Ratanajamit Chaveewan, Kaewpibal Peerasak, Setthawacharavanich Suwanna, Faroongsarng Damrongsak
Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Songkhla, Thailand.
J Med Assoc Thai. 2009 Nov;92(11):1500-7.
To compare the proportions of appropriate TDM utilization regarding the indication, sampling time, and application of the measured drug levels of antiepileptic drugs (AEDs) between the pre-intervention period and pharmacist intervention period.
The baseline evaluation and pharmacist intervention study of TDM use for phenytoin, carbamazepine, or valproic acid were conducted at a medical teaching hospital in Southern Thailand. TDM requests, interpretation and dosage adjustment recommendations were mainly responsible by residents. In the intervention period, each of the three-step TDM process was assessed by the pharmacist for appropriateness and a suggestion provided if necessary prior to a final recommendation made by the resident. The criteria for appropriateness of TDM for AEDs were developed and validated by two neurologists. The present study included 44 TDM tests (22 patients) during the baseline period and 43 tests (27 patients) during the intervention period. The proportions of appropriate TDM utilization between the two periods were compared using Chi-square test.
In the baseline period, proportions of appropriately performed TDM were: indication (63.6%), sampling time (47.7%), and application of drug levels (63.6%). Pharmacist intervention significantly increased the proportions of appropriate indication (97.7%, p = 0.001), sampling time (79.1, p = 0.0023), and applications (83.7%, p = 0.0293). There were 12 tests (27.3%) and 29 tests (67.4%) (p = 0.0001) during the baseline and the intervention period, respectively, that met all 3 criteria of appropriate TDM use. Sixteen requests without indication found in the baseline period was reduced to one in the intervention period, and thus reduced the unnecessary cost by 90%. Of 59 steady-state drug levels, 34 (57.6%, p = 0.0005) significantly correlated with clinical responses.
Pharmacist intervention significantly improved appropriateness of TDM use, and substantially reduced unnecessary costs. Using a screening checklist including the indication, sampling time and data needed for proper interpretation of the results can help improve the appropriateness of TDM utilization.
比较干预前期和药师干预期抗癫痫药物（AEDs）在适应证、采样时间及所测药物水平应用方面合理进行治疗药物监测（TDM）的比例。
在泰国南部的一家医学教学医院开展苯妥英、卡马西平或丙戊酸TDM使用的基线评估及药师干预研究。TDM申请、解读及剂量调整建议主要由住院医师负责。在干预期，药师会对TDM的三个步骤进行合理性评估，并在住院医师给出最终建议前必要时提供建议。AEDs的TDM合理性标准由两名神经科医生制定并验证。本研究包括基线期的44次TDM检测（22例患者）和干预期的43次检测（27例患者）。采用卡方检验比较两个时期合理进行TDM的比例。
在基线期，合理进行TDM的比例分别为：适应证（63.6%）、采样时间（47.7%）及药物水平应用（63.6%）。药师干预显著提高了合理适应证（97.7%，p = 0.001）、采样时间（79.1%，p = 0.0023）及应用（83.7%，p = 0.0293）的比例。基线期和干预期分别有12次检测（27.3%）和29次检测（67.4%）（p = 0.0001）符合TDM合理使用的所有3项标准。基线期发现的16项无适应证申请在干预期减少至1项，从而将不必要的费用降低了90%。在59个稳态药物水平中，34个（57.6%，p = 0.0005）与临床反应显著相关。
药师干预显著提高了TDM使用的合理性，并大幅降低了不必要的费用。使用包括适应证、采样时间及正确解读结果所需数据的筛查清单有助于提高TDM使用的合理性。
