The Pharmacist’s Role in Implementing Pharmacogenomics [Podcast]

25 Aug The Pharmacist’s Role in Implementing Pharmacogenomics [Podcast]

Picture what a pharmacist does—what’s the first thing that comes to mind? 

Most people think that a pharmacist’s job is just to fill prescriptions and answer questions about medications. But as healthcare continues to change, so does the role of pharmacists. 

With the industry moving towards personalized prescribing, pharmacists have become the key to successful pharmacogenomics (PGx) implementation. They have the knowledge, the time, and are trusted by both patients and prescribers. 

In this episode of the Precision Insights Podcast, Adrijana Kekic, pharmacogenomic pharmacist and the program director of education, outpatient pharmacy at the Mayo Clinic, delves into the ways in which pharmacists are getting involved in PGx and the role they will play in the future of personalized medicine.

Let’s jump right in.

Table of Contents

• Could you tell our listeners a bit about yourself and the impetus for your interest in pharmacogenomics?
• How do you see the role of pharmacists changing over the last three or four years, specifically in the personalized medicine arena? 
• In terms of implementing pharmacogenetics at the point of care, can you provide an example? 
• Mayo Clinic is a pioneer in the incorporation of drug-gene information in the clinician’s workflow. Can you share a bit about how it all happened and any challenges? 
• What do you think is going to be the most exciting development in personalized medicine going forward? 
• What do you think of the evolution of pharmacists into virtual care?

Could you tell our listeners a bit about yourself and the impetus for your interest in pharmacogenomics? 

I am a pharmacogenomic pharmacist currently working at Mayo Clinic in Arizona. I am very lucky to be able to practice pharmacy under two shields of clinical practice: direct patient experience and research and education. I semi-jokingly say that my focus is genes, drugs, and bugs. In other words, my focus is elements, especially genetic elements, that influence medication outcomes. 

I started pharmacy school in the former Yugoslavia during a time of adversity, and moved to the U.S., where I was able to continue my education. What I found really informative and inspiring during both times is that pharmacists continue to be the most accessible health care provider in both places.

We have extensive pharmacology knowledge, but I’ve seen people, including my family members, that were given correctly-prescribed medication or medications and had eclectic outcomes, including non-desired outcomes. I wanted to understand why and how we can personalize these medication therapies.

That’s the road that I have been on for the past 25 years, and my current focus: how we as pharmacists can use pharmacogenomics both as a tool for making better medication selections and for collaborating with the patients and their physicians in selecting better medications and having better medication outcomes.

How do you see the role of pharmacists changing over the last three or four years, specifically in the arena of personalized medicine? 

I have seen a lot of positive changes in recent years with respect to pharmacists playing a more engaged role in pharmacogenomics implementation initiatives. Pharmacists are taking the lead in their institutions, or at least being collaborative team members, when it comes to implementation. But I’m also seeing a movement of using pharmacogenomic testing at the point of care in community care settings. So it’s not only happening in hospital institutions or academic institutions, but with pharmacists taking the lead in their communities. For example, retail pharmacies, community pharmacies, and so on. 

There is a sense of satisfaction from being more involved in practicing on top of one’s license. There is also a sense of significant ramifications because pharmacists are expanding what they do and what they typically have done. Pharmacists incorporate pharmacology knowledge, but now they are adding this additional layer of genetic knowledge. You will often hear me say that I think of pharmacogenomics as pharmacology on steroids.

In order to understand how the basic science gets translated into clinical use, you have to have a good sense of how these medications are metabolized, so pharmacokinetic and pharmacodynamic knowledge is often needed and becomes essential. I think the pharmacists are medication experts, simply because they are the most extensively trained in applying pharmacology in their clinical practice and are therefore intuitive when it comes to implementing pharmacogenomics in their respective practices.

(Related Post: How Can Pharmacogenetics Be Helpful to Doctors? [Podcast]) 

In terms of implementing pharmacogenetics at the point of care, can you provide an example? 

There are actually several examples here in the US with the community pharmacies, including independent community pharmacies, using pharmacogenomic testing. There are several pharmacogenomic testing companies that are currently selling tests. That is a whole other conversation as to what kind of pharmacogenomic testing is available. The point becomes: how do we empower both pharmacists and physicians to know how to determine what type of pharmacogenomic testing should be used in their clinical practice? The hope is, whether it is in a community pharmacy setting, institutional setting and so on, that the pharmacogenomic testing used has a sound clinical board.

Mayo Clinic is a pioneer in the incorporation of drug-gene information in the clinician’s workflow. Can you share a bit about how it all happened and any challenges?

There are many challenges and opportunities in terms of PGx implementation. We touched on one, your basic and translational clinical research. How do we bring what we have observed in these studies to the clinic? Then, once we bring that to the clinic, how do we integrate that into the clinical workflow? One of the lessons is that there are a number of factors that need to be in place in order for the implementation to be successful.

3 Key Lessons Learned From Implementing Pharmacogenomics

One big lesson would be education. Education on pharmacogenomics knowledge and educating implementers is of the essence. As a matter of fact, we are not only focused on educating the clinicians who are practicing right now, but we’re also starting early, by implementing pharmacogenomic education in medical schools and medical residents getting PGx components and other genomic components as part of their education.

Once education is implemented, the question is: how do clinicians who have patients who were tested act on the results? Who’s going to guide them through this process? 

Our second big lesson has been to make sure that we have sound clinical decision support tools. Why is that important? Well, the pharmacogenomic data and studies are dynamic. This data changes. There could be new knowledge that is linked to a particular drug or set of genes or particular variants. A clinical decision support tool that is dynamic and working with this influx of knowledge can take a perceived and a real burden away from physicians or clinicians. They can have a guiding light as to how to act on the data and how to prescribe for patients that might be affected by these genes or genetic variants. Now this new knowledge can be implemented at the point of care. 

A third lesson is the need for standardization. These things need to be in place: standardized laboratory procedures and a process to make sure that the genetic language that’s used between different pharmacogenomic testing laboratories is not only sound but also reflective or the same.

There are many other things related to other issues such as pharmacogenomics testing, lab standardization, and reimbursement that we have encountered in terms of pharmacogenomics implementation. This really emphasizes the need for that institutional oversight. There should be logistics in place as far as: How do we interpret the evidence? What does clinical implementation look like based on the interpretation? To keep the ball rolling, there is still a lot to explore and develop in the field of pharmacogenomics.

You touched on some of the challenges that we need to overcome to make PGx useful in everyday clinical care. In your opinion, what do you think is going to be the most exciting development in personalized medicine going forward? 

There are several elements, but it seems like a lot of this leads to leveraging technology.

Some of the most exciting things that I am observing are how we can not only leverage but emphasize the need for things like artificial intelligence, machine learning, deep learning, and so on. We need to think about more complex or incomplete pictures here. 

We mentioned that pharmacogenomics is, in my mind, pharmacology on steroids. But when I meet with patients, it’s not just the genes or genetic variance that play a role here, it is usually a combination of things. For example, metabolomics, epigenomics, and microbiomes play a role as well. We also know that there are certain instances where gender plays a role in terms of medication metabolism and medication outcomes.

Patient specific factors change the outcomes for all of these factors that I just mentioned. We are hoping to have more of this multi-omics approach. AI seems like the most reasonable way to do that. 

Even with this pandemic, there are broad questions: how do we achieve better health with data sharing, interoperable data, telehealth, more empowered and patient-centered care, and scientists’ scientific breakthroughs? How do we integrate all of that to have better medication outcomes? We obviously cannot use traditional tools, so maybe the focal point will be challenging the ways that EHRs (electronic health records) are set up, making sure that we have this discrete data that is available to easily integrate in EHRs, and using AI to hopefully guide a better understanding of disease phenotypes and medication outcome phenotypes. 

(Related Post: Interoperability in Healthcare: Is It Living Up to The Hype?)

Due to the COVID-19 pandemic, we’ve just been through a watershed for virtual care. Seeing then how we can integrate all this complex information into a virtual consultation will be challenging. What do you think of the evolution of pharmacists into virtual care? 

We are, and we actually have been. Even prior to COVID-19, there were many efforts in place to integrate telehealth, telemedicine, or tele-counseling, especially when patients don’t have easy access to a pharmacist. This might be when patients live in rural areas or when patients might be bedridden, or when any patient-specific factors limit their exposure to direct face-to-face visits. 

The problem is that reimbursement is still lagging, just like with PGx. Because not only do we need larger, better empowered studies, we need these studies to produce results that are relevant for all. Personalized or precision medicine, even if you use them interchangeably or differently, are still predominantly white. We need to make sure that we are integrating data sets and compiling data sets that are representative of the overall population, not just pockets of the population. 

Telehealth has been very helpful as far as reaching out to people who may have limited access. More importantly, this is a consumer-driven endeavor; it’s less disruptive than having to get in your car and drive, go to the appointment, then drive back. The reimbursement part is going to be an interesting component to see, so hopefully better data will demonstrate the cost effectiveness of telehealth and PGx. 

Conclusion

It’s clear that pharmacists are in a unique position to lead the pharmacogenomic revolution, both in implementation and education. In fact, many pharmacists have already been implementing PGx into their pharmacy practice. But, there is still more to do. 

One of the key things that we have seen from this conversation is the need for standardization within the field of PGx. Not only would this improve the quality of communication about PGx, it is also likely required in order to implement the AI and machine learning techniques that are part of the future of personalized medicine.

The pandemic has shown how essential virtual health care is in our modern world. Leveraging technology to provide high-quality, safe virtual care is clearly on the rise, and PGx will likely be a part of that in the future with the right reimbursements and policy changes.

Thank you very much for giving us the time and helping us hear your experience and points of view, Adrijana!

About Precision Insights Podcast

The Precision Insights podcast is a podcast series consisting 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, healthcare executive, 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/health system as a result!

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