An Employee's Suffering from Depression and Anxiety

      Jane Allain is a 30-year old female, who struggled with anxiety and depression from the time she was 15-years old.  She was referred to Personalized Prescribing by a disability manager. Our pharmacist scheduled a phone appointment with Jane to discuss her medication history.  The pharmacist discovered that Jane also had uncontrolled asthma and a heart condition (i.e., enlarged ventricles).

      Jane informed the pharmacist that whenever she feels anxious, her heart condition gets worse, and she begins experiencing dizziness and fainting spells. When Jane was on Citalopram for help with anxiety, the frequency of the fainting spells increased, so this medication was subsequently discontinued. Jane also tried Venlafaxine and experienced dizziness, nausea, sleep interruption and night sweats when the dose of the medication was increased. Her physician thus decided to keep Jane on a low dose of Venlafaxine, though Jane had continued to experience tension and anxiety.   Jane has also been using her rescue asthma inhaler >3 times/ week due to shortness of breath.  Jane’s respiratory symptoms might also have been affected by her smoking habit, though she had made several unsuccessful attempts in the past to quit.

      During her phone conversation with the patient, our pharmacist conducted a pre-questionnaire with Jane to assess how her condition had affected her life and work productivity. Our pharmacist discovered that the dizziness and fainting spells were the main cause of Jane’s lost time from work, as Jane otherwise had no problems meeting deadlines in the workplace.

      After obtaining patient consent, the pharmacist ordered an Rx Report™ pharmacogenomic test. The pharmacist combined the genetic findings with Jane’s medication history to provide practical recommendations. Jane was provided with a summary report, and the pharmacist called her to explain the recommendations. In her phone discussion with Jane, our pharmacist recommended the avoidance of high-risk medications that can affect the heart (i.e., Citalopram, Escitalopram, Venlafaxine, and Tricyclic Antidepressants). Jane became aware that she was particularly at risk of increased heart rate when on these medications due to both her structural heart problem as well as one of her response genes. In addition, Jane was informed that she was a CYP2D6-intermediate metabolizer and thus has a reduced ability to break down Venlafaxine. This helped Jane understand why she was particularly susceptible to the dose-related side effects of this medication. Our pharmacist recommended alternatives that were not metabolized by CYP2D6,  that the patient was likely to respond well to according to additional genes tested.

One of these medications (Bupropion) was found likely to improve Jane’s mood and help her quit smoking. Jane was also informed that her frequent use of the asthma inhaler (Ventolin) could increase her risk of side effects (i.e., anxiety and heart palpitations). The pharmacist recommended additional therapy for asthma control (Flovent) to decrease inflammation in Jane’s lungs.  A copy of the summary report was faxed to Jane’s physician and the pharmacist shared the medication recommendations with Jane’s disability manager to inform him that the test had been completed.

      When the pharmacist called Jane for a follow-up discussion (a month later), Jane informed the pharmacist that the physician had discontinued the Venlafaxine and had started her on the Bupropion and Flovent inhaler. Jane experienced decreased anxiety and increased motivation and she was able to reduce the number of cigarettes that she smoked per day. Though Jane still experienced bouts of dizziness, she no longer had any fainting spells and could function well at work. Jane was informed that the pharmacist is available at any time, if she needed more help with stopping smoking.

A Health Professional's Struggle with Rheumatoid Arthritis

     Kiera Davies is a physician, who struggles with chronic pain. She was not on disability and decided to buy the Rx Report™ pharmacogenetic test.

      Our pharmacist spoke to Kiera to gather a comprehensive medication history. In her discussion with Kiera, the pharmacist learned that Kiera was diagnosed with Rheumatoid Arthritis (RA) in 2005 and was prescribed methotrexate with folic acid. Kiera was also prescribed Vimovo, which was a combination of an analgesic (i.e. Naproxen) and a stomach protectant (i.e. Esomeprazole), and she was taking levothyroxine for a thyroid problem.  In 2016, Kiera developed lower leg and foot fractures.  Kiera decided to stop the methotrexate as she suspected that her medication may have contributed to the fractures, as is noted in the literature. Kiera continued to struggle with chronic pain. The pain was so severe that the patient exclaimed: “I wish I could cut my leg off!”.

      After obtaining patient consent, the pharmacist ordered a pharmacogenetic test, which revealed that Kiera had a rare genetic variation in her MTHFR gene. This caused her to have a problem in converting folic acid to its active form. It is well known that Methotrexate can deplete folic acid levels. Physicians usually prescribe a folic acid supplement to prevent this deficiency. However, given that Kiera was not able to convert the folic acid in the supplement to its active form, she began to experience increased toxicities from the methotrexate (i.e. chronic bone inflammation and increased fracture risk).  The pharmacist conducted research and discovered case studies in which supplementation with the active form of folic acid alleviated chronic pain for patients with the MTHFR variation. Kiera was also taking the stomach protectant (esomeprazole) and the pharmacist noted that this medication can deplete Kiera’s Calcium and B12 levels and further reduce her bone density.

      The pharmacist scheduled a phone appointment with Kiera and explained to her the genetic findings. The pharmacist also provided a summary report, explaining the lab tests that would need to be ordered to further confirm the deficiency. A supplement (Leucovorin 10 mg once daily) was recommended as it contained the active form of folic acid. The pharmacist also recommended Calcium, Vitamin D and B12 supplementation and recommended seperating the Calcium supplement from the thyroid medication by at least 4 hours due to a potential interaction. Kiera found the pharmacist's advice to be very practical and helpful, and she liked the summary report as it not only identified the problem but also provided solutions.

      Given that Kiera is a physician herself, the pharmacist used medical language in her summary report, including the level of evidence used to support the recommendations as well as references. This is a unique case. Had the patient been referred to Personalized Prescribing through a disability management company, the pharmacist would have followed up with the disability manager to notify him/her that the test was complete and to share the medication recommendations.

       The pharmacist followed up with Kiera a month later. Though Kiera was busy and was not able to answer the phone, she responded with the following feedback:

      “I’m feeling great! I made the recommended changes and am now almost completely healed. Finally! I am spreading the word to my colleagues who think it’s a great idea for those with chronic disorders. Thank you for touching base. – Kiera”

A Child's Case with ADHD

      Mark Rabkin is a 14 year old boy who had recently been diagnosed with ADHD and anxiety. Mark had previously tried multiple ADHD medications, including Adderall and Concerta. Though he had experienced slight improvements in impulsivity, he also had major side effects (i.e., irritability, emotional inhibition, appetite loss, and insomnia). Mark remained on the Concerta, and his physician started  Strattera as adjunctive therapy. Mark experienced further emotional inhibition and missed a lot of school days due to the side-effects that he experienced from these medications.

        After gathering this comprehensive medication history and obtaining patient consent, the pharmacist suggested that Mark complete the Rx Report™ pharmacogenetic test.Once the results became available, the pharmacist corroborated the genetic findings with the clinical findings (i.e. Mark’s side effects). The pharmacist noted that Mark was a CYP2D6 intermediate metabolizer, and that he had a reduced ability to breakdown Adderall, Concerta and Strattera.

       The pharmacist set up a phone appointment with Rosa (Mark’s mother). In this phone call, the pharmacist explained that Mark was at high risk of the dose-related side-effects (i.e., insomnia, irritability, and loss of appetite) on Adderall, Concerta, and Strattera due to his genes. In addition, there is a drug interaction between the Concerta and the Strattera that can further increase the risk of these side effects. The pharmacist recommended some alternatives for Rosa and Mark to consider. A summary report was emailed to Rosa, reiterating what was explained on the phone, in simple, layperson language.

        The pharmacist also faxed Mark’s physician a more detailed medical summary report. This report recommended the discontinuation of Concerta and Strattera, as well as the use of alternatives. The alternatives included medications that are not metabolized by CYP2D6 and that are likely to be effective according to  genes tested. The report also explained the level of evidence used to support the recommendations, including references.  The pharmacist shared the medication recommendations with the disability manager as well to inform her that the pharmacogenetic test was complete.

       The pharmacist followed-up with Rosa by phone in July 2018, a month after the recommendations were made. Rosa informed the pharmacist that she had began to see positive changes in her son’s life soon after the ADHD medications were discontinued. Mark’s sleep duration and quality had improved, his appetite returned, and he was able catch up on the schoolwork that he had missed. Rosa was a patient herself, and she was surprised to learn that she was taking one of the medications (i.e. Desvenlafaxine) that was recommended for Mark. Medication response tends to be genetic, and Rosa had tolerated this medication well with few side-effects. Rosa decided that her son could try the Desvenlafaxine, if the stress of high school becomes difficult to manage in September. The pharmacist informed Rosa that the lines of communication would always remain open. If Mark were to start the desvenlafaxine at the beginning of the school year, Rosa could always call in to have a discussion with the pharmacist if she had any questions. Rosa was tremendously satisfied with the level of service provided.

A Patient with High Cholesterol

      Jordan is a 50 year old man who suffered from high cholesterol. His family physician had prescribed Simvastatin. Three months later, the physician increased the dose of Simvastatin, as Jordan’s cholesterol levels were still high. One and a half weeks later, Jordan started experiencing muscle pains in his feet and legs, which became unbearable. He visited his physician a couple of times, as no pain killers were helpful. He continued to feel debilitated and his lifestyle slowed down significantly, to a point where he was increasingly absent from work.

      Jordan was desperate to find a solution. He reviewed with his physician whether the pain could potentially be a side effect of Simvastatin. Assuming incompatibility with Simvastatin, Jordan decided to take the Rx Report™ genetic drug compatibility test. After the genetic analysis was completed at Personalized Prescribing’s laboratories, it was revealed that Jordan was an atypical responder to Simvastatin. Our pharmacist explained to Jordan and his physician that he has a genetic mutation which had caused him to experience extensive pain when using Simvastatin. Our pharmacist recommended Jordan use Crestor, instead of Simvastatin.

        Jordan was elated to find the cause for his excruciating pain. The physician changed Jordan’s medication immediately and after only two weeks on the new medication, Jordan informed us during a follow up call, of the fact that his muscle pain was gone, he was attending work regularly and he got his life back! Both Jordan and his physician were very thankful for the test and services provided by Personalized Prescribing Inc.

A Teenager's Clinical Depression

      Susy is a 13 year old girl who is an avid soccer player, an excellent student, and a fun,loving friend and daughter. Recently, her mood started to deteriorate, and she was diagnosed with clinical depression. As a result, her doctor prescribed her escitalopram. Unfortunately, the medication was not working for her and her depression became worse. Susy would stay in bed all day due to her depression, which led to her missing school, soccer, parties, and family functions. Because of this, Susy’s parents had to take increasing amounts of time off of work to care for her. 

      Fortunately for Susy, her father heard about Rx Report™ from a friend. Susy’s father ordered Rx Report™ right away to see what was going on with her medications. Susy’s Rx Report™ results came back, and alerted her doctor to the fact that escitalopram was simply not working for her. Her doctor switched her to another antidepressant that was predicted to work for her by her Rx Report™.

      After the switch to the right antidepressant, Susy went back to being the happy and fun,loving girl that her friends and family had previously known.

An Elderly Woman's Breast Cancer Therapy

      Jenny is a 43 year old woman who has two children and a husband. She was recently diagnosed with early stage breast cancer and was determined to beat it. She underwent surgery to remove the tumour and was given a treatment of chemotherapy and radiation, plus tamoxifen as hormone therapy. After completing all her chemo and radiation sessions, Jenny remained on tamoxifen to decrease the likelihood of the cancer returning. Jenny’s oncologist had intended to keep her on tamoxifen for at least five years after her chemo and radiation sessions ended. 

      Although the chemotherapy and radiation sessions were successful in removing all cancerous cells, Jenny wanted to make sure she was doing all she could to prevent the cancer from coming back. Jenny ordered her Rx Report™ test and collected her sample with the saliva kit. The results were sent to her oncologist who noticed that she was a poor metabolizer of tamoxifen, meaning the drug was actually doing nothing at all inside Jenny’s body. This put Jenny at an increased risk for relapse of breast cancer. Jenny’s oncologist immediately switched her to a medication that was compatible with her genetics. Luckily, Jenny caught her drug incompatibility before her cancer had a chance to come back. The Rx Report™ likely saved her life.

A Panic Attack due to Cannabis

      Scott R. is a 40 year old male who recently experienced a workplace accident that resulted in chronic back pain. Scott had tried using Tylenol#1 (i.e. codeine) and oxycodone for his pain but had not received significant relief despite the use of high doses. His physician began to suspect that he was abusing these medications, although Scott insisted that he just needed a more potent prescription medication to control his pain. Scott began to turn to cannabis for pain relief and started to experience panic attacks. He decided to call Personalized Prescribing Inc. when he heard that his company offered the Rx Report™ pharmacogenomic test as part of his benefit plan. Upon receiving the test results, Scott learned that he has a genetic mutation which prevented his liver from converting Codeine, Oxycodone, Hydrocodone and Tramadol into their active forms. The pharmacist recommended an alternative pain medication (i.e., Morphine) to Scott and his physician. The pharmacist also informed Scott that cannabis would not be a good option for him, as most studies have shown that cannabis is not effective for the treatment of muscle-related pain. In addition, cannabis strains high in THC are known to cause panic attacks. Scott was relieved to learn that there was an explanation for his past negative experience with medications. He also reported a drastic reduction in his pain upon the initiation of Morphine, on an as needed basis. He was better able to focus on his role as a financial analyst and felt that he had his life back.

Kim's Depression and Multiple Medication Issues

      Kim has had many issues with her depression and medications for a long time. After years of trial and error with various medications and therapies, she decided to invest in a pharmacogenomic test. Kim wanted to understand why her medications were not working for her. Via a simple and user-friendly process, she purchased the Rx Report™ test online, and followed the instructions provided to submit a saliva sample.

      After the genetic analyses were done, our pharmacist had a detailed discussion with Kim about her Rx Report™ test results and what they mean in reference to her current medications. Our pharmacist also explained to her that the test results had identified a genetic variation (a mutation) that she had, which caused her to be a poor metabolizer of drugs that she was taking at the time, thus increasing her risk of side effects. Additionally, she was also advised that she needed to avoid a certain group of medications due her specific genetic mutation and that she should try alternative drug options as recommended by the pharmacist.

       Kim was pleasantly surprised by the detail and simplified information she received from Personalized Prescribing. She eagerly took the pharmacogenomic test report to her physician and after further discussion, the physician changed Kim’s medication as suggested by our pharmacist.

       We followed-up with Kim after three months and this is what she said:

       “Thank you so much! I feel better than I have in a long time. I even started going to the gym again a couple weeks ago. Previously, just the thought of the gym was overwhelming! It’s not completely gone, but the symptoms are manageable now - I feel like I have my life back. Thank you again, please let me know if there’s anything I can do to help spread the word.”