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Mendelian randomization (MR) is a framework to estimate the causal effect of a modifiable health exposure, drug target or pharmaceutical intervention on a downstream outcome by using genetic variants as instrumental variables. A crucial assumption allowing estimation of the average causal effect in MR, termed homogeneity, is that the causal effect does not vary across levels of any instrument used in the analysis. In contrast, the science of pharmacogenetics seeks to actively uncover and exploit genetically driven effect heterogeneity for the purposes of precision medicine. In this study, we consider a recently proposed method for performing pharmacogenetic analysis on observational data-the Triangulation WIthin a STudy (TWIST) framework-and explore how it can be combined with traditional MR approaches to properly characterise average causal effects and genetically driven effect heterogeneity. We propose two new methods which not only estimate the genetically driven effect heterogeneity but also enable the estimation of a causal effect in the genetic group with and without the risk allele separately. Both methods utilise homogeneity-respecting and homogeneity-violating genetic variants and rely on a different set of assumptions. Using data from the ALSPAC study, we apply our new methods to estimate the causal effect of smoking before and during pregnancy on offspring birth weight in mothers whose genetics mean they find it (relatively) easier or harder to quit smoking., (© 2024 The Author(s). Genetic Epidemiology published by Wiley Periodicals LLC.)

Mendelian randomization (MR) is an epidemiological approach that utilizes genetic variants as instrumental variables to estimate the causal effect of an exposure on a health outcome. This paper investigates an MR scenario in which genetic variants aggregate into clusters that identify heterogeneous causal effects. Such variant clusters are likely to emerge if they affect the exposure and outcome via distinct biological pathways. In the multi-outcome MR framework, where a shared exposure causally impacts several disease outcomes simultaneously, these variant clusters can provide insights into the common disease-causing mechanisms underpinning the co-occurrence of multiple long-term conditions, a phenomenon known as multimorbidity. To identify such variant clusters, we adapt the general method of agglomerative hierarchical clustering to multi-sample summary-data MR setup, enabling cluster detection based on variant-specific ratio estimates. Particularly, we tailor the method for multi-outcome MR to aid in elucidating the causal pathways through which a common risk factor contributes to multiple morbidities. We show in simulations that our "MR-AHC" method detects clusters with high accuracy, outperforming the existing methods. We apply the method to investigate the causal effects of high body fat percentage on type 2 diabetes and osteoarthritis, uncovering interconnected cellular processes underlying this multimorbid disease pair., (© 2024 The Author(s). Genetic Epidemiology published by Wiley Periodicals LLC.)