VITAMINS & NUTRITIONAL ASESSMENT
A. Protein
Nutrition Care Process (NCP)
A systematic approach used by registered dietician (RD) to
identify, diagnose, and treat any nutrition-related problems or
disorders.
There are 4 components: nutrition assessment, nutrition
intervention, nutrition monitoring and evaluation.
As a medical technologist our role is on the nutritional
assessment…
NUTRITIONAL ASSESSMENT
A systematic process of obtaining, verifying, and interpreting
data in order to make decisions about the nature and cause of
nutrition-related problems.
Nutrition assessment incudes
 A-amphoteric or body composition measurements
 B-Biochemical analyses ( our role, focus here)
 C-Clinical examination (performed by physician)
 D-Dietary analysis and assessment to determine usual
food intake ( this is done by RD)
 E-Environmental assessment
 include consideration of all the other aspects of
the individual environment that may affect his
ability to purchase, prepare and consume food
 F-Focused nutrition physical examination ( by RD)
BIOCHEMICAL ASSESSMENT
Division of Biochemical assessment
 Macronutrients
 Carbohydrate protein fat metabolism and
utilization the change of these nutrients
during inflammation and disease can be very
important to know if treatment is effective.
The result is usually in a timely manner if
there is macronutrients assessment.
 Micronutrients
 More difficult yet may hold the key to your
diagnosis. For a patient strangles between
health and illness.
 Ex. insufficient / excess of the vitamins can
have a serious impact of enzymes and
biochemistry of human body
MACRONUTRIENTS
1. Serum albumin (long half-life: 20 days) is not a good
indicator of short term protein and energy deprivation but
levels are good indicators of chronic deficiency. First, it
helps identify chronic protein deficiency under conditions of
adequate non-protein-calorie intake, which leads to marked
hypoalbuminuria. This may result from the net loss of
albumin from intravascular and extravascular pools, causing
Kwashiorkor. Second, albumin may help define marasmus a
deficiency of calories with adequate protein status. In this
condition, the serum albumin remains normal despite
considerable loss of weight. Serum albumin is also an
accurate marker of the catabolic stress of infection.
2. TRASFERRIN is an early indicator of iron deficiency, and the
elevated level is the last to return to normal when iron
deficiency is corrected. With its short half-life and smaller
body pool as compared to albumin, it is also more likely to
indicate protein depletion before serum albumin
concentration changes. Transferrin can be also lowered in
non-protein or energy deficiency like nephrotic syndrome,
liver disorders.
3. TRANSTHYRETIN is also called thyroxin-binding pre-albumin.
Because of its short half-life (2 days) and small body pool,
transthyretin is a better indicator of visceral protein status
and positive nitrogen balance than albumin and transferrin.
It is also used an indicator of adequacy of a nutrition plan
because changes in plasma protein are correlated with
nitrogen balance. Transthyretin concentrations increase in
positive nitrogen balance and decrease in patients with
negative nitrogen balance.
4. RETINOL-BINDING PROTEIN is used as a metabolic marker
due to its half-life of 12 hours and its small body pool. On
top of this, it is excreted in urine and level is elevated in
renal failure.
5. INSULIN-LIKE GROWTH FACTOR 1 (formerly called
Somatodemin C) is important for stimulation of growth. It is
a nutritional marker in adults and children, although not
routinely.
6. FIBRONECTIN: (half-life 15 hours). A major protein
regulating phagocytosis. It is not exclusively produced in the
liver, and is a good indicator of sepsis, decrease during
infection or severe stress.
7. NITROGEN BALANCE is widely used indicators of protein
change and or adequacy of feeding in a controlled setting
(admitted). In healthy adult population, anabolic and
catabolic rates are in equilibrium, and the nitrogen balance
approaches zero. During stress, trauma, or burns, the
nutritional intake decreases, and due to an increase in
catabolism, nitrogen balance becomes negative.
 8. C-REACTIVE PROTEIN: increases dramatically in sepsis,
inflammation, & infection. High sensitivity CRP is an
additional marker for inflammation and has been applied as
predictor of cardiac disease and other cholesterol-related
atherosclerotic disorders.
9. CYTOKINES: Most of nutritional investigations on cytokines
have been performed on interluekin-1 (IL-1),IL-6 and tumor-
necrosis factor –alpha ( TNF-alpha).
10. GLUTEN SENSITIVITY ANTIBODIES: this has become the
latest protein assay to assess nutritional status due to celiac
disease (CD) and number of individuals with gluten
sensitivities resulting in diarrhea, abdominal bloating,
rashes, and vitamin deficiencies. The antibodies assays are
transglutaminase antibodies, endomysial antibodies (EMA),
and deaminated gliadin peptide antibodies (DGP). All of
these antibodies take the form of IgA and IgG isotypes.
B. Fat - inappropriate amount is needed for a balanced
diet.
C. Carbohydrate - closely linked to type 1 and type 2 DM
because these can be regulated by medication and diet.
PARENTERAL NUTRITION
 Is a means of intense nutritional support for patients who
are malnourished or in danger of becoming malnourished
because they are unable to take any nutrients when the
gut does not work.
 Need to monitor electrolytes, urine output, organ function
 Electrolytes are check during the PN of children
as this can increase and cause other problems.
 Urine testing in small premature infants
because too rapid parenteral nutrition in the
early phase of a PN can result to glycosuria. In
order to successfully feed the organ system
needs to be check.
MICRONUTRIENTS
Vitamins and Other Minerals
Vitamins - are low molecular weight compounds that are
obtained from diet and bacterial synthesis. Coined from the
words vital amines however this term has been change because
not all of these are amine in nature.
CLASSIFICATION
water soluble
Ex: B complex (thiamine, riboflavin, niacin, vitamins B12
and B6, biotin, folate) and vitamin C
non-water soluble are fat soluble vitamins
They are ADEK
Fat soluble vitamins
Vitamin A
Chemical name: Retinol, retinal, retinoic acid
Major sources: retinyl esters, metabolism of beta-carotene
RDA: Adult male: 900 µg/d; adult female: 700 µg /d
Function: vision, growth, immune responses, reproduction,
cancer Prevention
Deficiency: night blindness (nyctalopia), growth retardation,
abnormal taste response, dermatitis, recurrent infections
Assay: HPLC
 Retinol this is oxidized in the rads of eye retinal which
complex with opsin to form rhodopsin allowing dim light
vision. Retinol and vitamin D act thru specific nuclear
receptors in the regulation of cell proliferation.
 Measurement of retinol is most common means of assessing
vitamin A status in clinical setting.
 Retinol is the most commonly measured by HPLC
Toxicity: assess the measuring the retinyl esters levels in serum
rather than the retinol.
 Measurement of Retinyl is done rather than the retinol.
Sources: Yellow foods
VITAMIN D
Chemical name: Vitamin D2 : Ergocalciferol, cholecalciferol
Major sources: Vitamin D2: fish liver oils, fortified milk
Vitamin D3: activated sterols, exposure to
light, butter, salmon, egg yolk
RDA: Adults: 15 to 20 µg/d (depending on age)
Function: mineralization of bone and teeth; neuromuscular
activity
 important calcium in the body
Deficiency: Rickets (failure of bone to calcify) for young;
osteomalacia ( abnormal bone synthesis) for adults
Assay: LC-MS/MS
 Very important to measure 1,25-Hydroxy-2-D3 metabolic
form of vitamin D, PTH, and calcium levels in diagnosing
primary hyperthyroidism (?) and different type of rickets.
 When monitoring patient with chronic renal failure and
when assessing patients with 1,25-Hydroxy-2-D3 theraphy
VITAMIN E (antioxidants)
Chemical name: Tocopherols (α,β,γ,δ)
 Alpha is the most widely spread and most biologically
active form of vitamin E
 Patients with fat malabsorption are susceptible to
vitamin E deficiency. There is a synergistic function with
selenium and ascorbic acid. In order to have an effect of
vitamin E, you should take and selenium and ascorbic
acid.
  Vitamin E is also necessary for the maintenance of the
function or levels of vitamin A. You could have Vitamin A
with vitamin E.
 This is why most of the multivitamins that careful
amount of the different vitamins are computed however
it does not guarantee that you get rid of diseases, there
is always a possibility
Major sources: Vegetable oils, wheat germ, rice germ, green
leafy vegetables, nuts, legumes
RDA: Adult male: 15 mg/d foradults
Function: critical for normal neurologic structure & function;
Antioxidant
Deficiency: mild hemoytic anemia (newborn), red blood cells
fragility, ataxia
Assay: HPLC
VITAMIN K (related to bleeding)
Chemical name: Phylloquinones, menaquinones
Major sources: Green leafy vegetables, pork, liver, soybeans,
synthesis of intestinal bacteria
RDA: Males: 120 µg/d; females: 90 µg/d
 Large doses of vitamin K in infant can result to
hyperbilirubinemia
 In most laboratories vitamin k is not performed but it is
prothrombin time. Some procedure or brands of reagent
will give reference range between 10-15 seconds, if
vitamin k is deficient the PT could be more than 15
seconds (prolonged)
 Several herbal supplements like garlic, ginkgo, ginseng
may enhance the effect of coumadin (anti-thrombolitic)
can interact with platelets increasing the rate of
bleeding.
Function: formation of blood clotting factors esp prothrombin,
osteocalcins
Deficiency: Hemorrhage
Water Soluble Vitamins
B vitamins
 Serve as enzyme cofactors
 Transport atoms between molecules in enzyme-coupled
reactions
Vitamin B1
Chemical name: Thiamine
Major sources: Whole grain enriched breads, cereals, meat,
fish, legumes, milk, green vegetables
RDA: Adult male: 1.2 mg/d; adult female: 1.1 mg/d
Function: decarboxylation in major carbohydrate pathways and
in branched-chain amino acid metabolism
Deficiency: Infants: dyspnea, cyanosis, diarrhea, vomiting
Adults: beriberi(fatigue, peripheral neuritis), Wernicke-
Korsakoff syndrome (apathy, ataxia, visual
problems)
 beriberi can occur in chronic alcoholism thiamin
functional activities best measure by erythrocyte
transketolase activity before and after the addition of
thiamine pyrophosphate (TPP)
 Thiamine deficiency is present if the increase in activity
after the addition of pyrophosphate is >25%.
Reference ranges: Serum: 0.21 to 0.43 µg/dL; Urine: more than
100 µg/dL/24 h
Vitamin B2
Chemical name: Riboflavin
Major sources: Milk, liver, eggs, meat, green leafy vegetables
RDA: Adult male:1.3 mg/d; adult female: 1.1 mg/d
Function: Oxidation-reduction enzymatic reactions
Deficiency: Angular stomatitis (mouth lesions), dermatitis,
photophobia, neurologic changes.
 Very good of store of B2 well-nourished person or
adequate to prevent riboflavin deficiency for 5 months
Vitamin B6
Chemical name: Pyridoxine, pyridoxal, pyridoxamine
Major sources: Meat, poultry, fish, potatoes, vegetables
RDA: Adult male: 1.3 to 1.7.0 mg/d; adult female: 1.3 to 1.5
mg/d
Function: Enzyme systems involving amino acid transaminases,
phosphorylases, decarboxylases
Deficiency: infants: irritability, seizures, anemia, vomiting
weakness
adults: facial seborrhea
 It is a common skin problem, if it occurs in the scalp it is
the dandruff, if it is in the face (itchy, rednesss) rashes
and white scales
 Reference of B6 would be dependent on the age of the
person
Niacin
Chemical name: Nicotinic acid; nicotinamide
Major sources: Meat, poultry, legumes, whole grains
RDA: Adult male: 16 mg/d; adult female: 14 mg/d
Function: component of coenzymes
Deficiency: Pellagra (diarrhea, mucous membrane
inflammation, weight loss, disorientation)
 Component of Nicotinamide adenine dinucleotide (NAD)
and nicotinamide adenine dinucleotide phosphate
(NADP)
 Deficiency can result also from alcoholism
Folate
 Folate and Vitamins 12 are metabolically closely related
 Folate requirement increase during pregnancy and
gestation
Chemical name: Pteroylglutamic acid
Major sources: Organ meats, muscle meat, poultry, fish, eggs,
whole grain cereals
RDA: 400 µg/d for adults; same amount with women of child
bearing age to reduce incidence of fetal nueral child defects.
Function: coenzyme involved in one-carbon transfer
Deficiency: Megaloblastic anemia; in pregnant women- the
possibility of fetal neural defects
Assay: microbiologic assay using Lactobacillus casei
Vitamin B12
Chemical name: Cobalamin
Major sources: Organ and muscle meats, poultry, fish, eggs,
milk
RDA: Adults: 2.4 µg/d for adults
Function: Myelin formation, branched-chain keto scid
metabolism, folate interconversions, DNA synthesis
Deficiency: megaloblastic anemia (pernicious anemia)
neurologic disorders
 Pernicious anemia is now applied to B12 because of lack
intrinsic factor (secreted by the stomach, it is a unique
binding protein that mediates the absorption of B12 in
the ileum)
Assay: microbiologic assay using Lactobacillus leichmannii
Biotin (vitamin of hair and nails)
Major sources: Organ meats, egg yolks, nuts, legumes;
synthesize in the gut by bacteria
RDA: 30 µg/d
Function: Coenzyme for CO2 carboxylation reactions and for
carboxyl group exchange
Deficiency: Dermatitis can progress to mental and neurologic
changes, anorexia, peripheral vasoconstriction
Assay: isotopic dilution, chemluminscent. Photometric
Pantothenic Acid
Major sources: Meat, poultry, fish, whole grain cereals, legumes
RDA: 5 mg/d for adults
Function: Acyl-group transfer reactions
Deficiency: Depression, depressed immune system
Ascorbic acid
Chemical name: Vitamin C
Major sources: Citrus fruits, tomatoes, melons, cabbage, fresh
potatoes, green leafy vegetables
Function: potent reducing agent; synthesis of collagen; aids in
biosynthesis of some neurotransmitters; reduces risk of certain
cancers; prevents common colds
 Needed for iron intake, the synergistic effect
Deficiency: First: vague aches and pains; if long term: scurvy
(hemorrhage into skin, alimentary and urinary tract, anemia,
wound healing delayed)
Assay: 2,4-dinitrophenylhydrazine method; HPLC ( more
sensitive and specific)
Conditionally essential nutrients
Carnitine (for slimming)
Major sources: Meat, dairy products, peanut butter, asparagus
Function: Energy, metabolism and acyl group transport
Deficiency: Muscle weakness and fatigue
Minerals
Calcium/phosphorous/magnesium
□ Decreased ionized calcium may result to tetany; decreased
ionized calcium is often caused by increase in blood pH
 Have alkaline the ionized calcium is decreased
(dangerous)
□ Phosphorous has a reciprocal relationship with Ca; severe
hypophosphatemia is seen in prolonged PN.
 If calcium is elevated, phosphorus is low and vice versa
□ Reciprocal relationship between calcium and magnesium;
magnesium and phosphorous; low Mg can cause tetany
while high level causes increase cardiac atrioventricular
conduction time.
Iron
RDA 8 mg/d for adults over 51 yo; 18 mg/d for adult
females 19 to 50 yo
For respiration and transfer of oxygen to body tissues.
Iron absorption is enhanced by:
a) Low serum/body iron (because Ferritin is low and
apotransferrin is high) the two are essential stimulators
of iron absorption
b) Vitamin C (when we take iron supplements to enhance
absorption)
c) Copper
d) Cobalt
e) Manganese
Iron absorption is decreased by:
a) Excess ferritin
b) Phytic acid
c) Polyphenols of tea and wine
d) Calcium
Trace elements
A. Copper
□ Lack of copper affects the superoxide dismutase activity
that leaves the patients cells open to free radical
damage and cellular destruction
 Deficiency of copper is rare due to liver close
regulation of copper levels.
 However in pre-term babies in menkes kinky
hair disease and deficiency due to high dietary
intake of zinc, iron, and vitamin C can be
potential causes of copper deficiencies.
 Parenteral Nutrition can also lead to copper
deficiency. Diagnosis of copper deficiency can
also be confirmed when both serum copper, and
ceruloplasmin are decrease
 Parenteral = IV

B. Zinc
 Should be monitored frequently even patients when
patients receiving the supplement because zinc
absorption is very low (30-40% dietary intake)
 Deficiency of zinc is commonly due to lack of
absorption
□ Essential metal for over 200 metalloenzymes =for
protein synthesis, gene expression, transport processes,
immunologic reactions, wound healing
□ is required for vision, taste, and smell functions
□ Promotes tissue repair, connective tissue synthesis,
bone growth, and insulin synthesis
□ Involved in carbohydrate, protein, phosphorous
metabolism
□ For antibody production
C. Selenium RDA: 55 µg/d for adults
□ Cofactor for antioxidant enzyme glutathione peroxidase
□ Has also an influence on cancer , CVDs, DM, arthritis

Celiac disease deficiencies (CD)

CD is a food intolerance to gluten
Has a genetic basis in individuals that express HLA-DQ2 and
HLA-DQ8 on chromosome 6.
Intolerance to gluten is more frequently diagnosed late. The
inflammatory gluten amino acid is found in wheat, barley,
and rye. Exposure to these lead to inflammatory damage to
intestinal villi in the duodenum and jejunum and mal-
absorption.
 PRINCIPLES OF TDM
Therapeutic Drug Monitoring

TDM is a branch of clinical chemistry and clinical pharmacology

that specializes in the measurement of medication
concentrations in blood.

Purposes of TDM

§ Ensure that a given drug dose is within a range that

produces maximal therapeutic benefit (therapeutic
Weight of children are taken into consideration and
range)
computed for dosage. Geriatric Patients have other special
§ For most drug therapies, safe and effective
considerations also.
dosage regimen for the majority of the
population is established and TDM is not § The basis of TDM includes consideration of the route of
necessary administration, rate of absorption, distribution of drugs
§ If you are described anti-pyrectics (and some within the body, and rate of elimination.
antibiotics), the doctor will not subject you to
TDM. Pharmacodynamics Pharmacokinetics:
§ The standard dosage is the dose providing study of the biochemical assess the rate of
therapeutic benefits. & physiologic effects of absorption, distribution,
§ Identify when the drug is above or below a therapeutic drugs & their biotransformation,
range which may lead to inefficacy or toxicity. mechanisms of action excretion of drugs
§ Some drugs reach toxicity.
§ Thin line between underdosage, drug efficacy
and toxicity (overdosage).
§ Can also be used to determine non-compliance
§ Can also be used to reoptimize a dosing
regimen based on drug-to-drug interactions or
change in patient’s physiologic state that has
unpredictably affected circulating drug
concentrations.
§ Some drugs can and should be taken together,
some drugs are antagonists and some when
taking together enhance side effects.
§ Example: person with dengue fever
taking anti-hemolytic drug. Drug’s
effect is to enhance bleeding of the
person.
§ No 2 people have the same experience
with efficacy
 ROUTES OF ADMINISTRATION Drug distribution
§ The relative proportion between circulation and the
Drug delivery systems
tissues.
§ Tablets § Candy
§ Greatly dependent solubility of drug molecule in
§ Injections (Syringe) § Gum
fat (cell membrane is 2 layers of fatty acids), fat
§ Cigarettes § Implants
soluble or water soluble
§ Marijuana § Gas
§ Presence of carrier protein affects this
§ Beverages § Creams
(albumin).
§ Patches § Others?
§ Drugs that are hydro/hypophobic can easily
§ Suppositories § Stamps
traverse cellular membranes and partition into
§ For babies § Bandana
lipid compartments (adipose and nerve cells)
§ Drugs that are polar but not ionized also cross
cell membranes but are not sequestered into
lipid compartments
§ Free (biologically active drugs, not bound) drugs
elicit desired effects but are affected by protein
concentration.

Bioavailability
§ The fraction of administered dose that reaches its site
of action
§ Amount of drug that will give therapeutic effect
Drug absorption
§ Passage of drug through cell membranes to reach its
site of action
For orally ingested drugs, the efficiency of absorption from GIT
tract to its availability in dependent on:
§ Dissociation from its administered form
§ Solubility
§ Diffusion across GIT membranes
§ Tablets and capsules require dissolution before
being absorbed
§ Some drugs need active transport, some need
passive transport
Factors affecting Drug Absorption rate

• pH • Pregnancy,
• changes in intestinal • weight of patient
motility • Age
• bowel inflammation • Obesity
presence of food • pathologic conditions
•
 Drug metabolism
§ It is the biochemical modification of pharmaceutical
substances or xenobiotics respectively by living
organisms, usually through specialized enzymatic
systems.
§ The first-pass effect (first-pass metabolism) is a
phenomenon of drug metabolism where drug
concentration is greatly reduced before it reaches the
systemic circulation
§ Affects orally ingested drugs
§ When we take drugs, liver tries to eliminate
some of it, thus it is greatly reduced.
§ All substances observed from the intestine enter
the hepatic portal system, where circulating
blood is routed through the liver before it enters
the general circulation.
§ Certain drugs are subject to significant hepatic
uptake and metabolism during passage through
the liver.
§ Not all drugs have the same uptake and
metabolism, some go through first pass effect
§ Most drugs are xenobiotics, which means, they are
exogenous substances and yet are capable of entering
biochemical pathways intended for endogenous
substances.
§ They could induce MFO
§ Many potential substrates, Competitive and
non-competitive drug-to-drug interactions
affect Drug Elimination.
§ Drug elimination can be by several mechanisms
a. Elimination-kidneys
§ The plasma free fraction or a parent
drug or its metabolites is subject to
glomerular filtration, renal secretion, or
both.

The biochemical pathway responsible for drug

metabolism is the Hepatic Mixed Function Oxidase
System (MFO system).
§ Basic function of this system involves taking
hydrophobic substances & through a series of
enzymatic reaction, convert them into water
soluble products.
§ Phase 1 produce reactive intermediates
(metabolites)
§ Phase 2 conjugates functional groups to
reactive sites on the intermediates, resulting
into water soluble products (elimination of
drugs into urine)
§ Excessive phase 1 products result in toxic effect
o Acetaminophen overdose= cannot
metabolize acetaminophen into glutathione
conjugate (MFO is overwhelmed).
o Accumulation, cannot be eliminated, due to
lack of water-soluble products.
 Pharmacokinetics
PHARMACOGENOMICS
T1/2= true half-life
§ The rate of drug elimination can only be determined
after absorption and distribution
§ Peak drug level: maximum
§ Trough drug level: minimum
§ These are considered in TDM
§ Most drugs are administered on multiple dosage
regimen to ensure trough and peak in therapeutic
range and ensure that the peak is not in the toxic range.
§ It requires 5-7 doses to have a steady-state oscillation
§ At steady-state the rate of drug administration equals
the rate of elimination and plasma concentration - time
curves found after each dose should be approximately
superimposable
SPECIMEN COLLECTION
§ Timing of specimen collection is the single most
important factor in TDM
§ Specimen of choice: serum or heparinized plasma
§ Can be used to predict drug-drug interactions or as an
indicator if the drug will provide any therapeutic
benefit.
§ Trough conc= drawn right before next dose
§ Peak conc= drawn an hour after an orally
administered dose (except digoxin, a cardiac
drug, oberseved slowly and require several
hours before peak is measured)
§ Specimen of Choice: serum or heparinized plasma
§ EDTA, Citrated plasma, Oxalated Plasma have
calcium binding, could add a cations and
anions, not accepted.
§ The effectiveness of drug over a population that uses
can be divided into responders and noresponders.
Responders Nonresponders
Patients Do not demonstrate a beneficial and
benefiting from desired therapeutic effect from the
the therapeutic initiation of a given drug.
& desired effects § Common among
of the drug vaccination
§ The therapeutic effectiveness has been attributed to
the interindividual variation in the genetic
polymorphisms of the patients’ drug metabolism
pathways.
 Therapeutic Drugs Monitoring
Cardioactive Drugs
Antibiotics Drugs
Antiepileptic Drugs
Psychoactive Drugs
Immunosuppresives
Bronchodilators
CARDIOACTIVE DRUGS
TDM aid in achieving an appropriate dosage regimen for the
following cardioactive drugs:
• Cardiac glycosides
• Antiarrhythmics
1. DIGOXIN
□ cardiac glycoside for congestive heart failure
Inhibit membrane Na,K ATPase = decrease intracellular K ;
increase intracellular Ca in cardiac myocytes = increased
cardiac contractility
This effect is seen in serum level of 0.8-2 ng/mL [ 1-2.6
nmol/L]
>3 ng/mL [3.8 nmol/L] =decrease rate of ventricular
depolarization but toxic (not frequently used)
Symptoms of toxicity: nausea, vomiting & visual disturbance,
premature ventricular contractions, atrioventricular blockage
Factors affecting oral digoxin effect:
□ Diet
□ GIT motility
□ Formulation of the drug
□ Hypothyroidism [more sensitive to digoxin]
Peak is 2-3 hours post dose
Half life is 38 hours, can be extended by a slow release of tissue
digoxin into circulation (15 to 30 times greater than plasma)
□ In circulation, 25% of digoxin is protein bound
Elimination: Mainly through renal filtration while the
remainder is metabolized to several products by the liver
Monitoring: peak sometimes does not correlate with tissue
concentration, more concentrated in tissue rather than plasma
o Lab is done 8-10 hours after oral ingestion.
o Pregnant women, newborn and patients with uremia,
late stage liver disease may produce indigenous
substances that cross react with antibodies
2. QUINIDINE (quinidx, quinora??)
□ Naturally occurring drug to treat various cardiac
arrhythmic situations.
2 forms
□ quinidine sulfate
□ quinidine gluconate.
Common route: oral
□ Generally administered orally as GIT or gastrointestinal
absorption, is complete and wrapped in 4 quinidine sulfate
with peak serum concentration at 2 hours post dose.
□ Quinidine Gluconate is a slow release formulation with peak
serum concentration at 4 to 5 hours after oral dose (because
of this, trough level is drawn an hour after dose).
Toxic effects: nausea, vomiting, abdominal discomfort, Serious
complications are thrombocytopenia, & tinnitus.
o Cardio vascular toxicity: premature ventricular
contractions (PVC), occurs when blood level is 2
times the upper limit of therapeutic range
Monitoring: trough only, to ensure serum concentrations are
within the therapeutic dose assessment of peak is done only
when symptoms of toxicity are present
□ premature ventricular contractions (PVC)
□ Absorbed quinidine is 70-80% protein bound
o Unless the protein will be detached from the
drug that will only be the time that your drug
would be free and considered to be biologically
active (most quinidine is inactive?)
Half-life: 6-8 hours
Elimination by hepatic metabolism
□ Plasma quinidine can be determined by
chromatograohic or immunoassays.
Therapeutic range: 2-5um/mL
If with Barbiturate = enhanced hepatic clearance rate
[elimination is mainly by liver]
3. Procainamide
□ For treatment of cardiac arrhythmia
□ Oral is the most common route.
□ GIT absorption is rapid and complete
□ Absorbed drug is 20% protein bound
Peak level: 1 hr after ingestion
T½: 4 hrs
□ Active hepatic metabolite of drug: N-
acetylprocainamide
o Similar effect to the parent drug
Elimination: combination of hepatic metabolism & renal
filtration
□ Measurement is through immunoassay
4. DISOPYRAMIDE [Norpace]
□ Antiarrhythmic substitute for quinidine
o When side effects are unacceptable
□ Oral route of administration, absorption is rapid and
complete
Peak 1-2 hours post dose
□ In most patients, 3-7.5mcrogram/mL or equivalent of
8.8-22.1mmolL is effective, nontoxic
o Clinical perspectives must be taken into
considerations
Adverse effects:
□ dry mouth and constipation,
o seen in serum concentration of 4.5ug/mL or
13.3umol/L
□ bradycardia & atrioventricular node blockage
o Greater than 10 ug/mL or 29.5umol/L
T½ is 7 hours
Primarily eliminated through renal filtration
o A little of hepatic metabolism
□ Determination is by chromatography or immunoassay
ANTIBIOTICS
1. AMINOGLYCOSIDES
Group of antibiotics for treatment of infections caused by
gram-negative bacteria that are resistant to less toxic
antibiotics
Most common ex: gentamicin, tobramycin, amikacin, &
kanamycin
Administered through IV & IM
o Not absorbed by GIT
o not suitable for outpatient
□ toxic effects
o hearing and balance impairment
 irreversible
Elimination: renal filtration
These group of antibiotics are nephrotoxic & ototoxic
o possibility of nephrotoxic effect
 proteinuria
 electrolyte imbalance
 irreversible
Peak level: 1-2 hours post dose
□ 10% is protein bound
T½= 2 to 3 hours
Assessment: chromatography; immunoassay
2. TEICOPLANIN
For aerobic and anaerobic gram-positive bacilli and gram
positive cocci
o Proven effective against MRSA infections
Administered through IV/IM
o Poor absorption in GIT
T½= 70 to 100 hours
□ TDM is not routinely done because there is no established
relationship between plasma concentrations and toxicity
o Monitoring can assist dosage optimization
□ Trough specimens are measured
o Therapeutic range is at 10 to 60 mg/L for
treatment of endocarditis and 20-60 mg/L for
the treatment of staphylococci infections
10 to 60 mg/L for treatment of endocarditis and 20-60 mg/L
for the treatment of staphylococci infections
Adverse effects: nausea, vomiting, fever, diarrhea, mild
hearing loss.
3. VANCOMYCIN
□ A glycopeptide antibiotic against gram-positive cocci &
bacilli
Administered through IV
o poorly absorbed orally
Peak level at 1 hour after dose
□ High level is bound to protein, 55%
□ No established relationship between plasma
concentrations and toxic effects.
Toxic effects occur in the therapeutic range [3.45 to 6.9
µmol/L]:
□ Red man syndrome
 Erythemic flushing of extremities
□ Nephrotoxicity
 Occurs if >6.9umol/L concentration
□ Ototoxicity
 Occurs frequently at 40ug/mL or 27.6uL/L
□ Has long distribution phase
o Monitoring is only in the trough concentrations
to ensure that the drug is in therapeutic range
Elimination: renal filtration & excretion
T½= 4 -6 hours
Determination: immunoassay and chromatographic
techniques
 ANTIEPILEPTIC DRUGS
 Are a diverse group of pharmacological agents used in the
treatment of epilepsy, convulsions & seizures.
 Used as prophylactics
 Therapeutic ranges are considered as guidelines and
should be interpreted in accordance with the presenting
clinical context
 Analyzed by immunoassay and chromatography
 Examined and taken at trough stage
 Important to take the individual therapeutic range in
physiologic conditions
 There changes that occur in:
 Age
 Pregnancy
 Kidney disease
 Liver disease
SECOND GENERATION AEDs = as supplemental therapy for 1st
gen AEDs
FIRST GENERATION AEDs = considered the first-line drug to
treat convulsions; includes Phenobarbital, Phenytoin, Valproic
acid, Carbamazepine, Ethosuximide, Felbamate,
Gabapentin,Lamotrigine, Levetiracetam, Oxcarbaxepine,
Tiagabine, Topiramate, & Zonisamide
1. Phenobarbital
A slow acting barbiturate that effectively control several types
of seizures
Peak level is reached 10 hrs after ingestion
□ Absorption of oral dose is slow but complete
50% protein bound
T½= 70-100 hours
Toxic effects: drowsiness, fatigue, depression, reduced mental
capacity
Elimination: mainly by hepatic metabolism
o Renal filtration is also significant
□ Long half-life and slow absorption
o Blood levels do not change drastically without
dosing interval
□ Trough levels are typically evaluated
o Unless toxicity is suspected
Toxic effects: drowsiness, fatigue, depression, reduced mental
capacity
□ Inducer of hepatic MFO(hepatic Mixed Function Oxidase)
o Within 10-15 minutes after the initial dose
2. Primidone
□ Inactive form of phenobarbital
□ Converted to active form [phenobarbital] after
absorption
□ Primidone is used in preference of phenobarbital when
steady-state kinetics need to be established quickly
3. PHENYTOIN ( Dilantin)
Used as short-term prophylactic agent in brain injury
o Prevent loss of functional tissue
Oral administration; peak @ 3 to 12 hours
o Complete
87 to 97% protein binding
o High but variable
o Easily displaced by other protein bound drugs
Therapeutic ranges
Free phenytoin: 1-2 µmol/mL (4 to7.9 µmol/L)
Total phenytoin: 10 to 20 µg/mL (20 to 80 µmol/L)
T½= 6 to 24 hours
□ Assessment is through immunoassays
Elimination: hepatic metabolism
Toxic effect:
o Initiation of seizure
o Seizures ini patient receiving phenytoin may be a result
of sub therapeutic or toxic concentrations
Also an MFO inducer
o Reduces of half life of conccurently administered drugs
that are eliminated by this pathway
□ Toxicity is observed when total serum drug concentration is
within therapeutic range
□ Reduced binding occurs in anemia, hypoalbuminemia, co-
administration of other drugs with similar binding properties
Other adverse effect of phenytoin: Hirsutism, Gingival
hyperplasia, Vit D deficiency, Folate deficiency
□ Forphenytoin is an injectable proform that is metabolized in
the body for about 75 minutes
□ Most immunoassays cannot detect preform
o Peak level must be evaluated after the
conversion of the active drug is complete.
 4. VALPROIC ACID (valproate)
As monotherapy for the treatment of petit mal and absence of
seizures
□ Orally taken93% protein bound
o GIT absorption is rapid ang complete
□ 93% protein bound
o High protein binding capacity
o Decreases in renal failure, late liver diseases,
and coadministration drugs that compete its
binding
Elimination: hepatic metabolism
o May be induced by other AEDs
o Inhibited by administration of felbamate
Peak: 1-4 hours post dose
T½: 11 to 17 hours
Therapeutic range: 50-120 µg/mL (347 to 832 µmol/L)
□ Many factors can affect the free fraction of valproic so
determination of this form can provide a reliable index for
therapeutic and toxic concentrations
Toxic effects: Lethargy, nausea, Weight gain
o Pancreatitis
 Greater than 200ug/mL
o Hyperammonemia
 Greater than 200ug/mL
o Hallucinations
 Greater than 200ug/mL
o Hepatic dysfunction can occur even at therapeutic range,
thus, hepatic indicators should be checked in the first 6
months of therapy
5. CARBAMAZEPINE (Tegretol)
Effective treatment for most seizure disorders but is less
used due to toxic effects
□ Used when patients don’t respond well to other AEDs
□ Oral route
□ 70%-80% protein bound
Peak: 4 to 8 hours post dose
T½: 10 to 20 hours
Eliminated via hepatic metabolism
□ Can cause many liver dysfunction
□ Carbamazepine is an inducer of its own metabolism
□ Frequent analysis should be done on initiation of
therapy until the induction period has come to
completion
□ Toxic effect is diverse and variable.
There are those who show adverse reactions at therapeutic
range to include: rash, leukopenia, nausea, vertigo, febrile
reactions.
o Leukocyte counts should be assessed during the
first 2 weeks of therapy in order to detect
possible toxic effects
o Persistent increase in liver markers and
leukopenia results to discontinuation of drug
Therapeutic range: 4 to 12 µg/mL (16.9 to 50.8 µmol/L)
□ Plasma levels greater than 15 µg/mL are associated with
hematologic dyscrasias & possible aplastic anemia
6. ETHOSUXIMIDE (Zarontin)
□ For controlling petit mal seizure
□ Administered orally
Peak: 2-4 hours
Therapeutic range: 40 to 100 µg/mL (283 to 708 µmol/L)
□ Toxic effects are rare, tolerable, self-limiting
o Nausea
o Vomiting
o Dizziness
o Anorexia
o Lethargy
T½: 40 to 60 hours
Elimination: liver metabolism; 20% by renal filtration
7. FELBAMATE (Felbatol)
□ For severe epilepsies
o In children with mixed seizure disorder
o Refractory epilepsy
□ Orally administered
o Nearly completely absorbed by GIT
□ Nearly & completely absorbed in GIT with peak level
reached in 1 to 4 hrs
□ Only 30% bound to protein
T½: 14 to 22 hours
Eliminated by renal & hepatic metabolism
Therapeutic dose: 30 to 60 µg/mL (126 to 252 µmol/L)
□ Contraindicated with hepatic dysfunction
□ Metabolism of drug enhanced by phenobarbital,
primidone, phenytoin, carbamazepine- resulting to
decreased half-life
Adverse effect: fatal aplastic anemia & hepatic failure
 8. GABAPENTIN (Neurontin) Adverse effects
□ For complex partial seizures with or without generalized o Small percentage develop rash
seizures o Neurological effects
□ Oral administration with maximum bioavailability of 60% o Dizziness
and is reduced by antacids o GIT disturbance
o As a monotherapy or in conjunction with other AEDs o
o Suffering from complex partial seizure with or 10. LEVETIRACETAM (Keppra)
without generalized seizures □ For partial & generalized seizures
□ Children need a higher dose in order to maintain half-life; □ Oral administration- nearly entirely bioavailable
30% more □ Reaches peak an hour post dose
o Children eliminate the drug faster than adults □ 65% is excreted and changed in the kidneys
□ Does NOT bound to proteins and is not hepatically Half-life: 6 to 8 hrs
metabolized Adverse effects are minimal
o Dizziness
Eliminated unchanged by the kidneys o weakness
Peak is 2-3 hours post dose Rate of elimination is increased in children & pregnant women;
Half-life is 5-9 hrs in patient with normal kidney decreased in elderly

□ Preferred treatment in patients with liver disease and
treating partial onset seizures with acute intermittent
porphyria
□ Multiple daily doses is preferred as excessive high blood
concentration may cause adverse effects while low level
trough may lead to breakthrough seizures
Therapeutic range: 12-20 µg/mL (70.1 to 116.8 µmol/L)
9. LAMOTRIGINE (LAMICTAL)
□ For partial & generalized seizures
□ Oral administration
o Rapidly and completely absorbed in GIT
o Reaches peak levels in 3 hours after dose
□ Rapid & complete GIT absorption
General therapeutic range: 2.5 to 15 µg/mL
□ 55% protein bound
□ Need for TDM with Levetiracetam is not as pronounced
other AEDs due to its lack of pharmacokinetic variability
Therapeutic range: 8 to 26 µg/mL
11. OXCARBAZEPINE (Trileptal)
□ Prodrug that is almost metabolized to licarbazepine
□ For monotherapy of partial seizures & in secondarily
generalized tonic-clonic seizures.
□ 40% protein bound
Peak: 8 hrs post dose
Half-life: 8 to 10 hrs (adults)
□ children higher renal clearance
□ Renal clearance is reduced with renal dysfunction
Metabolism affected: phenytoin & phenobarbital

T½: 15 to 30 hours (if monotherapy) 12. TIAGABINE (Gabitril)

Hepatic metabolism-major elimination □ For treating partial seizures
□ elimination is highly dependent on age & physiologic □ Rapid & nearly complete absorption
condition ( younger infants metabolize slowly than Peak: 1 to 2 hrs
older infants; children metabolize 2X than adults) Half-life: 4 to 13 hrs
o also affected by: □ 96% protein bound
 phenobarbital □ Hepatic dysfunction prolongs half-life
 pyrimdone
Therapeutic range: 20 to 100 ng/mL
 phenytoin
Adverse effected: confusion, stuttering, mild sedation,
 carbamazepine
paresthesia
o metabolism is inhibited by
 valproic acid □ Dose titration is the best effective method in balancing
 half life is 60 hours therapeutic effects with adverse effects in central nervous
system
 13. TOPIRAMATE (Topamax) 2. Tricyclic antidepressants [TCA]
□ For partial & generalized seizures □ For depression, insomnia, extreme apathy, loss of libido
□ Completely bioavailable after oral administration □ Clin lab most relevant TCA are: imipramine, amitriptyyline &
doxepin
Peak: 1-4 hrs □ Oral administered
Half-life: 20-30 hrs Effect: slow gastric emptying & intestinal motility =slow rate of
□ 15% protein bound absorption= effect not seen in 2 to 4 weeks of treatment
□ major elimination through renal filtration Peak: 2 to 12 hrs
□ Children need higher dose to maintain plasma
□ 85 to 95% protein bound
concentration
□ Serum concentration is increased with renal dysfunction; Elimination: hepatic metabolism
decreased with other AEDs Serum concentration 2x upper limit = drowsiness,
□ Dose titration is effective in balancing therapeutic effect constipation, blurred vision, memory loss
and toxic effect Much higher plasma levels = seizure, cardiac arrhythmia,
unconsciousness
Adverse effects: change of taste with particular food, □ Higher variability & absorption, thus, evaluation is done
sensation of “pins & needles” in extremities. only at steady state
14. ZONISAMIDE (Zonegran)
□ Orally administered 3. Clozapine [Clozaril, FazaClo]
□ 60% protein bound; accumulates in RBC
An atypical antipsychotic used to treat otherwise treatment-
Peak: 4 to 7 hrs refractory schizophrenia (auditory hallucination), including its
Half-life: 50 to 70 hrs (monotherapy); reduced to 25 to 35 with negative symptoms, suicidal tendencies & various cognitive
other AEDs deficiencies

□ Major elimination is through liver metabolism Peak: 2 hours post dose

□ Children need higher dose Half-life: 8-16 hrs
□ Caution use with kidney disease
4. Olanzapine (Zyprexa)
Therapeutic dose: 10 to 38 µg/mL A thienobenzodiazepine derivative that effectively treats
schizophrenia, acute manic episodes, & recurrence of bipolar
PSYCHOACTIVE DRUGS disorders
Or psychotropic substance is a chemical substance that acts □ IM or oral administration
primarily upon the central nervous system where it alters brain Peak: 5 to 8 hours postdose
function, resulting in temporary changes in perception, mood, Half-life: 21 to 54 hours
consciousness and behavior.
□ Higher dose to men & smokers
1. Lithium [Eskalith, Lithoboid]
□ For manic depression [polar disorder] Therapeutic range: 20 to 50 ng/mL
□ Oral administration
□ Absorption is complete & rapid
□ No protein binding
Eliminated by renal filtration
Therapeutic range: 0.5 to 1.2 mmol/L
Toxic ranges at:
□ 1.5 to 2 mmol/L causes apathy, lethargy, speech
difficulties, muscle weakness
□ Greater than 2 mmol/L results to muscle rigidity,
seizures, coma
 IMMUNOSUPPRESSIVE DRUGS
Or immunosuppressive agents or antirejection
medications are drugs that inhibit or prevent activity of the
immune system. They are used in immunosuppressive therapy
to: Prevent the rejection of transplanted organs and tissues
1. Cyclosporine [Gengraf, Neoral, Sandimmune]
□ For suppression of host-versus-grat rejection of
heterotopic transplanted organs.
□ Orally given
3. Sirolimus [ Rapamune]
□ An antifungal agent; commonly used along with
cyclosporine or tacrolimus
□ Bioavailability at 15% if administered with cyclosporin
□ Extremely potent & requires TDM to monitor toxic
effects like thrombocytopenia , anemia, leukopenia,
infections & hyperlipidemia
□ Absorbed rapidly after a once-daily oral dose.
Peak is 1 to 2 hrs
Half-life is 62 hrs

Sequestered mostly in RBC= whole blood is the specimen of Therapeutic range if with cyclosporine is 4 to 12 µg/L ; if
choice cyclosporine discontinued is 12 to 20 µg/L
Eliminated through hepatic metabolism
4. Mycophenolic Acid (Myfortic)
□ Dose is organ related [Cardiac,liver, pancreas: □ A lymphocyte proliferation inhibitor
transplants need 300 ng/mL] □ Comes from mycophenolate mofetil
o Converted in the liver to active form
Peak: 1-6 hours (mycophenolic acid)
□ Supplemental therapy with cyclosporine & tacrolimus
Half-life: 12 hours
in renal transplant patients
Toxic effects at whole blood concentration of 350 to 400 □ Oral administration
ng/mL (291 to 333 nmol/L) o Common route
□ 95% protein bound
Adverse effects include renal tubular & glomerular Peak: 1-2 hours
dysfunction= hypertension T½: 17 hours
2. Tacrolimus FK-506 [Astagraf, Envarsus, Hecoria, Prograf] Therapeutic range: 1 to 3.5 µg/mL

ANTINEOPLASTICS
□ Oral; 100x potent than cyclosporine
Early use = low degree of toxicity than cyclosporine  Used in chemotherapy to kill cancer cells
Extensive use = same as cyclosporine producing
nephrototoxicity at therapeutic range 1. Methotrexate [Otrexup, Rasuvo)
□ Inhibits DNA synthesis in all cells
Peak: 1-3 hours
□ The efficacy of methotrexate is dependent on a controlled
□ 98% bound to protein period of inhibition
o One that is selectively detrimental to neoplastic
T½= 10-12 hours cells
□ Accomplished by administration of leucovorin
□ Toxic level can increase thrombus formation
o Which reverses the action of methotrexate at a
□ Eliminated exclusively by hepatic metabolism
specific time after methotrexate infusion
o “leucovorin rescue”
□ high dose given followed by leucovorin rescue has shown
effective therapy
□ failure to stop methotrexate actions = cytotoxic effects
□ Oral administration
Peak: 1 hour post dose
T½: 5 to 9 hours
Primary elimination: kidneys
Therapeutic dose: less than 1 µmol/L
 BRONCHODILATORS
Relieve asthma symptoms by relaxing the muscle bands that
tighten around the airways. This action rapidly opens the
airways, letting more air come in and out of the lungs.

1. THEOPHYLLINE [Theo-Dur, Theo-24, Uniphyl]

For respiratory disorders like asthma, stable chronic

obstructive pulmonary disease, patients with difficulty using
inhalers or those with nocturnal symptoms

Peak: for rapid release formation is 1-2 hours; modified-

release preparation is 4- 8 hours

□ 50-65% is protein bound

T½: 3 to 8 hours

Elimination primarily through liver; 20% though kidneys

Therapeutic dose: 10 to 20 mg/L (55 to 110 µmol/L)

Toxicity: insomnia, tachycardia, seizures, arrhythmias, possible

cardiorespiratory arrest
 CARDIOACTIVE ROUTE PEAK HALF-LIFE %PROTEIN ELIMINATION THERAPEUTIC RANGE
BOUND

Digoxin Oral 2-3 hours post dose 38 hours 25% Renal Filtration 0.8-2 ng/mL or 12.6 nmol/L
CG
Quinidine Oral QS: 2 hours post dose 6-8 hours 70-80% Hepatic Metabolism 2-5um/mL
A GIT QG: 4-5 hours post dose

Procainamide Oral 1 hour after ingestion 4 hours Combination of Renal filtration and Hepatic 4-8 ug/mL
A Metabolism
Disopyramide Oral 1-2 hours post dose 7 hours Primarily eliminated through renal filtration and 3-7.5ug/mL or 8.8-
A sub for quinidine little of hepatic metabolism 22.1mmolL

ANTIBIOTIC ROUTE PEAK HALF-LIFE %PROTEIN ELIMINATION THERAPEUTIC RANGE Assessment

BOUND

Aminoglycoside IV and 1-2 hours post dose 2-3 hours 10% Renal Filtration NA chromatography;
IM immunoassay
Teicoplanin IV and 70-100 Therapeutic range is at
IM hours 10 to 60 mg/L for
treatment of
endocarditis and 20-60
mg/L for the treatment
of staphylococci
infections
Vancomycin IV 1 hour post dose 4-6 hours 55% Renal Filtration and immunoassay and
excretion chromatographic techniques
ANTIEPILEPTIC ROUTE PEAK HALF-LIFE %PROTEIN ELIMINATION THERAPEUTIC RANGE Assessment
BOUND

Phenobarbital oral dose 10 hrs 70-100 hours 50% mainly by hepatic Trough levels are
is slow but metabolism but renal typically evaluated
complete filtration is also
significant
Primidone Inactive form of phenobarbital, converted after absorption
Phenytoin Oral 3 to 12 hours 6 to 24 hours 87 to 97% hepatic metabolism free phenytoin: 1-2 µmol/mL immunoassays
(dilantin) administra (4 to7.9 µmol/L)
tion Total phenytoin:10 to 20
µg/mL ( 20 to 80 µmol/L)
VALPROIC ACID Oral 1-4 hours post 11 to 17 hours 93% hepatic metabolism 50-120 µg/mL (347 to 832 hepatic indicators
(valproate) dose µmol/L) should be checked in
the first 6 months of
therapy
Carbamazepine Oral route 4 to 8 hours 10 to 20 hours 70%-80% hepatic metabolism 4 to 12 µg/mL (16.9 to 50.8 Leukocyte counts
(tegretol) post dose µmol/L) should be assessed
during the first 2
weeks of therapy
Ethosuximide oral 2-4 hours 40 to 60 hours liver metabolism; 20% by 40 to 100 µg/mL (283 to 708
(zarontin) renal filtration µmol/L)
Felbamate Oral 1 to 4 hrs 14 to 22 hours in 30% renal & hepatic 30 to 60 µg/mL (126 to 252
(felbatol) adults metabolism µmol/L)
Gabapentin Oral 2-3 hours post 5-9 hrs in patient 60% kidneys 12-20 µg/mL (70.1 to 116.8
(neurontin) dose with normal bioavailable µmol/L)
kidney
Lamotrigine Oral 3 hours after 15 to 30 hours 55% 2.5 to 15 µg/mL
(lamictal) dose
Levetiracetam Oral 1 hour post 6 to 8 hrs Nearly 65% is excreted and 8 to 26 µg/mL
(keppra) dose entirely changed in the kidneys
bioavailable
Oxcarbazepine 8 hrs post dose 8 to 10 hrs 40% 20 to 100 ng/mL
(trileptal) (adults)
Tiagabine 1 to 2 hrs 4 to 13 hrs 96%
(gabitril)
Topiramate 1-4 hrs 20-30 hrs 15% renal (urine) filtration
(topamax)
Zonisamide Oral 4 to 7 hr 50 to 70 hrs 60%, liver metabolism 10 to 38 µg/mL
(zonegran) (monotherapy); accumulates
reduced to 25 to in RBC
35 with other
AEDs
 PSYCHOACTIVE ROUTE PEAK HALF-LIFE %PROTEIN ELIMINATION THERAPEUTIC RANGE Assessment
BOUND

Lithium [Eskalith, Oral No protein renal filtration 0.5 to 1.2 mmol/L

Lithoboid] binding
Tricyclic Oral 2 to 12 85 to 95% hepatic metabolism
antidepressants
[TCA]
Clozapine 2 hours post 8-16 hrs
[Clozaril, FazaClo] dose

Olanzapine IM or oral 5 to 8 hours 21 to 54 hours 20 to 50 ng/mL

(Zyprexa) administra post dose
tion

IMMUNOSUPPRESSIVE ROUTE PEAK HALF-LIFE %PROTEIN BOUND ELIMINATION THERAPEUTIC RANGE

Cyclosporine [Gengraf, Neoral, Oral 1-6 hours 12 hours hepatic metabolism Toxic effects at whole blood
Sandimmune] concentration of 350 to 400
ng/mL (291 to 333 nmol/L)
Tacrolimus FK-506 [Astagraf, Oral 1-3 hours 10-12 hours 98% hepatic metabolism
Envarsus, Hecoria, Prograf]
Sirolimus [ Rapamune] 1 to 2 hrs 62 hrs Bioavailability at 15% 4 to 12 µg/L ; if cyclosporine is
if administered with discontinued, 12 to 20 µg/L
cyclosporin
Mycophenolic Acid (Myfortic) Oral 1-2 hours 17 hours 95% 1 to 3.5 µg/mL

ANTINEOPLASTIC ROUTE PEAK HALF-LIFE %PROTEIN ELIMINATION THERAPEUTIC RANGE

BOUND
Methotrexate [Otrexup, Oral 1 hour post dose 5 to 9 hours kidney filtration less than 1 µmol/L
Rasuvo)

BRONCHODILATOR ROUTE PEAK HALF-LIFE %PROTEIN ELIMINATION THERAPEUTIC RANGE

BOUND
THEOPHYLLINE [Theo-Dur, for rapid release formation is 3 to 8 hours 50-65% primarily through liver; 10 to 20 mg/L ( 55 to 110
Theo-24, Uniphyl] 1-2 hours; modified-release 20% though kidneys µmol/L)
preparation is 4- 8 hours post
dose
Clinical Chemistry MLS111B

LESSON 9
TRACE AND TOXIC ELEMENTS
• Lab environment must be carefully
controlled
• Place the examination of lab trace
element in a separate room
• Non shedding ceiling tiles
• airflow
➢ Careful collection

ALUMINUM
• Introduced through oral, inhalation, parenteral
• 50% of the body burden is in the bone; 25% of the
body burden is in the lungs
TRACE AND TOXIC ELEMENTS • Highest concentration is found in bone and
lungs
Instrumentation:
• Aluminum in lungs will increase with age
• FAAS
• Urine excretion is 95% wile bile elimination is at 2%
• Flame atomic absorption spectrometer
• Bound to transferrin in plasma
• Flame or flameless
• Over the counter is safe
• GFAAS
• Signs & symptoms of toxicity:
• Graphite furnace atomic absorption
a) encephalopathy
spectrometer
• stuttering,
• Flameless
• ICP-AES • gait,
• Inductively coupled plasma – atomic • disturbance,
emission spectroscopy • myoclonic jerks,
• Automation and excitation • seizures,
• ICP-MS • coma,
• Inductively coupled plasma – mass • abnormal EEG
spectrometry b) Osteomalacia or aplastic bone disease
• Sensitive c) Proximal myopathy
• Wide range of elements covered d) Increased risk of infection
• Relative freedom from interferences e) Microcytic anemia
Sample collection f) Increased left ventricular mass
➢ Analyte is low in specimen g) Decreased myocardial function
• Extraordinary measures are required to
ARSENIC
prevent contamination of specimen
• Special sampling and collection devices • US FDA approved in 2000, use arsenic trioxide for
• Clean galss tube treatment of acute promyelocytic leukemia
• High purity water and reagents • Ingested through food and water
• Careful selection of • Acute toxicity symptoms :
• Needles a) Gastrointestinal
• Evacuated collection tubes • nausea,
• Anticoagulants • emesis,
• Other additives • abdominal pain,
• Pipets must be carefully evaluated • rice water
• diarrhea
Clinical Chemistry MLS111B

LESSON 9
TRACE AND TOXIC ELEMENTS
b) bone marrow CADMIUM
• pancytopenia,
• anemia, • Airborne (largest source)
• basophilic stippling • Burning of fossil fuels
c) cardiovascular ( EKG changes) • ingestion, smoking
• Toxic symptoms
a) Acute effect seen in
d) CNS - Ingestion of high amounts: severe nausea,
• encephalopathy, vomiting, abdominal pain
• polyneuropathy) - Inhalation : respiratory distress
e) renal (renal failure) b) Chronic effect results to renal dysfunction
f) Hepatic (hepatitis) • Treatment
• Chronic toxicity symptoms • Chelating agent: EDTA
a) dermatologic
• Mees lines, CHROMIUM
• hyperkeratosis,
• Mostly through occupational exposure
• hyperpigmentation,
• Wood treatment
• alopecia
• Stainless steel
Blackfoot disease (BFD) a severe form of peripheral
• Welding
vascular disease (PVD) that leads to gangrenous changes
a) Hepatic ( cirrhosis, hepatomegaly) • Bound to albumin and transferrin
b) Cardiovascular ( hypertension, peripheral vascular • Transferring bind to chromium at site b
disease) • Albumin acts as acceptor and transporter of
c) CNS chromium if transferrin sites are saturated.
• Other protein binding proteins:
• “socks & glove” neuropathy,
• Beta globulins
• tremor
• Gamma globulins
d) Malignancies
• Lipoproteins
• squamous cell skin,
• Plays a role in maintaining normal metabolism of
• hepatocellular,
glucose, fat, & cholesterol
• bladder,
• Rarely to have deficiency
• lung, • Glucose intolerance
• renal • Glycosuria
• Toxic dose: 0.01 to 0.05 g • Hypercholesterolemia
• Lethal dose: 0.12 to 0.3 g • Impaired fertility
• Treatment: immediate lavage; use of activated • Decreased sperm count
charcoal • Cr(+6) is better absorbed and more toxic than
• Antidotes: chelating agents like dimercaprol, Cr(+3)
penicillamine, succimer • Intracellularly, Cr(+6) is reduced to reactive
intermediates.
• Producing free radicals
• Oxidize DNA
• Induces cell death
• In 2011, FDA to post mark surveillance studies on
metal hip replacement systems in response to an
increasing concern over failed implant devices in
Europe
Clinical Chemistry MLS111B

LESSON 9
TRACE AND TOXIC ELEMENTS
COPPER - emesis is blue-green
• Wilson’s disease ( copper accumulation)
• Important cofactor and is critical for the reduction of - Clinical findings include neurologic disorders, liver
iron in heme synthesis dysfunction
• Highest concentration in liver (10%), brain, heart, - Kayser-Fleisher rings in the cornea
kidneys - Green brown discoloration
• Also in: - Wilson’s halted with use of zinc acetate or chelation
• Cornea therapy
• Spleen
IRON
• Intestine
• Lungs • 1% of dietary iron is absorbed
• Transported by albumin, transcuprein, • Ferric iron is the dominant form in food
ceruloplasmin (liver) • Must be reduced
• Elimination is 98% through bile and 2% through • Vitamin C or ferric reductases
urine and perspiration • Vitamin C must be taken with iron to convert
• Copper deficiency is related to ferric to ferrous
• malnutrition, • Hepcidin regulates iron absorption in the upper GIT
• malabsorption, by modulating the export of iron from cells by
• chronic diarrhea, ferroportin
• hyperalimentation • After 120 days, the RBC breaks and iron is
• Deficiency symptoms: returned to circulation for use
1) neutropenia & hypochromic anemia (early • Iron is primarily lost by desquation by red cell loss
stages) to urine and feces
2) osteoporosis and various bone and joint • With each menstrual cycle, women lose about 20-
abnormalities 40mg of iron
3) Decreased pigmentation of the skin and general • Ferrous (Fe2+) & Ferric (Fe 3+) participate in redox
pallor chemistry.
4) Neurologic abnormalities to include hypotonia, • Intestinal absorption=main regulatory process
apnea, psychomotor retardation ( later stages) • Fe2+ =bound to ferritin; Fe 3+ bound to apotransferrin
• Menkes’ disease (extreme copper deficiency) • Absorption and transport capacity is increased in
- Symptoms appear at 3 months and death at age 5 iron deficiency, anemia, hypoxia
- Progressively fatal rain disease is characterized by • 2 to 2.5 g out of 3 to 5 g iron in the body is in
- Characterized by kinky or steely, and hemoglobin
retardation of growth. • Ferric iron release form binding proteins can
- Clinical signs include: enhance production of free radicals to cause
- progressive mental deterioration, oxidative damage
- coarse feces, • In iron loaded individuals treated with chelators to
- disturbance of muscle tone, bind and mobilize iron, the intake of vitamin C will
- seizures, promote the generation of free radicals
- episodes of severe hypothermia. • Iron deficiency :
• Excess copper • pregnancy,
- Copper toxicity has been associated with living • women of reproductive age,
near copper producing facilities • young children,
- Because of its toxic potential: • adolescents
- Irritant to epithelia and mucus membranes • Iron overload: collectively termed as
- Can cause hepatic and renal damage hemochromatosis (HH)
- hepatic and renal damage with hemolysis.
Clinical Chemistry MLS111B

LESSON 9
TRACE AND TOXIC ELEMENTS
a) Primary iron overload= associated with
heredity;
a) treatment: phlebotomy or chelators
• Exposure
b) Secondary iron overload=excessive dietary,
a) Childhood exposure through paint chips
medicinal, transfusional or due to metabolic
b) Adult occupational exposure in the smelting,
dysfunction
mining, ammunitions, soldering, plumbing,
LEAD ceramic glazing
Introduced via inhalation, gastrointestinal
Weaken lead absorption: MERCURY
• iron,
• Thimerosal is a preservative to vaccines in trace
• calcium,
level, except inactivated influenza vaccine
• magnesium,
• Reduced already due to toxicity
• alcohol,
• To children below 6 years old
• fat
• Signs and symptoms of intoxications are
Enhances lead absorption:
nonspecific= laboratory testing needed
• low zinc,
• Routes of administration
• low ascorbic acid
(1) Use of mercury in medicine has been reduced
• low citric acid
(1) Still be found in:
95% absorbed lead taken by RBCs= interferes
(1) Topical antiseptics
heme synthesis
(2) Stimulant laxatives
Distribution in soft tissues:
(3) Diaper rash ointment
• liver,
(4) Eyedrops
• kidneys,
(5) Nasal spray
• brain
(2) Widely used in the production of eye cosmetics;
>90% body lead burden is in the bones
eye mascara
• Excretion:
a) urine=76% (3) inhalation - primary as elemental mercury vapor
b) Feces= 16% but occasionally as dimethyl mercury
c) Hair, sweat, nails= 8% (1) inhaled mercury vapor is retained in the
• Toxicity effects (variable) lungs to about 80%
a) Children (usually seen @ 60 µg/dL) (2) metallic mercury passes through the
- IQ declines, GIT largely unabsorbed
- clumsiness, (4) ingestion -mercury containing foods such as
- gait abnormalities, predatory fish species
- headache, (5) cutaneous absorption of methyl mercury
- behavioral changes, through the skin or even through latex gloves
- seizures, (6) injection of relatively inert liquid mercury and
- severe cognitive mercury-containing tattoo pigments
- behavioral problems. (7) dental amalgams
b) Adults (8) Kidneys major storage organ of elemental or
- Peripheral neuropathies, inorganic mercury exposure.
- motor weakness, (9) Enters the food chain through volcanic activity
- chronic renal insufficiency, or coal combustion and smelting
- systolic hypertension,
- anemia
Clinical Chemistry MLS111B
LESSON 9
TRACE AND TOXIC ELEMENTS
(10) Methyl mercury is efficiently absorbed from
GIT and distribution to tissues like brain is
complete within 48 hours
(11) Halflives vary according to form and route of
exposure.
(1) Phenyl mercury half life is 5 days in the • High dietary & occupational exposure are linked to
blood
(2) Chronic exposure to inorganic mercury
results to 90% in urine
(3) Mercury can also accumulate in:
(1) Thyroid glands
(2) Pancreas
(3) Reproductive organs
(12) Eliminated in approx 60 days, except
organic forms can accumulate in the brain for
several years before they are eliminated.
MANGANESE
• 2% to 15% dietary manganese=absorbed in small
intestine
• Absorption is Age dependent, infants retain more
• Primary Elimination= bile
• Mn depletion results in:
• epilepsy,
• hip and joint abnormalities,
• heart and bone problems,
• stunted growth in children
• Mn toxicity causes:
• nausea,
• vomiting,
• headache,
• disorientation,
• memory loss,
• anxiety,
• compulsive laughing or crying
• Chronic Mn toxicity resembles Parkinson’s disease
MOLYBDENUM
• 25% to 80% is absorbed in stomach and small
intestine
• Retention in liver, skeleton, kidney
• Bound to alpha-macroglobulin and red blood cells
membranes
• Can cross placental barrier
• Deficiency is rare, results from total parenteral
nutrition in Crohn’s disease.
• Molybdenum cofactor deficiency results to seizures,
anterior lens dislocation, decreased brain weight,
death prior to 1 year of age
• Cofactor for molybdenum is molybdopterin
• Molybdenum toxicity is also rare
high BUA and high incidence of gout
• Elimination: urine and bile
SELENIUM
• Commonly used as antidandruff shampoos and
fungicides
• Deficiency: cardiomyopathy, skeletal muscle
weakness, osteoarthritis
• There is an endemic cardiomyopathy affecting
children and women of child bearing age in certain
areas in chine
• Associated with selenium deficiency
• Keshan disease
• Kaschin Beck disease
• Endemic osteoarthritis
• Also low selenium status
• Seen in northern china
• Acute oral exposure to extremely high selenium
levels= GIT symptoms & cardiovascular
• Nausea, vomiting, and diarrhea
• Tachycardia
• Chronic exposure= dermal effects & neurologic
problems
• Disease of the nails and skins, hair loss
• Unsteady gait and paralysus
• Selenium sulfide = probable human carcinogen
• Huebei province of china in the early 1960 almost
half of the population of the many villagers dies
from chronic selenosis
ZINC
• Deficiency is common
• Among those individuals that do not eat
meat
• body distribution :
• 60% in muscles;
• 30% in skeleton,
• 10% in eyes, prostate, hair.
• blood distribution:
• 80% in RBCs;
Clinical Chemistry MLS111B

LESSON 9
TRACE AND TOXIC ELEMENTS
• 17% in plasma,
• 3% in white blood cells.
• Absorption occurs primarily in jejunum.
• Absorption enhanced by animal proteins and amino
acids, intake of calcium and unsaturated fat.
• Absorption decreased:
• iron,
• taking zinc in empty stomach,
• presence of high copper levels,
• age.
• Old age
• Pregnancy
• Lactation
• Alcoholism
• Deficiency causes:
• growth retardation,
• slows skeletal maturation,
• causes testicular atrophy,
• reduces taste perception.
• Infants with acrodermatitis enteropathica or zinc
malabsorption develop a characteristic facial and
diaper rash
• Untreated symptoms would progress to:
• Growth retardation
• Diarrhea
• Impaired T-cell immunity
• Insufficient would healing
• Delayed testicular development
• Early death
• Zinc is nontoxic. But high and repeated doses can
lead to GIT symptoms, decrease in heme synthesis
due to induced copper deficiency and
hyperglycemia.
Clinical Chemistry MLS111b
Toxicology Introduction
Acute VS Chronic Toxicity
OUTLINE Acute Chronic
I. Toxicology Introduction Associted with adverse Assocated with repeated
II. Terms effects of a chemical frequent exposure for
III. Pharmacology vs. Toxicology that result from a single, extended peroids for
IV. Mechanistic toxicology or multiple exposures greater than 3 monthd and
V. Descriptive toxicology (<24hrs) possibly years, at doses
VI. Regulatory toxicology Occurs within 14 days that are insufficient to cause
VII. Specialization in toxicology an immediate acute effect
a. Forensic toxicology of toxicant; affects different
b. Clinical toxicology systems
c. Environmental toxicology
VIII. Toxin exposure routes Toxicity Rating System
IX. Basic techniques for detecting drugs in Rating Lethal oral dose in ave adlut
serum/urine Super toxic <5 mg/kg
a. Immunochemical Extremely toxic 5 – 50 mg/kg
i. EMIT Very toxic 50 – 500 mg/kg
ii. FPIA Moderately toxic 0.5 – 5 g/kg
b. Chromatographic Slightly toxic 5 – 15 g/kg
i. TLC Practically toxic >15 g/kg
ii. HPLC
iii. CE
iv. GC-MS Pharmacology vs. Toxicology
v. LC-MS
vi. Gas chromatography Comparison
coupled with IR Pharmacology Toxicology
spectroscopy The study of the origin, The study of adverse
nature, chemistry, effects of chemicals on
effects & use of drugs health
Dose is the amount of Dose is the amount of a
Toxicology Introduction drug absorbed from an chemical absorbed from
administration a chemical exposure
A drug can be Exposure is contact with
Terms administered one time
on short-term or long-
a chemical. Exposure
can be one time or
Poisons: toxic chemicals
term basis occur on a short-term or
Toxicity: degree to which toxins cause damage in long-term basis
the body A dose-response curve A dose-response curve
Toxic dose (TD): amount of the chemical that graphically represents describes the
produces a toxic effect the relationship between relationship of body’s
Lethal dose(LD) amount of the chemical or the dose of a drug and response to different
agent that causes death the response elicited amount s of an agent
such as drug or toxin
Median lethal dose (LD50): amount of a chemical
capable of killing one half of a tested population Both pharmacology and toxicology both include
Detection window: time in which drug can be the study of the possible adverse effects of the
detected in body fluids therapeutic drugs.
 Clinical Chemistry MLS111b
Toxicology Introduction
Comparison Acronym Meaning Role
Pharmacology Toxicology FDA Food & drug Safety on therapeutic
Routes of Routes of entry are administration drugs, cosmetics, food
adminitrationinclude ingestion, inhilation, or additives
oral, intramuscular, dermal absorption OSHA Occupational Safe & health work
intravenous, dermal, or safety & health environment
topical administration
Drugs have therapeutic Only toxic effects are of CPSC Consumer Regulates household
responses & side concern. Toxicity is the product safety chemicals
effects. Beyond the degree to which a commission
therapeutic dose, drugs chemical damages an DOT Department of Oversees transporting
may be toxic organ system, distrupts a transportation of chemical hazards
biochemical process, or
disturbs an enzyme
system Specialization in Toxicology
Potency is the amount Potency of a toxic Forensic
of drug required to chemical is the amount it
produce desired takes to elicit a toxic Clinical
response effect compared with Environmental
other chemicals Forensic Toxicology
Concerned with medicolegal consequences of
Topical cannot be seen in toxicology
exposure to chemicals or drugs
In the origin of toxicology, when cosmetics are
Main focus is to establish and validate the
gifted to royalty, incorporated in these
analytic performance of the methods used to
cosmetics are actually some poisons.
generate evidence in legal situations
The study of the adverse effects of xenobiotics [
include chemicals & drugs that are not normally Clinical Toxicology
found or produced in the body] in humans Study of interrelationships between xenobiotics
Disciplines are mechanistic, descriptive, & disease states
regulatory It emphasizes not only diagnostic testing but
also therapeutic interventions
Mechanistic Toxicology Environmental toxicology
Elucidates the cellular, molecular & biochemical Evaluation of environmental chemical pollutants
effects of xenobiotics within the context of dose- & their impact on human health
response relationship A boat may be leaking fuel or oil that may
Provide basis for rational therapy design & tests destroy living organisms in the area
to assess the degree of exposure Evaluation of air pollutants

Descriptive toxicology Dose-response Relationship

Uses the results from animal experiments to
predict what level of exposure will cause harm
in humans- process called risk assessment
Regulatory toxicology
Interpretation of the combined data from
mechanistic & descriptive studies is used to
establish standards that define the level of
exposure that not pose a risk to public health or
safety.
FDA guidelines for safe levels of exposure:
If measured effect is death: safe level is set
to NO OBSERVABLE EFFECT LEVEL
(NOEL)
Less outcomes, safe level is LOWEST
OBSERVE EFFECT LEVEL (LOEL)
LOEL is the dose at which the effect is first
measured
Toxin Exposure Routes
Dermal (Skin)
Ingestion ( stomach, digestive tract)
Clinical Chemistry MLS111b
Toxicology Introduction
o Most common and observed route of  Dead bodies that are exhumed and
administration par tis taken in order to be
o For most toxin to exert effect it must be examined
absorbed o These take a long time to decay
o Commonly absorbed in the GIT o Can be used if ever there is doubt
o Rapid absorption, absorption is complete regarding the probably cause of
o Absorption can be passive through diffusion death of a person
or process similar to absorption of nutrients Detection window: time in which drug can be
detected in body fluids
Applied both to drugs of abuse & therapeutic
Factors affecting absorption Basic types: immunochemical & chromatographic
 Solubility of toxin
 pH Immunochemical methods
 rate of dissolution Homogenous immunoassay
 GIT motility Common drug testing done today
 Resistance to degradation in the GIT Homogenous means that the assays are all
 Interaction with other substances performed in a solution , without any
o Other therapeutic drugs when taken can requirement for a phase separation that is
reduce the effect of other drugs traditionally used to separate bound from free
o If not trained to provide antidotes then do ligand = rapid & applied to STAT
not EMIT
Toxins not absorbed through GIT do not Enzyme-mediated ( or multiplied) immunologic
produce systemic effects but only local effects technique
like: o Reported as positive or negative
o Diarrhea Drug-enzyme complex is used as a marker
o Bleeding When drug is bound to the antidrug antibody,
o Malabsorption the active site of the enzyme is blocked, thus, if
o Will cause systemic effects substrate is added= no reaction occurs
secondary to toxins If drug is free, most enzyme-drug complex is
Inhalation ( respiratory tract ) displaced from the antidrug antibody, leaving
Others: the active sites free for the substrate to fit in
o injection
o eye
Skin is more permeable to fat-soluble chemicals
Skin exposure can have delayed-onset
systematic effects
Broken skin allows quick entry of toxin to
bloodstream
Inhalation is the fastest route for toxins to enter
the systemic circulation
Basic techniques for detecting drugs in
serum/urine
With illicit drugs, they are detected through When the drug is bound to the anti-drug
urine; noninvasive antibody, the active site of the enzyme is
Other drugs can be identified using: blocked.
o Hair o No reaction if substrate is added
o Nail If drug is free, most enzyme drug complex is
o Bone displaced from the anti-drug antibody
Clinical Chemistry MLS111b
Toxicology Introduction
o The active sites free to react with the
substrate
FPIA
Fluorescence polarization assay
drug is covalently attached to a fluorescent
label or flourophore
If a flourescent molecule is excited with
polarized light and is immobilized or stationary,
it will emit polarized light as flourophore.
Emitted light has the same polarization as the
exciting light. Ex. if exciting light is polarized to
the left, emitted light will also be polarized to the
left
In the presence of free drug, the drug-probe
complex is displaced from the antidrug HPLC
antibody. High-performance (or high pressure) liquid
Then, it is no longer immobilized. It tumbles chromatography
freely in the solution resulting in loss of Allows quantitative detection & sharper
polarization of the emitted light separation of drugs
Emitted light is now polarized equally to the left
Ex of uses:
& right
o Detection of cocaine & heroin in urine
o Separation & quantification of tricyclic
antidepressants

CE
Capillary electrophoresis is a variant of TLC
Driving force for separation is voltage rather
than pressure
Utilized in analytic forensic toxicologic &
molecular diagnostic studies

GC-MS- Gas chromatography-Mass

Chromatographic techniques
Applied to the qualitative detection of drugs of
abuse & toxins rather than determination of
levels of therapeutic drugs
o Reported as positive or negative
Major methods: TLC, HPLC, GC-MS
TLC- Thin layer chromatography
Based on relative affinities for a polar solid
stationary phase (usually a hydrated silicate) &
a mobile liquid phase that is nonpolar ( such as
10% methanol in chloroform)
Allows direct qualitative detection of drugs
Spectroscopy
“Gold standard” for detection & quantitation of
volatile drugs & poisons
Has high sensitivity & reliability
Used to confirm results obtained using
screening methods such as EMIT & TLC
LC-MS
Liquid chromatography-mass spectroscopy
Detects nonvolatile compounds
To confirm positive test results, for confirmation
of drugs-of-abuse assays, poisoning detection
in acute or chronic intoxication, therapeutic drug
identification & quantification
Clinical Chemistry MLS111b
Toxicology Introduction
Gas chromatography coupled with IR
spectroscopy
Infrared, or Fourier-transformed infrared,
spectroscopy (FTIR) utilizes light of high
wavelength, which excites vibronic states of
molecules
Every compound has a characteristic IR
“fingerprint”, so even closely related
compounds can be distinguished from one
another by gas phase IR
Clinical Chemistry MLS111b
TOXICOLOGY OF SPECIFIC AGENTS
Toxicology of Specific Agents
OUTLINE
I. Alcohol
a. Ethanol Terms
i. Pathology Antitussive
ii. Toxicology o Medication for coughing
iii. Laboratory methods Analgesia/Analgesics
b. Methanol o Inability to feel pain
i. Toxicology o Medicine used to relieve pain
c. Isopropanol Anesthetic
i. Toxicology o Substance that induces insensitivity to pain
d. Ethylene glycol Euphoria
e. Formaldehyde o State if intense excitement or happiness
f. Benzene GC
g. Xylene o Gas chromatography
II. Carbon monoxide ISE
a. Toxicology o Ion selective electrodes
b. Laboratory methods LC
III. Caustic agent o Liquid chromatography
a. Bleach MS
b. Bug repellants o Mass spectrometry
IV. Cyanide
a. Toxicology
b. Laboratory Methods Alcohol
V. Pesticides Includes;
a. Toxicology  Ethanol
VI. Therapeutic drugs  Methanol
a. Salicylates  Isopropanol
i. Toxicology  Ethylene glycol
ii. Laboratory methods
Toxicity causes disorientation, confusion,
b. Acetaminophen
i. Toxicology euphoria -> progress to unconsciousness,
ii. Laboratory methods paralysis, death (with high level of exposure)
VII. Drugs of Abuse Most alcohols display these effects at
a. Amphetamines and equivalent molar concentrations.
metamphetamines CNS Depressant
i. Methylenedioxymethylamph The similarities suggest a common depressant
etamine (MDMA, ecstacy)
effect on the CNS which is mediated by
b. Anabolic steroids
c. Cannabinoids changes in membrane properties
d. Cocaine In most cases, recovery form the CNS effect is
e. Opiates rapid and complete after the cessation of
f. Codeine exposure
g. Morphine
h. Methadone
i. Phenycyclidine
j. Lysergic diethylamine
k. Dextropropoxypene (darvon)
l. Sedative-Hypnotics [tranquilizers]
i. Barbiturates
ii. Benzodiazepines
iii. Hydromorphone
Clinical Chemistry MLS111b
TOXICOLOGY OF SPECIFIC AGENTS
The most significant pathway by which short
chain aliphatic alcohols can be metabolized is
the hepatic conversion of alcohol to aldehyde
by the presence of alcohol dehydrogenase and
further to an acid by hepatic aldehyde
dehydrogenase
Ethanol
A blood alcohol of 80 mg/dL has been
established as the statutory limit for motor
vehicle operation in the USA
Excessive ethanol exposure is a leading cause
of economic, social, & medical problems
throughout the world
Pathology
A continued consumption of ethanol can
compromise many organs;
o liver as the most sensitive organ.
Most pathologic consequences are associated
with chronic consumption
In an average individual, this correlates to 50g
of ethanol per day for 10 years
This pattern of consumption has been
associated with compromised function of
various organs.
o Liver is the most affected
The pathologic sequence starts with the
accumulation of lipids in the liver cells
(hepatocytes)
With continued consumption of alcohol, this
may progress to alcohol hepatitis with about
20% of individuals with long term high level
alcohol intake develops into toxic hepatitis.
Those who will not progress to toxic hepatitis,
progress to liver cirrhosis
Ethanol related disorders are consistently one
of the top 10 causes of hospital admissions
Ethanol case related premature mortality have
increased five folds
Consumption of ethanol during pregnancy may
lead to fetal alcohol syndrome or fetal alcohol
affected
o Both are associated with delayed
motor and mental development in
children
Alcoholic hepatitis/toxic hepatitis-cirrhosis
o Characterized as a fibrosis leading
to functional loss of the hepatocytes
o This condition is associated with
changes in many laboratory tests
related to hepatic function
COMMON INDICATORS OF ETHANOL ABUSE
Test
Increases can be seen before the
onset of pathologic consequences
GGT Increases in serum activity can occur
in many non-ethanol-related
conditions
AST Increases in serum activity can occur
in many non-ethanol-related
conditions
ALT/AST ratio If greater than 2-highly specific for
ethanol related liver disease
HDL High level is specific for ethanol
consumption
Increase erythrocyte MCV is
commonly seen with excessive
MCV ethanol consumption
Increases are not related to folate or
B12 deficiency
Toxicology
Extra acetaldehyde is a transient species as a
result of rapid adduct formation with amine
groups of proteins
Many pathologic effects of ethanol has been
correlated with the formation of these adducts
Formation of acetaldehyde adducts causes
changes in function of proteins
Clinical Chemistry MLS111b
TOXICOLOGY OF SPECIFIC AGENTS
Laboratory methods
Used in litigation in drunken driving cases
Requires appropriate chain of custody
procedure for specimen collection
Documentation of acceptable quality control
performance
Specimen: plasma, serum, whole blood
Method for legal application: GC
o Considered to be the established reference
method for ethanol and it can be used
because it is simultaneously measuring
other alcohols
o Other analytic methods for ethanol
measurements are:
 Cosmometry
 Chromatography
 Enzymatic methods
Collection:
o alcohol free venipuncture collection
 may add up to the alcohol level
in the blood
 use alcohol free disinfectant
o tubes capped all the time
 avoid evaporation of alcohol
o Sealed specimens can be refrigerated or
stored at room temp for 14 days without
loss of ethanol
o Sodium fluoride prevents increase of
ethanol from bacterial fermentation
Methanol
Wood alcohol
Common solvent
Accidental ingestion as a component of many
commercial products or as a contaminant of
homemade liquors
Toxicology
Methanol is initially metabolized by hepatic ADH
to formaldehyde
Formaldehyde is converted by hepatic ALDH
into formic acid
Formic acid causes severe acidosis which may
lead to death
o Optic neuropathy may lead to
blindness
As little as 4ml of methanol may lead to
blindness
Isopropanol
Aka rubbing alcohol
hepatic ADH
Isopropanol acetone
Primary metabolic end product is acetone
Toxicology
Acetone and isopropanol has a CNS
depressant effect which is similar to ethanol but
due to acetone having longer half-life,
intoxication with isopropanol can result in
severe acute phase ethanol like symptoms that
could persist for an extended period of time
Est lethal dose: 250 mL
Acetone has longer half-life=severe acute
phase ethanol-like symptoms that persist for an
extended period of time
Ethylene Glycol
Common component of hydraulic fluid &
antifreeze
Ingestion among children is common because
of its sweet taste
Immediate effects are similar to ethanol
Poisoning symptoms: anuria & necrosis
Toxic level: 786 mg/kg
explains anuria and necrosis
Formaldehyde
Water-soluble gas; byproduct of combustion
Widely used as disinfectant & fixative
Carcinogen
Exposure causes burning of eyes & irritates
mucous membrane or skin
Clinical Chemistry MLS111b
TOXICOLOGY OF SPECIFIC AGENTS
Benzene A colorless, odorless, tasteless gas that is
Colorless liquid rapidly absorbed into the blood from the expired
Aromatic hydrocarbon that is a natural air (silent killer)
constituent of crude oil Can be produced by the body, normally
Component of engine exhaust and tobcco circulating CO= 0-3%
smoke
Toxicology
Not regarded as acute toxic material
CO + Hb = COHb [Affinity is 200 to 225 x than
O2] =hypoxia
Acute exposure causes:
o Can displace oxygen
 Irritated eyes
o Higher affinity to oxygen than
 Skin
hemoglobin
 Nose
only treatment is 100% oxygen therapy
 Respiratory system
 Dizziness Symptoms of carboxyhemoglobinemia
 Anorexia COHb %
 Weakness 0.5 Typical in non-smokers
 Dermatitis 5 - 15 Value seen in smokers
 Bone marrow depression 10 Shortness of breath with vigorous
 Aplastic anemia exercises
Vomiting should not be induced after accidental 20 Shortness of breath with
ingestion as it can increase the chance of moderate exercises
aspiration 30 Severe headaches, fatigue,
Oral toxic level: 0.03 mg/m3 impairment of judgement
Xylene 40 - 50 Confusion, fainting on exertion
Liquid, aromatic hydrocarbon 60 - 70 Unconsciousness, respiratory
Lipophilic property is responsible for its narcotic
failure, death with continuous
exposure
& anesthetic effect
80 Immediately fatal
can dissolve lipid membrane, irritating eyes,
mucous membrane & skin
Expresses its toxic effect by causing a left shift
Causes:
in the oxygen-hemoglobin dissociation curve
o headache,
Decrease in oxygen delivery in tissues with high
o lack of muscle coordination,
oxygen demands
o dizziness,
o Heart and the brain
o confusion,
Laboratory methods
o impaired balance
Qualitative test ( uses 5 mL of 40% NaOH is
Toxic level: LD50= 200 to 4000 mg/kg
added to whole blood specimen)= Positive
result is the Persistence of a pink color of
Carbon Monoxide solution means presence of COHb level of 20%
Gas poison
or greater.
Produced by incomplete combustion of carbon-
o COHb has a cherry red appearance
containing substances from the environmental
sources like Quantitative assays:
 gasoline engines,
 improperly ventilated furnaces, differential spectrophotometry ( 4 to 6
 wood, differential wavelengths)
 plastic o this procedure has become the basis
 fires for several automation systems
Clinical Chemistry MLS111b
TOXICOLOGY OF SPECIFIC AGENTS
GC method ( reference method) The evaluation of cyanide requires rapid
o High accuracy and precision turnaround time because it would mean the life
o CO is released from Hb after treatment of the patient
with potassium ferrocyanide
o After analytic separation, CO is detected Laboratory methods
by changes in thermal conductivity and  ISE
COHb concentration is determined  Photometric analysis
 Two well microdiffusion methods
Caustic Agents Chronic low level exposure is evaluated by
Common among household products determining urinary thocyanate concentration
Bleach
Ingestion of approx 300 mL in adults & 100 mL Pesticides
in children = severe damage to exposed tissues Intentionally added to the environment to kill
Higher amounts= perforation of GIT mucosa= pests {insecticides} or grass {herbicides}.
shock or death Exposure:
o contaminated food/drinks,
Bug Repellants
o hand to mouth,
Contain N,N-diethyl-m-toluamide (DEET) in a
o transdermal absorption that occurs
conc of 14 to 95%
commonly among children
Human toxicity results from inhibition of the
o people working in farms who do not wear
CNS acetylcholinesterase
PPE
Toxic oral dose: 0.5 to 5 g/kg
Common insecticides:
Lowest dermal toxic dose: 35 mg/kg over 5
o organophosphate [most abundant],
days
o carbamates,
Cyanide o halogenated hydrocarbons
A supertoxic substance Organophosphates & carbamates inhibit
Exposure can be by inhalation, ingestion, acetylcholinesterase =prolonged presence of
transdermal acetylcholine in the receptor=wide range of
Is used in many industrial processes, a systemic effects
component of some insecticides & rodenticides Toxicology
Produced as a pyrolysis product from burning of Signs & symptoms: [SLUDGE]
some plastic-toxicity with smoke inhalation  salivation,
o Cyanide and CO exposure amy account  lacrimation,
for a significant portion of the toxicities  involuntary urination,
associated with fires and smoke  defecation,
inhalation  gastrointestinal distress
Cyanide + heme. Binding to mitochondrial  emesis
cytochrome oxidase = uncoupling of oxidative Or [DUMBBELS]
phosphorylation = depletion of ATP= low  diarrhea,
oxygen utilization= headaches, dizziness,  urination
respiratory depression that can progress to  meiosis,
seizure, coma & death  bradycardia,
Toxicology  bronchoconstriction,
Cyanide toxicity is associated with acute  emesis,
exposure at concentration sufficient [higher than  lacrimation
0.05 ppm or 1.5 mg/kg] to exceed rate of  alivation
enzymatic clearance
Clinical Chemistry MLS111b
TOXICOLOGY OF SPECIFIC AGENTS
Longer exposure leads to: Laboratory diagnosis:
o tachycardia, High sensitivity/specificity: GC or liquid
o muscular twitching, Chromatography [expensive & technically difficult]
o cramps, Practical method: chromogenic method
o apathy, [Trinder reaction: salicylate + ferric nitrate=
o slurred speech, colored complex read photometrically ]
o behavioral changes, Acetaminophen [tylenol]
o death Used as analgesic
ATROPINE: use as antidote o Either solely or in combination with
Laboratory methods other compounds
Serum: low sensitivity because Few adverse effects in healthy individuals
Acetylcholinesterase is a membrane-bound High protein binding
enzyme o Results to low free fraction
Red blood cells: higher sensitivity but not Toxicology
commonly done in reference laboratories because Overdose results to severe hepatotoxicity [ can
of low demand & the lack of automated method occur 3-5 days after ingestion]
Alternative screening test: measurement of Chronic, heavy ethanol consumers have rapid
serum pseudocholinesterase (SChE) metabolism of acetaminophen= increased
Advantage: same inhibition activity with RBC possibility of glutathione depletion=more free
Disadvantage: lack specificity & sensitivity radicals accumulation=faster hepatoxicity
Laboratory assessment
TOXICOLOGY OF THERAPEUTIC Measurement is useless because the drug is
DRUGS cleared rapidly from the serum
May occur due to accidental ingestion or Test is done after several hours of intake
intentional overdosage o There will be no more usefulness of
Salicylates (aspirin) testing and results
Used as: HPLC= reference method
 analgesic, o Not often used
 antipyretic, o Equipment is expensive
 anti-inflammatory drug o Only experienced medical
There is also an epidemiological relationship technologist or lab personnel can
between aspirin and childhood viral infections like: operate the instrument
 varicella Immunoassays =currently most common
 influenza competitive enzyme
 onset of Reyes’ syndrome fluorescence polarization systems
Toxicology
Acute ingestion effects: metabolic acidosis [due TOXICOLOGY OF DRUGS OF ABUSE
to acid property & formation of ketone bodies] & Drugs of abuse are legal and illegal drugs that
respiratory alkalosis = mixed acid-base provide the user with a desired effect
disturbance; inhibit Kreb’s cycle [more lactate Addiction: occurs when a person continues to use
formation] a drug despite adverse effects
Adverse effects of aspirin intake could include Tolerance: reduces the body’s reaction to the drug
interference of platelet aggregation or GIT The laboratory has a very sensitive role in the
function drug measurement result
Treatment: aimed at neutralizing & eliminating Result is associated in civil or criminal litigation
excess acids
Clinical Chemistry MLS111b
TOXICOLOGY OF SPECIFIC AGENTS
From the screening procedure using the spot
test to the GCMC procedures, this must have
accuracy and validity in every aspect.
Includes:
 Amphetamines and
metamphetamines
 Methylenedioxymethylamphe
tamine (MDMA, ecstacy)
 Anabolic steroids
 Cannabinoids
 Cocaine
 Opiates
 Codeine
 Morphine
 Methadone
 Phenycyclidine
 Lysergic diethylamine
 Dextropropoxypene (darvon)
 Sedative-Hypnotics [tranquilizers]
 Barbiturates
 Benzodiazepines
 Hydromorphone
Amphetamines & methamphetamine
Therapeutic drugs for narcolepsy and attention
deficit disorder.
Stimulant= produce an initial sense of increased
mental, physical capacity along with perception
of well-being
Toxicology
The initial effects are followed by:
 restlessness,
 irritability,
 psychosis
Structurally related to epinephrine,
norepinephrine & dopamine
Commonly abused- OTC amphetamine-like
medications for cold & allergy medications
Tolerance & psychological dependence develop
with chronic use
Overdose adverse effects: hypertension, cardiac
arrhythmias, convulsions, death
Methylenedioxymethylamphetamine
(MDMA, ecstacy)
is an illicit amphetamine derivative
Around 200 designer analogues designed
MDMA
Toxicology
Administered commonly through oral but can be
also given through injection, inhalation, smoking
o In tablets of 50mg-150mg
MDMA half-life is 8 to 9 hrs
Commonly eliminated by hepatic metabolism
Desired effects: euphoria, hallucinations, emphatic
& emotional responses, increased visual & tactile
sensitivity
Adverse effects: headaches, nausea, vomiting,
anxiety, agitation, impaired memory, violent
behavior, tachycardia, hypertension, respiratory
depression, seizures, hyperthermia, cardiac & liver
toxicity, renal failure
Onset of effects is about 30-60 minutes
Duration is 3.5 hours
Lab methods
GC-MS
Anabolic Steroids
Group of compounds related chemically to
testosterone
Used to be a treatment for male hypogonadism.
Increase muscle mass in healthy individuals=
improved athletic performance
Toxicology
Chronic use = toxic hepatitis, cardiomegaly
[=ischemia=cardiac arrhythmia=sudden death],
*accelerated atherosclerosis, *abnormal
aggregation of platelets [ *predisposition to
stroke & MI]
Obtained through black market

Lab methods Chronic use effect in male

 Immunoassay  Testicular atrophy
o Screening  Sterility
 LC and GC  Impotence
o Confirmatory
Clinical Chemistry MLS111b
TOXICOLOGY OF SPECIFIC AGENTS
Chronic use effect in female
 Development of masculine traits
 Breast reduction
 Sterility
Laboratory diagnosis
Challenging until discovery of newer test to
determine ratio of testosterone to
epitestosterone
Cannabinoids
Group of psychoactive compounds found in
marijuana
THC is the most potent & abundant
Marijuana or processed product (hashish) can
be smoked or ingested
Toxicology
Effect: sense of well-being & euphoria, impairment
of short-term memory & intellectual function
Chronic use: tolerance & mild dependence
Half-life is 1 day after a single use & 3-5 days in
chronic, heavy use
Major urinary metabolite is 11-nor-
tetrahydrocannabinol-9-carboxylic acid [THC-
COOH] and can be detected in urine 3-5 days
after a single use or up to 4 weeks in a chronic,
heavy use
Lab methods
Immunoassay
o Screening
GC-MS
o Confirmation
Cocaine
Effective local anesthetic with few adverse
effects at therapeutic concentrations
An alkaloid salt that can be administered
directly [by insufflation or IV] or inhaled as a
vapor when smoked in the free-base form
[crack]
Toxicology
At higher concentrations= potent stimulator
=elicits a sense of excitement & euphoria
Acute toxicity is associated with:
 hypertension,
 arrhythmia,
 seizure,
 MI
Half-life is 0.5 to 1 hr [ due to rapid hepatic
hydrolysis]
Primary hepatic metabolic product is
benzoylecgonine =eliminated to urine=detected
up to 3 days after a single use= sensitive &
specific indicator of cocaine use
Chronic heavy users, benzoylecgonine is
detected up to 20 days after the last dose
Laboratory methods
Immunoassay
o Screening
GC-MS
o Confirmatory
Opiates
Capable of analgesic, sedation, & anesthesia
Derived from opium poppy
Naturally occurring opiates include opium,
morphine, & codeine
Examples
Modified Heroin, hydromorphone (Dilaudid),
Opiates oxocodon (Percodan)
Meperidine (Demerol), methadone
Synthetic (Dolophine), propoxyphene (Darvon),
Opiates pentazocine (Talwin), fentanyl (Subimaze)
Chronic use leads to tolerance with physical &
psychological dependence
Acute overdose=respiratory acidosis due to
respiration of respiratory centers,
myoglobinuria, & possibly an increase in serum
detectors
High overdose=death due to cardiopulmonary
failure
Treatment of overdose includes the use of
opiate antagonist naloxone
Clinical Chemistry MLS111b
TOXICOLOGY OF SPECIFIC AGENTS
Laboratory methods Lysergic Diethylamine (LSD)
Immunoassay Extremely potent psychedelic & hallucinogenic
o Screening drug [ perceptual changes in colors, sound,
GC-MS distance, shape]
o Confirmatory Ingested in powder, gelatin-capsules, postage
stamp, sugar cubes, etc
Codeine There is rapid changing of emotions from
Opiate narcotic that is used to relieve mild to ecstasy to depression to paranoia
moderate pain
Used with other medications to reduce Effects:
coughing o dilated pupils,
o tachycardia,
Toxicity: respiratory depression o increased body temperature,
o excessive sweating,
Morphine o hypertension
Most abundant alkaloid found in opium ( milky
liquid in unripe poppy seeds) At higher doses: salivation, lacrimation, nausea,
Powerful analgesic [ can be used for pain in MI vomiting
and during labor]
Identification is challenging because the
Toxic symptoms: coma, respiratory detection window is only 12-24 hrs
depression, pulmonary edema, death
Dextropropoxypene (darvon)
Methadone Commonly in combination with acetaminophen
A synthetic analog of morphine & heroin to treat mild pain
Analgesic and is used for treatment of opioid Antitussive and local anesthetic
dependency Death results from intentional overdose, mixed
More active & toxic than morphine with alcohol

Phenycyclidine Sedative-Hypnotics [tranquilizers]

Has stimulant, depressant, anesthetic & CNS depressants
hallucinogenic properties Barbiturates & benzodiazepines are most
common types that are abused
Toxicology Overdose presents lethargy & slurred speech
Adverse effects: agitation, hostility, paranoia that rapidly progress to coma
Overdose causes stupor & coma Toxicity is potentiated by ethanol
Can be ingested or inhaled by smoking
A lipophilic drug that rapidly distributes in Laboratory methods
the fat and brain tissue Immunoassay
Elimination is slow as a result of redistribution o Screening
into the circulation and the hepatic metabolism GC and LC
In heavy users, can be detected 7 to 30 days o Confirmatory
after abstinence Barbiturates
CNS depressant used for their mild sedative,
Lab methods
anesthetic, hypnotic, anticonvulsant properties
Immunoassay
o Screening Routes: oral, IV
GC-MS
o Confirmatory Overdose: respiratory arrest, death
Clinical Chemistry MLS111b
TOXICOLOGY OF SPECIFIC AGENTS
Benzodiazepines
Ex valium, xanax are used as sedative-
hypnotics, antianxiety, anticonvulsants, muscle
relaxants
Less toxic than barbiturates
Toxic effect occurs if mixed with alcohol &
other CNS depressants

Hydormorphone
A morphine derivative & a potent centrally
acting analgesic
as alternative to morphine for the treatment of
pain & as antitussive
Used recreationally because it produces
euphoria & relieves stress
Lethal if in combination with alcohol or other
CNS depressants