Pharmacogenomics: Advancing medication management in long-term care

You’ve seen the alarming statistics: there are an estimated 100,000 deaths[i] and upwards of two million serious adverse drug reactions (ADRs) in the United States each year related to prescription drug use, costing the healthcare industry in excess of $136 billion annually according to the Food and Drug Administration. Older individuals are particularly at risk for ADRs due to polypharmacy, co-morbidities and a host of age-related variables and physiological changes that alter drug absorption and metabolism.

Genetic factors can also have a significant influence on drug response, which is estimated to account for 20 to 40 percent of inter-individual differences in drug metabolism and response.[ii] Patients with specific genetic variations are at increased risk from taking many widely prescribed drugs such as common anticoagulants, pain medications and antipsychotics.

Advances in precision medicine are helping to address this public health concern through the use of pharmacogenomics (PGx) testing to preemptively identify drug response based on a patient’s genetic makeup. In a growing number of hospitals and health systems, patients now undergo PGx testing as part of routine patient care, enabling physicians to ensure the safest, most effective medications are prescribed to every patient, reducing trial and error prescribing and improving treatment outcomes.

Implications for long-term care

The benefits of PGx testing and drug-gene decision support for long-term care (LTC) populations with polypharmacy is considerable. Half of all nursing home residents take nine or more medications per day and experience a disproportionate number of medication-related issue, according to the National Institutes of Health. The lifetime value of PGx testing is greatest in adults and the elderly who have the highest clinical risk for experiencing an adverse event (see Table 1).

 Table 1.  Adverse Drug Event Burden Increases with Age

Additionally, according to a June 2016 report from the Office of Inspector General, 30 percent of Medicare beneficiaries also take at least one commonly abused opioid, which are often metabolized differently in the elderly and can negatively interact with other medications. Too often, LTC patients take medications that are not clinically indicated, appropriate or effective for their medical condition. The end result is unnecessary healthcare utilization and increased costs due to drug interactions and ADRs, medication non-adherence, patient falls, functional decline and cognitive impairment.[iii]

PGx testing and drug-gene analytics at point of care

We are currently working with electronic health record (EHR) and prescribing (medication management) system vendors in a variety of healthcare settings to integrate genomic-based clinical decision support (CDS) tools that provide actionable drug-drug-gene data and alerts at the point of care. By having the information integrated into the existing clinical workflow, each time providers order a medication they are automatically alerted in real time regarding drug efficacy, potential interactions or dosing issues based on the patient’s genetics and current medications. A cycle of continuous medication monitoring is particularly important in elderly populations with multiple healthcare providers and frequent transitions of care.[iv]

A genomics-based CDS that is integrated into existing ordering, prescribing and/or medication management systems helps LTC organizations to:

• Screen patients that may benefit from a PGx test in order to maximize the care facility’s return on investment
• Flag patients who may be candidates for a PGx test when a specific medication is prescribed within the pharmacy system of the facility
• Order the appropriate PGx test panel based upon patient’s age, clinical conditions, and likely future prescriptions
• Be alerted to potential drug-gene and drug-drug interactions and adverse events
• Access medication and dosage alternatives that have lower risk

Genomic-based decision support tools also help LTC clinicians comply with the Joint Commission’s medication reconciliation requirements, ensuring an ongoing and automated process for comparing and reconciling the medications a patient is currently taking with every newly ordered medication to address potential interactions and guarantee a more precise medication reconciliation at every transition of care.

New technology is making it easier and faster for healthcare facilities of all types to adopt use of genomic decision support tools. We recently developed a PGx-based Application Programming Interface (API) using the Fast Healthcare Interoperability Resources (FHIR) specification, a new open-sourced standard for exchanging healthcare information to ensure interoperability and security, to help accelerate development of PGx-enhanced applications. Facilities can integrate the API into their existing information systems, which provides access to the required PGx knowledge platforms and data without the significant development costs of building the capability internally.

Since PGx results provide clinical validation of patients most likely to benefit from a given medication or treatment protocol, and given the mandate for quality outcomes at lower costs, genomic testing offers a compelling value proposition to providers and payers alike in the interest of providing value-based, cost-effective care. Over time, PGx testing and evidence-based prescribing may become the standard of care and may even become required by regulatory agencies and third-party payers.

Gene-guided medication management and integrated, evidence-based PGx data are poised to revolutionize patient care, and long-term care in particular, by helping clinicians reduce the use of ineffective medications to ensure more precise treatment throughout the continuum of care. The use of Software as a Service (SAAS) through standardized APIs can help to accelerate adoption of PGx by making it practical and affordable to integrate with existing systems.

Don Rule is CEO of Translational Software, Inc., a leader in the intelligent use of genetic data for clinical decision support and precision care. He can be reached at don.rule@translationalsoftware.com.