Therapeutic drug monitoring (TDM) involves measuring the plasma concentration of a drug to guide dosing for individual patients. TDM is primarily used for drugs with a narrow therapeutic index or steep dose-response curves to maximize efficacy and minimize toxicity. Common drugs monitored include digoxin, lithium, theophylline, phenytoin, and gentamicin. TDM helps optimize dosing, identifies non-compliance or toxicity, and facilitates dose adjustments based on concentration levels.
Therapeutic Drug Monitoring (TDM) is important tool to identify the drug concentration for their therapeutic range to minimize unwanted effects of particular drugs
Introduction to daily activities of clinical pharmacist.
Drug therapy monitoring,
Medication chart review
Clinical Progress
Pharmacist intervention
Detection and management of ADRs
Therapeutic Drug Monitoring (TDM) is important tool to identify the drug concentration for their therapeutic range to minimize unwanted effects of particular drugs
Introduction to daily activities of clinical pharmacist.
Drug therapy monitoring,
Medication chart review
Clinical Progress
Pharmacist intervention
Detection and management of ADRs
REVIEWING THE CLINICIANS PRESCRIPTION AND TREATMENT PROGRESSION IS THE FUNDAMENTAL RESPONSIBILITY OF PHARMACIST. THIS PRESENTATION WILL DEAL WITH VARIOUS ASPECTS OF REVIEWING PATIENT DRUGTHERAPY PLAN
Defined daily dose-DDD
B Pharm, Pharm D and medicine syllabus
Useful for examination and regulatory function information
Useful for Pharmacovigilance interview and medical coding also.
Good Luck and all the best!!!
Clinical pharmacokinetics and its application--
1)definition
2) APPLICATIONS OF CLINICAL PHARMACOKINETICS
Design of dosage regimens:
a) Nomograms and Tabulations in designing dosage regimen,
b) Conversion from intravenous to oral dosing,
c) Determination of dose and dosing intervals,
d) Drug dosing in the elderly and pediatrics and obese patients.
Pharmacokinetics of Drug Interaction:
a) Pharmacokinetic drug interactions
b) Inhibition and Induction of Drug metabolism
c) Inhibition of Biliary Excretion.
Therapeutic Drug monitoring:
a) Introduction
b) Individualization of drug dosage regimen (Variability – Genetic, Age and Weight, disease, Interacting drugs).
c) Indications for TDM. Protocol for TDM.
d) Pharmacokinetic/Pharmacodynamic Correlation in drug therapy.
e) TDM of drugs used in the following disease conditions: cardiovascular disease, Seizure disorders, Psychiatric conditions, and Organ transplantations
Dosage adjustment in Renal and Hepatic Disease.
a. Renal impairment
b. Pharmacokinetic considerations
c. General approach for dosage adjustment in renal disease.
d. Measurement of Glomerular Filtration rate and creatinine clearance.
e. Dosage adjustment for uremic patients.
f. Extracorporeal removal of drugs.
g. Effect of Hepatic disease on pharmacokinetics.
Population Pharmacokinetics.
a) Introduction to Bayesian Theory.
b) Adaptive method or Dosing with feedback.
c) Analysis of Population pharmacokinetic Data
Introduction to clinical pharmacy, Concept and Objectives of clinical pharmacy, Function and responsibilities of clinical pharmacist, Clinical Pharmacy services.
PHARMACOKINETIC MODELS
Drug movement within the body is a complex process. The major objective is therefore to develop a generalized and simple approach to describe, analyse and interpret the data obtained during in vivo drug disposition studies.
The two major approaches in the quantitative study of various kinetic processes of drug disposition in the body are
Model approach, and
Model-independent approach (also called as non-compartmental analysis).
REVIEWING THE CLINICIANS PRESCRIPTION AND TREATMENT PROGRESSION IS THE FUNDAMENTAL RESPONSIBILITY OF PHARMACIST. THIS PRESENTATION WILL DEAL WITH VARIOUS ASPECTS OF REVIEWING PATIENT DRUGTHERAPY PLAN
Defined daily dose-DDD
B Pharm, Pharm D and medicine syllabus
Useful for examination and regulatory function information
Useful for Pharmacovigilance interview and medical coding also.
Good Luck and all the best!!!
Clinical pharmacokinetics and its application--
1)definition
2) APPLICATIONS OF CLINICAL PHARMACOKINETICS
Design of dosage regimens:
a) Nomograms and Tabulations in designing dosage regimen,
b) Conversion from intravenous to oral dosing,
c) Determination of dose and dosing intervals,
d) Drug dosing in the elderly and pediatrics and obese patients.
Pharmacokinetics of Drug Interaction:
a) Pharmacokinetic drug interactions
b) Inhibition and Induction of Drug metabolism
c) Inhibition of Biliary Excretion.
Therapeutic Drug monitoring:
a) Introduction
b) Individualization of drug dosage regimen (Variability – Genetic, Age and Weight, disease, Interacting drugs).
c) Indications for TDM. Protocol for TDM.
d) Pharmacokinetic/Pharmacodynamic Correlation in drug therapy.
e) TDM of drugs used in the following disease conditions: cardiovascular disease, Seizure disorders, Psychiatric conditions, and Organ transplantations
Dosage adjustment in Renal and Hepatic Disease.
a. Renal impairment
b. Pharmacokinetic considerations
c. General approach for dosage adjustment in renal disease.
d. Measurement of Glomerular Filtration rate and creatinine clearance.
e. Dosage adjustment for uremic patients.
f. Extracorporeal removal of drugs.
g. Effect of Hepatic disease on pharmacokinetics.
Population Pharmacokinetics.
a) Introduction to Bayesian Theory.
b) Adaptive method or Dosing with feedback.
c) Analysis of Population pharmacokinetic Data
Introduction to clinical pharmacy, Concept and Objectives of clinical pharmacy, Function and responsibilities of clinical pharmacist, Clinical Pharmacy services.
PHARMACOKINETIC MODELS
Drug movement within the body is a complex process. The major objective is therefore to develop a generalized and simple approach to describe, analyse and interpret the data obtained during in vivo drug disposition studies.
The two major approaches in the quantitative study of various kinetic processes of drug disposition in the body are
Model approach, and
Model-independent approach (also called as non-compartmental analysis).
This presentation is aimed at providing information on automation in the GLP practices in the pharmaceutical industry.
-Standard Operating Procedures.
-Documentation in GALP.
-Logs and Related Forms.
Receptor types, mechanism, receptor pharmacology, drug receptor interactions, theories of receptor pharmacology, spare receptors and new concepts like biased agonism
Good Manufacturing Practice (GMP) 2day course Jo Havemann
The following topics were presented to the participants through lectures, group discussions and exercises during 16 hours:
- Core values and guidelines of Good Laboratory Practice (GLP)
- Factors that might lead to questionable research & manufacturing practices and their impact
- GMP compliance, national & international regulations, guidelines and authorities
- Quality Management and Assessment
- Digital GMP Solutions
Total quality management (TQM), and current Good Manufacturing Practice (cGMP...Dr. Ravi Sankar
TQM, cGMP, Introduction, Definition, Importance, TQM frame work, Key concepts (Principles) of TQM, specific steps in the cycle, Benefits of TQM, cGMP, principles of GMP, Improtance of GMP, why GMP established?, difference between GMP and cGMP, GMP and cGMP regulations, code of federal regulations.
Therapeutic Drug Monitoring (TDM) | Criteria and Indications of TDM | Why TDM...Shaikh Abusufyan
For all III YouTube Live Video lecture series of this topic click:
https://youtube.com/playlist?list=PLBVbJ9HCa1BZQtOerZuDjx4yo0eOeTHIy
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Website Blog: https://itasacademy.blogspot.com/
Therapeutic drug monitoring (TDM) is a process in clinical pharmacology which specializes in measuring the concentration of certain drugs in the body fluids and clinically interpreting it to obtain useful and often lifesaving information. It is defined as “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”. TDM is done only for a few selected drugs with a narrow therapeutic range where the challenge is to avoid both sub-therapeutic and overtly toxic doses.
A seminar on Therapeutic Drug Monitoring: An Overview
Presented on 14/12/2019
Handout:
• Case report: On lithium toxicity
• Introduction
• Historical Aspects: Developments in TDM from 1950`s till date
• Rationale & concepts of TDM:
1. Basis of TDM
2. Concepts involved: Peak & Trough, Dosing interval, Therapeutic window
• Criteria & indications for TDM
• Sampling & analysis techniques:
1. Request form for TDM
2. Types of samples used with advantages, disadvantages & indications 3. Timing of sample collection
4. Methods of analysis: HPLC, GC, MS, LCMS, TLC, HPTLC
• Result interpretation & dose adjustment
• Drugs for which TDM is done:
1. Drugs for which TDM is done commonly
2. Drugs for which TDM is indicated according to WHO
• Estimated cost of TDM per drug
• Recent updates:
1. TDM in special clinical scenarios
2. Therapeutic Drug Monitoring (TDM) V/s Target concentration Intervention
(TCI)
3. Pharmacogenetics in TDM
• Summary
• Conclusion
Therapeutic drug monitoring (TDM) is the clinical practice of measuring specific drug at designated intervals to maintain a constant concentration in a patients blood stream, thereby optimizing individual dosage regimen.
Need for Therapeutic Drug Monitoring, Factors to be considered during the Therapeutic Drug Monitoring, and Indian scenario for Therapeutic Drug Monitoring.
Title: "Therapeutic Drug Monitoring: Optimizing Medication Management"
Slide 1:
- Title: Introduction to Therapeutic Drug Monitoring
- Brief overview of TDM's importance in healthcare
Slide 2:
- Title: Why TDM?
- Explain the need for monitoring drug levels in patients
Slide 3:
- Title: Key Drugs Monitored
- List commonly monitored drugs and their therapeutic ranges
Slide 4:
- Title: TDM Process
- Describe the steps involved in TDM, from sample collection to interpretation
Slide 5:
- Title: Indications for TDM
- Discuss situations where TDM is crucial (e.g., narrow therapeutic index drugs)
Slide 6:
- Title: TDM Benefits
- Highlight the advantages of TDM, such as optimizing dosages and minimizing side effects
Slide 7:
- Title: Challenges in TDM
- Address obstacles in TDM, like cost and limited access to testing
Slide 8:
- Title: TDM in Clinical Practice
- Real-world examples of TDM's impact on patient care
Slide 9:
- Title: TDM Technologies
- Overview of analytical methods used for drug level measurement
Slide 10:
- Title: Case Studies
- Present cases where TDM made a significant difference in patient outcomes
Slide 11:
- Title: Future of TDM
- Discuss emerging trends and technologies in therapeutic drug monitoring
Slide 12:
- Title: Conclusion
- Summarize the key takeaways and emphasize the importance of TDM in modern healthcare
Slide 13:
- Title: Questions?
- Open the floor for questions and discussions.
Therapeutic drug mornitoring optimization, plasma drug concentration,. Drug level. Study protocol. Individualization for therapeutic drug mornitoring
What is therapeutic drug monitoring (TDM)? Therapeutic drug monitoring (TDM) is testing that measures the amount of certain medicines in your blood. It is done to make sure the amount of medicine you are taking is both safe and effective. Not all medications require therapeutic monitoring. Most drugs have a wide therapeutic index and can be prescribed based upon pre-established dosing schedules. The effectiveness of these treatments has been evaluated, but monitoring the concentration of the drug in the blood is not required for dosing.Aminoglycoside antibiotics (gentamicin) Antiepileptics (such as carbamazepine, phenytoin and valproic acid).Why do I need TDM? You may need testing when you first start taking a medicine. This helps your provider figure out the most effective dose for you. Once that dose is determined, you may be tested regularly to make sure the medicine is still effective without being harmful.
Therapeutic Drug Monitoring (TDM) involves the analysis, assessment, and evaluation of circulating concentrations of drugs in serum, plasma, or whole blood.
Immunosupressants and Immunostimulants their pharmacology, uses etc. Basics of immunology, innate immune response, acquired immune response, role of complement in innate immune response. Major histocompatibility complex, antibody structure. classification of immunosupressants, their mechanism of action, uses and adverse effects.
Pharmacology of antimalarial drugs with treatment of malaria. mechanism of action, uses, adverse effects of antimalarial drugs like chloroquine, quinine, artemisinin compounds.
Antileprosy drugs have been described with their pharmacology also this topic covers Multidrug treatment for leprosy including paucibacillary and multibacillary leprosy and lepra reactions
Pharmacology of cephalosporins, monobactums and carbapenums including their mechanism of action, indications, adverse effects.
The various generations of cephalosporins and their spectrum of action
Pharmacology of Penicllins (Beta lactam antibiotics), description of their mechanism of action, mechanism of resistance, classification, indications and adverse effects
Drugs for treatment of Diabetes MellitusNaser Tadvi
These slides contain the brief description of Insulin and the other oral drugs indicated in the treatment of Diabetes Mellitus. Their mechanism of action, effects, uses, Adverse effects etc.
Introduction to Autonomic Nervous systemNaser Tadvi
Lecture intends to give a brief overview of autonomic nervous system.
it includes the anatomical distribution of ANS, Neurohumoral transmission, co-transmission, receptors for ANS and synthesis of the neurotransmitters, Acetylcholine and Catecholamines
Lecture covers the pharmacology of anticholinergic drugs. Includes classification, therapeutic uses, adverse effects of anticholinergics. Atropine has been described as prototype drug.
Lecture includes definition of bioassay, Types of Assay and Bioassay , Indications, principles, advantages of bioassay. Example of a Bioassay with calculations. This lecture will be of help for postgraduate pharmacology students as well as undergraduates
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
2. Objectives
• Review the therapeutic monitoring of drugs
with low therapeutic indices
• Indications of therapeutic drug monitoring
• Clinical significance of Therapeutic drug
monitoring
• Give examples of drugs that need therapeutic
drug monitoring
3. What is therapeutic drug monitoring
• Therapeutic Drug Monitoring is measurement
of the plasma concentration level of a drug
and the coordination of this serum level with a
serum therapeutic range.
4. Why therapeutic drug monitoring
• Therapeutic drug monitoring can guide the
clinician to provide effective and safe drug
therapy in the individual patient using serum
drug concentration .
5. Why should drug level be monitored ?
• Certain drugs have a narrow therapeutic range
In concentrations above the upper limit of the
range, the drug can be toxic
• In concentrations below the lower limit of the
range, the drug can be ineffective. Not all
patients have the same response at similar
doses
6. Therapeutic range/ therapeutic
window
• The therapeutic range/ therapeutic window is
the concentration range of drug in plasma
where the drug has been shown to be
efficacious without causing toxic effects in
most people.
7.
8. Where to find information regarding
therapeutic range
• Recommended therapeutic ranges can
generally be found in the product inserts for
drugs that require monitoring.
• They are also available in books such as the
Physicians Desk Reference, and articles in the
primary medical journals.
9. Digoxin
• Plasma concentration –response relationship
– 0.5µcg/L: No therapeutic effect
– 0.7 µcg/L: some ↑ in force of contraction of heart
– 0.8- 2 µcg/L: Optimum therapeutic range
– 2 -2.5 µcg/L: ↑ risk of toxicity although tolerated
in some patients
– ˃ 2.5 µcg/L:
Gastrointestinal, cardiovascular and
CNS toxicity
10. Theophylline
• Plasma concentration response relationship
– ˃ 5mg/L: No
bronchodilation
– 5-10 mg/L: Some bronchodilation and possible
anti-inflammatory action
– 10-20 mg/L: optimum bronchodilation, minimum
side effects
– 20-30 mg/L: increased incidence of
nausea, vomiting and cardiac arrhythmias
– ˃ 30 mg/L: cardiac arrhythmias & Seizures
11. Lithium
• Plasma concentration response relationship
– ˃ 0.4
mmol/L: Little therapeutic effect
– 0.4 to 1 mmol/L: Optimum range for prophylaxis of
mania
– 0.8 to 1.2 mmol/L: Optimum range for acute mania
– 1.2 to 1.5 mmol/L: Causes possible renal impairment
– 1.5 to 3 mmol/L: Renal
impairment, weakness, drowsiness, thirst and
diarrhoea
– 3 to 5 mmol/L:
Confusion, spasticity, convulsions, coma and death
12. Phenytoin
• ˃ 0.5 mg/L: No therapeutic effect
• 5 to 10 mg/L: Some anti-convulsant action
• 10 to 20 mg/L: optimum concentration for
anticonvulsant effect
• 20-30 mg/L: Nystagmus, blurred vision
• ˃30 mg/L: Ataxia, drowsiness, coma
14. 1. Drugs for which
relationship between
dose and plasma
concentration is
unpredictable, e.g
Phenytoin
Serum phenytoin ( mol/l)
What are indications of TDM
Phenytoin dose (mg/day)
(from A. Richens and A. Dunlop, Lancet ii:247, 1975)
15. Indications
2. Drugs with a narrow
therapeutic window:measurement of plasma
concentrations of such
drugs will allow dosage
alterations to be made in
order to produce optimal
therapeutic effect or to
avoid toxic effects.
16. Indications
3. Drugs with steep dose
response curve for
which a small increase
in dose can result in a
marked increase in
desired or undesired
response e.g.
theophylline.
17. Indications
4. To evaluate compliance of patient
5. Drugs for which there is difficulty in
measuring or interpreting the clinical
evidence of therapeutic or toxic effects:Nausea & vomiting occur in both digitalis
toxicity & congestive heart failure.
6. For diagnosis of suspected toxicity &
Determining drug abuse
18. Indications
7. Renal disease: Alter the relationship between
dose & the plasma concentration. Important
in case of digoxin, lithium & aminoglycoside
antibiotics.
8. When another drug alter the relationship
between dose & plasma concentration e.g.
plasma concentration of lithium is increased
by thiazide.
19. Drugs not suitable for TDM
• Drugs that are used for treating diseases of which
their clinical end points can easily be
monitored, e.g., BP, HR, cardiac rhythm, blood
sugar, blood cholesterol and triglycerides, urine
volume, body temperature, pain, headache, etc.
• Drugs whose serum concentrations do not correlate
with therapeutic or toxic effects.
• Drugs with less complicated pharmacokinetics.
• Drugs having wide therapeutic index
• Hit and run drugs: omeprazole, MAO inhibitors
20. Clinical significance of TDM
1. Maximizes efficacy
2. Avoids toxicity
3. Identifies therapeutic failure
– Non compliance, subtherapeutic dose
4. Facilitates adjustment of dosage
New dose = Old dose X Desired Css/Old Css
5. Facilitates the therapeutic effect of drug by
achieving target drug concentration
6. Identify poisoning, drug toxicity and drug abuse
21. A retrospective survey
carried out at the
Massachusetts General
Hospital showed that
whilst prior to the use of
digoxin monitoring
13.9% of all patients
receiving this drug
showed evidence of
intoxication , following
introduction of
monitoring this fell to
5.9%.
22. A significant difference
with regard to length of
stay in the hospital
between patients on
gentamicin who were
monitored and their
dosage regulated
consequently versus
those who were not
(DeStache, 1990)
25. REQUEST FORM OF TDM
Patient Name.............................................
Date............................................... HN........................................................
Age.................................. Sex.................................
Wt...................................... Ht.........................................................
Ward.............................................Ordered
by....................................................... Phone No..........................................
DRUG LEVEL
REQUESTED......................................................................................................
............................................
REASON FOR REQUEST :
Suspected toxicity
Compliance
Therapeutic confirmation
Absence of therapeutic response
Please indicate when level is needed :
within
h
within - h
stat
others........................
TIME AND DATE OF LAST DOSE :
Date....................
Route : IV, IM, SC, PO, Others...........................
Time....................
Dose..........................
Freq..................................
THIS DRUG LEVEL IS FOR :
SAMPLING TIME :
Trough or predose level
Date.......................
Time.........................
Peak level
Date.......................
26. Can drug concentration in other fluids
of body be measured
• Yes
– Urine: benzodiazepines
– Sweat: cocaine & heroin
– Saliva: marijuana, cocaine, alcohol
– Breath: alcohol
27. Summary
• TDM is monitoring of plasma concentration of
drug for individualization of dose in patients
• Mainly indicated for drugs having narrow
therapeutic index, or to check compliance and
titration of dose
• Most common drugs to undergo TDM are
anticonvulsants, lithium, digoxin, gentamicin