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Therapeutic Drug Monitoring: Role for a Pharmacist in Multidisciplinary Antiretroviral Management

University at Buffalo, School of Pharmacy and Pharmaceutical Sciences, Erie County Medical Center, Department of Medicine, Division of Infectious Diseases; 315 Cooke Hall, Buffalo, NY 14260slish{at}buffalo.edu

Linda M. Catanzaro, PharmD, Qing Ma, PhD

University at Buffalo, School of Pharmacy and Pharmaceutical Sciences; Erie County Medical Center, Buffalo, New York

Olanrewaju Okusanya, PharmD, BCPS

Lisa M. Demeter, MD

Mary Albrecht, MD

Robin Difrancesco, MT, ACSP, MBA

Gene D. Morse, PharmD, BCPS, FCCP

The current treatment guidelines for HIV pharmacotherapy recommend combinations of antiretrovirals (ARVs) to achieve optimal suppression of HIV replication. However, the initiation and long-term management of ARV therapy in a patient is often complicated by variable medication adherence, complex medication use with multiple drug interactions, the occurrence of drug toxicity, and drug therapy for comorbid conditions that require additional patient education and laboratory monitoring. For these reasons, the inclusion of a well-trained pharmacist in multidisciplinary health system management strategies has been increasing. Furthermore, the use of fixed-dose ARVs is accompanied by considerable interpatient variation in pharmacokinetics yielding a range of drug exposures from any given ARV dose. One approach to overcoming this variable drug exposure is to use plasma concentration monitoring (eg, therapeutic drug monitoring [TDM]) as a clinical tool to adjust doses to achieve targeted concentration ranges, often in conjunction with HIV resistance tests. While data in support of TDM are emerging, the development of programs that include an HIV pharmaceutical care specialist and an adherence program with an integrated clinical pharmacology resource that can provide reliable TDM assays has been reported and provides the rationale for including pharmacists in the implementation of ARV TDM programs.

Key Words: Therapeutic drug monitoring • antiretrovirals • HIV • pharmacist-managed adherence clinic

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