Are you taking the right medications? | Viewpoint

Michael S. Awadalla of Tabula Rasa HealthCare (Photo: Tabula Rasa)

Before being taken by the public, all medications must undergo clinical trials. These are tests that are performed on enough people to ensure a drug is safe and effective. During this process, trials help identify recommended doses.

But when the drug is released in the real world, there is no guarantee that every patient will respond exactly the same way to a recommended dose. Some will get worse-than-expected side effects. For others, the drug will not work.

But why are there individual differences in response?

An individual’s genetics and knowledge of all other drugs taken by a patient can explain a lot of these differences. When pharmacists know this information, they can deliver personalized care and gauge if a particular drug or dose is best for a patient.

Your genetics: A clearer picture

Your genes have an enormous impact on how your body breaks down medications. This is called drug metabolism.

Pharmacogenomics helps pharmacists understand exactly how your genes impact metabolism. Pharmacists can look at a drug-gene pairing and evaluate whether you have the correct genetic makeup to metabolize the drug. If you do, your pharmacist might expect you’ll get a reasonable response from the medication. If not, the drug might not work at all, or it may cause more side effects.

Drug interactions: Getting clearer

This is a simple example based on one gene and one drug. But how many people take just one medication?

Very few. And we tend to see this especially in geriatrics, with 42% of older adults taking 5 or more prescription medications. We also know that there’s a 50% chance of a drug interaction in people taking 5-9 drugs. The probability of an interaction increases to 100% if someone is taking more than 20 drugs.

Now, let’s say a drug-gene analysis tells your pharmacist that you have the genetic makeup to properly metabolize clopidogrel, a blood thinner that helps prevent a heart attack. But if you’re also taking other drugs that hinder clopidogrel’s metabolism, this means clopidogrel will not properly thin your blood, so the interactions make it as if you didn’t have proper genetic makeup in the first place. This places you at greater risk of another heart attack – not a good outcome.

Existing systems fail us

Even if your pharmacist knows your entire drug regimen, traditional computerized support systems make it very difficult for your pharmacist to manage and integrate all the information related to complex drug regimens, genetic makeup and drug interactions. So, we fall short of truly personalized care.

Traditional systems use linear drug review, which looks at how one drug impacts another. The problem is, there could be hundreds of one-to-one interactions among the medications a person takes. This means hundreds of alerts for pharmacists to consider, which overloads the pharmacist with information.

Sometimes these alerts conflict. For instance, Drug A increases Drug B, but Drug C decreases Drug B. But what really happens to Drug B when Drugs A, B and C are taken together? In sum, important information can be easily missed due to many alerts, and there isn’t often a clear, holistic picture of a patient’s medication risk.

A better way

Better systems provide pharmacists with a comprehensive picture of the medication regimen’s pharmacodynamics and pharmacokinetics, while integrating genetic information. Pharmacodynamics looks at the effect medications have on the body. And pharmacokinetics considers how drugs might be absorbed, distributed and eliminated by the body. When this information is comprehensively analyzed, pharmacists can see much more clearly how a patient might respond to their medications. Such a system helps pharmacists truly personalize care.

This is not the end of the story. You may see multiple doctors who each prescribe different medications. With all of these silos, who’s challenging why you’re taking all of these prescriptions? So, another big part of personalized care is “deprescribing” to remove unnecessary meds. As medication experts, pharmacists can help coordinate this effort with your doctors.

After genetics are considered, interactions are minimized and unnecessary medications are deprescribed, pharmacists can fine-tune even further to fit your lifestyle. Different patients might take drugs that cause drowsiness at different times of the day or night, depending on their schedules.

Personalization works

Importantly, in reducing medication risk and advancing patient safety, personalized care helps reduce adverse drug events, emergency room visits and hospitalizations, which in turn reduces healthcare costs.

In fact, personalized care has been proven to significantly reduce total healthcare costs for Program of All-Inclusive Care for the Elderly (PACE) organizations – with research showing over $5,000 in cost benefit per patient with personalized medication management services. Similar results have been shown in a broader Medicare population.

So, personalized care driven by pharmacy is a win all around. It provides more confidence that patients are taking the right medications while reducing healthcare costs for organizations.

Michael S. Awadalla is executive vice president office of applied pharmacotherapy at Tabula Rasa HealthCare.