Therapeutic Drug Monitoring-

Introduction

Dr. Justin Kurian

Lecturer
JSS CP Mysore
 Definition

 TDM measures the concentration of medicines in

patients blood or plasma

 The amount of a medication in an individuals blood is

referred to a drug level/drug concentration/plasma
level/plasma concentration

 These concentration may determine an individuals

response to medication
 Definition
• International association for Therapeutic drug
monitoring and Clinical Toxicology

• “TDM is defined as the measurement of made in the

laboratory of a parameter that , with appropriate
interpretation , will directly influence prescribing
procedures.
• Commonly the measurement is in a biological matrix of a
prescribed xenobiotics, but it may also be of an endogenous
compound prescribed as a replacement therapy in an individual
who is physiologically or pathologically deficient in that
compound”
 Need or importance of TDM

 To maximize the efficacy & safety of the medication

 To minimize or prevent adverse effects of those

medications which have narrow therapeutic index

 TDM is performed for those drugs, the clinical

response of which cannot be measured directly

Ex: antihypertensives Vs phenytoin

 Some of the drugs requiring TDM

Digoxin MTX
Amiodarone Cyclosporin
CBZ Tacrolimus
Amikacin Vancomycin
Lithium Gentamycin
Theophylline Sod. Valproate
Therapeutic Index:

The ratio between toxic dose (LD 50) and effective dose
(ED 50)
i.e. TI = LD 50/ ED 50

Serum Drug Concentration:

The total concentration of the drug in the serum after it

is absorbed. It includes both free and protein bound
form
Therapeutic range:

A minimum serum drug concentration, below which the

desired drug effect is usually not seen and the
maximum serum drug concentration, above which
toxic effects are likely to outweigh therapeutic
benefits

Ex: Lithium 0.5-1.0 mmol/L

Digoxin 0.8-2.0 ng/mL
Bioavailability:

It is the fraction of the administered dose that reaches

systemic circulation

Clearance:

It is the volume of the blood or plasma that can be

completely cleared of a drug per unit time

Drug (Dose) interval:

It is the time gap between consecutive doses

Volume of distribution (Vd):

It is the amount of the drug in the body relative to the

concentration of drug in the blood or plasma

i.e. Vd=D/Cp
Where, Vd volume of distribution
D dose of the drug
Cp plasma concentration of drug

Ex: Vd of Digoxin 7L
Vd of Gentamycin 0.25 L
Vd of Theophylline 0.45 L
Half life (t½):

It is the time required for the drug concentration in the

plasma to be reduced by 50%, provided no drug
absorption occurs at the decline

Steady state concentration:

It is the drug concentration at which the body is in

equilibrium i.e. rate of drug absorption equals the
rate of elimination of drug
Loading dose:

It is the amount of drug that must be administered to

bring the drug concentration in the blood or plasma
into the therapeutic range, when initiating the
therapy.
Ex: loading dose of Amikacin 7.5 mg/Kg

Maintenance dose:

It is the amount of the drug that must be administered

to maintain the SSC
Ex: Maintenance dose of Amikacin 5 mg/Kg
Minimum concentration or Trough:

It is the lowest concentration of the drug with in a

dosing interval.
This typically reaches at the end of the dosing interval,
immediately before the next dose

Maximum concentration or Peak:

It is the highest concentration of the drug with in a

dosing interval. It usually reaches with in 2 hrs of drug
administration but also depends on ROA
 Indications/importance/essentials/needs of TDM

 If the drug has complex kinetics

 Narrow therapeutic margin
 Clinical quantification of drug effect is not easy
 Dose response relationship varies widely
 Drug-drug interaction
 Major changes in weight, fluid status, renal function,
hepatic functions of the patient
 To assess suspected overdose
 Suspected patient compliance or absorption of drug
 If the drug has complex kinetics

The metabolism & clearance of certain drugs ex:

Phenytoin are dependent on the dose & serum conc.
at any given time

The conc. can change dramatically with only slight

changes in dose or in rate of metabolism hence SDC
should be checked after each dosage change
 Narrow therapeutic margin

For drugs like lithium, gentamycin, digoxin and

phenytoin there is either little difference or even

overlap b/n conc. associated with therapeutic effects

and those asociated with toxicity, such drugs require

TDM
Clinical quantification of drug effect is not easy
The therapeutic effects of phenytoin are difficult to
measure because the goal of therapy is usually an
absence of phenomenon

Sometimes not easy to distinguish b/n signs &

symptoms of disease & ADRs of a drug treating that
disease
Ex: nausea, anorexia & arrythmias can be seen both in
CCF & drug used in management of same (digoxin)

Hence SDC of digoxin may be helpful in identifying the

cause
 Dose response relationship varies widely

The metabolism of drugs like procainamide depends on

the patients acetylator status

Hence same dose in two different patients may lead to

quiet different SDC
 Drug-drug interaction

When quinidine is added to the regimen of a patient

who is stabilised on digoxin,

Digoxin conc. May increase substantially over the next

few days, due to decreased digoxin clearance

Digoxin levels drawn 2-3 days after the addition of

quinidine would indicate the significance of the
interaction in a patient.
 Major changes in weight, fluid status, renal
function, hepatic functions of the patient

Weight & fluid status can change the Vd (usually based

on patient BW)of drugs, while renal & liver function
can change the elimination of the drug

In obese patients some drugs preferentially leave the

plasma in favour of adipose tissue, thus PDC for
these drugs are lower, resulting in a larger Vd
 Major changes in weight, fluid status, renal
function, hepatic functions of the patient ...

Drugs that have low solubility in fat remain in plasma

and produce higher plasma conc. resulting in smaller
Vd

In oedematous patients, the plasma conc. of the drugs

may be low, resulting in high Vd
 To assess suspected overdose

When promoted by signs and symptoms of overdose

consistent with one or more drugs, drug levels can

determine whether the suspected agent is the culprit

Suspected patient compliance or absorption of
drug
Patient may intentionally or unintentionally not take their
medication (non-compliance) as directed

It may be causing bothersome side effects or they may

not have enough money to buy the medicine or may
forgot to take the medicine like wise some patients
have GI absorption problems

hence PDC may be lower after oral administration of

drugs, hence TDM may be beneficial in these cases
• To assist dosage adjustment in various diseases
state

• To minimize the time period needed for dosage

adjustment

• To identify the poison and to assess the severity

of poisoning

• To assess the effectiveness of antidotes and

excretion of poisons
 Drug criteria for TDM
The conc. of free drug at the site must be consistently
proportional to the conc. in the serum i.e. SDC &
conc. at receptor site must be in equilibrium

The degree of serum protein & tissue must remain

relatively constant. In other words the % of free to
bound form of the drug must not fluctuate much
under common clinical conditions

The intensity & duration of pharmacological action

(efficacy & toxicity) must be correlated with the drug
conc. at the receptor site (site of action)
 Information needed for planning & evaluating
TDM
1. Demographics
Age, sex, race, height, weight.
To estimate BSA, CrCl, half life & dosing suggestions
2. History & physical examination
obtain from patient as well as from practitioners or
from med.record
Active disease & nutritional status
Presence of oedema, jaundice or dehydration
Smoking history/alcoholism
 This focus on kidney, liver & heart diseases & major
fluid status problems because it may have an impact
on VOD, Clearance, protein binding & presence of
free drug

3. Drug & dosing history

essential for proper interpretation of SDC

info. Required,
amount of drug received, date & time of each dose
should be obtained before performing TDM
The interaction of drugs whose concentration are commonly
monitored and whose kinetics (mainly elimination) are identified
from a careful drug history

4. Lab parameters
data related to the patients ability to eliminate drugs may be
needed for SDC measurement

for drugs which primarily eliminate by kidney,

BUN, Se. Cr and CrCl should be estimated
for drugs metabolise by liver, albumin, bilirubin, PT,
AST,ALT,ALP should be estimated
5. Recent / earlier reports of SDC
it is important because,
it suggests what concentration should be expected
for a given dose

It may also revel at what SDC the patient experience

a therapeutic or toxic effects

Obtaining the recent SDC reports are better

 Organisation of TDM/ steps involved in TDM

1. Pharmacist and physician develops dosing

recommendation or target concentration

2. Information required while dosing are, age, sex, height

& clinical status

3. Calculate the LD & MD & make recommendations

4. Organise the sample collection method& analysis

5. Physician consults CP to determine which sample to

draw (trough, peak or random)
6. If there is a question as to whether an adequate dose
of the drug is being achieved, it is to obtain trough
levels
7. Peak levels usually obtained 1-2 hrs after oral intake,
aprox. 1 hr after IM administartion & 30 mins after IV
administration
8. For patients, suspected having symptoms of drug
toxicity, the best time to draw the sample is during the
occurrence of symptom
9. Assess the risks while sampling such as bleeding from
the site, hematoma, fainting & puncturing of veins with
repeated pricking
10. Identify where the samples has to be sent
11. Give proper instruction to nurse regarding time of
sampling, sampling tubes (volume & colour of the
sampling tubes) volume of the blood to be drawn,
labelling instructions, storage & package information
12. Once the sample reaches lab, qualified technician
performs the analysis
defining the problem, a lab technician has to
determine the requirements of analytical precision,
accuracy, specificity and limits of detection, need to be
understood & also cost of analysis & no. Of samples to
be analysed has to taken into consideration
13. Choosing the best analytical method
it has a significant impact on all the measured
PK parameters that form the basis for TDM
like half-life, VOD, trough concentration, peak
concentration etc
14. Various assay methods are, HPLC, GLC, RIA
15. Standardise the assay, process the sample &
perform the assay according to SOP
16. Analyse the result & prepare report
 Assay of drugs

Method for assay of a drug is based on,

1. Physicochemical characteristics of the drug

2. Target concentration of measurement
3. Amount & nature of biological specimen
(serum/urine)
4. Availability of instrument
5. Cost of each assay
6. Analytical skill of lab person
 Pharmacokinetic evaluation
Pharmacokinetician evaluate the data
Most lab reports are based on total drug concentration
If the SDC is lower than anticipated, the parameters to be
taken in to consideration are,
 Patient compliance
 Error in dosage regimen
 Poor bioavailability
 Rapid elimination of drug
 Increased VOD
 Wrong dosage form (SR/CR than IR)
 SSC may not be reached
 Timing of blood sampling
If the SDC is higher than anticipated, the parameters to
be taken in to consideration are,
 Patient compliance
 Error in dosage regimen
 Wrong drug product (IR than CR/SR)
 Increased bioavailability
 Smaller VOD
 Slow elimination of drug

If the SDC is proper but patient is not responding to the

therapy, then it may be due to
Altered receptor sensitivity
Possible drug-drug interaction at receptor site
 Sample collection

Usually plasma or serum is used for drug assays, depending

upon the equipment used

However, for some drugs large shifts of drug b/n the RBC &
plasma takes place with storage & changes in
temperature, hence whole blood has to be assayed

Some blood collecting tubes especially those containing a

gel to separate cells & plasma may not be suitable for all
drugs due to drug adsorption by the gel or other
components of the tube
Analytical method used for assay should be
validated wrt,

Specificity
Sensitivity
Linearity
Precision
Accuracy
Stability
Ruggedness
Specificity:
It should be established by the demonstration via
chromatographic technique that the method is
specific for the drug
The method should demonstrate that there is no
interference b/n the drug, metabolites of the drug &
exogenous or endogenous substances

Sensitivity:
It is the minimum detectable level or conc. Of the drug
in serum which may be approximated as lowest conc.
Linearity:
Refers to the proportional relationship b/n the drug
conc. & the instrument response

Precision:
Refers to the variation or reproducibility of the data

Accuracy:
Refers to the difference b/n true drug conc. & known
(standard) drug conc.
Stability:
Standard drug conc. Should be maintained under the
same condition as the unknown serum sample & it is
assayed periodically to check the stability

Ruggedness:
It is the degree of reproducibility of the test results
obtained by the analysis of the samples by different
analytical laboratories
 Analytical methods in TDM

The methods used can be,

 Chromatographic methods
 Immuno assays
 Chromatographic methods

Advantages:

 Ability to identify & measure several drugs in single

run

 Drug metabolites (if present) are also readily

detected & quantitated

 Economic as these methods use bulk chemicals not

the kits
Disadvantages:

 Preparation of the sample may be lengthy procedure

 Sample preparation & operating HPLC requires a high

skill & technically demanding

 Cost of the instrument is high

 Immuno assays
 These are competitive protein binding assays
 The binding agent is a specific antibody raised
against the drug to be analysed

Immuno assays can be classified as,

Heterogeneous IA
Homogenous IA
Fluorescent IA
One step-dry chemistry
 Immunological methods used for
TDM
• Enzyme immuno assay:
• Cloned enzyme donor immuno assay
• Enzyme linked immuno sorbent assay
• Enzyme multiplied immuno assay
• Fluorescence polarization immuno assay
 Role of Pharmacist in TDM
A quality TDM service can only be achieved through
interaction of nurses, doctors, scientists & Pharmacist

 An initial selection of drug regimen

 Adjustment of the dosage regimen based on TDM
results & on clinical response
 Assessment of possible causes for unusual results
such as non-compliance, bioavailability problems,
medication errors & drug interaction
 To give information about sampling time of the drug
Educating the patients about importance of drug
therapy & adherence to the physicians instruction

To check for the drug interactions

Management of acute intoxification (poisoning due to

overdose)

Participation in research activities about TDM

Assessment of dosage adjustment for patients who are

on hemodialysis & peritoneal dialysis
 TDM in India

TDM is available in India through clinical pharmacology

dept. in big teaching hospitals otherwise private
hospitals are involved in measuring PDC

HPLC is the method of assay, some hospitals use

automated machines & use imported ready made
kits for plasma monitoring
 Factors influencing TDM in India

Cost

Alternative systems of medicine

Variation in bioavailability

Ethnic difference
 Heterogeneous IA
The bound tracer has to be separated from the unbound
in order to be measured
Adv:
 Minimises non-specific interferences (good specificity)
 Higher degree of sensitivity

Disadv:
 Need for separation state
 Limited suitability for continuous flow type
automation
 Homogenous IA

As the properties of the tracer molecule are modified

by its reaction with antibody separation is not
required

Adv:

 Higher speed, relative suitability for automation

 Relative stability of the reagents with longer shelf-life
Disadv:

 It requires relatively pure label specific antibody

which is costly

 Because of the absence of the separation step in the

immunoassay there may be increased background
interference from biological fluids
 Fluorescent IA
In this method, the label is a small fluorescent material
which is bound covalently with analyte
The intensity of fluorescence produced by this probe is
related to the standard conc. of the fluorescent
material
Adv:
 It make use of non-radioactive tracers

Disadv:
 Need for special equipment
 Possibilities of interference of fluorescent substances
 Radioactive IA
Disadv:

Because of harmful radiations, waste disposal is

complicated

Reagents used have very short shelf-life

 One step-dry chemistry
 Make use of dry membrane antibody coated cellular
strips

 Detects selected drugs or their metabolites at

specific cut-off conc.

 Primarily used for measuring conc. of drugs of abuse

 Used for rapid & qualitative detection

 Immunological methods used for TDM

Enzyme immuno assay:

In this method, the label on the tracer is an enzymes

The catalytic properties of enzymes allow the detection

& quantification of small quantities of drug

Ex: digoxin
 Cloned enzyme donor immuno assay

The method uses an antibody to detect the drug to be

measured & a label which allows measurement of
the binding reaction

It uses genetically engineered fragment of the enzyme

beta galactosidase as the label

Ex: theophylline, gentamycin, tobramycin, digoxin,

quinidine
 Enzyme linked immuno sorbent assay
The method uses enzyme action linked to an immuno
sorbent for estimation of drug

Ex: Theophylline, CBZ

Solid phase enzyme immuno assay:

An antibody/antigen is absorbed or covalently bound to
the surface so as to providing binding that are specific
for the assay target molecule

Ex: Theophyline, CBZ

 Enzyme multiplied immuno assay
An enzyme G6PDHS chemically coupled to a drug
molecule

So the activity of enzyme is inhibited, when the drug is

bound to it

The extent of enzyme activity reflects the proportion of

enzyme which is not bound to drug

Ex: phenytoin, phenobarbitone, CBZ, digoxin,

gentamycin, MTX, tobramycin
 Fluorescence polarization immuno assay
 Specific antibodies are used to isolate the desired
analyte

 Small fluorescent molecule excited with polarized

vertical light, rotates rapidly & emits polarized light in
comparison to large molecules

 The intensity of polarized light is a measure of conc.

of analyte

Ex: Digoxin, Cyclosporine, BZD, TCAs