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Clinical Pharmacokinetics & Pharmacodynamics

Welcome to the pharmacokinetics and pharmacodynamics category for pharmacists. This clinical pharmacy category contains links to resources on drug dosing in renal and liver disease, pharmacokinetic calculations, TDM (therapeutic drug monitoring) and more.

electronic Medicines Compendium (eMC)
Summaries of Product Characteristics (SPCs)

The SPC is used by healthcare professionals, such as doctors, nurses and pharmacists, and explains how to use and prescribe a medicine.

Source: medicines.org.uk
Clinical Resource: Summaries of Product Characteristics (SPCs)
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Last Checked: 17/02/14 Link Error: Report It

 

Interactive Clinical Pharmacology

The site has been designed to increase understanding of important and sometimes difficult concepts and principles in Clinical Pharmacology.

The site is for any student or practitioner requiring Clinical Pharmacology knowledge, e.g. undergraduate and post-graduate students in medicine, pharmacy and pharmacology. A basic understanding of physiology and pharmacology is assumed.

Tutorials

Drug Clearance
Drug Elimination
Volume of Distribution
The Half-Life
Dosing Variations
Oral Availability
Pharmacodynamics
Pharmacogenetics
Saturable Drug Metabolism
Protein Binding
PH and Pharmacokinetics
Dosing and Age
Drugs in Pregnancy
Drug Interactions
Drug Transport
Graph Plotter

Source: icp.org.nz
Clinical Resource: CE / CPD / Learning
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Collection of terms, symbols, equations, and explanations of common pharmacokinetic and pharmacodynamic parameters and some statistical functions

Source: agah.eu
Clinical Resource: Glossary
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The Merck Manual for Health Care Professionals
Pharmacokinetics

Topics in Pharmacokinetics

  • Overview of Pharmacokinetics
  • Drug Absorption
  • Drug Bioavailability
  • Drug Distribution to Tissues
  • Drug Metabolism
  • Drug Excretion
Source: merckmanuals.com
Clinical Resource: Manual
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The University of Nottingham
Reusable Learning Objects (RLOs)

RLOs are small, 'bite-sized' chunks of e-learning focussing on a particular narrow topic, containing typically 15-30 minutes of learning material.

RLOs

Bioavailability

Introduction to the concept of the bioavailability of drugs.

Clinical impact of changes in drug clearance

Examines some of the factors which affect total body clearance of a drug and how this, in turn, influences a drug's clinical impact.

Half-life of drugs

To understand the half-life of drugs and its relationship with volume of distribution and clearance.

Introduction to drug clearance

Provides a definition of clearance and a basic explanation of the processes

Pharmacokinetic and pharmacodynamic influences of aminoglycoside dosing

Examines how the absorbtion and distribution of aminoglycosides within the body affects the dosing regimens used.

Plasma Proteins and Drug Distribution

Examing the role of plasma proteins in the blood in the distribution and elimination of drugs in the body.

The Kidneys and Drug Excretion

The role of the kidneys in the excretion of drugs.

The Liver and drug metabolism

The role of the liver in the metabolism of drugs.

Understanding First Pass Metabolism

Description of first pass metabolism of orally-administered drugs in the liver and gastrointestinal tract

Volume of distribution

Explains the pharmacological concept of Volume of Distribution, and how it is calculated.

Source: nottingham.ac.uk
Clinical Resource: CE / CPD / Learning
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Pharmacokinetics and Pharmacodynamics - the basics

By the end of this session, you should be able to:

  • Define pharmacodynamics and the four basic processes involved in pharmacokinetics
  • Define parameters which can affect
    • Drug absorption
    • Drug distribution
    • Drug metabolism
    • Drug excretion
  • Understand the concept of agonist and antagonist
  • Define bioavailability, half life and therapeutic index and describe the relevance of these to drug action
Source: associationforprescribers.org.uk
Clinical Resource: Notes
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Last Checked: 30/08/16 Link Error: Report It

 

Back to basics: pharmacokinetics

In the first article in a series intended to remind pharmacists about the basic principles of pharmacokinetics, pharmacodynamics and therapeutic drug monitoring, Alison Thomson describes the principal pharmacokinetic parameters

Variability in drug dosage requirements

In the second article in a series intended to remind pharmacists about the basic principles of pharmacokinetics, pharmacodynamics and therapeutic drug monitoring, Alison Thomson describes inter-individual variability issues that should be considered when recommending a dosage regimen

Why do therapeutic drug monitoring

In this third article in our back to basics series on pharmacokinetics, Alison Thomson gives an overview of the factors that make therapeutic drug monitoring necessary and looks at some of the groups of drugs where monitoring is often needed

Examples of dosage regimen design

In this final article in our back to basics series on pharmacokinetics, Alison Thomson uses two case studies to describe approaches that can be taken to design drug dosage regimens to achieve target concentrations in individual patients

Source: pharmaceutical-journal.com
Clinical Resource: Journal Articles
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Last Checked: 30/08/16 Link Error: Report It

 

Pharmacokinetics made easy 9: Non-linear pharmacokinetics

When the dose of a drug is increased, we expect that the concentration at steady state will increase proportionately, i.e. if the dose rate is increased or decreased say two-fold, the plasma drug concentration will also increase or decrease two-fold.

Source: nps.org.au
Clinical Resource: Journal Article
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Pharmacokinetics made easy 11 Designing dose regimens

Continuous intravenous infusions and intermittent intravenous boluses are common ways of administering drugs such as gentamicin, lignocaine and theophylline.

Source: nps.org.au
Clinical Resource: Journal Article
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Pharmacokinetic Training Packet for Pharmacists

Table of Contents

Pharmacokinetic definitions and principles

Aminoglycoside overview

Extended-interval (Once daily) aminoglycoside dosing

Aminoglycoside pharmacokinetic calculations

Aminoglycoside dosing in patients with cystic fibrosis

Vancomycin overview and pharmacokinetic calculations

Clinical Pearls

Dialysis – Aminoglycosides and Vancomycin

TNMC Nephrology Protocol for Vancomycin Dosing

Clinical Pharmacokinetic Consult Service

Source: nebraskamed.com
Clinical Resource: Training Packet
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Kinetics Equations Pocket Guide

Source: nebraskamed.com
Clinical Resource: Pocket Guide
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Useful Pharmacokinetic Equations

Source: ufl.edu
Clinical Resource: Equations
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Half Life

Calculate the half-life of a drug from two plasma levels separated by a time interval.

Source: weill.cornell.edu
Clinical Resource: Calculator
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Clinical Pharmacokinetics Service & Anticoagulation Guidelines
Pharmacy Services
University of Kentucky Chandler Hospital

Table of Contents

List of Monitorable Drugs and Therapeutic Ranges
Basic Pharmacokinetic Concepts
Guidelines for Pharmacokinetic Monitoring
General Equations for BSA, IBW, and Clcr
Monitorable Drugs

Source: hosp.uky.edu/pharmacy
Clinical Resource: Manual
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TDM kinetics

Carbamazepine Digoxin Ethosuximide Phenobarbital Primidone Phenytoin Theophylline Valproic acid

Source: pathology.leedsth.nhs.uk
Clinical Resource: Table
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Pharmacokinetics of drug infusions

This article will describe, rather than derive equations to explain, the pharmacokinetics of i.v. infusions and a basic understanding of simple models of pharmacokinetics and the relationships between parameters is assumed.

Source: oxfordjournals.org
Clinical Resource: Journal Article
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Pharmacokinetics and Metabolic Drug Interactions

Pharmacokinetics and drug metabolism play an important role as determinants of in vivo drug action. The CYP450 enzyme family plays a determinant role in the biotransformation of a vast number of structurally diverse drugs. Many drug interactions are a result of the inhibition or induction of CYP enzymes. The non-compartmental pharmacokinetic analysis is the most used method for analyzing data from a drug interaction study. Compartmental analysis can be also useful and sometimes more informative than non-compartmental analysis. Many efforts to reduce polypharmacy are important, and pharmacokinetic tools used to study the mechanism of drug-drug interactions may help in a better management of pharmacotherapy including the avoidance of clinically relevant drug interactions.

Source: benthamscience.com
Clinical Resource: Journal Article
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International Union of Basic and Clinical Pharmacology Database of Receptors and Ion Channels

Welcome to the official database of the IUPHAR Committee on Receptor Nomenclature and Drug Classification.

Detailed, peer-reviewed pharmacological, functional and pathophysiological information on human, mouse and rat G Protein-Coupled Receptors, Voltage- and Ligand-Gated Ion Channels, Nuclear Hormone Receptors and selected Enzymes, including all Protein Kinases.

Source: iuphar-db.org
Clinical Resource: Database
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Prescribing in the Elderly

This bulletin will review the effect of increasing age on how medicines are handled by the body and will provide guidance on ensuring the effective use of medicines in this age group in order to improve medication safety.

Source: stjames.ie
Clinical Resource: Medicines Information Centre Bulletin
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Gender Differences in Responses to Medication and Side Effects of Medication

In recent years, there has been growing interest and increasing recognition that sex and gender may play a significant role in a person’s response to medication and should be an important part of individual prescribing.

Source: iasp-pain.org
Clinical Resource: Newsletter
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Last Checked: 07/05/15 Link Error: Report It

 

“Pharmacogenetics & ADRs”

The objectives of this lesson are such that upon completion the participant will be able to:

  1. Discuss the pharmacogenetic variables that cause adverse drug reactions.
  2. Describe the pharmacogenetic variants that cause pharmacokinetic changes in medications and increased risk of adverse drug reactions.
  3. Describe the risk of hypersensitivity reactions associated with various HLA-alleles.
Source: wfprofessional.com
Clinical Resource: CE / CPD / Learning
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Oral extended-release products

Drug products designed to reduce the frequency of dosing by modifying the rate of drug absorption have been available for many years. Early modified-release products were often intramuscular/subcutaneous injections of suspensions of insoluble drug complexes, e.g. procaine penicillin, protamine zinc insulin, insulin zinc suspensions or injections of the drug in oil, e.g. fluphenazine decanoate. Advances in technology have resulted in novel oral modified-release dosage forms.

Source: nps.org.au
Clinical Resource: Journal Article
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Drug Dosing in Obesity

The aim of this bulletin is to highlight the issues around drug dosing in obese patients.

Source: druginformation.co.nz
Clinical Resource: Drug Information Service Bulletin
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Obese Patients - Medication Dosing

Source: cshp-sk.org
Clinical Resource: Guideline
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UKCPA (United Kingdom Clinical Pharmacy Association): Drug Dosing in Extremes of Body Weight in critically ill patients
1st Edition September 2013

This document which represents information and experience of dosing of drugs in critically ill patients in extremes of body weight, has been produced by the Scottish Adult Critical Care Pharmacists Network (SACCPN) in an attempt to make the necessary information more readily available.

Source: scottishintensivecare.org.uk
Clinical Resource: Document
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Society of Family Planning Clinical Guideline for Contraceptive Considerations in Obese Women

Source: societyfp.org
Clinical Resource: Guideline
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Q: What is the appropriate dose of enoxaparin for the treatment of deep vein thrombosis in an obese patient?

A: Enoxaparin (Lovenox) is a low-molecular-weight heparin administered subcutaneously for the prevention and treatment of deep thrombosis (DVT) and pulmonary embolism (PE).

Source: duq.edu
Clinical Resource: Pharmaceutical Information Centre Publication
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How to Dose Antibiotics in the Critically Ill Obese Patient

Source: umem.org
Clinical Resource: Eduational Pearl
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Drug Therapy-Related Issues in Patients Who Received Bariatric Surgery (Part I)

This is part 1 of a two-article series that is aimed to address how pharmacotherapy is affected by bariatric surgery. The current article is aimed to provide a detailed review of process and factors that affect drug absorption from the gastrointestinal tract. The discussion may help clinicians better predict how bariatric procedures may affect oral drug absorption and pharmacotherapy.

Drug Therapy-Related Issues in Patients Who Received Bariatric Surgery (Part II)

This is part 2 of a two-article series that is aimed to address how pharmacotherapy is affected by bariatric surgery. The focus of this article is to review how each of the established bariatric procedures can affect pharmacokinetics based on information available in the literature. Other pertinent pharmacotherapy-related issues in patients with bariatric surgery, such as the risk of pill esophagitis, hormonal contraception, anticoagulant therapy, will be also addressed.

Source: virginia.edu
Clinical Resource: Journal Articles
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Q: What medication adjustments should be made for gastric bypass (bariatric) surgery patients?

A: Obesity is an increasing epidemic and estimated to affect about 30 percent of the American population. Many obese patients elect to undergo surgery after failed attempts at other alternatives for weight loss. There are three types of bariatric or gastric bypass surgery.

Source: duq.edu
Clinical Resource: Pharmaceutical Information Centre Publication
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Pharmacokinetic Variability in Pregnancy and Proposed Labeling Changes

This article will review pharmacokinetic changes in pregnancy.

Source: ufl.edu
Clinical Resource: Publication
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Introduction to the Safety of Drugs passing through Breastmilk

Most drugs pass into breastmilk – but generally in very small amounts (less than 1%).

Source: breastfeedingnetwork.org.uk
Clinical Resource: Factsheet
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LiverTox

LIVERTOX is a freely available website that provides up-to-date, comprehensive and unbiased information about drug induced liver injury caused by prescription and nonprescription drugs, herbals and dietary supplements.

LiverTox is a joint effort of the Liver Disease Research Branch of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the Division of Specialized Information Services of the National Library of Medicine (NLM), National Institutes of Health.

Source: nih.gov
Clinical Resource: Database
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Prescribing in liver disease

As the liver is responsible for the metabolism of many compounds, knowledge of a patient's hepatic function is required for the safe prescribing of many drugs. Assessing liver function by way of a patient history, examination and blood tests such as serum albumin and bilirubin, as well as prothrombin time, is recommended before prescribing some medications.

Source: nps.org.au
Clinical Resource: Journal Article
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Drug Use in Liver Impairment

Drugs that are predominantly hepatically cleared may require dosage adjustment in the presence of significant liver impairment. This bulletin discusses the general principles of the assessment of liver impairment with respect to drug metabolism, and the subsequent adjustment of drug doses.

Source: druginformation.co.nz
Clinical Resource: Drug Information Service Bulletin
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Q: What is the Child-Pugh scoring system and how does it relate to drug dosage?

The Child-Pugh or Child-Turcotte-Pugh grading scale utilizes five criteria to estimate the severity of liver disease.

Source: duq.edu
Clinical Resource: Pharmaceutical Information Centre Publication
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Frequently Asked Questions About GFR Estimates

Provides concise and direct answers to 23 frequently asked patient questions chosen by physicians about the use of glomerular filtration rate (GFR) in the evaluation of kidney function. Includes several related tables and graphs.

Source: kidney.org
Clinical Resource: Frequently Asked Questions
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Chronic
 Kidney 
Disease
 and 
Drug 
Dosing: 
Information
 for
 Providers


This 
document
 describes 
the 
National
 Kidney 
Disease 
Education 
Program's
(NKDEP) 
suggestions 
and 
rationales 
for 
assessment 
of 
kidney 
function
 for
 drug dosing
 purposes.

Source: nih.gov
Clinical Resource: Factsheet
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Drug Dosage Adjustment Using Renal Estimation Equations: A Review of the Literature

The purpose of this review is to examine the factors affecting drug clearance and the available evidence for drug dosing based on the CG and the abbrMDRD equations. The important differences and clinical utility of these equations should be appreciated before their use, and these are discussed.

Source: thomasland.com
Clinical Resource: Journal Article
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Drug Dosage Adjustments in Chronic Kidney Disease: The Pharmacist’s Role

An important issue in drug therapy is dosage adjustment in chronic kidney disease (CKD). Many drugs need to be adjusted depending on a person’s kidney function; it is the pharmacist’s duty to ensure a patient is taking the optimal dose.

Source: usask.ca
Clinical Resource: Drug Information Service Newsletter
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Last Checked: 17/02/14 Link Error: Report It

 

Automatic eGFR reporting — its role in screening for kidney disease and drug-dosing decisions

Glomerular filtration rate is the best measure of kidney function | Using MDRD eGFR as a screening tool for chronic kidney disease | Limitations to use of the Cockcroft–Gault or MDRD equation | Using estimates of GFR for drug-dosage adjustments

Source: nps.org.au
Clinical Resource: National Prescribing Service Publication
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Adult Drug Book
Kidney Disease Programme

Source: kdpnet.kdp.louisville.edu
Clinical Resource: Book
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WHO Model Formulary 2008 > Appendix 4: Renal Impairment

Source: who.int
Clinical Resource: Formulary
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Drug use in renal impairment

Dose adjustment in renal impairment
Drugs for which dose adjustment should be considered in patients with renal dysfunction

Source: druginformation.co.nz
Clinical Resource: Guidance
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Nephrology: 3. Safe drug prescribing for patients with renal insufficiency

On average, patients with renal insufficiency are taking at least 7 different medications to manage not only their underlying disease (such as diabetes) but also the symptoms related to their renal impairment (i.e., problems with mineral metabolism, anemia). The frequency of adverse drug reactions increases with the number of medications used, the degree of renal dysfunction, the age of the patient and the number of comorbid conditions.

Source: cmaj.ca
Clinical Resource: Journal Article
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Prescribing in renal disease

The appropriate prescribing of many drugs depends on knowledge of the patient's total renal function, which is proportional to their body mass. The Cockcroft-Gault method of calculating creatinine clearance takes into account the patient's weight. The recently introduced estimated glomerular filtration rate, which is now routinely reported with biochemistry test results, is useful for screening for renal disease, but is unsuitable for calculating doses as it does not take into account the patient's size.

Source: nps.org.au
Clinical Resource: Journal Article
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Using drugs safely in Chronic Kidney Disease

Chronic kidney disease (CKD) affects renal drug elimination and other important processes involved in drug disposition, including absorption, drug distribution and non-renal clearance. As a result, the reduced renal excretion of a drug or its metabolites can cause toxicity and the sensitivity to some drugs is increased even if elimination is unimpaired.

Source: pccj.eu
Clinical Resource: Journal Article
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Know your patient’s renal function – an important prescribing consideration

Know your patient's renal function - an important prescribing consideration discusses medicines that may require renal function monitoring in the general practice setting and highlights the need to assess renal function when prescribing these medicines, especially for older people or for those with diabetes.

Source: veteransmates.net.au
Clinical Resource: Brief
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Antibiotic doses in renal impairment

Dosing recommendations are based on creatinine clearance calculated using the Cockcroft-Gault equation.

Click on the antibiotic for details of each dose adjustment

Source: gloshospitals.nhs.uk
Clinical Resource: Database
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Guidelines for Antibiotic Dosing in Renal Failure and Dialysis

NOTE: the dosage information in this table is based on Cockgroft -Gault creatinine clearance and not eGFR since the majority of the published information is based on creatinine clearance.

Source: neessexccg.nhs.uk
Clinical Resource: Guideline
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Last Checked: 08/08/16 Link Error: Report It

 

Adult Anti-Infective Dosing Guidelines 2011-2012
NewYork-Presbyterian Hospital

Recommendations for Vancomycin and Aminoglycoside Dosing
Recommendations for Dose Adjustment in Patients With Renal Dysfunction

Source: cumc.columbia.edu
Clinical Resource: Guideline
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Last Checked: 09/03/15 Link Error: Report It

 

Renal Dosage Adjustment Guidelines for Antimicrobials

Source: nebraskamed.com
Clinical Resource: Dosing Protocol
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Antidepressants for depression in stage 3–5 chronic kidney disease: a systematic review of pharmacokinetics, efficacy and safety with recommendations by European Renal Best Practice (ERBP)

Source: european-renal-best-practice.org
Clinical Resource: Guidance
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Disease-modifying antirheumatic drugs (DMARDs) for rheumatoid arthritis

Table of disease-modifying antirheumatic drugs (DMARDs) includes contraindications and monitoring.

Source: nps.org.au
Clinical Resource: National Prescribing Service Publication
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Bisphosphonate prescribing in chronic kidney disease

Bone disease is commonly associated with chronic kidney disease (CKD), and the prevalence of skeletal abnormalities in those with end-stage renal disease approaches 100%. While renal osteodystrophy is the collective term for various types of uraemia-related bone remodelling, including hyperparathyroid bone disease, adynamic bone disease and osteomalacia, persons with CKD can also develop osteoporosis.

Source: rcpe.ac.uk
Clinical Resource: Journal Article
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Enoxaparin in patients with severe renal impairment

There have been a number of medication incidents reported recently involving the use of enoxaparin in patients with severe renal impairment (creatinine clearance less than 30ml/min) who, as a result of treatment have suffered a haemorrhage.

Source: medicinesgovernance.hscni.net
Clinical Resource: Memo
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Last Checked: 31/03/14 Link Error: Report It

 

Opioid Pharmacology

This review looks at the structure, chemistry, and metabolism of opioids in an effort to better understand the side effects, drug interactions, and the individual responses of patients receiving opioids for the treatment of intractable pain.

Source: painphysicianjournal.com
Clinical Resource: Journal Article
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Pharmacokinetics | Pain Community Centre

The ‘Pharmacokinetics’ course describes the basic ways in which drugs work as a foundation to studying applied pharmacology in pain.

Learning Materials

How Drugs Work
Pharmacokinetics: Absorption and Distribution
Pharmacokinetics: Metabolism and Excretion

Source: paincommunitycentre.org
Clinical Resource: CPD / CE / CME / Learning
Register to Access Content: Yes - registration is FREE to healthcare professionals

Last Checked: 17/06/14 Link Error: Report It

 

The American Society of Hypertension, Inc.: A Compendium of Antihypertensive Pharmacology

This compendium is made up of a highly authoritative series of up-to-date accounts of all the drug classes used in the contemporary treatment of hypertension. These papers, written by the leading experts in the field, individually and collectively represent an invaluable resource for clinicians as well as academicians in the field of hypertension therapy.

Source: ash-us.org
Clinical Resource: Compendium
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British Hypertension Society - Therapeutics

Descriptions and usage of the various classes of drugs most commonly used to treat hypertension.

Alpha-Adrenoceptor Antagonists
Angiotensin Converting Enzyme (ACE) Inhibitors
Angiotensin Receptor Blockers (ARBs)
Beta-Adrenoceptor Antagonists (Beta-Blockers)
Calcium Channel Blockers (CCBs)
Centrally Acting Agents
Direct Renin Inhibitors
Thiazide and Thiazide-Like Diuretics
Other Diuretics
Potent Direct Vasodilators

Source: bhsoc.org
Clinical Resource:
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Therapeutic drug monitoring: which drugs, why, when and how to do it

Therapeutic drug monitoring of concentrations of drugs in body fluids, usually plasma, can be used during treatment and for diagnostic purposes. The selection of drugs for therapeutic drug monitoring is important as the concentrations of many drugs are not clearly related to their effects.

Source: nps.org.au
Clinical Resource: Journal Article
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Practical considerations for Therapeutic Drug Monitoring

The timing of blood collection is important | Details to include on the request form | References

Source: bpac.org.nz
Clinical Resource: Article
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Therapeutic Drug Monitoring (TDM)

Caffeine Carbamazepine Ciclosporin Digoxin Ethosuximide Gentamicin Lithium Phenobarbitone Phenytoin Primidone Sodium Valproate Theophylline Tobramycin Vancomycin

Source: formulary.cht.nhs.uk
Clinical Resource: Bulletin
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Therapeutic drug monitoring

Contents:

  1. Introduction
  2. Carbamazepine
  3. Ciclosporin
  4. Digoxin
  5. Gentamicin
  6. Lithium
  7. Phenytoin
  8. Theophylline (aminophylline)
  9. Vancomycin
Source: mm.wirral.nhs.uk
Clinical Resource: Document
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Therapeutic drug monitoring

Therapeutic drug monitoring refers to the individualisation of dosage by maintaining plasma or blood drug concentrations within a target range (therapeutic range, therapeutic window). There are two major sources of variability between individual patients in drug response.

Source: nps.org.au
Clinical Resource: Journal Article
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ABC of Monitoring Drug Therapy

Digoxin

In this article we apply to digoxin the criteria which must be fulfilled in part or in full before the measurement of its plasma concentration can be considered worth while.

Phenytoin

In this article we apply to phenytoin the criteria that must be fulfilled in part or in full before the measurement of its plasma concentration can be considered worth while.

Lithium

In this article we apply to lithium the criteria which must be fulfilled in part or in full before measurement of its plasma concentration can be considered worth while.

Theophylline

In this article we apply to theophylline the criteria that must be fulfilled in part or in full before the measurement of its plasma concentration can be considered worth while.

Aminoglycoside Antibiotics

In this article we apply to aminoglycosides the criteria which must be fulfilled in part or in full before the measurement of their plasma concentrations can be considered worth while.

Cyclosporin

Monitoring whole blood concentrations of cyclosporin is an important part of treatment since its toxic:therapeutic ratio is very low. Also, the variable pharmacokinetics of cyclosporin among patients make accurate prediction of the initial dosage difficult. This variability results from differences in the drug's absorption, distribution, and clearance.

Making the Most of Plasma Drug Concentration Measurements

When the criteria are not rigorously met the regular use of plasma drug concentration measurements is hard to justify. None the less, measurements are sometimes made for other drugs, including anticonvulsants such as carbamazepine and ethosuximide; antiarrhythmic drugs; tricyclic antidepressants; and methotrexate.

Source: europepmc.org
Clinical Resource: Journal Articles
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Therapeutic drug monitoring | Epilepsy Society

Monitoring drug concentrations

When should drug concentrations be monitored?

Sample type

In most clinical settings the measurement of total serum concentrations will suffice and indeed most routine methods for measuring AEDs in sera do not discriminate between the component of drug that is free (unbound) and that that is bound to serum proteins.

Source: epilepsysociety.org.uk
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Pharmacokinetics of AEDs

Carbamazepine Ethosuximide Felbamate Gabapentin Lamotrigine Phenobarbital Phenytoin Valproate

Source: epilepsy.com
Clinical Resource: Table
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The clinical relevance of pharmacokinetics and drug interactions with anti epileptic drugs

In this paper an overview will be given of how knowledge of pharmacokinetic mechanisms determines which pharmacokinetic characteristics an AED should have. Various clinical factors such as age, underlying physiological conditions and drug interactions will also affect the pharmacokinetics and efficacy of AED medication. It will be shown how by anticipating changes in pharmacokinetics due to possible drug interactions, or alterations in one of the pharmacokinetic parameters, adverse effects and breakthrough seizures may be averted and aid in the choice of optimal AED therapy for each patient.

Source: mcppnet.org
Clinical Resource: Journal Article
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Clinical Significance of Pharmacokinetic Interactions Between Antiepileptic and Psychotropic Drugs

The purpose of this article is to provide a concise overview of pharmacokinetic interactions between psychotropic agents and antiepileptic drugs (AEDs).

Source: eu.wiley.com
Clinical Resource: Journal Article
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Monitoring Antiepileptic Drugs: A Level-Headed Approach

This review examines the elusive concept of therapeutic AED blood levels and potential uses and abuses of blood level monitoring, reinforcing appropriate uses for blood levels to ensure compliance and adjust for altered AED pharmacokinetics in the context of aging and disease states, pregnancy, or drug interactions.

Source: nih.gov
Clinical Resource: Journal Article
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Therapeutic drug monitoring for phenytoin

The antiepileptic phenytoin requires therapeutic drug monitoring during its use to ensure adequate seizure control and to avoid toxicity.

Source: auspharmlist.net.au
Clinical Resource: Pharmacy E-Bulletin
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Monitoring phenytoin serum concentrations

Phenytoin is a commonly used anticonvulsant but is one of the most difficult drugs to dose appropriately. It has a narrow therapeutic range and, because of saturable metabolism, small dose increases can result in disproportionately large increases in serum concentrations.

Source: druginformation.co.nz
Clinical Resource: Drug Information Service Bulletin
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Preventing phenytoin intoxication: Safer use of a familiar anticonvulsant

Phenytoin carries a special risk of dose-related toxicity, due to its saturation (zero-order) pharmacokinetics: serum levels often rise much more than would ordinarily be expected after initiating or increasing a maintenance dose. This predicts a vulnerability to toxicity, but does not predict exactly when this will occur in the individual.

Source: jfponline.com
Clinical Resource: Journal Article
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Adjusting phenytoin doses in a patient with co-morbidities

This article describes the application of therapeutic drug monitoring to achieve optimal dosing of phenytoin in an elderly patient with co-morbid conditions.

Source: clinicalpharmacy.org.uk
Clinical Resource: Journal Article
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Phenytoin Dosing Calculator

Source: globalrph.com
Clinical Resource: Calculator
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Factors influencing clozapine plasma concentrations

The use of therapeutic drug monitoring for clozapine is indicated in various situations, including poor compliance, inadequate response to treatment, presence of significant adverse effects, the presence of specific disease states (especially hepatic disease) and where there may be drug interactions.

Source: auspharmlist.net.au
Clinical Resource: Pharmacy E-Bulletin
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Digoxin - Loading Dose Guide (Adults)

The intravenous route should be reserved for use in patients requiring urgent digitalisation for supraventricular arrhythmias

Source: icid.salisbury.nhs.uk
Clinical Resource: Guidance
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Digoxin Dosing Calculator

Source: globalrph.com
Clinical Resource: Calculator
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Digoxin Monitoring: Why, When & How

This bulletin summarises digoxin therapy and provides advice on TDM.

Source: druginformation.co.nz
Clinical Resource: Drug Information Service Bulletin
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How is an intravenous aminophylline dose converted to an oral aminophylline or theophylline dose?
Prepared by UK Medicines Information (UKMi) pharmacists for NHS healthcare professionals

When changing a patient’s therapy from IV aminophylline to oral therapy with either theophylline or aminophylline, the bioavailability and the salt equivalence should be considered.

Source: sps.nhs.uk
Clinical Resource: Medicines Question and Answer
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British Society for Haematology Guideline: Measurement of non-Coumarin anticoagulants and their effects on tests of Haemostasis

Source: b-s-h.org.uk
Clinical Resource: Guideline
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British Society for Haematology Guideline on Oral Anticoagulation With Warfarin - Fourth Edition

Source: b-s-h.org.uk
Clinical Resource: Guideline
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Clinical Practice Guide on Antithrombotic Drug Dosing and Management of Antithrombotic Drug Associated Bleeding Complications in Adults February 2014

Presented by the American Society of Hematology, adapted in part from the American College of Chest Physicians Evidence-Based Clinical Practice Guideline on Antithrombotic and Thrombolytic Therapy (9th Edition).

Source: hematology.org
Clinical Resource: Guide
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WarfarinDosing.org

Welcome to WarfarinDosing.org, a free Web site to help doctors and other clinicians begin warfarin therapy by estimating the therapeutic dose in patients new to warfarin. This site is supported by the Barnes-Jewish Hospital at Washington University Medical Center, the NIH, and donations. Estimates are based on clinical factors and (when available) genotypes of two genes: cytochrome P450 2C9 (CYP2C9) and vitamin K epoxide reductase (VKORC1).

Recommendations on this Web site are based on data from over 1000 patients.Once information is entered onto the next page, the initial estimate of therapeutic dose explains 53% of the variability in a warfarin dose. If you return to the Web site and enter an INR value after 3 and/or 4 warfarin doses, the dose refinement is even more accurate.

Source: warfarindosing.org
Clinical Resource: Calculator
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Laboratory Monitoring of Warfarin Therapy

Crystalline warfarin sodium (Coumadin, Panwarfin, Sofarin, Coufarin, Athrombin-K) is the most widely used oral anticoagulant in the world. Warfarin interferes with the hepatic synthesis of the vitamin-K dependent coagulation factors by interfering with the vitamin K cycle. Laboratory monitoring of warfarin therapy is mandatory, since the agent has a relatively narrow therapeutic range.

Source: pathology.vcu.edu
Clinical Resource: Educational Resource
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Laboratory Monitoring of Low Molecular Weight Heparins

Routine laboratory monitoring is not routinely required, with the exception of patients with renal insuffciency. However, since LMWHs inhibit factor Xa more than thrombin, assays for anti-factor Xa activity, rather than the aPTT, must be used for monitoring.

Source: pathology.vcu.edu
Clinical Resource: Educational Resource
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Laboratory Monitoring of Unfractionated Heparin

Heparin therapy requires rigorous laboratory monitoring with the activated partial thromboplastim time (aPPT), since its bioavailability is variably affected by binding to plasma and cellular proteins. Unfractionated heparin is gradually being replaced by low molecular weight heparin, which has a longer half-life and more predictable bioavailability.

Source: pathology.vcu.edu
Clinical Resource: Educational Resource
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Heparin Dosing Protocols

Source: globalrph.com
Clinical Resource: Calculator
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Amiodarone monitoring protocol
Derbyshire Medicine Management Prescribing and Guidelines

Source: derbyshiremedicinesmanagement.nhs.uk
Clinical Resource: Protocol
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Antimicrobial Therapeutic Level Monitoring & Dosing Guidelines
East Kent Hospitals University NHS Foundation Trust

Aminoglycosides:

  • Gentamicin
  • Amikacin
  • Tobramycin

Glycopeptides:

  • Vancomycin
  • Teicoplanin

Antifungals:

  • Flucytosine
  • Itraconazole
  • Voriconazole
  • Posaconazole
Source: ekhuft.nhs.uk
Clinical Resource: Guidelines
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Aminoglycoside Conventional Dosing and Monitoring in Adults

Source: cumc.columbia.edu
Clinical Resource: Reference
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Aminoglycoside Dosing and Monitoring Recommendations

Aminoglycoside antibiotics have limited tissue distribution, are dependent on renal elimination, and have a narrow therapeutic index. Thus, careful selection of empiric dosing regimens and serum level monitoring are needed to ensure safety and efficacy of these drugs.

There are several approaches to dosing aminoglycosides:

High-Dose, Extended-Interval Dosing (“Once Daily”)

Multiple-Daily Dosing (“Traditional”)

Gram-Postive Combination Dosing (“Synergy”)

Source: idmp.ucsf.edu
Clinical Resource: Recommendations
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Guideline for Prescribing Gentamicin to Adults
Western Sussex Hospitals NHS

Source: gp.westernsussexhospitals.nhs.uk
Clinical Resource: Guideline
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Gentamicin Dose Calculator for Adult Patients

Source: scottishmedicines.org
Clinical Resource: Calculator
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Once Daily Gentamicin in Adults Dose Calculator

Source: nuh.nhs.uk
Clinical Resource: Calculator
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Intravenous Vancomycin Dose Calculator for Adult Patients

Source: scottishmedicines.org
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Page 3 - Are teicoplanin levels important – should we be monitoring them?

“There is little evidence to support a direct relationship between high trough or peak serum teicoplanin concentrations and most of the known toxicities”

Source: asainc.net.au
Clinical Resource: Newsletter
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Antifungal Therapeutic Drug Monitoring: Established and Emerging Indications

Several factors must be considered in determining the role of therapeutic drug monitoring in patient management. An accurate, rapid, and cost-effective drug assay must be readily available to the clinician. Two pharmacological features then determine the relevance of monitoring of concentrations of drug in blood. The foremost variable is an unpredictable drug dose-exposure relationship. Next, there must be a clear relationship between concentrations of drug in blood and either toxicity or treatment efficacy. Consideration of these pharmacological variables for available antifungal compounds is the focus of this review.

Source: asm.org
Clinical Resource: Journal Article
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Clinical Pharmacokinetics of Antifungal Drugs

The pharmacokinetic parameters and pharmacodynamics for systemic antifungal drugs are reviewed in this article, together with advice on how to optimise dosing in severely ill patients and practical information for pharmacists.

Source: eahp.eu
Clinical Resource: Journal Article
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Prescribing and Monitoring of Disease-Modifying Anti-Rheumatic Drugs (DMARDs) for Inflammatory Arthritis

The article thus aims to provide all UK GPs with clear instructions on how to prescribe and monitor the DMARDs in regular use in the UK.

Source: arthritisresearchuk.org
Clinical Resource: Report
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Generic and originator immunosuppressants ­ comparative list prices and bioequivalence data

Collation of comparative bioequivalence data for ciclosporin, tacrolimus and mycophenolate mofetil products plus NHS list prices as quoted in MIMS.

Source: esprit.org.uk
Clinical Resource: List and Data
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Pharmacologic Properties of Antiretrovirals

CCR5 Inhibitors
NNRTIs
Nucleoside RTIs
Nucleotide RTI
Integrase Inhibitors
Fusion Inhibitor
Pharmokinetic Enhancer
PIs

Source: hivclinic.ca
Clinical Resource: Charts
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Antiretroviral Dosing Recommendations in Patients with Renal or Hepatic Insufficiency

Dosing in Renal Insufficiency (Including with chronic ambulatory peritoneal dialysis and hemodialysis)
Dosing in Hepatic Impairment

Source: ashm.org.au
Clinical Resource: Table
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Comprehensive Antiretroviral Table: Adult Dosing, Dosage Form Modifications, Adverse Reactions and Interaction Potential
Renal/Hepatic Dose Adjustments

Source: nccc.ucsf.edu
Clinical Resource: Table
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ARV Hepatic Dose Adjustments

Source: washington.edu
Clinical Resource: Table
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ARV Renal Dose Adjustments

Source: washington.edu
Clinical Resource: Tables
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