Precision Medicine, Made for Pharmacists

AACP Article

No more one-size-fits-all drugs. As genetic screening becomes more affordable and pharmacogenetic research diversifies, pharmacists look to implement the therapeutic benefits.

By Athena Ponushis

The promise of personalized medicine paints a utopia, where scientists would understand the genetic variations responsible for diseases and be able to prescribe drugs aimed at those genes. Medical records would contain information unique to patients’ genomes—genetic features that may predispose them to disease, variations that might predict a drug or dosing response—along with environmental and lifestyle factors, such as poverty or diet. All this data would be in the face of a provider, at the moment of prescribing, to tailor treatments for better patient outcomes.

Such a visionary tomorrow leaves much work for today. Pharmacogenetic research needs to be diversified, to improve drug response and decrease drug toxicity for all people, not just those of European descent. And the medical community must keep an open mind—precision medicine does not have to save the market a lot of money to be of good value.

As the cost of genetic testing goes down, it may make good economic sense for a consumer to have a genetic test (the amount of health you’re buying for the amount of money you’re spending falls in line with what’s considered good value), making widespread implementation of precision medicine potentially feasible in 10 years.

Therein lies a call to pharmacists and schools of pharmacy, to increase pharmacogenetic research and education. “I really think pharmacogenomics is going to be the expertise of the pharmacists,” said Dr. Erica Woodahl, associate professor at the University of Montana. “Pharmacists know the most about drugs and their usage, so it makes perfect sense for this to fall within a pharmacist’s job. As we move toward implementation, hopefully we’ll have a model where most hospitals have a clinical pharmacist who has specific training in pharmacogenomics to review the records and offer consultations to providers, to really facilitate the pharmacogenetics of personalized medicine.”

Diversifying the Research

For more than a decade, Woodahl has been working with the Confederated Salish and Kootenai Tribes living on the Flathead Reservation in Montana. Precision medicine is most commonly used in large, urban centers, in academic medical hospital settings, which led to the genesis of Woodahl’s project: “If we are going to implement pharmacogenetics, but all the relevant research is based on people of European descent, how can we be confident those genetic tests are going to be applicable to populations where we have no information?”

Woodahl’s work includes the characterization of genetic variation and environmental factors that predict drug response and toxicity within the indigenous community. Woodahl and her research partners recently earned a $2.1 million grant from the National Institutes of Health to study precision medicine to help American Indian and Alaska Native people. The project will address how precision medicine research may benefit tribal people and align with tribal health priorities, as well as address the issue of data stewardship to support the participation of tribal communities in research.

Before they began their work, Woodahl and her colleagues made sure they had the consent of the community—partnering with the tribal health department, presenting to tribal council, forming a community advisory board, holding genetic education workshops. “I tell the community that we are using their genetic information to target drug delivery and drug dosage, so hopefully we can get the prescription right sooner so that they can feel better,” Woodahl said. “My long-term goal is to move the relevant data we discover into the clinics, to help implement pharmacogenetics in a tribal health setting, with information specific to the people here.”

She hopes her work will encourage other pharmacists to think about strategies to diversify their work, “to make sure we have diversity in pharmacogenetics research studies, so we can be more inclusive as we move toward implementation.”

Dr. Erica Woodahl“Hopefully we’ll have a model where most hospitals have a clinical pharmacist who has specific training in pharmacogenomics to review the records and offer consultations to providers, to really facilitate the pharmacogenetics of personalized medicine.”

Dr. Erica Woodahl

Putting Savings in Perspective

Dr. David Veenstra does not see any obvious cost savings to the larger healthcare marketplace from personalized medicine. Veenstra, professor, Comparative Health Outcomes, Policy & Economics (CHOICE) Institute at the University of Washington, studies the clinical, economic and policy implications of using genomic information in healthcare. “The expectation on precision medicine to save money overall, it’s unusual, it’s exceptionalism,” Veenstra said. “This technology should be viewed and approached just like many of the other technologies that we have in healthcare.”

With most new technologies developed to improve patient outcomes, Veenstra says oftentimes there’s an increase in cost, so he thinks it’s a misconception that precision medicine is going to save money. “I guess there’s an important ‘bigger-picture’ misconception that in order to provide good value, something has to be cost-saving, and that’s just not the case,” Veenstra added. “Anything that improves patient outcomes at a reasonable cost is a good value.”

Precision medicine can mean a number of different things—making a molecular diagnosis and giving a targeted treatment; or taking a genomic screen of a population, looking for disease risks; or it could mean pharmacogenomics. “So if someone asked, ‘Oh, is precision medicine a good economic value?’ that’s like asking, ‘Well, are drugs a good economic value?’” Veenstra says. “And the answer, of course, is it depends.”

A gene panel for a few hundred dollars, that’s a good deal

The current economic story Veenstra sees in precision medicine would be the dropping cost of genetic tests. “Let’s say it used to cost two or three hundred bucks just to look at one particular mutation or two mutations in one gene, and now for that price, you can look at 100 genes and thousands of genetic variants,” he says. “The actual costs of these genetic assays have dropped far enough that implementation at a broader level, combined with an increasing evidence base, makes widespread use potentially feasible in the near future.”

Veenstra predicts people, or their insurance, are going to start paying for pharmacogenomic screens, and that such activity could be common in 10 years.

What’s the value to the patient? Let’s say you had a pharmacogenetic screen, that information would be available to your provider and pharmacist, so if you’re prescribed a new medication that just so happens to have some kind of pharmacogenomic affect, the drug would be flagged to avoid an adverse reaction. Or a drug a little more likely to be effective would be chosen or the dose would be modified. Those are the kind of cases that pharmacists would help manage at the point of care, making adaptations to personalize medicine.

In that sense, it’s not like every person will have some tremendous benefit, but more so, a lot of different people will have a lot of small benefits for a relatively low cost.

“I think of it as the equivalent of knowing ahead of time what drugs you would be allergic to—what’s the value of that? That could be valuable to know,” Veenstra said, “instead of having a bad experience or poor outcomes, if the drug could potentially be avoided.”

Dr. David Veenstra“I guess there’s an important ‘bigger-picture’ misconception that in order to provide good value, something has to be cost-saving, and that’s just not the case. Anything that improves patient outcomes at a reasonable cost is a good value.

Dr. David Veenstra

Calling All Pharmacists

As cost becomes less of an issue for the implementation of precision medicine, other barriers linger: Technology, particularly data storage. Ethics—who sees it, what do they do with it? And then there’s education—schools of pharmacy must boost pharmacogenetic training, so pharmacists can increase physicians’ knowledge of pharmacogenomics.

“I really do see pharmacogenomics as being the purview of pharmacists,” Woodahl said. If a graduate student was interested in a research opportunity to pursue personalized medicine, Woodahl says the student would not have to look very far. Most schools of pharmacy have faculty members involved in some aspect of pharmacogenomics research.

“The majority of pharmacogenomics research is probably done in schools of pharmacy in this country,” Veenstra added, so there are great opportunities there, in institutions with long histories of funded research programs.

As far as career opportunities for Pharm.D. students, Veenstra sees pharmacists, particularly specialty pharmacists, assessing the evidence to try and understand when it makes the most sense to use certain drugs based on genetic tests.

“There’s a real morass of uncertainty there,” Veenstra said, “but I think pharmacists have good training to spend the time to provide guidance to clinicians and committees.”

Athena Ponushis is a freelance writer based in Ft. Lauderdale, Fla.