ACAAI shares little-known facts about allergy season

BY Michael Johnsen

To help those with seasonal allergies cope this spring, the American College of Allergy, Asthma and Immunology has put together a list of spring 
allergy facts:

  1. Every year is labeled as the worst for allergy symptoms, and there could be some truth to that. According to a recent study published in the Annals of Allergy, Asthma and Immunology, pollen counts slowly rise annually and are expected to double by the year 2040. This is due to economic growth, global environment sustainability, temperature and human-induced changes, such as increased levels of 
carbon dioxide.

  2. Taking allergy medication should be done well before the first sneeze. Allergists recommend to begin treating two weeks before symptoms 
typically surface.

  3. A mild winter may cause an early release of pollens from certain trees, and a longer season may be worsened by the priming effect. Once allergy sufferers are exposed to this early pollen, their immune system is primed to react to the allergens, meaning there will be little relief even if temperatures cool down before spring is in full bloom. If weather reports call for a streak of warm days, patients should begin taking medication.

  4. April showers could bring about allergy symptoms. Rain can promote plant and pollen growth. Wind accompanying a rainfall can stir pollen and mold into the air, also heightening symptoms. Allergists advise sufferers stay indoors when pollen counts are highest, which is often midday and afternoon hours.



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Spring forecast: Allergy sufferers beware

BY Michael Johnsen

Mold allergens will be particularly prominent this spring and summer, especially in the West, on account of the significant drought conditions across the central United States. Dry and hot weather helps lift the mold from the soil and into the air, contributing to hay fever along with any prominent tree pollens.

Since the beginning of 2013, dry and cold weather has prevailed over the West, according to the National Weather Service’s Climate Prediction Center. Throughout California and across the West Coast, the spring wet season is expected to wind down toward the end of March, and by May, precipitation will be sparse.

Temperature also plays a role in determining the severity of an allergy season, and a mild winter doesn’t bode well for allergy sufferers along the East Coast either. Early spring temperatures mean allergy symptoms will be intense and last longer than average.

While it’s difficult to detect the severity of the spring allergy season nationwide, traditionally, the milder the winter, the longer the season will be due to what is known as the priming effect, noted Stanley Fineman, immediate past president of the American College of Allergy, Asthma and Immunology.

“When winter weather turns unexpectedly warm, pollens and molds are released into the air earlier than usual, and then die down when it gets cold again,” Fineman said. “This pattern of weather can prime a person’s allergic reaction, so when the allergen reappears as the weather gets warm again, allergy symptoms are worse 
than ever.”

“We [were] already seeing patients coming in with allergy symptoms in Atlanta,” Fineman said. “Because it [was] still February, several people in the Southeast [had] been confusing their allergy symptoms for cold viruses.”

For those living in regions where pollen counts have not yet increased, ACAAI recommends sufferers begin taking medication now and make an appointment with their allergist.


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Ethnicity, genomics and personalized medicine

BY Jim Frederick

For well over a century, the Statue of Liberty has invited the world to “Give us your tired, your poor, your huddled masses yearning to breathe free.” Now, thanks to stunning advances in the sequencing of the human genome and patient-specific genetic research, America’s healthcare system is extending another invitation to this nation’s complex polyglot population: give us the rich diversity of your DNA.

Spawned by explosive advances in scientific knowledge about the human genome and personalized medicine, a revolution in patient care and medication management is on its way. Within a few years, pharmacogenomics will transform both the practice of pharmacy and the way medicines are prepared, prescribed and dispensed to patients for many chronic diseases. And it will allow prescribers and pharmacists to adapt medicines to the vast genetic diversity of America’s rich trove of ethnic groups and individual patients, based on those patients’ own ability to process and metabolize different 
drug compounds.

Researchers have found that more than half of all patients have variations in their DNA that can profoundly affect the way they react to many commonly prescribed medications. For instance, researchers have already established that “patients with a genetic variation in the gene identified as 2C19 are some three-and-a-half times more likely to have an adverse reaction” to the blood thinner Plavix (clopidogrel bisulfate), said Tasha Michaels, a clinical pharmacist with Kerr Drug who helped coordinate a six-month pharmacogenetic pilot program by Kerr in collaboration with the University of North Carolina’s Eshelman School of Pharmacy.

That study established the feasibility of a community pharmacy-based pharmacogenetic program and its acceptance by physicians and patients. The pilot — which involved a collaboration among pharmacists, physicians, Eshelman faculty and an outside genomic testing lab — demonstrated that pharmacists can screen participating patients, apply individualized genetic information from lab DNA tests to those patients at the pharmacy counter when dispensing prescriptions, adjust medications and dosages where needed in collaboration with the physician, and prevent drug mishaps or improve long-term patient outcomes.

Kerr’s Plavix pilot also demonstrated that pharmacists can perform the patient interventions required — including taking DNA samples from patients via buccal [cheek] swabs that “didn’t take that much more time” than a follow-up visit for medication therapy management would, Michaels said. “So you can easily work it into the pharmacy workflow.”
Drug labeling for more than 100 pharmaceutical therapies, including Plavix, has already been updated to include warnings of decreased response in individuals with certain genetic profiles. And in the not-too-distant future, predicts clinical pharmacist and former American Pharmacists Association officer Brad Tice, the vast majority of prescriptions dispensed will likely include specific genetic coding for 
each recipient.

“Pharmacogenomics is going to be as big for pharmacy as immunizations have been,” Tice told DSN Collaborative Care.
For some pharmacy practitioners, the new frontier of genomic-based medication therapy is already here. The advance units of community pharmacy, led by perennial retail health innovators like Kerr Drug and CVS Caremark, have already ventured into the fast-expanding world of genomic advances and pharmacogenetics with pilot programs or joint ventures that tailor drug therapy more effectively to individual patients, avoid some adverse drug reactions and in some cases, improve outcomes.

“The ultimate goal is to create ‘designer drugs’ matched to unique genetic profiles,” noted CVS Caremark in a report. Added Troyen Brennan, EVP and chief medical officer for CVS, “there is a growing desire by clients to tailor pharmaceutical treatment based on genetic inheritance.”

It’s what author Francis Collins calls “the revolution in personalized medicine” in his book, "The Language of Life: DNA and the Revolution of 
Personalized Medicine."

The dramatic gains made by scientists in gene sequencing have brought a more personalized form of drug therapy into focus. And the rapid growth of testing labs that can identify a specific patient’s genetic markers for his or her ability to metabolize or otherwise respond to specific drug compounds has brought the ability to tailor drug therapies to individual patients within reach of many community pharmacies.

“Pharmacogenetic testing is increasingly paving the way for more personalized drug management” and “should help improve drug response rates and reduce adverse events,” noted Howard McLeod, the Fred Eshelman Distinguished Professor of Pharmacogenomics and Individualized Therapy at the University of North Carolina’s Eshelman School of Pharmacy and director of the UNC Institute for Pharmacogenomics and 
Individualized Therapy.

Essentially, pharmacogenomics and pharmacogenetics — the two terms are often used interchangeably, even though they differ slightly in meaning — is the science of applying the fast-growing body of knowledge about the human genome to “how information in our genes influences our response to drugs,”McLeod said.

“In cancer and almost every other area of medicine, there are multiple drugs that work,” he noted. “But none of them work on more than half the patients. So when prescribers are faced with choosing what medicine to give a person, they often go with the drug they know best. And because there is often no way to know with great certainty how the drug may work on that individual, it may not be the one that will benefit the patient the most.”

Some of the variations are related to ethnicity. “There’s not that much ethnic variation for a drug like Plavix,” observed Michaels. “But there’s definitely more of a variable response for other drug classes,” based on “various enzymes” common to different racial groups that affect how they react to various molecular compounds. For instance, said Michaels, Asians tend to break down alcohol in their systems differently than other groups due to differences in their DNA.

APhA defines pharmacogenomics, or PGx, as “the use of patient-specific genetic characteristics to guide medication therapy, in order to maximize safety and efficacy, and narrow the drug choices for an individual patient.”

“Although the distinctions between PGx and pharmacogenetics are minimal, PGx generally refers to the study of the interactions among multiple genes/gene products and drug response, whereas pharmacogenetics is often used to describe the effects of a single gene,” noted the 
pharmacy group.

In the Journal of the American Pharmacists Association, APhA asserted that pharmacogenomics “will further enhance the community pharmacist’s ability to individualize therapy during medication processing or extensive MTM [i.e., medication therapy management].”
To that end, APhA said, “Pharmacists must take steps to assess the entire clinical picture and use pharmacogenomics where appropriate to optimize drug therapy.”

The tools to do so are increasingly within the reach of many pharmacists — and the need for their involvement in this expanding field of medicine is clear. “We know the genomic profiles already on 50% of medications, … and all new drugs are going to have it. So I really see pharmacists as being the provider,” Tice said. “There are not enough genetic counselors in the United States, and they’re going to mainly be focused on hereditary diseases, not as much on medication applications. So there’s even more of a need for pharmacists to step up in this area.”

What’s more, the APhA reported, “Pharmacogenomic testing technology has made conducting pharmacogenomics testing in community pharmacies possible. Pharmacists must arm themselves with the knowledge and skills specific to pharmacogenomics in order to fully integrate this expanding area into patient care and turn this into a great opportunity.”

Hurdles remain, however, for any pharmacy looking to apply pharmacogenetics to its practice model. “Despite many scientific discoveries and Food and Drug Administration-mandated drug labeling changes, neither pharmacists nor other healthcare providers recognize pharmacists as the pharmacogenomics expert,” 
APhA reported.

What’s more, noted the organization in a report in late 2012, “few primary care practitioners use the pharmacogenetic information contained in package inserts to order those pharmacogenetic tests that influence prescribing, even though we know that 1-in-4 prescription drugs dispensed is metabolized by 
polymorphic pathways.”

Another big challenge is the lack, thus far, of a clear and established payment standard for pharmacists who provide genetic-driven drug therapy and counseling, Tice said. “There are a lot of issues there. But just on a basic payment model, when the clinical justification can be established that we can test enough people to determine those who metabolize [a drug differently] … at some point, it becomes valuable from a prior-authorization perspective to pay a pharmacist to do the DNA test in certain criteria and provide counseling to the patient. It may be drug dependent, but you see a lot of the major plans are paying for these tests to be done. It’s growing very quickly.”

Lynn Dressler, assistant professor in the Division of Pharmaceutical Outcomes and Policy at the University of North Carolina’s Eshelman School of Pharmacy, and associate director of policy and ethics for its Institute for Pharmacogenomics, is one pharmacy researcher focused on “how pharmacogenomics will improve patient outcomes and change the standard of care in medicine,” according to UNC.

“I do think there’s information in your DNA that could be useful to your doctors and pharmacists, and to you as an individual, but it’s not the only piece of information that is helpful,” Dressler said. “Our lifestyle and environmental exposures also are contributing factors.”

Related: Study finds improvements in cardiovascular health among South Asians who receive culturally relevant coaching


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