Pharmacogenomics In Pharmacy Practice: Current Perspectives

QPGx-CARES: Qatar pharmacogenetics clinical applications and research enhancement strategies

Pharmacogenetic (PGx)-informed medication prescription is a cutting-edge genomic application in contemporary medicine, offering the potential to overcome the conventional "trial-and-error" approach in drug prescription. The ability to use an individual's genetic profile to predict drug responses allows for personalized drug and dosage selection, thereby enhancing the safety and efficacy of treatments. However, despite significant scientific and clinical advancements in PGx, its integration into routine healthcare practices remains limited. To address this gap, the Qatar Genome Program (QGP) has embarked on an ambitious initiative known as QPGx-CARES (Qatar Pharmacogenetics Clinical Applications and Research Enhancement Strategies), which aims to set a roadmap for optimizing PGx research and clinical implementation on a national scale. The goal of QPGx-CARES initiative is to integrate PGx testing into clinical settings with the aim of improving patient health outcomes. In 2022, QGP initiated several implementation projects in various clinical settings. These projects aimed to evaluate the clinical utility of PGx testing, gather valuable insights into the effective dissemination of PGx data to healthcare professionals and patients, and identify the gaps and the challenges for wider adoption. QPGx-CARES strategy aimed to integrate evidence-based PGx findings into clinical practice, focusing on implementing PGx testing for cardiovascular medications, supported by robust scientific evidence. The current initiative sets a precedent for the nationwide implementation of precision medicine across diverse clinical domains.

Identification of the effects of pathogenic genetic variations of human CYP2C9 and CYP2D6: an in silico approach

Genetic variations in the human cytochrome P450 family 2 subfamily C member 9 (CYP2C9) and cytochrome P450 family 2 subfamily D member 6 (CYP2D6) genes may affect drug metabolism and lead to alterations in phenotypes. Genetic variations are associated with toxicity, adverse drug reactions, inefficient treatment. Various in silico tools were combined to investigate the deleterious effects of missense non-synonymous single nucleotide polymorphisms (nsSNPs) of the human CYP2C9 and CYP2D6. The structural and functional effects of the high-risk non-synonymous SNPs in the human CYP2C9 and CYP2D6 were predicted by numerous computational mutation analysis methods. Out of 24 pathogenic missense SNPs in the CYP2C9, 22 nsSNPs had a decreasing effect on protein stability and 13 SNPs were showed to be located at conserved positions. Out of 27 high-risk deleterious non-synonymous SNPs in the human CYP2D6, 21 SNPs decreased protein stability and 16 nsSNPs were predicted to be positioned at conserved regions. Our present study suggests that the identified functional SNPs may affect drug metabolism associated with CYP2C9 and CYP2D6 enzymes.

Mapping Australian pharmacy school curricula for content related to pharmacogenomics

Background

Pharmacogenomics (PGx) is a rapidly growing field which promises to deliver personalized, more effective medications tailored to genetic information. Although the pharmacy profession is expected to lead the translation of pharmacogenomics into widespread clinical implementation, there is a reported lack of preparedness among its members. Assessing pharmacogenomic-related training in Australian pharmacy program curricula may highlight educational gaps and provide guidance for curricula revision.

Objective

To examine pharmacogenomic content in Australian tertiary pharmacy program curricula.

Methods

We reviewed the curriculum of 22 Australian registrable pharmacy degrees, including 16 Bachelors of Pharmacy programs (with or without honors) and six Masters of Pharmacy programs, for content related to pharmacogenomics and genetics. This was done by screening the publicly available electronic course profiles on each institution's website and searching for key terms such as "pharmacogenomics," "pharmacogenetics," "genes," and "genetics". Three mapping activities were completed to assess the breadth and depth of pharmacogenomic training according to; 1. Bloom's taxonomy, 2. Author-assigned domains comprising; Enabling science, Translational science and Clinical implementation, and 3. Pharmacogenomic competencies from the National Human Genome Research Institute (NHGRI).

Results

A total of 18 (82%) pharmacy registrable degree programs incorporated pharmacogenomics and/or genetics in their curricula. Four programs (18%) offered standalone PGx courses and 10 (45%) contained integrated PGx content in other science-related courses (i.e. pharmaceutical biology, biochemistry, microbiology etc.). Mapping activities showed that most learning objectives related to the "Understand" level of Bloom's taxonomy (61%), the "Basic Genetic Concepts" domain of NHGRI's competencies (64%) and "Enabling science" (84%).

Conclusions

Most Australian pharmacy registrable degrees have incorporated pharmacogenomic content in their curricula however, the scope of training is limited. Revisions to course curricula should be made to incorporate additional education with a focus on application-based training of clinical pharmacogenomics.

Community pharmacists’ perceived value on precision medicine, desired training components, and exposure during pharmacy education: Malaysia’s experience

Background: Precision medicine beckons new horizons for therapy geared to one’s genetics, lifestyle, and environmental determinants. Molecular, pathology, and clinical diagnostics can be integrated to provide pharmaceutical care.

Aims: The value and appeal of precision medicine to community pharmacists, knowledge attained, and training programmes perceived as necessary were evaluated.

Methods: Over 10 months, a published questionnaire, which was also digitally accessible during the COVID-19 outbreak, was distributed by hand, via email and social media. 300 community pharmacists across 9 districts in an urban state in Malaysia, self-administered and returned completed versions (response rate 75%). Three- or five-point Likert scale and multiple-choice responses were analysed using SPSS to assess whether or not exposure through the pharmacy curricula impacted current knowledge, perception and willingness to pursue precision medicine.

Results: Respondents were largely: females (N = 196, 65.3%) and practicing for up to 10 years (N = 190, 66.3%). Although knowledge levels were moderate (76%), positive perceptions were showcased (94%), and 80% were willing to integrate precision medicine into their daily practice. Although 61% did not or do not recall having had prior exposure to pharmacogenomics as part of their pharmacy school curricula, many (93%) were willing to attain knowledge by undergoing additional training. Desired training included current pharmacogenetic testing available (17%), interpretation of the test results (15%), and ethical considerations (13%). Community pharmacists who had 0.5–10 years’ work experience possessed greater knowledge (μ = 1.48, CI 1.35–1.61, p = 0.017), than the pharmacists who had 21–40 years of work experience (μ = 1.28, CI 1.05–1.51, p = 0.021). Exposure to the subject during pharmacy education positively impacted the willingness to integrate precision medicine in daily practice (p = 0.035).

Conclusion: Community pharmacists were receptive to and valued precision medicine. A relatively high number had prior exposure to concepts of precision medicine through the pharmacy curriculum, and were therefore willing to adopt the practice in their day-to-day provision of healthcare. With adequate training centred on bioethics, utilising pharmacogenetic testing, and interpretation of the results, community pharmacists will be equipped for the provision of precision medicine services in the foreseeable future.

Pharmacists' Knowledge, and Insights in Implementing Pharmacogenomics in Saudi Arabia

BACKGROUND

Pharmacogenomics (PGx) and personalized medicine embrace the potential to optimize drug treatment and improve the patient's quality of life. Pharmacists' roles include contributing to genetic testing, patient counseling, and pharmacotherapies selection for superior treatment outcomes. The aim of this study is to assess the pharmacists' knowledge, insight, and self-confidence toward PGx testing, identify their future preferred education patterns, and determine the barriers to pharmacogenomic testing implementation.

METHOD

A cross-sectional study was conducted using a previously validated questionnaire among pharmacists working in the Kingdom of Saudi Arabia (KSA). The questionnaire was designed in seven major categories, consisting of 26 questions.

RESULTS

A total of 671 pharmacists participated in this survey. As for knowledge, only 29.8% of pharmacists had good knowledge regarding PGx, while 42.9% had poor knowledge levels. Respectable PGx knowledge was significantly higher among outpatient dispensing pharmacists (33.6%; p = 0.049) and among pharmacists who had completed PGx testing-related training or education (40.3%; p = 0.001). Considering perception, it was positive among 50% of pharmacists and negative among 19.8%. With regard to self-confidence, it was high among 39.2% of male pharmacists (p = 0.042), among 43% of clinical pharmacists (p = 0.006), and among 44.8% of pharmacists who had extra credentials (p = 0.001). The utmost favored continuing-education learning approaches were workshops or seminars. The barriers to the implementation of PGx testing included a lack of testing devices, clinical guidelines, training or education, and personnel.

CONCLUSION

The present study revealed that pharmacists in KSA had inadequate knowledge and understanding of PGx. Nevertheless, the majority established that PGx is a valuable tool for augmenting drug efficacy and safety.

Nation-Wide Survey Assessing the Knowledge and Attitudes of Romanian Pharmacists Concerning Pharmacogenetics

Background: Pharmacogenetics (PGx) is an important component of personalized medicine that has the potential to improve medicines' effectiveness and safety. However, despite progress in technology and availability, PGx testing application into patient-care in Eastern Europe countries, has been slow. Objectives: Our aim was to describe knowledge and attitudes of Romanian pharmacists concerning PGx, and identify potential factors limiting PGx implementation. Method: An anonymous, web-based questionnaire was distributed to Romanian pharmacists registered in the National Pharmacists' Association (NPA) via an official e-mail sent by NPA representatives. Results: A total of 1,058 pharmacists completed the questionnaires, resulting in a response rate of 7.6%. Pharmacists were predominantly female (90.1%), younger than 49 years (87.5%) and mostly worked in community pharmacies (80.2%). Most pharmacists (64.8%) had a knowledge score between 30 and 49 points out of 60, and (75.4%) had attitude scores between 9 and 7 out of 10. Attitude and knowledge scores positively correlated. Conclusion: Despite performing fairly well on general questions regarding PGx, Romanian pharmacists may lack in-depth knowledge, which can affect their readiness to discuss PGx information with patients or other healthcare professionals. High pricing was considered an important impediment in PGx implementation.

Antibiofilm Activity of Azadirachta indica and Catharanthus roseus and Their Synergistic Effects in Combination with Antimicrobial Agents against Fluconazole-Resistant Candida albicans Strains and MRSA

The rapid emergence and spread of antimicrobial resistance has become a global public health concern that threatens the effective treatment of infectious diseases. One major approach adopted to overcome antimicrobial resistance is the use of plant extracts individually and/or with combination of antibiotics with plant extracts, which may lead to new ways of treating infectious diseases and essentially representing a potential area for further future investigations. In this study, the antifungal activities of Azadirachta indica leaf and Catharanthus roseus flower extracts against fluconazole-resistant Candida albicans strains (isolated from pregnant women with vulvovaginal candidiasis) and anti-methicillin-resistant Staphylococcus aureus (MRSA) were evaluated by agar well diffusion, microdilution, and biofilm inhibition assays. Subsequently, the determination of the combined antimicrobial activity of the individual plant extracts with (fluconazole and voriconazole) and (ampicillin, tetracycline, and streptomycin) against C. albicans strains and MRSA, respectively, was evaluated by checkerboard microdilution assay. Results from the study showed that the antimicrobial activity of the two plant extracts determined by time-kill kinetics was fungistatic with their MICs ranging from 0.1 to 4 mg/mL. Interestingly, all extracts were proved as good biofilm inhibitors of resistant C. albicans and MRSA from 10.1 to 98.82%. Their combination interaction with fluconazole, voriconazole, ampicillin, tetracycline, and streptomycin ranged from synergy to antagonism as per the parameters used. Overall, these results showed that A. indica leaf and C. roseus flower extracts have significant antifungal property. Furthermore, A. indica leaf and C. roseus flower extracts alone or in combination with fluconazole and voriconazole could provide a promising approach to the management of candidiasis caused by drug-resistant strains as well as their interaction with the antibacterial agents to combat the common infections caused by MRSA.

Examining key factors impact on health science students' intentions to adopt genetic and pharmacogenomics testing: a comparative path analysis in two different healthcare settings

BACKGROUND

There is an increasing interest worldwide in investigating healthcare stakeholders' perceptions and intentions to adopt pharmacogenomics (PGx) into clinical practice. However, the existing inquiries based on well-established theories and models that interpret their intentions to implement PGx are scarce. This study is the first that examines the impact of selected factors on health science students' intention to adopt genetic testing applications using the technology acceptance model while it compares two different cultural groups: Greeks (Europe; Christian) and Malays (Asia; Muslim).

RESULTS

Malay students were more persuaded about benefits of genomics for drug management compared to their Greek counterparts. However, participants from both countries appear to be particularly convinced about the benefits of genomics on disease management. Moreover, students from both countries considered the potential misuse of genetic information by corporate or government bodies as their most important concern; Greek students appeared to be considerably less worried than Malay about other probable hazards such as the deficient protection of privacy and confidentiality, which could be attributed to their religious background. Participants from both samples expressed very positive attitudes towards genetic research and testing and their favourable intentions to adopt genetic testing for personal use. Exploratory factors analysis and path analysis yielded quite similar results for both samples. Path analysis revealed that the factors of attitudes, concerns, drug management benefits and disease management benefits significantly influenced students' intentions to adopt genetic testing for personal use, with attitudes being the most inspirational factor with rather high impact, while training did not seem to affect participant's intentions. The squared multiple correlation of both models was quite satisfactory reaching to 0.55 for the Malaysian sample.

CONCLUSION

Similarities in the results of the two groups along with the relevant validity and reliability tests indicate that the proposed model is a good fit for future studies to interpret stakeholders' intentions to adopt genetic testing. Therefore, it can provide a promising and reliable basis for future model development to explain the relationships between intentions to adopt genetic testing and its predictors.

Pharmacogenetic interventions to improve outcomes in patients with multimorbidity or prescribed polypharmacy: a systematic review

Conventional medicines optimisation interventions in people with multimorbidity and polypharmacy are complex and yet limited; a more holistic and integrated approach to healthcare delivery is required. Pharmacogenetics has potential as a component of medicines optimisation. Studies involving multi-medicine pharmacogenetics in adults with multimorbidity or polypharmacy, reporting on outcomes derived from relevant core outcome sets, were included in this systematic review. Narrative synthesis was undertaken to summarise the data; meta-analysis was inappropriate due to study heterogeneity. Fifteen studies of diverse design and variable quality were included. A small, randomised study involving pharmacist-led medicines optimisation, including pharmacogenetics, suggests this approach could have significant benefits for patients and health systems. However, due to study design heterogeneity and the quality of the included studies, it is difficult to draw generalisable conclusions. Further pragmatic, robust pharmacogenetics studies in diverse, real-world patient populations, are required to establish the benefit of multi-medicine pharmacogenetic screening on patient outcomes.

Designing an evidence based community pharmacy service specification for a pharmacogenomic testing service

BACKGROUND

Pharmacogenomics is a novel arena of medicine that uses patients' Deoxyribonucleic Acid to support pharmacists and prescribers selecting the most appropriate medicine for patients.

AIM

To review and validate a service specification for a pharmacogenomics testing service.

METHOD

Consensus methods (Delphi method and the Nominal Group Technique) were deployed. A consensus panel comprising of pharmacists, prescribers and patients was convened to participate in the co-design process. Panel members were first surveyed to obtain their views on Behaviour Change Techniques identified as necessary for the service in a previous study. Following this, a workshop was convened to discuss, agree and confirm details for the service specification and recommend strategies for operationalisation. Outputs from the workshop were used to inform a final version of the service specification.

RESULTS

From the consensus panel (pharmacists (n = 6), general practitioners (n = 3) and patients (n = 3)), strategies for operationalisation of nine Behaviour Change Techniques were agreed as being required. In addition, several unique and innovative strategies for implementation of the community pharmacy service were identified and included in the service specification.

CONCLUSION

The research shows that to encourage community pharmacist engagement in providing a pharmacogenomic testing service and prescriber acceptance of recommendations for any changes to patients' prescriptions, a multi-professional launch event is required. To agree communication strategies and professional boundaries, training in clinical decision making and patient support materials are required as is guidance on how to deliver the service in a standardised manner. Finally, healthcare professionals would be reassured by the provision of an expert help-line for any complex patients.

Development of the pharmacogenomics and genomics literacy framework for pharmacists

BACKGROUND

Pharmacists play a unique role in integrating genomic medicine and pharmacogenomics into the clinical practice and to translate pharmacogenomics from bench to bedside. However, the literature suggests that the knowledge gap in pharmacogenomics is a major challenge; therefore, developing pharmacists' skills and literacy to achieve this anticipated role is highly important. We aim to conceptualize a personalized literacy framework for the adoption of genomic medicine and pharmacogenomics by pharmacists in the United Arab Emirates with possible regional and global relevance.

RESULTS

A qualitative approach using focus groups was used to design and to guide the development of a pharmacogenomics literacy framework. The Health Literacy Skills framework was used as a guide to conceptualize the pharmacogenomics literacy for pharmacists. The framework included six major components with specific suggested factors to improve pharmacists' pharmacogenomics literacy. Major components include individual inputs, demand, skills, knowledge, attitude and sociocultural factors.

CONCLUSION

This framework confirms a holistic bottom-up approach toward the implementation of pharmacogenomics. Personalized medicine entails personalized efforts and frameworks. Similar framework can be created for other healthcare providers, patients and stakeholders.

Barriers to clinical adoption of pharmacogenomic testing in psychiatry: a critical analysis

Pharmacogenomics (PGx) is the study of genetic influences on an individual's response to medications. Improvements in the quality and quantity of PGx research over the past two decades have enabled the establishment of commercial markets for PGx tests. Nevertheless, PGx testing has yet to be adopted as a routine practice in clinical care. Accordingly, policy regulating the commercialization and reimbursement of PGx testing is in its infancy. Several papers have been published on the topic of challenges, or 'barriers' to clinical adoption of this healthcare innovation. However, many do not include recent evidence from randomized controlled trials, economic utility studies, and qualitative assessments of stakeholder opinions. The present paper revisits the most cited barriers to adoption of PGx testing: evidence for clinical utility, evidence for economic effectiveness, and stakeholder awareness. We consider these barriers in the context of reviewing PGx literature published over the past two decades and emphasize data from commercial PGx testing companies, since they have published the largest datasets. We conclude with a discussion of existing limitations to PGx testing and recommendations for progress.

Development of a laboratory-based pharmacogenomics independent study and advanced pharmacy practice experience: Connecting basic science to clinical application

BACKGROUND AND PURPOSE

The role of pharmacists in pharmacogenomics (PGx) use clinically is expanding, leading to increased pharmacy education requirements. Current reports indicate that PGx is primarily taught through didactic courses, indicating a need for applied coursework in pharmacy curricula, including laboratory exercises and clinical experiences. Such courses are instrumental in helping students connect the science of PGx to patient care.

EDUCATIONAL ACTIVITY AND SETTING

An advanced PGx independent study and a similar advanced pharmacy practice experience (APPE) were developed. These courses included personal genetic testing, raw genetic sequence data analysis, and wet-laboratory genetic testing. The APPE included sessions with clinical pharmacists who use PGx and a genetic counselor, as well as a visit to a genetic reference laboratory. A pre-/post-examination and survey were used to measure the courses' effectiveness and student perceptions of their abilities, PGx, and course components. For this pilot study one student per course was evaluated.

FINDINGS

Each student completed all components of the courses successfully, supporting the feasibility of their implementation. Examination scores increased for both students with improvement in knowledge from basic genetics to clinical application. Both students also had a more positive perception of PGx after the courses and valued the various course components.

SUMMARY

Through this unique course format, pharmacy students developed expertise in understanding and implementing PGx which allowed them to gain skills that go beyond an introductory course. Our experience may provide guidance to other pharmacy programs in adding more applied PGx education to their curricula.

Knowledge, perception, and confidence of hospital pharmacists toward pharmacogenetics in Jeddah, Kingdom of Saudi Arabia

Background

Integrating pharmacogenetics (PGx) testing into clinical practice leads to personalized medicine, which improves treatments’ efficacy and safety. Successful implementation of such a service requires sufficient knowledge, perception, and self-confidence among healthcare providers, especially pharmacists.

Objectives

To evaluate governmental hospital pharmacists’ knowledge, perception, and self-confidence toward PGx testing in Jeddah, Kingdom of Saudi Arabia.

Method

This cross-sectional study was conducted using previously validated questionnaire. Pharmacists working in five randomly selected general governmental hospitals in Jeddah between August and October 2019 were interviewed. Comparative and descriptive analyses were used to analyze the data, and the significance level was at P-value < 0.05.

Results

A total of 119 pharmacists with a mean (±SD) age of 31.2 (±5.05) years were included with a response rate of 79.3%. The average total mean (±SD) score for PGx knowledge-based questions was low (2.4 ± 1.09 out of 5). Most of the participants, with a total mean score of (10.1 ± 1.6 out of 12), revealed a positive perception toward PGx testing and its implications. A moderate self-confidence score for utilizing PGx testing (4.3 ± 2.3 out of 8) was observed among the participants. Pharmacists who had completed postgraduate studies had a statistically higher mean knowledge score (P = 0.006) compared with pharmacists with undergraduate degrees.

Conclusion

Governmental hospital pharmacists have limited knowledge and understanding about PGx testing; however, the majority expressed a high level of awareness and agreed that PGx testing is a valuable tool for enhancing drug efficacy and safety. The study also highlighted the importance of improving pharmacists’ knowledge about PGx testing, which will help them in implementing such a valuable service into their clinical practice in Saudi hospitals.

Assessment and clinical utility of pharmacogenomics by healthcare practitioners in North Carolina

Aim: Perceived knowledge, use and perceptions of pharmacogenomics (PGx) testing were assessed among healthcare practitioners in North Carolina. Materials & methods: A validated survey was distributed to various healthcare professionals and analyzed for differences among the groups. Results: The majority of the 744 survey respondents acknowledged the perceived benefits of PGx testing, but indicated either never or rarely using it. A substantial percentage of practitioners reported educational experiences but the majority had received no training. Among groups reporting using PGx testing, barriers to implementation were cost and insufficient training. Conclusion: The perceived cost of PGx testing and insufficiency or lack of training are major contributing factors to the infrequent use of PGx testing by healthcare providers in North Carolina.

Democratizing genomics: Leveraging software to make genetics an integral part of routine care

Genetic testing can provide definitive molecular diagnoses and guide clinical management decisions from preconception through adulthood. Innovative solutions for scaling clinical genomics services are necessary if they are to transition from a niche specialty to a routine part of patient care. The expertise of specialists, like genetic counselors and medical geneticists, has traditionally been relied upon to facilitate testing and follow-up, and while ideal, this approach is limited in its ability to integrate genetics into primary care. As individuals, payors, and providers increasingly realize the value of genetics in mainstream medicine, several implementation challenges need to be overcome. These include electronic health record integration, patient and provider education, tools to stay abreast of guidelines, and simplification of the test ordering process. Currently, no single platform offers a holistic view of genetic testing that streamlines the entire process across specialties that begins with identifying at-risk patients in mainstream care settings, providing pretest education, facilitating consent and test ordering, and following up as a "genetic companion" for ongoing management. We describe our vision for using software that includes clinical-grade chatbots and decision support tools, with direct access to genetic counselors and pharmacists within a modular, integrated, end-to-end testing journey.