Personalized Medicine and The Pharmacist

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WHY PHARMACIES SHOULD ALL BE OWNED/OPERATED BY PHARMACISTS

1. Corporations create an environment incompatible with pharmacy practice

Large surface stores are modelled on high volume sales, low profit margins, simple products and low consumer interaction. Pharmaceutical care, on the other hand, centers around the needs of individual patients as well as complex and potentially dangerous technologies (i.e. pharmaceutical drugs). Selling warfarin in a one-stop location next to the toilet paper, chocolate and big screen televisions subconsciously conveys to the patient that their prescription is like any other consumer good; it should be cheap and it should be fast. This practice endangers the safety of the patient by trivializing the risks associated with pharmacotherapy and the information provided by the pharmacist during pharmaceutical counselling.

Additionally, the corporate environment imposes on the pharmacist unattainable goals which compromise pharmaceutical care. The performance of employed pharmacists is not assessed on their merits as good healthcare providers but rather on the number of prescriptions processed in any given day. Under such circumstances, medication review, pharmacovigilance, pharmaceutical counselling and continuation of care are set aside in order to maximize sales per hour.          

2. Corporations are inflexible entities

Pharmaceutical needs of individual patients are varied and unique. A given patient may require a compounded medicine, a veterinary product, a brand name medication, a prescription delivered after hours or simply social interaction. Such characteristics are incompatible with the inflexible large corporation model of chain-assembled goods. The real-life result is that patients are routinely refused pharmaceutical care, or referred elsewhere, due to high cost-to-profit ratios and time constraints. As pharmacy students, many of us have witnessed or heard about the atypical patient which the pharmacy staff would rather avoid servicing.        

3. Private enterprise stimulates quality of service and innovation

Pharmacy is unavoidably linked with consumerism. When corporate monopolies are removed, free enterprises in a competitor-rich environment must rely on a distinctive edge other than simple price differentiation. Individual pharmacies must then fight for the satisfaction and loyalty of patients (aka consumers) or die. As a result, business-wise entrepreneurs emerge and thrive by offering better and newer services/goods (i.e. quality care, medication review, disease specialization, compounding, injection services, etc) and enrich the environment and practice. Eventually, these become standard practices until the next great innovation perpetuating the cycle of innovation and enterprise.     

4. Pharmacy ‘store-in-stores’ erodes pharmaceutical care and commodotizes the pharmacy

Pharmacies located within grocery stores, department stores, etc. relegate the service to merely another aisle or service counter in the store, allowing the service to decrease at the pharmacy without being acted on by the consumer. Because of the added convienience of shopping while a perscription is filled the lack of service may be overlooked as an opportunity cost of the convienence. As this happens, a decrease in care creaps into society and overall negatively affects both patient care and the profession.

Pharmacy students in British Columbia seem to be headed into murky waters over the course of the next few years as the role of the traditional pharmacist appears to be in jeopardy.  In what already is a saturated local market, UBC expanded its pharmacy student enrollment by around 50% for the 2011/2012 academic year.  From discussions with recent graduates and pharmacists in practice, the number of new full-time positions and part-time positions with benefits in the Greater Vancouver area has been declining for the last couple of years.  This is forcing young registered pharmacists (RPh’s) to move farther out due to the oversupply of pharmacists in the GVRD. Sechelt alone has seen 2-3 new young RPh’s in the last couple of years, which is unheard of historically. Visualizing this movement of RPh’s as a wave, how far will new graduates have to relocate to avoid the crest?

Compounding the issue of an oversupply of pharmacists is the recent Regulation of Pharmacy Technicians.  As the government and businesses strive to save money however possible, it makes sense as a business model to employ regulated technicians that are compensated much less than pharmacists for doing a large portion of the same work.  Although it cannot happen immediately due to a lack of supply, it is only a matter of time before the ratio of technicians to pharmacists increases. Furthermore, once the proposed Pharm.D program becomes the standard, those with the current, specialized Pharm.D and everybody with their Bachelors in Pharmacy are going to see their degree devalued.

Generally speaking, current trends are indicating an aging population with mass retirements looming.  However, with proposed changes to the federal pension plan to increase the retirement age to 67, and an unstable global economy that already saw the markets crash in 2008, causing many people close to retirement to lose much of their RRSP’s and investment income, will people be able or willing to retire fully from their jobs?  Will this equate to  fewer new positions opening up for new Pharmacy graduates?

It is a time for pharmacists to decide how to add value to their profession and how to redefine their profession. In the past, pharmacists were the key to making drugs and compounds.  Gradually, that role became transferred to large pharmaceutical companies with the invention of various machines.  At that point, the pharmacists took on the role of dispensing the medications accurately and providing patients with advice about prescription and nonprescription medications.  Now, the technicians are taking on the role of dispensary and pharmacists will be expanding their practices so that they can focus on using their valuable knowledge to maximize their contributions to their patients’ health. As the internet becomes a more and more important part of the average citizen’s lives, citizens are becoming more informed.  However, with the ease of accessing and distributing information, they may find it difficult to distinguish the facts from myths. That is where pharmacists can come in, as the educator as well as the assessor in patients’ medications.

So what opportunities does the future hold for pharmacists? As our society is aging and more medications are being developed or refined, the physicians’ burden becomes heavier.  Pharmacists may be looked upon as consultants to assist physicians monitor patients’ drug use and choose the most appropriate drug regimen for patients.  With developments in the area of pharmacogenomics, pharmacists will become invaluable in determining drug treatments that minimize adverse drug events while providing the best therapy possible. As times are changing, the pharmacist’s role has to change as well.  There are many possible paths that can be taken, so it is up to the pharmacists to decide on the direction of the future profession.

The future of medicine is changing.

In countries all over the world, including here in Canada, there is a push to move away from the conventional one-size-fits-all approach that has been the standard of health care for some time. This old approach works a little something like this: if you are of such and such age, and are diagnosed with such and such condition, you should take such and such drug at this specific dose. It might seem slightly crude at first, but in reality the best initial therapy we could offer a patient up until now is the one that, on average, works the best for the most people possible. Individualization of drug therapy happens, of course. But in the patients for whom the conventional therapies are not the best, a slow, step-wise journey awaits them: First line options to second line to third line and so forth until they find a treatment that works for them. This cookie-cutter approach to patient care has its downfalls. Some patients, such as those with aggressive cancers, may not have the time to search for an ideal treatment. And what about the added costs that a trial-and-error approach has on our health care system? If only there was a way to effectively predict how well a certain drug would work for a certain patient…it would be a health care renaissance, improving quality of care enormously and cutting down on costs in the process.

This is where personalized medicine comes in. As my colleagues below will tell you, we are perfecting our ability to analyze a person’s individual genetic material- the DNA found in the center of all our cells – and search through it for secrets regarding what sort of medical treatment is best for them. Pharmacists, as drug experts and the essential link between the pharmaceutical product and the patient, will have a key role in this revolution.

The one-size-fits-all era of health care is drawing to a close, bending the knee to a more sophisticated and individualized one. We hope that you are just as excited as we are.  – Mihailo Veljovic

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Personalized medicine is the way of the future. We saw it coming. If we didn’t we should have. We have known for quite some time that not all people respond in the same way to drugs. Some may get no effect because their genetic make-up has not prepared them to metabolize a prodrug or conversely, a drug may be lethal to certain individuals, again due to their genetic make-up. By looking at a person’s individual DNA, drug therapies can be tailored to fit an individual’s needs. These new methods are going to make our current dosing based on a measured averages look crude in comparison but it is a thing we, as pharmacists, should embrace. More knowledge about our patient’s biology allows us to use our tools more effectively with less adverse drug reactions and better patient outcomes. So where do we fit in? We are the best suited profession to oversee the usage of such technology.  Doctors simply don’t have the time to learn everything there is to know about drugs and how they work at the molecular level let alone an entire new field of pharmacogenomics. Our profession has the electronic framework already in place to take on such an endeavour. It seems so logical that it’s hard to envision it any other way but this promising new role of a pharmacist will only happen if we advocate for ourselves effectively. No else will do it for us. The public and our colleagues need to know that we are the drug experts, we see the benefits to patients and we are going to lead the way into the future of personalized pharmaceutics.  – Gina Cragg

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The concept of personalized medicine is intriguing. We’ve all been told that each and every one of us is unique in terms of personality and physiology, yet many of our available treatments are based on evidence extrapolated from a population. Most importantly, treatments based on averages, or means may not apply to the outliers of the population; without personalized medicine, they are often neglected. Imagine if treatments were tailored to an individual based on their specific genes, enzyme function, and physiological parameters – that would truly be ideal. Drugs with narrow therapeutic windows can be administered with more confidence, expectations on a patient’s response would be more accurate, and a drug’s toxicological profile can be better managed. Forsaken drugs, abandoned because of high patient inter-variability, may be salvaged again, if we learn how to account for each patient’s differences. I am definitely excited to see health-care shifting in this direction.

Pharmacists, without a doubt, should have a prominent role in personalized medicine. With medication management services, we are extremely accessible to patients. We can have a role in adjusting, or tweaking treatments to provide optimal drug therapy. I would also like to witness a collaborative process with other health care professionals as well to treat individuals. The cost of treatment may escalate as well in order to complete the necessary tests (e.g. genome sequencing), which may prove impractical or problematic for the patient, but with the declining trend in the prices of these services, I am still optimistic. However, I feel like this initiative is still in its infancy; our curriculum has not shifted enough to prepare us for this monumental change yet, and the breadth of research still required for implementation is immense. Nevertheless, I fully support this revolutionary movement. – David Lee

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Personalized medicine is a general term encompassing a practice of health care where by the practitioners provides an individual patient with the best therapeutic care possible with the most current technology and medical knowledge available. This is based on multiple variables including the patient’s current condition(s), past conditions, family history, lifestyle including diet and behavioural habits, and their genetic makeup. Of course, in reality, the process to go through all the variables using surveys, questionnaires, lab tests and procedures, and genetic screening in one individual can take a multitude of time. Time that most if not all health care practitioners do not have. Currently, new scientific advances have allowed medicine to expand from chemicals to including proteins and even genomics to provide health care.

As pharmacists, personalized medication should definitely be incorporated into our practice especially in clinical settings where the pharmacist has access to the most tools.  It is understandable that in a community setting, the restrictions of the number of staff, volume of prescriptions, and time can really make personalized medication difficult to implement which is why a shift from what the general population considers as traditional pharmacy practice to a new and more innovative model is needed. However this is still under progress and an easy solution cannot be found without the cooperation of many individuals inside of pharmacy and out. –Stewart Lay

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With advancing pharmacogenomics, eventually, one day, we can have an additional section in the patient profile: genetic profile. Rather than looking up the disease prognosis, prevalence of side effects, precautions, etc in the data pooled together from study participants, we will be able to make more accurate predictions based on patients’ genetic profiles. This will make a huge difference to the field of pharmacy as there will be less uncertainty, less trial and error. Pharmacists can use this valuable information to aid in making decisions in what drug therapies to recommend and what to counsel patients on. Pharmacists are in the position to participate and allow this day to come sooner. Pharmacists can play a role in participating in studies to provide information regarding the effects patients (who are willing to participate in studies) experience after taking certain drugs. This information can then be correlated with their genetic makeup and allow conclusions to be drawn. – Sophie Liang

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Personalized medicine has two components. The first is the amalgamation of individuals’ genetic information regarding mutations that cause diseases and/or cause drugs to be metabolized differently, leading to changes in therapeutic effect, toxicity and susceptibility. The second is the use of an individual’s genetic information and compare it to the information in databases to determine their predisposition to developing certain diseases, their susceptibility to certain drugs for their disease state and the optimal therapeutic range for them. I personally think this is a very interesting field of pharmacy as it will allow us to reduce the number of adverse drug effects and insufficient therapeutic effects, minimize costs for patients by potentially allowing them to receive a lower dose. It will also allow health professionals to counsel patients on lifestyle changes that they can make now to prevent their likelihood of developing diseases that they are predisposed to. I see this as an exciting upcoming opportunity for pharmacists in a world where finding a job without having a specialty is increasingly difficult. The main challenge I foresee at the moment is getting people on board for the initial cost of genetic sequencing and putting together a comprehensive database. Our technology is improving at a rapid rate, however, the cost at this point is still beyond the means of the average citizen. Furthermore, most of the insurance companies have yet to be convinced of the benefit of covering this cost now in order to avoid the higher cost of managing illnesses in the future. – Shannan Dion

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The genomics company Life Technologies Corp. recently announced that by the end of 2012, it will be possible to sequence an individual’s genome for under $1,000 and within a day. This $1,000 milestone has been considered by many to be the tipping point of personalized medicine, but what will the implications really be to the health care system?
The main idea behind the personalized medicine model is to look at a patient’s unique DNA sequence to see if they are more susceptible to certain diseases, and to predict what their response to a medication will be, by comparing their genetic information to reference databases. Instead of using a one-size-fits-all approach we will be able to optimize a patient’s drug therapy based on how their body’s enzymes will metabolize a certain drug. The current trial-and-error system will become obsolete, as we will know ahead of time if a patient is a slow metabolizer (therefore at risk of increased side effects of a medication) and will adjust their dose accordingly. There is no doubt that medicine is eventually headed down this road, but how will pharmacists fit into this new picture of health care? Pharmacy is really in the perfect position to take on this role. Pharmacists are already the “drug experts”, we already have the knowledge about the effect of different metabolizing enzymes on drugs. We also were ahead of the curve when it comes to the electronic health records which will be vital to this new system of personalized medicine. PharmaNet could be an extremely useful tool if a patient’s genomic information was uploaded along with their medications. An individual could walk into any pharmacy in the province with a prescription and the pharmacist could be able to tell them within moments what their response to that medication will be, and could tailor their drug therapy to achieve the most optimal outcome. This could have a huge impact on the number of adverse drug reactions occurring, thus taking pressure off clinics and emergency rooms.

There are a number of barriers to implementing this model; no change ever occurs without overcoming some obstacles. With pharmacogenomics, there are many legal concerns to be addressed such as confidentiality, genetic discrimination, or mandatory genetic testing. Education of the public and other health care professionals will be essential, and pharmacists could play a major role here. Also it will still take time and lots of research before we fully understand the meanings of the thousands of different variations in the human genome. However in pharmacy in particular, it is my opinion that we need to be optimistic and innovative in order to cause change in the health care system or else other professions may move in and take over our roles. – Carly Webb

As we move away from the paternalistic ethos of medicine, we approach a unique way of incorporating patient-centered care: personalized medicine. Whereas the current approach of health care is largely based on trial and error of therapy and monitoring for the patient’s response, personalized medicine makes health care a truly individual experience by tailoring it the patient’s genetic makeup. The goal of personalized medicine is to optimize and deliver the best possible outcomes for each person by integrating advanced knowledge of disease at a molecular level with the individual’s unique genetic and environmental factors. As we gain deeper insights and understanding of current and new disease states, it is important that there are specialized treatments at our arsenal to properly provide patient-centered care.

One of the interesting developments in personalized medicine is pharmacogenomics.  The mapping of the human genome just over a decade ago has breathed new life into the area of therapeutics, giving rise to the new and exciting field of pharmacogenomics. This new area of research can potentially give us new insights into what drugs do to our bodies as well as how our bodies respond at the molecular level. Pharmacogenomics integrates genomics with existing knowledge in pharmacokinetics and pharmacodynamics, and seeks to develop personalized treatment based on the patient’s unique genome. This entails collecting information on the patient’s genome, and looking for unique genetic traits and deviations in particular genes. These genes typically code for enzymes and proteins crucial in the mechanism of action of the drug, and thus greatly affect the metabolism of the medication, and its effect on the individual as a whole. Contrary to the belief of some people, various individuals do not metabolize drugs in the same way. Some may have an allele resulting in a lower than normal level of metabolism of a drug, while others may have a genotype resulting in a completely non-functional enzyme. This can seriously affect the way a patient responds to a medication, and the dose required to achieve a desired effect. If we can tailor the dose and regimen of the drug according to the patient’s genetics, we can help to deliver the more effective drug therapy, and avoid unwanted adverse effects.

As we make the momentous shift toward an exciting new era of pharmacogenomic research, it is important to always relate it back to the concept of personalized medicine. Pharmacogenomics has already made an impact on cancer research and treatment. For example, an individual can be tested to see what levels of certain proteins they have in their body. If they then have a high level of a certain growth factor protein (breast cancer) which can be the cause of a tumour, treatment can be individualized based on the levels of this growth factor. Treatment in the future will also aim to just target this molecular pathway to minimize or even eliminate side effects which are quite undesirable in cancer treatment. This is just one example of how having the ability to tailor one’s medication regimen to his / her genetic map opens the gate to a much broader spectrum of medication options for an individual, especially those suffering from complex conditions and chronic illness. The conventional therapy we are currently accustomed to, while effective, may carry more cost over benefit with consideration of their side effects, complexity and rigid regimen. The knowledge that we will be able to introduce medications with minimized adverse reactions reassures the success rate of a medication therapy. Physicians will be able to take a closer look at the patient’s physiological and genetic profile and determine the best fit for their patient. Bacterial resistance may no longer be an area of concern, and hospitalized cases of serious drug reactions will no longer be a fear at the back of our minds. With personalized medicine, we are able to carry out a “best-fit” strategy as opposed to a “trial-and-error” system, elevating patient adherence and healthcare credibility. This is an exciting area in medicine as well as pharmacy. Imagine a day where we no longer see shelves of “top 40 drugs” on the pharmacy counters, instead having specially-formulated medications tailored to each patient. Not only will the most effective assessment be made for our patients, we, as pharmacists, will be able to exercise our knowledge and training to its fullest potential.

Another interesting aspect of personalized medicine is finding new and innovative ways to deliver treatment to patients in ways that maximize adherence. Medicine can be individualized through diversifying routes of deliveries in order to suit the individual differences and needs, and minimize side effects. For instance, it is a common practice to give oral antidepressants, gabapentin, and other oral medications for relieving pain. However, if formulated properly, the drugs can be incorporated into topical, transdermal creams to specifically target the site of pain through skin instead of systemic oral medications, thus reducing systemic side effects. The topical application not only decreases the side effects but may also increases compliance and convenience for patients. Another type of personalized medication includes using a patient’s own body fluids and parts to treat the patient’s condition. Autologous eye drop for treating dry eye is a good example which is effective and safe for the patient since it is a sterile ophthalmic solution extracted from a patient’s own blood serum. There are only four pharmacists in Canada who make the personalized drop for patients, which brings us to think how much more pharmacists can do for patients and expand the scope of practice.

Personalized medicine holds great promise for the future. If this process is made more cost effective/more readily available, this could reduce the amount of adverse drug reactions and related hospitalizations. This is advantageous to the patient, healthcare professionals and the taxpayers who help support the medical system. It will also allow us to provide more effective care for patients. If medical professionals know in advance how well a drug will work in a patient, they can help ensure that the patient in question receives optimal care at the lowest cost possible. If this up-and-coming idea of personalized medicine were to become more widespread, perhaps pharmacists would have the chance to establish their role in clinical decision-making. Pharmacists are in the ideal position to incorporate genetic testing into the role of drugs in therapy. We are the drug experts; furthermore, we are also very knowledgeable about the body’s various responses to these compounds. Pharmacists have the education required to interpret genetic tests and recommend appropriate drug therapy accordingly. The growth of personalized medicine would see the pharmacist being able to function within his/her full scope of practice and the patients receiving better health care.

Despite all the benefits patients may receive from “personalized medicine,” it may take a while before this idea can be fully implemented into the current health care system. As our profession embraces this new idea, many challenges await us. Money, time, patient’s acceptance, and the collaboration of different health care professionals are all potential barriers that we have to overcome in order to achieve this goal. We, as pharmacists, have a big role in introducing this new concept to patients, and explaining the purpose and benefits of doing so. Having the patients understand and acknowledge our care for them, will motivate us and the whole health care team to strive for this rather new but exciting and rewarding idea.

Stephanie Ho, Lingsa Jia, Caitlin Lang, Sarah Lee, Greg Ouellette, Megan Tromposch, Ken Wong, Tian Zhang

All the talk nowadays in local pharmacy classrooms is about the budding shift in pharmacy practice: moving the pharmacist out of the dispensary to newly furnished counselling booths, movement from product-centred care to outcome-focused patient care, optimal drug therapy outcomes for Canadians through patient-centred practice – that is to say, we’re talking about shifts towards Personalized Medicine.  And rightly so; the demands of health care are changing, and as our culture grows so should the practice of pharmacy grow, learn, and evolve towards the principles of practice that will allow us to provide for patients optimal, thorough, and well-evaluated care.  Pharmacogenomics is a valuable field in which a lot of potential for Personalized Medicine is available to be maximized, allowing for the impact of gene variation on drug response to be studied and the results to be used to help us tailor medical care to the individual patient.  Practice of Personalized Medicine has plenty of room to grow with advances in pharmacogenomics, as a student points out:

“I think personalized medicine is a very interesting and unique forefront to take on as a new service we can provide to our patients.  Not only will this set us apart from other health care professionals, it is also a tool to help us build a strong individualized therapeutic relationship.  Personalized medicine utilizes and integrates all aspects of what we learn in Pharmacy school and make us better equip to provide our patients with the best care possible.  Although pharmacogenomics is a new, and the use of genome sequencing is not easily accessible nor affordable – over time with increasing popularity and as more efficient, high-throughput technology is developed, these concerns are minor in comparison to the benefits of what personalized medicine can provide.  With extensive pre-existing databases of sequenced genomes and identification of genes responsible for breast cancer, Parkinson’s, and cystic fibrosis (just to name a few), development and the growth of personalized medicine is just the tip of the ice-berg.”
-a student

If Personalized Medicine is the forefront concept and priority with which we are advancing this march, our call-to-arms is going to be the BluePrint for Pharmacy: an extensive document released in 2009 that outlines some of the principles and policies behind developing this professional shift in practice.  The BluePrint identifies key areas of action -including increases in education and continual development, changes to legislation, regulation, and liability- all of which are in discussion and different phases of action today.

However, mixed in with excitement, we must also be critical and practical:

“Although I think that the Pharmacy Blue Prints are important for shaping the future of Pharmacy. I think that these plans are too idealistic and do not conform to the realities of society (taking into account how the government and employers want to cut back wages).
In the blueprints, it comments on how as Pharmacists we should do more, have we forgotten the business model where doing more means more compensation? Sure, we get compensation for our services, but the means of compensation are so tedious, time consuming and the value of compensation are not signficant that there would appear to be a lack of incentive to expand the role of Pharmacists
I think rather than spending a ridiculously long time trying to fufill each of the points made in the blue prints (like a checklist), we need to appoint a vocal, strong headed and perhaps “arrogant” leader to boost the image of Pharmacists in the healthcare hierachy. Too often are the Pharmacists thrown under the bus because we are too “polite” or too “inactive” to step up and fight for our recognition in the health care -team.”
-a student

Though there is discourse on what changes are appropriate and practical, a very common ground for many students and pharmacists on our changing practice is our lack of strong professional advocacy.  We do, however, seem united in our understanding of the strength in our ability to provide valuable, cognitive services, the potential for pharmacogenomics to positively impact the landscape of our practice, and the need for the appropriate changes to wage compensation to be addressed.

“As the role of the pharmacist continues to move away from dispensing and towards cognitive services, pharmacists need to prove their worth to both the government and society in general, as well as embrace the expansion of our scope of practice. We need to stress the importance of pharmacists’ interactions with patients. Pharmacists are in the perfect position to prevent ADRs, educate and ensure patient compliance, all of which are extremely important for improving patient health. In addition, as the field of genetics continues to grow, the opportunity for pharmacogenetics to be introduced into both hospital and community pharmacy practice is increasing. Using pharmacogenetics to personalize medications based on an individual’s DNA is quite possibly the future of pharmacy. Pharmacogenetics can be used by pharmacists to determine the most effective and safe drug therapy for an individual. In order for pharmacogenetics to become mainstream pharmacy practice, the cost of DNA sequencing needs to be affordable and completed before therapeutic decisions need to be made, pharmacists need to be educated in the field of pharmacogenetics and an E-health medical record that is easily updated and accessible to all healthcare professionals needs to be introduced. However, this switch from dispensing to cognitive services needs to be met with a changed model for compensation, where like doctors, pharmacists are paid for their services and time spent with patients, not for the amount of product sold. A major barrier to this is the fact that pharmacist compensation comes from both private and government sources with private companies profiting from Rx sales. This begs the questions: Should private companies continue to be involved in pharmacy practice? Where do we draw the line in public health care funding? What services should Pharmacists be paid for?”
-a student

Pharmacogenomics does face a lot of complications in these earlier stages of integration and development.  A new frontier of sorts, we can speculate that a number of issues can arise in practical application:

“Multiple obstacles currently lie on the path to the integration of pharmacogenomics into pharmacy practice. Many of these obstacles are likely due to that pharmacists simply do not feel ready.
Firstly, most pharmacists have not had much formal training in pharmacogenomics while pursuing their entry-to-practice programs. Newton et al. 2007 and a US survey have pointed out that pharmacists, particularly ones working in the community setting, are not well informed regarding advances in genomics technology and the pharmacogenomics of various disease states.
Secondly, pharmacists currently have limited direct access to complete medical records of their patients. Appropriate pharmacogenomics services cannot possibly be provided without full access to the genotype test results and comprehensive medical records. It will be interesting to see whether the introduction of electronic health records (eg e-Health) will be able to address this concern by broadening pharmacists’ access and encouraging collaboration among healthcare professionals.
Lastly, do pharmacists feel comfortable regarding utilizing pharmacogenomics in their practice and the impact that pharmacogenomics may have on the healthcare professional-patient relationship? Some pharmacists may have concerns regarding the psychological distress that genotype test results may bring to their patients, especially when the patients discover that they are pre-disposed to certain diseases.”
– a student

The BluePrint also outlines a detailed implementation plan that describes specific actions to execute its desired changes.  This plan relies heavily on success in sequence; coordination is required for this transition, and it is hard to say how effective we are currently being in creating these changes appropriately.  Furthermore, we still can’t be entirely sure where we can truly fit pharmacogenomics into this plan.

“I think the ideas brought forth in Blue Print for Pharmacy are both comprehensive and important in developing a new role for our profession. However, certain aspects are coming into effect before others and we find ourselves facing an awkward and challenging transition phase. For example, licensed technicians are beginning to graduate and practice in community pharmacy settings. This is part of the blueprint, and it means that things are going as planned – pharmacy technicians will take over the roles associated with dispensing and free up pharmacists, allowing them to focus on the more clinical aspects on community pharmacy. Unfortunately, the pharmacist’s role has not yet expanded to this breadth. One large reason for this may be compensation as there is no government program in place which allows pharmacists to be readily (and rightly) compensated for utilizing our specific knowledge and skill sets to help patients with their medications. There are programs in progress, such as the BC Medication Management Project, but these have not yet been expanded to include all the pharmacies in BC. Also, the Medication Review Services that started taking effect in April was found to be financially unsustainable by July and revised (aka limited). This raises the question of whether the profession of pharmacy, as outlined in the blue print, will ever be financially viable/sustainable in terms of government funded compensation. Meanwhile, as pharmacies continue to depend on dispensing prescriptions as a means to cover costs and as pharmacy technicians are able to take a more active role in dispensing activities at lower wages, pharmacists find their livelihood in jeopardy. Pharmacists are now pressured to find ways to expand their practice. One suggestion is for pharmacists to take a more active role in applying pharmacogenomic principles to practice. However, this is still quite a new area and genome sequencing of patients is, for many reasons, not readily available for pharmacists to interpret. For these reasons, pharmacists already in practice and students do not have adequate exposure to the field of pharmacogenomics. Perhaps in another few decades this will have changed. Whether pharmacogenomics is the answer or not, this is a transitional time for the profession of pharmacy and it will be exciting to be part of the change.”
-a student

All in all, we understand that change is necessary, and change is coming.  Action needs to be taken from this discourse, and our practice needs not only continued action, but sustainable action.  Where we can truly instigate our goals in this plan is still up for debate.

“Since the economic downturn, health care in general in Canada has taken a huge hit.  Not in the least, the pharmacy field is starting to feel the pressure.  Certainly, the talk of pharmacy practice change has been going on for awhile, even decades, but it is not until now, when our livelihoods are at stake, have we unanimously agreed that something has to be done.  I think the “Blue Print for Pharmacy” is a good idea, but it is just that…an idea.  It IS up to us to make the change. The “Blue Print” has provided us with the goals, the focus, and the methods of implementation.  But what was lacking all these years is the motivation.  Pharmacists has historically “done well” for themselves; there was no risk of unemployment, no risk of our jobs being taken over by someone who will work for less pay, and there was no drive to do anything differently.

I am glad the “Blue Print” focuses on patient-centered outcomes, but it also goes on in detail about implementing new business models.  Unfortunately, that is an indispensable part of our field and practice.  Unlike our partners, the doctors and nurses, our field has always had a business side.  It is what has worked for us.  Of course we care about providing the most safe and effective pharmacotherapy, of course we want to achieve patient-centred outcomes…we care so much that we are even the forerunners on personalized medicine based on pharmacogenomics. (It doesn’t get anymore patient-centered than that!)  But in order to serve our patients better, we need to be sustainable.  First and foremost, we need to be compensated for what we do, and the services we provide.  We need to allot time for these services.  We need to make room for the new certified technicians (yes, the same ones threatening to take over our jobs).  At the same time, we still need to be the most accessible health care providers in the community.  We certainly will not be able to do this the old way.  And the government does not have a bottomless pit of money to dole out to all pharmacists who claimed they have reviewed and improved their patients’ medications, whether they needed it or not.  Yes, we need to pressure the government.  We also need to pressure our own regulatory body, our own association, to speak up for us.  We need them to make the government realize we are an essential service, but we are not looking for a handout.  We need them to change the legislations to allow us the flexibility to be compensated for our services by other means.  In order to provide our expanded services to patients free of charge to them, we need the reimbursements from our partners, the pharmaceutical wholesalers.  We need to limit the ratio of technicians to pharmacist in each practice, in order to provide optimal care.  Lastly, we need to stop pandering to the corporations, the “big chains”.  The best way to change this field is from the ground up, starting with independently owned pharmacies, where the pharmacists have actual power to change the way work is being done.”
– a student

Group 1
References:

• Newton R, Lithgow J, Li Wan Po A, Bennett C, Farndon P. How will pharmacogenetics impact on pharmacy practice? Pharmacists’ views and educational priorities [Internet]. 2007 [cited 2011 Oct 24]. Available from: URL: http://www.geneticseducation.nhs.uk/media/16739/Pharmacogenetics.pdf
• Clemerson JP, Payne K, Bissell P, Anderson C. Pharmacogenetics, the next challenge for pharmacy? Pharm World Sci. 2006 Jun;28(3):126-30.

The pharmacy profession has been an ever-changing field. The traditional lick stick and pour model no longer is the only role of a pharmacist; however, pharmacists are now the forefront of new research and innovative medicine development. We see the rise of several compounding pharmacies that focus on research into new effective drug delivery system. Take the development of an autologous eye drop for example. Patients with severe dry eyes no longer need to seek different artificial eye drop products, which they may also risk themselves from sensitivity from contained preservatives, instead, they can use their own blood to create the most suitable eyedrop for themselves. More study needs to be conducted on the eyedrops long term efficacy; however, this idea has widened many health care professionals view on the role of pharmacists.

The idea of using one’s own body material to make the most compatible drug has been extended into the field of pharmacogenomics. What if we can give patients drugs based on their genetic composition; thus choosing only those drugs that have the most benefit to the patient? Will patients be cured faster? Can we ultimately find a cure to cancer using pharmacogenomics? These questions are currently unanswered, but we are sure that not only does this method reduce the cost of trying different medications that might not work in the end, but also reduces the side effects from specific drugs and increase the efficacy of the drugs used.

Below is a discussion from my colleagues on the changing field of pharmacy and how pharmacogenomics can shape the future of pharmacy:

Our Changing Role

The pharmacy profession has strengths, weaknesses, opportunities and threats.  Pharmacists are an easily accessible resource in the community.  Pharmacists are very approachable to the public which can help to ease the strained health care system for those willing to take advantage of the free advice.  The business aspect of a pharmacy however, acts as a hindrance to the availability and time a pharmacist has to spend with individual patients and their concerns.  A pharmacist is responsible for numerous activities while on the job; from dispensing medications and medication management to ensuring prescriptions are safe for their patients – this doesn’t leave much time for individual consultations that could help to prevent potentially avoidable situations such as adverse reactions due to a simple interaction that could have been avoided by simply spacing the medications, for example.  There are however, many opportunities for pharmacists, such as finding individual specialties, such as geriatrics, to better serve the public’s concerns related to their particular niche of knowledge.  Threats to the pharmacy profession too however, are increasing.  One major threat to pharmacists are registered pharmacy technicians; they will be able to accomplish the dispensing job of the pharmacist, and unless pharmacists find a new niche in which to apply their skills and knowledge, pharmacists may no longer be necessary.  Increasing the importance of medication management and the role of counselling, as part of the major skill set for pharmacists will provide pharmacists the opportunity to branch out from their dispensing roles, to better serve the public.

As said by Mark Kunzli, there is an increasing number of threats to our profession.  At the same time, however, we have opportunities to avoid this impending “doom,” one of those opportunities being personalized medicine.  This involves tailoring the drug therapy to the individual genome of the patient.  For example, if the patient has Alzheimer’s disease caused by a mutation, we can identify the mutation and the associated mechanism of disease.  Then, we can pick a drug that works on the specific gene mutation to reverse the effects of the disease.

Personalized medicine is becoming a more viable option for many patients due to the decreasing costs of genome mapping.  The current price offered by Illumina is $4000; in comparison, scientists spent $3 billion sequencing the first human a decade ago.  As well, with the new investment by the Canadian government of nearly $70 million into pharmacogenomics research, we are hopeful that the reality of personalized medicine will be accessible to the public in the near future.

In light of these facts, we see that pharmacogenomics is a viable future for our profession.  As the sneaky pharmacy technicians try to “steal our jobs,” we can counter by creating our own niche of personalized medicine.  Since this is a relatively new field, it is up to us to promote it and protect it from the reaches of the other health professions.  We can promote it as the ultimate culmination of patient centred care.  With these advances, we will be able to predict accurately the pharmacokinetic and pharmacologic profile of drugs unique to each individual, which would tell us the exact effects, side effects, intensity, and duration.  With patient input along the way, we would be able to make the “perfect” pharmacy care plan.

 The Future~Pharmacogenomics

Personalized medicine is an interesting concept. It involves analyzing a patient’s genetic information to see what type of metabolizing enzymes are present, and to what extent they are present. The reason why this is important is because each individual will have varying degrees of metabolizing enzymes, which will in turn influence how they respond to a certain medication. Too much of an enzyme can result in extensive metabolism, reducing the half life of drugs to the point where there will be no clinical effect. Too little of an enzyme and the drug will stay in the system for far too long, resulting in unwanted adverse reactions. Surprising to note, is that the exact opposite can happen as well where too much of an enzyme can result in reactive metabolites, which can lead to additional side effects; and too little of an enzyme could prevent a prodrug from being converted into its active form. To even further complicate things, metabolic enzymes often have numerous substrates, so when one drug is present, it can affect other concomitant medications as well, leading to drug-drug interactions and ultimately side effects or decreased efficacy. The list goes on and on. This is what is referred to as pharmacogenomics, which is where pharmacists can potentially come into play. As noted above, the pharmacist role in the community has been gradually engulfed by pharmacy technicians, who will accept lower pay, thus making the pharmacist community obsolete. Pharmacists can expose this niche, not only to remain active in the job market, but to also provide excellent medication therapy. By analyzing one’s genetic information to find out what metabolic enzymes are present and how they will affect a patient’s medications, we can reduce the occurrence of side effects and increase the effectiveness of the drug.

Personalized Medicine is an exciting approach to healthcare that allows truly individualized management. Unlike the traditional model where clinical diagnosis uses laboratory test results, patient history and examination to diagnose and treat in a general way, Personalized Medicine applies genetic and other information to allow customized diagnosis and treatment specific to the patient and their problem.

Using this approach to patient care could lead to more targeted treatment resulting in less side effects, improved efficacy and ultimately, greater medication effectiveness. Maybe this how we finally get to the elusive goal of improved patient adherence – the final path in a virtuous circle where improved therapy leads to a better patient experience and so on.

I was interested to see the federal government just allocated $65 million for Personalized Medicine – I feel this is indicative of where things are headed.
I definitely feel Pharmacists should be actively involved in delivering Personalized Medicine. Pharmacist involvement could include interpretation of specific pharmacogenetic tests, especially when they impact drug dosages and pharmacodynamics.

 What’s Next

Pharmacogenomics is definitely the future of pharmacy and it is a field that will surely optimize the health care by pharmacists by customizing the therapy to the individual. Soon, general guidelines for treatment of certain major conditions like asthma will be obsolete. If used wisely for certain conditions or medications that have polymorphic effects and great variation in the population, pharmacogenomics can improve the efficacy, side effect profile and decrease the cost of therapy, thereby providing safe and effective patient health care.