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.