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Self-made: It’s in the DNA

Published on 01 July 2014

By Brad Brown
Photography by Sid Hastings
Originally appeared in Script Summer 2014

A dizzying set of numbers and letters greet Dan Fieker ’79 on his computer screen, and he couldn’t be happier. The sequences—CYP450, 2C19, 3A5, 2D6—may seem vaguely familiar. (Or maybe not).

They correspond to different enzymes in the liver and determine how patients metabolize and process medication. His small office at Family Care Pharmacy in Highland, Illinois, cannot contain his enthusiasm for the emerging practice of pharma­cogenomics and what he believes is the next major evolution for patient care. He is one of a small number of pharmacists in the U.S. who is developing and being compensated for his work in the specialty area of practice.

Now appearing on his screen are the results of a genetic test from a patient being treated at a pain clinic several states away. The results of the test will determine, among other things, if her pain can be controlled by opiates without side effects.

“Physicians want to know if their patients will have pain control with narcotics,” Fieker explains. “It’s here in black and white, so physicians now know if they need to adjust their dosage.”

Fieker is a consultant for a genetic testing laboratory. Pharmacists and physicians are increasingly using genetic testing for patients who are taking a host of medications, such as warfarin or antidepressants, to help use the correct dosage. A physician orders the genetic test and includes the patient’s medication information. After the lab does its work, Fieker analyzes the results and submits his recommendations for medication therapy.

“We make the results actionable, and something they can use and apply rather than stick it away in the patient’s electronic medical record and never look at again,” Fieker says. “It’s a win for the patient, physician, and lab. We talk about medication therapy management all the time, and this to me, is a natural extension of that.”

The lab tests target enzymes in the liver that affect how approximately 120 medications, including NSAIDs, pain medication, blood thinners, antidepressants, and HIV antivirals, are metabolized. The enzymes determine how quickly the body breaks down the chemical ingredients in the medication. For instance, a patient might be a poor metabolizer of clopidogrel, a medication used to inhibit blood clots. Since the medication is a prodrug, the body metabolizes it into its active form. The patient is at risk of having less of the active ingredient in his system and not getting the full benefit of the drug. The opposite might be true if a patient is an ultra-rapid metabolizer, which could lead to a buildup of the active ingredient and, consequently, excessive bleeding.

“Then you’re putting yourself in a position where you’re exacerbating the side effects of medications,” Fieker says.

Fieker started exploring ways to integrate pharmacogenomics into his community pharmacy practice less than two years ago at a meeting of the National Community Pharmacists  Association (NCPA). Never one to miss out on an opportunity, Fieker decided to go to a 6 a.m. breakfast symposium. There, he talked to representatives of genetic testing labs and pharmacists who were involved in pharmacogenomics at a clinic in Alabama. After he returned home, he began thinking about how to make a program happen in the St. Louis area.

First, he met with Gloria Grice, Pharm.D., BCPS,  associate professor of pharmacy practice at the College, who was teaching a pharmacogenomics course with Marc Dorfman, Ph.D., adjunct biology instructor. Fieker left with a textbook and began reading. His interest in genetics was shared by a student who happened to be on rotation at Family Care Pharmacy.

“We fed off each other, thinking about the first steps we had to take in establishing a community-based program,” Fieker says.

From the beginning, Fieker did all of the legwork on the  concept. Working without a roadmap, he attended a symposium, continued to network with others in the field, and read everything available on the subject, both in textbooks and online. And there were no shortcuts along the way.

“From there on, it was about making the decision that I was going to figure out how to do this,” Fieker says. “It was consciously deciding to put the work into bringing the program to my community, so my patients and the physicians whom I collaborate with can benefit from this discipline.”

And experts say the door is wide open for pharmacists with an entrepreneurial spirit who are willing to get in on the ground floor of a new area of study.

“I don’t know if we know the potential yet,” says Kurt A. Proctor, Ph.D., RPh, senior vice president of strategic initiatives at NCPA. “Dan is on the leading edge of something that is clearly going to grow. I am extremely interested and had my own genes tested. I believe in it wholeheartedly.”

One of the many things Fieker loves about being an independent pharmacist is the ability to learn and try new things to expand his business. He still feels like a student of pharmacy even though he graduated from St. Louis College of Pharmacy more than three decades ago.

 “Pharmacists have an obligation to patients to take care of them as best we can,” Fieker says. “So we have an obligation to make sure that we’re giving them all the information they deserve.”

For now, Fieker is building his practical expertise. But he would like to eventually change the model and advocate for pharmacists to order genetic testing. Pharmacists in the community have already built rapport with physicians and can demonstrate how testing can benefit their practice.

“The physicians I work with in Highland all trust us,” Fieker notes. “Physicians come to me all the time with questions.”

Proctor is hopeful that other pharmacists will follow in the not-too-distant future.

“I think pharmacists can step up in this area, and it’s an  opportunity for them to demonstrate their value and role,” Proctor says. “Development in this field will be from pharmacists who take the time to understand it, realize they have the knowledge, and use it to provide better care for patients in their community.”

“I’ve been given this responsibility of patient care,” Fieker concludes. “There are all sorts of possibilities out there for all pharmacists. We just have to be willing to roll up our sleeves, work through some barriers, and be willing to dream a little. Almost anything you want to do is attainable, even when you’re 58.”

This story originally appeared in the summer 2014 issue of Script magazine at http://dev.stlcop.edu/news/publications/script.html.

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