Pharmacogenomics: Emerging opportunity for pharmacists

Challenges remain around reimbursement, workflow integration

Pharmacogenomics is possible, but not a reality yet. That’s the opinion of many experts in the field right now who see it as a service pharmacists should be aligned with, particularly within medication therapy management (MTM).

A study published in the March/April 2014 issue of JAPhA tested the feasibility of implementing pharmacogenomics services in a community pharmacy setting. The study, conducted in a single community chain pharmacy, found that prescribers are receptive to having community pharmacists perform pharmacogenetic testing, but key challenges remain around reimbursement and integrating pharmacogenomics into a pharmacist’s existing workflow.

“Is it worth going over those hurdles? I think our study showed that it is,” said Shanna K. O’Connor, PharmD, BCPS, one of the authors of the study and Assistant Professor in the Department of Pharmacy Practice and Science at the University of Arizona College of Pharmacy. “There was a high acceptance rate and a positive reaction from patients to what we were doing.”

She said that once reimbursement and workflow integration are figured out, pharmacogenetic testing services in pharmacy clinical practice could really hit the ground running.

Pharmacogenomics in MTM

Pharmacists are uniquely qualified to take a leadership role in pharmacogenomics, which is defined as identifying drug-to-gene interactions that can optimize drug therapy selection.

According to David Kisor, PharmD, Department Chair of Pharmaceutical Sciences at Manchester University College of Pharmacy in Indiana, pharmacogenomics can naturally fit into MTM. “Pharmacists understand the mechanisms of drug interactions and can easily grasp gene interactions,” said Kisor.

A case report published online before print in the Journal of Pharmacy Practice on February 23, 2014, led by Kisor, demonstrates specifically how pharmacists can use a patient’s genetic information and make drug therapy choices for them.

The report details a community pharmacist who identified a 65-year-old patient with myocardial infarction for genetic testing to determine the most optimal antiplatelet medication for him. After undergoing percutaneous coronary intervention and stent placement, the patient was prescribed clopidogrel 75 mg. But during an MTM evaluation when the pharmacist determined the patient’s cytochrome P450 (CYP)2C19 genotype, he found that he was an intermediate metabolizer of clopidogrel. The pharmacist recommended prasugel 10 mg for the patient going forward, which the cardiologist accepted.

“It fits perfectly with MTM because it’s not cut and dry. Few drugs go through only one pathway, and so if one pathway is inhibited or completely shut down based on a genetic test result, other pathways might still work,” said O’Connor.

Identifying drug-to-gene interactions is similar to the drug–drug, drug–allergy, and drug–disease checks that pharmacists already do. Incorporating pharmacogenomics into a pharmacist’s workflow—and the databases already developed—would be easy theoretically, according to O’Connor.

The challenge of pharmacists getting paid for pharmacogenetic testing services is likely more difficult to overcome. Even if pharmacists gain provider status, O’Connor said that doesn’t necessarily mean they get paid enough money to cover the time that goes into providing the service.

Current landscape

Only a handful of community pharmacists currently offer pharmacogenetic testing services to patients. Theresa Tolle, BSPharm, FAPhA, Owner of Bay Street Pharmacy in Sebastian, FL, is one of them. She was approached by the genetic testing company Genelex almost 3 years ago to offer the service to patients in her pharmacy, send the cheek swab to a testing lab, and interpret the results for patients. Tolle said the process became easier and less time consuming after the initial implementation and investment in continuing education courses that got her up to speed.

David Bright, PharmD, BCACP, Assistant Professor in the Department of Pharmaceutical Sciences at Ferris State University College of Pharmacy, said that while there may be some initial fear from pharmacists in understanding genetics and relating that to pharmacokinetics, where dosing decisions are made, it’s something they pick up quickly. He said there needs to be more focus on education not only for pharmacists, but for patients and physicians as well.

Currently, pharmacogenetic testing service in a pharmacy is mainly cash based since pharmacists can’t bill for cognitive services, according to O’Connor.

Tolle said she has always used pharmacogenetic testing as a marketing opportunity and has not been paid because of concerns about kickback provisions within Medicare and Florida state law. She is hopeful pharmacogenetic testing will soon be billable as an MTM service.