Guide for Drug Level Monitoring of Commonly Used Medications
Note: This reference should be used in conjunction with the appropriate clinical judgment of the health care team
Time to Steady State
Usual reference
Order Drug When to Draw Level? (when concentrations Special Considerations
range**
remain constant)*
“Trough” Aminoglycosides: Within 30 minutes before 3rd or 2-3 doses Trough: < 8 mg/L
Amikacin 4th dose (pediatrics: 3rd dose) Aminoglycoside special considerations:
Refer to UCSF Infectious Disease
Aminoglycosides: Traditional dosing: within 30 2-3 doses Trough: < 2 mg/L (< 1 Management Program (IDMP)
Also referred to Gentamicin or minutes before 3rd or 4th dose mg/L optimal) Antimicrobial Dosing Guidelines
as “level” tobramycin (pediatrics: 3rd dose) Peak therapeutic ranges vary
should always be depending on the severity of
before a dose Gram positive synergy: within 30 2-3 doses < 2 mg/L (< 1 mg/L infection i.e higher peaks for more
(trough) even if min before 3rd or 4th dose optimal) severe infections (e.g. cystic
(pediatrics: 3rd dose) fibrosis)
provider does not
For HD patients target Pre HD or
specify Pediatric CF extended interval 2-3 doses < 1 mg/L or Post HD level will depend on
dosing: within 30 minutes before undetectable severity of infection. Provider will
2nd dose determine if redosing needed.
ICN extended interval dosing: 1 dose < 2 mg/L (< 1.5 mg/L
within 30 minutes before 4th optimal) Cyclosporine, tacrolimus, sirolimus
dose special considerations:
Daily trough concentrations may
ICN extended interval dosing (HIE 1 dose < 2 mg/L (< 1.5 mg/L be monitored in inpatients due to
or significant asphyxia): within 30 optimal) many potential factors (including
minutes before 3rd dose drug interactions) affecting
concentrations
Carbamazepine Within 30 minutes before dose 2-5 DAYS 4-12 mg/L
(Tegretol®)
Phenytoin special considerations:
Cyclosporine Within 30 - 60 minutes before 4th 2-5 DAYS 50-500 mcg/L Check albumin level concurrently
(Neoral, Gengraf, dose with phenytoin level
Sandimmune®) Albumin-adjusted phenytoin level
Digoxin (Lanoxin ®) Within 30-60 minutes before dose 3-5 DAYS 0.5-2 mcg/L may be higher than reported i.e.
levels that are at target (10-20)
Draw at least 6 -8 hours post CHF (adult): 0.5-1.0
may actually be greater than 20
dose mcg/L
with hypoalbuminemia
Ethosuximide Before dose 4-7 DAYS 40-100 mg/L Levels may be hard to interpret for
(Zarontin®) patients on HD or on valproic acid. Free
phenytoin level may be warranted.
Lithium (Eskalith®) Within 30 minutes before dose 5 DAYS 0.5-1.5 mg/L
Draw at least 8-12 hours post
dose
Guide for Drug Level Monitoring of Commonly Used Medications
Note: This reference should be used in conjunction with the appropriate clinical judgment of the health care team
Time to Steady State
Usual reference
Order Drug When to Draw Level? (when concentrations Special Considerations
range**
remain constant)*
Phenobarbital Before dose 2-4 WEEKS 10-40 mg/L (adults)
(Luminal®) 15-40 mg/L(pediatrics)
Vancomycin special considerations:
Phenytoin (Dilantin®) Within 30 minutes before AM 3-4 DAYS Total phenytoin: 10-20 Troughs are not recommended if
“Trough”
anticipated duration of therapy is
or Fosphenytoin dose mg/L
short (≤ 3 days)
(Cerebyx®) Draw at least 4 hours post IV Free phenytoin: 1-2
Vancomycin peak levels should not
dose and 6-9 hours post PO dose mg/L
Also referred to be obtained
as “level” Procainamide IV 6-12 hours after start of 12-24 HOURS 4-8 mg/L Obtain trough in patients with
should always be unstable renal function, renal
(Procan®) infusion NAPA <30 mg/L
replacement therapy, when serum
before a dose PO draw prior to next dose (hepatic impairment)
Cr may not accurately reflect GFR
(trough) even if Primidone Within 1 hour before next dose 2-3 DAYS 5-15 mg/L i.e. patients > 70, reduced muscle
provider does not (Mysoline®) mass, severely altered volumes of
specify distribution, or for CNS infections,
Sirolimus Within 30 to 60 minutes prior to 6-10 DAYS 5-15 mcg/L endocarditis, ventilator-associated
th
(Rapamune®) 4 dose pneumonia, bacteremia or
If patient is concurrently on osteomyelitis caused by MRSA
cyclosporine, sirolimus must be Once weekly monitoring in adults
dosed 4 hours after cyclosporine is reasonable in patients with
stable renal function. (Data
Tacrolimus (Prograf®, Within 30 - 60 minutes before AM 3 doses 5-15 mcg/L
supporting safety of prolonged
Hecoria) dose
troughs of 15-20 mcg/ml is
limited.)
Valproic Acid Within 30 minutes before dose 2-3 DAYS 50-125 mg/L For pediatric patients, monitoring
(Depakote®, every 4 days is reasonable, but
Depakene®) patients may be monitored every
two days with doses ≥ 25
Vancomycin Within 30 minutes before 4th 3 doses 10-20 mg/L mg/kg/dose IV q6h.
dose 15-20 mg/L for serious Random vancomycin
infections concentrations may be
Pre or Post Aminoglycosides: Pre HD or 1 hour Post HD level -- 1-3 mg/L appropriate for patients with CrCl
Gentamicin or before a dose to determine if <10 ml/min not on renal
Hemodialysis Post HD: < 2 mg/L
Tobramycin redosing needed replacement therapy to assess
(HD) appropriateness of redosing
Vancomycin Before HD -- 10-20 mg/L
Guide for Drug Level Monitoring of Commonly Used Medications
Note: This reference should be used in conjunction with the appropriate clinical judgment of the health care team
Time to Steady State
Usual reference
Order Drug When to Draw Level? (when concentrations Special Considerations
range**
remain constant)*
Peak Aminoglycosides: 30 minutes after completion of 2-3 doses 20-30 mg/L**
Amikacin 30-minute infusion
60 minutes after IM dose
Aminoglycosides: Traditional dosing: 30 minutes 2-3 doses 5-10 mg/L**
Gentamicin or after completion of 30-minute Higher peaks may be
tobramycin infusion warranted based on Enoxaparin special considerations:
indication Levels are not routinely drawn in
ICN extended interval dosing: 30 1 dose 6–15 mg/L ** adults but may be indicated in
minutes after completion of 4th Draw in < 35 weeks certain circumstances such as
dose gestational age only severe renal impairment,
Enoxaparin 4 hours after dose 3 doses (adults) Daily dosing (adults): pregnancy, or morbidly obese
(Lovenox®) After first dose (pediatrics) 1 dose (pediatrics) 1-2 unit/mL Levels are routinely obtained in
After third dose (adults) pediatric patients and are drawn
Heparin level (Low
after the first dose
Molecular Weight Q12H dosing (adults
Heparin) and pediatrics): Heparin level (Low Molecular
0.5-1 unit/mL Weight Heparin) refers to the
Theophylline Immediate release products: 1-2 2-3 DAYS (adults) 5-20 mg/L antifactor-Xa level
(Theo-Dur®) hours after third dose 3 doses
Sustained release products: 4-8
hours after 3rd dose Variable, may check
earlier if toxicity or
reduced clearance
suspected
Random Level Aminoglycosides: Adult extended interval dosing: -- 2-30 mg/L per
Gentamicin or within 6-14 hrs after dose Hartford nomogram
tobramycin (provider to specify time of draw) If trough ordered,<1
mg/L or undetectable
* Time to steady state reflects maintenance dosing (no load)
** Reference range may differ for specific indications
Guide for Drug Level Monitoring of Commonly Used Medications
Note: This reference should be used in conjunction with the appropriate clinical judgment of the health care team
How do I interpret a level?
Concentrations drawn after a dose typically represent a peak level
Trough concentrations are usually drawn within 30 minutes prior to a dose
If a level was not drawn at the correct time, then please inform the team
What to do if a level is high
If level is high and drawn at the appropriate time, holding a dose may be warranted, especially if patient is exhibiting side effects
Always inform the team if a level is high to be sure that they are aware
References:
1. Package inserts: Prograf, Rapamune, Sandimmune, Gengraf
2. Winter ME. Basic Clinical Pharmacokinetics. 5th edition. Baltimore, MD: Lippincott Williams & Williams, 2010.
3. Lexi-Comp drug monographs, 2012; Lexi-Drugs online database. Accessed from www.lexi.com, 2012
4. Micromedex drug monographs, 2012; Micromedex online database. Accessed from www.micromedex.com
5. Boneu B, de Moerloose P. How and when to monitor a patient treated with low molecular weight heparin. Semin Thromb Hemost. 2001 Oct;27(5):519-22.
6. Hirsh J, Raschke R, Heparin and Low-Molecular Weight Heparin: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest 2004;126;188S-
203S
7. Rybak M, Lomaestro B, Rotschafer JC et al. Therapeutic monitoring of vancomycin in adult patients: A consensus review of the American Society of Health-System
Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists Am J Health-Syst Pharm. 2009; 66:82-98
8. Punzalan RC, Hillery CA, Montgomery RR, Scott CA, Gill JC. Low-molecular-weight heparin in thrombotic disease in children and adolescents. J Pediatr Hematol Oncol.
2000 Mar-Apr;22(2):137-42.
9. Garcia DA, Baglin TP, Weitz JI Samama MM. Parenteral Anticoagulants : Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest
Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141;e24S-e43S
Prepared by: Carmil Azran, PharmD, Adam Cooper, RN MDN, Kendall Gross, PharmD, Marnie Noelle, PharmD, Sarah Scarpace Lucas, PharmD, Anna Seto, PharmD and Lynn Tieu,
PharmD April 2012
