Understanding the relevance of altered binding of highly bound drugs can be challenging. The most important impact of an increase or decrease in FU is on how one ‘interprets’ the measurement of total drug concentrations. Changes in FU rarely, in selleck compound and of themselves, lead to a change in dosage recommendations. However, when interpreting total drug exposure (for highly bound drugs), free drug exposure should be considered as well, especially under conditions where FU may be altered (e.g. pregnancy). A classic example illustrating the importance of investigating FU changes is with phenytoin, a drug for which therapeutic drug monitoring (TDM) is employed. Patients with severe renal disease on average

have a doubling of phenytoin FU when compared to patients with

normal renal function [10]. Therefore, when TDM is used to optimize phenytoin therapy, the total drug concentrations targeted for adequate seizure control in renal patients are approximately 50% the concentrations targeted for patients with normal renal function. For example, a phenytoin concentration of 8 mcg/mL would represent an adequate concentration for a patient with severe kidney impairment while this same concentration may be deemed sub-therapeutic for an individual with normal kidney function. The same could hold true for other highly bound drugs used to treat a distinct population. In the case of LPV use in pregnancy, the Selleckchem BMS-354825 observed 18% relative increase in LPV unbound fraction during pregnancy (FU) should be considered when interpreting total drug measurements in pregnancy. However, the FU change of 18% we measured is smaller than the 28% reduction in AUC and the 56% reduction in 12 h trough concentration of total drug reported previously [4]. This earlier study demonstrated that an increased dose of LPV during pregnancy normalized total drug exposure and was well tolerated, yielding recommendations for this higher dose during third trimester and potentially second-trimester selleck kinase inhibitor pregnancy with a return to standard dosing 2 weeks following delivery [5]. On balance, the 18% increase in LPV unbound fraction does offset some of the change seen with total drug

exposure, but is not of sufficient magnitude to eliminate the need for an increased dose during pregnancy. The P1026s team wishes to thank the volunteers participating in this study and the study coordinators at the participating sites. We thank Abbott Laboratories, Abbott Park, Illinois, for their support of this work. The P1026s Team: Mark Mirochnick, MD; Alice M. Stek, MD; Edmund Capparelli, Pharm.D.; Brookie M. Best, Pharm.D.; Cheng-cheng Hu, PhD; Sandra K. Burchett, MD; Carol Elgie, BS; Diane T. Holland, MPhil; Beth Sheeran, MS, RD; Janne Schiffhauer, BS; Maureen Shannon, MS, CNM; James D. Connor, MD; Francesca Aweeka, Pharm.D.; Bradley W. Kosel, Pharm.D.; Kathleen A. Medvik, BS, MT; Elizabeth Smith, MD; Jennifer S. Read, MD.