A manifesto for clinical pharmacology from principles to practice

1. This is a manifesto for UK clinical pharmacology. 2. A clinical pharmacologist is a medically qualified practitioner who teaches, does research, frames policy, and gives information and advice about the actions and proper uses of medicines in humans and implements that knowledge in clinical practice. Those without medical qualifications who practise some aspect of clinical pharmacology could be described as, say, 'applied pharmacologists'. 3. Clinical pharmacology is operationally defined as a translational discipline in terms of the basic tools of human pharmacology (e.g. receptor pharmacology) and applied pharmacology (e.g. pharmacokinetics) and how they are used in drug discovery and development and in solving practical therapeutic problems in individuals and populations. 4. Clinical pharmacologists are employed by universities, health-care services, private organizations (such as drug companies), and regulatory agencies. They are mentors and teachers, teaching laboratory science, clinical science, and all aspects of practical drug therapy as underpinned by the science of pharmacology; they write and edit didactic and reference texts; researchers, covering research described by the operational definition; clinicians, practising general medicine, clinical toxicology, other medical specialties, and general practice; policy makers, framing local, national, and international medicines policy, including formularies, licensing of medicines and prescribing policies. 5. The future of clinical pharmacology depends on the expansion and maintenance of a central core of practitioners (employed by universities or health-care services), training clinical pharmacologists to practise in universities, health-care services, private organizations, and regulatory agencies, and training other clinicians in the principles and practice of clinical pharmacology.

International Union of Basic and Clinical Pharmacology. LXVII. Recommendations for the Recognition and Nomenclature of G Protein-Coupled Receptor Heteromultimers

G protein-coupled receptors (GPCRs) have long been considered to be monomeric membrane proteins. Although numerous recent studies have indicated that GPCRs can form multimeric complexes, the functional and pharmacological consequences of this phenomenon have remained elusive. With the discovery that the functional GABA(B) receptor is an obligate heterodimer and with the use of energy transfer technologies, it is now accepted that GPCRs can form heteromultimers. In some cases, specific properties of such heteromers not shared by their respective homomers have been reported. Although in most cases these properties have only been observed in heterologous expression systems, there are a few reports describing data consistent with such heteromultimeric GPCR complexes also existing in native tissues. The present article illustrates well-documented examples of such native multimeric complexes, lists a number of recommendations for recognition and acceptance of such multimeric receptors, and gives recommendations for their nomenclature.

Drug development and the FDA's Critical Path Initiative

Advances in biomedical research over recent decades have substantially raised expectations that the pharmaceutical industry will generate increasing numbers of safe and effective therapies. However, there are warning signs of serious limitations in the industry's ability to effectively translate biomedical research into marketed new therapies. Clinical pharmacologists should be aware of these signals and their potential impact. Here, we discuss a strategy, where clinical pharmacology can play an important role to improve the process of drug development.

New drugs and new targets

At the 8th World Congress on Clinical Pharmacology and Therapeutics, held August 1-6, 2004, in Queensland, Australia, there were late-breaking news symposia on presynaptic receptors as targets in the treatment of schizophrenia; cyclooxygenase inhibition, present and future; adiposity, drug treatment and causes; G-protein-coupled receptors, important new targets; osteoporosis, causes, prevention and cures; ischemic stroke; drugs and arrhythmias, causes and cures; and the pharmacology of cardiac protection. One of the plenary lectures was of targeted cancer therapies. The new drugs and new targets for therapeutic intervention from these presentations are discussed in this report.

Establishment and outcomes of a model primary care pharmacy service system

PURPOSE

The establishment and outcomes of a model primary care pharmacy service system are described.

SUMMARY

A primary care pharmacy practice model was established at a government health care facility in March 1996. The original objective was to establish a primary pharmacy practice model that would demonstrate improved patient outcomes and maximize the pharmacist's contributions to drug therapy. Since its inception, many improvements have been realized and supported by advanced computer and automated systems, expanded disease state management practices, and unique practitioner and administrative support. Many outcomes studies have been performed on the pharmacist-initiated and -managed clinics, leading to improved patient care and conveying the quality-conscious and cost-effective role pharmacists can play as independent practitioners in this environment. These activities demonstrate cutting-edge leadership in health-system pharmacy. Redesign has been used to improve consistent access to a medication expert and has significantly improved the quality of patient care while easing physicians' workload without increasing health care costs.

CONCLUSION

A system using pharmacists as independent practitioners to promote primary care has achieved high-quality and cost-effective patient care.

Pharmacologic management by clinical pharmacists of behavioral and psychological symptoms of dementia in nursing home residents: results from a pilot study

A pharmacist-based consulting service was developed for the pharmacologic management of behavioral and psychological symptoms of dementia (BPSD) in a nursing home setting. Patients were evaluated using the Behavioral Pathology in Alzheimer's Disease (BEHAVE-AD) rating scale, and pharmacotherapy was selected using a structured approach. Eleven patients were evaluated and treated with various psychotropic drugs. The most commonly administered drug was trazodone at a mean dosage of 70 mg/day (range 50-100 mg/day). Nine of the patients demonstrated satisfactory treatment responses as shown by a decreased BEHAVE-AD score of 30% or more (average BEHAVE-AD scores at baseline and 1 month after treatment were 13 +/- 4 and 4 +/- 3, respectively), and no clinical side effects were observed. The service was well received by the facility staff and primary care providers. These preliminary results suggest that pharmacists can play an important role in the pharmacotherapy of BPSD with positive clinical outcomes.

Therapeutic drug monitoring in a developing country: an overview

Therapeutic Drug Monitoring (TDM) was introduced in India in the mid and late 1980s and the last 10 years have seen it grow, together with the growth of separate Clinical Pharmacology departments. The TDM service in the country is broadly of two types: in large teaching hospitals where the service is available through departments of Clinical Pharmacology, and in the private sector, where drug estimations are done by clinical biochemistry departments with minimal interpretation. This article is based on literature review and our own experiences over a 10 year period in a department of Clinical Pharmacology. It focuses on the evolution of TDM, its problems such as lack of funding, special aspects such as the impact of ethnic differences, nutritional deficiencies, quality of medicines and availability of generic products; its utility as a research tool and its future.

An evolution of drug development and clinical pharmacology during the 20th century

The current state of clinical pharmacology and drug development did not just happen. Clinical pharmacology and the drug development process were born, evolved, and have come to the fore during the past 100 years. The past century has been one of accelerating progress in science and medicine. The progress has not been a straight line but rather more like a sidewinder moving across the desert. Drug development has moved from small experiments with concoctions, extracts, and potions along with the manufacturing and promotion of the purported remedies to processes that exploited unknowing patients to a process that now requires concept generation, discovery, research, planning, and development with many checks and balances for the protection of human subjects. The factors that contributed to this progression from inappropriate use of potions, concoctions, and snake oil to the highly regulated drug development process of today is described in some detail.

Lessons learned from the past: a guide for the future of clinical pharmacology in the 21st century

This article is a documentary of the history of the American College of Clinical Pharmacology (ACCP) and the Journal of Clinical Pharmacology. The history of the college and of the journal is presented as summarized by a few of the many leaders who played key roles in the growth of the profession of Clinical Pharmacology. Together, the college, the journal, and all clinical pharmacologists working in academia, industry, CROs, or government in many different subspecialty areas of the discipline contribute to the advancement of clinical pharmacology, the development of new drugs, and to an improved quality of life for mankind. Achieving leadership in health care in an era of change requires actions to be dynamic and flexible. Leaders must be capable of self-development and self-education. Leaders must examine challenges from top to bottom and build on the leadership foundations of vision, courage, and knowledge. Strong leaders are needed for the future of clinical pharmacology to address the rapidly changing environment for health care givers and the challenges faced by those working in drug development or training new leaders. One lesson from the past, from the professional life of Harry Gold, is that it is very important to convey the excitement of the field of clinical pharmacology and to pass on this excitement and knowledge base to those currently leading the educational process necessary to keep clinical pharmacologists in the forefront of the medical arena of today and tomorrow. The college became an instrument for change in the field of clinical pharmacology. Forward thinking efforts of the college did not allow stagnation. All founding leaders of the college were possessed of a dream of "what could be and what should be." Two points should be emphasized: the importance of teaching teachers how to teach and the importance of forming national networks, such as the college, to concentrate on the role of teaching students. Today's students are the leaders of tomorrow. The training of any given student in the field of clinical pharmacology continues over many years and requires the effort of many qualified mentors. The ACCP continues to prepare for the changing demands of a new millennium. The college responded to three challenges: (1) utilization of new technologies consistent with contemporary trends; (2) identification of new member services; and (3) dissemination of a position paper defining the philosophical foundations of the college. The basic tenant of the college remains the same today as it has been over the years: provide a multidisciplinary educational environment to have a broad appeal to the membership interested in clinical pharmacology.

Clinical pharmacologist wanted--where?

Many people could define with ease the job of a cardiologist, a paediatrician or an obstetrician. However, only a few would have any clear idea of how a clinical pharmacologist might fill a day. Indeed, within the medical profession, and often within the scientific community, there has been a sneaking suspicion that clinical pharmacologists are themselves unsure of their remit. This article describes the possible role for clinical pharmacologists and different areas where they can make significant contributions to medical services.

Best practice in therapeutic drug monitoring

It is the goal of Therapeutic Drug Monitoring (TDM) to use drug concentrations to manage a patient's medication regimen and optimise outcome. Limited resources require that drug assays should only be performed when they do contribute to patient management. For this to be the case a therapeutic drug monitoring service has a far greater role than just therapeutic drug measuring. This article describes the roles and functions of a Best Practice TDM service. The features which can and should be strived for in each step of the TDM process-the decision to request a drug level, the biological sample, the request, laboratory measurement, communication of results by the laboratory, clinical interpretation and therapeutic management-are discussed.

Structure and activities of hospital drug committees in Germany

OBJECTIVES

Hospital drug committees have been established to ensure rational drug use. However, with regard to their structure and duties remarkable differences between European countries may exist, reflecting the differences in drug legislation and market. Our aim was to obtain information about the structure, present activities and decision-making processes of hospital drug committees in Germany and especially the role of clinical pharmacologists in these committees.

METHODS

In 1995, a questionnaire with 36 items was designed and sent to all 450 hospitals in Germany with more than 400 beds. One hundred forty three returned questionnaires were evaluated.

RESULTS

According to hospital size, the median value for the annual drug budget (including the cost of blood and blood-derived products) in 1993 ranged between DM 2.4 million for hospitals with less than 500 beds and DM 30.0 million for university hospitals with more than 1,000 beds. In 53.2% of drug committees, a pharmacist holds the position of chairman, followed by medical specialists (32%); (clinical) pharmacologists hold this position in only 7.7% of the general hospitals, but in almost 50% of the university hospitals. In most cases, all clinical specialities are represented in the drug committee the number of members ranging between 5 and 40 (median 12). The number of drugs included in the internal drug list, ranging between 400 in hospitals with < 500 beds and about 700 in university hospitals, strongly correlated with the number of beds and, interestingly, with the number of drug committee members. Treatment guidelines were implemented mainly for antiinfectives (87%), infusion solutions (30%), anti-emetic drugs (5-HT3-receptor antagonists, 27%) and blood and blood-derived products such as intravenous immunoglobulins (23%). However, effective control of these guidelines was only performed in about 50% of the hospitals. A drug information service was provided in most hospitals, where 95% of queries were answered by pharmacists.

CONCLUSION

The results of our survey showed that German hospital drug committees vary considerably with regard to their function and control mechanisms of drug use. Most of the responders would appreciate a more intensive exchange of current problems and treatment guidelines. Although the process of pharmacotherapeutic decision making should be supported by clinical pharmacologists, experts in this field are often not involved in German hospital drug committees.

Clinical pharmacology and clinical trials in Japan

Clinical pharmacology is the pursuit of rational therapeutics by following the scientific principles of medicine and pharmacology. In Japan the roles for clinical pharmacology and clinical pharmacologists have been evolving since the discipline appeared in the 1950s. Clinical pharmacology and clinical trials for drug development depend on each other, and clinical pharmacologists play an important role in drug development in Japan. As the discipline becomes more important and complicated, many issues regarding drug therapeutics and clinical trials in Japan have been raised, and several points of view have been expressed. The following suggestions have been made to improve clinical pharmacology in Japan: (a) Medical education in the field of clinical pharmacology must be improved by creating or improving clinical pharmacology programs in medical schools. (b) The appropriate infrastructure for clinical trials must be established so that the physicians' workload is reduced, and patients' participation in clinical trials becomes much easier. (c) Scientific and ethical standards of the pharmaceutical industry must be improved, and the effort should be made to produce drugs with new mechanisms of action or with significant expected benefits. (d) The regulatory agency must provide stronger support, encompassing all the various points of view of academic institutes and the pharmaceutical industry. In light of the enthusiasm demonstrated by the government, physicians, and pharmaceutical industry in Japan for continued progress in clinical pharmacology, it seems likely that all its challenges will be overcome in the near future. Hence, despite the various problems discussed here the future seems promising for the continued development of clinical pharmacology.

Incorporation of clinical pharmacology into the fourth year of the medical curriculum: teaching clinical pharmacology without a clinical pharmacologist

In congruence with the educational goals of the institution, the pharmacology department has developed courses for senior students. By using the students' recently acquired clinical knowledge, these courses amplify material from the core course in pharmacology. Engaging students in this type of course requires significant commitment from the faculty involved and also from the dean and department chairman. This course has outlasted many curricular changes and has remained in the mainstream of medical education. Goals of this course remain consistent with current proposals to develop new directions in medical education.

Clinical pharmacology in Hungary: past, present and future

The authors outline the development of the clinical pharmacological network in Hungary. They describe some problems encountered during the development and discuss future plans.