Overview on monitoring of therapeutic drugs shivaji prataprao gawade sahyadri college of pharmacy, methwade, tal. The ideal tdm teama clinical pharmacologist, the use of drug measurements in biological. Drugs with a narrow therapeutic index where therapeutic drug levels do not differ greatly from levels associated with serious toxicity should be monitored. Where this cannot be done, therapeutic drug monitoring is used in two major situations 3. Lithium is a useful drug, particularly in the maintenance treatment of bipolar affective disorder. Amdisen proposed the use of a standardized 12 h serum lithium concentration, which subsequently became the universally accepted mode of monitoring lithium levels. Therapeutic drug monitoring follows these changes and accommodates them. The sample is taken 12 h 30 min after the last dose of lithium in patients who have been taking the drug in two or more divided dosages, and who have taken all their prescribed. Nhs grampian acute sector summary guideline for therapeutic drug monitoring tdm in adults version 2 antibiotic assays on the microbiology request card for serum levels, please supply details of the antibiotic level required, the time and date of the sample. Some of the factors complicating phenytoin dosing include a narrow therapeutic window, high degree of protein binding, and nonlinear pharmacokinetics. It is an easytoread source of information on intended use, pharmacokinetics, therapeutic range, and toxic. Although alternative methods of blood sampling have been suggested, serum measurements remains the mainstay of therapeutic drug monitoring tdm of lithium. Once the decision to monitor the concentration of a therapeutic drug has been made, it is important that a biological sample is collected to provide a clinically meaningful measurement.
Lithium naive patients should have lithium levels of 0. Therapeutic drug monitoring mimi emig md spectrum health and kent county health dept. Now, if you go below the presentation at the bottom of this page, there is a pdf download that you. A statement of good practice 1998 see also 3 nice guidelines for bipolar disorder july 2006 4 fedler c and stewart mj. The present paper reports analysis of a retrospective audit of tdm of lithium over a period of 4 years. The tdm service in the country is broadly of two types. Phenytoin carbamazepine gentamicin vancomycin teicoplanin lithium digoxin aminophylline theophylline work through the case studies and answer the questions using information resources available to you in your clinical practice environment. Therapeutic drug monitoring in a developing country. The lithium concentrations were targeted by a reference laboratory. Nov 20 page 1 of 10 medicines formulary therapeutic drug monitoring contents. Mar 06, 2009 pioneers of drug monitoring in the 1970s focused on adverse drug reactions and demonstrated clearly that by constructing therapeutic ranges, the incidence of toxicity to drugs such as digoxin, phenytoin, lithium, and theophylline could be reduced. Pdf appropriateness of therapeutic drug monitoring for.
Grand rapids, mi case 1 17 yo man with 2 weeks of cough weight 48kg admitted 309 father with tb 7 yr ago. As concerns about drug interactions, adverse effects, compliance, etc. Clinical practice typically results in mostly a subjective assessment of the safety and efficacy of antipsychotics. 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.
Guide for drug level monitoring of commonly used medications. Therapeutic drug monitoring involves not only measuring drug concentrations, but also the clinical interpretation of the result. May 31, 2018 patient requires monitoring and assessment for adverse events as the dose is increased closer to the therapeutic range. In 16 samples consisting of 1 control materials n 4, 2 pooled patient serum n 5, and 3 serum from individual patients n 7, lithium was measured in 19 laboratories using 20. Therapeutic drug monitoring aims to promote optimum drug treatment by maintaining serum drug concentration within a therapeutic range. Lithium eskalith within 30 minutes before dose draw at least 812 hours post dose 5 days 0. Medicines that interact with lithium are summarised in table 1. Tdm aimed at improving patient care by individually adjusting the dose of drugs for which clinical experience or clinical.
A retrospective serum lithium estimation data of 4 years were analyzed for drug levels, reasons for request, and correlation of levels with dose and side effects. Therapeutic drug monitoring of lithium in patients with. Patient requires monitoring and assessment for adverse events as the dose is increased closer to the therapeutic range. Pharmacoeconomic studies on therapeutic drug monitoring 105 i. Therapeutic monitoring of vancomycin in adult patients. The monitoring parameters cited are derived from a range of guideline sources, other. Lithium dosages should be adjusted in steadystate patients, using the serum trough level i. Pdf lithium therapeutic drug monitoring pattern at a. Therapeutic drug monitoring of antipsychotics mdedge.
Evaluation of therapeutic drug monitoring service 102 b. Prevalence of therapeutic drug monitoring for lithium and the. A retrospective serum lithium estimation data of 4 years were analyzed for drug levels, reasons for request, and correlation of. Lithium has a narrow therapeutic index and drug interactions, changes in diet and fluid intake. This study examines the interlaboratory variation and inaccuracy of lithium monitoring in denmark methods. Therapeutic drug monitoring medicines formulary, version 7 principal author. Lithium prescribing and monitoring in clinical practice. They make refer ence to a sustained slowrelease formulation which may be better tolerated by some patients. Summary guideline for therapeutic drug monitoring tdm in. Lithium therapy is safe, effective, evidence based, and in line with current.
Therapeutic drug monitoring tdm is the use of drug concentration. Managing patients on discharge if you require this document in an alternative format, i. Therapeutic drug monitoring tdm is a branch of clinical chemistry and clinical pharmacology that specializes in the measurement of medication levels in blood. Therapeutic drug monitoring tdm, a comparatively new investigational procedure in clinical pharmacology, is considered useful in patients suffering from mood disorders though it increases the health care cost. Safe and effective use of lithium australian prescriber. We have therefore investigated the prevalence of tdm for lithium and evaluated the impact of the regulatory warnings requiring routine tdm for lithium. Suggestions for drug monitoring in adults in primary care. Therapeutic drug monitoring of phenytoin is carried out to ensure effective and safe levels. Prevalence of therapeutic drug monitoring for lithium and. Therapeutic drug monitoring siemens healthineers global. Despite a long history of therapeutic drug monitoring tdm within psychiatry, routine monitoring of antipsychotic serum levels has not been unanimously adopted as standard practice.
Summary guideline for therapeutic drug monitoring tdm in adults. Symptoms are more severe with fa steronset hyponatremia. It is an easytoread source of information on intended use, pharmacokinetics, therapeutic range, and toxic concentrations, as well as bioavailability, disposition. This requires knowledge of the pharmacokinetics, sampling time, drug history and the patients clinical condition. Drug interactions with lithium mostly occur through the direct effect of other medicines on renal function, notably glomerular filtration rate and sodium absorption 1. Also, the therapeutic drug monitoring tdm laboratory provides an electronic report of all completed serum drug concentrations of patients admitted to. Therapeutic drug monitoring tdm is the use of drug concentration measurements in body fluids as an aid to the management of drug therapy for the cure, alleviation or prevention of disease. Regulatory warning on lithium at april 2012 in japanese. Pdf appropriateness of therapeutic drug monitoring for lithium.
Patients who have impaired clearance of a drug with a narrow therapeutic index are candidates for drug monitoring. Appropriateness of therapeutic drug monitoring for lithium article pdf available in journal of the medical association of thailand chotmaihet thangphaet 8911. Serum lithium is monitored to ensure levels within the narrow therapeutic window. Monitor for lithium toxicity and metabolic acidosis. How appropriate is therapeutic drug monitoring for lithium. Initial features of toxicity may include gastrointestinal discomfort, therapeutic drug monitoring tdm. Only two of four lithiumcontaining compounds listed in mims are suitable for lithium. Therapeutic drug monitoring abbott core laboratory. Its main focus is on drugs with a narrow therapeutic range, i. Facilities for prompt and accurate serum lithium determinations should be available before initiating treatment see dosage and administration 2. Therapeutic drug monitoring wirral medicines management. Lithium prescribing and monitoring in clinical practice a. Therapeutic drug monitoring of lithium in patients with bipo.
Lithium fda prescribing information, side effects and uses. We have therefore investigated the prevalence of tdm for lithium and evaluated the impact of. Therapeutic drug monitoring tdm for lithium is recommended in guidelines. Gareth malson updated with approvals from wirral drug and therapeutics committee. Pdf evaluate the appropriateness of therapeutic drug monitoring tdm for lithium.
Peak therapeutic ranges vary depending on the severity of infection i. Blood monitoring, prescribing, supply and administration 5. The drug monitoring services are to obtain clinical pharmacokinetic data that results into fewer adverse. Sep 14, 2015 practical issues in therapeutic drug monitoring ideally, a quality drug assay should be performed within a time frame that is clinically useful. Jan 04, 2015 therapeutic drug monitoring aims to promote optimum drug treatment by maintaining serum drug concentration within a therapeutic range. Article pdf available in therapeutic drug monitoring 374. Therapeutic drug monitoring therapeutic drug monitoring tdm is the use of drug concentration measurements in body fluids as an aid to the management of drug therapy for the cure, alleviation or prevention of disease. Practical issues in therapeutic drug monitoring ideally, a quality drug assay should be performed within a time frame that is clinically useful.
Drug interactions with lithium and therapeutic drug monitoring. Otherwise, tdm refers to the individualization of drug dosage by maintaining plasma or blood drug concentrations within a targeted therapeutic range or. Acceptable accuracyinterpreted as total differences from target. A drugs serum therapeutic range or index is the concentration range in which the drug is known to be effective while. History the science of therapeutic drug monitoring grew out of the recognition that. The narrow therapeutic index of lithium and the potential for acute and chronic side effects place an. A concise guide, fourth edition serves as a ready resource of information on commonly monitored drugs that will help readers make decisions relating to the monitoring and interpretation of results. However, serum drug levels should only be taken when there is a clear indication to. Regular monitoring of serum lithium and assessment for signs of lithium toxicity see below should be performed. This information is used to individualise dosage so that drug concentrations can be maintained within a target range. Lithium toxicity is closely related to serum lithium concentrations, and can occur at doses close to therapeutic concentrations. Lithium remains a mainstay of treatment for bipolar disorder but dose individualisation, measurement of serum drug concentrations and monitoring for adverse reactions are vital in order to maximise therapeutic response. It identifies when a person does not take the medication regularly as prescribed patient noncompliance and the effect of drug interactions, which may cause drug concentrations that are higher or lower than expected at a given dosage, and helps to personalize a dose to. Lithium prescribing and monitoring guidelines dorset formulary.
A study of the accuracy and analytical variation between laboratories in denmark. Therapeutic drug monitoring tdm is a norm while using lithium. Patients with serum drug concentrations on noncovered services are identified on a daily basis utilizing sunrise clinical manager scm. Ionselective electrode n 5, reflective spectrophotometric rsm, n 5, and spectrophotometric n 10 methods were used. Discontinue lithium or ith amiloride as a therapeutic agent 5. Therapeutic drug monitoring tdm is a clinical practice that involves measuring concentrations of a drug in a patients blood or plasma at designated intervals to provide guidance on individualized dosage regimen and adjustment of drug dosage to maintain a suitable concentration of the drug in the patients circulation. Guidelines for the prescribing and monitoring of inpatient. L1 when lithium is given chronically, with mild to moderate toxicity being expected at 1. Otherwise, tdm refers to the individualization of drug dosage by maintaining plasma or blood drug concentrations within a targeted therapeutic range or window. This study examines the interlaboratory variation and inaccuracy of lithium monitoring in denmark. Therapeutic drug monitoring tdm is generally defined as the clinical laboratory measurement of a chemical parameter that, with appropriate medical interpretation, will directly influence drug prescribing procedures.
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