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Therapeutic Drug Monitoring

Therapeutic Drug Monitoring

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Published by TAMIL

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Published by: TAMIL on Nov 04, 2009
Copyright:Attribution Non-commercial


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What is therapeutic drug monitoring?
Therapeutic drug monitoring is the measurement of specific drugs at intervals in order tomaintain a relatively constant concentration of the medication in the bloodstream. Drugsthat are monitored tend to have a narrow “therapeutic range” – the quantity required to beeffective is not far removed from the quantity that causes significant side effects and/or signs of toxicity. Maintaining this steady state is not as simple as giving a standard doseof medication. Each person will absorb, metabolize, utilize, and eliminate drugs at adifferent rate based upon their age, general state of health, genetic makeup, and theinterference of other medications that they are taking. This rate may change over timeand vary from day to day. Not all medications require therapeutic monitoring. Most drugs have a larger therapeuticrange and can be prescribed based upon pre-established dosing schedules. Theeffectiveness of these treatments is evaluated, but it is not usually necessary to determinethe concentration of the drug in the bloodstream. Examples of this include high blood pressure medications and many of the antibiotics given to treat bacterial infections. If theinfection resolves and the blood pressure is lowered, then the treatments have beeneffective.
Why is it important?
Many of the drugs that are monitored therapeutically are taken for a lifetime. They must be maintained at steady concentrations year after year while the patient ages and goesthrough life events such as pregnancies, temporary illnesses, infections, emotional and physical stresses, accidents, and surgeries. Over time, patients may acquire other chronicconditions that also require lifetime medication and that may affect the processing of their monitored drugs. Examples of these conditions includecardiovascular disease,kidney disease, thyroid disease, liver disease,and HIV/AIDS. Therapeutic drug monitoring follows these changes and accommodates them. It identifies patient noncompliance (when the patient does not take the medication regularly as prescribed), identifies the effect of drug interactions (may cause drug concentrations thatare higher or lower than expected at a given dosage), and helps to tailor dosages to fit thecurrent needs of the specific patient. Along with tests such as BUN,creatinine,and liver   panelto check kidney and liver function, monitoring can help identify decreases in theefficiency of and dysfunctions in the body in metabolizing and eliminating therapeuticdrugs.
How does TDM work?
Through years of testing, the optimum therapeutic blood level range for each drug has been determined. In this range, most people will be effectively treated without excessiveside effects or symptoms of toxicity. The drug dosage to reach this level must beindividually determined. When a patient starts on a monitored drug (or returns to it after an absence), the doctor adjusts the dose upwards and tests blood concentrationsfrequently until the appropriate steady state level is achieved. If a patient’s levels are too
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.
DrugCategoryDrugsTreatment Use
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

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