Why pharmacogenomics matters to community pharmacy

David Wright, Professor of Health Services Research at the University of Leicester leads a research team focused on design and implementation of routine pharmacogenomics (PGx) services in community pharmacy. IMI spoke to him to find out more about this developing field and the implications for community pharmacy.

Professor Wright leads studies concerned with improving the delivery of healthcare to patients and these often involve complex, multidisciplinary interventions. As such, these need to be developed and evaluated in accordance with Medical Research Council (MRC) guidance. It is not sensible to rush into short-term studies to test an idea – the so-called ‘ISLAGIATTs’ (‘it seemed like a good idea at the time’) approach, because they usually do not work. Far better, he says, to plan carefully.

“We need to listen to people, we need to learn from the literature [and] we need to sit down and co-design our intervention. And even when we’re all happy with it, [both] professionally and with the patients involved as well, we’ve then got to ….. feasibility test it – and that’s the bit I really enjoy”, he says. Only when the intervention has been refined and feasibility-tested is it time to undertake a randomised, controlled trial.

Professor Wright’s other role (as Head of the School of Healthcare)  is to manage the delivery of courses for a number of healthcare professionals including nurses, midwives, physiotherapists, operating department practitioners (ODPs) radiographers and the pharmacist prescribing team.  “What’s really interesting is seeing how those healthcare professionals are educated and trained compared to how pharmacists are educated and trained so I can see that these things all link up”, he says.

Why pharmacogenomics?

When first approached about the implementation of pharmacogenomics services by his colleague Dr Dhiren Bhatt, Professor Wright thought it was “futuristic” and was surprised to learn that services were already available in Australia, America, Canada and The Netherlands – but not in the UK.

“When I saw what it was, I was, like, blown over by it – really excited”, he recalls.

“Pharmacogenomics is clearly the next step. All pharmacogenomics is – is looking at someone’s DNA to work out what bits are different and therefore how that then affects how a patient’s drug should be prescribed. It took me a while to realise this, but we prescribe for the average patient. So, the BNF says the average patient will respond within this dose range with this drug and this is the best drug to start with.  But you know 20 per cent of people are either end of that normal distribution and they’re not average and therefore they might need a different drug or a different dose and what pharmacogenomics does is gives us that extra piece of information to say actually they might not want this drug, this is likely to cause a side effect or actually they need a high dose or a low dose or you just need to monitor them more carefully. So, it just gives us another piece in the jigsaw when we’re prescribing.” Furthermore, it improves patient safety and should lead to better outcomes more quickly, he adds.

Initially, he was concerned about how the DNA analysis could be done and interpreted but when he discovered that schemes are in place to do this and that “the software makes the recommendation – it says, for this patient, based on their DNA, you should be doing this – and that just blew me away”, he says.  He realised that it could become standard practice.

During a visit to Norway, where he holds a position of Professor Clinical Pharmacy at the University of Bergen, he discovered that PGx testing is routinely available to GPs. However, the service is little-used – GPs order on average one test per year.  “What that told me was that actually this isn’t something that GPs want to take on. This is an additional workload. …. If you look at the model in every other country, it’s pharmacist-delivered. So, for me, this is a real exciting opportunity for pharmacists to take centre stage, look after the patient, provide individualised care and work closely with GP. So, it’s no longer a service on the side, it’s a service integrated into the system to enhance patient care”, he says.

As part of this project a small-scale feasibility test in a mental health setting has just been completed, he adds.

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Professor David Wright BPharm, PGCHE, PhD FRPharmS is Head of the School of Healthcare, University of Leicester.

He also holds the position of Professor of Clinical Pharmacy at the University of Bergen, Norway.