Dr. David Showers, M.D., Family medicine describes his application of precision medicine by incorporating pharmacogenomics and medication reconciliation into his practice. For more information on how this capability could enhance your practice, please see this “Case for Practice Integration,” or contact us.
DR. DAVID SHOWERS, M.D.
I’m a family practice, board certified. I’ve been working here in Huntsville for about 15 years – since graduating from residency. I see basically infant to death. I see the whole gamut of patients in my practice.
Describe your early experiences with integrating GenoPATH into your practice and how it changed your practice overtime.
I started doing a little bit at the very beginning – just maybe one or two patients a week and starting to learn what pharmacokinetics was about. I thought it was very interesting information that could possibly affect my patients and maybe change the course or direction of management of my patients in the future, based upon the knowledge that I got from the tests. The first challenge was taking the time to relearn what we learned back in med school, [and] GenoPATH made that fairly simple because of the way they formatted their tests. We didn’t just get every report of results; we got what medications the patient was on and we had a pharmacy review of medications [and] we actually had options of medications that could be used if a person was a poor metabolizer or a rapid metabolizer. It made the learning process a steep curve. It made it easier. It probably took a good two to four months at the most before I knew as soon as I saw a medication what its metabolism was, whether it was going to affect my patient, and whether it was a good drug to prescribe, so there definitely is a learning curve to it. Fortunately, I picked the right company to go with to help make my process easier, because, as physicians, [we] don’t have much time to do all these extra things.
As a primary care doctor, now that I see, and now that I understand, these tests that have been done, I have been able to make changes on those patients to improve the outcomes of the management and actually reduce some side effects of the medications that they thought, “maybe this fatigue was just the fact that I’ve been working too hard,” or “maybe I’m not sleeping well.” Come to find out, if they are a poor metabolizer of a certain medicine, they are fatigued because of the medication, not because they aren’t getting enough rest. So many times I’ve taken people off of certain drugs, particularly beta blockers – Toprol being one of the most commonly prescribed medicines out there as a beta blocker – and I would say over 40-something percent of people are poor metabolizers of 2D6. You take them off of that medicine, and you change them to a different beta blocker – all these people who need to be on beta blockers for heart disease or heart failure, and I’ve been amazed at the improvements. They are not coming back saying that they are tired or fatigued, but yet you are still treating their symptom and disease process. It has definitely made a change in my practice.
Do you have any patient situations that are particularly memorable with respect to how this approach resulted in a better outcome for the patient?
Yes, I do. One in particular. Well, history of this patient: Ever since his teenage years, he has had extreme chest pain – gastric pain. He’s been to the ER many times, he’s been scoped many times, [and] he’s actually had a catheterization done on him. Come to find out, due to the fact that he is an ultra-rapid 2C19 metabolizer, [he] requires up to 200 percent of the recommended dosage to treat [his] symptoms. So, this guy has been going in with Dyspepsia [and] doctors give him these proton pump inhibitors over and over again at the maximum dose, and it wasn’t doing him any good, so he starts to think it’s cardiac, and every time he goes to the hospital, I sit back and think of all those tests this one patient had that could have been stopped if we just would have known how he metabolized that particular medicine. And ever since then, since I got the report, we bumped up his dosage of that particular medicine and he’s been symptom-free since adjusting that. Now, interestingly, he was also a poor 2D6 metabolizer and he was on Toprol, so I had to make some adjustments on his beta blocker as well, because they had put him on a beta blocker. I would say that’s probably the most memorable, but there are still quite a few different things in my practice that I have seen and that I’ve learned through this genetic testing that have changed the way I practice medicine and have actually benefited the patient and more than likely reduced admissions. If I would have had the information beforehand, I could have reduced some of the admissions.
I wish I could have this test done on every single person in my practice, from birth up, because once you do it, you know it, [and] in the future I will always know what drug to prescribe to my patients. In the long run, I feel like it leads to better patient care once you realize the differences in people’s metabolism of different medications.