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Evidence in Clinical Toxicology: The Role of Therapeutic Drug Monitoring

Ideally, all decisions in medicine should be based on the best possible evidence. The type of evidence required, how it is collected, and how it is used depends on the nature of the clinical practice and the individual clinical problem. This paper explores some of these issues in relation to evidence in clinical toxicology and raises the possibilities for closer collaboration with the role of therapeutic drug monitoring (TDM). In clinical toxicology practice, TDM may provide diagnostic or prognostic information that may assist in guiding treatment (1). However, in the current clinical setting, TDM has a relatively small role to play. On the other hand, from a research perspective, measuring toxin concentration has the potential to provide information that can assist in better understanding of individual toxins. This understanding may ultimately translate into better clinical care. The burden of illness associated with clinical toxicologic problems is high both within hospitals and within the community. In Australia, self-poisoning with therapeutic drugs is responsible for 50% of deaths in suicides (2). There are, however, considerable cultural differences—for example, in many countries agricultural chemicals are the major issue (3). Surveys of Australian hospitals show that 1% to 5% of admissions result from self-poisoning (4); of these, more than 60% of patients have ingested more than one substance (2). The inhospital death rate is less than 0.5%, largely a reflection of the effectiveness of supportive care rather than the administration of any “magic bullet.” Paradoxically, the majority of this care is delivered in general emergency departments, not in the specialist toxicology units that produce a disproportionate amount of opinion. The challenge is to establish an effective link between the two poles of clinical practice to generate and subsequently implement clinically useful evidence.