Implementation of a Standardized Medication Therapy Management Plus Approach within Primary Care

Medication Therapy Management (MTM) Plus process workflow. The MTM Plus process workflow employed the following steps: 1) evaluated medication utilization by performing medication reconciliation and assessing medication adherence; 2) performed PGx test by conducting informed consent specifically for the test, observing patient perform buccal swab for PGx test, and sending PGx test to laboratory with deidentified research number; 3) obtained additional patient-specific information from the EHR to inform the consult and documented this information into a secure, HIPAA-compliant form; 4) obtained PGx test results and matched them up to patient deidentified research number; 5) conducted consult, which was informed by clinical decision support data and PGx test results, and reviewed recommendations with a subgroup of a personalized medicine committee; and 6) shared consult, including PGx test results, with PCP. Abbreviations: EHR, electronic health record; MTM, medication therapy management; PCP, primary care physician; PGx, pharmacogenomics.

Types of medication-related problems identified by the pharmacist (N = 138). While performing consults, the pharmacist identified a total of 138 MRPs for the 50 patients enrolled onto the study. The most common types of MRPs identified were drug-drug interactions (29.0%), such as competitive inhibition involving 2 drugs (eg, metoprolol interfering with oxycodone activation) and multi-drug combination (eg, metoprolol and atorvastatin interfering with mirtazapine clearance), and DGIs (24.6%), such as inability to activate clopidogrel to its active metabolite and poor statin uptake into the liver. Abbreviations: ADR, adverse drug reaction; DGI, drug-gene interaction; MTM, medication therapy management; MRP, medication-related problem.

Types of recommendations made by the pharmacist (N = 138) and physician acceptance rates. For each MRP identified (N = 138) as part of the consult, the pharmacist made a recommendation for the PCP to resolve the MRP. The most frequent types of recommendations made were to monitor the patient (n = 38; 27.5%) and start alternative therapy (n = 35; 25.4%). Examples of monitoring recommendations included monitor for ADRs from nebivolol due to decreased CYP2D6 isoenzyme activity and monitor for side effects from mirtazapine due to multi-drug competitive inhibition. Examples of recommendations to start alternative therapy included switch clopidogrel to an alternative antiplatelet with a different metabolic pathway (eg, prasugrel or ticagrelor) due to a DGI and decrease dose of simvastatin or switch to an alternative statin (eg, rosuvastatin or pravastatin) due to a DGI. The majority of the pharmacist’s recommendations (90.9%) were accepted (ie, accepted or accepted with changes) by the PCPs. Abbreviations: ADRs, adverse drug reactions; DGI, drug-gene interaction; MTM, medication therapy management; MRP, medication-related problem; PCPs, primary care physicians.

Phenotype distribution of the genes tested in 50 patients. All 50 patients who underwent PGx testing had at least 1 genetic variant, and the majority (66.0%) had ≥5. Notably, among the genes tested, 36.0% of patients were identified as rapid metabolizers for the CYP2C19 isoenzyme; 40.0% were considered intermediate or poor metabolizers for the CYP2D6 isoenzyme; 30.0% were determined to have reduced activity for the SLCO1B1 transporter; and 50.0% and 14.0%, respectively, were identified as having reduced and significantly reduced VKORC1 activity. (Reduced and significantly reduced refer to intermediate and poor phenotypes respectively as shown in the figure.) *Thrombosis profile included testing the following genes: F2, F5, MTHFR (A1298C), and MTHFR (C677T). Abbreviations: PGx, pharmacogenomics; CYP, Cytochrome P450.