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Doctors: VA's Delay on Genetic Tests May Cost Lives

Image: Doctors: VA's Delay on Genetic Tests May Cost Lives
(Joe Raedle/Getty Images)

By    |   Wednesday, 14 March 2018 01:39 PM

John Foster of central Florida served two tours of duty in Iraq as a combat medic. In his second deployment, from 2006 to 2007, he tried to help save 11 members of his unit who died in combat.

It was the war's deadliest year, and it changed the lives of many brave American warriors and their families forever — including his.

Foster soon began suffering from post-traumatic stress syndrome, or PTSD. His symptoms were so severe that upon returning stateside, he took 13 different medications a day. But nothing could really keep the PTSD at bay.

Post 9/11, stories like Foster's are all too common. Depression, PTSD, and suicidal tendencies are so prevalent in the veteran community that 20 vets on average take their lives each day, according to the latest statistics.

Fortunately for Foster, 38, a potentially life-changing test made a big difference.

Foster's psychiatrist, Dr. Robert Pollack, a Florida board certified psychiatrist and the CEO of Psychiatric Associates of Southwest Florida in Fort Myers, Florida, recommended a genetic test that would help identify which drugs would be most effective given Foster's individual DNA.

That genetic data enabled Dr. Pollack to practice "precision medicine" — the targeting of drug remedies based on a patient's individual genome, rather than using a hit-or-miss approach.

Foster's story is posted online, and he credits the use of that DNA information to treat his illness — a field called pharmacogenetics — with making a major difference. He says it was the "key for me, to help unlock the personal information that I needed to get connected to the best treatment."

Physicians and geneticists on the cutting edge of the medical frontier warn that veterans less fortunate than Foster, who rely on the U.S. Department of Veterans Affairs rather than private physicians like Dr. Pollack, may not be getting the help they so desperately need when it comes to precision medicine.

They complain that the VA has been too slow to adopt a system-wide standard directing doctors to first obtain the genetic information needed to determine the most effective medicines for each patient, before they prescribe antidepressants.

Dr. Michael Nova, a leading innovator in the field of precision-medical diagnostics, says he has been trying to get the VA to adopt the rigorous use of genetic testing for years. Nova has degrees in biochemistry, physics, and medicine, and is credited with over 30 patents, with another 35 patents that are currently pending.

Nova, the chief innovation officer and founding team member of San Diego-based Pathway Genomics, one of the country's leading genetic consumer testing firms, says his company has jumped through multiple hoops trying to work with the VA.

Pathway conducted two trials with the local San Diego VA, one involving health-threatening obesity — a major issue for the veteran population — and a second that used pharmacogenetics in the prescription of mental health drugs.

After those trials his company spent a year obtaining the proper vendor permits to do business with the agency, to no avail.

"It made no difference," he tells Newsmax. "The biggest issue for the VA is 'who pays for the tests,' not necessarily if the tests have clinical validity."

He adds: "The clinical lab director of each facility has direct control over what tests get ordered, and over the budget. In general, they don't want to pay for anything they are not directly ordered to do."

Nova points out that many of the FDA-approved labels for anti-depressants, including Prozac, specifically advise the use of genetic testing to make sure the optimal drug is being prescribed — but there is no VA-wide mandate to do so.

In his experience, Nova says, VA doctors are much more likely to simply prescribe a drug and see if it works, rather than test to determine the right medication from the get-go.

So why does a drug work for some patients and not for others? Researchers say genetic variation makes a big difference, determining for example whether a patient is a "fast metabolizer" or a "slow metabolizer."

For a slow metabolizer — someone whose system takes a long time to break down a given drug — the medicine will linger in their system a long time, often making a standard dose too high. That could cause dangerous side effects.

But for a fast metabolizer, the reverse is true. Their body produces enzymes that quickly break up and eliminate a drug. So the same dose that would be excessive for one patient may have zero effect on another patient, whose system simply gets rid of the drug before it can have much effect.

Nova tells Newsmax that the mindset of many VA doctors is: "If you're only going to wait two or three weeks and find out if the drug is going to work or not, I'll just put him on another drug right after that."

Unfortunately, the suicide rate for veterans suggests they may not have enough time to follow a hit-or-miss approach.

One 2016 study published in the journal "Australian Prescriber" found that about two out of three patients suffering from major depression do not respond to the first drug they are prescribed. So the odds are the first drug won't work. And 75 percent of those who move on to drug No. 2 don't respond to that one either.

Considering that it typically takes four weeks or longer for a doctor to prescribe a drug, determine it isn't working, and switch a patient on to a new medication — not accounting for medical complications or bureaucratic snafus, mind you — it can easily take six months or longer to determine the best mode of treatment.

Indeed, the VA has noted that even after one year of treatment, less than 30 percent of depressed patients are relieved of their symptoms. The rest remain stuck in the trenches, hoping every day that the darkness won't consume them.

For a veteran and their family hunkered down in an emotional foxhole, it's a battle that never seems to end.

Dr. Pollack, the psychiatrist who treated combat medic John Foster, is sharply critical of the VA.

"I had a brief sojourn with the VA," Pollack tells Newsmax, "and was so disgusted with them I said, 'Go away.'"

Pollack likens working with the VA bureaucracy to "banging your head against a brick wall when it comes to treating patients."

Both Pollack and Nova concede that some VA doctors, and VA hospitals, do use precision medicine when treating depressed veterans. But doing so is haphazard, they say, and left up to individual doctors and administrators.

VA officials tell Newsmax there aren't enough studies yet to prove that genomic testing of depressed veterans will actually improve outcomes.

The VA's Health Services Research and Development and Genomic Medicine Implementation research programs have funded a new study, Precision Medicine in Mental Health Care, also known as PRIME Care, to determine whether to implement a comprehensive VA testing program for veterans suffering from depression and PTSD.

In May 2016, a VA report comparing pharmacogenomics-guided treatment to standard methods of care conceded that doctors "have typically taken a 'trial and error' approach" to prescribing anti-depressants.

While Nova generally defends the good intentions of the doctors, nurses, and administrators in the VA system, which has the staggering responsibility of caring for the health needs of over 9 million veterans, he points to a larger issue: There appears to be no upfront economic or other incentive for VA doctors to order genetic testing — even if it saves time, money, and even lives.

"Unfortunately, medicine is run economically," he says. "There are a lot of reasons that things don't necessarily get used, that would provide patients an advantage. But based on economics, they just don't do it.

"That's what we're facing," he says of getting the VA to implement genetic tests. "The validity is good, the evidence is good. It's just there's no real economic incentive to use it."

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John Foster of central Florida served two tours of duty in Iraq as a combat medic. In his second deployment, from 2006 to 2007, he tried to help save 11 members of his unit who died in combat.
doctors, va, delay, genetic tests
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2018-39-14
Wednesday, 14 March 2018 01:39 PM
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