The medication monitoring guidelines represent labs and monitoring that each provider should complete as a best practice if they are prescribing those medications/classes of medications.
Note: This is not an all-inclusive list.
Antipsychotics
| Category/Drug | Monitoring Type | Timing | Guidelines/Notes |
| All Antipsychotics | Blood Pressure (BP) / Heart Rate (HR) | At initiation; follow-up as clinically indicated | Antipsychotics, especially atypical antipsychotics, can increase the risk of weight gain, high blood pressure, and other metabolic issues, which are significant risk factors for cardiovascular diseases. |
| AIMS or DISCUS | At initiation; then annually (atypical) or bi-annually (typical) | The AIMS serves as a standardized tool for early detection, monitoring, and management of TD, ensuring appropriate treatment and minimizing potential harm. | |
| Height and Weight | At initiation; then every 3 months | Many antipsychotic medications can cause or exacerbate metabolic abnormalities like weight gain, glucose dysregulation, and hyperlipidemia. Weight gain is a component of metabolic syndrome, which significantly increases the risk of developing type 2 diabetes and cardiovascular disease. | |
| Fasting Lipid Profile & HgA1c | At initiation; at 4 months; then annually | Metabolic monitoring is crucial when using antipsychotic medications due to their potential to cause metabolic side effects like weight gain, elevated blood sugar, and abnormal lipid levels. Regular monitoring helps identify and manage these risks early on. Refer to PCP for lipid management when indicated. |
Antidepressants
| Category/Drug | Monitoring Type | Timing | Guidelines/Notes |
| All SNRIs | Blood Pressure | Initiation, dose change, and annually | By increasing norepinephrine, SNRIs can stimulate the sympathetic nervous system, which in turn can cause blood vessels to narrow (vasoconstriction) and heart rate to increase, leading to a rise in blood pressure 1 |
| Creatinine Level | At initiation | Many SNRIs require dosage adjustments in patients with moderate or severe renal impairment to prevent drug accumulation and toxicity | |
| Levomilnacipran ER (Fetzima) | Creatinine Level | At initiation and annually |
Fetzima and its inactive metabolites are primarily eliminated from the body through renal (kidney) excretion. This means that kidney function directly impacts how efficiently the body clears the drug. TLDR; changes in kidney function will require dose adjustments |
| Duloxetine (Cymbalta) | Liver Function Tests (LFTs) | As clinically indicated | Duloxetine therapy can be associated with transient asymptomatic elevations in serum aminotransferase levels and has been linked to rare instances of clinically apparent acute liver injury |
| Mirtazapine (Remeron) and Tricyclic Antidepressants | Weight | At each visit for 1 year, then annually | Increases appetite, potentially by blocking histamine H1 receptors and serotonin 5-HT2C receptors which normally suppress appetite. It can also shift metabolic processes towards carbohydrate preference and potentially induce insulin resistance. |
| Tricyclic Antidepressants | EKG | Before initiation of medication and with any report of symptoms suggestive of cardiac causes (chest pain, palpitations, SOB, syncope) | TCAs may also induce cardiovascular complications, including arrhythmias such as QTc prolongation, ventricular fibrillation, and sudden cardiac death, particularly in individuals with preexisting ischemic heart disease. Therefore, assessing a patient's cardiac health is important before prescribing TCAs. |
ADHD Medications
| Category/Drug | Monitoring Type | Timing | Guidelines/Notes |
| All Stimulants | PDMP Check | At initiation, with dose changes, at least twice annually |
Follow state-specific requirements: |
| Blood Pressure / Heart Rate | At baseline, with dose changes, and at least twice annually | Cardiovascular monitoring | |
| Cardiac Clearance/EKG | At baseline (if clinically indicated) |
Current clinical recommendations emphasize the need to assess the patient's personal and family cardiac history prior to initiation of ADHD pharmacotherapy, being vigilant about abnormal cardiovascular history (e.g., premature sudden/unexpected death in children or young adults, clinically important arrhythmias, prolonged QT syndrome, hypertrophic cardiomyopathy, and Marfan syndrome)8 EKG screening and cardiologist consultation are recommended for ADHD patients who have positive history of structural cardiac abnormalities |
|
| Weight | At every visit (under age 16) | Monitor for weight suppression | |
| Height |
Every 6 months (under age 16)
|
Most studies have concluded that while some effect on growth is apparent, discontinuation of treatment results in a rebound of growth to compensate for stimulant-induced loss in height. This is the basis for recommending “summer breaks”—when children forego stimulant treatment when on summer holiday from school 7 | |
| Strattera | Blood Pressure / Heart Rate | At initiation, with dose increases, and every 6 months | Monitor cardiovascular effects |
| Cardiac Evaluation | At baseline (if clinically indicated) | If cardiac risk factors are present | |
| Liver Function Tests (LFTs) | As clinically indicated | Consider if symptoms or concerns about liver function arise | |
| Weight | At every visit (under age 16) | Monitor for weight suppression |
Mood Stabilizers
| Category/Drug | Monitoring Type | Timing | Guidelines/Notes |
| Depakote | HCG / Pregnancy Test | Obtain negative pregnancy test prior to medication initiation in women of childbearing age |
Strongly recommend avoiding prescribing to women of childbearing age First trimester use of valproate has been associated with a 3-5% risk of neural tube defects, as well as an increased risk of other malformations affecting the heart, limbs, and genitals. Prenatal exposure to valproate may also result in lower IQ and increased risk of autism spectrum disorders in the offspring 2 |
| Weight | At each visit for 1 year, then annually | Monitor for weight gain | |
| CBC w/ Diff, LFTs, Valproate Level | 1 month after start, 6 months after, then annually | Monitor for hepatotoxicity, thrombocytopenia, and therapeutic level | |
| Tegretol (carbamazepine)8 | Weight | At each visit for 1 year, then annually (if not done elsewhere in 2 mo) | Weight gain is a common and frequent undesirable effect associated with the use of anticonvulsant drugs |
| CBC w/ Diff, LFTs, UA, BUN/Cr | Baseline | Baseline labs for safety monitoring | |
| CBC w/ Diff, LFTs, BUN/Cr, Na+ | 2 weeks after start/dose change, 6 months after, then annually | Na+ monitoring if symptomatic (hyponatremia risk) | |
| HLA-B*1502 allele screening |
Prior to prescribing (if possibility of HLA‑B*15:02 allele) Do not prescribe if allele is present (risk of Stevens-Johnson Syndrome)
|
HLA‑B*15:02, a specific allele common in several East and Southeast Asian populations, dramatically increases the risk of Stevens–Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) when drugs like carbamazepine are prescribed—especially without genetic screening 6 Do not prescribe if allele is present (risk of Stevens-Johnson Syndrome) |
|
| Ophthalmic Exam | As clinically indicated | Consider if visual symptoms present | |
| Tegretol Level | As clinically indicated | Consider with symptom change, pregnancy, or toxicity concerns | |
| Lithium | Lithium Level | Weekly until therapeutic range is achieved, then 1 month after to confirm, then every 6 - 12 months following stable range for monitoring | Monitor serum levels closely to avoid toxicity and ensure therapeutic dosing; draw blood ~12 hours after last dose (trough level) 4 |
| Weight | Each visit for 1 year, then annually | Monitor for weight changes | |
| CBC, BUN/Creatinine, TSH, UA, pregnancy test | Baseline | Assess overall health before starting lithium | |
| BMP, TSH | After 1 month, then every 6-12 months after | Monitor to detect early dysfunction or side effects | |
|
Topamax/ topiramate |
BMP, UA with micro | Baseline, 3 months, 6 months, then annually | Monitor renal function and electrolytes; watch for metabolic acidosis and kidney stones risk |
Substance Use Deterrents
| Category/Drug | Monitoring Type | Timing | Guidelines/Notes |
| Naltrexone (Vivitrol) | Liver Function Tests (LFTs) | Baseline, 3 months, 6 months, then annually | While naltrexone is generally considered safe, it can cause asymptomatic elevations in liver enzymes, and checking LFTs helps identify and manage any potential issues early on 11 |
| Disulfiram (Antabuse) | LFTs and Renal Function | Baseline | Baseline labs before starting treatment |
| LFTs | Monthly for first 6 months, then annually | Close monitoring during initial treatment 10 |
References:
- Calvi, A., Fischetti, I., Verzicco, I., Belvederi Murri, M., Zanetidou, S., Volpi, R., Coghi, P., Tedeschi, S., Amore, M., & Cabassi, A. (2021). Antidepressant drugs effects on blood pressure. Frontiers in Cardiovascular Medicine, 8, 704281. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8370473/
- Center for Women’s Mental Health. (2018, March 1). Outcomes of children exposed to antiepileptic drugs in pregnancy: No good news for valproate. MGH Center for Women’s Mental Health. https://womensmentalhealth.org/posts/outcomes-of-children-exposed-to-anti-epileptic-drugs-in-pregnancy-no-good-news-for-valproate/
- Centers for Disease Control and Prevention. (2023, October 3). Prescription drug monitoring programs (PDMPs). U.S. Department of Health & Human Services. https://www.cdc.gov/overdose-prevention/php/interventions/prescription-drug-monitoring-programs.html
- Chokhawala, K., Lee, S., & Saadabadi, A. (2024). Lithium. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519062/
- DeJongh, B. M. (2021). Clinical pearls for the monitoring and treatment of antipsychotic induced metabolic syndrome. The Mental Health Clinician, 11(6), 311–319. https://doi.org/10.9740/mhc.2021.11.311
- Fariba, K. A. (2024). Topiramate. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK554530/
- Ferrell, P. B., Jr., & McLeod, H. L. (2008). Carbamazepine, HLA‑B*1502 and risk of Stevens–Johnson syndrome and toxic epidermal necrolysis: US FDA recommendations. Pharmacogenomics, 9(10), 1543–1546. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2586963/
- Goldman, R. D. (2010). ADHD stimulants and their effect on height in children. Canadian Family Physician, 56(2), 145–146.https://pmc.ncbi.nlm.nih.gov/articles/PMC2821235/
- Maan, J. S., Duong, T. V. H., & Saadabadi, A. (2023, July 10). Carbamazepine. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482455/
- Sinha, A., Lewis, O., Kumar, R., Yeruva, S. L. H., & Curry, B. H. (2016). Adult ADHD medications and their cardiovascular implications. Case Reports in Cardiology.https://pmc.ncbi.nlm.nih.gov/articles/PMC4992783/
- Skinner, M. D., Lahmek, P., Pham, H., & Aubin, H. J. (2014). Disulfiram efficacy in the treatment of alcohol dependence: A meta-analysis. PLOS ONE, 9(2), e87366. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3919718/
- National Institute of Diabetes and Digestive and Kidney Diseases. (2020, March 24). Naltrexone. In LiverTox: Clinical and research information on drug‑induced liver injury. National Institutes of Health. https://www.ncbi.nlm.nih.gov/books/NBK548583/https://www.ncbi.nlm.nih.gov/books/NBK548583/
- Yekehtaz, H., Farokhnia, M., & Akhondzadeh, S. (2013). Cardiovascular considerations in antidepressant therapy: An evidence-based review. Journal of Tehran University Heart Center, 8(4), 169–176. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4434967/
Updated