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Phenytoin Level 

  • Author: Jennifer L Galjour, MD, MPH; Chief Editor: Eric B Staros, MD  more...
 
Updated: Nov 21, 2014
 

Reference Range

Phenytoin is used as both an abortive and preventive medication in seizure management.[1, 2, 3]

The total phenytoin reference range varies by age, as follows:

  • Children and adults: 10-20 µg/mL
  • Neonates: 8-15 µg/mL

Toxic phenytoin levels are defined as greater than 30 µg/mL.

Lethal levels are defined as greater than 100 µg/mL.

The reference range of free phenytoin is 1-2.5 µg/mL.

In patients with renal failure associated with hypoalbuminemia, free phenytoin levels may be more accurate than total phenytoin levels.[4, 5] However, the Sheiner-Tozer formula (below) can be used to correct the phenytoin level.[4, 6]

Adjusted concentration = measured total concentration / [(0.2 x albumin) + 0.1]

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Interpretation

Administration of phenytoin and interpretation of serum phenytoin levels vary depending on the clinical scenario. Loading doses to achieve rapid therapeutic levels should be checked 1 hour after an intravenous loading dose and 24 hours after an oral loading dose.[4]

Patients who are on long-term phenytoin therapy generally do not need to be monitored at intervals less than 3-12 months after a steady state has been reached unless clinically indicated, for example in patients who may have intentionally or unintentionally taken a toxic dose.[4]

Although the reference range is between 10 and 20 µg/mL, about half of patients’ seizures are controlled at values lower and higher than the therapeutic range.[6]

Some adverse effects of phenytoin are related to specific serum levels. Nystagmus is frequently observed at levels greater than 20 µg/mL.[5, 6] At greater than 30 µg/mL, patients may exhibit slurring of speech, ataxia, and movement disorders such as tremor, choreoathetosis, and orofacial dyskinesia.[5, 6] At serum levels that exceed 40 µg/mL, patients are often lethargic, stuporous, and confused and may require aggressive supportive measures.[5]

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Collection and Panels

Specimen: Blood

Container: Red-top tube

Collection method: Routine venipuncture

Loading doses to achieve rapid therapeutic levels should be checked 1 hour after an intravenous loading dose and 24 hours after an oral loading dose.[4]

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Background

Description

Phenytoin is an antiepileptic drug with several pharmacologic actions, including ion conductance, Na-K ATPase activity, synaptic transmission, and neurotransmitter release; the antiepileptic effects of phenytoin are thought to be primarily related to its action at the sodium channels during depolarization, preventing repetitive neuronal firing.[6]

Assessing phenytoin levels is useful in prophylaxis of seizures in patients with intracranial pathology, management of epileptic patients, and evaluation of patients with potential phenytoin overdose/toxicity.

Indications/Applications

Phenytoin is used as both an abortive and preventive medication in seizure management. Intravenous administration of phenytoin ceased seizure activity in 60%-80% of patients in status epilepticus within 20 minutes. Prophylactic indications include pregnancy-induced hypertension, postneurosurgery, cerebrovascular accidents, and traumatic brain injury. Of these, there is inconsistent evidence to support the routine use of phenytoin in patients who have undergone craniectomy.

Less-common uses of phenytoin include the treatment of neuropathic pain, motion sickness, muscular dystrophy, and arrhythmia.[6]

Phenytoin levels are helpful in determining therapeutic dosing in patients with epilepsy and in managing adverse effects and toxicity in accidental or intentional overdoses.

Considerations

Phenytoin is available in many formulations, including extended-release capsules. When managing patients receiving extended-release capsules, a random serum level will suffice given the prolonged half-life.[4]

Total phenytoin levels reflect both bound and unbound drug; because protein-bound phenytoin cannot cross the blood-brain barrier, only free phenytoin is active. In healthy adults, approximately 90% of phenytoin is bound to albumin. Corrected levels can be calculated using the Sheiner-Tozer method.[4, 6] Correction should be used in patients with uremia, hepatic disease, and AIDS.[6]

Concomitant use of valproic acid alters free phenytoin levels by competitively binding to serum albumin.[6]

Because hepatic metabolism is saturable, elimination of phenytoin may be delayed in patients with large ingestions.[5]

In addition to monitoring renal function, hepatic function, and albumin levels, physicians should be aware of antifolate and anti–vitamin K properties of phenytoin in pregnant women. Folate levels and abnormal bleeding profiles should be considered in pregnant women and newborns, with supplementation as indicated.[7]

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Contributor Information and Disclosures
Author

Jennifer L Galjour, MD, MPH Resident Physician, Department of Emergency Medicine, Mount Sinai School of Medicine

Jennifer L Galjour, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Suzanne Bentley, MD Assistant Professor, Departments of Emergency Medicine and Medical Education, Elmhurst Hospital, Mount Sinai School of Medicine

Suzanne Bentley, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Medical Womens Association, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Chief Editor

Eric B Staros, MD Associate Professor of Pathology, St Louis University School of Medicine; Director of Clinical Laboratories, Director of Cytopathology, Department of Pathology, St Louis University Hospital

Eric B Staros, MD is a member of the following medical societies: American Medical Association, American Society for Clinical Pathology, College of American Pathologists, Association for Molecular Pathology

Disclosure: Nothing to disclose.

References
  1. Sun Z, Zhong XL, Zong Y, Wu ZC, Zhang Q, Yu JT, et al. Activation of Adenosine Receptor Potentiates the Anticonvulsant Effect of Phenytoin Against Amygdala Kindled Seizures. CNS Neurol Disord Drug Targets. 2014 Aug 6. [Medline].

  2. Uchida Y, Ohtsuki S, Terasaki T. Pharmacoproteomics-based Reconstruction of In Vivo P-Glycoprotein Function at Blood-Brain Barrier and Brain Distribution of Substrate Verapamil in Pentylenetetrazole-kindled Epilepsy, Spontaneous Epilepsy and Phenytoin Treatment Models. Drug Metab Dispos. 2014 Jul 24. [Medline].

  3. Abraham AP, Vidyasagar A, Lakshmanan J, Nair S, Joseph M. Phenytoin toxicity in patients with traumatic brain injury. Neurol India. 2014 May-Jun. 62(3):285-9. [Medline].

  4. Waltham MA. Drug Information. Basow, DS (Ed). Phenytoin. 2012.

  5. Smollin C. Olson (Ed),. In K.R. Poisoning & Drug Overdose, 5e. Retrieved March 13, 2012 from http://www.accessmedicine.com/content.aspx?aID=2678603. 2007.

  6. Morita DA, Glauser TA. Phenytoin and Fosphenytoin. Wyllie’s Treatment of Epilepsy: Principles and Practice. 5 ed. 2011.

  7. Ropper AH, Samuels MA (2009). Epilepsy and Other Seizure Disorders. AH Ropper MA Samuels (Eds). Adams and Victor's Principles of Neurology. Retrieved from http://eresources.library.mssm.edu:2059/content.aspx?aID=3632229. 9. March 14, 2012. Chapter 16.

 
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