Drug

Indication

Therapeutic range 0.8- 2 micrograms/l

Monitoring

Common interactions

Signs of toxicity

Digoxin

Atrial fibrillation

Blood sample at least 6 h after last dose; ideally 8- 12 hours

Heart/Hepatic/renal disease decrease elimination. Hypothyroidism increases serum concentration AMIODARONE half digoxin dose Avoid use with St Johns Wort and clozapine. Digoxin concentration increased by Calcium channel blockers and diureticsmonitor Increased plasma concentration with macrolide antibiotics, calcium channel blockers Reduced plasma concentration with phenytoin, ritonavir Avoid use with St Johns Wort Increased risk of toxicity when given with platinum compounds; loop diuretics;

Nausea, vomiting, diarrhoea, blurred/ yellow vision; weakness, dizziness, confusion, headache; AV block; PR prolongation and ST- segment depression (Cardiac effects)

Theophylline

Bronchodilation

10-20 mg/l

trough sample 4-6 hours after dose and at least 5 days after starting treatment.

Nausea, vomiting, cardiac arrhythmias, headache; seizures

Gentamycin

Antibiotic

Peaks not above 12mg/l; trough not above 1mg/l

Sample 6- 14 hours post first dose to calculate dosage interval; then trough

Nephrotoxicity, ototoxicity

Lithium

Mood stabiliser

0.4- 1mmol/l

at least 14 h after last dose

Phenytoin

Epilepsy

5- 20 mg/l

trough sample

Carbamazepine Epilepsy

4- 12mg/l

Measure full blood count, liver function tests, urea, and electrolytes before starting treatment and every 6 months during treatment. trough sample

Increased plasma concentration with Ace Inhibitors; NSAID; SSRIs. Reduced plasma levels with diuretics. Avoid with amiodarone. Avoid concomitant use with azapropazone; st Johns Wort; Increased plasma concentration with amiodarone, metronidazole, rifamycin, trimethoprim, SSRIs, TCAs Reduced plasma concentration with antifungals; Increases metablolism of warfarin; Reduces concentrations of clozapine, quitiapine and aripiprazole (increase dose); calisum channel blockers; oestrogens (reduces contraceptive effect) Plasma concentration of both drugs reduced when given with theophylline. Plasma concentration increased by macrolide antibiotics; Accelerates metabolism of oestrogens, reduced contraceptive effect; Reduces effect of warfarin; reduces effect of aripiprazole,

Tremor, Renal impairment, ataxia, weakness, drowsiness, thirst, diarrhoea, confusion, convulsion, coma, death Nystagmus, blurred vision, ataxia, lethargy, confusion, muscular twitching, fever, sore throat, bleeding, bruising, rash, blistering, mouth ulcers, drowsiness, coma

Anaemia, stevens- Johnson syndrome, drowsiness, ataxia, Blurry vision, dizziness, Fever, sore throat, rash, mouth ulcers, bruising, bleeding

Measure plasma levels of carbamazepine every 6 months to exclude toxicity, because therapeutic levels and toxic levels are close. Phenobarbital Epilepsy 15- 40mg/l Trough sample

need to increase dose. Reduces concentration of ARVs; Aviod for two weeks after stopping MAOIs

Convulsive threshold lowered with TCA; Avoid with St Johns Wort; reduces plasma concentrations of ARVs; warfarin; Accelerates metabolism of oestrogens, reduced contraceptive effect Convulsive threshold lowered with TCA; SSRIs; tricyclics; antipsychotics (increased risk of neutropenia with olanzipine)Avoid with St Johns Wort;

Sedation, confusion, ataxia, insomnia, dizziness, hypoventilation, nausea, vomiting, coma

Valproate

Epilepsy

Trough sample Monitor liver function and bloods before therapy, and during first 6 months

Nausea, lethargy, confusion jaundice, dark urine, pale stool, bone loss, easy bleeding, itching, chills, fever, sore throat, rash, mouth ulcers, bruising, bleeding