by PGx Medical | Jul 13, 2017 | Uncategorized
Anticoagulants are one of the most frequently prescribed medications in elderly patients.
Polypharmacy is a growing concern in the elderly population
Some common cardiovascular disorders in older adults have a relationship to thrombosis, including ischemic heart disease, atrial fibrillation, valvular disease, and atherosclerotic vascular disease.
Thrombophilia (sometimes hyper coagulability or a prothrombotic state) is an abnormality of blood coagulation that increases the risk of thrombosis (blood clots in blood vessels). Such abnormalities can be identified in 50% of people who have an episode of thrombosis (such as deep vein thrombosis in the leg) that was not provoked by other causes.
Older adults represent a patient population at high thromboembolic risk, but also at high hemorrhagic risk. Physicians have a tendency to underuse anticoagulants in the elderly, most likely because of underestimation of thromboembolic risk and overestimation of bleeding risk.
Despite the stroke risk being much higher in the elderly population, the presence of associated comorbidities and accompanying polypharmacy leads to physicians’ being less eager to initiate anticoagulation therapy in the elderly, despite the greater absolute stroke risk reduction by doing so.
Another consideration in deciding on anticoagulation therapy is the elderly patients’ propensity to fall. According to the U.S. Centers for Disease Control and Prevention, every 11 seconds an older adult is treated in the emergency room for a fall; every 19 minutes, an older adult dies from a fall.
One of the most compelling examples of potential benefits from pharmacogenetic testing is warfarin. Warfarin is a widely prescribed oral anticoagulant; for decades it has been used as standard drug to prevent and treat thrombotic events in patients with deep vein thrombosis, various hypercoagulable states, atrial fibrillation, surgical cardiac valve replacement, etc.
One of the major problems with its use in clinical practice is large inter-individual variation – patients differ in sensitivity to warfarin, hence the dose requirements vary widely (up to 20-fold). The consequences of over- or under-anticoagulation can be serious. In patients less sensitive than typical, the standard doses may be too low to achieve anticoagulation and therapeutic failure may occur, while in highly sensitive individuals the same doses may lead to serious adverse effects, such as hemorrhage.
PGx Medical is the trusted and experienced resource for the implementation of pharmacogenetics into the field of aging services. We work with LTC communities, clinics and pharmacies across the country educating and implementing pharmacogenetics into their day-to-day patient care.
For more information on education opportunities or implementing pharmacogenetics, contact:
PGx Medical
info@pgxmed.com
405-509-5112
source: uptodate.com, ncbi.com, intechopen.com
by PGx Medical | May 23, 2017 | Uncategorized
Antipsychotic medications are meant to treat psychosis, but what about dementia?
In an article on changingaging.com, in a two part series Dr. Al Powers discusses Guidelines for Antipsychotic drugs in Dementia. Dr. Powers, ChangingAging Contributor, says “there are guidelines here in the U.S., both from the Federal government and from various professional organizations. But I believe these guidelines have holes a doctor can drive a med cart through. I believe we need to raise the bar in order to influence a change of habit in many professionals.”
“Putting aside the obvious point that there is no risk-free environment, let’s look at where the bulk of liability truly rests. These drugs have never been approved for use in dementia; in fact, the FDA has given them a black box warning, due to the risk of excess mortality and morbidity in this population. A doctor prescribing a drug for an unapproved use—with such a severe warning attached to the labeling—runs a much greater liability risk from an untoward side effect of the drug than from not using it,” said Powers.
Black Box Warning:
The Food and Drug Administration (FDA) is charged with the responsibility of regulating most medicines used by the public in order to ensure that pharmaceutical products are safe. One of its most straightforward ways of doing this is by issuing black-box warnings. The black-box warning appears on prescription drug labels and is designed to call attention to serious or life-threatening risks.
More dementia care professionals are speaking out about the use of antipsychotics with dementia patients.
An estimated 25% of nursing home and 13% of assisted living residents in the United States receive at least one antipsychotic medication in a given year. These medications are often used off-label and put the resident at risk for serious side effects. CMS has focused surveys on the reduction of antipsychotics in the nursing home over the past few years and rates have slowly declined.
Antipsychotic rates in nursing homes are required to be monitored as part of an overall quality program. The antipsychotic prescribing rate in both assisted living and nursing homes and the relationship between the use of antipsychotics and mortality remain an area of concern for providers, patients and families. One of the methods for ensuring that an older adult is on the right drug is pharmacogenetics. Pharmacogenetics is a simple swab of the cheek and helps guide healthcare professionals in proper prescribing. Eliminating unnecessary medications and making sure residents are on the right drug, at the right dose, based on each individuals genetic profile. For more information, contact PGx Medical at info@pgxmed.com or 405-509-5112.
Read more on the two-part series at changingaging.com
by brant bullard | Jan 1, 2015 | Partners
Dr. Jami Benton, MD
I have found the Metabolic Validation test to be very useful for patients in my clinic practice as well as my nursing home patients. It is quick to use! In fact, my nurses do all of the work and then they go thru the results and alert me of the medications that are less likely to work for those patients. It takes no time for me at all! The paperwork is very minimal and nurses can fill it out. The swab takes less than a minute to swab the inside of both cheeks. Then it gets mailed off and the results come back in just a few days.
I had a patient in my clinic that had seen multiple doctors, a psychiatrist and several counselors for her depression. She had tried many medications to help her depression but she complained that none of them made her feel better. We did the Metabolic Validation testing and found out that the patient had a gene mutation that kept ALL of the antidepressants from working. No wonder she never felt better with the medications! From the test results we found some alternative medications that could be used to treat her depression. She was so relieved that there was a really good reason for the previous anti-depressants not to work.
I had a patient who had shoulder surgery who kept complaining that the Hydrocodone did not help his pain. The Naproxen actually did better in controlling his pain. He did the Metabolic Validation testing and found out that Hydrocodone does not work well for his pain but Naproxen works best. This is helpful information if he ever has to use pain medication again.
I had a patient who complained that his pain meds were not working at all and would ask for more and more. I suspected he was a drug seeker but could not prove it. He did the Metabolic Validation testing and ALL of the narcotics work well for him. We now know he is a drug seeker and treat him appropriately.
The PGx Medical Metabolic Validation test is helpful if a patient is not responding to a medication as well as we think they should. This helps us chose appropriate medications that are more likely to work and avoid those that may cause problems for the patient. It is very helpful with resistant depression, psychosis and ADHD medication failures. I am even starting to use the testing first before prescribing any medication. Patients love the testing because we can avoid the medications that are not likely to work or those that could cause adverse reactions; they get on the right medications quicker with less trial and error. Insurances like it because it saves them money by getting quicker results without multiple medication changes.
Nursing Home surveyors encourage nursing homes to use the Metabolic Validation testing on patients to try to keep patients off of multiple medications and to use those that work well. It also decreases the adverse reactions and helps keep patients off of anti-psychotics or at least on minimal doses of anti-psychotics.
Jami Benton, M.D., graduated with a Bachelor of Science in biology from Northwestern Oklahoma State University. She then attended the American University of the Caribbean School of Medicine and completed a Master of Science, as well as a Doctor of Medicine, degree. Benton completed a residency in 2008 at the Oklahoma University Rural Family Practice residency program where she served as chief resident.
Benton has been committed to providing health care in northwest Oklahoma since completion of her residency. She is board certified in family practice and is a member of the American Academy of Family Practice.
Dr. Benton currently practices at Integris Family First in Enid, OK. She also see’s patients at the Integris Clinic – Cherokee Family Clinic in Cherokee, OK and is the current Medical Director at Cherokee Manor and Fairview Fellowship Home.
To schedule an appointment, please call 580-242-4300.
For more information on Metabolic Validation Testing, contact,
PGx Medical
Individualized Care – Personalized Medicine
info@pgxmed.com
405-509-5112
by brant bullard | Mar 31, 2014 | News
Pharmacogenomics is the science of determining how genetic variability influences physiological responses to drugs, from absorption and metabolism to pharmacologic action and therapeutic effect. With increasing knowledge of the molecular basis for a drug’s action has come the recognition of the importance of an individual’s genetic makeup in influencing how he or she may respond to a drug.
Genetic variants in drug metabolizing enzymes can have a significant effect on the way a person responds to a drug. They can speed up or slow down enzymatic activity, or even inactivate an enzyme. In some patients, known as rapid metabolizers, drugs are metabolized too quickly. As a result, the average dose of the drug may be broken down too quickly to be effective, and a higher dose may be needed. Conversely, where the metabolite of the drug is active, as in the case of codeine (see below), rapid metabolism may lead to excessive accumulation of the active metabolite, which may result in toxic levels. In slow metabolizers, a drug administered at the recommended dose can accumulate due to such slow metabolism, potentially reaching toxic levels in the patient’s system and leading to adverse reactions. Such patients may require a smaller dose. In conjunction with other factors, pharmacogenomics offers the potential to enable doctors to identify the patients who are rapid or slow metabolizers of certain drugs and to adjust dosing accordingly to achieve both effective and safe treatment.
- Rapid metabolizers may break down a drug too quickly and require higher doses.
- Slow metabolizers may build up toxic levels of the drug and require smaller doses.
Clinical Applications of Pharmacogenomics
Warfarin (Coumadin and generics), an anticoagulant, is a recent example of the clinical use of pharmacogenomics to improve dosing. Warfarin has a narrow therapeutic window and a wide range of inter-individual variability in response, requiring careful clinical dose adjustment for each patient. Genetic variants in the warfarin target, the vitamin K epoxide reductase (VKORC1), as well as the warfarin metabolizing enzyme, cytochrome P450 2C9 (CYP2C9), influence the variation in patient response. Patients with certain variants of these genes eliminate warfarin more slowly and typically require lower warfarin doses. In those individuals, a traditional warfarin dose would more likely lead to an elevated International Normalized Ratio (INR), a longer time to achieve a stable warfarin dose, and a higher risk of serious bleeding events during the induction or dose-titration period of warfarin therapy. (FDA News)
Another recent example involves ultrarapid metabolizers of codeine, who have multiple copies of the gene for cytochrome P450 2D6 (CYP2D6), the enzyme that converts codeine into morphine, its active metabolite.
Tests to identify the three genetic polymorphisms for warfarin, codeine, and carbamazepine described above are commercially available.
Read more at FDA.com
For more information on the PGx Metabolic Validation Program, contact:
PGx Medical
Individualized Care – Personalized Medicine
info@pgxmed.com
405-509-5112
by brant bullard | Mar 10, 2014 | Journal articles, News
With the increasing need for personalized medicine, pharmacists are beginning to embrace pharmacogenetics. And with continued education, they will have the capacity to improve patients’ lives.
The age of pharmacogenetics has arrived. Pharmacists are taking notice and using this information to help determine which patients require specific treatments, to guide dosage selection, and to predict how patients will respond to therapy.
“After decades of research, pharmacogenetics is moving from research into routine clinical practice,” said James Hoffman, PharmD, MS, BCPS, medication outcomes and safety officer at St. Jude Children’s Research Hospital in Memphis, Tennessee. “Pharmacists can help lead the way.”
Dr. Hoffman spoke about how pharmacists can better harness the power of pharmacogenetics at the American Pharmacists Association Annual Meeting and Exposition in Los Angeles, California.
He pointed out that more than 100 drug labels now provide pharmacogenetic information, and the US Food and Drug Administration uses genetic information in safety warnings, such as the recent boxed warning for codeine use in children.
Genetic tests are not being used as much as they could be to help decide on drugs and doses, Dr. Hoffman explained. However, the fact that we can now “genotype 225 genes relevant to drug metabolism for the cost of 1 or 2 single gene tests” will likely lead to increased use, he noted.
The first step to increasing pharmacist involvement in pharmacogenetics is to reduce existing knowledge gaps. “There is a need for more active learning experiences, such as continuing education and continuing professional development, to demonstrate the utility of pharmacogenetic principles in a variety of disciplines,” she said. “It was not surprising to discover in my preliminary results that only 9% of respondents had completed any continuing education related to pharmacogenetics.” Pharmacists who want to be more involved, and even those who are unsure, need to actively seek out educational experiences.
Pharmacists with access to pharmacogenetic information should use it when recommending changes to a patient’s drug therapy. “Many community pharmacists were able to identify the appropriate tests required for various drugs, but the majority struggled with modifying drug regimens when provided with pharmacogenetic data,” Dr. Ammons explained. Increased documentation is essential to provide pharmacists and other healthcare providers with a foundation for the application of such information.
Both Dr. Ammons and Dr. Hoffman point out that education and collaboration are critical to getting pharmacists involved in pharmacogenetics. With more knowledge, they will have the capacity to improve patients’ lives.
Read entire article at Medscape.com
