|This month I contacted Marieke Sturkenboom, Vice-Chair of the Pharmacometrics Committee, whom I didn’t realise works with Daan Touw, our first interviewee. It was wonderful to hear from Marieke’s perspective as a young scientist being welcomed into this world class laboratory and clinical service. It is also interesting to hear about how Marieke and her colleagues have been involved in the challenges that many modern hospitals go through, such as implementation of electronic patient records, upgrading to international laboratory standards and upgrading dose adaptation software.
Hospital Pharmacist and Clinical Pharmacologist
University Medical Centre, Groningen, NL
Can you tell us a little bit about your respective roles? What is a typical day like for you?
I am a hospital pharmacist and clinical pharmacologist at the University Medical Centre Groningen, a large academic hospital in the north of the Netherlands. I started working here in 2005 and I am very grateful to work in this hospital and moreover this fantastic lab. Prof Donald Uges established the lab in the 70’s and never ceased to implement new techniques, resulting in a very wide range of drugs we can analyse for the hospital, but also as a reference centre in the country, either in routine TDM, toxicology or research. When Prof Donald Uges retired, he was succeeded by Prof Daan Touw.
We start our days with a meeting in which the pharmacist on call presents overnight or weekend cases. There are several typical days for me (alternatively, you could say there is no such thing). If I am on lab duty, I do the routine TDM of antibiotics (aminoglycosides, glycopeptides and sometimes beta lactams, quinolones), immunosuppressants, and psycho-active drugs. I am on call for both toxicological and TDM questions and cases.
If I am not on lab duty or any of the other duties in the department, I do projects for the lab or the department. At the moment, the hospital is busy preparing to implement a new electronic patient record, and this also requires substantial involvement from hospital pharmacists.
One of my areas of attention is the quality system of the lab. In the Netherlands, many laboratories involved in bioanalysis and TDM are changing from a former Dutch quality system called CCKL to ISO 15189 (Medical laboratories – Requirements for quality and competence). In 2015, we successfully transferred to ISO 15189 and a recent third control visit has concluded successfully.
Another project that I am working on is the implementation of MWPharm ++ in our department. MWPharm is a software that was developed at the University of Groningen (D.K.F. Meijer, J.H. Proost and colleagues) and which is used in many hospitals in the Netherlands to calculate dose adaptations based on drug concentrations. We have been using the DOS version of MWPharm for over 25 years. I am currently testing the new version to see whether it is comparable to our ‘golden standard’.
Together with Daan, I also supervise trainees performing at the lab. And last, but not least, of course there are a lot of meetings I attend
Is there anything that your laboratory does, or that is done at your hospital/centre, that you would consider innovative?
Daan Touw, Jan-Willem Alffenaar and Remco Koster are particularly innovative in developing many new methods for bioanalysis in TDM, research and clinical toxicology using novel techniques and alternative matrices, such as saliva, hair and Dried Blood Spots. We are pretty active in the field of PK/PD of anti-infective drugs, especially anti-tuberculosis drugs and anti-fungals. We are quite successful in implementing former research projects in daily patient care. The high quality of our TDM services implemented in daily patient care, although maybe not unique, is something I am pretty proud of.
At our lab, we have a long history of education of hospital pharmacists and technicians in toxicological analysis and providing advice to physicians.
What technological innovations have entered into use during your career that has permitted a change, or evolution, in practice?
I suppose the implementation of mass spectrometry in the field of TDM and toxicology has been a major change. Shortening of turn-around times, higher sensitivity and specificity and the lower volume required have had a major impact on our daily routine for both TDM and toxicology. Also, the wide availability of the internet and information technology; for example, it is now possible to be on call and look for information wherever you might be. In my opinion, it does have a counter-side, as I notice for myself, but also in others, that everything you knew by heart starts to fade away.
How did you become interested in your area of expertise?
During my training as a hospital pharmacist, I came across the lab and was soon convinced that this was what I’d loved the most. When I finished my training, I was asked to come to work at the lab by Prof Donald Uges and with that single phone call I was convinced to work there. Donald further increased my interest in toxicology and Daan encouraged me to take part in the toxicological education of hospital pharmacist trainees.
Is there anything that you’ve seen or heard about recently and thought “I’d like to incorporate that idea at my centre”?
I heard that it might be possible to use Nonmem in dose adjustments for daily patient care. MWPharm is unable to incorporate important covariates in more complex models, and this is a promising idea.
Another idea is TDM of immunosuppressants using AUCs. Although not new, we have not been able to not implement due to limited staff availability.
I have heard that some centres that have been able to extract essential data from EPRs to their modelling software; I would be very interested to implement that in our centre.
What sort of research do you have on the horizon that you think might influence clinical practice in the future?
I would like to limit this question to my fields of interest. Then the first thing that comes to mind is personalized medicine. As I mentioned before, we implemented several research projects on PK/PD in daily patient care. I think we will continue this work in future.
What do you consider is the future for TDM and CT? What are you excited about? What are the challenges we face?
I am not particularly good at forecasting, but despite this restraint, I suppose the TDM and PK/PD modelling will become more important in personalized medicine, especially for high cost drugs and cases in which we cannot or do not want to wait for an effect, such as with anti-infective drugs.
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