Doing More With Less: Pragmatic Implementation of Vancomycin Area-Under-the-Curve (AUC) Monitoring

2021 ◽  
pp. 089719002110272
Author(s):  
Joanne Huang ◽  
Jeannie D. Chan ◽  
Thu Nguyen ◽  
Rupali Jain ◽  
Zahra Kassamali Escobar
Keyword(s):  
Quality Improvement ◽  
High Risk ◽  
Therapeutic Drug Monitoring ◽  
Paradigm Shift ◽  
Area Under The Curve ◽  
Cost Effective ◽  
Practical Method ◽  
Therapeutic Drug ◽  
Short Term ◽  
Quality Improvement Process

Universal area-under-the-curve (AUC) guided vancomycin therapeutic drug monitoring (TDM) is resource-intensive, cost-prohibitive, and presents a paradigm shift that leaves institutions with the quandary of defining the preferred and most practical method for TDM. We report a step-by-step quality improvement process using 4 plan-do-study-act (PDSA) cycles to provide a framework for development of a hybrid model of trough and AUC-based vancomycin monitoring. We found trough-based monitoring a pragmatic strategy as a first-tier approach when anticipated use is short-term. AUC-guided monitoring was most impactful and cost-effective when reserved for patients with high-risk for nephrotoxicity. We encourage others to consider quality improvement tools to locally adopt AUC-based monitoring.

Tu1286 Early Therapeutic Drug Monitoring for Prediction of Short-Term Mucosal Healing in Patients With Ulcerative Colitis Treated With Infliximab

2015 ◽  
Vol 148 (4) ◽  
pp. S-848 ◽  
Author(s):  
Konstantinos Papamichael ◽  
Niels Vande Casteele ◽  
Thomas Billiet ◽  
Ann Gils ◽  
Sophie Tops ◽  
...  
Keyword(s):  
Ulcerative Colitis ◽  
Therapeutic Drug Monitoring ◽  
Drug Monitoring ◽  
Mucosal Healing ◽  
Therapeutic Drug ◽  
Short Term

Is There a Role for Therapeutic Drug Monitoring of Anti-TNF Monoclonal Antibodies in Inflammatory Bowel Disease

2015 ◽  
Vol 33 (Suppl. 1) ◽  
pp. 70-77 ◽  
Author(s):  
Filip Baert
Keyword(s):  
Monoclonal Antibodies ◽  
Therapeutic Drug Monitoring ◽  
Drug Monitoring ◽  
Treatment Guidelines ◽  
Therapeutic Drug ◽  
Serum Concentrations ◽  
Short Term ◽  
Clear Dose Response ◽  
Inflammatory Bowel

In recent years it has become clear that therapeutic drug monitoring can be an important tool to optimize outcome and costs of anti TNF treatment including the subcutaneous and fully human monoclonal antibodies. There is a clear dose response curve between early serum concentrations of all monoclonal antibodies and response both short term and long term. The wide variations in early serum concentrations are insufficiently explained by classic pharmacokinetic factors. Low early concentrations can lead to anti-drug antibody formation and ensuing loss of response. Therapeutic drug monitoring allows to rationalize the current practice of dose optimization and the use of concomitant immunomodulator treatment. However more prospective studies are needed before strong recommendations can enter treatment guidelines.

scholarly journals A Moving Target—Vancomycin Therapeutic Monitoring

2020 ◽  
Vol 9 (4) ◽  
pp. 474-478
Author(s):  
Alaina N Burns ◽  
Jennifer L Goldman
Keyword(s):  
Clinical Practice ◽  
Therapeutic Drug Monitoring ◽  
Drug Monitoring ◽  
Clinical Care ◽  
Area Under The Curve ◽  
Therapeutic Monitoring ◽  
Therapeutic Drug ◽  
Moving Target ◽  
Efficacy And Safety ◽  
Vancomycin Trough

Abstract Therapeutic drug monitoring (TDM) has been a common practice to optimize efficacy and safety of vancomycin. While vancomycin trough-only TDM has widely been integrated into pediatric clinical practice since 2009, recently updated vancomycin TDM guidelines published in March 2020 recommend area under the curve (AUC) based TDM for vancomycin instead of trough-only TDM. In this review, we discuss the rationale behind the change in TDM recommendations, describe two approaches for calculating vancomycin AUC in clinical practice, and address considerations for integrating vancomycin AUC TDM into pediatric clinical practice. Our primary goal is to provide pediatric clinicians with a resource for implementing vancomycin AUC monitoring into clinical care.

scholarly journals Therapeutic Drug Monitoring: Fundamentals, And Optimization

2021 ◽  
Author(s):  
Ahmed Ali ◽  
Mahran Abdel-Rahman
Keyword(s):  
Therapeutic Drug Monitoring ◽  
Drug Monitoring ◽  
Cost Effective ◽  
Drug Level ◽  
Therapeutic Drug ◽  
Relevant Research ◽  
Request Form ◽  
Narrow Therapeutic Range ◽  
Analytical Tools

Therapeutic drug monitoring (TDM) is a teamwork clinical pharmacokinetic services aimed to optimize pharmacotherapy of certain drugs such as those with a narrow therapeutic range, complicated pharmacokinetics. It involves the determination of drug level in blood samples taken at the appropriate time. Interpretation of results requires integration of pharmacokinetics, the pharmacodynamics of the drug and the patient’s clinical profile. To be cost-effective the service should be optimized. This review was written by experts from different developing countries to highlight the fundamentals of the service and provide suggestions for its optimization. These cover the rationale of requesting drug level, design of request form, optimal sampling, and analytical tools. guidelines for appropriate interpretation of drug levels; completeness of the roles of the qualified medical team; continuing education and skills development; involve the patients in improving the service, conducting relevant research; use PK software and integration of TDM with pharmacogenomics

scholarly journals 788. Therapeutic Drug Monitoring for Pyrazinamide During Tuberculosis Treatment: What Is the Diagnostic Accuracy?

2018 ◽  
Vol 5 (suppl_1) ◽  
pp. S282-S283
Author(s):  
Ginger Anderson ◽  
Christopher Vinnard
Keyword(s):  
High Risk ◽  
Therapeutic Drug Monitoring ◽  
Diagnostic Accuracy ◽  
Roc Curve ◽  
Drug Monitoring ◽  
Sparse Sampling ◽  
Blood Sampling ◽  
Successful Outcome ◽  
Therapeutic Drug ◽  
Blood Levels

Abstract Background Pyrazinamide (PZA) is a key drug for both drug-sensitive and drug-resistant tuberculosis (TB). Patients co-infected with TB and human immunodeficiency virus (HIV) are more likely to have low blood levels of PZA, associated with inferior outcomes. Therapeutic drug monitoring (TDM) with sparse blood sampling is recommended for high-risk groups, including HIV/TB patients, but the accuracy is uncertain. We performed a pharmacokinetic (PK) simulation study to estimate the diagnostic accuracy of TDM for PZA among HIV/TB patients. Methods We recently performed a population PK study among HIV/TB patients in Botswana, identifying a 1-compartment model with first-order elimination. In the current work, we performed an intensive PK simulation (n = 10,000 patients) to determine the accuracy of sparse blood sampling in identifying HIV/TB patients with low PZA blood levels, as defined by the AUC in a dosing interval (AUC0-24) predictive of successful outcome (363 mg*hr/L). PZA dosing followed WHO guidelines with weight-based dosing bands. In secondary analysis, we examined the peak concentration (Cmax) target predictive of 2-month sputum conversion (58 mg/L). To determine the accuracy of sparse sampling (2- and 6-hours), we performed receiver-operating-characteristic (ROC) analysis, with bootstrapping (n = 1,000) for 95% confidence intervals (CI), and defined accuracy as the area under the ROC curve. Results In this simulation PK study of PZA among HIV/TB patients, the PZA AUC0-24 fell below the target in 29% of patients, while in 71% of patients the PZA Cmax was below the target. For the AUC0-24 target, the area under the ROC curve was 0.69 (95% CI 0.68–0.70) for a single 2-hour sample, increasing to 0.75 (95% CI 0.74–0.76) for 2- and 6-hour samples. For the Cmax target, diagnostic accuracy was similar for a 2-hour sample (0.87, 95% CI 0.86–0.87) and 2- and 6-hour samples (0.88, 95% CI 0.88–0.89). Conclusion We observed modest diagnostic accuracy of TDM for identifying in silico HIV/TB patients with low PZA AUC0-24, and higher accuracy for low Cmax. By identifying diagnostic performance characteristics of sparse sampling strategies, including optimal cut-offs, the ROC framework can support wider implementation of TDM in high-risk TB populations. Disclosures All authors: No reported disclosures.

Strategies for physician education in therapeutic drug monitoring

1998 ◽  
Vol 44 (2) ◽  
pp. 401-407 ◽  
Author(s):  
David W Bates ◽  
Steven J Soldin ◽  
Petrie M Rainey ◽  
Joseph N Micelli
Keyword(s):  
Quality Improvement ◽  
Therapeutic Drug Monitoring ◽  
Drug Monitoring ◽  
Physician Education ◽  
Therapeutic Drug ◽  
Inpatient Setting ◽  
Drug Concentrations ◽  
And Behavior ◽  
Traditional Approaches

Abstract Although therapeutic drug monitoring (TDM) is probably very useful overall, studies suggest that it could be used better. Many drug concentrations appear to have inappropriate indications or suboptimal timing, particularly in the inpatient setting. Undermonitoring is also a concern. Thus, it may be possible to both improve the quality of TDM and reduce the overall costs of care. Here we review approaches for improving the use of TDM and present some illustrative experiences. Specific approaches discussed include use of traditional approaches such as lectures and newsletters, multidisciplinary quality improvement efforts, formal TDM services, and use of the computer as a tool for education and behavior change. Computerized methods appear to hold substantial potential, particularly as more organizations develop better information systems, but other approaches are also effective and are complementary. To be most successful, interventions should consider all stages of the process.

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