Therapeutic Drug Monitoring: The Need for Practical Guidance
Abstract
To the Editor—Sekaggya-Wiltshire et al demonstrated in an important observational study in patients coinfected with tuberculosis and human immunodeficiency virus (N = 268) that time to sputum culture conversion was longer in patients with low drug concentrations [1]. In a similar high-tuberculosisburden setting in East Africa, we have also found such pharmacokinetic variability to be common and peak concentrations for key drugs to be well below the expected range [2]. In the accompanying editorial, Pasipanodya and Gumbo highlighted the central role of pharmacokinetic variability in determining treatment response, justifying that therapeutic drug monitoring (TDM) is necessary in tuberculosisendemic settings, and recommended implementation of TDM to detect patients at risk for suboptimal drug exposure [3]. While the first opus of TDM for management of tuberculosis was penned by Peloquin in 2002 [4], few settings routinely employ it in 2018. Clearly, more needs to be done to deliver TDM to patients in most need. We suggest 3 practical steps. First, it is a logistic and financial challenge to be able to process multiple blood samples to determine serum exposure within a dosing interval using current assays [1] in a programmatic setting. Rapid turnaround time of TDM results conveyed to the bedside is required to make a difference in treatment. Such barriers to care can be overcome with multianalyte assays combining the analysis of drugs in a single test using modern mass…
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