians should offer CYP2C19 genotype testing when considering treatment with clopidogrel after an ischaemic stroke or Transient Ischaemic Attack (a “mini stroke”) has begun today, Wednesday 3 April 2024.
NICE currently recommends clopidogrel as a treatment option for people at risk of a secondary stroke. For some people with certain variations in a gene called CYP2C19 other treatments could work better. The genotype test would identify people who have the gene variants so they can be offered an alternative treatment.
The draft guidance recommends testing only for people who have very recently had a stroke or TIA. This is because the risk of another event is higher at this time and therefore so is the potential benefit of testing. As the risk of a recurrent stroke or a “mini stroke” reduces over time, so does the benefit of testing.
For this reason, those people already taking clopidogrel will not be offered retrospective testing.
People who are currently taking clopidogrel should continue with the treatment until they and their NHS clinician consider it appropriate to stop.
Laboratory-based CYP2C19 genotype testing was the committee’s preferred option followed by the Genedrive CYP2C19 ID Kit point-of-care test. If neither of the first two options are available, the Genomadix Cube point-of-care test can be used.
The NICE committee suggested that a phased rollout could be used when introducing laboratory-based testing with testing initially offered to people with a higher risk of stroke recurrence who would benefit most from it, such as people who have had a non-minor stroke. The committee recognised that it will take time to build up the testing capacity as no testing is currently undertaken to find out if clopidogrel is a suitable treatment.
Around 35,850 people in England, Wales and Northern Ireland have a non-minor stroke each year.
An estimated 32% of people in the UK have at least one of the highlighted CYP2C19 gene variants. They are more common in people with an Asian family background but can be found in people of any ethnicity. Evidence has suggested that people with these variants have an increased risk of another stroke when taking clopidogrel compared to those without them.
If the test discovers they have one of the CYP2C19 gene variants, the person can be treated with another medicine to prevent future strokes.
Around 11 million items of clopidogrel are dispensed each year at a cost of around £16 million to the NHS.