This month we hear from Ranita Kirubakaran, clinical pharmacist working in Seberang Jaya Hospital, Penang, Malaysia. At the Rome 2022 IATDMCT congress, Ranita won the Young Scientist poster prize for her work titled ‘Matters close to the heart: adaptation of tacrolimus models to inform therapeutic drug monitoring using the PRIOR approach.’ This work was conducted as part of her PhD while she was based at St Vincent’s Hospital Sydney. Ranita has since returned to Malaysia and shares about her experiences. Looking forward to further excellent work from this bright Young Scientist! Read on!
I recently completed my PhD in Clinical Pharmacology at UNSW Sydney and am currently working as a clinical pharmacist at a public, tertiary hospitals in Malaysia. Fortunately, I don’t have a typical day as it varies from day-to-day. I run pharmacist-led clinics for thalassemia, pain and warfarin on Mondays, Tuesdays and Fridays, respectively. The warfarin clinic, for example, involves performing dosage adjustments based on INR, dispensing and counselling patients on warfarin and the importance of compliance, and scheduling future blood tests and follow-up appointments. On the remaining working days, I work at an outpatient pharmacy filling more than 1,000 prescriptions. This involves other value-added patient-focused services such as drive-through pharmacy, postage of medication and an integrated drug dispensing system. Outside of work, I usually spend quality time with my family. I am a cricket lover. Whenever time permits, I try to catch up with the match scores.
Coming from a developing country, the implementation of model-informed precision dosing in routine clinical practice is scarce. However, while I was based at St. Vincent’s Hospital Sydney during my PhD candidature, I was fortunate to have gained experience in using dosing software to guide vancomycin dosing in a diverse patient populations (critically ill, obese etc.). Importantly, I have had the privilege to witness the steps taken by the multi-disciplinary teams in implementing model-informed precision dosing advisory services in clinical practice, including understanding current clinical practice, to identifying suitable models, optimizing dosing software and IT systems, educating healthcare professionals, clinical review of dose recommendations and evaluation of the implemented service.
The implementation of model-informed precision dosing to facilitate dose individualisation for various TDM drugs in routine clinical practice. Its utilisation had overcome some of the obstacles we face in clinical practice such as the poor collection of timed drug concentrations (e.g., trough concentrations) and estimation of drug exposure, AUC0-12 using intensive sampling drug concentrations.
I am not a lab person and never worked as a TDM pharmacist. I had limited exposure to TDM and none to pharmacometrics prior to pursuing my PhD. The research activities I performed during my PhD and collaborative efforts with experts in the respective fields drove my interest in TDM and pharmacometrics.
The use of dried blood spots as a new monitoring strategy to measure drug concentrations.
Biomarkers have great potential in treatment optimization.
Adaptation of model-informed precision dosing to help clinicians in individualizing drug therapy, particularly for drugs with narrow therapeutic windows. While this approach is still evolving, it is still largely uncommon in developing countries. There is now various dosing software to allow this to happen.
Barriers are primarily, resources (money, staffing etc) and secondly, acceptance of this new approach by healthcare professionals.
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