Personalized Medicine and The Pharmacist

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