CLINICAL CHEMISTRY III

THERAPEUTIC DRUG MONITORING

Chapter 7: Therapeutic Drug Monitoring

Therapeutic Drug Monitoring (TDM)

 Involves the analysis, assessment, and

evaluation of circulating concentrations of drugs in
serum, plasma, or WB.
 Purpose: to ensure that a given drug dosage
produces maximal therapeutic benefit and minimal
adverse toxic effect.

Common indications for TDM:

 The consequences of overdosing and under dosing are serious.

 There is a small difference between a therapeutic and a toxic dose.
 There is a poor relationship between the dose of drug and circulating concentration but a good
correlation between circ. conc. and therapeutic or toxic effects.
 There is a change in the patients physiologic state that may unpredictably affect circulating drug
concentrations
 A drug interaction is/or maybe occurring.
 Helps in monitoring px's compliance

ROUTES OF ADMINISTRATION

 Oral - common route of delivery, convenient, safe and relatively lack of discomfort.
 Intravenously (IV) - problems of absorption by the gastrointestinal tract are eliminated
 Intramuscular (IM)
 Subcutaneous (SC)
 Inhaled
 Suppository

*Bioavailability - the unchanged fraction of the administered dose as it enters systemic circulation

ABSORPTION

 For tablets and capsules- require dissolution before being absorbed

 Liquid solutions - more rapidly absorbed
 Most drugs are absorbed by passive diffusion.
 Weak acids - absorbed in the stomach
 Weak bases - absorbed in the intestine

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*Changes in the intestinal motility, pH, inflammation, as well as food or other drugs may change absorption
characteristics.

First pass metabolism - following absorption across the gut wall, the portal blood delivers the drug to deliver
prior to the entry into the systemic circulation.

If the drug is rapidly metabolized by the liver the amount of unchanged drug that gains access to the systemic
circulation is decreased.

DRUG DISTRIBUTION

A. Size of organ
 Large organ can take up large amount of drug (e.g. skeletal muscle)
 Small organ can take up smaller amount of drug (e.g. brain)
B. Blood flow
 Important in the rate of uptake
 Well perfused tissues often achieve high tissue concentration of drugs
 Poorly perfused tissues may have lower concentration
C. Solubility
 The solubility of a drug in tissue influences the concentration of the drug in the extra cellular
fluid surrounding the blood vessels.
 Drugs that are highly hydrophobic can easily traverse cellular membranes and partition into
lipids compartments, such as adipose and nerve cells
 Drugs that are polar but not ionized also cross cell membranes but do not sequester into lipid
compartments.
 Drugs that are ionized can diffuse out of the vasculature but at a slow rate

*Volume of distribution - the hypothetical volume of fluid into which the drug is disseminated.
Vd = D/Ct

DRUG ELIMINATION

The rate of elimination determines the duration of action for most drugs. Therefore, knowledge of time
course of concentration in plasma is important in predicting the intensity and duration of effect for most
drugs.

First-order elimination - implies that the rate of elimination is proportionate to the concentration.
∆C/∆T = -kC
Zero-order elimination - implies elimination at a constant rate regardless of concentration.

CLEARANCE

Clearance refers to the volume of fluid that would be completely cleared of drug if all the drugs being
excreted/metabolized were removed from that the volume.
 kidney - often the major organ or excretion

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 liver - also contributes to drug loss through metabolism and /or excretion into the bile

Xenobiotics-are substances not normally found in human systems yet they are capable of entering
biochemical pathways intended for endogenous substances.

Hepatic mixed function oxidase system (MFO)

 Biochemical pathway responsible for a large portion of drug metabolism.
 Involves in taking hydrophobic substances and, through a series of enzymatic reactions, converting
them into water-soluble substances
 Commonly divided into two functional groups or phases, Phase I and Phase II
1. Phase I - reactions produce reactive intermediate
2. Phase II - reactions conjugate functional groups to these reactive sites, the products of
which are water-soluble
 Changes in hepatic status can result in changes in the concentration of circulating drugs eliminated
by this pathway.
 Hepatic disease states characterized by a loss of functional tissue may result in slow rates of
clearance and corresponding longer half-lives.

PHARMACOKINETICS

Pharmacokinetics is the mathematical modeling of drug concentration in the circulation. This process assists
in establishing or modifying a dosage regimen.

*The goal of a multiple dosage regimen is to achieve a trough that is in the therapeutic range and a peak that
is not in the toxic range.

SAMPLE COLLECTION

 Timing of specimen collection is the single most important factor in TDM.

 Trough concentration for most drugs are drawn right before the next dose
 Peak concentrations are drawn 1 hour after an orally administered dose
 Serum or plasma is the specimen of choice for the determination of circulating concentrations of
most drugs
 Heparanized plasma is suitable for most drug analysis
 EDTA, citrated, oxalated plasma are not usually acceptable specimen because they are calcium-
binding anticoagulants that may interfere with the analysis.

PHARMACOGENOMICS

Responders - are the patients benefiting from the therapeutic and desired effects of the drug
Nonresponders - are the patients that do not demonstrate a beneficial and desired therapeutic effect from the
initiation of a given drug regimen

*Pharmacogenetic profiling can be used to predict drug-drug interactions or as an indicator if drug will
provide any therapeutic benefit at all.

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CARDIOACTIVE DRUGS

Many cardiac conditions are treated with drugs. Of these drugs, only a few require TDM. The cardiac
glycosides and antiarrhytmias are two classes of drugs for which assessment of serum concentration aids in
decisions regarding the dosage regimen.

Digoxin

 Digoxin is a cardiac glycoside used in the treatment of congestive heart failure

 It inhibits Na+, K+ -ATPase which causes a decrease in intracellular potassium, resulting in
increased intracellular calcium in cardiac myocytes (increased in calcium improves cardiac
contractility)
 Orally administered
 Its absorption varies because of the influence of dietary factors, gastrointestinal motility, and
formulation of drug
 Eliminated primarily by renal filtration and the remainder is metabolized to several products by the
liver
 The half-life of plasma digoxin in 38 hours in an average adult
 Hyperthyroid patients display a resistance to digoxin actions; hypothyriod patients are more
sensitive
 Immunoassay is used to measure total digoxin concentration in serum

Quinidine

 Earliest known antiarrhythmic agents

 Quinidine is a naturally occurring drug that can be used to treat various cardiac arrhythmic situation
 The two most common formulations are quinidine sulfate and quinidine gluconate
 Orally administered
 Gastrointestinal absorption is complete and rapid for the sulfate
 Sulfate - peak serum concentrations are reached about two hours after an oral dose
 Gluconate - peaks serum concentration is reached 4-5 hours after an oral dose
 Absorbed quinidine is about 70-80% bound to serum proteins
 Eliminated by hepatic metabolism
 Chromatography or immunoassay is used to determine plasma quinidine concentration

Procainamide

 Procainamide is used to treat cardiac arrhythmia like quinidine

 Orally administered
 Gastrointestinal absorption is rapid and complete
 Peak plasma concentration occur at about 1 hour
 Absorbed procainamide is about 20% bound to plasma proteins
 Eliminated by a combination of renal filtration and hepatic metabolism
 Immunoassay can be used to measure both procainamide and its active metabolite

Disopyramide

 Procainamide is another drug used to treat cardiac arrhythmias

 Commonly used as quinidine substitute when quinidine adverse effects are excessive

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 Orally administered
 Gastrointestinal absorption is complete and rapid
 Peak serum concentration is 1-2 hours
 It binds to several plasma proteins
 Primarily eliminated by renal filtration and to a lesser extent by hepatic metabolism
 Chromatography or immunoassay can be used to determine the plasma concentration of
disopyramide

ANTIBIOTICS
Aminoglycosides

 Used to treat infections with gram-negative bacteria that are resistant to less toxic antibiotics
 Causes nephrotoxicity and ototoxicity
 Not well-absorbed from the gastrointestinal tract
 IV or IM administered
 Eliminated by renal filtration
 Chromatography or immunoassay are used to determine aminoglycosides

Vancomycin

 Effective against gram-positive cocci and bacilli

 IV administered
 Toxic effects: Red-man syndrome, nephrotoxicity, and ototoxicity
 Eliminated by renal filtration and secretion
 Chromatography and immunoassay are used to determine vancomycin

ANTIEPILEPTIC DRUGS
-Antiepileptic drugs are used as prophylactics.

A. First Generation Antiepileptic Drugs

 Phenobarbital
- Slow acting barbiturate that controls every type of seizures.
- Oral absorption is low but complete.
- Peak is about 10 hrs after oral dose.
- 50% protein bound in the circulation
- Eliminated by hepatic metabolism
- Half-life: 70-100 hrs.
- Toxic adverse effects: fatigue, drowsiness, depression and reduced mental capacity
- Clearance is through MFO system

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- Primidoe- inactive form

 Phenytoin
- Treatment for seizure disorders
- Short term prophylactic agent in brain injury preventing loss of functional tissue
- Administered orally
- GI absorption is variable and sometimes incomplete
- 87%-97% protein bound in the circulation but easily displaced by other highly protein
- bound drugs.
- Reduced protein binding may occur with anemia, hypoalbuminemia and in the
coadministration of other highly protein – bound drugs.
- Toxicity is observed when total serum conc. is within the therapeutic range.
- Major toxicity: initiation of seizures.
- Other adverse effects: hirsutism, gingival hyperplasia, vit. D deficiency and folate
deficiency.
- Eliminated by hepatic metabolism
- Therapeutic range: 1-2 ug/mL

 Valproic Acid
- Monotherapy for the treatment of petit mal and absence seizures.
- Administered orally
- GI absorption is rapid and complete.
- 93% protein bound in the circulation
- Percentage bound decreases in renal failure, in late liver disease, and with
coadministration of other drugs that may compete for the binding site.
- Eliminated by hepatic metabolism
- Therapeutic range: 50-120 ug/mL
- Adverse effects: nausea, lethargy and weight gain.
- High serum levels are associated with pancreatitis, hyperammonia and hallucinations.

 Carbamazepine
- Less frequently used because of its serious adverse effects.
- Administered orally
- 70%-80% protein bound in the circulation
- Eliminated by hepatic metabolism
- Therapeutic range: 4-12 ug/mL
- < 15 ug/mL plasma concentrations are associated with hematologic dyscrasias and
possible aplastic anemia.

 Ethosuximide
- For control of petit mal seizure.
- Administered orally
- Therapeutic range: 40-100 ug/mL
- Toxicities are rare, tolerable and self-limiting.

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B. Second Generation Antiepileptic Drugs

 Felbamate
- For severe epilepsies such as Lennox-Gastaut syndrome and refractory epilepsy.
- Administered orally
- Nearly completely absorbed by the GI
- Peak serum concentration: reached within 1-4 hrs.
- 30% bound to serum proteins
- Eliminated by renal and hepatic metabolism
- Half-life: 14-22 hrs in adults
- Clearance is higher in children
- Contraindicated by hepatic dysfunction
- Metabolism is enhanced by enzyme inducers like Phenobarbital, primidone, phenytoin,
and carbamazepine.
- TDM may be indicated due to the narrow therapeutic range.
- Adverse effects: fatal aplastic anemia and hepatic failure

 Gabapentin
- Administered orally
- Maximum bioavailability: 60%
- Doesn’t bind to serum proteins
- Eliminated unchanged by the kidneys
- Half-life: approx. 5-9 hrs
- Therapeutic concentration: 12-20 ug/mL
- Maya be the most likely treatment consideration in patients with liver disease and in
treating partial-onset seizures in patient with acute intermittent porphyria.

 Lamotrigine
- For partial and generalized seizures
- Administered orally
- Rapidly and completely absorbed in the GI tract.
- Approx. 50% protein bound
- Eliminated by hepatic metabolism
- Half-life: 15-30 hrs
- Rate of elimination is dependent on age and physiologic condition
- Valproic acid is an inhibitor of lamotrigine
- Therapeutic range: 2.5-15 ug/mL

 Levetiracetam
- Indicated in partial and generalized seizures
- Administered orally
- Doesn’t bind to serum proteins
- Half-life: 6-8 hrs.

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- Rate of elimination: increased in children and pregnant women; decreased in the

elderly.
- Its clearance correlates with GFR that may be used monitoring patients with renal
impairment.
- Therapeutic range: 8-26 ug/mL

 Oxcarbazpine
- For monotherapy of partial seizures and in secondarily generalized tonic-clonic
seizures.
- 40% protein bound
- Peak concentration is 8 hrs
- Metabolized by the liver
- Half-life: 8-10 hrs
- Higher clearance rate in children
- Serum concentration: 12-35 ug/mL

 Tiagabine
- For treating partial seizures
- 96% protein bound
- Half-life: 4-13 hrs.
- Metabolized by hepatic mixed-function oxidase pathway
- Hepatic dysfunction prolongs half-life
- TDM may be indicated due to intraindividual and interindividual variations.
- Therapeutic concentration: 20-100 ug/mL
- Side effects: symptoms of confusion, difficulty in speaking clearly, mild sedation, and
a tingling sensation in the body’s extremities especially in the hands and fingers.

 Topiramate
- For partial and generalized seizures
- Orally administered
- Peak concentration: within 1-4 hrs
- 15% protein bound
- Majority is eliminated by renal filtration and the remainder is by hepatic metabolism.
- TDM may be indicated at steady state to provide the clinician with an effective
individual baseline concentration, at therapeutic failure and to monitor drug-drug
ineractions.

 Zonisamide
- Therapy for partial and generalized seizures.
- Administered orally
- Absorbed from the GI tract
- 60% protein bound and accumulates in the RBCs
- Metabolized by the liver via glucoronide conjugation, acetylation, and oxidation and
then renal extraction.

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- For monotherapy, its half-life is 50-70 hrs

- Children requires higher dosage
- Serum concentration: 10-38 ug/mL
- TDM may be indicated at steady state to detect drug-drug interactions and at
therapeutic failure.

PSYCHOACTIVE DRUGS

Lithium

 Orally administered
 Used to treat manic depression (bipolar disorder)
 A cationic metal that does not bind to proteins
 Absorption is complete and rapid
 Distribution is uniform throughout total body water
 It eliminated predominately by renal filtration and is subject to reabsorption
 Ion-selective electrode – commonly done in determination of serum lithium
 Flame emission photometry and atomic absorption – viable methods

Tricyclic Antidepressants

 A class of drugs used to treat depression, insomnia, extreme apathy, and loss of libido.
 In many patients, they slow gastric emptying and intestinal motility, which significantly slows the
rate of absorption. As a result, peak serum conc. are reached in the range 2-12 hrs
 TCAs are highly protein bound (85%-95%)
 Eliminated by hepatic metabolism
 The rate of elimination can also be influenced by the co-administration of other drugs that are
eliminated by hepatic metabolism
 The toxicity of TCAs is dose dependent
 Many of the immunoassays for TCAs use polyclonal antibodies, which cross-react among the
different TCAs and their metabolism and are used as screening rather than blood concentration
monitoring and TDM
 In this analytic system, the results are reported out as “total tricycles”
 Chromatographic method

Clozepine

 An atypical antipsychotic used to treat otherwise treatment-refractory schizophrenia, including its

negative symptoms, suicidal tendencies, and various types of cognitive deficiencies associated with
the disease.
 Research has found that there is not a well-established clinical serum conc., beneficial effects of the
drug have been demonstrated at 350-420 ng/mL
 TDM indicated to check for compliance and in patients with altered pharmacokinetics

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 TDM may also be used in avoiding symptoms of toxicity and overdosing, which may present in
seizures

Olanzapine

 a thienobenzodiazapine derivative that treats schizophrenia, acute manic episodes, and the
recurrence of bipolar disorders
 admininstered as a fast-acting intramuscular injection- at dose of 2.5- 10 mg per injection
 more likely administered orally
 85% absorbed, although approx 40% inactivated by first-pass metabolism
 Women and non-smoker – tend to have a lower clearance and thus a higher serum concentration
compared with men and smokers
 TDM help to optimize clinical response while balancing it with adverse affects with a therapeutic
range of 20-50 ng/mL

IMMUNOSUPPRESSIVE DRUGS
Transplantation medicine is a rapidly emerging discipline within clinical medicine. The clinical laboratory
plays important roles that determine the success of any transplantations program. Among these
responsibilities, monitoring of the immunosuppressive drugs used to prevent rejection is of key concern.
Most of these drugs require establishment of individual dosage regimens to optimize therapeutic outcomes
and minimize toxicity.

Cyclosporine

 A cyclic polypeptide that has potent immunosuppressive activity

 Primary clinical use: suppression of host-vs-graft rejection of heterotropic transplanted organs
 Administered as an oral preparation
 Absorption: 5%- 50%
 Because of high variability, the relationship between oral dose and blood concentration is poor;
therefore TDM is an important part of establishing an initial dosage regimen
 Whole blood is the specimen of choice to avoid preanalytic variable
 Eliminated by hepatic metabolism to inactive products
 Immunosuppression requirements differ depending on the organ transplanted
 Cardiac, liver, and pancreas transplants have highest requirement (300ng/mL)
 WB concentrations in the range of 350-400 ng/mL – have been associated with toxic effects
 Toxic effects: primarily renal tubular and glomerular dysfunction which may result in hypertension
 Several immunoassays are available for determination of whole blood cyclosporine concentration
 Chromatographic methods are available

Tacrolimus (FK-506)

 Orally administered immunosuppressive that is 100 times more potent than cyclosporine

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 Early use of tacrolimus suggested a low degree of toxicity compared with cyclosporine therapeutic
concentrations
 It has been associated with thrombus formation
 Gastrointestinal uptake is highly variable
 Eliminated by hepatic metabolism
 Metabolic products are primarily secreted into the bile
 Increases in immunoreactive tacrolimus may be seen in cholestasis as a result of cross-reactivity
 High-performance liquid chromatography-mass spectrophotometry (HPLC/MS)- most common
method
 Several immunoassays are available

Sirolimus (Rapamycin)

 Antifungal agent with immunosuppressive activity

 For patients receiving kidney transplants
 Extremely potent and requires TDM due to its inherent toxicity
 Adverse events: thrombocytopenia, anemia, leukopenia, infections, and hyperlipidemia
 Commonly use in conjunction with cyclosporine or tacrolimus
 It is rapidly absorbed after once-daily oral administration, with peak blood levels at about 1 hour
 oral bioavailability: 15% when taken in conjunction with cyclosporine
 serum concentration is affected extensively by intestinal and hepatic first-pass metabolism
 half-life of 62 hrs
 binds more to lipoproteins than to serum protein
 Whole blood – ideal specimen for analysis
 TDM commences using a trough level specimen obtained 5-7 days after initiation of therapy
 Therapeutic range is 4-12 ug/L when it used in conjunction with cyclosporine and 12-20ug/L if
cyclosporine is discontinued
 Assayed using Chromatography

Mycophenolic acid

 Mycophenolate mefetil (MMF) is the prodrug , which is rapidly converted in the liver to its active
form of mycophenolic acid (MPA).
 Lymphocyte proliferation inhibitor
 Used most commonly as supplemental therapy with cyclosporine and tacrolimus in renal transplant
patients
 Low trough levels increase the risk of acute rejection
 Orally administered
 Once in circulation, it is 95% protein bound
 Therapeutic serum concentrations: 1.0-3.5 ug/mL
 MPA and its metabolites can be assayed using plasma specimen as the most likely sample of choice
when using chromatography.
 Immunoassay is a less specific, yet common, method in assaying plasma MPA.

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ANTINEOPLASTICS
Assessment of the therapeutic benefit and toxicity of most antineoplastic drugs is not aided by TDM, because
correlations between plasma concentration and therapeutic benefit are hard to establish. Many of these
reagents are rapidly metabolized or incorporated into cellular macromolecular structures within seconds to
minutes of their administration. Considering that most antineoplastic agents are administered intravenously
as a single bolus, the actual delivered dose is more important than circulating concentrations.

Methotrexate

 One of the few antineoplastic drugs in which TDM offers benefits to a therapeutic regimen
 High dose methotrexate followed by leucovorin rescue has been shown to be an effective therapy
for various neoplastic conditions
 In general, neoplastic cells divide rapidly than do normal cells
 Methotrexate inhibits DNA synthesis in all cell
 Neoplastic cells, as a result of their rapid rate of division, have a higher requirement for DNA and
are susceptible to depravation of this essential constituents before normal cells
 Accomplished by administration of leucovorin, which reverses the actions of methotrexate at a
specific time after methotrexate infusion- Leucovorin rescue
 Failure to stop methotrexate actions results in cytotoxic effects to most cells
 The basic principles of TDM, which address absorption, distribution, and elimination, can also be
applied to nontherapeutic substances that have entered the body

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