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HelpEpic Code LAB848 Doxepin and Nordoxepin, Serum
Additional Codes
Mayo Code: DXPIN
Performing Laboratory
Mayo Clinic Laboratories in Rochester
Useful For
Monitoring doxepin therapy
Evaluating potential doxepin toxicity
Evaluating patient compliance
Specimen Type
Serum RedSpecimen Required
Supplies: Sarstedt Aliquot Tube 5 mL (T914)
Collection Container/Tube: Red top (Serum gel/SST are not acceptable)
Submission Container/Tube: Plastic vial
Specimen Volume: 1 mL
Collection Instructions:
1. Collect specimen immediately before next scheduled dose (minimum 12 hours after last dose).
2. Centrifuge and aliquot serum into a plastic vial. Serum must be separated from cells within 2 hours of collection.
COLLECTION NOTE: Volumes listed are in serum or plasma, draw approximately 2 1/2 times the requested volume in whole blood.
Specimen Minimum Volume
0.25 mL
Specimen Stability Information
| Specimen Type | Temperature | Time | Special Container |
|---|---|---|---|
| Serum Red | Refrigerated (preferred) | 28 days | |
| Frozen | 28 days | ||
| Ambient | 7 days |
Reject Due To
| Gross hemolysis | Reject |
| Gross lipemia | Reject |
| Gross icterus | Reject |
Day(s) Performed
Tuesday, Thursday, Sunday
Reference Values
Therapeutic concentration (doxepin + nordoxepin): 50-150 ng/mL
Note: Therapeutic ranges are for specimens collected at trough (ie, immediately before next scheduled dose). Levels may be elevated in non-trough specimens.
Clinical Information
Doxepin is recommended for the treatment of psychoneurotic patients with depression or anxiety, or with depression or anxiety associated with alcoholism or organic disease.
Nordoxepin (N-desmethyldoxepin) is the major metabolite and is usually present at concentrations equal to doxepin. Optimal efficacy occurs at combined serum concentrations between 50 and 150 ng/mL.
Like other tricyclic antidepressants, the major toxicity of doxepin is expressed as cardiac dysrhythmias, which occur at concentrations more than 500 ng/mL. Other side effects include nausea, hypotension, and dry mouth.
Cautions
This test cannot be performed on whole blood. Serum must be separated from cells within 2 hours of collection; if serum is not removed within this time, tricyclic antidepressant levels may be falsely elevated due to drug release from red blood cells.
Specimens that are obtained from gel tubes are not acceptable because the drug can absorb on the gel and lead to falsely decreased concentrations.
Interpretation
Most individuals display optimal response to doxepin when combined serum levels of doxepin and nordoxepin are between 50 and 150 ng/mL. Some individuals may respond well outside of this range or may display toxicity within the therapeutic range; thus, interpretation should include clinical evaluation. Risk of toxicity is increased with combined levels are above 500 ng/mL.
Therapeutic ranges are based on specimens collected at trough (ie, immediately before the next dose).
Reporting Name
Doxepin and Nordoxepin, SMethod Name
Liquid Chromatography Tandem Mass Spectrometry (LC-MS/MS)
Method Description
The tricyclic antidepressants are extracted from serum using a solvent to precipitate proteins. The supernatant is removed, and analysis is by liquid chromatography tandem mass spectrometry.(Unpublished Mayo method)
CPT Code Information
80299
LOINC Code Information
| Test ID | Test Order Name | Order LOINC Value |
|---|---|---|
| DXPIN | Doxepin and Nordoxepin, S | 43122-1 |
| Result ID | Test Result Name | Result LOINC Value |
|---|---|---|
| 63507 | Doxepin | 3579-0 |
| 37125 | Nordoxepin | 3862-0 |
| 37126 | Doxepin and Nordoxepin | 3582-4 |
Report Available
3 to 5 daysTest Classification
This test was developed and its performance characteristics determined by Mayo Clinic in a manner consistent with CLIA requirements. It has not been cleared or approved by the US Food and Drug Administration.Clinical Reference
1. Wille SM, Cooreman SG, Neels HM, Lambert WE. Relevant issues in the monitoring and the toxicology of antidepressants. Crit Rev Clin Lab Sci. 2008;45(1):25-89
2. Thanacoody HK, Thomas SHL. Antidepressant poisoning. Clin Med (Lond). 2003;3(2):114-118
3. Hiemke C, Bergemann N, Clement HW, et al. Consensus guidelines for therapeutic drug monitoring in neuropsychopharmacology: Update 2017. Pharmacopsychiatry. 2018;51:9-62
4. Milone MC, Shaw LM. Therapeutic drugs and their management. In: Rifai N, Chiu RWK, Young I, Burnham CAD, Wittwer CT, eds. Tietz Textbook of Laboratory Medicine. 7th ed. Elsevier; 2023:420-453
Forms
If not ordering electronically, complete, print, and send a Therapeutics Test Request (T831) with the specimen.