Critical values for therapeutic drug levels.The concept of critical values for drug levels was developed by Daniel Daniel, book of the Bible Daniel, book of the Bible. It combines "court" tales, perhaps originating from the 6th cent. B.C., and a series of apocalyptic visions arising from the time of the Maccabean emergency (167–164 B.C. M. Baer, MD, professor emeritus e·mer·i·tus adj. Retired but retaining an honorary title corresponding to that held immediately before retirement: a professor emeritus. n. pl. of laboratory medicine, Oregon Oregon, city, United States Oregon, city (1990 pop. 18,334), Lucas co., NW Ohio, a suburb adjacent to Toledo, on Lake Erie; inc. 1958. It is a port with railroad-owned and -operated docks. The city has industries producing oil, chemicals, and metal products. Health Sciences University, Portland Portland, town, England Portland, town (1991 pop. 12,945), Dorset, S England. It is on the Isle of Portland, a small rocky peninsula. Portland stone has been used in St. Paul's Cathedral and other important London buildings. Lobsters and crabs are harvested. , OR, and first published in the April 1982 issue of MLO MLO Mycoplasma-like organism(s) . This table is an expanded version of that publication and newly revised by Diane DIANE Diversified Information and Assistance Network (Tennessee Valley Authority) DIANE Direct Information Access Network for Europe DIANE Digital Integrated Attack and Navigation Equipment M. Lyle Lyle may refer to:
abbr. Latin Pharmaciae Doctor (Doctor of Pharmacy) , BCPS BCPS Baltimore County Public Schools (Maryland) BCPS Board Certified Pharmacotherapy Specialist (pharmacist certificate) BCPS Broward County Public Schools (Florida) , Critical Care Clinical Pharmacy Clinical pharmacy is the branch of Pharmacy where pharmacists provide patient care that optimizes the use of medication and promotes health, wellness, and disease prevention [1] Specialist, Portland VA Medical Center. Dr. Baer is a member of MLO's Editorial Board and editor of MLO's "Tips from the Clinical Experts" department.
Drug Indication Therapeutic range
Acetaminophen Analgesic 5-20 mcg/mL
Amikacin Antimicrobial Peak: 15-30 mcg/mL
Trough: < 10 mcg/mL
Amiodarone Antiarrhythmic 0.5-2mcg/mL
Amitriptyline Antidepressant/analgesic 125-250ng/mL
(neuropathic pain)
Carbamazepine Antiepileptic/mood 4-12mcg/mL
stabilizer
Cyclosporins Immunosuppressant 100-400mcg/mL
Digoxin Inotrope, AV node blocker 0.8-1.2 ng/mL *
(immuncassay)
Doxepin Antidepressant 110-250ng/mL
Ethosuximide Antiepileptic 40-100 mcg/mL
Flecainide Antiarrhythmic 0.2-1.0 mcg/mL
Flucytosine Antifungal Not established
Gentamicin, Antimicrobial Peaks
Tobramycin 4-8mcg/mL. - standard
8-12mcg/mL-once daily
Trough
< 1.0 mcg/mL-standard
< 0.5 mcg/mL-once daily
Imipramine Antidepressant >180-240ng/mL
Lamotrigine Antiepileptic/mood 1-4 mcg/mL
stabilizer
Lidocaine Antiarrhythmic 1.5-5mcg/mL
Lithium Mood stabilizer Acute: 1-1.6 mEq/L
Chronic:0.6-1.2mEq/L
Nortriptyline Antidepressant/analgesic 50-150ng/mL
(neuropathic pain)
Phenobarbital Antiepileptic 15-40mcg/mL
Phenytoin Antiepileptic 10-20mcg/mL
Primidone Antiepileptic 5-12mcg/mL
Procainamide Antiarrhythmic PA:4-8mcg/mL (NAPA:
(PA) 10-20mcg/mL)
(metabolite:
NAPA)
Protriptyline Antidepressant 70-250ng/mL
Quinidine Antiarrhythmic 2-5mcg/mL
Salicylate Analgesic/anti-inflammatory 10-30 mg/L
Sirolimus Immunosuppressant 5-15ng/mL
Tacrolimus Immunosuppressant 5-20 ng/mL
Theophylline Bronchodilator 5-20mcg/mL
Valproic acid Antiepileptic/mood 50-125mcg/mL
stabilizer
Vancomycin Antimicrobial Trough concentrations:
General: 10-15mcg/mL
Pneumonia: 15-20mcg/mL
Voriconazole Antifungal >0.25-1000 mcg/mL
Drug Critical Value Clinical
correlation
Efficacy Toxicity
Acetaminophen >200 mcg/mL *drawn 4 UNCLR YES
hours after ingestion
Amikacin Trough >10mcg/mL YES YES
Amiodarone >2.5mcg/mL UNCLR YES
Amitriptyline >500ng/mL UNCLR YES
Carbamazepine >20 mcg/mL YES YES
Cyclosporins >500mcg/mL YES YES
Digoxin >2.0ng/mL UNCLR YES
Doxepin >500ng/mL UNCLR YES
Ethosuximide > 200 mcg/mL YES YES
Flecainide > 1.0mcg/mL UNCLR YES
Flucytosine > 100-200 mcg/mL NO YES
Tobramycin Trough >2mcg/mL YES YES
Imipramine Not clear(>500nq/mL) YES YES
Lamotrigine >20mcg/mL UNCLR UNCLR
Lidocaine >60mcg/mL YES YES
Lithium > 2.0mEg/L YES YES
>5mEq/L
potentially fatal
Nortriptyline >500ng/mL UNCLR YES
Phenobarbital > 60 mcg/mL YES YES
Phenytoin > 40 mcg/mL YES YES
Primidone >24mcg/mL YES YES
(metabolite: > l0mcg/mL YES(NO) YES
NAPA) (>40mcg/mL| (YES)
Protriptyline >500ng/mL UNCLR YES
Quinidine >6mcg/mL YES YES
Salicylate >40mg/dL NO YES -
weakly
Sirolimus >15ng/mL YES YES
Tacrolimus >25ng/mL NO YES
Theophylline >25mcg/mL UNCLR YES
Valproic acid >200mcg/mL YES * As YES
anti-epileptic
Vancomycin Trough >20mcg/mL UNCLR * UNCLR
* Daily dose may
correlate more
with toxicity than
trough
Voriconazole >6mcg/mL UNCLR YES
Drug Comments
Acetaminophen Determination of if a concentration
is toxic is dependent upon when it
is drawn in relation to the time of
ingestion of the dose. Multiple
serum concentrations will be needed
to monitor improvement and removal
of drug.
Amikacin Peak: 1 hour after end of infusion
Trough: before next dose
Amiodarone Trough concentration Concentrations
more accurate with chronic treatment
(due to long half life of drug)
Amitriptyline Trough concentration Life
threatening cardiac toxicity and/or
seizures with concentration [greater
than] 1000 ng/mL
Carbamazepine Trough concentrations preferred
Correlate serum concentration with
clinical presentation.
Cyclosporine Specific goal concentration
dependent upon clinical situation.
For concentrations drawn with
intravenous therapy, blood should be
drawn from site other than that
where drug is infusing.
(cyclosporine adheres to plastic)
Digoxin Concentrations should be drawn
[greater than] 8 hours after last
dose
* Concentrations [greater than]
1.5 in heart failure patients may be
associated with higher mortality.
Consult assay instructions for
potential interfering factors.
Doxepin Trough concentration
Ethosuximide Trough concentration
Flecainide Midpoint or trough concentration
Monitoring recommended when given
concurrently with medications that
may decrease metabolism (increase
concentrations)
Flucytosine Concentration should be a peak drawn
2 hours post dose.
Gentamicin, Goal concentration (peak and trough)
Tobramycin dependent upon dosing method. Peak:
1 hour after end of infusion Trough:
before next dose
Imipramine Concentration= imipramine +
desipramine(metabolite)
Lamotrigine Trough concentration.
High concentrations generally associated
with increased
somnolence/confusion.
Lidocaine Concentration can be drawn at any
point (from separate IV line)
Lithium Serum concentrations may increase in
presence of hyponatremia.
Concentration: 12 hours after dose
Nortriptyhline Trough concentration
Phenobarbital Trough or mid interval
concentration
Phenytoin Toxicity may occur at lower
concentrations in presence of
hypoalbuminemia.Consider free
phenytoin.
Primidone Metabolized to Phenobarbital
Procainamide (PA) Use as an antiarrhythmic decreasing
(metabolite: NAPA) NAPA concentrations increase in
renal insufficiency/failure
Mid-point or trough concentration
Protriptyline Trough concentration
Quinidine Midpoint or trough concentration
Salicylate Serum concentration should be used
in conjuction with clinical
presentation to make decision on
therapy. Multiple serum
concentrations will be necessary to
monitor improvement and removal of
drug.
Sirolimus Trough concentration Whole blood
samples.
Tacrolimus Trough: 12 hours after given dose.
Whole blood samples
Theophylline Pulmonary literature suggest that
concentrations 5-15mg/L may be as
efficacious with less toxicity.
Trough or mid-interval concentration
depending upon drug formulation.
Valproic acid Toxicity may occur at lower
concentrations in presence of
hypoalbuminemia. Consider free
valproic acid. Trough concentration
preferred.
Vancomycin Monitoring of peaks no longer
recommended. Goal trough
concentration dependent upon
indication.
* Only trough concentrations of
15-20mcg/mL for pneumonia have
been proven to correlate. Trough:
before next dose
Voriconazole Trough concentration preferred.
Steady state trough achieved after 7
days of therapy.
UNCLR = unclear
Ranges are approximate and may vary with laboratory and/or assay.
Proper interpretation of therapeutic drug concentrations requires that
the specimen be drawn at an appropriate time in relation to drug
administration.
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