Drug Monitoring, Therapeutic

Synonym/Acronym

N/A

Rationale

To monitor specific drugs for subtherapeutic, therapeutic, or toxic levels in evaluation of treatment and to detect toxic levels in suspected overdose.

Patient Preparation

There are no food, fluid, activity, or medication restrictions unless by medical direction; note the time and date of the last dose of medication taken. Obtain a culture, if ordered, before the first dose of aminoglycosides. Other considerations prior to medication administration include documentation of adequate renal function with Cr and BUN levels, documentation of adequate hepatic function with ALT and TBil levels, and documentation of adequate hematological and immune function with platelet and WBC count. Patients receiving methotrexate must be well hydrated and, depending on the therapy, may be treated with sodium bicarbonate for urinary alkalinization to enhance drug excretion. Leucovorin calcium rescue therapy may also be part of the protocol.

Drug* (Anticonvulsants)		Route of Administration
Carbamazepine		PO
Ethosuximide		PO
Lamotrigine		PO
Phenobarbital		PO
Phenytoin		PO
Primidone		PO
Valproic acid		PO

*Recommended collection time = trough: Immediately before next dose (at steady state) or at a consistent sampling time.

Drug (Antidepressants)	Route of Administration	Recommended Collection Time
Amitriptyline	PO	Trough: Immediately before next dose (at steady state)
Nortriptyline	PO	Trough: Immediately before next dose (at steady state)
Protriptyline	PO	Trough: Immediately before next dose (at steady state)
Doxepin	PO	Trough: Immediately before next dose (at steady state)
Imipramine	PO	Trough: Immediately before next dose (at steady state)

Drug (Antidysrhythmics)	Route of Administration	Recommended Collection Time
Amiodarone	PO	Trough: Immediately before next dose
Digoxin	PO	Trough: 12–24 hr after dose
	PO	Never draw peak samples
Disopyramide	PO	Trough: Immediately before next dose
	PO	Peak: 2–5 hr after dose
FlecainideFlecainide acetate	PO	Trough: Immediately before next dose
	PO	Peak: 3 hr after dose
LidocaineLidocaine hydrochloride	IV	15 min, 1 hr, then every 24 hr
Procainamide	IV	15 min; 2, 6, 12 hr; then every 24 hr
Procainamide	PO	Trough: Immediately before next dose
	PO	Peak: 75 min after dose
Quinidine sulfate	PO	Trough: Immediately before next dose
	PO	Peak: 1 hr after dose
Quinidine gluconate	PO	Trough: Immediately before next dose
	PO	Peak: 5 hr after dose
Quinidine polygalacturonate	PO	Trough: Immediately before next dose
		Peak: 2 hr after dose

Drug (Antimicrobials)	Route of Administration	Recommended Collection Time*
Amikacin	IV, IM	Trough: Immediately before next dose
	IV, IM	Peak: 30 min after the end of a 30-min IV infusion
Gentamicin	IV, IM	Trough: Immediately before next dose
	IV, IM	Peak: 30 min after the end of a 30-min IV infusion
Tobramycin	IV, IM	Trough: Immediately before next dose
	IV, IM	Peak: 30 min after the end of a 30-min IV infusion
Tricyclic glycopeptide and vancomycin	IV, PO	Trough: Immediately before next dose
	IV, PO	Peak: 30–60 min after the end of a 60-min IV infusion

*Usually after fifth dose if given every 8 hr or third dose if given every 12 hr.

IM = intramuscular; PO = by mouth.

Drug (Antipsychotics, Mood Stabilizers)	Route of Administration	Recommended Collection Time
Haloperidol	PO	Peak: 3–6 hr
Lithium	PO	Trough: at least 12 hr after last dose; steady state occurs at 90–120 hr

Drug (Immunosuppressants)	Route of Administration	Recommended Collection Time
Cyclosporine	PO or IV	12 hr after dose or immediately prior to next dose
Methotrexate	PO or IM	Varies according to dosing protocol
Everolimus	PO	Immediately prior to next dose
Sirolimus	PO	Immediately prior to next dose
Tacrolimus	PO	Immediately prior to next dose

Leucovorin therapy, also called leucovorin rescue, is used in conjunction with administration of methotrexate. Leucovorin, a fast-acting form of folic acid, protects healthy cells from the toxic effects of methotrexate.

Normal Findings

Method: Immunoassay for acetaminophen, amikacin, amiodarone, carbamazepine, cyclosporine, digoxin, disopyramide, ethosuximide, flecainide, gentamicin, imipramine, lidocaine, methotrexate, phenobarbital, phenytoin, primidone, procainamide, quinidine, salicylate, tobramycin, valproic acid, and vancomycin. Chromatography for amitriptyline, doxepin, haloperidol, nortriptyline, and protriptyline. Ion-selective electrode for lithium. Liquid chromatography/tandem mass spectrometry for everolimus, lamotrigine, sirolimus, and tacrolimus.

Drug/Class (Analgesics, Anti-inflammatories, and Antipyretics)	Therapeutic Range Conventional Units	Conversion to SI Units	Therapeutic Range SI Units	Half-Life	Protein Binding	Metabolism	Excretion	Crosses Placenta/Enters Breast Milk
Acetaminophen	5–20 mcg/mL	SI units = Conventional Units × 6.62	33–132 micromol/L	1–3 hr	10%–25% (dose dependent)	1° hepatic (CYP2E1, CYP1A2, CYP2D6, UGT)	1° renal	Yes/Yes (small amounts)
Salicylate	10–30 mg/dL (anti-inflammatory); 2–10 mg/dL (antipyretic/analgesic)	SI units = Conventional Units × 0.073	0.7–2.2 mmol/L (anti-inflammatory); 0.15–0.7 mmol/L (antipyretic/analgesic)	2–3 hr (low dose)	80%–90%	1° hepatic (CYP2C19)	1° renal	Yes/Yes

It should be noted that acetaminophen and acetylsalicylic acid are contained in many other medications, such as cold and cough medicines.

Drug/Class (Anticonvulsants)	Therapeutic Range Conventional Units	Conversion to SI Units	Therapeutic Range SI Units	Half-Life	Protein Binding	Metabolism	Excretion	Crosses Placenta/Enters Breast Milk
Carbamazepine	4–12 mcg/mL	SI units = Conventional units × 4.23	16.9–50.8 micromol/L	15–40 hr (single dose); 16–24 hr (repeated dosing)	70%–80%	Hepatic (CYP3A4)	1° renal; 2° fecal	Yes/Yes
Ethosuximide	40–100 mcg/mL	SI units = Conventional units × 7.08	283.2–708 micromol/L	25–70 hr	0%–5%	Hepatic (CYP3A4, CYP2E1)	Renal (20%)	Yes/Yes
Lamotrigine	1–14 mcg/mL	SI units = Conventional units × 3.9	3.9–54.6 micromol/L	25–33 hr (monotherapy)	50%–55%	Hepatic (UGT1A4)	1° renal; 2° fecal	No information/Yes (Note: Significant binding to tissues containing melanin)
Phenobarbital	Adult: 15–40 mcg/mL	SI units = Conventional units × 4.31	Adult: 64.6–172.4 micromol/L	Adult: 50–140 hr	50%–60%	Hepatic (CYP2C19)	1° renal; 2° fecal	Yes/Unknown
	Child: 15–30 mcg/mL	SI units = Conventional units × 4.31	Child: 64.6–129.3 micromol/L	Child: 60–180 hr	50%–60%	Hepatic (CYP2C19)	1° renal; 2° fecal	Yes/Unknown
Phenytoin	10–20 mcg/mL	SI units = Conventional units × 3.96	40–79 micromol/L	7–42 (avg 22) hr	85%–95%	Hepatic (CYP2C9, CYPC219)	1° renal and biliary	Yes/Yes
Primidone	Adult: 5–12 mcg/mL	SI units = Conventional units × 4.58	Adult: 22.9–55 micromol/L	4–12 hr	0%–20%	Hepatic (CYPC219)	1° renal	Yes/No information
	Child: 7–10 mcg/mL	SI units = Conventional units × 4.58	Child: 32.1–45.8 micromol/L
Valproic acid	50–125 mcg/mL	SI units = Conventional units × 6.93	346.5–866.2 micromol/L	8–15 hr	85%–95%	Hepatic (not CYP450 dependent)	1° renal	Yes/Yes

Drug/Class (Antidepressants)	Therapeutic Range Conventional Units	Conversion to SI Units	Therapeutic Range SI Units	Half-Life	Protein Binding	Metabolism	Excretion	Crosses Placenta/Enters Breast Milk
Amitriptyline	125–250 ng/mL	SI units = Conventional units × 3.6	450–900 nmol/L	10–50 hr	85%–95%	Hepatic (CYP2D6)	1° renal	Yes/Yes
Nortriptyline	50–150 ng/mL	SI units = Conventional units × 3.8	190–570 nmol/L	16–90 hr	90%–95%	Hepatic (CYP2D6)	Renal	Probable/Yes
Protriptyline	70–250 ng/mL	SI units = Conventional units × 3.8	266–950 nmol/L	60–90 hr	91%–93%	Hepatic (CYP2D6)	Renal	No information/Probable
Doxepin	110–250 ng/mL	SI units = Conventional units × 3.58	393.8–895 nmol/L	10–25 hr	75%–85%	Hepatic (CYP2D6, CYP2C19, CYP1A2, CYP3A4)	Renal	Probable/Yes
Imipramine	180–240 ng/mL	SI units = Conventional units × 3.57	642.6–856.8 nmol/L	8–20 hr	86%–95%	Hepatic (CYP1A2, CYP2C19, CYP2D6)	1° renal; 2° fecal	Probable/Yes

Drug/Class (Antidysrhythmics)	Therapeutic Range Conventional Units	Conversion to SI Units	Therapeutic Range SI Units	Half-Life	Protein Binding	Metabolism	Excretion	Crosses Placenta/Enters Breast Milk
Amiodarone	0.5–2.5 mcg/mL	SI units = Conventional units × 1.55	0.8–3.9 micromol/L	15–142 (58 avg) days	90%–95%	1° hepatic (CYP3A, CYP2C8)	1° biliary	Yes/Yes
Digoxin	0.5–2 ng/mL	SI units = Conventional units × 1.28	0.6–2.6 nmol/L	36–48 hr	20%–30%	Hepatic (16%) (not CYP450 dependent)	Renal	Yes/Yes
Disopyramide	2.8–7 mcg/mL	SI units = Conventional units × 2.95	8.3–20.6 micromol/L	4–10 hr	50%–65%	Hepatic (CYP3A4)	Renal	Yes/Yes
Flecainide	0.2–1 mcg/mL	SI units = Conventional units × 2.41	0.5–2.4 micromol/L	11–27 hr	40%–50%	Hepatic (CYP2D6)	Renal	Probable/Yes
Lidocaine	1.5–5 mcg/mL	SI units = Conventional units × 4.27	6.4–21.4 micromol/L	1.5–2 hr	60%–80%	1° hepatic (CYP3a4)	Renal	Yes/Yes
Procainamide	4–10 mcg/mL	SI units = Conventional units × 4.25	17–42.5 micromol/L	2–6 hr	10%–20%	Hepatic (CYP2D6)	Renal	Yes/Yes
N-acetyl procainamide	10–20 mcg/mL	SI units = Conventional units × 4.25	42.5–85 micromol/L	4–15 hr	10%–20%	Hepatic (CYP2D6)	Renal	Yes/Yes
Quinidine	2–5 mcg/mL	SI units = Conventional units × 3.08	6.2–15.4 micromol/L	6–8 hr	70%–90%	Hepatic (CYP3A4)	Hepatic (20% unchanged in urine)	Yes/Yes

Drug/Class (Antimicrobials)	Therapeutic Range Conventional Units	Conversion to SI Units	Therapeutic Range SI Units	Half-Life	Protein Binding	Metabolism	Excretion	Crosses Placenta/Enters Breast Milk
Amikacin	Peak: 15–30 mcg/mLTrough: 4–8 mcg/mL	SI units = Conventional units × 1.71	Peak: 26–51 micromol/L Trough: 7–14 micromol/L	2–4 hr	50%	Renal	1° renal	Yes/Yes (small amts)
Gentamicin (standard dosing)	Peak: 5–10 mcg/mLTrough: Less than 2 mcg/mL	SI units = Conventional units × 2.09	Peak: 10.4–20.9 micromol/L Trough: Less than 4.2 micromol/L	2–4 hr	50%	Renal	1° renal	Yes/Yes (small amts)
Tobramycin (standard dosing)	Peak: 4–8 mcg/mLTrough: Less than 1 mcg/mL	SI units = Conventional units × 2.09	Peak: 8.4–16.7 micromol/L Trough: Less than 2.09 micromol/L	2–4 hr	50%	Renal	1° renal	Yes/Yes (small amts)
Tobramycin (once daily dosing)	Peak: 8–12 mcg/mL Trough: Less than 0.5 mcg/mL	SI units = Conventional units × 2.09	Peak: 16.7–25 micromol/L Trough: Less than 1 micromol/L
Vancomycin	Trough (general) values vary with indication: 5–15 mcg/mL	SI units = Conventional units × 0.69	3–10 micromol/L	5–8 hr	55%	Renal	1° renal (IV); feces (oral)	Yes/No information

Drug/Class (Antipsychotics and Mood Stabilizers)	Therapeutic Range Conventional Units	Conversion to SI Units	Therapeutic Range SI Units	Half-Life	Protein Binding	Metabolism	Excretion	Crosses Placenta/Enters Breast Milk, Protein Binding (%)
Haloperidol	6–24 ng/mL	SI units = Conventional units × 2.66	16–63.8 nmol/L	21–24 hr	90%	Hepatic (CYP3A4)	Hepatic	Yes/Yes
Lithium (chronic)	0.6–1.2 mEq/L	SI units = Conventional units × 1	0.6–1.2 mmol/L	18–24 hr	0%	None	Renal	Yes/Yes

Drug/Class (Immunosuppressants)	Therapeutic Range Conventional Units	Conversion to SI Units	Therapeutic Range SI Units	Half-Life	Protein Binding	Metabolism	Excretion	Crosses Placenta/Enters Breast Milk
Cyclosporine	100–300 ng/mL kidney transplant	SI units = Conventional units × 0.832	83.2–249.6 nmol/L	8–24 hr	90%–98%	Hepatic (CYP3A4)	Biliary	Yes/Yes
	200–350 ng/mL cardiac, hepatic, pancreatic transplant	SI units = Conventional units × 0.832	166.4–291.2 nmol/L	8–24 hr	90%–98%	Hepatic (CYP3A4)	Biliary	Yes/Yes
	100–300 ng/mL bone marrow transplant	SI units = Conventional units × 0.832	83.2–249.6 nmol/L	8–24 hr	90%–98%	Hepatic (CYP3A4)	Biliary	Yes/Yes
Methotrexate	Low dose: Less than 0.5 micromol/L after 48 hr	SI units = Conventional units × 1	Low dose: Less than 0.5 micromol/L after 48 hr	3–10 hr (low dose)	35%–50% (dosage dependent/varies individually)	Hepatic and intracellular	1° renal; 2° fecal	Yes (embryotoxic)/Yes
Drug/Class (Immunosuppressants)	Therapeutic Range Conventional Units	Conversion to SI Units	Therapeutic Range SI Units	Half-Life	Protein Binding	Metabolism	Excretion	Crosses Placenta/Enters Breast Milk
	High dose: Less than 5 micromol/L at 24 hr; less than 0.5 micromol/L at 48 hr; less than 0.1 micromol/L at 72 hr	SI units = Conventional units × 1	High dose: Less than 5 micromol/L at 24 hr; less than 0.5 micromol/L at 48 hr; less than 0.1 micromol/L at 72 hr	8–15 hr (high dose)	35%–50% (dosage dependent/varies individually)	Hepatic and intracellular	1° renal; 2° fecal	Yes (embryotoxic)/Yes
Everolimus	Transplant: 3–8 ng/mL	SI units = Conventional units × 1.04	Transplant: 3.1–8.3 nmol/L	18–35 hr (kidney); 30–35 hr (liver)	75%	Hepatic (CYP3A4)	1° fecal; 2° renal	Yes/Yes
	Oncology: 5–10 ng/mL	SI units = Conventional units × 1	Oncology: 5–10 nmol/L	18–35 hr	75%	Hepatic (CYP3A4)	1° fecal; 2° renal	Yes/Yes
Sirolimus	Maintenance phase: kidney transplant: 4–12 ng/mL; liver transplant: 12–20 ng/mL	SI units = Conventional units × 1.1	Kidney transplant: 4.4–13.2 nmol/L; liver transplant: 13.2–22 nmol/L	57–78 hr	92%	Hepatic (CYP3A4)	1° fecal	No information
Tacrolimus	Maintenance phase: kidney transplant: 6–12 ng/mL; liver transplant: 4–10 ng/mL; pancreas transplant: 10–18 ng/mL; bone marrow transplant: 10–20 ng/mL	SI units = Conventional units × 1.24	Kidney transplant: 7.4–14.9 nmol/L; liver transplant: 5–12.4 nmol/L; pancreas transplant: 12.4–22.3 nmol/L; bone marrow transplant: 12.4–24.8 nmol/L	10–14 hr	99%	Hepatic (CYP3A4, CYP3A5)	1° fecal	Yes/Yes

Therapeutic targets for the initial phase post-transplantation are slightly higher than during the maintenance phase and are influenced by the specific therapy chosen for each patient with respect to coordination of treatment for other conditions and corresponding therapies. Therapeutic ranges for everolimus, sirolimus, and tacrolimus assume concomitant administration of cyclosporine and steroids.

Critical Findings and Potential Interventions ⬆ ⬇

Note: The adverse effects of subtherapeutic levels are also important. Care should be taken to investigate signs and symptoms of too little and too much medication.

Timely notification to the requesting health-care provider (HCP) of any critical findings and related symptoms is a role expectation of the professional nurse. A listing of these findings varies among facilities.

Analgesics, Anti-inflammatories, and Antipyretics

Acetaminophen: Greater than 200 mcg/mL (4 hr Postingestion): (SI: Greater than 1,324 micromol/L [4 hr Postingestion])

Signs and symptoms of acetaminophen intoxication occur in stages over a period of time. In stage I (0 to 24 hr after ingestion), symptoms may include gastrointestinal (GI) irritation, pallor, lethargy, diaphoresis, metabolic acidosis, and possibly coma. In stage II (24 to 48 hr after ingestion), signs and symptoms may include right upper quadrant abdominal pain; elevated liver enzymes, aspartate aminotransferase (AST), and alanine aminotransferase (ALT); and possible decreased kidney function. In stage III (72 to 96 hr after ingestion), signs and symptoms may include nausea, vomiting, jaundice, confusion, coagulation disorders, continued elevation of AST and ALT, decreased kidney function, and coma. Potential interventions depend on the length of time the toxicity has persisted. Toxicity noted within 1 hr may be treated with gastric decontamination (stomach pumping) or if alert, administration of activated charcoal. Those with a high level of acetaminophen may be treated within 8 hr of ingestion with N-acetyl-cysteine (NAC) to protect against liver toxicity. Acute toxicity can lead to renal failure. Recommended interventions include hemodialysis, and the administration of NAC to see if it helps. Transplant referral may be considered.

Acetylsalicylic Acid (ASA): Greater than 40 mg/dL: (SI: Greater than 2.9 mmol/L)

Signs and symptoms of salicylate intoxication include ketosis, convulsions, dizziness, nausea, vomiting, hyperactivity, hyperglycemia, hyperpnea, hyperthermia, respiratory arrest, and tinnitus. Potential interventions include administration of activated charcoal and gastric lavage within 60 minutes of ingestion; whole bowel irrigation may be considered in some cases; alkalinization of the urine with bicarbonate; hemodialysis, and a single dose of vitamin K (for rare instances of hypoprothrombinemia). Consider intubation for those with worsening mental and respiratory status.

Anticonvulsants

Carbamazepine: Greater than 20 mcg/mL (SI: Greater than 85 micromol/L)

Signs and symptoms of carbamazepine toxicity include respiratory depression, seizures, leukopenia, hyponatremia, hypotension, stupor, and possible coma. Potential interventions include gastric lavage within 60 min of ingestion; whole bowel irrigation with protected airway (complications include ileus or bowel obstruction); administration of multi-dose activated charcoal; charcoal hemoperfusion; hemodialysis or plasmapheresis; intravenous lipid emulsion; airway protection and support; administration of fluids and vasopressors for hypotension; benzodiazepine (lorazepam, diazepam) to prevent seizures; cardiac monitoring; sodium bicarbonate (wide QRS greater than 100 msec); monitoring of vital signs; and discontinuing the medication. Emesis induction not recommended due to risk of CNS depression and seizures. Emetics are contraindicated.

Ethosuximide: Greater than 200 mcg/mL (SI: Greater than 1,416 micromol/L)

Signs and symptoms of ethosuximide toxicity include nausea, vomiting, and lethargy. Potential interventions include administration of activated charcoal; charcoal hemoperfusion; cathartics; emesis unless obtunded, convulsing, or comatose (no emetics); gastric lavage (contraindicated if ileus is present); hemodialysis; airway protection and support; assisted ventilation or intubation if needed; suction as necessary; beta agonist such as albuterol for severe bronchospasm; hourly assessment of neurological function; administer diazepam or lorazepam for seizures; anticipate and treat shock; monitor and treat cardiac arrhythmias. Discontinue medication.

Lamotrigine: Greater than 20 mcg/mL (SI: Greater than 78 micromol/L)

Signs and symptoms of lamotrigine toxicity include severe skin rash, nausea, vomiting, ataxia, decreased levels of consciousness, coma, increased seizures, nystagmus. Potential interventions include frequent vital signs; induced emesis with airway protection; administration of multiple dose activated charcoal; administration of saline cathartic and gastric lavage (contraindicated if ileus is present); airway protection and support; hourly assessment of neurologic function; medication discontinuation; hemodialysis may be considered.

Phenobarbital: Greater than 60 mcg/mL (SI: Greater than 259 micromol/L)

Signs and symptoms of phenobarbital toxicity include cold, clammy skin; ataxia; central nervous system (CNS) depression; hypothermia; hypotension; cyanosis; Cheyne-Stokes respiration; tachycardia; possible coma; and possible renal impairment. Potential interventions include administration of activated charcoal; consider gastric lavage; airway protection and support; possible intubation and mechanical ventilation (especially during gastric lavage if there is no gag reflex); monitoring for hypotension; forced alkaline diuresis; hemodialysis; administration of bemegride as a CNS stimulant; and medication discontinuation.

Phenytoin (Adults): Greater than 40 mcg/mL (SI: Greater than 158 micromol/L)

Signs and symptoms of phenytoin toxicity include double vision, nystagmus, lethargy, CNS depression, and possible coma. Potential interventions include airway protection and support; intubation with assisted or mechanical ventilation; monitor for and manage hypotension with isotonic solution bolus; initiate vasopressors (norepinephrine or dopamine); cardiac (ECG) monitoring with ACLS bradycardia management (atropine, epinephrine, transcutaneous or transvenous pacing); administration of activated charcoal within 1 hr of ingestion unless depressed metal state; benzodiazepines, phenobarbital or levetiracetam for persistent seizures; not recommended are induced emesis, gastric lavage, or whole bowel irrigation; hemodialysis is controversial and should be used with caution; and discontinuing the medication.

Primidone: Greater than 15 mcg/mL (SI: Greater than 69 micromol/L)

Signs and symptoms of primidone toxicity include ataxia, anemia, CNS depression, lethargy, somnolence, vertigo, and visual disturbances. Potential interventions include symptom management; supportive treatment; urine alkalinization; forced diuresis; possible hemodialysis; airway protection and support; assisted or mechanical ventilation; possible albuterol for bronchospasam; seizure management with diazepam or lorazepam; suction as needed; no emetics or forced emesis due to aspiration risk; cautiously treat hypotension with fluids considering overload risk; medication discontinuation.

Valproic acid: Greater than 200 mcg/mL (SI: Greater than 1,386 micromol/L)

Signs and symptoms of valproic acid toxicity include loss of appetite, mental changes, numbness, tingling, and weakness. Potential interventions include airway protection and support with assisted or mechanical ventilation; hypotension management with boluses of isotonic crystalloid and vasopressors; possible benzodiazepines for seizure management; administration of activated charcoal within 2 hours of ingestion unless there is aspiration risk due to patient sedation; activated charcoal can be given more than 2 hr after ingestion if the medication was enteric coated; administration of L-carnitine for those who present with altered mental status; opioid antagonist naloxone to reverse CNS depression; consider hemodialysis and hemoperfusion; and discontinuation of the medication.

Antidepressants

Amitriptyline: Greater than 500 ng/mL (SI: Greater than 1,800 nmol/L)

Nortriptyline: Greater than 500 ng/mL (SI: Greater than 1,900 nmol/L)

Protriptyline: Greater than 500 ng/mL (SI: Greater than 1,900 nmol/L)

Doxepin: Greater than 500 ng/mL (SI: Greater than 1,790 nmol/L)

Imipramine: Greater than 500 ng/mL (SI: Greater than 1,785 nmol/L)

Signs and symptoms of cyclic antidepressant toxicity include agitation, drowsiness, hallucinations, confusion, seizures, dysrhythmias, hyperthermia, flushing, dilation of the pupils, and possible coma. Potential interventions include administration of activated charcoal within 2 hr of ingestion with protected airway; no emesis induction; airway protection and support; assisted airway or mechanical ventilation; use of benzodiazepines, phenobarbital, or propofol for seizure management; intralipid emulsion, sodium bicarbonate for the hemodynamically unstable, dysrhythmias; temporary pacemaker; fluids and vasopressors (norepinephrine) for hypotension; gastric lavage for the significantly toxic; and cardiac (ECG) monitoring.

Antidysrhythmics

Amiodarone: Greater than 2.5 mcg/mL (SI: Greater than 3.9 micromol/L)

Signs and symptoms of pulmonary damage related to amiodarone toxicity include bronchospasm, wheezing, fever, dyspnea, cough, hemoptysis, and hypoxia. Potential interventions include activated charcoal for acute oral ingestions; monitoring pulmonary function with chest x-ray; monitoring liver function tests to assess for liver damage; monitoring thyroid function tests to assess for thyroid damage (related to the high concentration of iodine contained in the medication); and cardiac (ECG) monitoring for worsening of dysrhythmia, bradycardia, VT; temporary pacemaker; monitor for hypotension, vasopressors; discontinuing the medication.

Digoxin: Greater than 2.5 ng/mL (SI: Greater than 3.2 nmol/L)

Signs and symptoms of digoxin toxicity include dysrhythmias, anorexia, hyperkalemia, nausea, vomiting, diarrhea, changes in mental status, and visual disturbances (objects appear yellow or have halos around them). Potential interventions include discontinuing the medication; continuous cardiac (ECG) monitoring (prolonged P-R interval, widening QRS interval, lengthening Q-Tc interval, and atrioventricular block); transcutaneous pacing; administration of multidose activated charcoal (if the patient has a gag reflex and CNS function)most effective when given within 6 to 8 hr of ingestion; monitoring electrolyte levels potassium, calcium, serum creatinine, and digoxin; support and treatment of electrolyte disturbance; administration of atropine for the hemodynamically unstable bradyarrhythmic; administration of lidocaine for VT; administration of Digibind or DigiFab(digoxin immune Fab). The amount of Digibind or DigiFabgiven depends on the level of digoxin to be neutralized. Digoxin levels must be measured before the administration of Digibind or DigiFab. Digoxin levels should not be measured for several days after administration of Digibind or DigiFabin patients with normal kidney function (1 wk or longer in patients with decreased kidney function). Digibind or DigiFabcross-reacts in the digoxin assay and may provide misleading elevations or decreases in values depending on the particular assay in use by the laboratory. If Digibind or DigiFabis not available, multidose activated charcoal, atropine, and antidysrhythmics phenytoin or lidocaine may be used. Hemodialysis may be used with severe toxicity. Binding resins such as cholestyramine and colestipol may break enterohepatic circulation.

Disopyramide: Greater than 7 mcg/mL (SI: Greater than 20.6 micromol/L)

Signs and symptoms of disopyramide toxicity include prolonged Q-T interval, ventricular tachycardia, hypotension, and heart failure. Potential interventions include gastrointestinal decontamination by lavage; multidose activated charcoal and cathartic; discontinuing the medication; airway protection and support; cardiac (ECG) monitoring and treatment for bradyarrhythmia, ventricular tachycardia, torsade de pointes; hemodialysis or hemoperfusion for large dose ingestion; administration of diazepam, phenytoin, or phenobarbital for seizures; administration of fluids and vasopressors for hypotension.

Flecainide: Greater than 1 mcg/mL (SI: Greater than 2.41 micromol/L)

Signs and symptoms of flecainide toxicity include exaggerated pharmacological effects resulting in dysrhythmia. Potential interventions include discontinuing the medication; gastrointestinal decontamination, gastric lavage unless unconscious within 1 hr of ingestion; administer atropine, pacing prior to intubation and lavage to prevent vagal stimulation; administer activated charcoal unless contraindicated; continuous cardiac (ECG), respiratory, and blood pressure monitoring.

Lidocaine: Greater than 6 mcg/mL (SI: Greater than 25.6 micromol/L)

Signs and symptoms of lidocaine toxicity include slurred speech, CNS depression, cardiovascular depression, convulsions, muscle twitches, and possible coma. Potential interventions include continuous cardiac (ECG) monitoring; airway protection and support; and seizure precautions and administration of benzodiazepines, barbiturates, propofol; oxygen hyperventilation to raise the seizure threshold; administration of lipid emulsions to bind free circulating local anesthetics.

Procainamide: Greater than 10 mcg/mL (SI: Greater than 42.5 micromol/L); N-Acetyl Procainamide: Greater than 40 mcg/mL (SI: Greater than 170 micromol/L)

The active metabolite of procainamide is N-acetyl procainamide (NAPA). Signs and symptoms of procainamide toxicity include torsade de pointes (ventricular tachycardia), nausea, vomiting, agranulocytosis, and hepatic disturbances. Potential interventions include airway protection and support; emesis; cardiac (ECG) monitoring, asystole, heart block, ventricular arrhythmias; gastric lavage; seizure precautions; administration of sodium lactate; monitor for hypotension; and administration of hypertonic sodium bicarbonate.

Quinidine: Greater than 6 mcg/mL (SI: Greater than 18.5 micromol/L)

Signs and symptoms of quinidine toxicity include ataxia, nausea, vomiting, diarrhea, respiratory system depression, hypotension, syncope, anuria, dysrhythmias (heart block, widening of QRS and Q-T intervals, torsades de pointes), asystole, hallucinations, paresthesia, and irritability. Potential interventions include airway protection and support; hypoxia management; administration of sodium lactate; monitoring potassium and magnesium; cardiac (ECG) monitoring and temporary transcutaneous or transvenous pacemaker, cardioversion; administer magnesium sulfate for torsades de pointes; medication discontinuation.

Antimicrobials

Amikacin: Greater than 10 mcg/mL (SI: Greater than 17 micromol/L)

Gentamicin: Peak Greater than 12 mcg/mL, Trough Greater than 2 mcg/mL (SI: Peak Greater than 25 micromol/L, Trough Greater than 4 micromol/L)

Tobramycin: Peak Greater than 12 mcg/mL, Trough Greater than 2 mcg/mL (SI: Peak Treater than 25 micromol/L, Trough Greater than 4 micromol/L)

Vancomycin: Trough Greater than 30 mcg/mL (SI: Trough Greater than 21 micromol/L)

Signs and symptoms of toxic levels of the antibiotics gentamicin and tobramycin are similar and include loss of hearing and decreased renal function. Suspected hearing loss can be evaluated by audiometry testing. Impaired renal function may be identified by monitoring blood urea nitrogen and creatinine levels as well as intake and output. The most important intervention is accurate therapeutic drug monitoring so the medication can be discontinued before irreversible damage is done. Potential interventions include supportive treatment; airway support and protection; oxygen administration and mechanical ventilation; managing fluid and electrolytes; monitor for superinfections; monitor for nephrotoxicity; assess for ototoxicity; consider hemodialysis; medication discontiunation.

Antipsychotics and Mood Stabilizers

Haloperidol: Greater than 42 ng/mL (SI: Greater than 112 nmol/L)

Signs and symptoms of haloperidol toxicity include hypotension, myocardial depression, respiratory depression, and extrapyramidal neuromuscular reactions. Potential interventions include emesis induction (contraindicated in the absence of gag reflex or central nervous system depression or excitation) and gastric lavage followed by administration of activated charcoal; airway protection and support; airway maintenance with use of oropharyngeal airway, endotracheal tube, tracheostomy, mechanical ventilation; manage hypotension with IV fluids, concentrated albumin, vasopressors phenylephrine or norepinephrine; cardiac (ECG) monitorng, dysrhythmias, torsades de pointes, Q-T prolongation; discontinue medication.

Lithium: Greater than 2 mEq/L (SI: Greater than 2 mmol/L)

Signs and symptoms of lithium toxicity include ataxia, coarse tremors, muscle rigidity, vomiting, diarrhea, confusion, convulsions, stupor, T-wave flattening, loss of consciousness, and possible coma. Potential interventions include whole bowel irrigation; gastric lavage; administration of intravenous fluids with diuresis, electrolyte management; consider hemodialysis; peritoneal dialysis if hemodialysis is unavailable; discontinue medication; consider anticonvulsant medication.

Immunosuppressants

Cyclosporine: Greater than 500 ng/mL (SI: Greater than 416 nmol/L)

Signs and symptoms of cyclosporine toxicity include increased severity of expected adverse effects, which include nausea, stomatitis, vomiting, anorexia, hypertension, infection, fluid retention, hypercalcemic metabolic acidosis, tremor, seizures, headache, and flushing. Potential interventions include close monitoring of blood levels to make dosing adjustments; inducing emesis (if orally ingested); performing gastric lavage (if orally ingested); airway protection and support; assisted or mechanical ventilation; seizure precautions; withholding the drug, and initiating alternative therapy for a short time until the patient is stabilized. Medications that may be considered to help decrease drug levels are rifampicin, rifabutin, isoniazid, barbiturates, phenytoin, carbamazepine, intravenous trimethoprim, intravenous sulfadimidine, imipenem, cephalosporins, terbinafine, ciprofloxacin, ticlopidine, octreotide, and nefazodone.

Methotrexate: Greater than 5 micromol/L

Signs and symptoms of methotrexate toxicity include increased severity of expected adverse effects, which include nausea, stomatitis, vomiting, anorexia, bleeding, infection, bone marrow depression, and, over a prolonged period of use, hepatotoxicity. The effect of methotrexate on normal cells can be reversed by administration of 5-formyltetrahydrofolate (citrovorum or leucovorin). 5-Formyltetrahydrofolate allows higher doses of methotrexate to be given. Potential interventions include immediate toxicity treatment with administration of leucovorin, thymidine, glucarpidase; adequate fluid hydration; urinary alkalinization with sodium bicarbonate; consider hemodialysis and hemoperfusion.

Everolimus: Greater than 15 ng/mL (SI: Greater than 15 mcg/L)

Signs and symptoms of everolimus pulmonary toxicity include hypoxia, pleural effusion, cough, and dyspnea. Possible interventions include dosing adjustments, administration of corticosteroids, and monitoring of pulmonary function with chest x-ray. Use of everolimus is contraindicated in patients with severe hepatic impairment. Concomitant administration of strong CYP3A4 inhibitors may significantly increase everolimus levels.

Sirolimus: Greater than 25 ng/mL (SI: Greater than 28 mcg/L)

Signs and symptoms of sirolimus pulmonary toxicity include cough, shortness of breath, chest pain, and rapid heart rate. Possible interventions include dosing adjustments, administration of corticosteroids, and monitoring of pulmonary function with chest x-ray.

Tacrolimus: Greater than 25 ng/mL (SI: Greater than 31 mcg/L)

Signs and symptoms of tacrolimus toxicity include tremors, seizures, headache, high blood pressure, hyperkalemia, tinnitus, nausea, and vomiting. Possible interventions include treatment of hypertension, administration of antiemetics for nausea and vomiting, and dosing adjustments.

Overview ⬆ ⬇

Study type: Blood collected in a red-top tube exceptfor cyclosporine, everolimus, sirolimus, and tacrolimus which are collected in a lavender-top [EDTA] tube; related body system: Multisystem.

The metabolism of many commonly prescribed medications is driven by the cytochrome P450 (CYP450) family of enzymes. Genetic variants can alter enzymatic activity that results in a spectrum of effects ranging from the total absence of drug metabolism to ultrafast metabolism. Impaired drug metabolism can prevent the intended therapeutic effect or even lead to serious adverse drug reactions.

Poor metabolizer (PM) are at increased risk for drug-induced adverse effects due to accumulation of drug in the blood, and ultra rapid metabolizer (UM) require a higher than normal dosage because the drug is metabolized over a shorter duration than intended. In the case of prodrugs, which require activation prior to metabolism, the opposite occurs: PM may require a higher dose because the activated drug becomes available more slowly than intended, and UM requires less because the activated drug becomes available sooner than intended. Other genetic phenotypes used to report CYP450 results are intermediate metabolizer (IM) and extensive metabolizer (EM).

Testing for specific CYP450 genotype defects can be performed in some laboratories on blood and buccal specimens. The test method commonly used is polymerase chain reaction. Counseling and informed written consent are generally required for genetic testing. Testing allows for the possibility of personalized adjustments to the medication regimen or decisions to seek alternative drugs, which in turn results in safer, more effective treatment.

CYP2C9 is a gene in the CYP450 family that metabolizes phenytoin as well as other drugs, such as the antihypertensive drug losartan and the anticoagulant drug warfarin. CYP2D6 is a gene in the CYP450 family that metabolizes tricyclic antidepressants such as nortriptyline, antipsychotics such as haloperidol, and beta blockers.

Testing for the genetic variants of CYP2D6, CYP2C19, CYP2C8, CYP2C9, CYP3A4, and CYP3A5 is used to predict altered enzyme activity and anticipate the most effective therapeutic plan. Results may also explain adverse reactions. The inheritance pattern for the CYP450 enzymes is autosomal co-dominant where two alleles of a gene each code for a slightly different variation of an enzyme; the two genetic variants equally influence expression of the enzymes produced.

Analgesics, Anti-inflammatories, and Antipyretics

Acetaminophen is used for headache, fever, and pain relief, especially for individuals unable to take salicylate products or who have bleeding conditions. It is the analgesic of choice for children less than 13 yr old; salicylates are avoided in this age group because of the association between aspirin and Reye syndrome. Acetaminophen is rapidly absorbed from the GI tract and reaches peak concentration within 30 to 60 min after administration of a therapeutic dose. It can be a silent killer because by the time symptoms of intoxication appear 24 to 48 hr after ingestion, the antidote is ineffective.

ASA is also used for headache, fever, inflammation, and pain relief. Some patients with cardiovascular disease take small prophylactic doses. The main site of toxicity for both drugs is the liver, particularly in the presence of liver disease or decreased drug metabolism and excretion. Other medications indicated for use in controlling neuropathic pain include amitriptyline and nortriptyline

Anticonvulsants

Anticonvulsants are used to reduce the frequency and severity of seizures for patients with epilepsy. Carbamazepine is also used for controlling neurogenic pain in trigeminal neuralgia and diabetic neuropathy and for treating bipolar disease and other neurological and psychiatric conditions. Valproic acid is also used for some psychiatric conditions, such as bipolar disorder, and for prevention of migraine headache.

Antidepressants

Cyclic antidepressants are used in the treatment of major depression. They have also been used effectively to treat bipolar disorder, panic disorder, attention deficit-hyperactivity disorder, obsessive-compulsive disorder, enuresis, eating disorders (bulimia nervosa in particular), nicotine dependence (tobacco), and cocaine dependence. Numerous drug interactions occur with the cyclic antidepressants.

Antidysrhythmics

Cardiac glycosides are used in the prophylactic management and treatment of heart failure and ventricular and atrial dysrhythmias. Because these drugs have narrow therapeutic windows, they must be monitored closely. The signs and symptoms of toxicity are often difficult to distinguish from those of cardiac disease. Patients with toxic levels may show GI, ocular, and CNS effects and disturbances in potassium balance.

Antimicrobials

The aminoglycoside antibiotics amikacin, gentamicin, and tobramycin amikacin sulfate, gentamicin sulfate, and tobramycinare used against many gram-negative (Acinetobacter, Citrobacter, Enterobacter, Escherichia coli, Klebsiella, Proteus, Providencia, Pseudomonas, Raoultella, Salmonella, Serratia, Shigella, and Stenotrophomonas) and some gram-positive (Staphylococcus aureus) pathogenic microorganisms.

Aminoglycosides are poorly absorbed through the GI tract and are most frequently administered IV. Peak and trough collection times should be documented carefully in relation to the time of medication administration. Creatinine levels should be monitored every 2 to 3 days to detect renal impairment due to toxic drug levels.

Vancomycin is a tricyclic glycopeptide antibiotic used against many gram-positive microorganisms, such as staphylococci, Streptococcus pneumoniae, group A beta-hemolytic streptococci, enterococci, Corynebacterium, and Clostridioides difficile. Vancomycin has also been used in an oral form for the treatment of pseudomembranous colitis resulting from Clostridioides difficile infection. This approach is less frequently used because of the emergence of vancomycin-resistant enterococci (VRE).

Antipsychotics and Mood Stabilizers

Haloperidol is an antipsychotic tranquilizer used for treatment of acute and chronic psychotic disorders, Tourette syndrome, and hyperactive children with severe behavioral problems. Frequent monitoring is important due to the unstable relationship between dosage and circulating steady-state concentration.

Lithium is used in the treatment of bipolar disorder. Daily monitoring of lithium levels is important until the proper dosage is achieved. Lithium is cleared and reabsorbed by the kidneys. Clearance is increased when sodium levels are increased and decreased in conditions associated with low sodium levels; therefore, patients receiving lithium therapy should try to maintain a balanced daily intake of sodium.

Lithium levels affect other organ systems. A high incidence of pulmonary complications is associated with lithium toxicity. Lithium can also affect cardiac conduction, producing T-wave depressions. These ECG changes are usually insignificant and reversible and are seen in 10% to 20% of patients on lithium therapy. Chronic lithium therapy has been shown to result in enlargement of the thyroid gland in a small percentage of patients. Other medications indicated for use as mood stabilizers include carbamazepine, lamotrigine, and valproic acid.

Immunosuppressants

Cyclosporine is an immunosuppressive drug used in the management of organ rejection, especially rejection of heart, liver, pancreas, and kidney transplants. Its most serious adverse effect is renal impairment or chronic kidney disease. Cyclosporine Ciclosporineis often administered in conjunction with corticosteroids (e.g., prednisone) for its anti-inflammatory or immune-suppressing properties and with other drugs (e.g., everolimus, sirolimus, tacrolimus) to reduce graft-versus-host disease.

Cyclosporine, sirolimus, and tacrolimus are metabolized by the cytochrome enzyme CYP3A4, which is essential to achieve the desired therapeutic effect.

Methotrexate is a highly toxic drug that causes cell death by disrupting DNA synthesis. Methotrexate is also used in the treatment of rheumatoid arthritis, psoriasis, polymyositis, and Reiter syndrome.

Many factors must be considered in interpreting drug levels, including patient age, patient ethnicity, patient weight, interacting medications, electrolyte balance, protein levels, water balance, conditions that affect absorption and excretion, and the ingestion of substances (e.g., foods and dietary supplements) that can potentiate or inhibit the intended target concentration.

These medications are metabolized and excreted by the kidneys and may be contraindicated by medical direction in patients with kidney disease and cautiously advised in patients with kidney impairment. Information regarding medications must be clearly and accurately communicated to avoid misunderstanding of the dose time in relation to the collection time. Miscommunication between the individual administering the medication and the individual collecting the specimen is the most frequent cause of subtherapeutic levels, toxic levels, and misleading information used in the calculation of future doses.

Some pharmacies use a computerized pharmacokinetics approach to dosing that eliminates the need to be concerned about peak and trough collections; random specimens are adequate. If administration of the drug is delayed, notify the appropriate department(s) to reschedule the blood draw and notify the requesting HCP if the delay has caused any real or perceived therapeutic harm.

Indications ⬆ ⬇

Monitor some patients who have a pacemaker, who have impaired kidney or liver function, who have had an organ transplant, or who are taking interacting drugs.
Suspected overdose/misuse.
Suspected subtherapeutic levels.
Suspected toxicity.
Therapeutic monitoring for adherence to and effectiveness of treatment.

Interfering Factors ⬆ ⬇

Factors That May Alter the Results of the Study

The number of drugs available for treatment of diseases and amelioration of related symptoms has skyrocketed in recent times. Adverse drug reactions (ADRs) are a significant cause of injury and death; they are preventable to a large extent. Facilities continuously develop and revise their medication administration policies and procedures to ensure patient safety in this area. Many facilities use pharmacology software, pharmacy consults, and drug guides to identify potential issues.

Computerized programs with current databases can generate warnings that take into consideration the patient’s age, weight, creatinine level (reflection of kidney function), clinical problems, and medication profile. Intuitively, situations that might be identified as high risk are polypharmacy (patients using multiple medications, e.g., four or more), and certain classes of medications that have well-known and documented ADRs such as antimicrobials, anticoagulants, anticonvulsants, antidysrhythmics, chemotherapeutics, and insulins.

Drug levels are affected by a number of factors:

Route of administration (IM, IV, PO, rectal)
Absorption
Distribution
Metabolism
Excretion
Half-life
Diseases that affect the organs involved in absorption, distribution, metabolism, and excretion (e.g., digestive, kidneys, liver)
Patient’s demographic data (age, height, weight, gender, ethnicity)
Administration may interfere with the effectiveness of other medications.
Coadministration of other medications may potentiate or diminish levels.

Other Considerations

Blood drawn in serum separator tubes (gel tubes) is not acceptable; interference with test methods may occur.
Cyclic antidepressants may potentiate the effects of oral anticoagulants.

Potential Medical Diagnosis: Clinical Significance of Results ⬆ ⬇

Level		Response
Normal levels		Therapeutic effect
Subtherapeutic levels		Adjust dose as indicated
Toxic levels (especially in the presence of hepatic or renal impairment)		Adjust dose as indicated

Nursing Implications, Nursing Process, Clinical Judgement ⬆

Before the Study: Planning and Implementation

Teaching the Patient What to Expect

Discuss how this test is designed to evaluate how much medication is within the system to assess effectiveness and make therapeutic treatment changes.
Explain that a blood sample is needed for the test.

After the Study: Implementation & Evaluation Potential Nursing Actions

Avoiding Complications

Missing scheduled collection times relative to the dosing schedule can provide misleading information that may result in erroneous interpretation of levels, creating the potential for a medication error–related injury to the patient.

Treatment Considerations

Administer antibiotic therapy if ordered.
Discuss the importance of completing the entire course of antibiotic therapy, even if signs and symptoms disappear before completion of therapy.
Anticonvulsants: Discuss the importance of immediately reporting any unusual sensations (e.g., ataxia, dizziness, dyspnea, lethargy, rash, tremors, mental changes, weakness, or visual disturbances) to his or her HCP.
Antidepressants: Discuss immediately reporting any unusual sensations (e.g., severe headache, vomiting, sweating, visual disturbances) to his or her HCP. Blood pressure should be monitored regularly.
Antidysrhythmics: Discuss immediately reporting any unusual sensations (e.g., dizziness, changes in vision, loss of appetite, nausea, vomiting, diarrhea, weakness, or irregular heartbeat) to his or her HCP. Instruct the patient not to take medicine within 1 hr of food high in fiber (as the fiber may decrease absorption by binding some of the medication, reducing its bioavailability). Testing for aspirin responsiveness/resistance may be a consideration for patients, especially women, on low-dose aspirin therapy.
Aminoglycosides: Discuss immediately reporting any unusual symptoms (e.g., hearing loss, decreased urinary output) to his or her HCP. Instruct the patient receiving lithium to immediately report any unusual symptoms (e.g., anorexia, nausea, vomiting, diarrhea, dizziness, drowsiness, dysarthria, tremor, muscle twitching, visual disturbances) to his or her HCP.

Safety Considerations

Ensure that all therapeutic drug levels are drawn within the correct time period in relation to when the medication is administered (peak and trough). Collaborate with the pharmacist to make adjustments as necessary to ensure proper results.
Failure to adhere to specimen collection policies places the patient at risk for injury.

Nutritional Considerations

Discuss the reasons for avoidance of alcohol consumption while taking hepatotoxic medications.
Anticonvulsant drugs: These drugs antagonize folic acid, and there is a corresponding slight increase in the incidence of fetal malformations in children of epileptic mothers.
Women of childbearing age who are taking antiepileptic drugs should also be prescribed supplemental folic acid to reduce the incidence of neural tube defects.
Newborns of women who have epilepsy may demonstrate a temporary deficiency of vitamin K–dependent blood clotting factors at birth.
Vitamin K deficiency is drug induced and can be avoided by administering vitamin K to the mother in the last weeks of pregnancy and to the neonate at birth.
Phenobarbital has been associated with low folate and B-vitamin levels in all patient populations; supplementation may be ordered, if needed.
Phenobarbital also decreases biologically active levels of vitamin D and reduces calcium absorption.
Dietary recommendations may include increased consumption of vitamin D–fortified foods and supplementation may be ordered, if needed.
Immunosuppressant therapy: Those on immunosuppressant therapy tend to have decreased appetites related to the adverse effects of the medication.
Instruct patients to consume a variety of foods within the basic food groups, maintain a healthy weight, be physically active, limit salt intake, limit alcohol intake, and be a nonsmoker.

Clinical Judgement

Consider how to encourage lifestyle changes necessary to facilitate embracing therapeutic recommendations.

Follow-Up and Desired Outcomes

Recognizes the importance of following the medication regimen and instructions regarding food and drug interactions.
Participates in medication reconciliation to ensure accurate collaboration between prescribing HCPs related to medication type, dose, and frequency.
Strictly adheres to the therapeutic medication regimen designed to treat the corresponding diagnosis.
Reviews medication side effects and therapeutic effects; agrees to report any related concerns to the HCP.