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AST and ALT range
0-40unit/L
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AST/ALT measures what and reflects how?
- hepatocellular damage
- ↑ in valproate therapy, hepatitis, and cirrhosis
- ↓ in chronic ETOH liver disease
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Alkaline phosphate (ALP) range
30-120units/L
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Alk phos (ALT) measures what and reflects how?
- cholestasis, bile flow
- hepatocellular damage
- ↑ in gallbladder and liver dz as well as bone injury/growth
- ex: young boy will by high
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Creatine kinase (CK) range
0-139
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Creatine kinase (CK) measures and reflects what?
- muscle injury
- increased in MI, neuromalignant syndrome
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BUN range and measures what
- 8-18 for kidney function
- increased in lithium therapy
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Creatinine range and measures what?
0.6-1.2 for kidney function increased with lithium therapy
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GFR range and is best for what
- >90 and overall kidney function
- note: geriatric will have normal Cr but reduced GFR d/t muscle mass
- -no dose adjustments when GFR>60
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Valproate and anti-epiletpic labs for initiation and how often?
- liver panel (ALT, ALT, AST), bili, albumin, CBC
- baseline, monthly then every 6-24 monhs
-
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Valproate, when to stop med?
if ALT/AST >2-3x upper limit
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Valproate common complications/SE?
- N/V/jaundice
- thrombocytopenia and neutropenia
- easily bruising, etc
- SJS (rare)
- screening for HLA-B, high in Asian
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Lithium range acute tx then maintenance
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Lithium initial lab work and test
as well as maintenance
- BUN/Cr, GFR, TSH, electrolytes, CBC, hCG, and UA
- baseline EKG (50+ ekg q6-12mo)
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When do you check lithium levels when initiating?
- 12 hours post dose initiation (trough)
- 4 days --> then every 4 days
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How is lithium absorbed and metabolized
- via GI tract and is NOT metabolized
- excreted 100% unchanged in urine
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When is lithium contraindicated (3 pts)?
Pts in ACUTE renal failure, dehydration, and NA depletion
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Lithium is OK for stable KD and transplants, but when do you make changes
reduce if GFR<60
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Lithium affects by renal function (3):
- -Dehydration= increase levels
- -increased Na= decrease in levels
- -decreased Na= increase levels
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What level can you see lithium toxicity at?
1.5 but typically occur >2
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Lithium toxicity sxs
lethargy, fatigue, clumsiness, muscle cramping, N/V, tremors, confusion, blurred vision, nystagmus, AMS, arrhythmias,
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Education for lithium pts
sxs of toxicity, lab work, and avoid dehydration
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Which meds can increase lithium levels
- -ACE, ARBs, NSAIDs
- -K sparring diuretics
- -Thiazide diuretics
- -Tetracyclines, Metronidazole
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Which med can decrease lithium levels?
Theophylline
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Possible effects of being on lithium
- -thyroid hypofunction, goiter
- -cardiac events
- -Renal, PPP
- -fine hand tremor
- -weight gain
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Clozapine initiation lab work
WBC--> absolute neutrophil count (ANC)
worry about WBC so low they can't fight infection
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What level does ANC have to be to start Clozapine and when do we stop it?
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Clozapine maintenance lab work
- ANC weekly for 6 months
- then q2 weeks for 6 months
- monthly if ANC 1500
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Highest risk of what with Clozapine
agranulocytosis
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What is a substrate?
uses enzyme to modify so it can reach drug site of action
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Which meds use 2D6 substrate pathways?
- -Fluoxetine, Paroxetine, Sertraline
- -Venlafaxine, Duloextine
- -TCAs
- -Haloperidol, Aripiprazole
- -BBs
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Which meds use the 1A2 substrate pathways?
- Duloxetine, mirtazapine, clozapine,
- haloperidol, olanzapine, asenapine
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Which meds use 3A4 substrate pathways? What % are meds
- Sildenafil, statins, xanax, venlafaxine
- 50%
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What is an inhibitor?
blocks pathways and keeps substrate form exiting--> can cause toxicity
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Which meds use the 2D6 inhibitor pathways?
- Fluoxetine, paroxetine, bupropion,
- duloxetine
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Which meds use the 1A2 inhibitor pathways?
Fluvoamine, fluoxetine, paroxetine, Sertraline
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What is an inducer
accelerates, and reduces substrate level
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Hypothyroidism mnemonic
- Mom's so tired
- -mem loss
- -obesity
- -menorrhagia
- -slowness
- -skin and hair dryness
- -onset graudual
- -tiredness
- -intolerance to cold
- -raised BP
- -energy levels fall
- -depression/delayed reflexes
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Hyperthyroidism mnemonic
- SWEATING
- -sweating
- -weight loss
- -emotional lability
- -appetite increased
- -tremor/tachy
- -intolerance of heat, irreg men, irritability
- -nervousness
- -goiter, GI problems
- -
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What are the most common thyroid test
- TSH:most reliable and r/o
- TF4 (free T4): f/u test to support dx
- TPO: helps detect autoimmune thy dz
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What are the normal ranges for TSH and Free T4?
-
What does high TSH and low FT4 indicate?
untreated hypothyroidism or inadequate thyroxine dose
-
What does a low TSH and FT4 indicate?
untreated hyperthyroidism or high thyroxine dose
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When should DM testing start if no risk factors
45 yo q 3 years
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