Analysis toolkit for evaluation of drug titration practice in acute lymphoblastic leukemia maintenance

Objective During the 2-year maintenance treatment phase (MT) of acute lymphoblastic leukemia (ALL), personalized patient-specified titration of oral antimetabolite drug doses is required to ensure maximum tolerated systemic drug exposure. Drug titration is difficult to implement in practice and insufficient systemic drug exposure resulting from inadequate dose titration increases risk of ALL relapse.Materials and Methods We developed an open-source R-based analytical toolkit, including the allMT R package and an interactive web-based R Shiny VIATAMIN application, to evaluate antimetabolite drug titration during MT.Results Evaluation is initiated with basic visualization analysis of drug titration, in both individual patients and patient cohorts. Observations are supplemented with descriptive analyses of hematological toxicity frequency and prescriber compliance rates with protocol drug titration rules. In individual patients, visual and quantitative analyses indicate recurring potentially correctable suboptimal drug titration patterns. In patient cohorts, the toolkit enables evaluation of the impact of interventions to optimize MT drug titration.Discussion Incorporation of the toolkit in a forthcoming clinical decision support system for MT would enable real-time examination and course correction of drug titration practice.Conclusion Future versions will be enhanced to include other variables that influence drug titration practice, including clinical toxicity data and later, pharmacological markers of antimetabolite, adherence, and drug activity. Acute lymphoblastic leukemia (ALL) is the most common childhood cancer. Many children are cured with modern treatment. Treatment typically lasts 2.5 years, including a critical 2-year maintenance phase where children take oral anti-cancer drugs. To ensure optimal treatment, drug doses during the maintenance phase must be adjusted carefully for each child, a process called drug titration. This requires regular blood tests and close monitoring of treatment history. Drug titration is a challenging task and clinical practitioners currently lack specialized tools to efficiently manage this process. To address this requirement, we have developed open-source tools to help visualize drug titration patterns and identify opportunities to improve titration practice. These tools also help highlight when children may be experiencing difficulties tolerating drug treatment. We anticipate that these tools will enhance patient care during the maintenance treatment phase by providing insights into treatment patterns and by highlighting potential areas for improvement in practice.