The Necessity of Monitoring
Have you ever cooked a hot dog? You throw the hot dog in the pan, warm it through, and pull it out when it looks done. Now, is that process the same for roasting a chicken? Nope, with a roast chicken you put it in the oven for the prescribed time, but before pulling it out, you check its internal temperature to ensure proper cooking. In both instances you are preparing meat, but the chicken requires more invasive monitoring than the hot dog.
The same variation in monitoring is true for medications. Some drugs require no monitoring because researchers have determined a standardized dose that is both safe and effective. Furthermore, these drugs are metabolized and absorbed in a consistent manner by different patients; therefore, the healthcare provider can be confident that the drug, once ingested, will behave a specific way.
For example, Mary has a sore throat. You, the healthcare provider, determine it's strep throat. You prescribe penicillin, using the appropriate dosing schedule for Mary's age. There is no further monitoring necessary. Mary's cured - end of story.
On the other hand, some drugs require monitoring because they behave differently. Specifically, some drugs have a narrow therapeutic index, meaning they're only safe and effective within a small range. The level of medication that will help the patient is very close to the level that will harm the patient and to the level that will be useless. Indeed, many drugs that require the kind of monitoring we're discussing in this lesson have a high risk of toxicity because of the narrow therapeutic index.
Also, some drugs have significant absorption and metabolism variability, meaning that the drug is processed very differently in different people. Sometimes this is a factor of the patient's age, gender or general state of health.
What Is Therapeutic Drug Monitoring?
Therapeutic drug monitoring (TDM) involves checking a patient's body fluids, most often blood plasma, at a certain time to determine the level of a specific drug. TDM is used in addition to physical examination, patient history, and other factors when determining if the proper dosage of the medication is being given.
In addition to certain types of medications, certain situations require TDM, such as:
- The patient doesn't seem to have a therapeutic response at the expected dose.
- The healthcare provider is unsure if the patient is taking the medication as prescribed.
- The patient is experiencing more side effects from the medication.
- The healthcare provider suspects interaction of the drug with other drugs.
- The patient needs to stop taking a medication, requiring a steady weaning off process.
Let's examine the procedure used to successfully perform TDM.
Procedure for Therapeutic Drug Monitoring
TDM is an incredibly useful tool, but like any tool, it must be used properly or it will be ineffective. The biggest issue with TDM is timing. The blood plasma sample must be collected at the proper time and in the proper manner in order for the lab value to hold any significance.
A healthcare provider may use TDM to know when a medication has reached a steady state, which is when the amount of drug being ingested equals the amount being excreted. TDM allows the healthcare provider to track the patient's response to initial doses of drugs that are difficult to manage due to variability and narrow therapeutic indexes.
Determining the steady state of a medication depends on the drug's half-life, or the amount of time it takes for half of the drug ingested to be eliminated from the bloodstream. Usually it takes about five half-lives for a medication to reach steady state.
However, if TDM is being used to monitor response to a medication once a steady state has been reached, then the sample needs to be obtained at trough. Trough means just prior to the next dose of medication. For example if a medication is given every 12 hours and the patient's last dose was at 8pm, then the TDM sample needs to be collected at 7:55 am, just before the next dose of medication.
This timing information must be made available to the technician in order to correctly calculate the drug concentration in the sample. So the technician must know:
- The time the sample was obtained.
- The time of the last dose of the medication.
- When the drug regime was initiated.
Lastly, the level of the medication must be reported back to the provider as quickly as possible, preferably within 24 hours. Why? So that the provider can make changes before the level in the patient's body changes significantly.
In addition to proper timing, the sample needs to be collected in the proper manner. Some drugs require that the blood sample remain unclotted; conversely, other drugs require that the blood be clotted. Also, certain drugs require that the sample be kept at a certain temperature or away from light. Therefore, it is important that the technician review any restrictions of a particular drug before drawing a sample for TDM.
Examples of Drugs Requiring Therapeutic Drug Monitoring
Of the thousands of drugs currently used in the United States, only about twenty are routinely monitored with TDM. These medications treat a wide variety of conditions.
|Class of Drugs||Drug Name|
Therapeutic drug monitoring (TDM) is important for drugs with a:
- narrow therapeutic index
- high risk of toxicity
- high variability in absorption and metabolism
When collecting a sample for TDM, timing is the most important issue. If you're checking to see if the drug has reached a steady state, the sample must be obtained after five half-lives of the drug have occurred. If you're checking a maintenance level, the sample must be obtained at the trough, or just before the next dose is administered.
TDM is a tool that can be immensely useful when performed properly and interpreted within clinical context.
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Therapeutic Drug Monitoring Word Scramble Activity
In this activity, you will check your knowledge regarding the definition and techniques of therapeutic drug monitoring presented in the lesson.
For this activity, study the scrambled letters and try to unscramble or rearrange the letters to form a word or phrase that fits the given clues. To do this, you must right-click and print this page. With a pencil and an eraser, neatly write your answers in the blank space provided.
- ALMSL AGERN
- IEDS FEECSTF
- ATYEDS ESTTA
- AHTUETRPCEI SERSPNEO
- DRNTAEADDZIS DOSE
- _____ is any of a group of narrow-spectrum antibiotics that are synthesized from molds and can be used to alleviate a sore throat.
- Medications that have a narrow therapeutic index need to be monitored since these are only safe and effective within a _____ _____.
- Patients experiencing more _____ _____ from the medication require TDM.
- _____ is a challenge in TDM for blood plasma samples must be collected at the proper time and in the appropriate manner to hold any significance.
- The _____ is measured just before the next dose of medication is administered.
- Some drugs require that the blood sample remain _____; others require the sample to be kept at a certain temperature.
- Normally, it takes about five half-lives for a drug to reach a _____ _____.
- Monitoring is needed when a patient doesn't seem to have a _____ _____ at the standard dose.
- There is a considerable probability of _____ when the dosage of medications having a narrow therapeutic index is wrongfully administered.
- Drugs that have already been given a _____ _____ can be taken without the need for monitoring.
- SMALL RANGE
- SIDE EFFECTS
- STEADY STATE
- THERAPEUTIC RESPONSE
- STANDARDIZED DOSE
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