Pharmacogenomics: Trailblazers Welcome

AMANDA ELCHYNSKI, PHARM.D., HAD AN 'AH-HA' MOMENT in her third year of pharmacy school. During her studies, she worked as a community pharmacy intern, counseling patients, and performing all of the other duties of a pharmacist. Like many other pharmacists and health care providers, she also became frustrated seeing patients respond inconsistently to their medications.

A New Career Direction

"During that same year, I took a course on pharmacogenomics, and it really opened my eyes as to why the patients I was seeing were having these variable responses," said Dr. Elchynski, who at the time, was a clinical pharmacogenetics fellow at the Center for Pharmacogenomics and Precision Medicine, Department of Pharmacotherapy and Translational Research at the University of Florida (UF) College of Pharmacy. She pointed to research showing that genes may account for up to 95% of the variability in response to medications and that a growing number of gene-drug pairs can help guide prescribing to optimize treatment efficacy and safety.

After realizing the value of pharmacogenomics in patient care, Dr. Elchynski completed a rotation in pharmacogenomics in the outpatient setting, where she reviewed results directly with patients and found that many patients were relieved to understand why their medication wasn't working or was causing side effects.

"Finding out the results also made patients more amenable to changing medications," noted Dr. Elchynski, who is now a Pharmacogenomics Coordinator at Arkansas Children's Hospital. "I want to deliver this up-and-coming care approach and also help expand it from being available only to select groups and locations to being widely used as a standard of care," she said.

While pharmacogenomics is an exciting and cutting-edge field, one of Dr. Elchynski's preceptors said that, partly because they have limited exposure to the topic during their studies, only a small subset of students wants to enter a career in the field.

Educational Programs in Pharmacogenomics

"It's hard to think about pursuing something as a career path if you only hear about it for two or three hours in your entire pharmacy curriculum," said Emily Cicali, Pharm.D., clinical assistant professor in the department of pharmacotherapy and translational research at UF College of Pharmacy.

She said pharmacogenomics is spread throughout the didactic pharmacy curriculum at UF because "it is a concept that transcends any specific disease state." UF pharmacy students learn about the topic through core courses as well as elective opportunities, like a clinical application course, a summer intensive research program for students in the Pharm.D. program, a fourth-year pharmacogenomics elective advanced practice rotation, and pharmacogenomics residencies and fellowships, she said. The residency/fellowship offers pharmacists the opportunity "to live and breathe everything pharmacogenomics," Dr. Cicali explained.

"Once residents gain baseline knowledge of the topic, they start writing consult notes, either in the form of recommendations for clinical interventions or as part of a clinical trial," she explained. "And every resident does a deep dive into one gene-drug pair and creates a best practice alert for providers in the electronic health record, and they participate in a research project that's pharmacogenomics related."

Pharmacists considering a career in pharmacogenomics can look forward to employing both clinical and research skills, Dr. Cicali enthused. "It's an evolving field, so you can combine skillsets in really interesting ways, like collecting metrics for clinical practice in order to show growth and sustainability of the program," she said. "Every day is different, which is one of my favorite things about this work."

Encouraging Patient-Learners

To help pique his own students' interest in the field, ASHP Fellow George E. MacKinnon III, R.Ph., Ph.D., M.S., Founding Dean of the School of Pharmacy and professor in the genomic sciences and precision medicine center at the Medical College of Wisconsin, Milwaukee, and his colleagues have created a first-year pharmacy class on pharmacogenomics that turns students into "patient-learners."

In addition to presenting the course material through conventional pedagogical approaches, students submit their own saliva for pharmacogenomics testing if they are willing to do so. They then discuss the results with their peers, focusing on the relevance of the results to their or their families' medication histories, Dr. MacKinnon explained.

"Getting some perspective as to what this testing really means gets students very excited about the topic," he said. "The reality is that 97% of us have a clinically significant gene variant that could result in sub-optimal therapy or side effects, and these could be mitigated if we guide treatment with pharmacogenomics."

MacKinnon is confident the field will attract an increasing number of students and pharmacists, given the growing importance he expects it to play in clinical practice.

"I think it will become our bread and butter and no different than what we started doing 30 years ago in the hospital setting, when pharmacists began pharmacokinetic monitoring in our patients receiving anti-infectives, theophylline, and other agents that were managed for optimal outcomes and reduced toxicities," said Dr. MacKinnon.

Opportunities and Professional Growth

Trained graduates with expertise in pharmacogenomics can expect a growing number of job opportunities, agreed long-time ASHP member Julie Johnson, Pharm.D., Dean and Distinguished Professor of the UF College of Pharmacy said.

"The number of health systems hiring people with this expertise in the field is rapidly expanding," she said, noting that UF has 16 faculty members focused on the clinical and research aspects of pharmacogenomics.

"I see a lot of demand moving forward, but if pharmacists are not there to lead pharmacogenomics at an institution, [administrative] leaders will turn to nurses or physicians or genetic counselors to do so," she noted. "For people who are creative, innovative, and entrepreneurial, I think there are a ton of ways to be a trailblazer, like implementing pharmacogenomics in the healthcare setting, being a leader in research or working in the private sector to develop tools to help advance the field."