Centralized Core Laboratory - Mayo Clinic Laboratories :
Send Out
PATIENT INFO
Patient Name:
Medical Record #:
BD: //Sex: F M
PHYSICIAN INFO
Physician Name :
Address:
Ph: ()-Fax: ()-
Additional Report to:
Ph: ()-Fax: ()-
TESTS REQUESTED
Test Name:
ICD9 Code: (required)
1. Amitri/Nortriptyline
2.
3.
4.
5.
6.
SPECIMEN INFO
Collection Date & Time:
Collected By:
Hospital:
Test ID :
AMINT
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Red top (no anticoagulant) tube
Collection Volume:
2.5 mL
Minimum Volume:
1.0 mL
Cause for Rejection:
Collected in Get Tube
Storage:
Refrigerated
Availability:
Sent to reference lab
Methodology:
Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)
Special Instructions:
Collect immediately prior to next dose. Centrifuge and take off cells within 2 hours of collection.
If collected at an offsite location, send by a STAT Courier to Hospital lab (Akron or Mahoning Valley).
Lab/Phone:
330-543-8418
TAT:
3-5 days
Additional Info:
Reference range:
Amitriptyline 80-200 ng/mL.
Risk of toxicity is increased with combined levels are above 500 ng/mL.
Nortriptyline 70-170 ng/mL.
Risk of toxicity is increased with nortriptyline levels above 500 ng/mL.
Therapeutic ranges are based on specimens collected at trough (ie, immediately before the next dose).
CPT Code:
80335
Panel Includes:
Amitriptyline; Nortriptyline; Total Amitrip/Nortriptyline
Amitri/Nortriptyline
Test ID/Workstation :
AMINT
Specimen Type:
Blood
Tube Type:
Red top (no anticoagulant) tube
Collection Volume:
2.5 mL
Cause for Rejection:
Collected in Get Tube
Storage:
Refrigerated
Availability:
Sent to reference lab
Methodology:
Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)
Special Instructions:
Collect immediately prior to next dose. Centrifuge and take off cells within 2 hours of collection.
If collected at an offsite location, send by a STAT Courier to Hospital lab (Akron or Mahoning Valley).
Lab/Phone:
330-543-8418
TAT:
3-5 days
Additional Info:
Reference range:
Amitriptyline 80-200 ng/mL.
Risk of toxicity is increased with combined levels are above 500 ng/mL.
Nortriptyline 70-170 ng/mL.
Risk of toxicity is increased with nortriptyline levels above 500 ng/mL.
Therapeutic ranges are based on specimens collected at trough (ie, immediately before the next dose).
CPT Code:
80335
Panel Includes:
Amitriptyline; Nortriptyline; Total Amitrip/Nortriptyline
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