Drug levels and overdose timing
16 min
- Confirm dose and draw time before comparing a drug level with its trough or peak target
- Recognize when binding changes make a total drug level understate the free drug
- Decide whether an acetaminophen level can be plotted on the nomogram
Try first
Get the idea
The time makes the number
A drug concentration is read against a target only at the right time after a dose. Every request carries the drug, the dose and route, the time of the last dose or the end of the infusion, and the draw time.1
- A trough is drawn immediately before the next dose.
- A peak's time is set by the drug's monitoring protocol.
- A specimen with no collection time is reported with that gap stated, or recollected.1
A specimen drawn from a line used to infuse the same drug carries drug left in the catheter. It can read many times the true concentration.2
Total drug can hide the free drug
Routine assays measure total drug, bound plus unbound. Phenytoin is about 90% bound to albumin, and the free 10% carries its activity. Hypoalbuminemia, uremia, pregnancy and displacing drugs such as valproate raise the free fraction. A patient can then show toxicity with the total inside its target range.2 Free phenytoin is measured by ultrafiltration or equilibrium dialysis at 37 °C. Albumin correction equations perform poorly in uremia and critical illness.2
The acetaminophen nomogram needs a clock
The Rumack-Matthew nomogram applies from 4 to 24 hours after a single acute ingestion at a known time. The US treatment line passes through 150 µg/mL at 4 hours and halves every 4 hours:3
Treatment line (µg/mL) = 150 × 0.5(hours since ingestion − 4) ÷ 4
| Hours after ingestion | 4 | 8 | 12 | 16 |
|---|---|---|---|---|
| Treatment line (µg/mL) | 150 | 75 | 37.5 | 18.8 |
Three results cannot be plotted:3
- a concentration drawn before 4 hours, when absorption is still under way and the result can understate what is coming
- an ingestion at an unknown time
- repeated doses over hours or days
The laboratory reports the concentration with the ingestion and draw times. The poison service or treating team decides on the antidote.3
References
- Clinical and Laboratory Standards Institute. Toxicology and Drug Testing in the Medical Laboratory. 3rd ed. CLSI guideline C52. Clinical and Laboratory Standards Institute; 2017. Accessed September 27, 2026. https://clsi.org/shop/standards/c52/
- Rifai N, Chiu RWK, Young I, Burnham CAD, Wittwer CT, eds. Tietz Textbook of Laboratory Medicine. 7th ed. Elsevier; 2023.
- Dart RC, Mullins ME, Matoushek T, et al. Management of acetaminophen poisoning in the US and Canada: a consensus statement. JAMA Netw Open. 2023;6(8):e2327739. doi:10.1001/jamanetworkopen.2023.27739
Watch one
A roommate saw a woman swallow a bottle of acetaminophen tablets at 21:00, all at once. Her acetaminophen concentration, drawn at 03:00, is 118 µg/mL. Can the result be plotted on the nomogram, and where does it fall?
- Check the ingestion: a single acute ingestion, with the time known from a witness.
The nomogram describes the fall in concentration after one dose taken at one time.
- Count the hours: 21:00 to 03:00 is 6 hours, which is inside the window.
The line applies only from 4 to 24 hours after ingestion.
- Find the line at 6 hours: 150 × 0.5(6 − 4) ÷ 4 = 150 × 0.50.5 = 150 × 0.707 = 106 µg/mL.
The line falls by half every 4 hours from 150 µg/mL at 4 hours.
- Compare: 118 µg/mL is above 106 µg/mL.
A result above the line is what the treating team acts on.
- Report the concentration with the 21:00 ingestion and 03:00 draw times.
The team needs both times to read the result.
Your turn
Use it
- A man in the intensive care unit receives vancomycin every 12 hours through a peripherally inserted central catheter.
- The last infusion ended at 06:00, and the next dose is due at 18:00.
- A trough was drawn at 17:30. The collector notes it was drawn through the catheter lumen used for vancomycin.
- He also takes phenytoin.
| Test | Result | Previous | Reference interval | Flag |
|---|---|---|---|---|
| Vancomycin, trough | 62.4 µg/mL | 15.6 µg/mL1 day ago | 10.0–20.0 µg/mL | Delta |
| Phenytoin, total | 12 µg/mL | 13 µg/mL1 day ago | 10–20 µg/mL | |
| Albumin | 2.0 g/dL | 2.1 g/dL1 day ago | 3.5–5.0 g/dL | Low |
| Creatinine | 3.4 mg/dL | 3.3 mg/dL1 day ago | 0.74–1.35 mg/dL | High |
Specimen: H 12, L 18, I 3. Drawn 17:30 through the catheter lumen used for vancomycin
The clue that settles it is the draw site:
- The vancomycin trough rose from 15.6 to 62.4 µg/mL in one day at a steady creatinine.
- The collector drew it through the lumen used for vancomycin.
The vancomycin is redrawn from a clean site before the dose. The phenytoin tube has no such problem, and its total is released with a comment about the free fraction.
Results
- Confirm dose and draw time before comparing a drug level with its trough or peak target
- Recognize when binding changes make a total drug level understate the free drug
- Decide whether an acetaminophen level can be plotted on the nomogram
To review
6 questions from this step will come back in Review.
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The rest of this step
A short briefing, a demonstration at the bench, 3 practice problems and a short case.
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