Pharmacogenomics in Pharmacy Practice
Creators: Shields, Meagan R
Publisher: name: University of Alberta Library
Year: 2022

<p>Background: Pharmacogenomics (PGx) has potential to improve healthcare through personalized drug selection and dosing using genetic predictors of pharmacokinetics and/or pharmacodynamics (PK/PD). Research is uncovering PGx’s impact on morbidity and mortality from medication adverse effects and/or inefficacy. Additionally, prescribing guidelines are available from organizations such as the Clinical Pharmacogenomics Implementation Consortium to assist PGx-guided medication assessment. With competency in medication therapy management (MTM) and understanding of PK/PD, pharmacists are proposed to be implementers of PGx. Despite potential benefits and resources for PGx, it is not broadly utilized in Canada. For pharmacists to adopt PGx, it is imperative to evaluate the feasibility and clinical utility of PGx in pharmacy practice, and thus this thesis aims to 1) evaluate prior pharmacy PGx research, 2) improve and assess pharmacist PGx competencies, and 3) implement and observe PGx in community pharmacies.<br>
Methods: A scoping review was conducted to identify non-oncologic pharmacy practices utilizing PGx. Terms were applied to MEDLINE, Embase, Scopus, CINHAL, and Web of Science Core Collection from inception to November 2020. With this review and other literature, a course on PGx was created. Pharmacists in Alberta were invited to participate in 5 hours of didactic lectures and 6 case studies through virtual synchronous, online asynchronous, or mixed method learning. Course efficacy was evaluated through pre- and post-course surveys measuring subjective and objective competency in PGx through 11 Likert-scale and 7 exam-style questions, respectively. Following education, some pharmacists implemented PGx testing in community pharmacies. Data was collected on demographics, PGx indication, PGx results, and identification of drug-gene interactions (DGIs). A feasibility assessment was performed, summarizing mean time of service.<br>
Results: The review found 43 studies between 2007-2020 describing applications of PGx in pharmacy practice. Most occurred in institutional (51.2%) or community pharmacy (23.3%) settings, with others in primary care clinics (11.6%), long-term care (4.7%), pharmacy benefit managers (4.7%), hospice (2.3%), and home-health (2.3%). Cardiovascular, psychiatric, and analgesic PGx applications were most common, with many studies evaluating the use of multi-gene panels in a complex polypharmacy population. Therefore, these topics were of key focus in the PGx education course. Thirty-six pharmacists (10 synchronous, 9 asynchronous, and 17 mixed) were included in the primary analysis. These pharmacists reported experience in community (88.9%), hospital (38.9%), academic (8.3%), and industry (5.6%) settings; 69.4% reported prior education or exposure to PGx. Responses on confidence and opinions in PGx moved from a median of “Disagree” at baseline to “Agree” after receiving PGx education (2-point difference on Likert Scale [1,2]; p &lt; 0.001), indicating improved self-rated competency and positive opinions after training. Likewise, participant grades on the knowledge test improved with education (20.8 ± 21.9% pre-course vs. 70.2 ± 19.1% post-course, p &lt; 0.001 with a strong correlation between increases in attested and tested competency (mean Likert responses in agreeance with confidence in pharmacogenomics increased by 0.12 ± 0.03 points for every correct answer gained on the knowledge test after education; r = 0.516, p = 0.002). Pharmacists trained in PGx provided PGx testing to a total of 46 patients among 8 pharmacies across Alberta. Twenty-four test results have been returned with a mean of 1.1 DGIs per patient. Fifteen had care-plans with 26 drug therapy problems (DTPs) identified. DTPs were managed by monitoring without medication changes in 11 DTPs, and through recommendations made to the patient’s primary care provider in 11 DTPs. Recommendations were to change medication (27.3% of recommendations), followed by dose increase (27.3%), dose decrease (18.2%), start new medication (18.2%), and stop medication (9.1%). On average, PGx-based services took pharmacists a total of 78.3 ± 12.2 minutes to provide (n = 9), with test turnaround times at 60 (30,65) days (n = 19).<br>
Conclusion: PGx research in pharmacy has grown over the last decade, with evidence supporting a variety of indications. Pharmacists improved their knowledge in PGx proportional to their own self-assessed ability improvement through a tailored education program. Pharmacists were able to utilize PGx to identify DGIs and DTPs in implementation, collaborating with patients and other healthcare providers to tailor medication therapy in a precision medicine framework. Through evaluating the evidence, educating pharmacists, and observing the use of PGx in practice, we can support broad-scale adoption and future research of PGx in pharmacies across Alberta.</p>