PJ view: a pharmacogenomic revolution is gathering pace

There has been rapid progress in the use of pharmacogenomics in patient care over the past 18 months — and it appears to be just the start.
Illustration of a cannon made out of a pill bottle firing a tablet with a DNA trail

In January 2022, The Pharmaceutical Journal decided to launch a conversation in pharmacy about genomic medicine.

We said at the time that pharmacogenomics had the potential “to revolutionise patient care in the years ahead” and that we wanted to explore what that could mean for day-to-day practice and its “potential implications for pharmacy professionals”.

More than a year later, we can confidently say that this revolution has truly started.

To date, in the UK, genetic testing has largely been confined to supporting the diagnosis of rare genetic diseases or before starting certain types of chemotherapy. Indeed, testing for specific variants of the DPYD gene before initiating fluoropyrimidine-based chemotherapy has become the biggest pharmacogenomic testing project in NHS history, but it appears to be just the start.

A much-anticipated international study definitively showed that carrying out routine pharmacogenomic panel testing before prescribing commonly prescribed drugs can help reduce adverse events in patients. Exclusively revealed by The Pharmaceutical Journal in November 2022, the 36-month PREPARE study showed that adverse reactions were reduced by a third for 39 routinely prescribed drugs, including codeine, clopidogrel, escitalopram, flucloxacillin and simvastatin, compared with usual care.

It’s a proactive approach that has been successfully rolled out in some countries — including in community pharmacies in the Netherlands and Canada, as covered in an episode of The PJ Pod — and will start to be tested in the northwest of England in June 2023.

The ‘Progress programme’, which is being led by the University of Manchester, is a NHS pilot that will start in June 2023 and will see GP practices carrying out pharmacogenomic testing before patients are prescribed statins, certain antidepressants and proton pump inhibitors. It will initially involve four GP surgeries, but is designed to inform whether a national service should be introduced across England. Those leading the programme stressed that it was important that each GP practice chosen for the pilot employed a pharmacist who would be involved in the project.

We have moved from a discussion about how pharmacy is to be involved, to one about what pharmacy is already doing

As Vicky Chaplin, pharmacy lead for genomics at NHS England, said at the Clinical Pharmacy Congress in May 2023, the pilot is looking at potentially including a panel of tests, “so you can look at all the results across various medications and tailor a patient’s treatment throughout their lifetime”. That is an ambitious aim, but one that makes sense in light of the PREPARE study’s findings.

This all comes as draft National Institute for Health and Care Excellence (NICE) published advice that supports genetic testing before prescribing clopidogrel, an approach that has already been implemented by hospital clinical pharmacists in one area of Scotland. Around 32% of people in the UK have a variant of the CYP2C19 gene, which means that clopidogrel will not work as well for them, and gives them around a 46% increased risk of another stroke when taking clopidogrel compared with those without the variant.

NICE has also recommended that newborn babies who need antibiotics should be given a rapid genetic test to check whether they can be safely treated with gentamicin, a development that aims to protect the 1,250 babies born each year who have the m.1555A>G variant that increases their risk of gentamicin-associated hearing loss.

Compared with when we launched our call in January 2022, the discussion around pharmacy involvement in genomics has moved on considerably. In March 2022, a report produced jointly by the Royal College of Physicians and British Pharmacological Society said pharmacists were “an essential component” of a pharmacogenomic service. In addition, the new vision for the future of pharmacy in England, developed by the Royal Pharmaceutical Society and the King’s Fund and published in December 2022, suggested that pharmacy professionals will use genomic data as a matter of course within the next decade.

In the past 18 months, we have moved from a discussion about how pharmacy is to be involved, to one about what pharmacy is already doing and when this will become standard practice. Let’s hope we see the same amount of progress in the next 18 months. PJ

Last updated
The Pharmaceutical Journal, PJ, May 2023, Vol 310, No 7973;310(7973)::DOI:10.1211/PJ.2023.1.187228

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