Clinical Pharmacology 400 2012

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Transcript Clinical Pharmacology 400 2012

Clinical Pharmacology 400
Jim Wright
Clinical Pharmacologist
7 lectures
Outline of series
 Clinical Pharmacology as a career.
 Therapeutics Initiative, Therapeutics Letter.
 Cochrane Collaboration, Principles of Evidence Based
 How do drugs get approved for prescription.
 Clinical trials, what do the numbers mean?
 Approach to prescribing a drug.
 Discussion of a clinical trial.
Clinical Pharmacology 400
Clinical Pharmacology as a Career
 What is Clinical Pharmacology?
 Determinants of drug choice.
 Benefits and harms of drugs.
 What is the problem?
 My training and journey at the university.
 Ways to become a Clinical Pharmacologist.
 Types of work.
What is a Clinical
 A Medical Specialist who has the training to deal with
complex problems associated with drugs in patients.
Minimum amount of information
needed before prescribing or taking a
 Patient problem and goal of therapy.
 Therapeutic options.
 Choice of therapy and evidence to justify choice.
 Prescription (dose and regimen).
 Method of assessing drug effect.
 Mechanism of action.
 Major route of inactivation.
 Important contraindications and adverse effects.
Determinants of drug choice.
What is the optimal order?
 Diagnostic condition
 Drug industry marketing
 Expert opinion
 Past experience
 Best available evidence
 Clinical pharmacology knowledge.
Actual order of determinants of
choice of drug today
 Diagnostic condition
 Drug industry marketing
 Expert opinion
 Past experience
 Best available evidence
 Clinical pharmacology knowledge.
Optimal order of determinants of
choice of drug
 Diagnostic condition
 Best available evidence
 Clinical pharmacology knowledge
 Past experience
 Expert opinion
 Drug industry marketing
Optimizing use of
prescription drugs:
The Elephant in the Room
What is the elephant that nobody wants to talk
Definition of Advertising
“The science of arresting the human
intelligence long enough to get money from it.”
Stephen Leacock
Our Daily Meds
by Melody Petersen
How the Pharmaceutical Companies Transformed
themselves into Slick Marketing Machines and
Hooked the Nation on Prescription Drugs
The Magnitude of the
Prescription Drugs
Why do we need Clinical
To solve this problem
What is the problem in a
bigger context?
For most of the DAILY drugs that people take, we
do not know whether the benefits outweigh the
How I became a Clinical
 2 years undergrad in Science (Experimental Psychology)
 4 years medical school (University of Alberta) including
summer research in Pharmacology lab.
 1 year rotating internship Montreal General Hospital (MGH).
 1 year Internal Medicine resident at MGH
 1 year Teaching Fellow in Nairobi, Kenya.
My training (cont)
 4 years combined Doctoral research and Internal medicine
residency training (Dept of Pharmacology and MGH, McGill
 1975-76, one year Post doctoral training in Clinical
Pharmacology at Hammersmith Hospital, London, UK
My degrees
 MD, University of Alberta 1968
 PhD, McGill University, 1976
 FRCP(C), Internal Medicine, 1975
My journey at UBC
First Phase
 1977 Assistant professor in Pharmacology &
Therapeutics and Medicine.
 Clinical Pharmacologist – Clinical practice, (in hospital
consultations and outpatient clinic).
 1977-1983, MRC funded basic research into
mechanisms of adverse drug effects and drug
 Teaching – Pharmacology to Medical students,
Graduate students.
My journey at UBC
Second Phase
 In 1983 I began doing clinical trials (mostly drug industry
funded on new antihypertensive drugs).
 Between 1983 and 1994, I was principal investigator for 15
trials with >10 different drug companies.
 Examples of drugs studied: fosinopril, irbesartan, terazosin,
lemakalim, etc.
My journey at UBC
Third Phase
 In 1994 the Therapeutics Initiative was formed and I was
appointed the Clinical Managing Director.
 I stopped all drug industry funded research.
 1994 to present -- main activity, Managing Director of TI and
Editor-in-Chief of Therapeutics Letter.
 2001, I was appointed Coordinating Editor of the Cochrane
Hypertension Review Group.
My journey (cont)
 3 sabbaticals, Stockholm, Sweden (85-86); Wellington, New
Zealand (96-97); Lyon, France (2005-6).
 Many changes and variety of work during my career.
 Understanding drug effects is extremely complex, interesting
and challenging.
 I enjoy the fact that I do different things almost every day.
Ways to become a Clinical Pharmacologist today.
 Pre-med. Opportunities to get involved with TI or
Cochrane during summer.
 Medical training. Electives in Clinical Pharmacology.
 Residency in Internal Medicine; 3 core years.
 Residency in Clinical Pharmacology; 2 years.
 Fellowship in Internal Medicine end of first year of
Clinical Pharmacology training.
 Certification exam in Clinical Pharmacology with Royal
College of Physicians end of second year.
Alternate ways to become a Clinical
Pharmacologist today.
 Residency in Pediatrics, Psychiatry, Emergency Medicine,
Anesthesiology; 3 core years.
 Fellowship in Clinical Pharmacology for 2 years.
Career Paths
 Mostly Clinical
 Consultations in hospital and outpatient clinic.
 Chair, Pharmacy and Therapeutics Committee in hospital.
 Presentations at rounds.
Career Paths (cont)
 Mostly research.
 Conduct Clinical trials
 Some clinical practice
 Some teaching.
Career Paths (cont)
 Academic
 Research doing clinical trials or lab based research
 Major teaching responsibility, undergraduate and graduate
 Some clinical practice.
Career Paths (cont)
 Government
 Evaluating drugs for Federal or Provincial governments.
 Teaching and training responsibility.
Career Paths (cont)
 Industry
 PhD or MD or MD, PhD
 Research
 Drug development basic or clinical
 Administration
 You already have a good background training in
 Clinical Pharmacology is interesting, highly challenging and
greatly needed.
 Prescription drugs are not used optimally and are a major
cause of unnecessary death.
Conclusions (cont)
 Physicians both family practitioners and specialists are not
adequately trained in Clinical Pharmacology.
 Physicians are highly vulnerable and unknowingly influenced
by Big Pharma.
 Because number and complexity of drugs is expanding
Clinical Pharmacologists are badly needed.
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