Lithium continues to be a main drug in mood disorders despite risks associated with high blood levels of lithium and introduction of a number of mood stabilizers. Therapeutic drug monitoring (TDM) is a norm while using lithium. The present paper reports analysis of a retrospective audit of TDM of lithium over a period of 4 years. A retrospective serum lithium estimation data of 4 years were analyzed for drug levels, reasons for request, and correlation of levels with dose and side effects. Of 4359 requests received during the study period, about 80% were for routine monitoring and about 3% each were for adverse effects and relapse or irregular treatment. Twelve percent of the requisition forms were incomplete and therefore could not be analyzed. Out of requests of TDM for adverse effects, lithium levels were above therapeutic range (>1.2 mmol/L) in 17%, subtherapeutic (<0.6 mmol/L) in 23%, and within therapeutic range (0.6-1.2 mmol/L) in 60% cases. Thirty percent of the requisitions for routine monitoring had lithium levels in subtherapeutic range and 7% were above therapeutic range. TDM for lithium is necessary in clinical practice, and this study further confirms the need for TDM, as lithium levels remain below or above the therapeutic range in a substantial number of cases. Regular lithium level monitoring helps in uncovering unsuspected poor compliance and for better clinical management.
A retrospective study was conducted to assess the appropriateness of the utilization of therapeutic drug monitoring (TDM) services with regards to antiepileptic drugs (AEDs) at a tertiary care hospital, and analysis of 5094 samples of the carbamazepine (CBZ), phenytoin (PHT), valproic acid (VAP), and phenobarbitone (PB) was undertaken. Maximum requisitions were received for CBZ (54.92%) followed by PHT (27.05%), VAP (14.40%), and PB (3.61%). About 2.12% requisitions were received for patients taking unlabeled AEDs. Reasons for TDM were routine monitoring (36.3%), adverse drug reactions (ADRs) (17.2%), relapse (30.7%), no response (3.35%), and irregular treatment (2.24%) and not mentioned (10.5%). Majority of the samples (69%) were drawn for measuring trough levels; however, in 22% time of last dose was not mentioned and 9.64% were for peak or random levels. In all, 6.9% requisitions for TDM were sent before steady-state levels, and in 15.5% duration of therapy was not mentioned. Blood levels within therapeutic range were found with CBZ (63%) followed by PB (56.52%), VAP (45.99%), and PHT (42.52%). Blood levels were above therapeutic range in 45.69%, 29%, and 21.73% patients taking VAP, PHT, and PB, respectively. Unsuspected poor compliance was uncovered in 11.8%, 41.2%, and 29.3% requisitions sent with ADR, relapse, and routine monitoring as reason for drug levels, respectively. Only half of all AED measurement requisitions were complete and met the criteria for appropriate AED-level determination. Incomplete requisitions lead to difficulty in uniform interpretation of results and thus add to unnecessary costs.
Patients suffering from chronic diseases like epilepsy often use complementary and alternative medicine (CAM) as first-line treatment because of myths, superstitions, and stigma attached to the disease. The present study reports on 108 patients with epilepsy presenting to an allopathic hospital with uncontrolled seizures, status epilepticus, or drug toxicity. Blood samples of these patients taking unlabeled pills from a CAM provider specializing in the treatment of epilepsy contained prescription antiepileptic drugs (AEDs) such as carbamazepine, phenytoin, valproic acid, and phenobarbitone. Serum samples in all but 5 patients demonstrated presence of one or more AEDs. Most of the patients had serum levels of these AEDs either in the subtherapeutic or in the supratherapeutic range. The authors alert clinicians that the patients resorting to “safe” or “natural” CAM may end up receiving modern prescription medicines from unauthorized CAM providers in toxic or subtherapeutic doses.
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