Overview of therapeutic drug monitoring

Abstract

Therapeutic drug monitoring (TDM) is the clinical practice of measuring specific drugs at designated intervals to maintain a constant concentration in a patient's bloodstream, thereby optimizing individual dosage regimens. It is unnecessary to employ TDM for the majority of medications, and it is used mainly for monitoring drugs with narrow therapeutic ranges, drugs with marked pharmacokinetic variability, medications for which target concentrations are difficult to monitor, and drugs known to cause therapeutic and adverse effects. The process of TDM is predicated on the assumption that there is a definable relationship between dose and plasma or blood drug concentration, and between concentration and therapeutic effects. TDM begins when the drug is first prescribed, and involves determining an initial dosage regimen appropriate for the clinical condition and such patient characteristics as age, weight, organ function, and concomitant drug therapy. When interpreting concentration measurements, factors that need to be considered include the sampling time in relation to drug dose, dosage history, patient response, and the desired medicinal targets. The goal of TDM is to use appropriate concentrations of difficult-to-manage medications to optimize clinical outcomes in patients in various clinical situations.

Figure 1

Process for reaching dosage decisions with therapeutic drug monitoring.

Figure 2

Concept of the therapeutic range [20].

Figure 3

Measuring the plasma digoxin concentration may be helpful in confirming the diagnosis of toxicity [21].

Figure 4

Relationships of pharmacokinetics and pharmacodynamics and factors that affect pharmacokinetic and phamacodynamic variability [16].

Figure 5

Plasma steady-state phenytoin concentration (Css) in relation to total daily dose. At all dosages, there are large intersubject variations in mean Css.