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Monday, October 1, 2007

Drugs that Require Frequent Monitoring

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Drugs that Require Frequent Monitoring

Drug

Therapeutic and Toxic Levels

Acetaminophen (Tylenol)

Therapeutic: 1-30 mcg/ml
Toxic: >200 mcg/ml
Contraindicated in:
Liver disease
Side Effects of Toxicity:
Hepatic Necrosis

Alcohol (Ethanol)

Therapeutic Level: 100 mcg/ml
Toxic: >400 mcg/ml

Amitriptyline (Elavil)

Therapeutic: 120-250 mcg/ml
Toxic: >500 mcg/ml
Contraindicated in: Narrow-angle glaucoma and potential fatal reactions when used with MAO inhibitors
Side Effects of Toxicity:
Drowsiness, sedation, lethary, fatigue, dry mouth and eyes, blurred vision, hypotension, and tachycardia.
Caution patients to use a sun screen.
Therapeutic effects within 2 to 6 weeks of initiating therapy.

Carbamazepine (Tegretol)

Therapeutic: 8-12 mcg/ml
Toxic: >15 mcg/ml
Contraindicated in:
Bone marrow depression
Side Effects of Toxicity:
Drowsiness, dizziness, and ataxia.
Caution patients to use a sun screen and to carry a medical alert card.

Chlordiazepoxide (Librium)

Therapeutic: 700-1000 mcg/ml
Toxic: >5000 mcg/ml
Contraindicated in:
Comatose patients with CNS depression, narrow-angle glaucoma
Side Effects of Toxicity:
Drowsiness and dizziness.
Alcohol Withdrawal Treatment: Assess patients for signs and symptoms of delirium tremors (DTs).

Desopyramide (Norpace)

Therapeutic: Variable
Toxic: >7 mcg/ml
Contraindicated in:
Cardiogenic shock, 2nd and 3rd degree heart blocks, sick sinus syndrome
Side Effects of Toxicity:
Signs and symptoms of congestive heart failure.

Diazepam (Valium)

Therapeutic: 100-1000 mcg/ml
Toxic: >5000 mcg/ml
Contraindicated in:
Comatose patients with CNS depression, narrow-angle glaucoma
Side Effects of Toxicity:
Sedation with ataxia, dizziness, and slurred speech.
Therapeutic effects within 1 to 2 weeks of initiating therapy.

Digitoxin

Therapeutic: 20-35 ng/ml
Toxic: >45 ng/ml
Contraindicated in:
Uncontrolled ventricular arrhythmias, AV block
Side Effects of Toxicity:
Abdominal pain, anorexia, nausea, vomiting, visual disturbances, bradycardia, and other arrhythmias.

Digoxin

Therapeutic: 0.8-1.5 mcg/ml
Toxic: >2 mcg/ml
Contraindicated in:
Uncontrolled ventricular arrhythmias, AV block
Side Effects of Toxicity:
Abdominal pain, anorexia, nausea, vomiting, visual disturbances, bradycardia, and other arrhythmias.

Doxepin

Therapeutic: 30-150 mcg/ml
Toxic: >500 mcg/ml
Contraindicated in:
Narrow-angle glaucoma
Side Effects of Toxicity:
Sedation, fatigue, blurred vision, hypotension, dry mouth, and constipation.
Caution patients to use a sun screen.
May cause hypotension, tachycardia, and potentially fatal reactions when used with MAO inhibitors
Therapeutic effects within 2 to 6 weeks of initiating therapy.

Glucocorticoids

Contraindicated in:
Serious infections
Signs of adrenal insufficiency: Hypotension, weight loss, weakness, nausea, vomiting, anorexia, lethargy, confusion, restlessness.
Side Effects:
Depression or euphoria, personality changes, hypertension, decreased wound healing, petechiae, ecchymoses, hyperglycemia, hypokalemia, hypernatremia, fluid retention, aseptic necrosis of joints, osteoporosis, cushingoid appearance (moon face, and buffalo hump)
Monitor blood sugars, BUN, creatinine.
Advise patients that medication should NOT be abruptly discontinued by tapered off over 2 to 4 weeks.

Imipramine (Tofranil)

Therapeutic: 125-250 mcg/ml
Toxic: >500 mcg/ml
Contraindicated in:
Narrow-angle glaucoma
Side Effects of Toxicity:
Disturbed concentration, confusion, restlessness, agitation, convulsions, drowsiness, mydriasis, arrhythmias, fever, hallucinations, vomiting, and dyspnea.
Caution patients to use a sun screen.
Therapeutic effects within 2 to 6 weeks of initiating therapy.

Lithium

Therapeutic: 0.6-1.2 mcg/ml
Toxic: >2 mcg/ml
Serum levels should be monitored twice weekly during initiation of therapy and every 2 to 3 months durgin chronic therapy.
Contraindicated in:
Severe cardiovascular or renal disease, dehydrated or debilitated patients
Side Effects of Toxicity:
Vomiting, diarrhea, slurred speech, decreased coordination, drowsiness, muscle weakness, and twitching.
Therapeutic effects within 1 to 3 weeks of initiating therapy.

Lidocaine (Xylocaine)

Therapeutic: 1.5-6 mcg/ml
Toxic: >6-8 mcg/ml
Contraindicated in:
Advanced AV block
Side Effects of Toxicity:
Confusion, excitation, blurred or double vision, nausea, vomiting, ringing in ears, tremors, twitching, convulsion, difficulty breathing, severe dizziness or fainting, and slow heart rate.

Magnesium sulfate

Contraindicated in:
Hypermagnesemia, hypocalcemia, anuria, and heart block
Side Effects of Toxicity:
Decreased respiratory rate, bradycardia, arrhythmias, hypotension, drowsiness, flushing, sweating, and hypothermia.
Monitor neurologic status before and throughout therapy.
Institute seizure precautions.

Methotrexate

Therapeutic: Variable
Toxic: >454 mcg/ml (48 hours after high dose)
Contraindicated in:
Pregnancy and lactation (teratogenic effects)
Side Effects of Toxicity:
Hyperuricemia, abdominal pain, diarrhea, stomatitis, hepatotoxicity, pulcomary toxicity, nephrotoxicity, anemia, leukopenia, thrombocytopenia, and folic acid deficiency
Caution patients to use a sun screen.
Rescue Drug to Prevent Fatal Toxicity:
Leucovorin (folinic acid)

Phenobarbital

Therapeutic: 15-40 mcg/ml
Toxic: Varies 35-80 mcg/ml
Contraindicated in:
Comatose patients with CNS depression
Side Effects of Toxicity:
Confusion, drowsiness, dyspnea, slurred speech, and staggering.

Phenytoin (Dilantin)

Therapeutic: 10-20 mcg/ml
Toxic: Varies with symptoms
Contraindicated in:
Sinus bradycardia and heart block
Side Effects of Toxicity:
Nystagmus, ataxia, confusion, nausea, slurred speech, and dizziness.
Caution patients to carry a medical alert card.

Procainamide (Promestyl)

Therapeutic: 5-12 mcg/ml
Toxic: >15 mcg/ml
Contraindicated in:
AV block and myasthenia gravis
Side Effects of Toxicity:
Confusion, dizziness, drownsiness, decreased urination, nausea, vomiting, and tachyarrhythmias.

Primidone (Mysoline)

Therapeutic: 5-10 mcg/ml
Toxic: >15 mcg/ml
Contraindicated in:
Porphyria
Side Effects of Toxicity:
Ataxia, lethargy, changes in vision, confusion, and dyspnea.
Caution patients to carry a medical alert card.

Propranolol (Inderal)

Therapeutic: Varies
Toxic: Vaires
Contraindicated in:
Uncompensated congestive heart failure, pulmonary edema, cardiogenic shock, bradycardia, and heart block
Side Effects of Toxicity:
Bradycardia, severe dizziness or fainting, severe drowsiness, dyspnea, bluish fingernails or palms, and seizures.
Caution diabetic patients to monitor blood sugar.

Quinidine

Therapeutic: 2-6 mcg/ml
Toxic: >8 mcg/ml
Contraindicated in:
Conduction defects and digitalis glycoside toxicity
Side Effects of Toxicity:
Tinnitus, hearing loss, visual disturbances, headache, nausea, and dizziness.
Cardiotoxicity signs include QRS widening, cardiac asystole, ventricular ectopic beats, idioventricular rhythms, paradoxical tachycardia, and arterial embolism.

Salicylate

Therapeutic: Varies
Toxic: Varies
Contraindicated in:
Hypersensitivity to aspirin or other salicylates, bleeding disorders or thrombocytopenia
Side Effects of Toxicity:
Tinnitus, headache, hyperventilation, agitation, mental confusion, lethargy, diarrhea, and sweating.
May take 2 to 3 weeks for maximum effectiveness.

Theophylline

Therapeutic: 10-20 mcg/ml
Toxic: >20 mcg/ml
Contraindicated in:
Uncontrolled arrhythmias and hyperthyroidism
Side Effects of Toxicity:
Anorexia, nausea, vomiting, stomach cramps, diarrhea, confusion, headache, restlessness, flushing, increased urination, insomnia, tachycardia, arrhythmias, and seizures. Tachycardia, ventricular arrhythmias, or seizures may be the first sign of toxicity.

Valproic Acid (Depakene)

Therapeutic: 50-100 mcg/ml
Toxic: >100 mcg/ml
Contraindicated in:
Hepatic impairment
Side Effects of Toxicity:
Anorexia, severe nausea an dvomiting, yellow skin or eyes, fever, sore throat, malaise, weakness, facial edema, lethargy, unusual bleeding or bruising, or seizures.

Antibiotics that Require Frequent Monitoring
(Aminoglycosides)

Drugs

Troughs

Peaks

Amikacin

5 mcg/ml

35 mcg/ml

Gentamicin

2 mcg/ml

10 mcg/ml

Kanamycin

5 mcg/ml

35 mcg/ml

Neomycin

2 mcg/ml

16 mcg/ml

Streptomycin

Varies

25 mcg/ml

Tobramycin

2 mcg/ml

20 mcg/ml

Vancomycin

5-10 mcg/ml

25 mcg/ml

Aminoglycosides must be monitored carefully for side effects including ototoxicity (vestibular and cochlear), nephrotoxicity, neurotoxicity, and hypersensitivity reactions. Monitor patients for tinnitus, vertigo, hearing loss, rash, dizziness, or difficulty urinating.

Renal lab tests that must be monitored include urinalysis, specific gravity, BUN, creatinine, and creatinine clearance.

Liver lab tests that must be monitored include , AST (SGOT), ALT (SGPT), serum alkaline phosphatase, bilirubin, creatinien, and LDH concentrations.

Trough# levels are referred to as the minimum drug concentration that proceeds the administration of a single dose of medication. Trough levels should be drawn just prior to the next dose.

Peak* levels are referred to as the maximum drug concentration that follows the administration of a single dose of medication. Peak levels should be drawn 1 hour after IM injections and 30 minutes after a 30-minute IV infusion is completed.

Drugs that Require an Antidote

Drug

Antidote

Acetaminophen

Acetylcysteine

Anticholinesterases (Cholinergics)

Atropine, Pralidoxime

Antidepressants
(MAO inhibitors and tryamine-containing foods may lead to hypertensive crisis including symptoms of chest pain, severe headache, nuchal rigidity, nausea and vomiting, photosensitivity, and enlarged pupils)

Phentolamine

Benzodiazepines

Flumazenil

Cyanide

Amyl nitrite, sodium nitrite, sodium thiosulfate

Digoxin, digitoxin

Digoxin immune Fasb (Digibind)

Fluorouracil (5FU)

Leucovorin calcium

Heparin

Portamine sulfate

Ifosfamide
(Adverse effects cause hemorrhagic cystitis)

Mesna

Iron

Deferoxamine

Lead

Edetate calcium disodium, dimeraprol, succimer

Methotrexate
(Adverse effects cause folic acid deficiency)

Leucovorin calcium

Opioid analgesics, heroin

Nalmefene, Naloxone

Thrombolytic agents

Aminocaproic acid (Amicar)

Tricyclic antidepressants

Physostigmine

Warfarin (Coumadin)

Phytonadione (Vitamin K)

Insulins

Insulin

Onset

Peak

Duration

Regular IV

10-30 min

15-30 min

30-60 min

Regular SC

30 min-1hr

2-4 hr

5-7 hr

NPH

1-4 hr

6-12 hr

18-28 hr

Lente

1-3 hr

8-12 hr

18-28 hr

Ultralente

4-6 hr

18-24 hr

36 hr

Monitor patients for onset of HYPOGLYCEMIA reaction that typically occurs during the Peak Phase following administration of insulin. Signs and symptoms of HYPOGLYCEMIA include mental confusion, hallucinations, convulsions, pale, cool, clammy skin, tachycardia, and anxiety. Treatment includes the administration of oral glucose. Severe hypoglycemia is life-threatening and requires treatment with IV glucose, glucagon, or epinephrine.

Signs and symptoms of HYPERGLYCEMIA include polyuria, polydipsia, and polyphagia, hot, red, and dry skin. Treatment includes insulin administration. Severe hyperglycemia is usually caused by missing, miscalculating or mistiming doses of insulin or oral medication or by overeating or drinking. Severe hyperglycemia is life-threatening and requires treatment with IV replacement and IV insulin.






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