Test ID: PNY
Phenytoin, Total, Serum
Secondary ID 
A test code used for billing and in test definitions created prior to November 2011
NY State Approved Indicates the status of NY State approval and if the test is orderable for NY State clients.
Useful For Suggests clinical disorders or settings where the test may be helpful
Monitoring for appropriate therapeutic concentration
Assessing compliance or toxicity
Method Name A short description of the method used to perform the test
Immunoassay
Reporting Name A shorter/abbreviated version of the Published Name for a test; an abbreviated test name
Aliases Lists additional common names for a test, as an aid in searching
Dilantin (Do Phenytoin, Total unless Free specified)
Dilantin (Phenytoin)
Dilantin + Phenobarb ORDER 8643
Diphenylhydantoin
Diphenylhydantoin + Phenobarb ORDER 8643
Phenytoin (Dilantin)
Phenytoin Total + Phenobarb ORDER 8643
Phenytoin, Free and Total ORDER 9993
Phenytoin, Total and Free ORDER 9993
Specimen Type Describes the specimen type needed for testing
Specimen Required Defines the optimal specimen. This field describes the type of specimen required to perform the test and the preferred volume to complete testing. The volume allows automated processing, fastest throughput and, when indicated, repeat or reflex testing.
Container/Tube: Red top
Specimen Volume: 1 mL
Specimen Minimum Volume Defines the amount of specimen required to perform an assay once, including instrument and container dead space. Submitting the minimum specimen volume makes it impossible to repeat the test or perform confirmatory or perform reflex testing. In some situations, a minimum specimen volume may result in a QNS (quantity not sufficient) result, requiring a second specimen to be collected.
Reject Due To Identifies specimen types and conditions that may cause the specimen to be rejected
| Hemolysis | Mild OK; Gross reject |
| Lipemia | Mild OK; Gross reject |
| Icterus | Mild OK; Gross reject |
| Other | NA |
Specimen Stability Information Provides a description of the temperatures required to transport a specimen to the laboratory. Alternate acceptable temperature(s) are also included.
| Specimen Type | Temperature | Time |
|---|---|---|
| Serum Red | Refrigerated (preferred) | 14 days |
| Ambient | 14 days | |
| Frozen | 14 days |
Clinical Information Discusses physiology, pathophysiology, and general clinical aspects, as they relate to a laboratory test
Phenytoin is the drug of choice to treat and prevent tonic-clonic and psychomotor seizures. If phenytoin alone will not prevent seizure activity, coadministration with phenobarbital is usually effective.
Initial therapy with phenytoin is started at doses of 100 mg/day to 300 mg/day for adults or 4 mg/kg/day for children. Because absorption is variable and the drug exhibits zero-order (nonlinear) kinetics, dose must be adjusted within 5 days using blood concentration to guide therapy. Oral bioavailability ranges from 80% to 95% and is diet-dependent.
Phenytoin exhibits zero-order pharmacokinetics; the rate of clearance of the drug is dependent upon the concentration of drug present. Therefore, phenytoin does not have a classical half-life like other drugs, since it varies with blood concentration. At a blood concentration of 15 mcg/mL, approximately half the drug in the patient's body will be eliminated in 20 hours. As the blood concentration drops, the rate at which phenytoin is excreted increases.
Phenytoin has a volume of distribution of 0.65 L/kg, and is highly protein bound (90%), mostly to albumin.
Some drug side-effects occur in the therapeutic range; these include gingival hyperplasia, hyperglycemia, and skin rash.
Phenytoin pharmacokinetics are significantly affected by a number of other drugs. As noted above, phenytoin and phenobarbital are frequently coadministered. Induction of the cytochrome P450 enzyme system by phenobarbital will increase the rate at which phenytoin is metabolized and cleared. At steady-state, enzyme induction will increase the rate of clearance of phenytoin such that the dose must be increased approximately 30% to maintain therapeutic levels.
Uremia has a similar effect on phenytoin protein binding. In uremia, by-products of normal metabolism accumulate and bind to albumin, displacing phenytoin which causes an increase in the free fraction.
Valproic acid, an antiepileptic frequently coadministered with phenytoin, competes for the same binding sites on albumin as phenytoin. Valproic acid displaces phenytoin from albumin, reducing the bound fraction and increasing the free fraction. The overall effect of coadministration of a therapeutic dose of valproic acid is that the total concentration of phenytoin decreases due to increased clearance but the free fraction increases; the free concentration of phenytoin, which is the active form remains virtually the same. Thus, no dosage adjustment is needed when valproic acid is added to maintain the same pharmacologic effect, but the total concentration of phenytoin decreases.
In contrast to the valproic acid situation, in renal failure, there is not the same opportunity for the free phenytoin fraction to be cleared. The end result is that both the total and free concentration of phenytoin increase, with the free concentration increasing faster than the total. Dosage must be reduced to avoid toxicity.
The free phenytoin level is the best indicator of adequate therapy in renal failure.
Toxicity is a constant possibility because of the manner in which phenytoin is metabolized. Small increases in dose can lead to very large increases in blood concentration, resulting in early signs of toxicity such as nystagmus, ataxia, and dysarthria. Severe toxicity occurs when the blood concentration is >30 mcg/mL and is typified by tremor, hyperreflexia, and lethargy. The outcome of phenytoin toxicity is not as serious as phenobarbital because phenytoin is not a central nervous system sedative.
Reference Values Describes reference intervals and additional information for interpretation of test results. May include intervals based on age and sex when appropriate. Intervals are Mayo-derived, unless otherwise designated. If an interpretive report is provided, the reference value field will state this.
Therapeutic concentration: 10.0-20.0 mcg/mL
Toxic concentration: > or =30.0 mcg/mL
Interpretation Provides information to assist in interpretation of the test results
Dose should be adjusted to achieve steady-state blood concentrations between 10 mcg/mL to 20 mcg/mL.
Cautions Discusses conditions that may cause diagnostic confusion, including improper specimen collection and handling, inappropriate test selection, and interfering substances
No significant cautionary statements
Clinical Reference Provides recommendations for further in-depth reading of a clinical nature
1. Richens A: Clinical pharmacokinetics of phenytoin. Clin Pharmacokinet 1979;4:153-169
2. Moyer TP: Therapeutic drug monitoring. In Tietz Textbook of Clinical Chemistry. 4th edition. Edited by CA Burtis, ER Ashwood. WB Saunders Company, Philadelphia, 2005, pp 1237-1285
Method Description Describes how the test is performed and provides a method-specific reference
Enzyme-multiplied immunoassay technique (EMIT) is performed using the Olympus analyzer. EMIT offers an alternative to the traditional spectroscopic and chromatographic method for quantitating blood concentrations of drugs. The technique for drugs is based upon an enzymatic assay for glucose-6-phosphate dehydrogenase, using spectral properties at 340 nm, in which the reduction of nicotinamide adenine dinucleotide (NAD) substrate is monitored. The basis of the drug detection technique is an immunological reaction between the drug and a specific antibody. The reagent contains the enzyme (glucose-6-phosphate dehydrogenase) to which the drug is covalently bound and antibody-specific to the drug. The antibody binds most of the drug-bound enzyme, rendering the enzyme inactive. This results in a baseline enzymatic activity. In the presence of free drug, antibody equilibrates between free drug and enzyme-bound drug leaving some of the drug-bound enzyme uncomplexed and able to catalyze the reaction. If more free drug is introduced, either as standard or sample, then competition for the antibody takes place between the drug in the sample and the drug attached to the enzyme. This results in more drug-bound enzyme being left uncomplexed and able to catalyze the enzyme reaction at a greater rate as compared to the baseline activity. The observed enzyme activity increases with the amount of total free drug in the sample. (Package insert: EMIT 2000 Phenytoin Assay. Olympus, Melville, NY. October 2005)
Day(s) and Time(s) Test Performed Outlines the days and times the test is performed. This field reflects the day and time the sample must be in the testing laboratory to begin the testing process and includes any specimen preparation and processing time required before the test is performed. Some tests are listed as continuously performed, which means assays are performed several times during the day.
Monday through Sunday; Varies
Analytic Time Defines the amount of time it takes the laboratory to setup and perform the test. This is defined in number of days. The shortest interval of time expressed is "same day/1 day," which means the results may be available the same day that the sample is received in the testing laboratory. One day means results are available 1 day after the sample is received in the laboratory.
Maximum Laboratory Time Defines the maximum time from specimen receipt at Mayo Medical Laboratories until the release of the test result
Specimen Retention Time Outlines the length of time after testing that a specimen is kept in the laboratory before it is discarded
Performing Laboratory Location The location of the laboratory that performs the test
Test Classification Provides information regarding the medical device classification for laboratory test kits and reagents. Tests may be classified as cleared or approved by the US Food and Drug Administration (FDA) and used per manufacturer's instructions, or as products that do not undergo full FDA review and approval, and are then labeled as an Analyte Specific Reagent (ASR), Investigation Use Only (IUO) product, or a Research Use Only (RUO) product.
CPT Code Information Provides guidance in determining the appropriate Current Procedural Terminology (CPT) code(s) information for each test or profile. The listed CPT codes reflect Mayo Medical Laboratories interpretation of CPT coding requirements. It is the responsibility of each laboratory to determine correct CPT codes to use for billing.
80185
LOINC® Code Information Provides guidance in determining the Logical Observation Identifiers Names and Codes (LOINC) values for the result codes returned for this test or profile.
| Result ID | Reporting Name | LOINC Code |
|---|---|---|
| 8604 | Phenytoin, Total, S | 3968-5 |
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