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Pharmacogenetics – the future of drug benefit plans

By Liz Bernier

Imagine a doctor’s visit where you need a new prescription. It’s for depression. You receive a prescription with a number of caveats about side effects – take it before bed if it makes you feel too drowsy to wake up in the morning. Take it with food if it makes you too nauseous to concentrate. Come back in six weeks to touch base about how it’s working; call if you have any pressing concerns.

Now, imagine your new prescription works wonders, straight away. No significant side effects. No experimentation with different formulas until you find the right drug. No time wasted; no fuss, no muss.

That could be the brave new world of drug prescribing – at least if Michael Prouse has anything to say about it.

Dr. Michael Prouse is the director of operations at Personalized Prescribing Inc., or P3. P3 is a personalized medicine company, a provider of pharmacogenetics testing, with a focus on the employer side.

“We’re Canadian-owned and Canadian-operated, and we’re committed to providing the highest quality pharmacogenetic solutions to organizations with an ultimate goal of improving the overall health of the workforce,” said Prouse. “Our mantra is always to bring personalized medicine to the workforce and to employers, and the way we do that is [by being a] provider of pharmacogenetic testing, which is drug compatibility testing that basically ensures that you’re on the right medication, at the right dose, the first time when taking a medication.”

The case for pharmacogenetics

Generally, the numbers make a pretty strong case for pharmacogenetic testing, says Prouse. Forty-one per cent of Canadians are currently taking prescription medications, according to research stats gathered by P3.

An estimated 840,000 hospitalized patients are given drugs that cause serious adverse reactions for a total of 2.74 million serious adverse drug reactions. About 128,000 people die from drugs prescribed to them, according to 2014 research from Harvard University’s Edmond J. Safra Center for Ethics.

“What science is showing us is that we actually are all unique, and we all have unique sets of liver enzymes – and based on those unique sets of liver enzymes, we are all unique in the way that we metabolize medications.” – Dr. Michael Prouse

One in four hospital admittances are drug-related, which costs us up to $17.7 billion per year, according to P3. And in the United States, adverse drug reactions are the fourth leading cause of death, says Prouse.

“That’s ahead of pulmonary disease, that’s ahead of diabetes, AIDS, pneumonia, accidents and automobile deaths,” he said. “It’s a severe problem in our society, and the reason is because physicians are generally prescribing from a one-size-fits-all [philosophy] – ‘What worked on one patient surely should work for another.’ But what science is showing us is that we actually are all unique, and we all have unique sets of liver enzymes – and based on those unique sets of liver enzymes, we are all unique in the way that we metabolize medications.”

But by allowing employees to utilize pharmacogenetic testing – or “drug compatibility testing” – many of these adverse reactions could be eliminated, says Prouse.

“If you’re on the right medication the first time, then you’re not going to be suffering from the long trial and error period of selecting a medication that works,” he said. “If you’re on the wrong medication, and you have a mental illness, you’re already having to deal with all those issues with the mental illness – you don’t need another problem that’s making the situation worse, such as a medication incompatibility.”

Many statistical reviews have shown that roughly 40 per cent of mental illness medications won’t work the first time; they’re just not effective, he says.

“It’s literally a shot in the dark selecting these medications. Our experience is that this tool has become a very targeted approach to combatting mental illness in the workplace,” said Prouse. “One in five people will suffer from a mental illness at some time in their life. And when it comes to the [treatment] component, it’s not like removing an aberration on their skin, and when that’s abolished, the medication is working – [in this case], it’s all in the beholder’s head. And it’s really hard to keep that objective.”

The new drug benefit plan

Pharmacogenetics has been shown to reduce disability claims, increase productivity and improve health outcomes among a general employee pool, says Prouse. And if that’s not enough, it’s also a valuable tool to help contain the burgeoning costs of drug plans amidst an aging workforce.

“We have found that the biggest use of pharmacogenetics to make your drug plan more effective is for people who are on polypharmacy. So imagine someone who is on three antidepressants. This is what I often see in the field... They first get prescribed the medication as a one-size-fits-all [solution] from their doctor, and imagine they’re a poor metabolizer of that medication. So now…they go back to the doctor and say, ‘I’m not feeling well on this.’ And the doctor says, ‘Let’s try another antidepressant to combat that,’” said Prouse.

Following this pattern, employees will often end up using more and more medications to cope with adverse drug reactions from the initial ones.

“What we do is identify which one single medication out of that whole cocktail would work, and predict which ones are ineffective. So what it could do is reduce three ineffective medications to one effective medication – which would drastically reduce your drug plan expenditure, but also improve the health of the patient simultaneously,” said Prouse.

The testing process itself is pretty straightforward, he says – employees with an organization enrolled in the program can call P3 directly at a toll-free number to have a consultant walk them through the process.

“After that’s done, the employee will be able to see what they want to see on their report. Sometimes, people don’t want to see any genetic information whatsoever – they only want to see the drug recommendations,” he said. “We’re only looking at liver enzymes – we don’t test for any disease risk.”

Once they decide these things, they receive their DNA kit in the mail. It’s a non-invasive kit – a “spit kit” – which takes only a couple minutes to complete. Then Puralator will come and pick it up, and take it to P3’s laboratory, says Prouse.

A pharmacogenetic consultant – like Prouse – will then go through the results with the employee.

“I’ll take into account their genetic information, their liver enzymes, see their metabolization status, and then I’ll look at their environment. I’ll ask, ‘Are you drinking grapefruit juice?’ Because it’s a potent liver enzyme inhibitor that can make a lot of antidepressants ineffective. So I’ll check the environmental factors, what other medications [they are] on.

“We’ll marry the environmental aspects and the genetic aspects into one summary.”

This type of testing empowers the patient, so they now can drive an advocacy conversation with their doctor. All of these factors can really help in changing prescribed medication down the line, says Prouse.

Although it may seem a little “sci-fi” when you first learn about it, pharmacogenetic testing has been around for more than a decade in Canada out of Mount Sinai Hospital, he says. And while it is impressive science, essentially it’s just one more tool to ensure employees have the best care available.

“At the end of the day, [health care providers] will utilize us as a tool – just like a carpenter uses a saw, a hammer or whatnot – we’re an additional tool that a doctor will utilize to increase the accuracy of a prescription,” said Prouse. 

Liz Bernier is a communications specialist at the Human Resources Professionals Association.

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