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Cultural and Genetic Diversity in
America: The Need for Individualized
Pharmaceutical Care
National Medical Association
National Pharmaceutical Council
November 2002
Report Summary
• Genetic, cultural and environmental factors
affect a patient’s response to a given
medicine
• Cost containment policies need to be
broad and flexible enough to allow access
to full “tool box” of medicines
• Patients must receive care tailored to their
specific needs to prevent disparities in
health care
Diversity of the U.S. Population
1990
White
74%
2000
Hispanic
8%
Hispanic
11%
Black
11%
Other
7%
Black
13%
White
72%
Other
4%
Source: U.S. Census figures and projections
Disparities in Health Care for
Minorities
• Disparities in quality of care documented,
particularly African, Asian and Hispanic
heritage
• Receive less intensive medical care:
• Fewer vaccinations
• Less drug therapy for pain
• Fewer antiretroviral drugs for HIV/AIDS
• Lack of insurance/under-insurance
Disparities in Cultural Competency
• Care may be compromised due to crosscultural language and communication
barriers
• Cultural beliefs play a vital role in
determining if the explanation of illness or
treatment makes sense
• Lack of representation of minority groups
in health professional workforce
– Physicians in America: only 2.2% AfricanAmerican; 2.8% Hispanic
Disparities in Health Literacy
• Over 90 million adults in the U.S. have low
health literacy
• Those for whom English is a second
language more likely to have limited health
literacy and self-management skills,
including ability to take medications
properly
• Health education materials are written at
too high a level
Factors Contributing to
Variability in Drug Response
BIOLOGICAL FACTORS
Age
Gender
Genetics
Disease
CULTURAL FACTORS
Attitude
Beliefs
Family influence
ENVIRONMENTAL
FACTORS
Climate
Smoking
Parasites
Alcohol
Pollutants
Drugs
Adapted from Poolsup et al. (2000).
VARIABILITY IN:
Drug metabolism
Drug receptors
Drug response proteins
Disease progression proteins
Effectiveness of Antihypertensive
Agents in Black Patients
Calcium Channel Antag.
Diuretic
Beta-blocker
ACE Inhibitor
20
15
10
5
0
10
20
30
40
Diastolic
Systolic
Reduction in Blood Pressure (mm Hg)
Source: Hall, 1990
Drugs Showing Cross-Racial
Differences in Metabolic Rates
• Antidepressants: amitriptyline*, imipramine*,
clomipramine, desipramine, nortriptyline, phenelzine
• Antianxiety agents: diazepam*, clonazepam,
nitrazepam
• Antipsychotics: chlorpromazine, perphenazine,
thioridazine, haloperidol
• Beta-blockers: metoprolol*, propranolol*, timolol*,
labetalol, pindolol, oxprenolol, acebutalol
• Cardiovascular agents: captopril*, methyldopa,
hydralazine, procainamide, warfarin
*Most commonly prescribed (top 100)
Adapted from Meyer, 1992.
Cultural Factors Influencing
Treatment
• Attitudes and health beliefs may affect the
effectiveness of or adherence to a drug
therapy
 Trust and respect: Eye contact, touching, distrust of
American health system
 Health beliefs and practices: Alternative therapies,
keeping illness to themselves, lack of understanding
modern medicines and long-term treatments
 Family values: Who makes family health decisions,
family support system, alternative remedies?
Matching the Pieces for
Individualized Therapy
Disease
Cultural Heritage
Overall Treatment Cost
Medicine
Best Fit
Optimal Therapy
Good Fit
Poor Fit
Adequate Therapy “Generic” Therapy
Individualized Rx Care
Right Patient
Right Illness
Right Drug
Individualized
Rx Care
Right Time
Right Dose
The Future of Individualized
Rx Therapy
• Race and ethnicity are crude markers for
genetic variations that may indicate how
an individual will respond to a drug
• Advances based on human genome will
eventually enable drug therapy tailored to
individuals
• Genetic “fingerprint” of individuals will
identify variations in genes known to affect
drug metabolism
Recommendations
• Health care institutions should implement
cost containment practices that are broad
and flexible enough to enable choices of
medicines for all patients
• Physicians should give individualized
treatment to each patient and take into
account racial and ethnic origin
– Physicians should be mindful of uncommon
responses or unexpected side effects
Recommendations (cont.)
• Pharmaceutical companies should
continue to include significant numbers of
diverse patients in drug metabolism
studies and clinical trials
• Hospitals, managed care groups and other
health service providers should employ
practitioners who are racially and
ethnically representative of the patient
population being served
For Further Information:
National Medical Association:
www.nmanet.org
National Pharmaceutical Council:
www.npcnow.org