Issuu

Individualizing Pharmaceutical Care Advancements and Future Practices

E y c a m r a h P c u n d o i E t y ca c a m r a h a P c u n d o i ducat Pharmacy E ca u n d o i E t a y Educ n Pharmac c u d o i E t a y c c a u d m E r a y h P u n 2013 Edition d o i E t a y c c a u d m E r a y h P n o i t a y c c a u d m r a h P cation d on Ph E y c a m r a h P d E tion y c a m r a h P n o i E t a y c a m r a h P cation armacy h P n ucatio harmac P n o i t a a duc m r a h P n o i ucat

IPSF Phuture | Issue 18 | August 2013

phuture phuture@ipsf.org education@ipsf.org http://pharmacy-ed.ipsf.org

ISSN 2307-132X

9 772307 132005

ipsf Since establishment in 1949, IPSF now represents more than 270 000 pharmacy students and recent graduates in over 70 countries worldwide. IPSF is the leading international advocacy organisation of pharmacy students promoting improved public health through provision of information, education, networking, and a range of publication and professional activities.

ac Pharm ac armac ducation PhariomnacPharmac atioEdnucPhatariomn Ph mac onucat acyarEdmucacy PhariomnacPhar ducaytiEd mn Ph nucat ac mac ar io at Ph io Ed uc ar at y onuc ducaytiEd macyarEdmac atioEdnucPhatariomn Ph mac onucPhatarion Ph acy EdmucacyationucPhatariomnacPhar ac ducaytiEd Phatariomn Phar Ed ac uc arm y on m Ed ti ac uc Ph ar y ca m du macy tiEdon PhatariomnacPharEducatyioEdnucPhationmac armac ar Ph cay Educ armacPhyarmac ion Phatarion Ph ac ucation ardu onucPhation y Edmucacaty EducPhariomnacPharmac Ph m caytiEd ducation Phardu mac tion PhatariomnacPharEd ationucatarmacPharmac ca uc armacPhyarmucacy Ed ucation ardu macy Ed n EducacatyioEdnucPhationmac Ph ationucPhatio acPhyarm ation Phar m ar ducation PhyarEdmucacy Ed n m Educacy E ationucPhatio armnacPhyarmucatyioE n Phar ducation PhyarEdmucacy Ed m Ed ac ationucPhatio armnacPhyarmucatyioE n Phar ducation PhyarEdmucacy Ed ationucPhatio acPhyarEdmac tion Pharm m ar ducatiaronmacPhyarEdmucacy Edon Ph on ca du ti ducati ac on Ph ca m ti ar du on ca ti Ph duca du ducation

Phuture

content Messages from IPSF

Page 4

Individualized Pharmaceutical Care Page 6

Pharmacogenomics: A Novel Approach in Achieving Personalized Pharmaceutical Care Page 11

The Challenge of Individualized Pharmaceutical Care: The Need of an Interdisciplinary Education Page 13

Achieving Quality Individualized Pharmaceutical Care: Begins with Interdisciplinary Education Page 17

FIPEd-IPSF Student Learning Experience Questionnaire Page 20

Personalized Care: Impact of Vitamin D Polymorphic Variants on Body Parameter Page 22

Gaining The Confidence of The Patient: The Key to Individualizing Pharmaceutical Care Page 25

Contacts Page 27

Issue #18, August 2013

Design & Layout

Ms.IPSFAlexandra Marques Chairperson of Media and Publications Publication Editor

Mr.IPSFFahmi Fuady Phuture Coordinator Reviewed by

Ms. Shirley Yeung Ms. Yuqian Liu Mr. Marouen ben Guebila

Proofread by

Ms. Yuqian Liu [Editor-in-Chief ] Chairperson of Media and Publications publications@ipsf.org Editor-in-Chief editor@ipsf.org

IPSF 2013ÂŠ

a h P n o i t a c c m r a a du m h r P a n h o P i t n a Messages d o c i E t u a y duc y Ed PhairomnaPcharm t n a o c i E t u a y d c du y E PhairomnaPchar t n a o c i t u a y d c c E a u Mr. Fahmi Fuady , d y Phairomn Pha t n a o c i t u a y d c c E a u y d c m h r a P a m n h r o P a i t h n a o P c i t u n a d o c i c E t a u a y d c c m r a u P a m n h r o P a i t h n a o P c i t u n a d o c i E t a u a y d c c m r a a du m n h r o P a i t h n a o P c i t u n a d o c i E t u y d c m r a uca a m n h r o P a i t h n a o P c i t u n a d o c i E t u a y d c m E r a a y duc m h r o P a i t h n a o P c i t u n a d o c i E t u a y d c E r a a y duc m h r P a i t h n a o P c i t u n a d o c i E t u a y d c c E a a y du m h r P a t h n a o P c i t u n a d o c i E t u a y d c c E a u d h acy rm From the International Pharmaceutical Students’ Federation

‘‘

IPSF Phuture Coordinator 2012-13

Dear IPSF’ers,

It is a great honour for me to present to you the 18th issue of IPSF Annual scientific/ educational supplement, Phuture. In this edition, we have a selection of articles written by students and recent graduates in IPSF network, regarding recent developments, current practices and the future of ‘Individualizing Pharmaceutical Care’. We are hoping that by sharing this we will help facilitate the development of new ideas that can bring us closer to the practice of an ideal individualized pharmaceutical care.

‘‘

I would like to express my sincerest gratitude to everyone who has been involved in the process during the development and preparation for this issue. Enjoy reading. Viva la Pharmacie!

IPSF Phuture 2013

c a c m r a a c ma tion Pchaatiromn Ph c a u a d E harmnaPcharm dmuaccMr.yMarouen benPGuebila , o i t n a o c c i t a u a d c c m E r a u a y d m h ErmFrom r ac Personalized P a n h to Precision Medicine o P i t n a o c c i t a u a d c c m E r a u a y d c m h E r a P a m n h r o P a catiodnucati c a c m E r a u a y d c m h yhaErma ion Pchaatiron P c t a u a d c c m E r a u a y d c m h cPhyaErma tion Pchaatiron P c a u a d c c m E r a u a y d c m h E r a P a y c m n h aPhar ationuPcatio c a d c c m E r a u a y d c m h E r a P a y c m n mnaPhar catiEodnuPchatio ac u y d c m E r a a y c m h r a P a m h n on P y EduaccaytiEo m r a c m h r a P a m h n rion P o i t a c E u y d c m E r a a y c m h r a P a m atiron Ph duccaytiEon m E r a a y c m h r a P a n o i t haromn Ph a In ancient Greece, Pythagoras was the first to say that humans respond differently to drugs. Since then, in all modern drug discoveries and developmental processes, industries try to take into account the specificities of patients’ subpopulations based on age or gender. Nevertheless, the interest for personalized medicine –in its modern meaning- grew that the attrition rates of new compounds started to increase, especially due to phase IV adverse reactions. Benefits started to regress, and when looking for the reasons, researchers started to understand that those adverse reactions that lead to the drug withdrawal from the market, are happening because the medicine was not optimized for patients within some subpopulations.

that one could present his/her genotype to the pharmacist and get the best drug at an optimized dose. Unfortunately, this wasn’t the reality; most studies failed and couldn’t find a genetic factor responsible for these variations in drug response. Since then, researchers started thinking about a new approach, a new paradigm. They thought that instead of targeting each individual, it would be wise and more achievable to target subpopulations. This paradigm had a lot of influence in the research programs of the pharmaceutical industry, and paved the way for new disciplines in science that had to be explored. We, as pharmacists, need to adapt ourselves and push for reforming our education, both in science and practice, to be able to meet these modern challenges.

These findings along with the technological breakthrough in the sequencing technology, allowed the investigation of genetic variations (including SNP, CNV and epigenetic factors) that could cause the difference in pharmacokinetics and pharmacodynamics of the drug.

This is why this theme was chosen for Phuture this year. It will open our eyes on a thrilling world.

‘‘

Billions of dollars were invested by the industry and governments in large population studies, the scientists thought that the era of personalized medicine has come. They thought

Enjoy reading!

IPSF Phuture 2013

Phuture

‘‘

IPSF Chairperson of Pharmacy Education 2012-13

a h P n o i t a c c m r a a du m h r P a n h o P i t n a d o c i E t u a y duc y Ed PhairomnaPcharm t n a o c i E Individualized Pharmaceutical Care t u a y d c du y E PhairomnaPchar t n a o c i t u a y d c c E a u d y Phairomn Pha t n a o c i t u a y d c c E a u y d c m h r a P a m n h r o P a i t h n a o P c i t u n a d o c i c E t a u a y d c c m r a u P a m n h r o P a i t h n a o P c i t u n a d o c i E t a u a y d c c m r a a du m n h r o P a i t h n a o P c i t u n a d o c i E t u y d c m r a uca a m n h r o P a i t h n a o P c i t u n a d o c i E t u a y d c m E r a a y duc m h r o P a i t h n a o P c i t u n a d o c i E t u a y d c E r a a y duc m h r P a i t h n a o P c i t u n a d o c i E t u a y d c c E a a y du m h r P a t h n a o P c i t u n a d o c i E t u a y d c c E a u d h acy rm Mr. Hrvoje Rimac , M. Pharm., Faculty of Pharmacy and Biochemistry, University of Zagreb - Croatia

What is (Individualized) Pharmaceutical Care?

“With pharmaceutical care, the pharmacist works with patients in a one-on-one discussion to determine their individual medication needs...”

Over the past decades there has been a trend for pharmacy practice to move away from its original focus on medicine supply towards a more inclusive focus on patient care. The role of the pharmacist has evolved from that of a compounder and supplier of pharmaceutical products towards that of a provider of services and information and ultimately that of a provider of patient care. Pharmaceutical care is the next generation of pharmacy practice, which goes beyond the traditional pharmacy service of filling prescriptions. Pharmacists practicing pharmaceutical care are true health advisors. With pharmaceutical care, the pharmacist works with patients in a one-on-one discussion to determine their individual medication needs; the pharmacist’s task is to ensure that the patient’s drug therapy is appropriately indicated, the most effective available, the safest possible and convenient for the patient – the goal is to help them get the best results from use of your medicines. Individualized pharmaceutical care requires patients to inform their pharmacists about their

IPSF Phuture 2013

medical history, what prescription medicines they are taking, non-prescription or over-the counter products they use (like aspirin, vitamins, health food products, etc.), any drug or or food allergies or problems they have in using their medicines and other information that may relate to their treatment; in other words, it requires patients to be active participants in their own health care. Even though medicines will always be an important part of health care, more important than having access to medicines is knowing how to use them correctly.

With patient’s active participation in their own treatment, it can be easier to address patient’s question and concerns regarding therapies, assess how well current drug therapies are working, review patient’s understanding of all medications, collect informations to identify, resolve and prevent drug therapy problems and by doing that decrease the number of hospital and nursing home admissions on national level.

Alongside with Individual Pharmaceutical Care goes Individual Medication Management System (IMMS) which will enable analysis of the course of pharmacotherapy and elimination of drug problems, which are the chief goals of pharmaceutical care. The essential task of pharmaceutical care is to guarantee that the pharmacotherapy applied to the patient is as appropriate, efficacious and safe as possible. The principal action to achieve that goal is to

recognize and solve real drug-related problems and to prevent potential problems. It has been determined by numerous studies that up to 60% of patients do not apply drugs according to the doctor’s recommendations. For example, only 12% of patients receiving statins abide pharmacotherapeutic regimens. Another problem is the fact that as much as 40% of elderly patients interfere with the process of their treatment by voluntary reduction, increasing or omission of consecutive doses or additional application of OTC drugs patients disturb the prescribed scheme of pharmacotherapy. The risk of occurrence of complications in those patients is twice as high as in the patients who exhibit a high degree of discipline.

other reasons.

Another meaning Pharmaceutical Care

Pharmacogenetics is the field of study that examines the impact of genetic variation on drug response. By measuring the levels of proteins, genes or specific mutations, it is possible to provide a specific therapy for an individual’s condition – adequate medicine(s) in optimal dose(s) with the benefits of increasing their efficacy and safety. Additionally, such methods might also be used to assess a patient’s risk factor for a number of conditions and tailor individual preventative treatments which can be as simple as changing one’s eating habits.

Individualized

As opposed to common understanding of the term Individualized Pharmaceutical Care, it can also take up another meaning – „intelligent use of information to promote health, prevent disease, detect disease early, and treat disease in a manner that acknowledges the unique genetic, personal, family, environmental, and cultural circumstances of the individual‖ (John Hopkins University, 2).

Historically, the pharmaceutical industry has developed medications based on empirical observations and known disease mechanisms, which have been extensively studied over the past century. For example, antibiotics were based on the observation that microbes produce substances that inhibit other species. Medications for high cholesterol target the absorption, metabolism and generation of cholesterol. Despite being the best solutions for most patients, in some cases standards medicines have no effect, or even worse, they can harm the patient even more because they metabolize the medicine differently, lack the receptor with which the medicine should interact or for some

As almost every disease has a genetic component, everybody’s genetic makeup offers clues to their risk of developing a disease, the probable course a disease will take and the most effective therapeutic options. This form of individualized health care is a rapidly evolving science that is guiding the development of so-called ― designer drugs‖ that will be individually tailored, administered and dosed based on a patient’s specific genetic composition. The goal is to have fewer adverse effects and holds the promise of treating diseases years before the symptoms would become apparent. Pharmacogenetics and rational drug design

Interindividual variation in response to a xenobiotic was probably first described by Pythagoras in 510 BC when he noted that some individuals developed hemolytic anemia after ingestion of fava beans. Today the most known interindividual differences in the activity of drug-metabolizing enzymes are polymorphisms of the cytochrome P450 enzymes – CYP450 (genetic variation in a population is termed as ‘polymorphism’ when both gene or allelic variants exist with a frequency of at least one percent). Individual’s genetic inheritance can significantly affect the body’s response to drugs. It may be possible to predict therapeutic failures

IPSF Phuture 2013

Phuture

a h P n o i t a c c m r a a du m h r P a n h o P i t n a d o c i E t u a y duc y Ed PhairomnaPcharm t n a o c i E t u a y d c du y E PhairomnaPchar t n a o c i t u a y d c c E a u d y Phairomn Pha t n a o c i t u a y d c c E a u y d c m h r a P a m n h r o P a i t h n a o P c i t u n a d o c i c E t a u a y d c c m r a u P a m n h r o P a i t h n a o P c i t u n a d o c i E t a u a y d c c m r a a du m n h r o P a i t h n a o P c i t u n a d o c i E t u y d c m r a uca a m n h r o P a i t h n a o P c i t u n a d o c i E t u a y d c m E r a a y duc m h r o P a i t h n a o P c i t u n a d o c i E t u a y d c E r a a y duc m h r P a i t h n a o P c i t u n a d o c i E t u a y d c c E a a y du m h r P a t h n a o P c i t u n a d o c i E t u a y d c c E a u d h acy rm or severe adverse drug reactions in individual patients by testing for important DNA sequence variations or polymorphisms (genotyping) in key drug-metabolizing enzymes, receptors, transporters, etc. Potentially, test results could be used to optimize drug choice, avoid serious adverse effects and decrease medical costs. As far as it goes for CYP450 enzymes, four phenotypes have been identified: Poor metabolizers which lack functional enzymes, intermediate metabolizers who are heterozygous for one deficient allele, extensive metabolizers who have 2 normal alleles and ultra rapid metabolizers who have multiple gene copies. Ultra rapid metabolizers of an active drug may not reach therapeutic concentrations at usual recommended doses of active drugs due to increase in enzyme activity, while poor metabolizers may suffer more adverse effects at usual doses due to reduced enzyme activity leading to increased concentrations of the drug. Conversely, for administered prodrugs that must be bioactivated by CYP450 enzymes into active metabolites, ultra rapid metabolizers may suffer adverse effects and poor metabolizers may not respond. For example, it has been observed that patients on antipsychotics develop Parkinsonism like side effects with high frequency in poor metabolizers compared with extensive metabolizers. Over sedation has been observed in poor metabolizers in many studies following treatment with thioridazine and other antipsychotics. Polymorphic CYP2C9 accounts for majority of phenytoin metabolism, several side effects have been reported including CNS intoxication such as ataxia and diplopia in patients with defective CYP2C9 alleles following phenytoin treatment. Other examples of drug toxicities that can be predicted by P450 polymorphism include those exerted by codeine, tramadol, methadone, warfarin, acenocoumarol, and clopidogrel.

IPSF Phuture 2013

Major pharmaceutical companies do take pharmacogenetic aspect of CYP450 into account during drug development and any compound showing high affinity for a polymorphic P450 enzyme is terminated. Recently, the AmpliChip (Roche Molecular Systems, Inc.) was cleared for marketing by the FDA. The AmpliChip is a microarray consisting of many DNA sequences complementary to two CYP450 genes applied in microscopic quantities at ordered locations on a solid surface (chip). The AmpliChip tests the DNA from a patient’s white blood cells collected in a standard anticoagulated blood sample for 29 polymorphisms and mutations for the CYP2D6 gene and two polymorphisms for the CYP2C19 gene. According to FDA labeling, “Information about CYP2D6 genotype may be used as an aid to clinicians in determining therapeutic strategy and treatment doses for therapeutics that are metabolized by the CYP2D6 product” (de Leon, 2006) Individualized oncology

pharmaceutical

care

Oncology is a field of medicine with a long history of classifying tumor stages and subtypes based on anatomic and pathologic findings. This approach includes histological examination of tumor specimens from individual patients (such as HER2/NEU in breast cancer) to look for markers associated with prognosis and likely treatment responses. Thus, “individualized medicine” was in practice long before the term was coined. New molecular testing methods have enabled an extension of this approach to include testing for global gene, protein, and protein pathway activation expression profiles and/or somatic mutations in cancer cells from patients in order to better define the prognosis in these patients and to suggest treatment options that are most likely to succeed. Examples of personalized cancer management include testing for disease-causing mutations in the

BRCA1 and BRCA2 genes, which are implicated in hereditary breast – ovarian cancer syndromes and targeted therapy – the use of medications designed to target aberrant molecular pathways in a subset of patients with a given cancer type. For example, trastuzumab is used in the treatment of women with breast cancer in which HER2 protein is overexpressed. Tyrosine kinase inhibitors such as imatinib have been developed to treat chronic myeloid leukemia (CML), in which the BCR-ABL fusion gene (the product of a reciprocal translocation between chromosome 9 and chromosome 22) is present in >95% of cases and produces hyperactivated abl-driven protein signaling (Saglio, Morotti et al, 2004). Notable concerns and opportunities

“One of the significant barriers to genetic testing is thought to be the fear of discrimination...” One of the significant barriers to genetic testing is thought to be the fear of discrimination, such as from an insurer or employer, as the data could be used in much the same way any other actuarial statistics are processed. In the realm of cancer, companies are already offering to perform predictive genomic analysis from a patient’s oral swab for a nominal fee. However, no consensus has been reached on how to use that information, and as such, it might cause more harm than good. Because autopsy studies show the actual incidence of cancer to be far greater than that reported in life, we must question the utility of using genetic data to predict incidence. If a patient suffers no clinical consequences from living with an undetected cancer, then using personal data to predict cancer development and ferret out preclinical lesions is problematic for obvious reasons. Autopsy studies show that the true incidence of cancer is much greater than what is reported. Proteomic analysis of a

patient’s peripheral blood holds promise as a means of early cancer detection. However, for the patients who die not having suffered from or known about their cancer, they might be better off without having it detected and certainly would be better if left untreated. Currently, there is no proven efficacy for preventative therapeutic intervention for most cancers. However, because the technology is here, we need to begin a discussion about how to use it wisely. A potential use of genomics and proteomics would be not the detection of cancer but, instead, a prediction of which patients might benefit from therapy and which would better be left alone. Conclusion

As health care records move to electronic systems, there is an opportunity to compile information taken from individuals and use it to conduct large studies that advance the entire health care system. Such information could be used to better monitor diseases and outbreaks, target medical services where they are most helpful, reduce unnecessary testing and treatments, prevent medical errors, and accelerate medical research and delivery of new treatments.

Creative use of the emerging biological data can unravel the mysteries of an individual’s health and disease. These data can help us to understand what distinguishes one person from another and to tailor prevention, diagnosis and treatment to improve health dramatically. By allowing us to manage health and disease on an individual level, this emerging data can also reduce the waste in our current health expenditures. For most cancer patients today, therapy is chosen and implemented on a watch-andwait basis. Although an individual’s clinical information is used to decide which regimen is likely to work best, we still employ only data referring to outcomes of groups of patients. Currently, an individual patient’s biologic data is

IPSF Phuture 2013

Phuture

a h P n o i t a c c m r a a du m h r P a n h o P i t n a d o c i E t u a y duc y Ed PhairomnaPcharm t n a o c i E t u a y d c du y E PhairomnaPchar t n a o c i t u a y d c c E a u d y Phairomn Pha t n a o c i t u a y d c c E a u y d c m h r a P a m n h r o P a i t h n a o P c i t u n a d o c i c E t a u a y d c c m r a u P a m n h r o P a i t h n a o P c i t u n a d o c i E t a u a y d c c m r a a du m n h r o P a i t h n a o P c i t u n a d o c i E t u y d c m r a uca a m n h r o P a i t h n a o P c i t u n a d o c i E t u a y d c m E r a a y duc m h r o P a i t h n a o P c i t u n a d o c i E t u a y d c E r a a y duc m h r P a i t h n a o P c i t u n a d o c i E t u a y d c c E a a y du m h r P a t h n a o P c i t u n a d o c i E t u a y d c c E a u d h acy rm rarely employed in a systematic way to predict the best course of therapy. However, the advent of low-cost individual genomic and proteomic analysis provides hope that we are entering a new era of personalized, patient-specific care. A compelling example involves screening for common cancers. By integrating population data about the age and risk factor-specific prevalence rates with personal data on family history and other factors, we can individualize each person’s cancer screening protocol. Doing so increases the chance of detecting the cancer early, while minimizing the risk and costs of false-positive screens and inappropriate invasive tests or treatments. In the near future, it will become routine for a doctor to order targeted genomic and epigenomic profiles in those situations where the new information has value. When analyzed carefully, these profiles can improve prevention, diagnosis and treatment decisions. Of course, the patient’s complete health record – showing the genetic and epigenetic profile, medical history, and much more – will follow the patient wherever he or she may go, precluding the need for new diagnostic tests every time there is a move or change of doctors.

And where in all that do pharmacists fit in? The advancement of technology has brought us into a new era of pharmaceutical care. The pharmacist is now considered an integral part of the health care team. We must embrace this role and focus our efforts on proper counseling for the patient because pharmacists represent the crucial link between doctors and patients with their unique combination of medical and people skills which are to be used in betterment of patient focused medical care – individualized pharmaceutical care. References: de Leon J. AmpliChip CYP450 Test: Personalized medicine has arrived in psychiatry. Expert Rev Mol Diagn 2006;6:277-86.

10 IPSF Phuture 2013

Geer Mohammad Ishaq, Mir Javed Iqbal, Parvaiz Ahmed Koul. „FACP Optimizing Clinical Outcomes through Pharmaceutical Care, accessed June 12, 2013, http:// www.physicians-academy.com/Upload/de565bc792dc-460c-bfd3-6467d06d0d64.pdf John Hopkins University. „Hopkins inHealth Announcement, June 27, 2012; http://web.jhu.edu/ administration/provost/initiatives/ihi/120627%20 Hopkins%20in%20Health%20announcement.docx John Hopkins University. „White Paper on the Johns Hopkins Individualized Health Initiative―, http:// web.jhu.edu/administration/provost/initiatives/ ihi/120821%20Individualized%20Health%20 white%20paper.doc Indiana University. “Sharing individual health information could improve care and reduce costs for all.” ScienceDaily, April 15, 2013. Inger Johansson and Magnus Ingelman-Sundberg. „Genetic Polymorphism and Toxicology—With Emphasis on Cytochrome P450, Toxicological Sciences, 2011;120: 1–13. Kalra Bhupinder Singh. „Cytochrome P450 enzyme isoforms and their therapeutic implications: An update, Indian J Med Sci 2007;61:102-116. Mansour JC, Schwarz RE (August 2008). “Molecular mechanisms for individualized cancer care”. J. Am. Coll. Surg. 2007;2:250–258. Magdalena Waszyk-Nowaczyk, Marek Simon and Karolina Matwij. „Individual Medication Management System (IMMS) as a Proposition of Obeying the Doctor’s Recommendation with Pharmacist Cooperation, Acta Poloniae Pharmaceutica - Drug Research, 2012;69:971-978. Mayo Clinic. Individualized Medicine, accessed June 13, 2013, http://www.mayoclinic.org/development/ individualized-medicine.html Nicodemo ‘Nick’ Calla. Personalized Medicine: Where Is Specialty Pharmacy Heading?, Published Online: March 22, 2011, accessed June 13, 2013, http://www.pharmacytimes.com/publications/ s p e c i a l t y - p t / 2 0 1 1 / Fe b r u a r y - 2 0 1 1 / S P TPersonalizedMedicine-0211 Saglio G, Morotti A, Mattioli G, et al. (December 2004). “Rational approaches to the design of therapeutics targeting molecular markers: the case of chronic myelogenous leukemia”. Ann. N. Y. Acad. Sci. 1028 (1):423–31. Scott Ely. „Personalized medicine: individualized care of cancer patients, Translational Research 2009;154:303–308 van’t Veer LJ, Bernards R (April 2008). “Enabling personalized cancer medicine through analysis of gene-expression patterns”. Nature 452 (7187): 564– 70.

c a c m r a a c ma tion Pchaatiromn Ph c a u a d c m E Farmawati, r a a dmuaccMs.yNoorviana m h r P a n h o P i t n a o c c i t a u a d c c m E r a u a y Pharmacogenomics: d c ApproachPinhAchieving m h ErmAaNovel r P a n o i Personalized t n a o c c i t a u a d c c m E Pharmaceutical Care r a u a y d c m h E r a P a m n h r o P a catiodnucati c a c m E r a u a y d c m h yhaErma ion Pchaatiron P c t a u a d c c m E r a u a y d c m h cPhyaErma tion Pchaatiron P c a u a d c c m E r a u a y d c m h E r a P a y c m n h aPhar ationuPcatio c a d c c m E r a u a y d c m h E r a P a y c m n mnaPhar catiEodnuPchatio ac u y d c m E r a a y c m h r a P a m h n on P y EduaccaytiEo m r a c m h r a P a m h n rion P o i t a c E u y d c m E r a a y c m h r a P a m atiron Ph duccaytiEon m E r a a y c m h r a P a n o i t haromn Ph a “...this new field of study is improving and becoming an essential aspect in pharmaceutical care for patients.”

A lot of endeavours for effective and safe medication have been developed to find the best health care for patiens. The revolutionary of novel approach in improving the quality of therapy has been done over the past few years. Development of therapy for patients has improved as the development of science and technology. As we know, therapeutic medications only focus on a large group of patients with the same results in common. Determination of dose given to the patients based on some factors, such as age, weight, height, and body surface. The outcomes of the therapy may vary in one patients and another, some are effective and some even give toxicity effects. The variations of the outcome of therapy may caused by several factors, including age, gender, health status, nutrition, comedications, and genetics. (Sadee and Dai, 2005)

Recent development of the treatment for patients only aims at the general population. The term “one drug fits all” has been a method in determining the medications for patients. The vast majority of the drugs in the “one drug fits all” method only based on age of patient using common type of drug for a certain disease, irrespective of individual response based on genetics. The results may differ for each patients, which are effective in a group of

patients, while to the other group are ineffective and unsafe. The ineffective medications not only cause failure but also increase health expenditure.

The observation of individualized therapy based on genetics began in 1950s when the term “pharmacogenetic” is recognized as the new discipline of study and the research as well. The different responses in individuals have been observed through some cases, such as during the World War II, antimalarial drug, primaquine, induced hemolysis in American soldier, particularly in the African decents. In 1956, reported that patients with deficiency of butyryl-cholinesterase or pseudocholinesterase genetically, died after injected succinylcholine during anesthesia. Those cases led in personalized medicine with a new research that human gene affecting different response in medication. After the study of Human Genome Project has been completed, pharmacogenetics and pharmacogenomics emerged as the new discipline of study. Pharmacogenetics and pharmacogenomics examine the variety of human genes and difference response of the medicine. Thus, further purpose of pharmacogenetics and pharmacogenomics study is to dispense the right medicine to the right patient in right time with the right dose in personalized therapy. Research on individualized therapy was applied in pharmacogenetics which studies phenotypegenotype experiment, then developed to a

IPSF Phuture 2013

Phuture

Student of Faculty of Pharmacy, Universitas Indonesia – Indonesia

Pharmacogenomics observes gene sequence in order to determine structure and expression of the gene. The key in pharmacogenomics is in mRNA, when mRNA changes the expression, there will be changes in protein as well. mRNA itself is varied within individuals, so the expression and the gene function are varied too. The expression of the gene is also influenced by the environment, if the environment stimulates the gene, the expression of gene will be affected. The gene expression that influences the drug response in patients is controlled by polymorphism genetics. Polymorphism cytochrome P450 (CYP450), a system enzyme in human, is related to absorption, distribution, metabolism, and elimination of drugs. Thus, mutations in CYP450 yield different drug responses in human. These mutations occur in various human races, hence some drugs may give therapeutical effects and the other may give adverse effects. The pharmacogenomics approach can be useful in treating patients with disease that requires targeted therapy such as cancer. Recent therapy for cancer using chemotherapy is not specific for the cancer cell but the drugs also attack normal cell. Selectivity in disease-induced-gene increases the efficacy of therapy and reduces side effects. Pharmacogenomics is also useful in determining which gene that is responsible in hereditary disease in a certain human races. Thus, pharmacogenomics provides treatment

12 IPSF Phuture 2013

for patients within small group which experience adverse effects of drugs as their genes are different from another group of patients.

Despite its significance improvement in personalized medicine, there are some barriers in implementing pharmacogenomics in medical therapy. Since pharmacogenomics analyses patientâ€™s genome sequence, it requires advanced techniques to study human gene and its complexity. Only few researches have been conducted in applying pharmacogenomics technique so only few drugs and diseases have been analysed using pharmacogenomics. Furthermore, pharmacokinetics and pharmacodynamics of the patients have to be considered in using pharmacogenomics to ensure the safety and efficacy of the therapy. These barriers are not only faced by physicians and pharmacists in clinics and hospitals, but also in pharmaceutical industries. The challenges are inventing new drugs based on pharmacogenomics research and introducing the drugs in the market. Therefore, it requires new regulation and fund in conducting the research. Pharmacogenomics education for health care professionals as well as the students is crucial since current curriculum only encompasses minimal information about pharmacogenomics, yet this new field of study is improving and becoming an essential aspect in pharmaceutical care for patients. References: Kalow, W. Pharmacogenetics and pharmacogenomics: origin, status, and the hope for personalized medicine. The Pharmacogenomics Journal 6. 2006 : 162â€“165 Mancinelli, Laviero, Cronin, Maureen and SadĂŠe ,Wolfgang. Pharmacogenomics: the promise of personalized medicine, AAPS PharmSci; 2 (1) Article 4. 2000 : 1-13 Miller, M Piquette and Grant, DM. The Art and Science of Personalized Medicine. Clinical Pharmacology & Therapeutics. 2007 : 81 311-315. Sadee, Wolfgang and Dai, Zunyan. Pharmacogenotics/ genomics and personalized medicine, Human Molecular Genetics Vol. 14. 2005 : 207 - 214

c a c m r a a c ma tion Pchaatiromn Ph c a u a d dmuaccMr.yJiayiEGong, PhairomnaPcharm t n a o c c i t a u a d The Challenge of Individualized c c m E r a u a y d ErmPharmaceutical riomn Ph ac n PhaatCare: o c c i t a u a d The Need of an Interdisciplinary Education c c m E r a u a y d c m h E r a P a m n h r o P a catiodnucati c a c m E r a u a y d c m h yhaErma ion Pchaatiron P c t a u a d c c m E r a u a y d c m h cPhyaErma tion Pchaatiron P c a u a d c c m E r a u a y d c m h E r a P a y c m n h aPhar ationuPcatio c a d c c m E r a u a y d c m h E r a P a y c m n mnaPhar catiEodnuPchatio ac u y d c m E r a a y c m h r a P a m h n on P y EduaccaytiEo m r a c m h r a P a m h n rion P o i t a c E u y d c m E r a a y c m h r a P a m atiron Ph duccaytiEon m E r a a y c m h r a P a n o i t haromn Ph a “Visualising the areas of development in individualised care for a patient is much like that of a needle...“

This article makes us focus on two aspects of patient care, individualisation and collaboration via a team-based approach. Individualisation of pharmaceutical care is an exciting area of development that has taken off in the recent years since the unveiling of human genetics through the human genome project in 2003, which opened up whole new avenues of personalised medication at a genetic level (Ross, et al., 2004). Parallel to the bio-molecular advancement of pharmaceutical care, there are also improving social factors such as adherence and education. What are some new approaches to improve adherence? How are pharmacists trying to tailor medicines education to various patients? Visualising the areas of development in individualised care for a patient is much like that of a needle; on the sharp-end is the precise and molecular involvement using pharmacogenomic medicines, nanotechnology and advancement in diagnostic assays. On the broader is a much widerscope encompassing that of telemedicine, patient counselling, and patient medicines use review. However this is focusing on mainly the treatment whereby a patient’s disease status has been determined. Taking a step back from treatment is where interdisciplinary care comes

into play. The idea of working as a single unit sharing and transferring knowledge between different health disciplines: pharmacist, dentist, physiotherapist, nurses, occupational therapist, physicians and etc. This team is then able to provide a wider scope of the care needed for our patient, not only in their disease condition but other aspects such as medicines adherence, mobility, dental care and others. Let us begin with the bio-molecular end of our needle model; I’ve briefly touched upon the idea of the human genome project. What this project allowed us to do was enabling us to map out the human genotype that eventually translated to our various phenotypes from our gender, to what disease we may be more susceptible to. This then led to pharmacogenetics which was an idea conceived well before genome project and was defined by Vogel in 1959 as ‘The study of the role of genetics in drug response’ (Vogel, 1959). The first genetic deficiency identified was cholinesterase deficiency in 1955. Some newer examples of pharmacogenetics include abacavir, whereby 5-8% of patients will suffer abacavir hypersensitivity. In New Zealand clinicians must screen for the carriage of the HLAB*5701 allele in any HIV-infected patient prior to commencement of abacavir therapy (GlaxosmithKlein, 2012). Other examples such astrastuzumab in Her+ (human epidermal growth factor receptor) breast cancer and screening of TPMT (Thiopurine S-methyl transferase) in azathioprine are well IPSF Phuture 2013

Phuture

B. Pharm., graduated from School of Pharmacy, University of Otago - New Zealand

Nanotechnology has been around since 1995 with the introduction of PEGylate- liposomal doxorubicin, however nanotechnologies are not without faults as objects honing onto the atomic level of size, quantum mechanical effects begin to play a part making the object less predictable in behaviour, thus modelling and extensive investigation into safety and human bio-compatibility are required (Sakamoto, et al., 2010). Some other application of nanotechnology can also give clinical advantages such as medical imaging and diagnostic procedures via the use of iron oxide constructs and colloidal nano gold particles (Sakamoto, et al., 2010). Nanotechnology has also begun to play a role in diagnostic tools in predicting better prognosis. The development of new diagnostic tools are largely thanks to the human genome project which can account for a greater variation in heterogeneity in the population such as altered genes, proteins that may potentiate pathological conditions (Sakamoto, et al., 2010). Such is the case also for biomarkers whereby through unique altered processes of metabolism in a disease state, certain unique peptides and metabolites are produced that will indicate onset or presence of diseases (Sakamoto, et al., 2010). Going up the spine of the needle and looking at social aspects of individualised therapy, one can begin at the individualised dosing of medicines based on renal function through

14 IPSF Phuture 2013

each patientâ€™s glomerulus filtration rate (GFR) and hepatic functions as indicated by Albumin concentration and their INR (Huang, Temple, Throckmorton, & Lesko, 2007) (Verbeek, 2008). These are the clinical manifestations from the patientsâ€™ genetic predisposition and their phenotype. When making a clinical decision on appropriate dosing of medication, we have to take into account their co-morbidities, response level, metabolism, and adverse effects, when making a clinical decision on appropriate dosing of a medication. The Common rule in medicines is to start slow and titrate upwards till response has been achieved, but it is up to the clinician to make the judgement call on how low to start with and how slow to go up. These decisions have to be tailored to the patient, such examples include cilazapril, where if the patient has a eGFR of10- 40ml/min/1.73m2 they should not be dosed at more than 0.5mg daily to start off with, others that will need titration are the likes of Allopurinol, whereby doses are low to start with around 50mg depending if eGFR is <30ml/min/1.73m2, but doses can be titrated at upwards of 600mg depending on response based on serum urate levels and side-effects (Woods, 2013). It shows not only do the patient has a huge spectrum of medicine responses and also dose requirements. Thus thereâ€™s no one model that fits all but it is a process of careful titration and monitoring for response and side-effects. Of course there is the case when a medicine chosen is not working and there is therapeutic failure. Thus we have to make an informed choice on using alternatives that will also take into account the patient current state of metabolism, disease, co-morbidities and adherence.

Going further up the needle spine and shifting the focus from medicinal care, to an educational aspect, no matter how well we tailor our medicines to our patient, if he/ she does not have the impetus to adhere to

therapy, therapeutic failure will eventually be the end-point. Thus it is very much important to educate our patient on the importance of medicine and it very much resembles that of a sales pitch whereby we as the vendor in this case must find the ‘hook’ for each patient in order to grab their attention and to sell to them the reasons why they must take their medicines. In fact my analogy demonstrates a point of communication, by delivering the content in an analogy it gives estranged situation a familiar context such as being in the hospital with a heart attack and being told to take 4 completely new medicines; of course such analogies will be purely dependent on the patient and thus coming back to our individualised patient care. Amongst things such empathy, building rapport, actively listening, and reflection there are other skills that are required to be a good patient counsellor. One needs to be able to identify communication barriers and seek to overcome them. Barriers include cultural, gender, literacy, and disabilities (Teutsch, 2003).

“...no matter how well we tailor our medicines to our patient, if he/she does not have the impetus to adhere to therapy, therapeutic failure will eventually be the end-point.” Lastly at the other end of the needle, whereby the both health professional and medicine focus is dimmed; pharmaceutical care is taken into the patient’s own environment such as telemedicine. The process may be taken place in real time (video conferencing) or asynchronously such as diabetes management (patient enters glucose results when prompted) (Wootton, 2012).Another approach would be the likes of a study conducted in hospitals in China, whereby text messages are sent to patient cell phones in regards to their

medication (Mao, Zhang, & Zhai, 2008). Most patients enrolled in the study were satisfied by the service and had a positive attitude towards it (Mao, Zhang, & Zhai, 2008). A Mobile Pharmacy Service System (MPSS) was developed in this study whereby information such as reminder to take the medication, practical information such as method of administration and adverse drug reactions were sent to the patient’s mobile phones (Mao, Zhang, & Zhai, 2008). This does raise the possibility of care via correspondence for patients that may have difficulty in accessing health services due to their remote location, morbidity state and disabilities. However the method of text messaging will not be a solution to all, as the authors also acknowledges the fact that the elderly have trouble reading the small messages. Though thinking ahead, mobile phones should have in the future adjustable font sizes that would overcome such problem.The key is again tailoring, the author of the article does also point out that by using a system such as MPSS, and it hopes to lighten the workloads of hospital pharmacist, thereby hopefully increase the use of time and resources. A needle is only useful if a thread is tied on, and in this case the thread is the interdisciplinary team. Let’s play the devil’s advocate here, why do we need an interdisciplinary team? Is it be the more the merrier or the less is actually more? Well the answer lies with patient needs, each member of the team brings in a different area of expertise and perspective on patient needs, but if too many, it would become a redundant process swamped in opinions and arguments and the key here is early exposure in education. Learning to work at early stages of education would mean that students are exposed to various professions and know how each other works (Leïpzig, et al., 2002). In a case such as musculoskeletal care, a multidisciplinary team approach was trialled in the South Devon health services involving orthopaedic surgery,

IPSF Phuture 2013

Phuture

“Pharmaceutical education needs to be ready to evolve and embrace the future of pharmaceutical and interdisciplinary care.” Pharmaceutical education needs to be ready to evolve and embrace the future of pharmaceutical and interdisciplinary care. Education needs will have to evolve beyond the normal medicinal chemistry, pathology, physiology etc. A shift in paradigm from factual based learning to that of conceptual and application based learning will be required. The curriculum should be updated continuously to provide up-to-date clinical practice guidelines and be in line with the latest research and evidence-based care. It is imperative that students will be able to develop their ability to think critically and be given the freedom to make their clinical own decisions. The future of medicine will only grow exponentially and students must be equipped with the skills and knowledge to rationalise the optimal agent for each patient. There should be a greater extent of interdisciplinary learning to increase exposure of various health professions to each other at an earlier stage. So that when put into clinical practice, future health professionals are well equipped to work in a team-based situation. Finally, I believe individualised pharmaceutical care will grow in the coming years as technology improves, de-limiting our abilities to find

16 IPSF Phuture 2013

new biomarkers and drugs targets and the increase in information-sharing technology will promote integrated care. With these growth and changes, it is imperative that the education sector be able to pick up and equip students with the skills necessary to tackle new age problems with new age tactics.

References: Ainsworth, R., Conboy, V., Norman, J., & Viner, N. (2004). Towards Multidisiplinary teamworking in musculoskeletal care: evolution of service. Musculoskeletal Care , 2 (2), 113-119. GlaxosmithKlein. (2012, July). Medsafe data sheet. Retrieved May 2013, from http://www.medsafe. govt.nz/profs/datasheet/k/Kivexatab.pdf Huang, S., Temple, R., Throckmorton, D., & Lesko, L. (2007). Drug interaction studies: study design, data analysis, and implications for dosing and labelling public policy. Clinical pharmacology and Therapeutics , 81, 298-304. Leïpzig, R. M., Hyer, K., Ek, K., Wallenstein, S., Vezina, M., Fairchild, S., et al. (2002). Attitudes toward working on interdisciplinary Healthcare teams: A comparison by Discipline. J Am Geriatr Soc , 50, 1141-1148. Mao, Y., Zhang, Y., & Zhai, S. (2008). Mobile phone text messaging for pharmaceutical care in a hospital in china. Journal of Telemedicine and Telecare 2008 , 14, 410-414. Pharmac. (2013, May). Pharmac. Retrieved from Pharmac: www.pharmac.govt.nz/2013/05/01/SA1192.pdf Ross, J. S., Schenkein, D. P., Kashala, O., Linette, G. P., Stec, J., Symmans, W. F., et al. (2004). Pharmacogenomics. Adv Anat Pathol , 11 (4), 211-220. Sakamoto, J., Van de Ven, A. L., Godin, B., Blanco, E., Serda, R., Grattoni, A., et al. (2010). Enabling individualised therapy through nanotechnology. Pharmacological Research , 62, 57-89. Teutsch, C. (2003). Patient-doctor communication. Medical Clinics of North America , 87 (5), 1115-1145. Verbeek, R. K. (2008). Pharmacokinetics and dosage adjustment in patients with hepatic dysfunction. European Journal of Pharmacology , 64, 1147-1161. Vogel, F. (1959). Moderne Probleme der Humangenetik. Ergeb Inn Med Kinderheikd , 12, 52-125. Woods, D. (2013, May). New Zealand Formulary. Retrieved May 1, 2013, from www.nzf.org.nz Wootton, R. (2012). Twenty years of Telemedicine in chronic disease management- an evidence synthesis. Journal of telemedicine and telecare 2012 , 18, 211220.

c a c m r a a c ma tion Pchaatiromn Ph c a u a d dmuaccMs.yLinaER. Bader,PhairomnaPcharm t n a o c c i t a u a d c c m E r a u Achieving Quality Individualized a y d ErmPharmaceutical riomn Ph ac n PhaatCare: o c c i t a u a d c c m E r a u Begins with Interdisciplinary Education a y d c m h E r a P a m n h r o P a catiodnucati c a c m E r a u a y d c m h yhaErma ion Pchaatiron P c t a u a d c c m E r a u a y d c m h cPhyaErma tion Pchaatiron P c a u a d c c m E r a u a y d c m h E r a P a y c m n h aPhar ationuPcatio c a d c c m E r a u a y d c m h E r a P a y c m n mnaPhar catiEodnuPchatio ac u y d c m E r a a y c m h r a P a m h n on P y EduaccaytiEo m r a c m h r a P a m h n rion P o i t a c E u y d c m E r a a y c m h r a P a m atiron Ph duccaytiEon m E r a a y c m h r a P a n o i t haromn Ph a “...by creating optimal treatments specifically-tailored for individual patients, individualised medicine allows pharmacists to practice true patient-centred care. “

Since the completion of the Human Genome Project in April 2003, scientific knowledge in human genetics has witnessed a significant expansion, especially in the field of individualised medicine. Broadly considered, an ‘individualised medicine’ approach involves integrating an individual’s genetic information into the treatment or prevention of complex diseases (McCullough, 2011). Accordingly, such an approach is aimed at reducing the alarmingly high rates of adverse drug reactions (ADRs) (Gurwitz et al. 2005, Whitcomb 2011), increasing the chances of therapeutic success (McKinnon and Anderson, 2011), empowering patients to be true partners in their own health care (Marken, 2011), and potentially reducing health care costs associated with chronic illness and drug complications (Qattan et al., 2012). As such, by creating optimal treatments specifically-tailored for individual patients, individualised medicine allows pharmacists to practice true patient-centred care. In light of this, integrating fundamental elements of pharmacogenetics and pharmacogenomics in pharmacy curricula has become a top

academic priority over the past decade (Marken 2011, Qattan et al. 2012). At the same time, the need for collaborative efforts in genetics education, involving all scientists, clinicians and health professionals, remains as crucial as ever. This is especially important considering the transformative impact of 21st century trends (notably globalisation) in blurring professional boundaries, which has ushered in an era in which delivering quality patient-care is seldom achieved without multi-professional collaboration (Bradley, 2009). In this regard, the lack of proper crosssector health professional education remains a major obstacle to the implementation and application of pharmacogenomics in clinical practice (McKinnon and Anderson, 2011). This is particularly the case when it comes to the skill-sets required for the participation of pharmacists in the field, notably genetics, pharmacoepidemiology, health economics, therapeutics, simulation and modelling, and regulatory pathways (McKinnon et al., 2007). This is rendered even more challenging by the fact that pharmacists in pharmacogenomics perform three distinct roles: as researchers discovering and evaluating pharmacogenomics-based therapies, as educators teaching health professionals the application of pharmacogenomic knowledge in clinical settings, and as clinicians recommending and monitoring patient-

IPSF Phuture 2013

Phuture

School of Pharmacy, University of Nottingham – United Kingdom

a h P n o i t a c c m r a a du m h r P a n h o P i t n a d o c i E t u a y duc y Ed PhairomnaPcharm t n a o c i E t u a y d c du y E PhairomnaPchar t n a o c i t u a y d c c E a u d y Phairomn Pha t n a o c i t u a y d c c E a u y d c m h r a P a m n h r o P a i t h n a o P c i t u n a d o c i c E t a u a y d c c m r a u P a m n h r o P a i t h n a o P c i t u n a d o c i E t a u a y d c c m r a a du m n h r o P a i t h n a o P c i t u n a d o c i E t u y d c m r a uca a m n h r o P a i t h n a o P c i t u n a d o c i E t u a y d c m E r a a y duc m h r o P a i t h n a o P c i t u n a d o c i E t u a y d c E r a a y duc m h r P a i t h n a o P c i t u n a d o c i E t u a y d c c E a a y du m h r P a t h n a o P c i t u n a d o c i E t u a y d c c E a u d h acy rm specific treatments (Brock et al., 2002). Moreover, with the remit of clinical pharmacists now extending to include prescribing and screening services, the pharmacy profession is engaged in radically redefining itself (Bradley, 2009). Such changes are especially relevant to the issue of pharmacogenomics; for instance, with screening services potentially including genetic testing, pharmacists will be able to inform their prescribing practice by considering the effects of drug-gene interactions. Moreover, the lack of communication or understanding – so crucial in crossing interdisciplinary boundaries – further confirms that successful interdisciplinary collaboration, at both the educational and clinical stages, is the key ingredient in creating, and nurturing, the right professional skills and personal compatibilities. Indeed, as has often been pointed out, an overlap in scientific expertise among health professionals does not, in-andof itself, necessarily facilitate collaboration. Rather, while all health professionals must be equipped with the right genetics education in their respective curricula, the emphasis ought to be placed chiefly on equipping them with the necessary interdisciplinary skills (Qattan et al., 2012).

In this post-Genome era of personalised medicine, needs-integrated, convergent scientific disciplines - that enable us to decipher the characteristics of diseases both at the individual and population levels – it is imperative that the appropriate mechanisms are put in place to facilitate collaboration and multidisciplinary approaches. For example, in the context of current scientific and medical research, most career advancement prospects at universities and research institutions are often shaped more by a researcher’s own individual contribution as an independent researcher, than by his or her role in a wider

18 IPSF Phuture 2013

team effort. Of course, since collaborative efforts continue to be viewed as lower-impact research, this is hardly surprising. Nevertheless, radical changes to the way a researcher’s efforts are presently viewed, assessed and rewarded, notably in the context of professional progress, are thus clearly both necessary and urgent.

It must be noted that, although the prospect of fully-realised individualised medicine might be decades away, it nevertheless gives rise to a number of controversial ethical, legal and social challenges that would need to be continuously discussed and addressed through public debate and legislation (Gurwtiz et al., 2005). These include foetal and neonatal screening, vulnerable age-groups, confidentiality, and genetic discrimination (Ross and Moon 2000, Burgess 2001). The latter item may be exemplified by the potential global health inequalities produced by nations equipped to develop ethnic-based, population-tailored medicine and those that are not. With this in mind, it is important that policymakers and governmental agencies are involved in health professional education, both in terms of shaping the modalities of genetics education in national curricula, but also in exploring the network of strategic relationships tying all parties in the areas of ethical, legal and social issues.

“...any serious efforts aimed at achieving quality Individualized Pharmaceutical Care must have, as their starting basis, a strong focus on interdisciplinary education.” Ultimately, our continued ability to achieve scientific breakthroughs, in a world of such astonishing, ever increasing, complexity, relies heavily on adopting a more interdisciplinary approach to our scientific and academic efforts. Moreover, interdisciplinary activities are bound

References: Bradley, C. P. (2009). The future role of pharmacists in primary care. The British Journal of General Practice, 59(569), 891-892. Brock, T.P., Faulkner, C.M., Williams D.M., & Smith, S.R. (2002). Continuing education programs in pharmacogenomics for pharmacists. American Journal of Health-System Pharmacy, 59(8), 722-725. Burgess, M. M. (2001). Beyond consent: ethical and social issues in genetic testing. Nature Reviews Genetics, 2, 147-151. Gurwitz, D., Lunshof, J. E., Dedoussis, G., Flordellis, C. S., et al. (2005). Pharmacogneomics education: International Society of Pharmacogenomics recommendation for medical, pharmaceutical, and health school deans of education. The Pharmacogenomics Journal, 5(4), 221-225. Marken, P.A. (2011). Personalized medicine: are we preparing our students for the knowledge revolution? American Journal of Pharmaceutical Education, 75(3), Article 48. McKinnon, R. A., Ward, M.B., & Sorich, M.J. (2007). A critical analysis of barriers to the implementation of pharmacogenomics into clinical practice. Therapeutics and Clinical Risk Management, 3(5), 751-759. McKinnon, R., & Anderson, C. (2011). Transforming pharmaceutical education to accelerate the acceptance and implementation of personalized medicine. American Journal of Pharmaceutical Education, 75(6), Article 107. McCullough, K. B., Formea, C. M., Berg, K. D., Burzynski, J. A., et al. (2011). Assessment of the pharmacogenomics

IPSF Phuture 2013

Phuture

to grow in scope and prominence as the chief drivers of new concepts and products, and such prominence must be reflected in the evolving notions of educational, scientific, research and health-care strategies of the future. In this context, and in light of the arguments presented in this article, it seems evident that any serious efforts aimed at achieving quality Individualised Pharmaceutical Care (IPC) must have, as their starting basis, a strong focus on interdisciplinary education. A furthering, as well as a consolidation, of the drive towards a greater-interdisciplinary approach to IPC will thus ensure an enhancement of local and global research and innovation capacities as well as a necessary and successful reform of international health care systems.

a h P n o i t a c c m r a a du m h r P a n h o P i t n a Ms. Naoko Arakawa, d o c i E t u a y duc y Ed PhairomnaPcharm t n a FIPEd-IPSF Student Learning Experience o c i E t u a y d c c E r a u a y d m h Questionnaire: r P a n h o P i t n a o c i t u a y d c c E a u d y Phairomn Pha t n a o c i t u a y d c c E a u y d c m h r a P a m n h r o P a i t h n a o P c i t u n a d o c i c E t a u a y d c c m r a u P a m n h r o P a i t h n a o P c i t u n a d o c i E t a u a y d c c m r a a du m n h r o P a i t h n a o P c i t u n a d o c i E t u y d c m r a uca a m n h r o P a i t h n a o P c i t u n a d o c i E t u a y d c m E r a a y duc m h r o P a i t h n a o P c i t u n a d o c i E t u a y d c E r a a y duc m h r P a i t h n a o P c i t u n a d o c i E t u a y d c c E a a y du m h r P a t h n a o P c i t u n a d o c i E t u a y d c c E a u d h acy rm School of Pharmacy, UK

Research Associate, FIP Collaborating Centre, University College London,

Students’ input to the advancement of future

pharmacy education

“Your participation in this survey is vital to provide a better evidence for assisting the development of global pharmacy education policy recommendations.” The Quality of health professional education has been paid much attention from a wide range of stakeholders (Frenk et al., 2010). Obviously, pharmacy education is not an exception. Why is the quality of pharmacy education? Driven by ever changing health system, practice environment, and extended roles of pharmacists, pharmacy graduates need to be technically competent and efficient as well as enable of working in team, adapting and introducing the change where needed (WHO, 2011; Anderson et al., 2010; Anderson et al., 2011; Breland, 2007). Therefore, pharmacy education needs to be quality-assured in order to prepare pharmacy graduates to have necessary competencies to serve a wide range of their future. To achieve higher and equitable quality, the global infrastructure for pharmacy education needs to be mapped to the required competencies of pharmacists for meeting given health needs in any country. It is very important that the students’ learning experiences need to be considered and integrated in a process of the development of educational policies and

20 IPSF Phuture 2013

practices as students are at the heart of preservice education.

FIP Education Initiatives (FIPEd) and IPSF are now undertaking a collaborative global survey, Student Learning Experience Questionnaire (SLEQ: http://www.codegnet. org.uk/moII_2013/). SLEQ was adapted from previously developed the Course Experience Questionnaire (CEQ; Wilson et al., 1997) and the Shortened Study Process Questionnaire (S-SPQ; Fox et al., 2001), aiming at collecting data to measure and map global patterns of students’ learning experiences and their quality of learning in pharmacy programmes across nations. Collected data will provide key evidence for education advancement. SLEQ is on-line survey in currently six different languages (English, French, Japanese, Mandarin-Chinese, Portuguese, and Spanish) available at http://www.codegnet.org.uk/ moII_2013/. As of June 2013, 782 students over 45 countries have responded to this questionnaire. The timeline for this project has been further extended to allow for more aspiring voices from pharmacy students globally.

Your participation in this survey is vital to provide a better evidence for assisting the development of global pharmacy education policy recommendations. Please click on the

c a c m r a a c ma tion Pchaatiromn Ph c a u a d dmuaccy E PhairomnaPcharm t n a o c c i t a u a d c c m E r a u a y d Ermac n Phatiromn Ph a o c c i t a u a d c c m E r a u a y d c m h E r a P a m n h r o P a catiodnucati c a c m E r a u a y d c m h yhaErma ion Pchaatiron P c t a u a d c c m E r a u a y d c m h cPhyaErma tion Pchaatiron P c a u a d c c m E r a u a y d c m h E r a P a y c m n h aPhar ationuPcatio c a d c c m E r a u a y d c m h E r a P a y c m n mnaPhar catiEodnuPchatio ac u y d c m E r a a y c m h r a P a m h n on P y EduaccaytiEo m r a c m h r a P a m h n rion P o i t a c E u y d c m E r a a y c m h r a P a m atiron Ph duccaytiEon m E r a a y c m h r a P a n o i t haromn Ph a Remember that your voice is the best evidence to inform the future of pharmacy. Tell us how you feel about your learning experiences and become change-makers. References: Anderson, C., Bates, I. & Brock, T. 2011. Seven Billion Humans and 98 Trillion Medicines Doses. American Journal of Pharmaceutical Education, 75, Article 194. Anderson, C., Bates, I., Futter, B., Gal, D., Rouse, M. & Whitmarsh, S. 2010. Global Perspectives of Pharmacy Education and Practice. World Medical & Health Policy, 2, Article 2. Breland, B. D. 2007. Believing what we know: pharmacy provides value. American Journal of Health-System Pharmacy, 64, 1284-91. Fox, R. A., McManus, I. C. & Winder, B. C. 2001. The shortened Study Process Questionnaire: An investigation of its structure and longitudinal stability using confirmatory factor analysis. British Journal of Educational Psychology, 71, 511-530. Frenk, J., Chen, L., Bhutta, Z. A., Cohen, J., Crisp, N., Evans, T., Fineberg, H., Garcia, P., Ke, Y., Kelley, P., Kistnasamy, B., Meleis, A., Naylor, D., Pablos-Mendez, A., Reddy, S., Scrimshaw, S., Sepulveda, J., Serwadda, D. & Zurayk, H. 2010. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet, 376, 1923-1958. WHO, World Health Organization. 2011. Transformative Scale Up Health Professional Education - An Effort to Increase the Numbers of Health Profesiionals and to Strengthen Their Impact on Population Health [Online]. Geneva: Health Systems and Services (HSS / HRH), WHO. Available: http://www.who.int/hrh/ resources/transformative_education/en/ [Accessed 30 May 2013]. Wilson, K. L., Lizzio, A. & Ramsden, P. 1997. The development, validation and application of the Course Experience Questionnaire. Studies in Higher Education, 22, 3353.

IPSF Phuture 2013

Phuture

survey link (http://www.codegnet.org.uk/ moII_2013/) and answer in the language that best suits you. SLEQ should take no more than 15 minutes of your time. If you have any enquiries about this survey, please contact Naoko Arakawa (naoko.arakawa.11@ucl.ac.uk) or Marouen Ben Guebila (education@ipsf.org).

a h P n o i t a c c m r a a du m h r P a n h o P i t n a Ms. Joanna Sajkowska, d o c i E t u a y Mr.Pawel Kozielewicz,uc y Ed c m r a a d m h r P a n h o P i t n a o c i E t u a y Personalized Care: d c c E r a u a y d m h r P a Impact of Vitamin D Polymorphic Variants P onh Body Parameter n o i t n a o c i t u a y d c c E a u d y Phairomn Pha t n a o c i t u a y d c c E a u y d c m h r a P a m n h r o P a i t h n a o P c i t u n a d o c i c E t a u a y d c c m r a u P a m n h r o P a i t h n a o P c i t u n a d o c i E t a u a y d c c m r a a du m n h r o P a i t h n a o P c i t u n a d o c i E t u y d c m r a uca a m n h r o P a i t h n a o P c i t u n a d o c i E t u a y d c m E r a a y duc m h r o P a i t h n a o P c i t u n a d o c i E t u a y d c E r a a y duc m h r P a i t h n a o P c i t u n a d o c i E t u a y d c c E a a y du m h r P a t h n a o P c i t u n a d o c i E t u a y d c c E a u d h acy rm M. Pharm. Faculty of Pharmacy, Medical University of Warsaw M. Pharm. Faculty of Pharmacy, Medical University of Warsaw

“In order to treat each patient separately we need special instruments and knowledge how to use them in order to give aid more effectively.”

The development of pharmaceutical care is a fundamental issue that is brought on nowadays. It is widely known that the standard procedures according to which the doctors and the pharmacists provide help to patients may not be sufficient in the next decade. We, as people, live longer and we are exposed to more and more antigens and with the changing climate pharmaceutical care needs to be individual. We should perceive the individual pharmaceutical care as a phenomenon in which a patient is not treated as a member of a large group of patients who have similar and well-described symptoms, but instead he is treated as an individual whose disease occurs not as a clear picture but rather as an blurred image of different processes that take place in his body. In order to treat each patient separately we need special instruments and knowledge how to use them in order to give aid more effectively. Individualization of pharmaceutical care can be viewed as a major part of a personalized medicine which is described as “an emerging practice of medicine that uses an individual’s genetic profile to guide decisions made in regard to the

22 IPSF Phuture 2013

prevention, diagnosis, and treatment of disease” (definition from National Human Genome Research Institute). Personalized medicine gets the best of pharmacogenomics which is a new emerging field of science that studies how the genes affect the patient’s response to given drugs. Patient’s genetic profile determines how he responds to different drugs he takes. The most important genes when the matter of drugs metabolism is considered are the genes that encode the CYP450 family proteins. These enzymes are responsible for the activation or deactivation of virtually any xenobiotic we can think, including drugs or nutrition. Among the drugs that have already been reported to give different results in patients with different genetic profiles are: warfarin (CYP2C9 genetic polymorphism), clopidogrel (2C19 genetic polymorphism) or codeine (CYP2D6 genetic polymorphism) to name just a few. Molecular receptors and cell membrane pumps are the other group of proteins with which strong interactions are very important for the drug to be active. Genes encoding these proteins can also occur in a variety of polymorphic variants and thus determine the patient’s response, e.g. herceptin (HER2 receptor) or olanzapine (MDR protein). Obviously, the lists grow longer and longer with the novel discoveries made by researchers on daily basis. Not only substances registered as prescription drugs are being tested but also over-the-counter medicines

observed the deficit characterized by reduced absorption of calcium. Vitamin D levels were moderate in 32% of women. Moreover, only 13% of the entire population supply “the sunshine vitamin” in the right amount so that in this group it can be assumed that all processes involving vitamin D were carried out properly. Therefore, in the future it is likely that majority of the population will develop diseases caused by the deficiency of vitamin D. The alarmingly low levels of vitamin D among Polish women may be associated with weight gain and increase in diastolic blood pressure. It was demonstrated that women with a lower content of 25(OH)D3 were more obese. Of the total population, BMI >30 was observed in 32 patients, of which 24 women (75%) had a lower amount of vitamin D. Furthermore, these women weighed an average of 1kg more than women with good vitamin D levels. It is concluded that there exists the dependence between increased body weight and low vitamin D levels. Moreover, we observed effects of vitamin D action on cardiovascular parameters. The diastolic blood pressure was on average more than 2 mmHg higher in women with lower levels of “the sunshine vitamin”.

25-hydroxyvitamin D3 [25(OH)D3]. 30 ng/ml is a recommended level of 25(OH)D3, whereas concentrations higher than 20 ng/ml are low but still considered safe for the patient. The amount of 25(OH)D3 below 20 ng/ml may result in reduced intestinal absorption of calcium and the excessive bone resorption, which may lead to the pathological changes in their microarchitecture.

The other aims of this study were to assess the frequency of the nuclear receptor of vitamin D [VDR] gene polymorphisms FokI and two enzymes which are involved in the metabolism of vitamin D – cyp2R1 and cyp24A1 among Polish women (n=154). Furthermore, we wanted to search for correlations between these polymorphic variants and bone turnover parameters and related cardiovascular disease.

The results of the study point to the alarmingly low levels of vitamin D among Polish women. The average concentration of 25(OH)D3 was 17,58 ± 9,55 ng/ml and it was below 20 ng/ml in 68% subjects. Besides, in several cases we

It was demonstrated that a number of correlations exist between polymorphic variants of the genes and pathological conditions, such as: obesity and vitamin D deficiency. The newly discovered link between energy metabolism

IPSF Phuture 2013

Phuture

and diet supplements that are sold regularly in community pharmacies. This issue should be taken seriously and be given a deep insight as these products can be bought freely by patients with, in some cases, realistic potential of overdosing. Pharmacists given the instruments of pharmacogenomics could prevent such incidents and regarded by people on a same level as doctors of medicine are.

It is believed that the results of our study may have an interesting impact on the pharmaceutical care in terms of vitamin D supplementation. We have proven that polymorphism of some genes related to vitamin D metabolism e.g. can play part in different levels of bone turnover. Since importance of vitamin D is wellknown, we strongly believe cyp2R1 and FokI polymorphisms should be known to patients so that every patient can properly supply this vitamin and stay free of cardiovascular and other metabolic diseases. Ideally, in our opinion, in the near future patients will be able to undergo medical tests that will specify their “genetic image”. There are a few companies now that provide such tests on specific genes related to serious diseases. The knowledge about expression of some genes and not the others will provide help that is needed so much these days. All the tests should be covered by national medical insurance and be performed as a routine test. These results then will be stored in the database and can be viewed by pharmacists and doctors. The insight into a patient’s genetic profile will determine what drugs shall be prescribed and what doses should be taken by a patient. What is more, drugs – food interactions may be predicted and thus prevented.

24 IPSF Phuture 2013

In this article we wanted to show the influence of patients’ genetic profile on the pharmaceutical care that can be provided to them. Vitamin D studies performed by our group were taken as an example that showed what dependencies occur between specific genes and body parameters among the population of Polish women. We hope we have given a valuable insight into the practical and clinical aspects of pharmacogenomics and how this emerging field of study will help pharmacists in their dayto-day work.

References: Tremblay, J. and P. Hamet, Role of genomics on the path to personalized medicine. Metabolism, 2013. 62 Suppl 1: p. S2-5. Holick, M.F., Vitamin D deficiency. N Engl J Med, 2007. 357(3): p. 266-81. Zittermann, A., Vitamin D and disease prevention with special reference to cardiovascular disease. Prog Biophys Mol Biol, 2006. 92(1): p. 39-48. Marcinkowska-Suchowierska, E., et al., Vitamin D supplementation in adults - guidelines. Endokrynol Pol, 2010. 61(6): p. 723-9. Dobnig, H., et al., Independent association of low serum 25-hydroxyvitamin d and 1,25-dihydroxyvitamin d levels with all-cause and cardiovascular mortality. Arch Intern Med, 2008. 168(12): p. 1340-9. Langdahl, B.L., et al., Polymorphisms in the vitamin D receptor gene and bone mass, bone turnover and osteoporotic fractures. Eur J Clin Invest, 2000. 30(7): p. 608-17. Motyl, K.J., L.R. McCabe, and A.V. Schwartz, Bone and glucose metabolism: a two-way street. Arch Biochem Biophys, 2010. 503(1): p. 2-10. Ducy, P., The role of osteocalcin in the endocrine cross-talk between bone remodelling and energy metabolism. Diabetologia, 2011. 54(6): p. 1291-7.

c a c m r a a c ma tion Pchaatiromn Ph c a u a d c m r a a dmuaccMr.yJorgeE A. Schlöttke, m h r P a n h o P i t n a o c c i t a u a d c c m E r a u a y d m h ErmGaining r ac The P a Confidence of The Patient: n h o P i t n a o c i The c Key to Individualizing Pharmaceutical Caremac t u a d c E r a u a y d c m h E r a P a m n h r o P a catiodnucati c a c m E r a u a y d c m h yhaErma ion Pchaatiron P c t a u a d c c m E r a u a y d c m h cPhyaErma tion Pchaatiron P c a u a d c c m E r a u a y d c m h E r a P a y c m n h aPhar ationuPcatio c a d c c m E r a u a y d c m h E r a P a y c m n mnaPhar catiEodnuPchatio ac u y d c m E r a a y c m h r a P a m h n on P y EduaccaytiEo m r a c m h r a P a m h n rion P o i t a c E u y d c m E r a a y c m h r a P a m atiron Ph duccaytiEon m E r a a y c m h r a P a n o i t haromn Ph a “Is it the pharmacist the one who does not assert in making his knowledge be respected?”

In 2009 and with the law 26.567, the “over-thecounter” medications returned to the Pharmacies, but the snow ball has started to roll over and it´s going to be a very hard work to stop it.

To start talking about the individualization pharmaceutical care in Argentina, first we must understand the law that came up about 60 years ago that had established the way to get medications.

To sell medications outside a Pharmacy is punished by the law today, but it´s very common to find antispasmodics, antitussives, analgesics, antipyretics, anti-inflammatories, including antibiotics sold outside.

In 1967, the law Nr. 17.565, established that the medications were only able to be sold in pharmacies. and anything outside of the establishment was considered an illegal practice and it was punished by law. Given the law efficiency, the patient went to the Pharmacy very confident to get their medication, but the situation was about to change.

Why do people still buy their medications in unauthorized places and do not come to the Pharmacy? Is it the pharmacist the one who does not assert in making his knowledge respected?

In the beginnings of the 90’s (on 1991 to be accurate) was dictated the Decree 2284, that in the articles 13th , 14th and 15th of the Chapter 1, which said that the medication “over-thecounter” can be sold on “commercials markets” outside the Pharmacy. Now in Argentina, the patients can buy their medications in supermarkets, trains, buses, and on the streets. The people can find this alternatives ways easier, cheaper and faster to get medications, but the risks are imminent to the patient´s health. Such as: adulterated drugs, fake, expired, without any traceability.

In Argentina we have to implement individualized pharmaceutical care, also it is necessary to recover the patient trust on the Pharmacist.

In the Pharmacy office, the pharmacist not only has to exercise his profession, he also has to be a psychologist, advisor, and friend of the patients; these are the basic things to achieve individualized pharmaceutical care.

“The Pharmacist must distinguish himself on care and the patient must feel confident in his hands.”

The Pharmacist must distinguish himself on CARE and the patient must feel confident in his hands. A good care is the only way to win the

IPSF Phuture 2013

Phuture

4th year student at Faculty of Chemistry, Biochemistry and Pharmacy, National University of San Luis – Argentina

The Pharmacist is not only dedicated on taking down medication boxes from the shelves, his truly dedication has to be the care of the patient. The real work is to welcome the patient, look after the patient, and test the situation that surrounds him, and the environment where he lives. Medication is not the first option. The professional must test if the disease does not come from bad habits, the problem can be solved changing different habits, for example: exercise, eating healthy food, and avoid smoking. Once all of those instances are exhausted, there is where we have to appeal to the medications. When the patient has the medication in his hands, he must feel that the Pharmacist has taken care of him and improved his health.

The pharmacist must find the place and the time to make a file to each one of his patients. These must include his personal data, and medication information. By this way we will be able to test some pharmacological aspects such as; interactions, adverse reactions and contraindications; with these data we can prevent potential risks, get better efficiencies treatment and guarantee to the patient a rational use of the medication.

Individualization pharmaceutical care does not finish here. To finish the work the pharmacist has to ensure that the patient fulfills the treatment and one of the possibilities could be to ask the person to bring the packages that he took the last time, when he comes back to get the next medication, and by this way (paying attention to the amount of medication in the package) we will have a tentative answer about the accomplishment of the treatment. When the pharmacist gets the complete confidence of the patient, individualized pharmaceutical care will be an old subject and we will raise new challenges.

26 IPSF Phuture 2013

References:

Ministry of Health of Republic Argentina.[Law No. 17565 â€œPharmaceutical Activityâ€?].Buenos Aires; 1967. Available from: http://www.msaludlarioja.gob.ar/ imagenesdin/legislacion/Ley%20Farmaceutica%20 17565.pdf .

Official Bulletin of Republic Argentina. [Decree 2284/91]. Buenos Aires; 1991. Available from:http://200.69.252.41/hypersoft/Normativa/ NormaServlet?id=537 Ministry of Health of Republic Argentina.[Law 26567. Pharmacies. Drugs. Free sale. Subjects]. Buenos Aires; 2009. Available from: http://ricardo.cofa. org.ar/wp-content/uploads/2012/07/ley26567MEDICAMENTOS-SOLO-EN-FARM.pdf

c a c m r a a c ma tion Pchaatiromn Ph c a u a d y E PhairomnaPcharm dmuaccContacts t n a o c c i t a u a d c c m E r a u a y d Ermac n Phatiromn Ph a o c c i t a u a d c c m E r a u a y d c m h E r a P a m n h r o P a catiodnucati c a c m E r a u a y d c m h yhaErma ion Pchaatiron P c t a u a d c c m E r a u a y d c m h cPhyaErma tion Pchaatiron P c a u a d c c m E r a u a y d c m h E r a P a y c m n h aPhar ationuPcatio c a d c c m E r a u a y d c m h E r a P a y c m n mnaPhar catiEodnuPchatio ac u y d c m E r a a y c m h r a P a m h n on P y EduaccaytiEo m r a c m h r a P a m h n rion P o i t a c E u y d c m E r a a y c m h r a P a m atiron Ph duccaytiEon m E r a a y c m h r a P a n o i t haromn Ph a Authors

Ms. Noorviana Farmawati, Student of Faculty of Pharmacy, Universitas Indonesia – Indonesia; noorviana.farmawati@gmail.com Mr. Jiayi Gong B. Pharm., Graduated from University of Otago - New Zealand; jay.gong@gmail.com Ms. Lina R. Bader, University of Nottingham – United Kingdom; paxlb1@nottingham.ac.uk

Ms. Naoko Arakawa, Research Associate, FIP Collaborating Centre, University College London, School of Pharmacy - United Kingdom naoko.arakawa.11@ucl.ac.uk Ms. Joanna Sajkowska M.Pharm., Faculty of Pharmacy, Medical University of Warsaw – Poland; jsajkowska@gmail.com Mr. Pawel Kozielewicz M.Pharm., Faculty of Pharmacy, Medical University of Warsaw – Poland; pawelkozielewicz@gmail.com Mr. Jorge A. Schlöttke, 4th year student at Universitdad Nacional de San Luis – Argentina; presidencia.aefra@gmail.com

Editorial

Mr. Fahmi Fuady, International Pharmaceutical Students’ Federation Phuture Coordinator 2012-13 phuture@ipsf.org | fahmi_fuady@hotmail.com

Mr. Marouen Ben Guebila, International Pharmaceutical Students’ Federation Chairperson of Pharmacy Education 2012-13 education@ipsf.org | marouen.b.guebila@gmail.com Ms. Yuqian Liu, International Pharmaceutical Students’ Federation Editor-in-Chief 2012-13 editor@ipsf.org | yuqiancliu@gmail.com

Ms. Alexandra Marques, International Pharmaceutical Students’ Federation Chairperson of Media and Publications 2012-13 publications@ipsf.org | aviz.marques@gmail.com

IPSF Phuture 2013

Phuture

Mr. Hrvoje Rimac M.Pharm., Faculty of Pharmacy and Biochemistry, University of Zagreb - Croatia; hrvoje.rimac@gmail.com

International Pharmaceutical Studentsâ€™ Federation PO BOX 84200 2508 AE Den Haag The Netherlands Tel: +31 70 302 1992 Fax: +31 70 302 1999 Email: ipsf@ipsf.org Website: www.ipsf.org

is licensedPhuture under the Creative2013 Commons Attribution-NonCommercial-NoDerivs 3.0 Unported 28This workIPSF License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/3.0/.