Monitoring blood levels of selected drugs. Remember to factor in the many confounding variables

Appropriate use of various pharmacologic agents involves not only awareness of therapeutic indications and side effects but also familiarity with clinical use and timing of blood level monitoring. The effective as well as the toxic level of antiepileptic drugs varies widely among patients, so the patient's response is more important than the serum drug level. These agents may interact with other disease states, other drugs, and even other antiepileptic agents. Because of digoxin's long half-life and the effect of physical exercise on serum concentration, the timing of serum collection is important. The usefulness of measuring amiodarone serum concentrations is controversial, but findings may help identify patients at risk for side effects related to the drug. Procainamide has a very short half-life and concentrations change over a short period, so blood levels of this agent should be measured before administration of a dose. The dose of levothyroxine required to restore a normal thyroid hormone level varies with age, coexistent conditions, and use of other medications. After the appropriate dose is determined, follow-up monitoring yearly is necessary (more often in the elderly). Efficacy and toxicity of theophylline are directly related to serum concentrations, and a reduced target level of 5 to 15 micrograms/mL has recently been suggested. Proper monitoring is important, because metabolic changes and drug interactions can cause either subtherapeutic or toxic levels.