Cultural and Genetic Diversity in America

Cultural and Genetic Diversity in America: The Need for Individualized Pharmaceutical Care National Medical Association National Pharmaceutical Council November 2002 Report Summary • Genetic, cultural and environmental factors affect a patient’s response to a given medicine • Cost containment policies need to be broad and flexible enough to allow access to full “tool box” of medicines • Patients must receive care tailored to their specific needs to prevent disparities in health care Diversity of the U.S. Population 1990 White 74% 2000 Hispanic 8% Black 11% Other 7% Hispanic 11% Black 13% White 72% Other 4% Source: U.S. Census figures and projections Disparities in Health Care for Minorities • Disparities in quality of care documented, particularly African, Asian and Hispanic heritage • Receive less intensive medical care: • Fewer vaccinations • Less drug therapy for pain • Fewer antiretroviral drugs for HIV/AIDS • Lack of insurance/under-insurance Disparities in Cultural Competency • Care may be compromised due to crosscultural language and communication barriers • Cultural beliefs play a vital role in determining if the explanation of illness or treatment makes sense • Lack of representation of minority groups in health professional workforce – Physicians in America: only 2.2% AfricanAmerican; 2.8% Hispanic Disparities in Health Literacy • Over 90 million adults in the U.S. have low health literacy • Those for whom English is a second language more likely to have limited health literacy and self-management skills, including ability to take medications properly • Health education materials are written at too high a level Factors Contributing to Variability in Drug Response BIOLOGICAL FACTORS Age Gender Genetics Disease CULTURAL FACTORS Attitude Beliefs Family influence ENVIRONMENTAL FACTORS Climate Smoking Parasites Alcohol Pollutants Drugs VARIABILITY IN: Drug metabolism Drug receptors Drug response proteins Disease progression proteins Adapted from Poolsup et al. (2000). Clozapine-Induced Blood Disorder in Schizophrenic Patients 20% 15% 10% 5% 0% Ashkenazi Jewish All Patients Source: Lieberman et al, 1990 Effectiveness of Antihypertensive Agents in Black Patients Calcium Channel Antag. Diuretic Beta-blocker ACE Inhibitor 20 15 10 5 0 10 20 30 40 Diastolic Systolic Reduction in Blood Pressure (mm Hg) Source: Hall, 1990 Blood Concentrations of BetaBlocker After a Single Dose (80 mg) Propranolol (nmol/liter) 400 350 300 250 200 150 100 50 0 0 1 2 3 4 5 6 7 8 9 10 11 12 HOURS Source: Zhou, et al, 1989. Whites (n=9) Chinese (n=10) Differences in Response to Cardiovascular Agents Drug Class/Examples β-blockers, especially propranolol (also nadolol, penbutolol, atenolol) Labetalol, combined alphaand β-blocker Diuretics, e.g., hydrochlorothiazide Clinical Response Blacks less responsive Equally effective in blacks and whites Blacks respond better to monotherapy Drugs Showing Cross-Racial Differences in Metabolic Rates • Antidepressants: amitriptyline*, imipramine*, clomipramine, desipramine, nortriptyline, phenelzine • Antianxiety agents: diazepam*, clonazepam, nitrazepam • Antipsychotics: chlorpromazine, perphenazine, thioridazine, haloperidol • Beta-blockers: metoprolol*, propranolol*, timolol*, labetalol, pindolol, oxprenolol, acebutalol • Cardiovascular agents: captopril*, methyldopa, hydralazine, procainamide, warfarin *Most commonly prescribed (top 100) Adapted from Meyer, 1992. Cultural Factors Influencing Treatment • Attitudes and health beliefs may affect the effectiveness of or adherence to a drug therapy  Trust and respect: Eye contact, touching, distrust of American health system  Health beliefs and practices: Alternative therapies, keeping illness to themselves, lack of understanding modern medicines and long-term treatments  Family values: Who makes family health decisions, family support system, alternative remedies? Matching the Pieces for Individualized Therapy Medicine Disease Cultural Heritage Overall Treatment Cost Best Fit Optimal Therapy Good Fit Poor Fit Adequate Therapy “Generic” Therapy Individualized Rx Care Right Patient Right Drug Right Illness Individualized Rx Care Right Time Right Dose The Future of Individualized Rx Therapy • Race and ethnicity are crude markers for genetic variations that may indicate how an individual will respond to a drug • Advances based on human genome will eventually enable drug therapy tailored to individuals • Genetic “fingerprint” of individuals will identify variations in genes known to affect drug metabolism Recommendations • Health care institutions should implement cost containment practices that are broad and flexible enough to enable choices of medicines for all patients • Physicians should give individualized treatment to each patient and take into account racial and ethnic origin – Physicians should be mindful of uncommon responses or unexpected side effects Recommendations (cont.) • Pharmaceutical companies should continue to include significant numbers of diverse patients in drug metabolism studies and clinical trials • Hospitals, managed care groups and other health service providers should employ practitioners who are racially and ethnically representative of the patient population being served For Further Information: National Medical Association: www.nmanet.org National Pharmaceutical Council: www.npcnow.org