A Moving Residual Limb: Botulinum Toxin to the Rescue

Movement disorders post-amputation are a rare complication and can manifest as the jumping stump phenomenon, a form of peripheral myoclonus. The pathophysiology remains unknown and there is currently no standardized treatment. We describe the case of a 57-year-old male with unremitting stump myoclonus, starting one month after transtibial amputation, in his residual limb without associated phantom or neurological pain. The consequence of the myoclonus was a reduction in prosthetic wearing time. Failure to respond to oral medication led us to attempt the use of botulinum neurotoxin Type A injections in the involved muscles of the residual limb. Injection trials, over a two-year period, resulted in an improvement of movement disorder, an increased prosthetic wearing time and a higher satisfaction level of the patient. Injection of botulinum toxin type A should be considered as an alternative treatment for stump myoclonus to improve prosthetic wearing time and comfort.

Population pharmacokinetics of nitroglycerin and of its two metabolites after a single 24-hour application of a nitroglycerin transdermal matrix delivery system

The purpose of this study was to assess the ability of our previously constructed pharmacokinetic (PK) model to describe nitroglycerin (GTN), 1,2-dinitroglycerin (1,2-GDN), and 1,3-dinitroglycerin (1,3-GDN) plasma concentrations after a single-dose application of a GTN transdermal matrix delivery system. GTN, 1,2-GDN, and 1,3-GDN plasma concentrations were simultaneously fitted using a first-pass, mixed-order release, one-compartment PK model. Population PK parameter values were derived using an iterative two-stage methodology (IT2S). Some of the mean PK parameters estimates and their interindividual variability (CV%) were the percentage of the delivered GTN dose reaching the systemic circulation released by a first-order process A, 53% (44); the 1,2-GDN and 1,3-GDN formation rate constants, k(f1)9 h(-1) (67) and k(f2) 0.5 h(-1) (38), respectively; the metabolite elimination rate constant, k(m) 1 h(-1) (27); GTN, 1,2-GDN, and 1,3-GDN volumes of distribution (Vc/F 6 L [45]), V2/F 78 L [51]), and V3/F 29 L [40]), respectively). Mean calculated elimination half-lives (t1/2+/-standard deviation [SD]) for GTN and the GDN metabolites were 7+/-4 minutes and 33+/-7 minutes, respectively. The proposed PK model fitted the observed plasma concentrations of GTN, 1,2-GDN, and 1,3-GDN very well. This new transdermal matrix delivery system appears to behave pharmacokinetically in the same manner as a transdermal reservoir delivery system (Transderm-Nitro, Ciba-Geigy, Mississauga, Canada).

Ability of a first-pass pharmacokinetic model to characterize cyclosporine blood concentrations after administrations of Sandimmune or Neoral formulations

Most recent cyclosporine (CsA) pharmacokinetic (PK) studies have focused on noncompartmental analysis. Because CsA undergoes significant first-pass elimination after oral dosing, the most appropriate compartment model may need to take this process into account for the construction of a valid population PK model for Sandimmune (SAN) and Neoral (NEO) formulations. Twenty patients with cardiac transplants were stabilized for at least 4 weeks on a certain dose of SAN, then changed to the same daily dose of NEO. Blood samples were obtained at times 0, 1, 2, 3, 4, 6 and 12 hours after dosing at steady state. Pharmacokinetic modeling was performed using ADAPT II. Quality of fit was assessed by visual graph inspections, R2 values, and Akaike criterion test. Eight pharmacokinetic models were constructed and evaluated. These included one- and two-compartment with and without a first-pass effect and a time-lag. Neoral and SAN data were consistently best fitted using a two-compartment or the two-compartment first-pass model. However, a time-lag process was found to be necessary for SAN. The use of a two-compartment first-pass with (SAN) or without (NEO) a time-lag process appears to fit CsA concentrations at least as well as a two-compartment model. This first-pass model may be very useful for population pharmacokinetics and Bayesian control analysis.

Novel pharmacokinetic modelling of transdermal nitroglycerin

PURPOSE

To construct a pharmacokinetic (PK) model and to determine population PK parameters of nitroglycerin (GTN), 1,2-dinitroglycerin (1,2-GDN), and 1,3-dinitroglycerin (1,3-GDN).

METHODS

Data were obtained in thirty healthy volunteers following a single dose of a GTN reservoir transdermal patch. Blood samples were obtained just before and at 0.5, 1, 2, 3, 4, 6, 8, 12, 14, and 24 hours after the patch application and 1 hour after its removal. GTN, 1,2-GDN, and 1,3-GDN concentrations were determined using HPLC and simultaneously best fitted using a first-pass mixed-order release one-compartment PK model. Individual estimates (ADAPT-II) were used as priors for a population PK analysis (IT2S). Fitted parameters included the percentage (A) of the nitroglycerin dose reaching the systemic circulation that was released from the patch by a first-order process (K1); two absorption (ka1 and ka2), two metabolite formation (kf1 and kf2) and one metabolite elimination (k(m)) rate constants; and three volumes of distribution Vc/F, V2/F and V3/F.

RESULTS

Nitroglycerin mean population parameter estimates and inter-individual variability (CV%) were: A 35% (65), K1 0.06 h-1(91), ka1 5 h-1(46), ka2 0.47 h-1(39), kf1 11 h-1(42), kf2 0.6 h-1(34), k(m) 1.4 h-1(29), V0/F 6 L(31), V2/F 73 L(34), and V3/F 23 L(29). The average elimination half-lives for GTN and the two metabolites were 5 and 32 minutes, respectively.

CONCLUSIONS

The proposed PK model fitted observed concentrations of GTN, 1,2-GDN and 1,3-GDN very well. This model should be useful to predict drug and metabolite concentrations and to assess bioequivalence of two transdermal formulations.

Comparison of a fluorescence polarization immunoassay of netilmicin in plasma, peritoneal dialysate, and urine with a high-performance liquid chromatographic method

The quantitative analysis of netilmicin in plasma, peritoneal dialysate, and urine using the fluorescence polarization immunoassay (FPIA) of the Abbott TDx system is compared with the modified high-performance liquid chromatography (HPLC) method of Peng et al., which was chosen as a reference. Using the least square method, we found that the results of the FPIA (y) correlated well with those obtained with HPLC (x). The three regression equations for the plasma, peritoneal dialysate, and urine samples, respectively, were y = 0.71x + 0.44 with r = 0.88 and n = 45; y = 0.94x + 1.22 with r = 0.93 and n = 95; and y = 0.92x + 0.70 with r = 0.93 and n = 61. The corresponding mean errors (FPIA-HPLC) with their 95% confidence intervals were -0.19 (-0.38 to -0.02), 0.69 (-0.42 to 1.81), and -0.13 (-1.13 to 0.87) microgram/ml. According to results of the Wilcoxon matched-pairs signed-ranks test, these errors did not represent a significant bias. The FPIA is thus suitable for analyzing netilmicin in the three biological fluids studied except when dialysate is contaminated with Amuchina. In this case, HPLC should be used.

Gentamicin pharmacokinetics in newborn and 42-day-old male piglets

The pharmacokinetics of gentamicin was investigated in six newborn male piglets, aged from 4 to 12 h at the time of administration of the drug, and six 42-day-old castrated male piglets, that had been weaned for 2 weeks following a single intravenous bolus of 5 mg/kg. Gentamicin was measured in serum and in urine by a fluorescence polarization immunoassay. The serum concentration-time data were best described by a three-compartment open model. A rapid initial distribution phase (pi phase) was observed in every animal. The serum beta half-life (t 1/2 beta) was significantly longer in the newborn piglets (mean +/- SEM) (5.19 +/- 0.30 h) than in the older group (3.50 +/- 0.23 h) (P < 0.05). Mean residence time was similarly longer in younger piglets (6.62 +/- 0.57 h) than in older animals (2.86 +/- 0.11 h) (P < 0.05). The steady-state volume of distribution (Vdss) was significantly larger for younger pigs (0.785 +/- 0.036 L/kg) than in elder pigs (0.474 +/- 0.029 L/kg) (P < 0.05). Urinary gamma half-life (t 1/2 gamma u) was 72.66 +/- 10.78 h in the newborn piglets and 69.20 +/- 14.77 h in the 42-day-old animals. A urinary delta phase was observed in three of the 42-day-old piglets and gave a mean t 1/2 delta u of 232.01 +/- 14.55 h. Percentages of urinary recovery of the administered dose after 144 h were 94.18 +/- 1.01 and 94.04 +/- 1.12 in the newborn and 42-day-old animals, respectively. Serum gentamicin clearance was significantly lower in younger animals (0.121 +/- 0.007 L/h.kg) than in the 42-day-old group (0.166 +/- 0.010 L/h.kg). It is suggested that in the newborn piglets, the increase of Vd(SS) could be explained by a higher proportion of extracellular water while the lower clearance could be attributed to a reduced glomerular filtration capacity. Gentamicin dosage requirement in the newborn piglets would therefore have to be adjusted, in order to take into consideration the observed differences in the man values of these latter pharmacokinetic parameters.

An open study of tolerability and pharmacokinetics of raclopride extended release capsules in psychiatric patients: a Canadian study

The tolerability and pharmacokinetics of raclopride extended release (ER) capsules have been evaluated after a single oral dose and at steady state, with 3 different daily doses in 4 male patients requiring neuroleptic treatment. In this 3-week open study, the drug was administered to patients in increasing bid doses of 8 mg, 12 mg and 16 mg, respectively, for each 1-week treatment period, following a 1-week placebo washout. With this limited number of patients, assessments of clinical chemistry, hematology, cardiovascular variables and adverse symptoms suggest that raclopride is safe and well-tolerated in the group studied. The administration of repeated doses of raclopride showed linear pharmacokinetics based on parameter values which are either constant (effective elimination half-life, total plasma clearance, and dose-normalized area under the plasma concentration-time curve) or varying proportionally (trough plasma concentration, peak plasma concentration, average plasma concentration and the area under the plasma concentration-time curve for a dosage interval at steady state) with the doses. The linear 1-compartment open model with zero-order absorption was the most appropriate pharmacokinetic model describing the raclopride plasma concentration profile after a single 8 mg dose of raclopride ER capsules. The ER formulation reduced the fluctuation between peak and trough plasma drug concentrations which has been reported before with instant release dosage forms. In this study, the increase of plasma prolactin concentrations above the normal limit was transient and returned to normal levels. Although the plasma prolactin concentration tended to increase with the drug dose, no direct relationship between raclopride dose and prolactin plasma concentrations was found. The correlation of plasma prolactin response with the plasma raclopride concentration showed a low level of hysteresis.

Effect of cimetidine on hepatic biochemical changes, liver toxicity and major urinary metabolite excretion of trichloroethylene in rats

The effects of cimetidine (CIM) (an inhibitor of the hepatic microsomal monooxygenase system) on the metabolism and hepatotoxicity of trichloroethylene (TRI) were studied in male Sprague-Dawley rats. Rats were given three doses of 120 mg/kg i.p. (low-dose regimen) of CIM at 0, 6 and 11 h for 1 day, or ten doses of 200 mg/kg (high-dose regimen) at 8, 11, 14 and 17 h for 2 days and 8 and 11 h on 3rd day. Trichloroethylene (0.5 or 0.65 ml/kg) was administered i.p. 1 h after 2nd dose (low-dose regimen) or 9th dose (high-dose regimen) of CIM. In the low-dose regimen study, the activity of hepatic microsomal aminopyrine N-demethylase was decreased 1 and 5 h after the second dose and 7 h after the third dose of CIM, but became normal 20 h after the last dose. The cytochrome P-450 content and the activities of aniline hydroxylase and epoxide hydratase remained unchanged. Trichloroethylene at both dose levels produced liver toxicity, as verified by increase in activities of SDH and SGPT as well as by liver histology. Cimetidine alone had no such effect. An apparent reduction in TRI toxicity by CIM (at both dose regimens) could be observed histologically. The biochemical tests (SDH and SGPT) corroborated the histological changes only when TRI was given at a dose of 0.5 ml/kg combined with a high-dose regimen of CIM. Cimetidine at both dose regimens had a tendency to decrease the in vivo metabolism of TRI.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of four-day treatment with carbamazepine at different dose levels on microsomal enzyme induction, drug metabolism and drug toxicity

The effect of intraperitoneal injections of 0, 30, 60 and 100 mg/kg of carbamazepine (CBZ), twice a day for 4 days, was studied in 4 groups of 6 male Sprague-Dawley rats per group to evaluate its hepatic enzymatic induction, toxicity and metabolism. Rats were sacrificed on the fifth day and the urines of the last 24 hours were collected. While the activities of hepatic microsomal aminopyrine N-demethylase and epoxide hydratase tended to increase with the dose of CBZ, the cytochrome P-450 content and the activity of aniline hydroxylase however reached a maximum at 60 mg/kg. The percentage of the administered daily dose of CBZ excreted as unchanged CBZ in the urine increased considerably with the dose, while that of metabolites such as carbamazepine-10,11-epoxide (CBZ-E), trans-10,11-dihydrodihydroxycarbamazepine (TDC), and thioethers (T) did not markedly change. These data not only corroborate a maximum in enzyme induction but also suggest a saturation of the induced hepatic enzymes. Urinary T and TDC, representing more than 50% and less than 10%, respectively of the total amount recovered, tend to demonstrate that the glutathione conjugation with the intermediates of CBZ leading to the formation of higher mercapturates could be more important than the epoxide-diol pathway for the metabolism of CBZ under conditions of repeated dosing.

Rapid high-performance liquid chromatographic assay of acetaminophen in serum and tissue homogenates

The quantitation of a hepatorenal toxic drug, acetaminophen, in blood and target organ tissues is needed for toxicokinetic and distribution studies. A rapid, sensitive and simple method is described to assay acetaminophen in rat serum and liver or kidney homogenates by reversed-phase high-performance liquid chromatography, using an octadecyl (3 micron particle size) Apex column, a mobile phase consisting of a mixture of distilled water-acetonitrile (86:14) and ultraviolet detection at 245 nm. Short retention times of ca. 3.75 and 6.25 min are observed for acetaminophen and the internal standard (sulfamerazine), respectively. A sensitivity of 50 ng/ml is easily achieved for 100-microliter serum and liver or kidney homogenate samples. The proposed method proved to have satisfactory recovery, precision and accuracy. The preliminary results obtained with human plasma of volunteers and of patients treated with various drugs show that the assay, with a sensitivity of 25 ng/ml, would be of considerable interest in clinical monitoring of acetaminophen.

Effects of route of administration on the dose-dependent metabolism of acetaminophen in rats: relationship with its toxicity

The urinary metabolic excretion profile of acetaminophen (A) was reexamined in adult male Sprague-Dawley rats after administration of a single intraperitoneal (i.p.) or per oral (p.o.) dose of 100 or 750 mg/kg to 4 groups of animals, followed by collecting urines at 8, 24, 48 and 72 hr. The higher dose was administered in the form of a micronized suspension. The amounts of glucuronide, sulfate and mercapturate of A and unchanged A excreted in the urines were measured as a function of time. The pattern of urinary metabolic excretion of A was found to be dependent not only on the dose, but also on its route of administration as well as on the time of urine collection. When A was administered orally, the drug appears to be subjected to a gut and/or gut-wall first-pass elimination. The mean total urinary recovery of the drug was 70% after 72 hr following the administration of the higher dose of A. The hepatorenal toxicity was assessed by measuring the levels of serum glutamic-pyruvic transaminase activity and of urinary creatinine. The higher dose of A showed the potential to produce hepatic and renal toxicity when given i.p., but not when given orally. These toxic effects seem to be related with a high percentage of urinary A mercapturate and unchanged A when A was given i.p. as compared to those when it was given orally.

Simultaneous determination of the major metabolites of styrene and acetaminophen, and of unchanged acetaminophen in urine by ion-pairing high-performance liquid chromatography

An improved isocratic high-performance liquid chromatographic method for the quantitative determination of the major urinary metabolites of styrene in urine is described. The high separation efficiency of an ion-pairing system using tetrabutyl ammonium chloride allows also the simultaneous determination of acetaminophen and its three major metabolites with those of styrene in rat urine. Simplicity, reproducibility and a short analysis time provide a useful tool for the toxicokinetic studies of these two hepatorenotoxic xenobiotics after their co-administration. An aliquot of the diluted urine is directly injected into the liquid chromatograph. The limits of sensitivity and detection of the metabolites of styrene are better than those reported before. Preliminary works indicate that the method would also be applicable for analysis of these metabolites in human urine and would therefore be useful in monitoring styrene exposure to workers especially when they take acetaminophen.

Comparison of the erythrocyte partitioning method with two classical methods for estimating free drug fraction in plasma

A modification of the erythrocyte partitioning method for the rapid estimation of plasma-free drug fractions (fu) is described and applied to five basic drugs. In the procedure, which uses readily available clinical laboratory equipment, fu is calculated from measurements of drug partitioning between plasma and erythrocytes, and between buffer and erythrocytes. Results obtained are compared with those from equilibrium dialysis or ultrafiltration techniques for amitriptyline, imipramine, quinidine, lidocaine, and propranolol. For each drug, the mean value of fu obtained with the erythrocyte partitioning procedure was not found to be significantly different from that determined by one of the two other classical techniques. The erythrocyte partitioning method lead to reproducible (mean C.V. = 6.25) and precise values of fu when compared to the other methods; its clinical application to lidocaine gave results which agreed with those obtained by equilibrium dialysis.

Quinidine and propranolol binding to very low and low density lipoproteins of human plasma

The interaction of quinidine (Q) and propranolol (P) with human very low density lipoproteins (VLDL) and low density lipoproteins (LDL) was determined by ultrafiltration in phosphate buffer (pH 7.4) for Q and in phosphate and Tris buffers (pH 7.4-7.5) for P, respectively. The Scatchard plots of Q are curved and were best described by a model assuming two independent classes of binding sites on lipoproteins. When working with P, the Scatchard plots were also nonlinear, but positive cooperativity was observed for the VLDL fraction in phosphate buffer and apparently also for the LDL fraction in Tris buffer. These nonlinear curves were described by the model used for Q, excluding any data falling in the cooperating region. The binding parameters, primary (K1) and secondary (K2) affinity constants and the number of sites in each class of independent binding sites, were generated by a computer program. The results of this in vitro study suggest that drug binding (and possibly distribution) to lipoproteins may be affected by the nature and concentration of some ions present in serum.

Cimetidine interaction with dipotassium clorazepate disposition in the anesthetized dog

Cimetidine (CIM) was used as an interacting agent on the disposition in dogs of dipotassium clorazepate ( CZP ) and its main metabolite nordiazepam (ND) in order to study some of the factors contributing to pharmacokinetic interspecies variation of benzodiazepines in dogs and man. A 0.5 mg/kg of body weight intravenous (i.v.) bolus dose of CZP was administered to 12 anesthetized mongrel dogs, 6 of them receiving also, 30 min before, a 1 mg/kg i.v. bolus dose of CIM followed by a constant i.v. infusion (1 mg/kg/hr) of CIM. Plasma ND and CZP concentrations were measured as a function of time with an high-performance liquid chromatography method. Plasma levels of CZP declined mono- and biexponentially in 1 and 5 dogs, respectively, for each group of animals. No statistically significant difference was found between CZP pharmacokinetic parameters when the 2 groups of dogs were compared. However, a 37% decrease in ND beta half-life, t1/2 beta, when CZP was associated with CIM, was found to be statistically significant. The i.v. administration of pure ND in two dogs, has shown that ND declines biexponentially with a t1/2 beta similar to the one estimated after CZP dosing in control animals. The hepatic metabolism of ND was found to be flow-independent and restrictive. The data, along with previously reported CIM interactions, suggest that several factors, which would be species-dependent, must be responsible of CIM effect on other drugs.

Urinary excretion kinetics of intact quinidine and 3-OH-quinidine after oral administration of a single oral dose of quinidine gluconate in the fasting and non-fasting state

To obtain more precise urinary excretion data of intact quinidine (D) and its main metabolite, 3-OH-quinidine (DM), the specific HPLC method of Bonora et al has been used to follow its urinary excretion kinetics. In a cross-over study, 2 commercial dosage forms of quinidine gluconate, fast- and slow-release, were administered to 18 healthy subjects who had fasted for 10 hours in 3 treatments which were administered during the fasting period (T1), and before (T2) of after (T3) a standard breakfast. The urine was collected at fixed time intervals for 72 hours after the administration of a single dose (405 mg of quinidine base). The difference between the drug release characteristics of the two products was studied by analysing the cumulative amount of D and DM excreted as a function of time, and the time required to reach the maximum value for the urinary excretion rate of intact quinidine. A food effect could be noticed among treatments with the conventional fast-release dosage form when comparing the maximum values of the urinary excretion rate of D (T2 greater than T1). There was no significant difference in the percentage of drug absorbed from the 2 products, according to the data on the cumulative amount of D and DM. The parameters estimated for quinidine and the metabolite were: the apparent half-life of elimination, the urinary excretion rates and the time to reach a maximum value in the urinary excretion rate. The urinary excretion rate constant and the renal clearance were also quantified for quinidine by combining urinary parameters with the corresponding serum data previously reported.

High-performance liquid chromatography determination of dipotassium clorazepate and its major metabolite nordiazepam in plasma

A rapid and sensitive high-performance liquid chromatographic method is described for the quantitative analysis of dipotassium clorazepate (CZP) and its major metabolite nordiazepam (ND) in fresh human and dog plasma. The method consists of two separate selective ND extractions from a plasma sample without and with conversion of all the CZP to ND. For quantitation, diazepam (DZP) is used as the internal standard. The chromatographic phase utilized in a reversed-phase Hibar EC-RT analytical column prepacked with LiChrosolv RP-18 with a solvent system consisting of acetonitrile-0.05 M sodium acetate buffer, pH 5.0 (45:55). The UV absorbance is monitored at 225 nm using a variable-wavelength detector. The mean assay coefficient of variation over a concentration range of 20-400 ng per ml of plasma is less than 3% for the within-day precision. Recoveries of ND, DZP and CZP (as ND) are essentially quantitative at all levels investigated. The calibration curves of ND are rectilinear (r2 = 0.99) from the lower limit of sensitivity (2 ng/ml) to at least 2000 ng/ml in plasma. Applicability of the method to CZP and ND disposition studies in the anaesthetized mongrel dog is illustrated. When the two separate selective nordiazepam extractions from plasma cannot be performed immediately after blood sampling, an extrapolation kinetic method is suggested for the estimation of CZP concentration. In all previous in vivo studies, CZP has been determined only with gas-liquid chromatographic methods.

Relative bioavailability of three commercial quinidine dosage forms

Bioavailabilities of three quinidine formulations were compared. Two tablets of each dosage form were administered to 12 healthy volunteers according to a repeated Latin square design; plasma levels of unchanged and total drug were determined. Quinidine was absorbed significantly more rapidly from one of the formulations than the other two; the bioavailability of this formulation, calculated from intact drug data, normalized for subject differences, was also significantly greater than that of the other two, 68 and 76 per cent respectively. Individual comparisons of area under the curve (AUC) indicated that estimated relative bioavailability depends on the specificity of the assay, the adjustment of the AUC for the area beyond the last measurable plasma concentration and the normalization of the AUC. The data suggest there is a correlation between dissolution rate and peak plasma concentration.

Bioavailability of three commercial sustained-release tablets of quinidine in maintenance therapy

The bioavailability of three quinidine formulations was estimated during a dosing interval at steady state following their administration in 12 selected patients in accordance with a Latin-square 3 x 3. Each subject received the three dosage forms as two tablets every 12 hr for 6 days. Blood and urine samples were taken on the 7th day during the regular 12-hr dosing interval. Unchanged quinidine was determined by a reported spectrofluorometric procedure. The total fluorescence of plasma quinidine and metabolites also was monitored. The data obtained indicate that one dosage form gave a high peak level followed by a fall in the concentration. The two other forms presented a relatively lower peak followed by a plateau and then a decline. The differences between the dose-corrected values of Cp,max were statistically significant. Secondary effects were observed particularly with one dosage form and could be related to the high Cp,max value and/or the high percentage of quinidine liberated rapidly in the GI tract. Blood and urinary data indicated an equivalent degree of absorption. The dissolution behavior of the formulations and their absorption data suggest that there is a correlation between the quantity dissolved at 30 min and Cp,max.

Comparison of two spectrofluormetric procedures for quinidine determination in biological fluids

Different methods for the spectrofluorometric determination of quinidine in plasma and urine were studied. The alkaline washings of plasma and urine extracts remove fluorescent metabolites, as shown by TLC analysis of urine extracts, and do not lead to a significant loss of alkaloids. The spectrofluormetric assays without alkaline washings of the benzene extract averaged 18% higher than the assays with alkaline washings. Since unchanged quinidine and hydroquinidine are responsible for antiarrhythmic activity, the method with alkaline washing is more appropriate for the control of quinidinemia than are other methods. The therapeutic plasma concentration range becomes 0.8-2.5 microng/ml with this methods.