23andMe Personal Genome Service (PGS) Pharmacogenetic Reports

K193492 · 23AndMe, Inc. · QDJ · Aug 17, 2020 · Medical Genetics

Device Facts

• Record ID: K193492
• Device Name: 23andMe Personal Genome Service (PGS) Pharmacogenetic Reports
• Applicant: 23AndMe, Inc.
• Product Code: QDJ · Medical Genetics
• Decision Date: Aug 17, 2020
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 862.3364
• Device Class: Class 2
• Attributes: Software as a Medical Device

Indications for Use

The 23andMe Personal Genome Service (PGS) is a qualitative genotyping assessment system applied to genomic DNA isolated from human saliva collected using the Oragene Dx OGD-500.001 to simultaneously detect, report, and interpret genetic variants in a broad multigene test. The assessment system is intended to enable users to access information about their genetics that could aid discussions with a healthcare professional. The 23andMe Pharmacogenetic Reports are indicated for reporting of the following variants: [Table of variants for CYP2C19, CYP2C9, CYP3A5, UGT1A1, DPYD, TPMT, SLCO1B1, CYP2D6]. This report is for over-the-counter use by adults over the age of 18 and provides genetic information to inform discussions with a healthcare professional about metabolism of therapeutics. The 23andMe Personal Genome Service pharmacogenetic reports for CYP2C9, CYP3A5, UGT1A1, DPYD, TPMT, SLCO1B1 and CYP2D6 describe if a person has variants associated with metabolism of some therapeutics, but does not describe if a person will or will not respond to a particular therapeutic, and does not describe the association between detected variants and any specific therapeutic. 23andMe Personal Genome Service pharmacogenetic reports for CYP2C19 describes if a person has variants associated with metabolism of some therapeutics and provides interpretive drug information regarding the potential effect of the identified metabolizer phenotype on citalopram and clopidogrel therapy. The PGS Pharmacogenetic Reports are not a substitute for visits to a healthcare professional. The information provided by this report should not be used to start, stop, or change any course of treatment.

Device Story

Direct-to-consumer, over-the-counter DNA testing service; utilizes Oragene-Dx saliva collection kit; samples processed at CLIA-certified labs. Input: genomic DNA from saliva. Process: multiplex genotyping beadchip assay (Illumina Infinium HTS) detecting >500,000 variants; proprietary software analyzes raw scan data to determine genotypes; integrates results into pre-defined report templates. Output: personalized reports detailing detected variants, predicted metabolic function, and interpretive drug information for citalopram and clopidogrel (CYP2C19). Used by consumers to inform discussions with healthcare professionals; does not diagnose conditions or predict drug response. Benefits: provides genetic insights for medication metabolism discussions; removes requirement for independent confirmatory testing for most CYP2C19 results (except *3/*17 genotype).

Clinical Evidence

No clinical trials performed. Analytical validation provided via method comparison against bidirectional Sanger sequencing (reference method) using customer biobank samples. Studies evaluated PPA and NPA for CYP2C19 *2, *3, and *17 variants. Combined results across two studies (n=652) showed 100% PPA and 100% NPA for all variants. Reproducibility studies confirmed performance across sites, operators, and reagent lots. User comprehension study leveraged from predicate (DEN180028).

Technological Characteristics

Qualitative genotyping microarray; Illumina Infinium HTS assay on customized Global Screening Array BeadChip. Silicon wafer/silica bead platform; oligonucleotide capture probes. Energy source: instrumentation for scanning/quantification. Connectivity: cloud-based data transmission to manufacturer for analysis. Software: proprietary genotype calling and reporting algorithms. Sterilization: N/A (collection kit is sterile).

Indications for Use

Indicated for adults >18 years old for qualitative genotyping of specific variants in CYP2C19, CYP2C9, CYP3A5, UGT1A1, DPYD, TPMT, SLCO1B1, and CYP2D6 genes from saliva to inform discussions with healthcare professionals regarding therapeutic metabolism. Not for diagnosing conditions, predicting drug response, or making treatment decisions.

Regulatory Classification

Identification

A pharmacogenetic assessment system is a qualitative in vitro molecular diagnostic system intended to detect nucleic acid variants isolated from human specimens for the purpose of assessing the presence of genetic variants that impact the metabolism, exposure, response, risk of adverse events, dosing, or mechanisms of prescription or over-the-counter medications. The intended use of the device must not include an indication for use in supporting or sustaining human life, being of substantial importance in preventing impairment of human health, or presenting a potential, unreasonable risk of illness or injury.

Special Controls

A pharmacogenetic assessment system must comply with the following special controls:

*Classification.* Class II (special controls). A pharmacogenetic assessment system must comply with the following special controls:(1) Design verification and validation must include: (i) Data appropriate, as determined by FDA, to demonstrate the analytical accuracy and reliability of the device in intended use specimens, including precision, reproducibility, accuracy, limits of detection, and interferences. This information must include: (A) Data demonstrating appropriate, as determined by FDA, reproducibility for each genotype using each claimed sample type. Reproducibility data must be evaluated using specimens collected and processed in a manner consistent with the device's instructions for use, or, as determined by FDA, an appropriate alternative sample panel. (B) Analytical data demonstrating the limits of detection, including the minimum amount of input deoxy-ribonucleic acid (DNA) that will consistently produce accurate results. (C) Data demonstrating no clinically significant effects from endogenous and exogenous interferents relevant to each intended use specimen type. Interference data must also include an assessment of potentially interfering genetic sequences ( *e.g.,* variants proximal to the variant of interest, pseudogenes).(D) Validation data appropriate, as determined by FDA, to support specimen collection and handling claims. (E) Clinical data generated in intended use patient populations demonstrating the pharmacogenetic association between the genetic variant tested and any clinical claims or therapy-related recommendations associated with that genotype. (ii) Results from an appropriate, as determined by FDA, user comprehension study that demonstrate the intended user can use the device safely. The user comprehension study must be designed to include the following: (A) Study participants from a statistically sufficient sample size and a demographically diverse ( *e.g.,* age, education level) population that is representative of the intended use population and naive to use of the device, and(B) An evaluation of all result comprehension concepts that are critical for safe use of the device. (2) The labeling required under § 809.10 of this chapter must include: (i) Clear information, written in language appropriate for the intended user, that describes instructions for how test results should be interpreted. These instructions must be supported by valid scientific evidence and include: (A) Appropriate explanation of the claimed pharmacogenetic associations for all variants included in the test, any relevant variants not included in the test ( *e.g.,* that may contribute to false negative results), and specific considerations by ethnicity, and(B) Appropriate explanation of non-genetic and non-tested genetic factors that may impact interpretation of the test results; (ii) Detailed descriptions of analytical performance including, as applicable, precision, reproducibility, accuracy, limits of detection, and interferences as specified in paragraph (b)(1)(i) of this section, in language appropriate for the intended user; (iii) A warning statement that the patient should not use the test results to stop or change any medication, and that medications should always be taken as prescribed by a healthcare professional; (iv) A limiting statement explaining that this test is not intended to inform the patient about their current state of health, including whether the patient should or should not take a medication, or how much of a medication the patient should take, as appropriate; (v) A warning statement that the test does not diagnose any health conditions and is not a substitute for visits to a doctor or other healthcare professional; and (vi) A prominent and conspicuous limiting statement that the test provides only a preliminary test result that needs to be confirmed using an independent pharmacogenetic test without such a limitation prior to making any medical decisions. Alternatively, appropriate design verification and validation activities, including the generation of robust analytical data demonstrating appropriate analytical accuracy and reliability of test results for each genetic variant included in the test report, must be performed that demonstrate that the test can be used to make well-informed clinical decisions. (3) The test report must include an appropriate description of how the test results should be used by healthcare providers who may receive the test results from their patients, as applicable. (4) Publicly available pre-purchase labeling with unrestricted access that contains the following information must be provided: (i) A clear description of the test and its technology, the genotypes detected, and relevant clinical claims associated with each genotype; (ii) A clear description of what information the test will provide. This includes variant information, the limitations associated with the test, and any precautionary information about the test the user should be aware of before purchase; and (iii) A discussion of answers to frequently asked questions that is sufficient to provide intended users with an appropriate understanding of information specific to each pharmacogenetic association that is claimed. (5) The genetic test must use a sample collection device that is FDA-cleared or -approved, or classified as 510(k) exempt, with an indication for in vitro diagnostic use in DNA testing. (6) The intended use of the device must not include an indication for use in supporting or sustaining human life, being of substantial importance in preventing impairment of human health, or presenting a potential, unreasonable risk of illness or injury.

Predicate Devices

• 23andMe Personal Genome Service (PGS) Pharmacogenetic Reports (DEN180028)

Submission Summary (Full Text)

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FDA U.S. FOOD & DRUG ADMINISTRATION

# 510(k) SUBSTANTIAL EQUIVALENCE DETERMINATION DECISION SUMMARY

ASSAY ONLY

## I Background Information:

A 510(k) Number

K193492

B Applicant

23andMe, Inc.

C Proprietary and Established Names

23andMe Personal Genome Service (PGS) Pharmacogenetic Reports

D Regulatory Information

| Product Code(s) | Classification | Regulation Section | Panel |
| --- | --- | --- | --- |
| QDJ | Class II | 21 CFR 862.3364 - Pharmacogenetic Assessment System | CH - Clinical Chemistry |

## II Submission/Device Overview:

A Purpose for Submission:

Modification of the CYP2C19 report

B Measurand:

Genotype of select alleles in Cytochrome P450 2C19 (CYP2C19), 2C9 (CYP2C9), 2D6 (CYP2D6), 3A5 (CYP3A5), UDP glucuronosyltransferase family member A1 (UGT1A1), dihydropyrimidine dehydrogenase DPYD, thiopurine methyltransferase (TPMT), solute carrier organic anion transporter family member 1B1 (SLCO1B1)

C Type of Test:

Qualitative genotyping microarray

Food and Drug Administration

10903 New Hampshire Avenue

Silver Spring, MD 20993-0002

www.fda.gov

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# III Intended Use/Indications for Use:

## A Intended Use(s):

See Indications for Use below.

## B Indication(s) for Use:

The 23andMe Personal Genome Service (PGS) is a qualitative genotyping assessment system applied to genomic DNA isolated from human saliva collected using the Oragene Dx OGD-500.001 to simultaneously detect, report, and interpret genetic variants in a broad multigene test. The assessment system is intended to enable users to access information about their genetics that could aid discussions with a healthcare professional. The 23andMe Pharmacogenetic Reports are indicated for reporting of the following variants:

| Gene | Variant(s) |
| --- | --- |
| CYP2C19 | *2, *3, *17 |
| CYP2C9 | *2, *3, *5, *6, rs7089580 |
| CYP3A5 | *3 |
| UGT1A1 | *6, *28 |
| DPYD | *2A, rs67376798 |
| TPMT | *2, *3C |
| SLCO1B1 | *5 |
| CYP2D6 | *2, *3, *4, *5, *6, *7, *8, *9, *10, *11, *15, *17, *20, *29, *35, *40, *41 |

This report is for over-the-counter use by adults over the age of 18 and provides genetic information to inform discussions with a healthcare professional about metabolism of therapeutics.

The 23andMe Personal Genome Service pharmacogenetic reports for CYP2C9, CYP3A5, UGT1A1, DPYD, TPMT, SLCO1B1 and CYP2D6 describe if a person has variants associated with metabolism of some therapeutics, but does not describe if a person will or will not respond to a particular therapeutic, and does not describe the association between detected variants and any specific therapeutic.

23andMe Personal Genome Service pharmacogenetic reports for CYP2C19 describes if a person has variants associated with metabolism of some therapeutics and provides interpretive drug information regarding the potential effect of the identified metabolizer phenotype on citalopram and clopidogrel therapy.

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The PGS Pharmacogenetic Reports are not a substitute for visits to a healthcare professional. The information provided by this report should not be used to start, stop, or change any course of treatment.

## C Special Conditions for Use Statement(s):

OTC - Over The Counter

Special Conditions for Use Statements for CYP2C9, CYP3A5, UGT1A1, DPYD, TPMT, SLCO1B1, CYP2D6 reports

- Do not use your results to start, stop or change any course of treatment.
- Results from this test should not be used to make medical decisions. Results should be confirmed by an independent genetic test that is prescribed by your attending physician before taking any medical action.
- This test does not provide information on associations between specific DNA variants and any specific therapeutic.
- This test does not diagnose any health conditions, predict drug response, provide medical advice, or determine whether a medication is indicated for the user.
- This report does not determine if a person will or will not respond to a particular therapeutic.
- This test does not detect all genetic variants related to drug metabolism. The absence of a variant tested does not rule out the presence of other genetic variants that may be related to drug metabolism.
- This test is not a substitute for visits to a healthcare professional. You should consult with a healthcare professional if you have any questions or concerns about your results.
- This test may not be able to determine a result for all variants analyzed.
- Different companies offering genetic testing may be measuring different genetic variants for drug metabolism, so you may get different results from a different test.
- As with every test the possibility for an incorrect result exists. Speak to your personal healthcare professional or a genetic counselor if your results are unexpected.

Special Conditions for Use Statements specific for the CYP2C19 report

- Do not use your results to start, stop or change any course of treatment.
- This test does not diagnose any health conditions, provide medical advice, or determine whether a medication is indicated for the user.
- This test provides interpretive drug information on certain therapeutics.
- This report does not determine if a person will or will not respond to a particular therapeutic.
- This test does not detect all genetic variants related to drug metabolism. The absence of a variant tested does not rule out the presence of other genetic variants that may be related to drug metabolism.
- This test is not a substitute for visits to a healthcare professional. You should consult with a healthcare professional if you have any questions or concerns about your results.
- This test may not be able to determine a result for all variants analyzed.
- This test does not provide interpretive drug information for the CYP2C19 *3/*17 heterozygous genotype. In addition, results for this genotype should be confirmed by an independent genetic test that is prescribed by your attending physician before taking any medical action.
- Different companies offering genetic testing may be measuring different genetic variants for drug metabolism, so you may get different results from a different test.

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- As with every test the possibility for an incorrect result exists. Speak to your personal healthcare professional or a genetic counselor if your results are unexpected.

## D Special Instrument Requirements:

Same as referenced in DEN140044

## IV Device/System Characteristics:

## A Device Description:

The 23andMe PGS is a non-invasive DNA testing service that uses qualitative genotyping. It is a direct-to-consumer, over-the-counter, DNA genetic test. A user's saliva is self-collected using the Oragene-Dx device manufactured by DNA Genotek, Inc. (previously cleared under K141410), which consists of a sealable collection tube containing a stabilizing buffer solution. Once the sample is collected, it is shipped to one of two Clinical Laboratory Improvement Amendments (CLIA)-certified laboratories for testing.

DNA is isolated from the saliva and tested in a multiplex assay using a customized genotyping beadchip, reagents, and instrumentation. The multiplex assay simultaneously tests for more than 500,000 variants, including those for the previously authorized indications, as well as for the indication proposed herein.

The raw data is generated by the scanning instrument's software, and then sent to 23andMe (the Manufacturer). The data are analyzed using the Manufacturer's proprietary software, and a genotype is determined for each tested variant. The results for certain of these variants, as noted in the indications for use, are used to generate personalized reports for users that provide information about the predicted metabolic function of the tested variants. Personalized reports are generated for each user to provide results of the testing performed. These reports tell the user which variant(s) has/have been detected in their sample and provide information on the predicted metabolic function of the specific genetic variants. The genetic variants detected by the test are associated with the metabolism of some therapeutics. If no variant is detected, that information is also provided. If the association between the predicted metabolic function and the combination of detected variants has not been established, the report indicates that the results cannot be determined. The personalized reports are intended to present scientific concepts to users in an easy-to-understand format. The reports provide information about the association between the detected variant and the predicted metabolic function that has been associated with the metabolism of some drugs, further described below. The reports are designed to help users understand the meaning of their results and inform conversations with their doctor or other healthcare professional.

The 23andMe PGS Pharmacogenetic Reports detect 33 variants in 8 genes: CYP2C19, CYP2C9, CYP2D6, CYP3A5, CYP2D6, DPYD, TPMT, and UGT1A1. The 23andMe PGS Pharmacogenetic Reports provide information on the associated enzyme or protein function and the predicted metabolizer phenotype for variants in drug metabolizing enzymes: CYP2C19, CYP2C9, CYP2D6, CYP3A5, CYP2D6, DPYD, TPMT, and UGT1A1. The metabolizer phenotypes and corresponding identification is described in DEN180028.

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In this 510(k), 23andMe submitted additional analytical validation for CYP450 2C9 in saliva samples. This robust analytical data demonstrating appropriate analytical accuracy and reliability was sufficient that the limitation statement regarding independent confirmation of the result required per the Special Control (2)(iv) of 21 CFR 862.3364 was no longer required in the labeling for the CYP2C19 report.

The 23andMe PGS Pharmacogenetics Report for CYP2C19 also includes drug specific test reports for two drugs metabolized by CYP2C19, citalopram and clopidogrel. These test reports may indicate a likely typical response to medication is expected based on the users genotype inferred metabolizer phenotype. Alternatively, the reports may indicate for clopidogrel that the medication is less likely to be effective, based on the users genotype inferred metabolizer phenotype. For citalopram, the test reports may indicate that the user is at increased risk of side effects, based on the users genotype inferred metabolizer phenotype. Other possible outcomes for either test report are that the result cannot be determined or the result cannot be interpreted.

## B Principle of Operation:

The PGS is indicated to be performed using a genotyping BeadChip assay, which covers more than 500,000 genetic markers. The BeadChip consists of silicon wafers etched to form wells loaded with silica beads, on which oligonucleotide capture probes are immobilized. DNA from saliva is fragmented and captured on a bead array by hybridization to immobilized SNP-specific primers, followed by extension with hapten-labeled nucleotides. The primers hybridize adjacent to the SNPs and are extended with a single nucleotide corresponding to the variant allele. The incorporated hapten-modified nucleotides are detected by adding fluorescently labeled antibodies in several steps to amplify the signals. Instrumentation is used for extraction and processing of the DNA, and the BeadChip is used for scanning and quantification of the results. The genotype content is separated, analyzed, and then integrated into pre-defined report templates specific for each condition associated with each genotype. Genotypes are determined using two software packages. For 23andMe PGS Pharmacogenetics Report, the variants detected are:

| Gene | Variants |
| --- | --- |
| CYP2C19 | *2, *3, *17 |
| CYP2C9 | *2, *3, *5, *6, rs7089580 |
| CYP2D6 | *2, *3, *4, *5, *6, *7, *8, *9, *10, *11, *15, *17, *20, *29, *35, *40, *41 |
| CYP3A5 | *3 |
| TPMT | *2, *3C |
| DPYD | *2A, rs67376798 |
| UGT1A | *6, *28 |
| SLCO1B1 | *5 |

## V Substantial Equivalence Information:

## A Predicate Device Name(s):

23andMe Personal Genome Service (PGS) Pharmacogenetic Reports

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B Predicate 510(k) Number(s): DEN180028

C Comparison with Predicate(s): D

| Device & Predicate Device(s): | K193492 | DEN180028 |
| --- | --- | --- |
| Device Trade Name | 23andMe Personal Genome Service (PGS) Pharmacogenetic Reports | 23andMe Personal Genome Service (PGS) Pharmacogenetic Reports |
| General Device Characteristic Similarities | | |
| Intended Use | Provides genetic information to inform discussion with a healthcare professional about metabolism of therapeutics | Same |
| Reagents | Illumina Infinium HTS Assay Reagents (Same reagents, different packaging) | Illumina Infinium HTS Extra Assay Reagents |
| BeadChip | Illumina Global Screening Array customized for the PGS. The chip is designed to detect specific single nucleotide polymorphisms (SNPs) as well as other genetic variants; all markers refer to specific positions in the National Center for Biotechnology Information (NCBI) reference human genome. | Same |
| Sample Matrix | Saliva | Same |

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| Collection kit | Oragene Dx Saliva collection device (OGD-500.001) | Same |
| --- | --- | --- |
| General Device Characteristic Differences | | |
| CYP2C19 Report | Provides interpretive drug information regarding the potential effect of the identified metabolizer phenotype on citalopram and clopidogrel therapy | Does not provide interpretive drug information for any drugs |
| | Does not require confirmatory testing | Confirmatory testing required for all reports |

VI Standards/Guidance Documents Referenced:

None.

VII Performance Characteristics (if/when applicable):

A Analytical Performance:

1. Precision/Reproducibility:

The reproducibility information for this device that was previously described in the Decision Summary for DEN180028 was confirmed with intended use specimens (saliva) Information from a homozygous rare *3/*3 intended use sample was provided in DEN180028. Reproducibility studies were conducted for the three CYP2C19 alleles reported by the 23andMe PGS Pharmacogenetics Report for CYP2C19. The reproducibility studies were designed to determine the imprecision due to assay run, lot, instrument, operator, day and site. Genotypes of the DNA samples were confirmed using bidirectional Sanger sequencing.

The study was performed at two sites across three days using three operator teams at each site. Samples were genotyped in replicates of three using three lots of reagents and three instrument sets. 6 saliva samples were included in this study, in addition to the *3/*3 sample included in DEN180028, covering a representative set of the genotypes detected by the device. Information regarding samples that failed quality control (FQC) was also for the first run was also provided. All FQC replicates were rerun once in one confirmatory run by one operator team, using the corresponding reagent lot from the initial QC failure. All samples produced the correct genotype when rerun. No incorrect calls or no calls were observed in this study.

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Results obtained are summarized below stratified by genotype and site:

CYP2C19*2

| Genotype | Number of samples (81 replicates per sample) | Number of total replicates (including FQCs* and no calls) | Number of Correct Calls | Number of Incorrect Calls | Number of FQCs (First run) | Number of No Calls |
| --- | --- | --- | --- | --- | --- | --- |
| Site 1 | | | | | | |
| Homozygous Common (GG) | 2 | 162 | 147 | 0 | 15 | 0 |
| Heterozygous (AG) | 2 | 162 | 149 | 0 | 13 | 0 |
| Homozygous Rare (AA) | 2 | 162 | 149 | 0 | 13 | 0 |
| Site 2 | | | | | | |
| Homozygous Common (GG) | 2 | 162 | 162 | 0 | 0 | 0 |
| Heterozygous (AG) | 2 | 162 | 162 | 0 | 0 | 0 |
| Homozygous Rare (AA) | 2 | 162 | 162 | 0 | 0 | 0 |

*FQC = Failed quality controls

CYP2C19*3

| Genotype | Number of samples (81 replicates per sample) | Number of total replicates (including FQCs* and no calls) | Number of Correct Calls | Number of Incorrect Calls | Number of FQCs (First run) | Number of No Calls |
| --- | --- | --- | --- | --- | --- | --- |
| Site 1 | | | | | | |
| Homozygous Common (GG) | 2 | 162 | 147 | 0 | 15 | 0 |
| Heterozygous (AG) | | 81 | 74 | 0 | 7 | 0 |
| Site 2 | | | | | | |
| Homozygous Common (GG) | 2 | 162 | 0 | 0 | 0 | 0 |

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| Genotype | Number of samples (81 replicates per sample) | Number of total replicates (including FQCs* and no calls) | Number of Correct Calls | Number of Incorrect Calls | Number of FQCs (First run) | Number of No Calls |
| --- | --- | --- | --- | --- | --- | --- |
| Heterozygous (AG) | 1 | 81 | 0 | 0 | 0 | 0 |

*(results from a saliva sample with the homozygous rare AA genotype can be found in the Decision Summary for DEN180028)

CYP2C19*17

| Genotype | Number of samples (81 replicates per sample) | Number of total replicates (including FQCs* and no calls) | Number of Correct Calls | Number of Incorrect Calls | Number of FQCs (First run) | Number of No Calls |
| --- | --- | --- | --- | --- | --- | --- |
| Site 1 | | | | | | |
| Homozygous Common (CC) | 2 | 162 | 149 | 0 | 13 | 0 |
| Heterozygous (CT) | 1 | 81 | 75 | 0 | 6 | 0 |
| Homozygous Rare (TT) | 2 | 162 | 147 | 0 | 15 | 0 |
| Site 2 | | | | | | |
| Homozygous Common (CC) | 2 | 162 | 162 | 0 | 0 | 0 |
| Heterozygous (CT) | 1 | 81 | 81 | 0 | 0 | 0 |
| Homozygous Rare (TT) | 2 | 162 | 162 | 0 | 0 | 0 |

2. Linearity:

Not applicable.

3. Analytical Specificity/Interference:

Endogenous and Exogenous Substances

A series of studies were conducted to assess the effects of endogenous substances, exogenous substances, microbial substances, and smoking on the 23andMe PGS Test. The results of the endogenous and exogenous interference studies can be found in the Decision Summary for DEN140044.

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Interfering Mutations

Analyses were performed to identify potentially interfering variants within the 50-nucleotide probe-binding regions of the three CYP2C19 variants detected by this test. The results of the analysis for interfering mutations can be found in the Decision Summary for DEN180028.

4. Assay Reportable Range:

Not applicable.

5. Traceability, Stability, Expected Values (Controls, Calibrators, or Methods):

The traceability, stability and expected values for the device were previously reviewed in DEN140044.

6. Limit of Detection:

The Limit of Detection (LoD) study was performed to confirm the lowest concentration of DNA starting from intended use samples that is necessary for successful assignment of the correct CYP2C19*2, *3, and *17 variants using the 23andMe PGS test. Study samples were saliva samples from the sponsor's biobank and included homozygous common, heterozygous common, and homozygous rare genotypes for each allele.

Three replicates of each sample were diluted to three different DNA concentrations (5, 15, and 50 ng/μl) and genotyped by the PGS test in a blinded fashion using 3 lots of reagents. To confirm the genotype call, each sample was sequenced by bidirectional Sanger sequencing. Genotype calls from the PGS test were compared with genotypes from Sanger sequencing to determine the rates of correct genotype calls at each DNA concentration.

This study yielded 100% correct calls per genotype for all samples across all reagent lots, at all sample concentrations tested. Therefore, the LoD is confirmed at the lowest concentration tested (5 ng/μL). The performance requirement for the PGS test, specified in the laboratory standard operating procedures (SOPs), is set at a minimum of 15 ng/μL DNA and maximum of 50 ng/μL DNA.

7. Assay Cut-Off:

Not applicable.

B Comparison Studies:

1. Method Comparison with Predicate Device:

Accuracy was evaluated through calculation of agreement of the genetic variant determinations between the 23andMe PGS test results and Sanger bidirectional sequencing (comparator) results. Saliva samples were randomly selected from the 23andMe customer biobank without prior reference to genotype information. Genotyping results were compared between the PGS test and bidirectional sequencing to calculate positive and negative percent agreement (PPA and NPA)

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with the sequencing results used as the reference. The comparison study results for each allele detected for the CYP2C19 study report are shown below:

CYP2C19 *2

| Genotype | Correct Calls | Incorrect Calls | No Calls | Failed Quality Controls | % PPA | %NPA |
| --- | --- | --- | --- | --- | --- | --- |
| Homozygous Common (GG) | 304 | 0 | 0 | 0 | 100% | 100% |
| Heterozygous (AG) | 118 | 0 | 0 | 0 | 100% | 100% |
| Homozygous Rare (AA) | 10 | 0 | 0 | 0 | 100% | 100% |

CYP2C19 *3

| Genotype | Correct Calls | Incorrect Calls | No Calls | Failed Quality Controls | % PPA | %NPA |
| --- | --- | --- | --- | --- | --- | --- |
| Homozygous Common (GG) | 432 | 0 | 0 | 0 | 100 | 100 |

CYP2C19 *17

| Genotype | Correct Calls | Incorrect Calls | No Calls | | Failed Quality Controls | % PPA | %NPA |
| --- | --- | --- | --- | --- | --- | --- | --- |
| Homozygous Common (CC) | 279 | 0 | 0 | | 0 | 100 | 100 |
| Heterozygous (CT) | 129 | 0 | 0 | | 0 | 100 | 100 |
| Homozygous Rare (TT) | 17 | 0 | 0 | | 0 | 100 | 100 |

In a separate study, samples were selected on the basis of ethnicity to increase the proportion of rare *3 variants in the study population. Samples were not selected on the basis of genotype.

Genotyping results were compared between the PGS test and bidirectional sequencing to calculate percent agreement with the sequencing results used as the reference. The comparison study results for each allele detected for the CYP2C19 study report are shown below:

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CYP2C19 *2

| Genotype | Correct Calls | Incorrect Calls | No Calls | Failed Quality Controls | % PPA | %NPA |
| --- | --- | --- | --- | --- | --- | --- |
| Homozygous Common (GG) | 114 | 0 | 0 | 0 | 100% | 100% |
| Heterozygous (AG) | 91 | 0 | 0 | 0 | 100% | 100% |
| Homozygous Rare (AA) | 24 | 0 | 0 | 0 | 100% | 100% |

CYP2C19 *3

| Genotype | Correct Calls | Incorrect Calls | No Calls | Failed Quality Controls | % PPA | %NPA |
| --- | --- | --- | --- | --- | --- | --- |
| Homozygous Common (GG) | 197 | 0 | 0 | 0 | 100 | 100 |
| Heterozygous (AG) | 31 | 0 | 0 | 0 | 100 | 100 |
| Homozygous Rare (AA) | 3 | 0 | 0 | 0 | 100 | 100 |

*CYP2C19 *17

| Genotype | Correct Calls | Incorrect Calls | No Calls | Failed Quality Controls | % PPA | %NPA |
| --- | --- | --- | --- | --- | --- | --- |
| Homozygous Common (CC) | 228 | 0 | 0 | 0 | 100 | 100 |
| Heterozygous (CT) | 2 | 0 | 0 | 0 | 100 | 100 |

Combined results:

CYP2C19 *2

| Total *2 calls | Total *2 correct calls | Total *2 Incorrect calls | PPA (%) | NPA (%) | 95% CI (%) |
| --- | --- | --- | --- | --- | --- |
| Study 1 | 432 | 0 | 100 | 100 | 99.2-100% |
| Study 2 | 229 | 0 | 100 | 100 | 98.4-100% |
| Combined | 661 | 0 | 100 | 100 | 99.4-100% |

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CYP2C19 *3

| Total *3 calls | Total *3 correct calls | Total *3 Incorrect calls | PPA (%) | NPA (%) | 95% CI(%) |
| --- | --- | --- | --- | --- | --- |
| Study 1 | 432 | 0 | 100 | 100 | 99.2-100 |
| Study 2 | 231 | 0 | 100 | 100 | 98.4-100 |
| Combined | 663 | 0 | 100 | 100 | 99.5-100 |

CYP2C19 *17

| Total *17 calls | Total *17 correct calls | Total *17 Incorrect calls | PPA (%) | NPA (%) | 95% CI (%) |
| --- | --- | --- | --- | --- | --- |
| Study 1 | 425 | 0 | 100 | 100 | 99.1-100 |
| Study 2 | 230 | 0 | 100 | 100 | 98.4-100 |
| Combined | 655 | 0 | 100 | 100 | 99.4-100 |

The combined information across both studies is presented in the following table by diplotype:

| Diplotype | Study 1 | Study 2 | Total Results (2 Studies combined) | |
| --- | --- | --- | --- | --- |
| | n | n | n | 95% Lower Confidence Interval |
| *1/*1 | 177 | 89 | 266 | 98.6 |
| *1/*2 | 93 | 79 | 172 | 97.9 |
| *1/*3 | 0 | 20 | 20 | 83.2 |
| *1/*17 | 104 | 2 | 106 | 96.6 |
| *2/*2 | 9 | 24 | 33 | 89.4 |
| *2/*3 | 0 | 11 | 11 | 71.5 |
| *2/*17 | 24 | 0 | 24 | 85.8 |
| *3/*3 | 0 | 3 | 3 | 29.2 |
| *17/*17 | 17 | 0 | 17 | 80.5 |
| Total calls | 424 | 228 | 652 | 99.4 |

Confirmatory testing failed to provide a result for one or more positions for 15 samples across the two studies, leading to an incomplete genotype for these samples. The calls for individual SNPs which could be confirmed for these samples are included in the tables provided for *2, *3 and *17 accuracy, however only those samples with full genotyping information are included in the 652 correct genotypes included diplotype accuracy table above.

The additional analytical information described above is sufficient to remove the residual uncertainty about the analytical results of this test. Therefore, the test reports will no longer include the statement described in DEN180028:

"Results from this test should not be used to make medical decisions. Results should be confirmed in a clinical setting with independent genetic testing before taking any medical action."

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Since no information for the *3/*17 genotype was included in either of the two studies described above, the sponsor will not return interpretive information for this genotype and this report will continue to include a limitation that results for this genotype should be confirmed by an independent genetic test before taking any medical action.

2. **Matrix Comparison:**
Not applicable.

C **Clinical Studies:**

1. **Clinical Sensitivity:**
Not applicable.

2. **Clinical Specificity:**
Not applicable.

3. **Other Clinical Supportive Data (When 1. and 2. Are Not Applicable):**

i. **Potential effect of genetic result on clopidogrel and citalopram therapy:** The impact of protein or enzyme function for each allele and the predicted metabolizer phenotypes were previously identified from data in the literature for each allele for each gene. The potential effect of lack of effect of each of the predicted metabolizer phenotypes on clopidogrel and citalopram therapy were identified from data in the literature.

ii. **User Comprehension Study:** The user comprehension study previously described for DEN180028 was leveraged to support the test reports in k193492. Information regarding the user comprehension testing can be found in the Decision Summary for DEN180028.

In addition to supportive user comprehension testing, prior to opening a drug specific test reports, the user must actively agree to the following statements:

“I understand that my medications should always be taken as directed by my healthcare professional.

I will NOT use my results to start, stop, or change any medication on my own.”

D **Clinical Cut-Off:**

Not applicable.

E **Expected Values/Reference Range:**

The package insert and user test reports include allele frequencies from 23andMe customers. The package insert for each test report indicated that the allele frequencies provided are from the

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23andMe customer database and may not be representative of the actual allele frequencies in the presented populations. The following allele frequencies will be provided in the CYP2C19 package insert and user test report:

| Ethnicity | *2 | *3 | *17 |
| --- | --- | --- | --- |
| European | 14.62% | 0.02% | 21.76% |
| African American | 17.34% | 0.11% | 21.78% |
| Ashkenazi Jewish | 13.27% | <0.01% | 21.57% |
| East Asian | 30.65% | 6.50% | 0.86% |
| Hispanic/Latino | 13.24% | 0.14% | 16.30% |
| South Asian | 33.62% | 0.34% | 16.96% |
| Middle Eastern | 11.19% | 0.12% | 21.18% |
| Other | 18.71% | 1.77% | 16.24% |

## VIII Proposed Labeling:

The labeling supports the finding of substantial equivalence for this device.

## IX Conclusion:

The submitted information in this premarket notification is complete and supports a substantial equivalence decision.

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