How appropriate is therapeutic drug monitoring for lithium. Medicines that interact with lithium are summarised in table 1. Monitor for lithium toxicity and metabolic acidosis. Summary guideline for therapeutic drug monitoring tdm in adults. Therapeutic drug monitoring involves checking blood concentration of medication to insure that its within a certain range. May 31, 2018 patient requires monitoring and assessment for adverse events as the dose is increased closer to the therapeutic range. Lithium dosages should be adjusted in steadystate patients, using the serum trough level i. Pharmacoeconomic studies on therapeutic drug monitoring 105 i. The monitoring of therapeutic drugs involves measuring drug concentrations in plasma, serum or blood. Therapeutic drug monitoring aims to promote optimum drug treatment by maintaining serum drug concentration within a therapeutic range. 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. Appropriateness of therapeutic drug monitoring for lithium article pdf available in journal of the medical association of thailand chotmaihet thangphaet 8911.
Therapeutic drug monitoring tdm for lithium is recommended in guidelines. Drug interactions with lithium and therapeutic drug monitoring. Jul 27, 1998 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. The lithium concentrations were targeted by a reference laboratory.
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. 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. 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. Therapeutic drug monitoring of antipsychotics mdedge. Therapeutic drug monitoring of psychotropic medications. The tdm service in the country is broadly of two types. Blood monitoring, prescribing, supply and administration 5. Also, the therapeutic drug monitoring tdm laboratory provides an electronic report of all completed serum drug concentrations of patients admitted to. A statement of good practice 1998 see also 3 nice guidelines for bipolar disorder july 2006 4 fedler c and stewart mj.
Serum lithium is monitored to ensure levels within the narrow therapeutic window. This requires knowledge of the pharmacokinetics, sampling time, drug history and the patients clinical condition. We have therefore investigated the prevalence of tdm for lithium and evaluated the impact of. Lithium toxicity is closely related to serum lithium concentrations, and can occur at doses close to therapeutic concentrations.
It is an easytoread source of information on intended use, pharmacokinetics, therapeutic range, and toxic concentrations, as well as bioavailability, disposition. 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. Symptoms are more severe with fa steronset hyponatremia. A drugs serum therapeutic range or index is the concentration range in which the drug is known to be effective while. Summary guideline for therapeutic drug monitoring tdm in. Discontinue lithium or ith amiloride as a therapeutic agent 5. The present paper reports analysis of a retrospective audit of tdm of lithium over a period of 4 years. Prevalence of therapeutic drug monitoring for lithium and the.
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. Managing patients on discharge if you require this document in an alternative format, i. Gareth malson updated with approvals from wirral drug and therapeutics committee. Prevalence of therapeutic drug monitoring for lithium and. Article pdf available in therapeutic drug monitoring 374. This study examines the interlaboratory variation and inaccuracy of lithium monitoring in denmark methods. 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 eskalith within 30 minutes before dose draw at least 812 hours post dose 5 days 0.
Amdisen proposed the use of a standardized 12 h serum lithium concentration, which subsequently became the universally accepted mode of monitoring lithium levels. Patients who have impaired clearance of a drug with a narrow therapeutic index are candidates for drug monitoring. Therapeutic drug monitoring of lithium in patients with. Therapeutic drug monitoring wirral medicines management. A study of the accuracy and analytical variation between laboratories in denmark. Initial features of toxicity may include gastrointestinal discomfort, therapeutic drug monitoring tdm. Drug interactions with lithium mostly occur through the direct effect of other medicines on renal function, notably glomerular filtration rate and sodium absorption 1. Otherwise, tdm refers to the individualization of drug dosage by maintaining plasma or blood drug concentrations within a targeted therapeutic range or. Therapeutic drug monitoring medicines formulary, version 7 principal author. 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. L1 when lithium is given chronically, with mild to moderate toxicity being expected at 1. Clinical practice typically results in mostly a subjective assessment of the safety and efficacy of antipsychotics.
A retrospective serum lithium estimation data of 4 years were analyzed for drug levels, reasons for request, and correlation of. 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. This study examines the interlaboratory variation and inaccuracy of lithium monitoring in denmark. Lithium fda prescribing information, side effects and uses. Some of the factors complicating phenytoin dosing include a narrow therapeutic window, high degree of protein binding, and nonlinear pharmacokinetics. We have therefore investigated the prevalence of tdm for lithium and evaluated the impact of the regulatory warnings requiring routine tdm for lithium.
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. Therapeutic drug monitoring follows these changes and accommodates them. This information is used to individualise dosage so that drug concentrations can be maintained within a target range. Lithium has a narrow therapeutic index and drug interactions, changes in diet and fluid intake.
Patient requires monitoring and assessment for adverse events as the dose is increased closer to the therapeutic range. Evaluation of therapeutic drug monitoring service 102 b. Therapeutic drug monitoring mimi emig md spectrum health and kent county health dept. 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. Overview on monitoring of therapeutic drugs shivaji prataprao gawade sahyadri college of pharmacy, methwade, tal. The monitoring parameters cited are derived from a range of guideline sources, other. Jan 04, 2015 therapeutic drug monitoring aims to promote optimum drug treatment by maintaining serum drug concentration within a therapeutic range.
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. Lithium naive patients should have lithium levels of 0. Lithium is a useful drug, particularly in the maintenance treatment of bipolar affective disorder. Therapeutic drug monitoring tdm is the use of drug concentration. Pdf appropriateness of therapeutic drug monitoring for lithium. Therapeutic monitoring of vancomycin in adult patients. The narrow therapeutic index of lithium and the potential for acute and chronic side effects place an. Nov 20 page 1 of 10 medicines formulary therapeutic drug monitoring contents. Pdf evaluate the appropriateness of therapeutic drug monitoring tdm for lithium.
The ideal tdm teama clinical pharmacologist, the use of drug measurements in biological. Guide for drug level monitoring of commonly used medications. Lithium prescribing and monitoring in clinical practice. 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. Its main focus is on drugs with a narrow therapeutic range, i. Safe and effective use of lithium australian prescriber. Therapeutic drug monitoring tdm is a norm while using lithium. Suggestions for drug monitoring in adults in primary care.
Therapeutic drug monitoring of lithium request pdf. Therapeutic drug monitoring of lithium in patients with bipo. 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. Grand rapids, mi case 1 17 yo man with 2 weeks of cough weight 48kg admitted 309 father with tb 7 yr ago. Although alternative methods of blood sampling have been suggested, serum measurements remains the mainstay of therapeutic drug monitoring tdm of lithium. History the science of therapeutic drug monitoring grew out of the recognition that. As concerns about drug interactions, adverse effects, compliance, etc.
Now, if you go below the presentation at the bottom of this page, there is a pdf download that you. Pdf appropriateness of therapeutic drug monitoring for. Only two of four lithiumcontaining compounds listed in mims are suitable for lithium. Peak therapeutic ranges vary depending on the severity of infection i. It is an easytoread source of information on intended use, pharmacokinetics, therapeutic range, and toxic. Lithium prescribing and monitoring guidelines dorset formulary. Facilities for prompt and accurate serum lithium determinations should be available before initiating treatment see dosage and administration 2. 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. Therapeutic drug monitoring involves not only measuring drug concentrations, but also the clinical interpretation of the result. Therapeutic drug monitoring of antipsychotics mdedge psychiatry. Therapeutic drug monitoring abbott core laboratory. Otherwise, tdm refers to the individualization of drug dosage by maintaining plasma or blood drug concentrations within a targeted therapeutic range or window. Regulatory warning on lithium at april 2012 in japanese.
Patients with serum drug concentrations on noncovered services are identified on a daily basis utilizing sunrise clinical manager scm. Lithium prescribing and monitoring in clinical practice a. Guidelines for the prescribing and monitoring of inpatient. Ionselective electrode n 5, reflective spectrophotometric rsm, n 5, and spectrophotometric n 10 methods were used. 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.
Acceptable accuracyinterpreted as total differences from target. Pdf lithium therapeutic drug monitoring pattern at a. 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. Therapeutic drug monitoring of phenytoin is carried out to ensure effective and safe levels. Therapeutic drug monitoring in a developing country. Lithium therapy is safe, effective, evidence based, and in line with current. Therapeutic drug monitoring siemens healthineers global. When an effect, such as changes in blood pressure, pain or serum cholesterol is readily measured, the. Drugs with a narrow therapeutic index where therapeutic drug levels do not differ greatly from levels associated with serious toxicity should be monitored.
Therapeutic drug monitoring tdm is the measurement of the serum level of a drug to ensure its concentration is within the therapeutic range. 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. Practical issues in therapeutic drug monitoring ideally, a quality drug assay should be performed within a time frame that is clinically useful. Tdm aimed at improving patient care by individually adjusting the dose of drugs for which clinical experience or clinical. Regular monitoring of serum lithium and assessment for signs of lithium toxicity see below should be performed. Where this cannot be done, therapeutic drug monitoring is used in two major situations 3. However, serum drug levels should only be taken when there is a clear indication to.
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