CLINICAL PHARMACOGENETIC LABORATORY REQUEST FORM Information about Diet Patient's Habits 1. THERAPEUTIC DRUG MONITORING (TDM) Number Name of Molecule Expected Number of Days to Achieve Therapeautic Range Steady State (Css)
1. Alprazolam
2. Amisulpiride
3. Amitriptyline+Nortriptyline
4. Aripiprazole Dehidroaripiprazole
5. Bupropion(under investigation)
6. Carbamazepine+ 10,11-epoxide metabolite
7. Chlorpromazine
8. Citalopram
9. Clomipramine + Norclomipramine
10. Clonazepam
11. Clozapine + Norclozapine
12. Diazepam + N-desmethyldiazepam
13. Donapezil
14. Duloxetine HCL
15. Escitalopram
16. Fluoxetine + Norfluoxetine
17. Flupentixol
18. Fluvoxamine
19. Gabapentine
20. Haloperidol
21. Lamotrigine
22. Levetiracetam
23. Lorazepam
24. Maprotiline
25. Memantine
26. Metylphenidate
27. Mianserine
28. Mirtazapine
29. Moclobemide
30. Naltrexone
31. Olanzapine
32. Opipramol
33. Paliperidone
34. Paroxetine
35. Pimozide
36. Pregabaline
37. Quetiapine
38. Reboxetine
39. Risperidone + 9-OHrisperidone
40. Rivastigmine
41. Sertindole
42. Sertraline Desmethylsertaline
43. Sulpiride
44. Tianeptine (Under investigation)
45. Topiramate
46. Trazadone HCL
47. Trifluoperazine
48. Venlafaxine + O- Desmethylvenlafaxine
49. Ziprasidone
50. Zuclopenthixol 2. GENETIC PROFILE (PSYCHOTROPIC PANEL) □ CYP2C9 □CYP2D6 □CYP2C19 □CYP1A2 When Obtaining a Genetic Sample:
1) Samples must be contained in hemogram tubes (with purple caps.)
2) For administration of this test, the patient's appetite or use of any other medication is considered necessary.
When Obtaining a TDM Sample For Doctors: For Technicians:
1) For measurement of the lowest concentration, blood must be
1) Samples should be placed into tubes that contain sodium
obtained from the patient right before the last dose of
medication, usually 4 days after the beginning of administration.
2) The volume of the sample must be at least 1.5-2 mL.
2) One blood sample is enough for a patient who takes more
3) After the blood sample is obtained at room temperature, it
than one kind of medication at the same time. On the other
should be centrifuged at 4000 rpm for 15 minutes to seperate the
hand, if the medication is administered within seperate intervals,
plasma. The seperated plasma should be placed into a dry and
seperate blood samples must be obtained from the patient for
4) The seperated plasma should arrive to the laboratory inside a
3) When a TDM report is requested for any type of medication
administered to the patient, then a seperate steady-state is done
5) The sample should be given to the NPISTANBUL
Neuropsychiatry Hospital Biochemical Laboratory or the Clinical
4) When a toxicity evaluation is requested, a seperate blood
sample must be obtained after the steady-state according to the
Signature of Requesting Doctor: .
Patient Name: ___________________________________________ DOB: ___________ Appt. Date: __________ Appt. Time: __________Patient Phone: _________________ Referring Physician: ______________________________ SPECIAL REPORTING INSTRUCTIONS:J E R E M Y N . W I E R S I G M . D . , P. A . Addl. Referring Physicians: _______________________________________________________❑ Films with Report to Offic
CLINICAL PHARMACOGENETIC LABORATORY REQUEST FORM