What is pharmacogenetics, and how can pharmacogenetics be helpful to doctors?
In our Precision Insights Podcast, Dr. Martin Dawes interviewed Sue Paul of SyneRxgy Consulting, a company that aims to simplify patients’ medication lists and help improve medication adherence.
Sue shares her experience in implementing pharmacogenetic information when reviewing medication options with patients. She also discusses some challenges in getting physicians on board with incorporating pharmacogenetics into the medication decision process.
Let’s get started with our conversation with Sue Paul!
Can you tell listeners a little bit about yourself and how you got here?
I am Sue Paul, and I’ve been a pharmacist for over 20 years. In the past 20+ years, I kept seeing such a big gap between patients and medications, especially the patient’s understanding of drugs.
In the clinical setting that I was in, I never felt like I had the time to take care of patients or educate them properly. Either, I was too busy filling in or checking prescriptions; or I was in the hospital working on a tight time frame.
To address these limitations in the care continuum, I created a business called SyneRxgy Consulting, where I work in the physicians’ offices or patients’ homes. In the patients’ homes, I help manage their medications, especially after a transition of care. And in the physicians’ offices, they are primarily utilizing my skills to manage the chronic disease state that the patient has and their medications.
Besides SyneRxgy Consulting, what other projects are you currently working on?
I also have two other businesses. One of them is called Medipreneurs. Medipreneurs Summit is an annual conference for pharmacy entrepreneurs. We’ve had two successful meetings, and we’re working on our third, which will take place in April 2020. It is an event that brings healthcare professionals together. All of us have one goal; to break down the barriers so we can provide better care for patients.
My third business is PGx101. When we were incorporating pharmacogenetics into the physician’s office, we realized that not enough pharmacists or healthcare providers knew about the science behind it. I certainly didn’t want to start another business; however, it did feel like the right thing to do. With this 20-hour of continuing education, we train pharmacists and other healthcare providers on the principles and implications of pharmacogenetics.
Let’s talk about how the complexity of pharmacogenetics can make physicians throw up their hands. Do you find that sort of response when you are talking to clinicians?
I haven’t, but I think this kind of response could happen when there is a lack of education for physicians around the implementation of pharmacogenetics. With more baseline awareness of pharmacogenetics, the will is there but requires educational support and clinical usability.
Several other companies do offer training programs on pharmacogenetics. Unlike the other training programs out there, the benefit of our training is that we make our training actionable in real-case scenarios. We teach people how to implement pharmacogenetics because I think that is one of the most significant barriers.
I look at pharmacogenomics, as the potassium level, INR, or blood pressure. It’s similar to these key indicators that help physicians care for patients.
Going to your experience working with clinics, how is it organized that you can help physicians provide care to their patients? What will happen?
The physician will identify a patient who isn’t responding to drugs, is unwilling to take medications but desperately needs them, or has some mental health issues. Then, they’ll schedule those patients with me or one of our behavioral health coaches who will do the pharmacogenetic test. In a week or two, we’ll schedule the patient for a follow-up to go over the results when the report comes back.
I saw two patients last week who have mental health issues. They were going through a medication-assisted treatment for substance use disorder. We were trying to get the patients on the correct medicine so they can handle their mental health challenges on the road to recovery.
In the physician’s office, I went through the report with the patients. Then, between the patients and me, we decided what medications work best depending on what the patient’s symptoms were. Once we reached a shared decision, I presented that to the physician, and she gave the go-ahead to send in the medication orders.
How long do you think it takes to go through medications and pharmacogenetic information with the patient?
It takes around 15 minutes if we’re using a comprehensive report. With the current FDA involvement, that started on August 1st, 2019, where we’re taking medications off the report, I need to go through a little bit more thoroughly before the office visit. But when the drugs are on the report, it’s a lot quicker to go through them with patients.
When you get a pharmacogenetic test report, what are some of the information you see on the report?
Depending on how many synapses we are testing for the single nucleotide polymorphism or alleles, the results tell us if there are any genetic variants. And the report also shows issues where the patient may not be metabolizing the medicine well or breaking it down as well as they should.
Dr. Martin Dawes adds that the report would translate those alleles into a drug metabolism level. Either the patient has a poor metabolizer, normal metabolizer, or ultra metabolizer of a specific drug. We then convert the drug metabolizer into the decision to increase the dose or lower the dose of the medication.
Do you discuss the potential adverse events with patients? And where do you find that information?
Absolutely. For immediate information, I’ll go to Medscape, because it’s not as complicated. But if I need to delve a little bit further, I’ll go to the drug label. As we build up our experience of maybe 200-300 drugs, we started to know the side effects without having to go back and look for information. As when physicians began their practices, they were looking for the parameters for the potassium level, but now they know it from experience.
In your experience, do you see a pharmacist-assisted process being a part of standard care as we move forward?
I mean, that’s my dream to see pharmacists working with physicians as a team along with the patients to improve health outcomes.
There will still be retail pharmacies because it’s a product that the patients will buy. However, the service involved will be all done by the technicians or through a software application.
As for the pharmacists, they will have an office where patients can go in. Pharmacists and patients will go over all the medications together, ensuring that the medicines are all necessary, checking for interactions, and more.
When you are talking with the patients, what are the tools that you are using?
I use many visuals. I have the benefit of working in a lower health literacy environment, so I’ve had to simplify things. For example, I’ll take the water faucet and turn it on a gentle stream. Next thing, I’ll push it up to the full blast and show patients that this is your blood pressure level.
When you are doing these engagement process, are there any a-ha moments with patients?
Some diabetic patients don’t understand why they have to take medicines. In this case, I’ll use tomato paste and vinegar to show the thickness of their blood, depending on their blood glucose level. With my demonstration, patients get a better idea of their blood viscosity. Sometimes, they’ll come back to the physician and say, “I think my blood kind of looks like ketchup today doctor. I’ve been eating too many cookies.”
These engagements with patients are more than just science; they are very much a driver to building meaningful relationships. Take the patient I had this week as an example; when she saw the medications that she has failed in the past appeared in the red zone on her PGx report, she gets it. She trusts that care providers will be prescribing her with medicines that play better with her genes.
From your perspective, what is the value proposition for listeners to embrace pharmacogenetics use at the point of care?
Yes, there are so many benefits. It’s the most rewarding thing. I think one of our most successful cases was this one patient who had been addicted to opioids. We got around the right medicines, and she’s been able to come off her medication-assisted therapy, Suboxone, which we don’t see that very often. Because we were able to treat the mental health issues adequately with the correct medicine, she was able to get healthy.
The majority of clinicians and maybe half pharmacists are not au fait with what pharmacogenetic is. How do you see us changing that?
I do think offering training is helpful. Last week, I heard that one professor is testing all of his first-year pharmacy students before they ever get any drug information. The pharmacogenetic information then stays with them throughout their pharmacy educational career.
Our own Dr. Martin Dawes, added, “It’s also important to point out that not all but most pharmacogenetic panels have no predictability what so ever. The panels only provide information on drugs.” He went on to say that in order for pharmacogenetics to be truly embraced, it needs to be seamlessly integrated into the tools clinicians use at the point of care.
When we’re talking about pharmacogenetics, is there a place that you would tend to go to for your information?
CPIC guidelines, which is short for Clinical Pharmacogenetics Implementation Consortium. They gather all sorts of pharmacogenetics information and categorize them into evidence-based ratings and scalings. I consider them the go-to place to get my evidence for pharmacogenetics.
Dr. Martin Dawes adds, “It’s useful for people who haven’t heard much about pharmacogenetics to learn about this international consortium that pulls all evidence together from across the world. I see the CPIC guidelines as equivalent to a Cochrane library but for pharmacogenetics. It’s a place you can get appraised evidence. It’s also put into a language that is quite easy for us as clinicians to use straight away, for example, the level of clinical evidence and the recommendation about dosage.
Certainly, CPIC is something that I would recommend listeners to look up if they haven’t heard about it. Because it is an indication that pharmacogenetics has moved from just a science and a few people to an international body and groups around the world who are taking this information and sharing them with others.”
Are the physicians you are working with getting involved in interpreting the pharmacogenetic as well as learning about this at the same time as you are implementing it?
Absolutely. We were able to test all our providers so that they can see what information patients get from pharmacogenetic tests. I think that probably was one of the best ways for them to know how this works. We don’t use all the tests from the same lab. Some tests don’t have drugs on them, so I’ve been interpreting more and more tests. And it’s cute because the physicians will try to interpret it. Sometimes it’s right, and sometimes it’s wrong.
Is there anything else you would like to share with listeners at this time?
Look into pharmacogenetics if you can. We have lots of resources on our website, PGx101.com. There are many free resources for you to get started. If our training doesn’t work out for you, I’m happy to offer other training. And I love what GenXys is working on. Especially how their clinical decision support software, TreatGx, can bring all the variables together in a more straightforward format. By integrating pharmacogenetics with other health variables, the software assists providers and help patients get better health outcomes.
Conclusion
To wrap things up, we’d like to give the audience three key takeaways that are essential to the future of therapeutics.
- There needs to be more education on the implementation of pharmacogenetics at the point of care.
- We need to be sharing experiences as groups interested in providing precision care.
- We need to have a 1 to 1 relationship with our patients, either in their homes or in the physicians’ offices, to discuss pharmacogenetics as part of their treatment optimization.
Lastly, we also have to start empowering patients to take control of their own health, especially getting them involved in the decision-making process. We think pharmacogenetics is a trigger for the way we’re starting to share information with patients. Precisely on that point, there are four to five medications and sometimes many more for an individual to look at for a particular condition. And having care systems and software applications that show patients information gives them the confidence to participate in their medication decision process.
Everyone has been talking about shared decision making to improve healthcare for about 20 years. We believe pharmacogenetics may be a trigger for truly enabling that.
Thanks for sharing your experience and patients stories, Sue!
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The Precision Insights podcast is a podcast series consists of inspiring conversations around precision medicine with industry thought leaders and innovators. Every two months (and sometimes more), we share the most cutting-edge technologies, processes, and initiatives in precision medicine. If you’re a patient, healthcare provider, employer, or someone simply interested in precision healthcare, you’re sure to find something useful in each episode. We hope that you’ll join our listeners and start taking control of your health, or implement precision health into your workplace/clinics as a result!
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