Cultural and Genetic Diversity in America: The Need for Individualized Pharmaceutical Care

1. Cultural and Genetic Diversity in America: The Need for Individualized Pharmaceutical Care National Medical Association National Pharmaceutical Council November 2002

2. 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

3. 1990 2000 Hispanic Hispanic 8% 11% White White Black 74% 72% 11% Black Other 13% 7% Other 4% Diversity of the U.S. Population Source: U.S. Census figures and projections

4. 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

5. Disparities in Cultural Competency • Care may be compromised due to cross-cultural 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% African-American; 2.8% Hispanic

6. 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

7. 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).

8. Clozapine-Induced Blood Disorder in Schizophrenic Patients Source: Lieberman et al, 1990

9. 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) Effectiveness of Antihypertensive Agents in Black Patients Source: Hall, 1990

10. Blood Concentrations of Beta-Blocker After a Single Dose (80 mg) Source: Zhou, et al, 1989.

11. Differences in Response to Cardiovascular Agents

12. 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.

13. 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?

14. Medicine Disease Cultural Heritage Overall Treatment Cost Best Fit Optimal Therapy Good Fit Adequate Therapy Poor Fit “Generic” Therapy Matching the Pieces for Individualized Therapy

15. Individualized Rx Care

16. 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

17. 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

18. 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

19. For Further Information: National Medical Association: www.nmanet.org National Pharmaceutical Council: www.npcnow.org