Abstract
Many individuals ≥65 have multiple illnesses and polypharmacy. Primary care physicians prescribe >70% of their medications and renew specialists’ prescriptions. Seventy-five percent of all medications are metabolised by P450 cytochrome enzymes. This article provides unique detailed tables how to avoid adverse drug events and optimise prescribing based on two key databases. DrugBank is a detailed database of 13,000 medications and both the P450 and other complex pathways that metabolise them. The Flockhart Tables are detailed lists of the P450 enzymes and also include all the medications which inhibit or induce metabolism by P450 cytochrome enzymes, which can result in undertreatment, overtreatment, or potentially toxic levels. Humans have used medications for a few decades and these enzymes have not been subject to evolutionary pressure. Thus, there is enormous variation in enzymatic functioning and by ancestry. Differences for ancestry groups in genetic metabolism based on a worldwide meta-analysis are discussed and this article provides advice how to prescribe for individuals of different ancestry. Prescribing advice from two key organisations, the Dutch Pharmacogenetics Working Group and the Clinical Pharmacogenetics Implementation Consortium is summarised. Currently, detailed pharmacogenomic advice is only available in some specialist clinics in major hospitals. However, this article provides detailed pharmacogenomic advice for primary care and other physicians and also physicians working in rural and remote areas worldwide. Physicians could quickly search the tables for the medications they intend to prescribe.
Highlights
Primary care physicians prescribe medications for most illnesses and renew medications prescribed by specialists
Electronic medical records in community primary care do not provide pharmacogenomic advice and the prescribing advice in guidelines written by organisations of specialists is contained in many hundreds of very lengthy documents that are difficult to identify during the workflow of primary care physicians
A major research focus has been using pharmacogenomics to improve prescribing for mental health
Summary
Primary care physicians prescribe medications for most illnesses and renew medications prescribed by specialists. To optimise therapy and avoid adverse drug events (ADRs), it is important that physicians thoroughly understand the pharmacogenomics of all the medications they prescribe. Electronic medical records in community primary care do not provide pharmacogenomic advice and the prescribing advice in guidelines written by organisations of specialists is contained in many hundreds of very lengthy documents that are difficult to identify during the workflow of primary care physicians. Primary care physicians select medications and dosages according to the guidelines they are able to locate by searching, may need to wait to assess the effects of the medications on patients and receive the patient’s observations about possible ADRs. If the physician does not check the effects of prescriptions with blood levels and patients do not report problems, potentially inappropriate medications may be prescribed and patients experience undertreatment, overtreatment, or ADRs. The best solution is to provide primary care physicians with pharmacogenomic data and pharmacogenetic-based Decision Support Tools (DSTs)
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