as a surrogate or end-point marker of effect (PD monitoring) e.g. concentration of an endogenous compound, enzymatic activity, gene expression, etc. either as a complement to PK monitoring or as the main TDM tool; it requires interpretation of the results, taking into account pre-analytical conditions, clinical information and the clinical efficiency of the current dosage regimen; this can be achieved by the application of PK-PD modeling; it can potentially benefit from population PK/PD models possibly combined with individual pharmacokinetic forecasting techniques, or pharmacogenetic data. Characteristics of drugs candidate to therapeutic drug monitoring In pharmacotherapy, many medications are used without monitoring of blood levels, as their dosage can generally be varied according to the clinical response that a patient gets to that substance. For certain drugs, this is impracticable, while insufficient levels will lead to undertreatment or resistance, and excessive levels can lead to toxicity and tissue damage. Indications in favor of therapeutic drug monitoring include: consistent, clinically established pharmacodynamic relationships between plasma drug concentrations and pharmacological efficacy and/or toxicity; significant between-patient pharmacokinetic variability, making a standard dosage achieve different concentration levels among patients (while the drug disposition remains relatively stable in a given patient); narrow therapeutic window of the drug, which forbids giving high doses in all patients to ensure overall efficacy; drug dosage optimization not achievable based on clinical observation alone; duration of the treatment and criticality for patient's condition justifying dosage adjustment efforts; potential patient compliance problems that might be remedied through concentration monitoring. TDM determinations are also used to detect and diagnose poisoning with drugs, should the suspicion arise. Examples of drugs widely analysed for therapeutic drug monitoring: Aminoglycoside antibiotics (gentamicin) Antiepileptics (such as carbamazepine, phenytoin and valproic acid) Mood stabilisers, especially lithium citrate Antipsychotics (such as pimozide and clozapine) Digoxin Ciclosporin, tacrolimus in organ transplant recipients TDM increasingly proposed for a number of therapeutic drugs, e.g. many antibiotics, small molecule tyrosine kinase inhibitors and other targeted anticancer agents, TNF inhibitors and other biological agents, antifungal agents, antiretroviral agents used in HIV infection, psychiatric drugs etc. Practice of therapeutic drug monitoring Automated analytical methods such as enzyme multiplied immunoassay technique or fluorescence polarization immunoassay are widely available in medical laboratories for drugs frequently measured in practice. Nowadays, most other drugs can be readily measured in blood or plasma using versatile methods such as liquid chromatography–mass spectrometry or gas chromatography–mass spectrometry, which progressively replaced high-performance liquid chromatography. Yet,