high, the doctor will adjust them lower. Often, each different dosage level will take ashort period of time to stabilize so these corrections up and down may take place over afew days or weeks (although if they are causing symptoms associated with toxicity, theywill be decreased relatively rapidly to relieve these symptoms). It is important that patients work closely with their doctors during this process and not make their ownadjustments or stop taking their medication. Abrupt changes can sometimes worsenconditions and cause acute symptoms.Once the patient’s results are in the therapeutic range and their clinical signs indicate thatthe treatment is appropriate, then the doctor may monitor the drug at regular intervals andas needed to accommodate changes in patient status to ensure that the drug stays in thetherapeutic range. The frequency of testing required will depend on the drug and on theneeds of the patient. If treatment does not appear to be fully effective or if the patient haseither excessive side effects or signs of toxicity, then testing will be done to see if bloodconcentrations have become too low or high. If they have, then the dosage will beadjusted; if they have not, then the patient and doctor may need to re-evaluate the use of that specific medication and consider switching to another type of drug if it is available.The timing of blood collection is an important part of therapeutic drug monitoring. Whena person takes a dose of a drug, the amount in the blood rises for a time period, peaks,and then begins to fall, usually reaching its lowest level (trough) just before the nextdose. To be effective, peak levels should be below toxic concentrations and trough levelsshould remain in the therapeutic range. Through experience and studies, doctors knowwhen to expect peaks and troughs to occur and will request blood sample collections aseither trough levels (usually drawn just before the next dose), peak levels (timing variesdepending on the drug), or sometimes will request a random level. Consistent andaccurate interpretation of the results depends on the timing of sample collection. If a patient is unable to take their medication and have their blood drawn at the appropriatetime interval, then they should talk to their doctor before the sample is collected.
Monitored Drugs by CategoryThere are several categories of drugs that require monitoring, assummarized here.
CardiacdrugsDigoxin, digitoxin, quinidine, procainamide, N-acetyl-procainamide (a metabolite of procainamide)Congestive heart failure,angina,
arrhythmiasAntibioticsAminoglycosides (gentamicin, tobramycin,amikacin), Vancomycin, Chloramphenicol
Infections with bacteria that areresistant to less toxic antibioticsAntiepilepticsPhenobarbital, phenytoin,valproic acid,
carbamazepine,ethosuximide, sometimesEpilepsy, prevention of seizures,sometimes to stabilize moods