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May 2022
Personalized Medicine
Personalized medicine refers to a field in which practitioners use diagnostic and genetic tests to determine the best course of treatment for individual patients. Despite veterinary medicine seeing higher rates of burnout and more overwhelmed clinics, personalized medicine—also known as precision care— is still relevant. In fact, it is perhaps more relevant than ever.
Applying Genetic and Other Testing to Redefine Standards of Care
“Telehealth allows more time for personalized education and medical care through the use of genetic testing and home diagnostics kits.”
—JESSICA TRIMBLE, DVM, ANIPANION
Personalized medicine refers to a field in which practitioners use diagnostic and genetic tests to determine the best course of treatment for individual patients. Despite veterinary medicine seeing higher rates of burnout and more overwhelmed clinics, personalized medicine—also known as precision care— is still relevant. In fact, it is perhaps more relevant than ever.
As the profession seeks to move forward, it is imperative to analyze every element of care to determine the best and most effective options for clients and patients. This could mean implementing new technologies, devices, and even testing methods.
Benefits of Personalized Medicine
The benefits of personalized medicine are both quantitative and qualitative. From the quantitative perspective, personalized medicine places a larger emphasis on the data from certain testing methods to present better options for diagnostics, treatment, preventive care, and management of acute and chronic disease. For example, patients with uncontrolled diabetes may require prolonged frequent glucose monitoring. This allows clinicians to understand how blood glucose levels change throughout the day with activity levels, diet, and any other factors. From there, the clinician is better able to prescribe methods to bring those levels under control.
On the qualitative side, personalized medicine allows for better client-veterinary relationships. Veterinarians can take information from tests and have more in-depth conversations with their clients. From there, they can work together to develop plans for prevention, management, training, and other aspects of pet care. This could result in a drastic improvement in the pet’s health, which in turn has a positive impact on the human-animal bond.
Whether it is preventive or diagnostic care, personalized medicine has a place in the conversation.
Preventive Medicine
An excellent example of combining preventive care with personalized medicine is genetic testing. Genetic testing can be used to analyze a patient’s genome and look for specific genetic markers that could possibly lead to issues. A prime example of this is the identification of a mutation in the MRD1 (multidrug resistance 1) gene in dogs. Testing for this specific marker is relevant for dogs who may be at risk of serious adverse drug reactions.
While the concept of “white feet, don’t treat” may be a point of consideration when considering multidrug-resistant defects in certain breeds of dogs, an MDR1 test is more specific and more accurate. This test could remove the uncertainty and frustration for clinicians and clients when prescribing certain drugs.
According to Jessica Boudreaux-Milligan, DVM, of dog DNA testing company Embark Veterinary, the ideal time for a genetic test is at a young age. A clinician would prescribe a test and use the information to help “lessen the effect of a possible chronic condition, postpone the onset of disease, and improve the quality of life of the pet.” The beauty of these tests is that veterinarians already do this automatically. Veterinarians have a working knowledge of breed-specific illnesses, predispositions, and conditions. Genetic testing just offers a more accurate—and individualized—version of this.
Currently, genetic tests are marketed as a financial investment for a lifetime of care. This information could be used to make lifestyle changes that could postpone onset, lessen severity, and/or prevent disease altogether, which offers an overall reduction in medical cost. On top of that, preventive care is typically cheaper than emergent and urgent care.
In addition, Kari Cueva, DVM, senior manager, Veterinary Genetics, at Embark Veterinary, spoke about how clinicians underestimate the value of genetic testing for pets. “Owners are delighted by [genetic testing]. They believe that you value their pet on an individual level,” Cueva said.
For example, a veterinarian telling an owner that their dog is part retriever could suggest trying out new toys to see if their dog is super excited to play fetch.
“If you personalize your approach to patients, the rewards will speak for themselves,” Cueva said.
It is important to understand that most genetic testing is not diagnostic. Some diagnose genetic disorders, but most of them only quantify genetic predisposition to certain illnesses and diseases. This is very important to communicate to clients because most other tests ordered are diagnostics, meaning there is a positive/negative or yes/no answer implied. Boudreaux-Milligan said that with the implementation of this tool, “conversations are changing from positive/negative to susceptible/not susceptible. This allows for more of a gray area.”
Regardless of the gray areas, genetic testing gives veterinarians a tool that was previously unavailable. Most veterinarians can guess one or two possible breeds in a multibreed animal; however, more hidden inherited traits are not going to be visible. Sure, the understanding that a boxer or boxer-mix should be monitored for dilated cardiomyopathy comes in handy. But other unseen factors could be even more helpful, and genetic testing pulls back the curtain on this.
Diagnostic Care
Diagnostics in personalized medicine are slightly less discussed but still just as important as preventive care. As mentioned, some tests diagnose genetic disorders, allowing certain conditions to be discovered long before the onset of the disorder or illness. This gives the veterinarian and client a head start on adjustments to diet, exercise, medication, or anything else.
For Cueva, her breakthrough case was a mixed-breed puppy that she adopted. She decided to do genetic testing to determine the different breeds of her dog. The results came back with a positive for progressive retinal atrophy (PRA). Since she knew about it ahead of time, she was able to train her dog with voice commands instead of hand commands and consider better lighting around her home to aid her dog in the night as its vision degenerated.
Early detection and diagnosis are always beneficial for treatment and improved quality of care and life. In addition, the increased pressure for antibiotic and antiparasitic stewardship is ever-present. Clinicians are becoming more adept at testing for specific resistance strains in bacterial and parasitic infections, thereby reducing the prescribing of broad-spectrum antibiotics. As new infections arise and more resistant strains become common, this type of personalized medicine technique may become the only option for providing relief to patients.
What is the next step? Other genetic markers have been identified for specific cancers and tumors, and diagnosing these can help when considering treatment options. Submitting biopsies for specific genetic testing, outside of cytology studies, allows for the integration of more targeted pharmacology and even the implementation of immunotherapies and gene therapies as they are developed.
Integration of At-Home Testing
Clients know about options like genetic testing and want access to them. And, there are pet care companies willing to meet their demands, with or without the input of veterinary professionals.
“Telehealth allows more time for personalized education and medical care through the use of genetic testing and home diagnostics kits,” said Jessica Trimble, DVM, chief veterinary officer at telehealth provider Anipanion. “The client has more input because they can order some of these tests and have more conversations with their veterinarians.”
Some diagnostic companies offer at-home genetic testing and diagnostics such as urinalysis and fecal sampling. Most of these tests involve the client submitting saliva, urine, or a fecal sample and receiving the results. Then, the client typically discusses these results with their veterinarian. Though this disrupts the routine of the veterinarian ordering diagnostics, receiving results, making diagnoses, and recommending treatments, there are benefits to letting clients be a bigger part of the conversation.
For example, if clients are more involved, there is potentially more understanding and compliance with veterinarian recommendations concerning nutrition, medication, exercise, and other factors. It also could save time for the practice since they don’t have to schedule an appointment to obtain the sample from the pet, or process or send out the sample to the lab. Of course, the practice would also lose the income from those services.
At the end of the day, at-home testing is still data that can be interpreted by a professional, including the prescribing veterinarian. Veterinarians can also recommend reputable companies to their clients and use the information to provide better and more personalized care, which can lead to better client retention.
Limiting Factors
Having clients lead the charge with some at-home testing can be a double-edged sword. Obviously, clients are not specialists who can reliably interpret data on their own. In addition, clinics have their own preferences when it comes to working with labs, and not all diagnostic companies are the same—meaning, results may vary. Nevertheless, clients are increasingly involved in their pet’s care. In these uncertain times, people want more control over their lives, and that includes their pets. In addition, “Dr. Google” isn’t a fad that is going away, and pet owners are less likely to just take their veterinarian’s word for what their options are. They want to bring something to the table.
There is also a steep learning curve for clinicians as new technologies come out. Sequencing and microarrays are phasing out polymerase chain reaction (PCR) tests, which introduces new forms of data that veterinarians need to be able to understand and interpret for clients. This requires an understanding of statistics and genetics outside of the field of theriogenology. Some newer diagnostic companies are solving this problem by providing a robust support staff to assist veterinarians in interpreting results. Some also offer additional training opportunities. Though useful, this could present an issue for veterinarians who are already overwhelmed with their day-to-day duties. But, learning now could save time and expense in the long run.
Accessibility can also be a limitation. Currently, the costs are high for some genetic tests and newer diagnostics. While prices have dropped over the past decade, many are still out of range for clients. But, as offerings increase and the concepts are more widely accepted, the prices will ideally reduce.
One of the main points of contention, especially with at-home testing, is that these tests are pulling money away from the clinics. However, there is an argument that these at-home tests could instead drive up revenue for local clinics. Pet owners who order an at-home genetic, urinalysis, or fecal test are not equipped to interpret the results or prescribe the necessary treatments. Where do they go? Their local veterinarian. That initial “loss of revenue” to an at-home test could turn into a new client for the clinic. If they present results that don’t seem viable, new testing can be done.
Personalized and Precise Care
Overall, there are pros and cons to every new development, especially in the veterinary field. Veterinary professionals are tasked with balancing costs, efficacy, accuracy, and necessity daily. Personalized medicine mandates looking at each animal on an individual level as opposed to as a subset of a breed, which takes more time—time that veterinarians don’t always have. Nevertheless, if the profession is to move forward and achieve any sort of stability considering the high demand for their expertise, new ideas, techniques, and technologies are going to have to become a part of the conversation. Personalized medicine could be another point to redefine standards of care.
Terrisha Buckley is a freelance writer with a bachelor’s degree in biology and an extensive background in research as well as experience working in the veterinary profession. |
Photo credits: Irina_Strelnikova/iStock via Getty Images