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Drug Therapy Monitoring
Overview :
TDM is a practical tool that can help the physician provide effective and safe drug therapy in patients who need medication. Monitoring can be used to confirm a blood drug concentration level that is above or below the therapeutic range, or if the desired therapeutic effect of the drug is not as expected. If this is the case, and dosages beyond normal then have to be prescribed, TDM can minimize the time that elapses.
TDM is important for patients who have other diseases that can affect drug levels, or who take other medicines that may affect drug levels by interacting with the drug being tested. As an example, without drug monitoring, the physician cannot be sure if a patient's lack of response to an antibiotic reflects bacterial resistance, or is the result of failure to reach the proper therapeutic range of antibiotic concentration in the blood. In cases of life-threatening infections, timing of effective antibiotic therapy is critical to success. It is equally crucial to avoid toxicity in a seriously ill patient. Therefore, if toxic symptoms appear with standard dosages, TDM can be used to determine changes in dosing.
Drawn blood, used for TDM, demonstrates a drug action in the body at any specific time, whereas drug levels examined from urine samples reflect the presence of a drug over many days (depending on the rate of excretion). Therefore, blood testing is the procedure of choice when definite data are required. However, for adequate absorption and therapeutic levels to be accurate, it is important to allow for sufficient time to pass between the administration of the medication and the collection of the blood sample.
| Therapeutic Drug Monitoring: Therapeutic And Toxic Range | |||||||
|---|---|---|---|---|---|---|---|
| Drug Level∗ | Use | Therapeutic Level∗ |
Toxic | ||||
| ∗Values are laboratory-specific | ∗∗Concentration obtained 30 minutes after the end of a 30-minute infusion. | ||||||
| Acetaminophen mg/ml |
Analgesic, antipyretic |
Depends on use |
>250 | ||||
| Amikacin mg/ ml |
Antibiotic | 12-25 mg/ ml∗∗ |
>25 | ||||
| Aminophylline ng/ ml |
Bronchodilator | 10-20 mg/ml | >20 | ||||
| Amitriptyline ng/ ml |
Antidepressant | 120-150 ng/ml | >500 | ||||
| Carbamazepine mg/ml |
Anticonvulsant | 5-12 mg/ml | >12 | ||||
| Chloramphenicol mg/ml |
Antibiotic | 10-20 mg/ml | >25 | ||||
| Digoxin ng/ml | Cardiotonic | 0.8-2.0 ng/ml | >2.4 | ||||
| Gentamicin | Antibiotic | 4-12 mg/L | >12 mg/L |
||||
| Lidocaine | Antiarrhythmic | 1.5-5.0 mg/ml | >5 mg/ ml |
||||
| Lithium mEq/L | Antimanic | 0.7-2.0 mEq/L | >2.0 | ||||
| Nortriptyline ng/ ml |
Antidepressant | 50-150 ng/ml | >500 | ||||
| Phenobarbital mg/ ml |
Anticonvulsant | 10-30 mg/ml | >40 | ||||
| Phenytoin mg/ml | Anticonvulsant | 7-20 mg/ml | >30 | ||||
| Procainamide mg/ ml |
Antiarrhythmic | 4-8 mg/ml | >16 | ||||
| Propranolol ng/ml | Antiarrhythmic | 50-100 ng/ml | >150 | ||||
| Quinidine mg/ml | Antiarrhythmic | 1-4 mg/ml | >10 | ||||
| Theophylline mg/ ml |
Bronchodilator | 10-20 mg/ml | >20 | ||||
| Tobramycin mg/ ml |
Antibiotic | 4-12 mg/ml∗∗ | >12 | ||||
| Valproic acid mg/ ml |
Anticonvulsant | 50-100 mg/ml | >100 | ||||
Blood specimens for drug monitoring can be taken at two different times: during the drug's highest therapeutic concentration ("peak" level), or its lowest ("trough" level). Occasionally called residual levels, trough levels show sufficient therapeutic levels; whereas peak levels show poisoning (toxicity). Peak and trough levels should fall within the therapeutic range.
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