An Interview with Alain Verstraete

This month’s blog interview is with long-term member, Alain Verstraete. I met Alain in 2011 and we have collaborated in the Communications Committee since then. Alain is the head of the toxicology laboratory in Ghent University Hospital, and professor at the faculty of medicine and health sciences of Ghent University. He has a long research history investigating driving under the influence of drugs, but has more recently changed course to investigate antimicrobial TDM.

Can you tell us a little bit about your respective roles? What is a typical day like for you?

I studied medicine and specialized in laboratory medicine. Thirty years ago I started up the toxicology laboratory in Ghent University Hospital, and I continue to be in charge. In addition, I teach part-time as senior professor at the faculty of medicine and health sciences of Ghent University. I also coordinate the training of pharmacists and medical doctors who specialize in Laboratory medicine.

My daily work is a mix of being in the lab for method development and medical validation of the daily results, consulting with requesting physicians and colleagues from the labs who send samples to us, managing the lab, meetings at the faculty or in the hospital, and education activities.

I am also active in national and international scientific societies. I was president of TIAFT 2011-2014, The International Association of Forensic Toxicologists, and am currently president of the toxicological Society of Belgium and Luxembourg.

Is there anything that your laboratory does or that is done at your hospital that you would consider innovative in terms of TDM and Clinical Toxicology?

Two months ago we implemented a Q-Exactive Hybrid Quadrupole-Orbitrap Mass Spectrometer in the lab, and we are currently developing and validating quantitative methods for a whole range of drugs. Method development has been surprisingly easy (yes!) and method validation has been progressing very well. This instrument will allow us to consolidate many methods into a more manageable number, as well as simplify sample preparation, so I think it will certainly improve the efficiency and turnaround time of the lab.

Is there anything that you’ve seen elsewhere or heard about and thought “I’d like to incorporate that idea at my center”?

When I visited to professor Uges at the Groningen University Medical Centre several years ago I was really impressed by the ability of his lab to develop quantitative methods very quickly (in a few hours) to help clinicians in overdose cases: it is my dream to implement this in my lab as well.

Why is TDM not applied more widely and what can we do about it?

For the physician and for the patient, TDM is an added burden. It requires extra blood draws and consultations. So it is much better to prescribe a medication that doesn’t need TDM. But of course in some cases there is no choice: one needs that drug and one needs TDM to use it optimally. In order to have a wider application of TDM, we need many things: clear evidence of the benefits and good communication of this information, reliable analysis results, not too costly and with results reported in a timely manner to the clinician, who might need our help for interpreting the results.

We could also focus on less invasive sampling, and (for hospitalized patients) semi continuous or continuous monitoring. In the 30 years of my career in laboratory medicine and TDM in particular, we have seen little progress in miniaturization for automated tests, where the reaction volume is still in the (hundreds of) microliters. Compare this to genetic analysis where miniaturization has progressed much more rapidly. Costs have been reduced markedly, even more quickly than Moore’s law. We haven’t seen this evolution yet in clinical chemistry in general or TDM in particular.

What sort of research do you have on the horizon that you think might influence clinical practice in the future?

I have two PhD students and a post-doc performing research that I supervise. My main research area until recently was ‘driving under the influence of drugs’, but that work has concluded. My main focus now is therapeutic monitoring of antibiotics in the intensive care unit and in patients with cystic fibrosis. In addition, several graduate and master students contribute to our research efforts, and I find it stimulating to coach them. We also have quite a lot of international students. TDM of antibiotics is a field where there are a lot of new developments. It is still not clear if it will have a place in routine care, but we are progressing and we hope to be able to contribute to answering this question.

What do you consider is the future for TDM and CT? What are you excited about? What are the challenges we face?

I think TDM has a bright future as a part of personalized medicine. There is a growing evidence for the need for TDM for an increasing number of drugs.

For CT I am less positive. In the last 30 years that I worked in this field, we have observed a decreasing number of requests for toxicological analysis in overdose cases. This is partly explained by reimbursement issues that are specific to my country. Another explanation is that most new drugs are less toxic than previous eras of drug development. For instance, when we started toxicology, one third of the poisonings were with barbiturates that were very toxic. Benzodiazepines are much less toxic. The same is true for tricyclic antidepressants compared to the safer SSRIs. In Europe many of the toxic pesticides and herbicides that caused very severe poisonings, like paraquat or cholinesterase inhibitors, have now been prohibited and we very rarely see any intoxications with them. At present we have been generally spared from new psychoactive substances in Belgium, probably because possession of less than 3 g of cannabis for one’s own use isn’t sanctioned, so I have not devoted much effort to this very challenging field.

How do you keep up-to-date in your field?

I subscribe to alerts of several journals in my field so I receive their contents every month or every issue. I also go to a lot of scientific meetings where I hear presentations or see posters about the latest developments in our field. In addition, I follow a few people and organizations on Twitter (the IATDMCT Twitter feeds is very useful!) that direct me to new developments. I receive a several newsletters by email and sometimes I pick up new information or new ideas. Sometimes they point to webinars that can also be inspiring.