However this patient treated successfully with a single dose

However, this patient treated successfully with a single dose of IVIG alone without aspirin confirming the new available data that show it is unnecessary to expose children to high- or medium-dose aspirin therapy in acute KD when the data show no appreciable benefit in preventing the failure of IVIG therapy or Coronary Artery Lesion formation or in shortening fever duration (Weng and Ou, 2011).
In the Andrew C. Lau, 1 study, she examined the efficacy of IVIG and salicylate (the active metabolite of aspirin) in inhibiting the 3 critical steps in disease pathogenesis of KD: T cell activation, TNF production, and TNF-mediated MMP-9 expression. Basically the TNF induced MMP-9 activity in smooth muscle g to moles calculator is key to the development of coronary artery disease. In other hand, T cell activation leading to TNF-mediated MMP-9 activity is therefore a critical pathway in the development of coronary artery elastin breakdown in KD. IVIG was capable of inhibiting this mechanism even at subtherapeutic concentrations. However, Salicylate at therapeutic concentration cannot inhibit any of the 3 processes examined, and IVIG was not able to overcome the undesirable effects of salicylate-induced TNF expression. This implies that the usefulness of aspirin may be limited to its antiplatelet and antipyretic actions, which can be achieved at much lower doses (Lau, 2009).

Conclusion

Introduction
Therapeutic drug monitoring (TDM) is an established useful clinical service in pharmacotherapy. It helps in identifying alternations in drug disposition, adjusting drugs’ dosage regimen and minimizing adverse effects (Doogue and Martin, 2010; Eliasson et al., 2013; Mehler-Wex et al., 2009). It is widely applied to a variety of drug classes such as antibiotics, antiepileptics, immunosuppressant and others (Eliasson et al., 2013; Kang and Lee, 2009). Several studies found that inappropriate utilization of TDM such as inappropriateness in indications, sampling time and application of results, might lead to a significant waste of resources especially for developing countries (Norris et al., 2010; Ostad Haji et al., 2013; Nilsson et al., 2001; Ab Rahman et al., 2013; Ratanajamit et al., 2009; Dalaklioglu, 2013). In Oman, TDM use is limited for tertiary care hospitals, which are few. Among these is the Sultan Qaboos University Hospital (SQUH), a university teaching hospital, were TDM was introduced almost 15years ago. In 2012 the total number of TDM requests was 6558. These were carried for the following drugs: carbamazepine, phenytoin, valproic acid, digoxin, phenobarbital, gentamicin, tobramycin, amikacin, vancomycin, theophylline, lithium, cyclosporine, and methotrexate. Two retrospective studies at SQUH one on antiepileptic drugs (AEDs) and the other on vancomycin, have been conducted. The evaluated AEDs TDM requests (354) showed that 50%, 37% and 13% of all reported concentrations were either below, within or above the therapeutic range, respectively (Al Za’abi et al., 2013a). Similarly the vancomycin study showed that 70.2% and 7.6% of the samples were either below or above the recommended range, respectively (Al Za’abi et al., 2013b). Despite the availability of this service there was no study documenting the appropriateness of sampling time and indications of these requests. Therefore the present study was performed to prospectively assess the appropriateness of indications, sampling time and outcome of TDM requests at SQUH.

Materials and methods
The study was a prospective, cross-sectional type. It was conducted over a four month period; October 2013 to January 2014 at SQUH, an 855 bed university teaching hospital. It included all TDM requests for inpatients. Patients were identified using TDM requests reaching the biochemistry laboratory where the measurements for drugs are usually carried out, and retrieved using the hospital information system program “Trackcare”. A data collection sheet was created to collect the required information. It contained information regarding demographic data such as sex and age, request data such as unit, time, indications and results outcome. The drugs’ concentrations were measured by an automated analyzer Roche Hitachi Cobas® systems.