This document discusses therapeutic drug monitoring (TDM), which involves measuring drug concentrations in the body to optimize pharmacotherapy. TDM includes monitoring the pharmaceutical, pharmacokinetic, pharmacodynamic, and therapeutic effects of drugs. It is useful for individualizing drug therapy, assessing compliance, diagnosing and preventing toxicity, and detecting drug interactions. Drugs that are good candidates for TDM have a narrow therapeutic index, variable pharmacokinetics, and a reasonable relationship between concentrations and effects. Common drugs monitored include antibiotics, anticonvulsants, cardiac glycosides, and immunosuppressants. Proper sample collection and interpretation considering the patient's details and potential confounders are important for TDM to effectively guide treatment decisions.
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
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.
Therapeutic drug monitoring (TDM) is a process in clinical pharmacology that 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.
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.
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
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.
Therapeutic drug monitoring (TDM) is a process in clinical pharmacology that 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.
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.
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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
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
- 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
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THERAPEUTIC DRUG MONITORING- NPMCN 260722.pdf
1. THERAPEUTIC DRUG
MONITORING
DR. ADEDAYO FOLORUNSHO ASALU
CONSULTANT PHYSICIAN/ CLINICAL PHARMACOLOGIST
LECTURE DELIVERED AT THE GENERAL MEDICNE UPDATE COURSE
FACULTY OF INTERNAL MEDICINE, NPMCN
26/07/2022
3. MONITORING DRUG THERAPY
• This is the broader concept
• Involves the four processes of drug therapy
✓Pharmaceutical Process
- in-vitro measures of adherence
✓Pharmacokinetic Process-
- Measurement of drug levels in appropriate body fluids
✓Pharmacodynamic Process
- Measures of appropriate physiological/pharmacological effects of
administered drugs
✓Therapeutic effect
- evaluating drug effect in relation to therapeutic effect
4. MONITORING THERAPEUTIC PROCESS
✓Anticonvulsant therapy- seizure frequency, complimentary to
measuring blood level of the drugs
✓Drugs for angina pectoris- frequency of attacks
✓Diuretics in Oedema- weight loss
✓Frequency of Hospital admissions in Patients with Chronic Heart
Failure
5. MONITORING PHARMACODYNAMIC PROCESS
• Some pharmacological effects can be measured as “surrogate
markers” of therapeutic outcome
• Surrogate markers are usually easier, cheaper and can be measured
quickly and earlier
✓Anticoagulation and PT, measure as INR
✓Insulin therapy and Blood glucose monitoring
✓Antithyroid drugs and Serum 𝑇3, 𝑇4 and TSH levels
6. MONITORING PHARMACOKINETIC PROCESS
• This is the “domain” of Therapeutic Drug Monitoring TDM
• Relevance of Pharmacokinetics and PK parameters
- what dose of drug to give
- Frequency of its administration
- When steady-state is achieved
- Need for dose alteration in certain medical conditions
- Understanding of mechanism of certain drug-drug interactions
7. Relationship between dose and effect; Pk & Pd
• Relationship between dose-effect; PK-PD
dose plasma conc site of action effect Clinical Outcome
PHARMACOKINETICS PHARMACODYNAMICS
• The concept of therapeutic range of drug concentrations
9. • Its basically the use of drug concentration measurements in body
fluid as an aid in drug therapy. “the quantification and interpretation
of drug concentration in body fluid (usually blood/plasma) to
optimize pharmacotherapy”
• The goal is to use drug concentrations to manage a Patient’s
medication regimen and optimise outcome
• It involves the clinical laboratory measurement of drug
concentrations in biological fluid and the appropriate interpretation
of those concentrations with the intent of influencing drug therapy
• Its process is predicated on the assumption that there is a
relationship between dose and plasma or drug concentration and
between the later and pharmacodynamics effect
• Its interpretation requires knowledge of the pharmacokinetics,
sampling time, drug history and the patient’s clinical condition
• Therapeutic drug measurement + interpretation TDM
10. TDM- INDICATIONS
Limited resources require that drug assay should only be performed when
they contribute to patient’s management
1. Individualization of drug therapy
2. Assessing compliance/adherence
3. Toxicity
- Diagnosing toxicity, especially when the manifestation of toxicity and
disease state are similar (Digoxin, Theophylline)
- Avoiding toxicity (Aminoglycosides)
4. Diagnosing and investigating Treatment failure (TDM can help distinguish
between ineffective drug treatment and non-compliance)
5. Change in patient’s clinical state, especially major organ failure
6. Monitoring and detecting drug interactions
7. Guiding withdrawal of therapy
11. DRUG CRITERIA FOR TDM
• Low Therapeutic Index (NTI) or Narrow Therapeutic Window
• Significant Pharmacokinetic variability –e.g Drugs with saturable kinetics for
example Phenytoin
• Reasonable relationship between plasma conc. and clinical effects (both
therapeutic and toxic)
• Drugs for which the relationship between dose and plasma concentration is
unpredictable ..and by inference, absent relationship between dose and effect
• Drugs that are not metabolized to active metabolites.
• Drugs for which there is difficulty in measuring or interpreting the clinical
evidence of therapeutic or toxic effect
• Established target concentration range
• Availability of cost-effective analytical assays to determine drug and
metabolite concentrations
13. TDM- METHOD/PROCEDURE/ANALYSIS
• Procedure
- Recovery of body fluid
- Separation from the biological components
- Identification of molecules concerned
- Quantification
• The Analytical methodology employed should ideally
i. distinguish between unchanged drug and metabolite
ii. Detect small amounts
iii. Simple to use as routine assay
iv. Be unaffected by other drugs concomitantly administered
14. ✓ Spectrophotometry and Fluorimetry- not very sensitive, large
volume of samples, complex extraction procedures and interference
by other compounds
✓Thin Layer Chromatography TLC- adequate resolutions to identify
many drugs but challenges with accurate quantification, time
consuming and with inadequate sensitivity
✓High Performance Liquid Chromatography HPLC- highly specific,
precise and sensitive. Also, multiple analysis possible. Extraction steps
also required, slow, single serial analysis
✓Radio immune assay RIA
✓Enzyme Immunoassay –few advantages over RIA especially that no
radioactive tracer is required
✓Fluorescence polarization Immunoassay FPIA
15. PRACTICAL CONSIDERATIONS & USE
• Rational indication for the requests (clinical question/indication)
• Accurate and adequate patient information
✓ details to include on request form
- Time sample was collected, especially in relation to drug administration
- Time dose was given
- Dosage regimen (dose, duration, dosage form)
- Patient demographics (age/gender)
- Concomitantly administered medications, a detailed drug history
- Relevant co-morbidities (eg renal or liver disease)
- Indication for testing (eg toxicity, non-compliance)
16. • An appropriate specimen and timing of collection
✓Usually serum/plasma but whole blood required in few instances.
✓Timing of sample collection
- In most cases when SS is reached but earlier, if toxicity is suspected
-at the appropriate time in relation to the last dose: generally
measured in the elimination phase (correlates with trough conc); gives
a more reliable guide to drug dosing
- Peak conc. for some aminoglycosides
- Not during the distribution phase (no equilibrium between plasma
and tissue concentration)
17. INTERPRETATION
• Correct interpretation and appropriate response should consider the
target range and the patient. “Treat patient and not drug level”
• Potential sources of error
- Assuming patient is at steady-state
- Assuming patient is adherent to therapy
- Not knowing the sampling time in relation to dose administration
- Not considering decreased renal/hepatic function
- Not considering Drug interactions
- Using reference range as absolute values
18. • Sample Concentration lower than anticipated
- Patient non-compliance
- Error in dosage regimen
- Rapid elimination
- Poor bioavailability
- DDI
- Css not yet achieved
19. • Sample Concentration higher than anticipated
- Patient non-compliance
- Error in dosage regimen
- slow elimination
- Decreased renal/hepatic function
- DDI
- Time sampling
20. • Before making dose adjustments, consider:
- If the sample was taken at the correct time with respect to the last
dose
- If a steady state has been reached
- If the patient is adhered to the treatment
- If there is a DDI
- If there is a liver/kidney dysfunction
+ the individual patient without rigid adherence to a target range