As the Centers for Medicare and Medicaid Services (CMS) continue with alacrity to assert regulations moving our entire healthcare system toward value-based care, here are a couple of thoughts for us to ponder regarding pharmacy in general and LTC pharmacy in particular.
Pharmacists, remember the term “competitive inhibition”? Think back to learning pharmacokinetics and/or pharmacogenomics, or maybe even biopharmaceutics, medicinal chemistry, and/or pharmaceutics. As pharmacy students, we learned about inducers and inhibitors. We learned about bioavailability and half-lives. We also learned about affinity coefficients and their effect on competitive inhibition.
The approximately 200 genes we have that are singularly purposed to rid the body of poisons (think meds) most often activate pro-drugs and eliminate most drugs, affecting metabolism by making the medications polar or water-soluble. The enzymes often polarize a methyl group to a hydroxyl group or even conjugate it to an acid.
Competitive inhibition is when more than one medication is seeking the same gene’s enzyme for metabolism. A common example would be the gene CYP3A4. Let us think of CYP3A4 as a parking space. We have many CYP3A4 parking spaces in our gut and liver — the prime area to mount an attack against foreign oral items. If three of a patient’s medications that are metabolized by CYP3A4 are all given at the same time (e.g., at breakfast), the one with the strongest affinity for the CYP3A4 spaces will occupy those spaces first. The other meds that have lower affinity coefficients continue to circulate — working and working and working as a pro-drug, inducing side effects, and/or as an active drug, increasing activity. Thus, an unintentional overdose is looming.
We rarely use this science in pharmacy practice, because the software and accompanying medication decision support aids have not been available at the point of care. So we have relied on algorithms and formularies to select meds, and on nursing rules to determine what time of day to administer them. Over the decades this nonpersonalized approach has neither protected patients nor mitigated medication misadventuring. Patients’ medication regimens have not been personalized and optimized using science, and poor medication-related patient outcomes have been the norm.
Value-based care demands that pharmacy change course, soon. Why? Because outcomes demonstrated by long-term care and hospital providers are being measured, and their referrals may be dependent on their quality metrics — poor outcomes could lead to exclusion from narrow networks. Pharmacy will be measured on medication safety metrics, which may include:
- Medication adherence scores
- Mediation safety indicators
- Competitive inhibition/unintentional overdose risk
- Multidrug-gene simultaneous interactions (including opioids)
- Anticholinergic, cognitive, or sedative burden
- Drug-induced cardiac arrhythmia risk
- Fall patterns
Fortunately, CMS is our advocate, as can be seen by the 2017 Enhanced Medication Therapy Management initiative. CMS is promoting change, resetting the focus on medication safety and pharmacist care innovation. This is one of many new and exciting initiatives encouraging us to apply our medication expertise toward personalized and precision pharmacotherapy.
Now we must collaborate with our software friends to provide us with disruptive medication risk mitigation tools we need to effect change and eliminate what is often termed the fourth-leading cause of death. It is time to place the science that is behind the medication safety metrics into our pharmacy computer systems. CT
Calvin Knowlton, B.Sc.Pharm., Ph.D., is CEO, chairman, and founder of Tabula Rasa HealthCare, which is devoted to leveraging technology to improve healthcare with its proprietary solution set of technology-enabled products and services for medication management and risk adjustment. He can be reached at firstname.lastname@example.org.