Classroom pharmacogenetics, post-hospital medications, and post-brain-surgery drugs take top honors

By David Jacobson / Thu May 26, 2016

Gary Rifkind, PharmD, Class of 1960.

Studies of pharmacogenetics testing of pharmacy students as a teaching tool, an improved system to resolve medication issues after patients go home from the hospital, and the prophylactic use of an antiseizure drug for brain surgery patients took top honors at the Department of Clinical Pharmacy 18th Annual Spring Research Seminar.

The poster session, covering a total of 37 projects and highlighting research by UCSF School of Pharmacy student pharmacists, residents, and faculty members, was held on May 4, 2016 on the Parnassus campus.

Rifkind Award winners

The Gary Rifkind Spring Research Seminar Awards of $1,000 each were created to recognize and inspire clinical pharmacy research. They are the gift of alumnus Gary Rifkind, PharmD ’60. Winners of the 18th annual Rifkind awards are:

Student pharmacist

Dalga Surofchy, PharmD class of 2017, for “Incorporating pharmacogenetic testing into graduate pharmacy curriculum significantly enhances students’ knowledge and attitude towards personalized and precision medicine.”

Resident

Crystal Zhou, PharmD, for “Levetiracetam for seizure prophylaxis after cerebrovascular surgery.”

Other

Marilyn Stebbins, PharmD, for “Identification and resolution of post-discharge medication issues using IVR technology and an interprofessional approach.” Co-authors: Margaret Wheeler Emrick, RN, and Judie Tran, PharmD.

Elisabeth Fall

Left to right: Dalga Surofchy, PharmD class of 2017; Crystal Zhou, PharmD, resident; Marilyn Stebbins, PharmD, Department of Clinical Pharmacy.

Evaluating personal pharmacogenetics testing as an educational tool

The poster study lead-authored by Surofchy, a third-year student pharmacist, evaluated the impact of including voluntary pharmacogenetic testing of PharmD students as a supplement to a course on pharmacogenomics—the study of how genetics affect an individual’s drug response.

The study used before-and-after surveys to assess the effects of students undergoing pharmacogenetic testing on their subsequent knowledge and attitudes. Also called genotyping, such testing is a cornerstone of the emerging practice of precision medicine, which seeks to match treatments to individual patients’ genetics to optimize efficacy and reduce adverse effects.

Out of 122 students in the required first-year pharmacogenomics course, 73 consented to be tested for variations (mutations) in one of five selected genes. Each of the genes expresses either an enzyme that metabolizes drugs (affecting availability, toxicity) or a protein relevant to drugs’ effects. Among those included:

CYP2D6—Mutations affect up to 14 percent of Caucasians versus 1 percent or fewer of Asians. Variations alter a key enzyme’s function and thus metabolism of pain relievers, the breast cancer drug tamoxifen, antidepressants, and medications for attention deficit disorder.

CYP2C19—Mutations affect about 20 percent of Asians, but at most five percent of Caucasians. Variations alter an enzyme’s function, reducing the effectiveness of Plavix (clopidogrel), a leading drug used to treat blood clots, and altering response to medications to reduce stomach acid (proton pump inhibitors) and some antidepressants.
UGT1A1—Mutations affect nearly 20 percent of those of African ancestry versus only 2 percent of Asians. Resulting enzyme function variation reduces clearance of some cancer drugs (irinotecan) and can cause Gilbert syndrome, a toxin buildup that can yield mild jaundice.

Surofchy et al surveyed student knowledge in areas such as evaluating the usefulness of and interpreting results from pharmacogenetic tests. They also addressed attitudes, such as the likelihood that a student would recommend such testing and integrate it into their clinical practice.

Results: Improvements of 100 percent in knowledge and of 70 percent in attitude-related questions (for example, greater likelihood of use in patient care) were found among the PharmD students who underwent the genotyping. Notably, even students who did not undergo testing were positively affected, with 60 percent stating that seeing their classmates receive results and discussing them in class reinforced concepts taught in the course.

Surofchy and co-authors conclude that their study demonstrates that “an interactive hands-on approach to educating future pharmacists about pharmacogenetics is a fundamental curricular change that should become commonplace.” Publication of a paper is posted online in 2016).

Assessing antiseizure prophylaxis for vascular brain surgeries

The poster study lead-authored by Zhou evaluated the use of a drug, levetiracetam (LEV), to prevent seizures in patients in the week after they have undergone surgery on blood vessels in the brain to stem or prevent bleeding or blockages. A previous review found 2.3 percent of patients suffered seizures during their hospital stay after surgery for bleeding on the brain.

Currently, the poster noted, the practice of starting patients on antiseizure medications after cerebrovascular surgery varies and evidence for it is limited. To address this and help to establish standards, the researchers retrospectively reviewed the medical records of 160 adult patients who had such surgeries at UCSF Medical Center during a recent two-year period—and who were not at increased seizure risk or already taking antiseizure drugs.

The study by Zhou et al found most patients (115, or 72 percent) did not receive preventive LEV after surgery. Two of those patients (or 1.7 percent) had postoperative seizures within a week—a number that was not statistically significant. Analysis found no correlation between those seizures and:

the type of surgical procedure
blood loss during surgery
one type of brain bleeding associated with greater seizure risk

Results: The study concluded that LEV prophylaxis may not be necessary in lower risk patients. The researchers cited a need for studies with larger sample sizes as well as ones to track seizures after hospital discharge and to look at specific patient characteristics (e.g., location of aneurysm) that might increase concerns about post-surgical seizures and be added to prophylactic care guidelines.

Resolving post-discharge medication issues via an interprofessional approach

The poster co-authored by Stebbins described the implementation of a new approach to the medication-related problems that can arise when a patient is discharged from the hospital. For example, a previous study of a large New York teaching hospital found more than 40 percent of discharged patients experienced one or more medication errors during this transition.

Stebbins et al described the reengineering and expansion of a UCSF Medical Center program in which nurses followed up with discharged patients by phone within 48 hours. In 2013, this Care Transitions Outreach Program contracted with the UCSF School of Pharmacy to provide additional medication expertise.

Nurses and pharmacists developed medication-related questions that would be asked as part of a newly automated interactive system, introduced in 2014, for those follow-up calls. Based on keypad-entered answers, patients and families are connected to specially trained nurses for help. They can, in turn, escalate medication-related issues to a pharmacist.

Results: Recordkeeping and data analysis during initial and later stages of the revamped program found 75 percent of discharged patients responded to the automated calls. Most medication issues concerned:

Insurance—need for prior authorization, no coverage, uncovered costs
Access—need for transportation, pharmacy out of stock or not stocked
Prescriptions—errors, failed transmissions, formulation changes
Directions—not understood, questions on how to taper doses
Side effects and/or ineffectiveness

Based on a 2014 evaluation of the program by the School identifying and quantifying medication-related issues during the first five months, ongoing improvements were made. The poster noted that these included:

A collaboration starting in April 2015—between the School, medical center nursing and pharmacy, and Walgreens at UCSF—provides hospital bedside delivery of discharge medications. Results are forthcoming from a study comparing patients’ medication access at the time of the 48-hour follow-up phone call using this bedside delivery versus the traditional discharge medications process.
To improve effectiveness and efficiency, the interprofessional program was expanded to include more nurses, additional dedicated pharmacist hours, and a coordinator dubbed a health navigator.
The School uses the Care Transitions Outreach Program as a learning experience for pharmacy residents and PharmD students under pharmacist guidance. In January 2016, two medical/pharmacy student pairs were added, providing them exposure to potential medication safety issues facing patients in hospital-to-home transitions.