Hospital Pharmacist
Vol 10 No 11 p471
December 2003

Review of circulars and official publications
by Alex Bower, MRPharmS

During October, the Department of Health issued “The NHS cancer plan: three year progress report – maintaining the momentum”. The report notes that the “postcode lottery” is being tackled through the implementation of NICE appraisals of new chemotherapy drugs for the treatment of ovarian, lung, brain, pancreatic, breast and bowel cancers as well as leukaemias and lymphomas. It is noted, however, that unacceptable variations in the uptake of drugs in different parts of England still apply. Reference is made to the benefits of multidisciplinary team working. Interestingly, pharmacists are not specifically mentioned although, elsewhere in the document, it is noted that the DoH is undertaking a review of chemotherapy services that will include the development of a competency framework for pharmacists. The report also notes the progress made in reducing death rates from cancer.

Hospital pharmacists with an interest in oncology will wish to access the full, 68-page report here and ensure that they play a part in encouraging the appropriate uptake of relevant drugs.

“The interventions procedure programme: working with the National Institute for Clinical Excellence” was issued on 13 November by the DoH as HSC 2003/011. From that date, medical practitioners planning to undertake new types of interventional procedures must seek approval from their trust’s clinical governance committee. An interventional procedure is defined as one used for diagnosis or treatment that involves incision, puncture, entry into a body cavity, electromagnetic or acoustic energy.

The chair of the committee is responsible for notifying such situations to the National Institute for Clinical Excellence (NICE), unless the intervention is already listed on the NICE website or is used within a protocol approved by the appropriate research ethics committee. The clinical governance committee should only approve use of the procedure if the doctor has met externally set standards of training, patients are made aware of the lack of experience of use of the intervention when consent is sought, and arrangements are in place for clinical audit that captures outcome data. The arrangements will be monitored through Commission for Health Improvement (or Commission for Healthcare Audit and Inspection from 2004) reviews. The circular allows for retrospective approval if a new procedure needs to be used in an emergency situation. Hospital pharmacists will wish to be aware of these new controls.

A recently announced invitation for bids for service development initiatives in genetics led me back to the genetics White Paper issued by the Department of Health in June 2003. For those who did not read it at the time, it would make interesting reading over the Christmas period. The full 99-page report is entitled “Our inheritance, our future: realising the potential of genetics in the NHS”. It is available here

The paper provides a thoroughly fascinating insight into the potential for tailoring the use of existing drugs, new gene based drugs and therapies and prevention and treatment regimes to an individual’s genetic profile. It also looks at the possibilities of genetics offering people more precise diagnoses and risk predictions.

Over the next few decades, it is envisaged that we will learn more about how genes can make us more predisposed to, or protect us from, disease. We will discover how genes affect individual patient responses to medicines (for example, differences in drug metabolism or idiosyncratic adverse reactions) and how prescribing can be more effectively tailored to individuals. Genetic testing, which could be carried out in pharmacies and which could predict a patient’s response to medicine and enable doses to be tailored accordingly, will become a real possibility. New pharmaceutical products linked to a pharmacogenetic test are likely to become available within the next five years. An understanding of how diseases such as cancer operate at the cellular level will lead to treatments being developed that target the disease rather than just controlling symptoms. Gene based medicines will aim to switch a helpful gene on or a harmful gene off. Gene therapy is the deliberate introduction of genetic material into a patient’s cells in order to treat or prevent disease and it is expected that licensed medicines will be available within a decade. It is envisaged that, in the longer term, gene therapy may become a cornerstone of modern medicine. In the case of haemophilia, gene therapy might replace a lifetime of injections with a single treatment to correct the genetic defect which causes the disease. It is hoped that gene therapy will lead to approved treatments for cancer, cardiovascular disease, arthritis and some forms of blindness such as macular degeneration. Progress in developing gene based vaccinations is noted. NICE has produced appraisals for two medicinal products that require analysis of genetic features of tumour cells before they are used (ie, trastuzumab and imatinib).

Up to £2.5m is to be invested in pharmacogenetic research on existing medicines with a focus on:

• Classes of medicines that are commonly used (such as drugs to lower blood pressure), particularly expensive or used in otherwise healthy people (such as oral contraceptives)
• Investigating serious adverse reactions which occur in response to a number of different types of medicines
• Medicines whose use is limited because of genetic related toxicity

These are exciting developments and there would seem to be considerable scope for pharmaceutical input. Hospital pharmacists might wish to consider if they wish to focus on this developing area of pharmacogenetics as a hospital pharmacy specialism with a view to ensuring that they engage in appropriate education, training and research.

  * PDF files on PJ Online require Acrobat Reader 4 or later.

Mr Bower is a consultant pharmacist