Ensom, Mary H H

The Canadian Journal of Hospital Pharmacy (CJHP) / Le Journal canadien de la pharmacie hospitalière (JCPH)

C J H P – Vol. 54, No. 1 – Spring 2001 J C P H – Vol. 54, no 1 – printemps 20016EDITORIAL2001: A Pharmacogenomics OdysseyMary H.H. EnsomWhile attending the United States PharmacopeiaQuinquennial Meeting 2000, I listened with fascination as Dr George Poste, a leader in the commercial application of genetic technology, declaredhis prediction that in the future, patients would havetheir medical history data recorded on a subcutaneousimplantable chip instead of merely having a “smartcard”. Other speakers described how the tremendousamount of genetic data generated by the HumanGenome Project has fuelled the recent explosion of pharmacogenomics research. In 1990, the Human Genome Project was conceivedas a 15-year project, but because of advances insequencing technology, mapping the complete set ofinstructions that make up our human genome is expectedto be complete by 2003.1 This is no small feat, as theseinstructions consist of approximately 3.2 billion basepairs of nucleic acids, which code for up to 100 000genes on 23 pairs of chromosomes!2Although most authorities date the birth of “pharmacogenetics” to the early 1950s, others suggestthat observations of highly variable drug response weremade as early as 510 BC, when Pathagoras observedadverse reactions (specifically, hemolytic anemia) afteringestion of fava beans by some individuals.3“Pharmacogenomics”, however, is a more recent addition to our terminology, having first been used inthe literature in 1997.4 Pharmacogenomics is a broaderfield and involves genome-wide analysis of the geneticdeterminants of drug efficacy and toxic effects.5What, then, are the implications of pharmacoge-nomics research for the institutional pharmacist?Pharmacy practice continues to evolve toward directpatient care. Pharmacogenomics research offers thepromise of an important tool to help personalize drugtherapy, that is, finding the best drug to be administeredat the effective dosage that is safe the first time. To fulfill this promise, pharmacists of the future will needto apply this new body ofknowledge to our patienteducation and monitoringroles, as in the followingexamples.• The pharmacist of thefuture may need toexplain to the patientwhy a certain medicationwas chosen over anotheron the basis of his or herparticular genetic profile. • Knowledge of a patient’s genetic profile may alsohelp us to explain why an adverse drug reaction ismore serious for one patient than for another. • The pharmacist may also help patients to understandthe implications of their newly determined genetic profile and field patients’ questions regarding ethical issues.2As the pharmacogenomics knowledge base continues to grow, it will become increasingly importantfor the pharmacist to become knowledgeable about thisdiscipline and its societal implications.2 As such, modification of curricula in pharmacy schools and extensive educational programming for current practitioners will be essential to enable future practitionersto participate in this “new therapeutic arena”.1In the future, instead of targeting a patient’s drug concentrations within a therapeutic range, as in traditional clinical pharmacokinetic monitoring, pharmacists will likely make dosage recommendationsfor some drugs on the basis of the individual patient’sgenotype. Given the waning use of traditional aminoglycoside therapy, which has been the primaryfocus of pharmacokinetic monitoring over the years,pharmacogenetics-oriented monitoring of other drugsmay well become the therapeutic drug monitoring of the future.7C J H P – Vol. 54, No. 1 – Spring 2001 J C P H – Vol. 54, no 1 – printemps 2001This individualization of drug therapy and the complexity of drug selection are expected, more thanever, to necessitate a team approach to health care.Existing collaborative relationships not only betweenthe pharmacist and the patient but also with physicians,clinical laboratories, and other health-care professionals,must be expanded to include this new focus. As pharmacists, we will be expected to be an integral partof the team because of our extensive knowledge baseof how other factors (such as food, concomitant medications and pathophysiologic conditions, gender,environment, and socioeconomic status) may contributeto the success or failure of a treatment plan. In addition,the pharmacist is one of the health-care professionalsmost likely to be “aware of the demand for cost-effectiveness, the rapid growth of disease managementprograms, and the narrowing of formularies.”6As a 12-year-old in the 1960s, when the movie2001: A Space Odyssey was first released, I could hardly imagine what the world would be like at such a distanttime in the future. But here we are in what seemed, longago, to be a futuristic time. While many of the predictions of Stanley Kubrick’s work of science fictionhave not come to pass, I continue to be fascinated andamazed by such tremendous advances in science andtechnology, far beyond the wildest imaginings of that12-year-old. I hope that the “pharmacogenomicodyssey” will stimulate us all to consider the potential of this dynamic area. Perhaps we will even anticipateand prepare for it together.References1. Knapp KK. The Human Genome Project [conference summary].APhA 2000 — American Pharmaceutical Association AnnualMeeting. Available at: http://www.medscape.com/medscape/CNO/2000/APHA/APHA-04.html (accessed 2000 Nov 1).2. Carrico JM. Human Genome Project and pharmacogenomics:implications for pharmacy. J Am Pharm Assoc 2000;40:115-6.3. Almuete VI. Drug therapy and pharmacogenomics [conference summary]. APhA 2000 — American Pharmaceutical AssociationAnnual Meeting. Available at: http://www.medscape.com/medscape/CNO/ 2000/APHA/APHA-03.html (accessed 2000 Nov 1).4. Marshall A. Genset-Abbott deal heralds pharmacogenomics era.Nat Biotechnol 1997;15:829-30.5. Mancinelli L, Cronin M, Sadee W. Pharmacogenomics: the promiseof personalized medicine. AAPS [Am Assoc Pharm Sci] Pharmsci2000;2:30-7.6. Langevin BC. Pharmacogenomics: tailoring drug therapy. J AmPharm Assoc 1999;39:597-8.Mary H.H. Ensom, PharmD, FASHP, FCCP, is Professor, Faculty ofPharmaceutical Sciences, University of British Columbia, and ClinicalPharmacy Specialist, Pharmacy Department, Children’s and Women’sHealth Centre of British Columbia in Vancouver, British Columbia. Sheis also an Associate Editor for CJHP.Address correspondence to:Dr Mary H.H. EnsomPharmacy Department (OB7)Children’s and Women’s Health Centre of British Columbia4480 Oak StreetVancouver BCV6H 3V4e-mail: ensom@interchange.ubc.cacontinued from page 5quinine, and antituberculous drugs — butnocephalosporins, fluoroquinolones, or antiviral agents.The only antifungal drugs were gentian violet and griseofulvin. Zimbabwe has among the highest rates of infectionwith the human immunodeficiency virus (HIV) in theworld, and 1 of every 4 women who presented inlabour at the Howard Hospital had the virus. Treatmentfor this infection is generally nonexistent in Zimbabwebecause of the high cost. Veahavta started a study at theHoward Hospital to investigate the use of short-course(and affordable) antiretroviral treatment for HIV-infectedwomen in labour, with the aim of preventing transmission of the infection to newborns. HIV testingsupplies and medications have been donated. One ofmy responsibilities was to audit the conduct of thestudy, which has been under way for a little less than a year. I found my brief experience at the Howard Hospitalin Zimbabwe enjoyable and immensely rewarding. I amcertain that I learned much more than I was able to contribute in such a short time. I was most affected bythe observation that, despite our concerns in Canadaabout shrinking health-care resources, there is no comparison between what we have access to here andwhat is available there. Zimbabwe is a beautiful countrywith many natural resources and enormous potential.Unfortunately, it now faces huge political, economic,and social challenges, largely because of a corrupt andinefficient government. I have returned home with amuch greater appreciation for the freedom and benefitswe enjoy in Canada.Andrew E. Simor, MD, FRCPC, FACP, is Head of the Department ofMicrobiology and an Infectious Diseases Consultant, Sunnybrook andWomen’s College Health Sciences Centre, University of Toronto,Toronto, Ontario.

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