NSW Health Estimates: The Government's Response to Pharmacogenomics

The Public Accounts Committee Recommendations that clinical pharmacologist (specialists in drug prescribing and medication issues) be employed in each hospital district and pharmacogenomics is actively pursued and funded.

Ms. Dawn Walker (NSW Green's Senator) asked the Minister for Health, Brad Hazzard, questions regarding the employment of specialist clinical pharmacologist and the employment of pharmacogenomic testing. 

The questions and their answers are below. 

It appears to us that the Minister is being given grossly outdated or incorrect information. 

We have requested a meeting with him to ensure he is updated. We will keep you updated on whether the minister agrees to meet and ask for volunteers to meet with him. 

QUESTION 52. Have there been advertisements for clinical pharmacologists in the Northern Rivers? a) If not, why not? b) Have there been advertisements for these positions in any other Local Health Districts in NSW? i. If not, why not?

ANSWER 52.No. (a-b) The decision to advertise for specific positions is determined at the local level in accordance with the service delivery needs and models of care within the district or network.

OUR COMMENT: This answer suggests to us that the NSW Government has no active policy to reduce medicine errors. Studies show that medication errors can account for up to 40% of admissions (particularly for mental health and geriatric beds). We have been provided with studies done as far back as 2004 that show that 40% of beds were due to medication errors and the Government had increased beds by 30% to cope with that demand. How much money is the Government wasting (let alone lives it is ruining) by not tackling this issue? 

ADDENDUM: We have now been asked to have a meeting with the Northern Rivers local health NSW Local Health Service. We have also been advised that few teaching hospitals have clinical pharmacologists to train doctors on medicine issues. 

 

 

QUESTION 53. Are you aware of pharmacogenomics tests that can predict an individual’s reaction to medication, such as the ‘myDNA Medication test’? (a) Has including these in health care services delivery been investigated? (b) Will the department consider integrating these types of tests into health care in the future?

ANSWER 53. (a-b) There is limited evidence supporting the routine use of pharmacogenomic testing in clinical practice. For most patients, careful titration of drug dose will be sufficient to ensure maximum benefit while avoiding serious side effects. As part of the implementation of the NSW Health Genomics Strategy, the clinical evidence for the use of pharmacogenomics as part of clinical care into the future will continue to be monitored.

OUR COMMENT: This position is so out of date or unreasonable you have to ask what the agenda actually is. Who is the Government serving?

The position may be reasonable if it was to ensure that no medicine was prescribed and no risk taken. 

What this response fails to understand is the portion of the population for which the medications will not work, or will be toxic, regardless of the dose. Simply carefully titrating the dose will not work. This is amply demonstrated through the stories we have collected.  

Furthermore to say there is limited evidence shows a limited understanding of genetic testing. So let's look at the evidence.

  • There are now international guidelines and recommendations for pharmacogenetic testing based on a review of the evidence that has been fully implemented into the Dutch prescribing system.[i]

  • Following this successful implementation, these guidelines are now being implemented throughout the EU. 

  • The American Food and Drug Administration now include pharmacogenomic information where there is sufficient evidence on drug literature.

  • The application of genetics has widespread applications including the need for new medicines. 


In relation to mental health, simply because it was the subject of the NSW Inquiry, and shortly a federal inquiry, here is the evidence:

  • There are now 6 randomized trials that show that using a multiple gene pharmacogenetic test, improves the treatment of depression in guiding drug treatment. There are at least 6 more being carried out at present. That is, there is three times the number of trials, as that needed to list the medicines.[ii][iii][iv][v][vi][vii]

  • Studies show that despite the availability of a wide range of different antidepressants and antipsychotics, a high proportion of patients will not respond sufficiently to treatment and that genetic variation has been identified as an important factor underlying the variation in psychiatric drug response in 36 commonly used antidepressants and 38 antipsychotics. [viii]

  • Studies show patients who metabolize very slowly or too fast have 67% more medical visits and 4 times more disability claims than those with normal pharmacogenomic test results. There are now 12 published studies corroborting significant savings for applying pharmacogenetics.

  • A 2008 report, involving all stakeholders found that the implementation of pharmacogenomic testing could lead to a $12 billion saving in Australia within 5 years equating to approximately 2% of total healthcare spending. These savings did not include mental health or aged care. [ix]

  • This level of savings has been corroborated by a trial at Melbourne Health. [x]

 

Now let's look at the status quo that Government seems to accept:

  • Patients on antidepressants are two to three times more likely to suicide on antidepressants than on sugar pills. [xi]

  • Patients are almost twice as likely to die if they are receiving mental health treatments as if they are not. [xii]

  • Those receiving mental health-related treatments are likely to die up to 20 years earlier due to medical complications including from the medicines prescribed. [xiii]

  • There is a 30% higher incidence of metabolic disease, diabetes, cancer, arthritis, asthma, and cardiovascular disease with people on mental health medicines.[xiv]

  • In Australia, there were 57,008 adults on disability due to mental illness in 1990. The number rose to 241,335 in 2011 - a four-fold increase. Why are so many people going onto disability? [xv]

  • Studies show that up to 40% of all mental health beds are due to medication errors. In one location this was shown to have resulted in a 30% increase in beds to keep up with demand. 


It is also worth noting that despite repeated letters to the Health Department they were unable to explain this position at all instead continuing to cite the dogma that there is insufficient evidence without either explaining what evidence is missing or what the plan is to reduce medicine errors. 

 

 

[i] https://www.pharmgkb.org/guidelines.

[ii] Winner JG, Carhart JM, Altar CA, Allen JD, Dechairo BM. A prospective, randomized, double-blind study assessing the clinical impact of integrated pharmacogenomic testing for major depressive disorder. Discov Med. 2013;16(89):219-27.

[iii] Singh AB. Improved Antidepressant Remission in Major Depression via a Pharmacokinetic Pathway Polygene Pharmacogenetic Report. Clin Psychopharmacol Neurosci. 2015;13(2):150-6.

 

[iv] Perez V, Salvart A, Espadeler J, et. al. Efficacy of prospective pharmacogenetic testing in the treatment of major depressive disorder results of a randomized, double-blind clinical trial. BMC Psychiatry. 2017;17:250.

 

[v] Elliott LS, Henderson JC, Neradilek MB, Moyer NA, Ashcraft KC, Thirumaran RK. Clinical impact of pharmacogenetic profiling with a clinical decision support tool in polypharmacy home health patients: A prospective pilot randomized controlled trial. PLoS One. 2017;12(2):e0170905.

[vi] Saldivar JS, Taylor D, Sugarman EA, Cullors A, Garces JA, Oades K, et al. Initial assessment of the benefits of implementing pharmacogenetics into the medical management of patients in a long-term care facility. Pharmacogenomics Pers Med. 2016;9:1-6.

 

[vii] Bradley P, Shiekh M, Mehra V, et al: Improved efficacy with targeted pharmacogenetic-guided treatment of patients with depression and anxiety: a randomized clinical trial demonstrating clinical utility. J Psychiatr Res 2017; 96:100–10.

 

[viii] Kirchheiner J, Nickchen K, Bauer M, Wong ML, Licinio J, Roots I, et al. Pharmacogenetics of antidepressants and antipsychotics: the contribution of allelic variations to the phenotype of drug response. Mol Psychiatry 2004; 9:442-473).

 

[ix] Australian Centre for Health Research. “Improving the Quality. Use of Medicines in. Australia.Realising the Potential of. Pharmacogenomics”. October 2008.

[x] Melbourrne Health and GenesFx, “MVP Proof of Concept Pharmacogenomic Decision Support System,” 18th of September 2014.

[xi] Healy D. Lines of evidence on the risks of suicide with selective serotonin reuptake inhibitors. Psychother Psychosom. 2003 Mar-Apr;72(2):71-9. Review. PubMed PMID: 12601224. https://www.ncbi.nlm.nih.gov/pubmed/12601224

 

[xii] Australian Bureau of Statistics. 08/09/2017 4329.0.00.006 – Mortality of People Using Mental Health Services and Prescription Medications, Analysis of 2011 data.

 

[xiii] Testimony of Associate Professor Allen https://www.parliament.nsw.gov.au/ladocs/transcripts/268/Transcript

[xiv] http://www.mentalhealthcommission.gov.au/our-reports/our-national-report-cards/2012-report-card.aspx

 

[xv] Whitaker, Robert. Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. New York: Crown Publishers, 2010