Mark Rabkin is a 14-year old boy who was diagnosed with ADHD and anxiety. He has been referred to Personalized Prescribing by a disability manager in June 2018. Mark previously tried multiple ADHD medications, including Adderall and Concerta. Though he 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 the Strattera as adjunctive therapy. Mark experienced further emotional inhibition and missed a lot of schooldays due to the side-effects that he experienced from his medications.
After gathering this comprehensive medication history and obtaining patient consent, the pharmacist ordered a pharmacogenetic test for Mark. 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 Mark 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, using simple, patient 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 additional 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 began to see positive changes in her son’s life soon after the ADHD medications were discontinued. Mark’s sleep duration and quality has 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 is 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 little side-effects. Rosa decided that her son can try the Desvenlafaxine, if the stress of high school becomes difficult to manage in September. The pharmacist informed Rosa that the line of communication will always remain open. If Mark was to start the desvenlafaxine at the beginning of the school year, Rosa can 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.