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    Guidelines For Therapeutic Drug Monitoring

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    SeptaniaDiniArviani
    This document provides guidelines for therapeutic drug monitoring of several drugs, including digoxin, phenytoin, primidone, sodium valproate, carbamazepine, phenobarbital, lithium, theophylline. For each drug, it lists the approximate half-life, time to steady state, recommended sample timing and target concentration range. It provides additional notes on phenytoin reporting, including an equation to adjust phenytoin levels based on albumin concentration. Raised adjusted phenytoin levels greater than 25 mg/L will be phoned. References for guidelines on lithium and other anticonvulsants are also listed.

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    Guidelines For Therapeutic Drug Monitoring

    Uploaded by

    SeptaniaDiniArviani
    31 views2 pages
    This document provides guidelines for therapeutic drug monitoring of several drugs, including digoxin, phenytoin, primidone, sodium valproate, carbamazepine, phenobarbital, lithium, theophylline. For each drug, it lists the approximate half-life, time to steady state, recommended sample timing and target concentration range. It provides additional notes on phenytoin reporting, including an equation to adjust phenytoin levels based on albumin concentration. Raised adjusted phenytoin levels greater than 25 mg/L will be phoned. References for guidelines on lithium and other anticonvulsants are also listed.

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    Guidelines for Therapeutic Drug Monitoring

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    This document provides guidelines for therapeutic drug monitoring of several drugs, including digoxin, phenytoin, primidone, sodium valproate, carbamazepine, phenobarbital, lithium, theophylline. For each drug, it lists the approximate half-life, time to steady state, recommended sample timing and target concentration range. It provides additional notes on phenytoin reporting, including an equation to adjust phenytoin levels based on albumin concentration. Raised adjusted phenytoin levels greater than 25 mg/L will be phoned. References for guidelines on lithium and other anticonvulsants are also listed.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    31 views2 pages

    Guidelines For Therapeutic Drug Monitoring

    Uploaded by

    SeptaniaDiniArviani
    This document provides guidelines for therapeutic drug monitoring of several drugs, including digoxin, phenytoin, primidone, sodium valproate, carbamazepine, phenobarbital, lithium, theophylline. For each drug, it lists the approximate half-life, time to steady state, recommended sample timing and target concentration range. It provides additional notes on phenytoin reporting, including an equation to adjust phenytoin levels based on albumin concentration. Raised adjusted phenytoin levels greater than 25 mg/L will be phoned. References for guidelines on lithium and other anticonvulsants are also listed.

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    of 2

    BLOOD SCIENCES

    DEPARTMENT OF CLINICAL BIOCHEMISTRY


    Title of Document: Guidelines for Therapeutic Drug Monitoring
    Q Pulse Reference No: BS/CB/DCB/TOX/3 Version NO: 7
    Authoriser: Peter Beresford Page 1 of 2

    DRUG HALF LIFE (approx) TIME TO SAMPLE TARGET RANGE COMMENTS


    (HOURS) STEADY TIMING
    STATE
    1) Half life increased in renal
    Adults 38-77 6-13 days At least 6 hours 0.8 - 2.0 g/L and/or CCF
    DIGOXIN after last dose 2) Hypokalaemia potentiates
    toxicity
    1) Half life increased in
    ADULTS 20-40 But highly Variable Trough sample 5 – 20 mg/L chronic hepatic dysfunction
    PHENYTOIN*
    variable and dependent on dose 1-2 weeks (dose (Albumin-adjusted) 2) Bioavailability varies
    dependent) betweeen manufacturers
    PRIMIDONE Adults 10-12 2-2.5 days No range for parent drug Measure Phenobarbitone
    Not routinely available. May be
    Adults 6-17 3 days Immediately 50 – 100 mg/L used to assess compliance
    SODIUM
    VALPROATE Children 4-14 2 days
    2 weeks or more Threshold for toxicity may be
    CARBAMAZEPINE Adults and children 5-27 (1 week after Before Oral 4 – 12 mg/L reduced in multiple
    adjusted dose) anticonvulsant therapy1
    Adults 50-120 10-25 days
    10 – 40 mg/L Alkaline urine may increase the
    PHENOBARBITONE Infants/Children 40-70 8-15 days Dose rate of elimination

    Aim for: 1) Half life increased in renal


    12- 14 hours post 0.6 – 0.8 mmol/L normally dysfunction
    Adults 14-24 (up to 36 in the 2-4 days dose 0.8 – 1.0 mmol/L if patient has 2) Note that not all tablet
    LITHIUM elderly) relapsed previously on Li or preparations are slow
    has sub-syndromal symptoms release2
    Adults (>16yrs): Oral Dosing:
    8.7 (mean average) 2 days 6-7 hours after slow 1) Half-life reduced by up to
    release preparation 50% in smokers
    THEOPHYLLINE Neonates 10 – 20 mg/L 2) Half life increased in
    Premature 30 6 days 2 hours after syrup hepatic failure
    Full term 24 5 days
    * See additional notes on Phenytoin reporting
    BLOOD SCIENCES
    DEPARTMENT OF CLINICAL BIOCHEMISTRY
    Title of Document: Guidelines for Therapeutic Drug Monitoring
    Q Pulse Reference No: BS/CB/DCB/TOX/3 Version NO: 7
    Authoriser: Peter Beresford Page 2 of 2

    Phenytoin reporting.

    All phenytoin results are reported in the following panel, with an Adjusted Phenytoin value,
    calculated using the Scheiner-Tozer equation (see below) to take into account the effect of protein
    binding.

    Albumin … g/L (35-50)


    Phenytoin … mg/L (5-20)
    Adjusted Phenytoin … mg/L (5-20)

    Albumin-adjusted phenytoin is a better guide to biologically active phenytoin than total levels
    when albumin is reduced. Interpret results with caution if albumin less than 20g/L or in the
    presence of other factors that may influence phenytoin binding (eg other highly protein-bound
    drugs, uraemia, hepatic impairment and pregnancy).

    Scheiner-Tozer Equation
    To adjust to an albumin concentration of 40g/L:
    Adjusted Phenytoin = Phenytoin___
    (Alb x 0.9) + 0.1
    40

    Telephoning Raised Phenytoin Levels

    Adjusted phenytoin greater than 25 mg/L will be phoned.

    References
    1) Clinical Chemistry 1998; 44 (5): 1085 – 1095
    2) Guidelines to Monitoring Lithium: A statement of good practice 1998
    see also
    3) NICE guidelines for bipolar disorder (July 2006)
    4) Fedler C and Stewart MJ. Plasma total phenytoin: a possibly misleading test in developing
    countries. Ther Drug Monit. 1999, 21: 155-160

    For Lamotrigine, Gabapentin, Topiramate and Vigabatrin see: Syva Drug Monitor Vol 2: issues 2,
    5 and 10

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