Polygenic risk scores in pharmacogenomics: methodological challenges, current applications, and perspectives for clinical implementation.

Abstract

Inter-individual variability in drug response remains a major challenge in clinical pharmacology. While clinical pharmacogenetics is largely based on actionable single-gene variants, increasing GWAS evidence indicates that many drug-response phenotypes are polygenic. Polygenic risk scores (PRS) offer a framework to capture cumulative effects across pharmacokinetic, pharmacodynamic, and disease-related pathways, enabeling probabilistic risk stratification beyond monogenic models. This review summarizes the current status of PRS in pharmacogenomics (PGx-PRS), highlighting key challenges including limited sample sizes of drug-exposed cohorts, heterogeneous phenotype definitions, ancestry-related portability issues, and incomplete representation of complex pharmacogenes such as CPY2D6. Current applications are discussed across cardiovascular, psychiatric, and oncological settings, where PRS show emerging potential for benefit-risk stratification but remain insufficiently validated for routine care. Clinical implementation will require standardized methodologies multi-ancestry validation, integration with rare-high impact ADME (Absorption, Distribution, Metabolism, and Excretion) variants, and clearer regulatory pathways. With these advances, PGx-PRS may become clinically relevant tools for precision prescribing and drug development.