Br. J. clin. Pharmac. (1990), 29

Letter to the Editors

133

Therapeutic drug monitoring - an hypothesis still in need of testing I very much enjoyed the spirited response of Drs Watson and Thomson (1989) to my leading article. Although the quotation in their introductory paragraph was not particularly apt, its author is most appropriate. Giordano Bruno was a philosopher and sceptic at a time when the only acceptable philosophy was that of the Church. For his heresy, he fell into the hands of the Inquisition and was burnt at the stake. Perhaps, Drs Watson and Thomson have a similar fate in mind for me, for daring to question the dogma of therapeutic drug monitoring. Most of their lengthy epistle preaches the gospel of clinical pharmacokinetics and there is little place for reasoned argument. None of the studies quoted remotely approaches, far less meets, the requirements of an adequate evaluation of therapeutic drug monitoring. Even the best (Bootman et al., 1979) relied upon an historical control group, a major weakness recognised by the authors themselves and an independent critic (Vozeh, 1987). No amount of assumptions, statistics or advanced pharmacokinetics can overcome such defects in design. Do these studies represent a 'wealth of data' in support of therapeutic drug monitoring or a blind act of faith? Four centuries have passed

since Bruno's incineration and still religious zeal confronts scientific thought. The value of therapeutic drug monitoring to the practising physician has not been proven but an hypothesis has been generated. This now needs to be tested prospectively. Despite the disingenuous comments of Drs Watson and Thomson, even Dr Vozeh agrees: 'The main conclusion of this article is that we have very little direct evidence concerning the cost-benefit of therapeutic drug monitoring, and that prospective evaluation of the effectiveness of this therapeutic procedure is needed' (Vozeh, 1987). One must hope that, before too long, the non-clinicians who operate the service will also be converted. GORDON T. McINNES University Department of Medicine and Therapeutics, Gardiner Institute, Western Infirmary, Glasgow GIl 6NT

(Received 8 September 1989, accepted 13 September 1989)

References Bootman, J. L., Wertheimer, A. I., Zaske, D. & Rowland, C. (1979). Individualizing gentamicin dosage regimens in burn patients with gramnegative septicaemia: a cost-benefit analysis. J. pharm. Sci., 68, 267-272. Vozeh, S. (1987. Cost-effectiveness of therapeutic drug monitoring. Clin. Pharmacokin., 13, 131-140.

Watson, I. D. & Thomson, A. H. (1989). The value of therapeutic-drug monitoring to the practising physician - an hypothesis needing sensible application! Br. J. clin. Pharmac., 28, 619-620.

Therapeutic drug monitoring-an hypothesis still in need of testing.

Br. J. clin. Pharmac. (1990), 29 Letter to the Editors 133 Therapeutic drug monitoring - an hypothesis still in need of testing I very much enjoyed...
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