Precision medicine has been given ambitious descriptors: a miracle, a marvel, even a panacea. Consumers are plugging into the hype, with a recent survey commissioned by Wolters Kluwer finding that 68% of Americans believe their own DNA could help guide their providers’ prescription decisions.
But at the other end of those hopeful expectations are the sobering realities of genomic innovations that haven’t yet found sweeping success. One 2018 opinion from the Advisory Board emphasized a 93% failure rate of precision medicine, for example. Another 2019 piece from Stat called for a vigorous debate on its utility.
Pharmacists are finding themselves at the crossroads of those dueling dynamics as their role and reach expands: The same Wolters Kluwer survey found that 61% of Americans expect primary care to occur outside the traditional doctor’s office, largely in pharmacies, retail clinics, and pharmacy clinics.
With pharmacists assuming influential roles across interventional care, many may interact with genomics more than ever before. But as they do, pharmacists should consider the realities of precision medicine, advise expert panelists from a recent Wolters Kluwer webinar titled “Pharmacy Next: Safer, Affordable and Personalized.”
Exploring topics across pharmacogenetics and beyond, panelists discussed key areas to address before genomics fully grows into its promise.
New developments in team-based precision pharmacy
With pharmacogenetic associations, providers can start to understand which drugs are likely to help or hurt patients. And that understanding is steadily growing thanks to newly available data, such as the All of Us program which released its first batch of genomic insights in 2022.
“On a day-to-day basis, I’m really lucky that I get to see a lot of the benefits that precision medicine can provide,” said Natasha Petry, PharmD, MPH, BCACP, at Sanford Health and NDSU. “I get to look at pharmacogenetics results, and I get to look at disease predispositions and screenings and help patients either get on a medication that’s more likely to work or avoid a medication because of an increased risk of adverse events.”
Dr. Petry sees that playing out in primary care—a key opportunity for pharmacists—as well as cardiology, pain management, and other specialties. As pharmacists become more involved in that interdisciplinary genomic care, successful models increasingly incorporate a team-based approach, adds Stacey McCoy PharmD, MS, BCPS, Pharmacy Clinical Program Manager, CSC at Wolters Kluwer.
“Successful implementation of a comprehensive pharmacogenomics program should involve interprofessional collaboration involving testing, diagnosis, clinical and patient education, along with the usage of technology via the electronic health record and clinical decision support,” she said, citing team-based models at Vanderbilt, the University of North Carolina, Mayo Clinic, and the University of Florida. “The delivery of care using this system can be described as interdisciplinary involving health-system administrators, laboratory clinicians, nurses, dieticians, pharmacists, and physicians.”
The need for more evidence-based insights
Momentum notwithstanding, pharmacogenetics has limitations—like the need for more evidence. As pharmacists see their roles expand, they should avoid relying outright on genomic insights, panelists explained.
“Sometimes the provider will say, well, we'll get a genetic test and we'll be able to look at this whole list and provide recommendations,” Dr. Petry said. “And that's just not the case where we're at right now. There's just not enough evidence-based prescribing information to make recommendations for all medications.”
Webinar moderator Dan Streetman, Associate Director, Clinical Content - Referential Drug Interactions and Pharmacogenomics, agrees:
“While we know that genomics can impact the safety and effectiveness of dozens of medications, many fewer studies have described how to use this information to improve clinical outcomes,” he said. “I think this is an essential piece for getting widespread acceptance of pharmacogenomics that will be needed for its adoption into the mainstream.”
Contextualizing pharmacogenetics care, education, and consent
Even with all the evidence in the world, though, there’d still be blind spots that impact care. Pharmacists should continue to consider that fuller health picture—zooming out beyond pharmacogenetics toward more context that assesses social determinants of health and other health contributors.
“Genetics is just one piece of the puzzle,” Dr. Petry said. “It's not the end all, be all. We have to consider the other clinical components of the patient’s care.”
Technology can help provide that context, from decision support and systems integrations that enable more comprehensive care to resources that help consumers learn about the changing genomics universe.
“Work needs to be done to ensure EHRs, laboratories, and clinical decision support systems can work together to get the necessary information to the prescriber,” Streetman said. “Surveys have also consistently found that prescribers and other clinicians want more education about pharmacogenomics.”
Education is indeed critical, added Daniel Knecht, MD, MBA, of CVS Caremark:
“We need to spend the time and effort to actually explain what an allele or a snip or a genetic mutation means,” he said. “What are the implications for that patient and their family?”
Beyond all that, there’s still the question of consent. It’s considered one of the bigger ethical issues of precision medicine, hearkening back to cautionary tales such as Henrietta Lacks’. If pharmacists become more involved in pharmacogenetic decision-making, they’ll need to prepare for these responsibilities as well.
“What’s more personal than your DNA?” Dr. Petry said. “When we think about patients being willing to get this test done, [we need to consider] where are they getting it done and what are the processes behind who’s doing it…. We’ve seen a thirst of consumers for this information, but how closely are they reading those consent forms?”
Pharmacogenetics, today and tomorrow
Precision medicine has saved many lives, but its potential hasn’t fully been realized… yet. As pharmacists await more evidence from which to guide the everyday decision-making expected of their changing roles, they should prepare themselves for the likely rush of personalized pharmacy care.
Getting ready will require a few changes to contextualize genomics, such as technology that integrates systems, provides decision support, and educates consumers. But pharmacists may also need to consider the nuances of ethics, equity, and consent, as well as how best to meaningfully integrate genomics into care.
All that to say—there are promises, yes. But there are also realities to consider first.
“I would love to sit here and be the cheerleader and say, it's everything that we’re selling it to be and maybe it someday can be,” Dr. Petry said. “But, as a whole, there's a lot more work that we need to do. And we need to prepare for it to make precision a part of the standard of care.”
Download the panel report and the survey infographic to learn more about the shifting pharmaceutical industry and the expanding role of the pharmacist. Visit Pharmacy Next to view the full webinar and explore additional survey resources.