0020753599322COINV10.

DIGIT
Digitoxin Therapeutic drug monitoring
Order information
Analyzer(s) on which cobasc pack(s) can be used
COBASINTEGRA 400 plus
20753599 322 Digitoxin (200 tests) System-ID 0753599
COBAS INTEGRA 800
Preciset TDM II System-ID 0768294
03375781 190 Calibrators A-F (6 1 5 mL)
Diluent (1 10 mL)
Roche-TDM
OnLine Digitoxin Controls
System-ID 0766658
20766658 322 Level I (2 5 mL)
System-ID 0766666
Level II (2 5 mL)
System-ID 0766674
Level III (2 5 mL)

English Storage and stability

System information Shelf life at 28C See expiration date on
Test DIGTM, test ID 0-559 cobasc pack label
Intended use COBASINTEGRA400 plus system
In vitro diagnostic test for the quantitative determination of digitoxin in
serum or heparinized plasma on COBASINTEGRA systems. On-board in use at 1015C 8weeks

Summary COBASINTEGRA800 system

Digitoxin is a digitalis glycoside that exerts a positive inotropic effect that On-board in use at 8C 26weeks
subsequently increases the contractile response of the myocardial fibers in The on-board in use stability period begins at the time of cobasc pack
patients experiencing congestive heart failure. Cardiac glycosides also can puncture.
produce several electrophysiologic effects that produce negative
chronotropic effects on the human heart. These effects tend to slow down Specimen collection and preparation
and regulate a rapid, irregular beat like that found in patients experiencing For specimen collection and preparation only use suitable tubes or
cardiac arrhythmias.1 collection containers.
Test principle Only the specimens listed below were tested and found acceptable:
Kinetic interaction of microparticles in solution (KIMS) as measured by Unhemolyzed serum
changes in light transmission. Unhemolyzed heparinized plasma
The COBASINTEGRA Digitoxin test is a homogeneous immunoassay The sample types listed were tested with a selection of sample collection
based on the principle of measuring changes in scattered light or tubes that were commercially available at the time of testing, i.e. not all
absorbance which result when activated microparticles aggregate. The available tubes of all manufacturers were tested. Sample collection systems
microparticles are coated with digitoxin and rapidly aggregate in the from various manufacturers may contain differing materials which could
presence of a digitoxin antibody solution. When a sample containing affect the test results in some cases. When processing samples in primary
digitoxin is introduced, the aggregation reaction is partially inhibited, slowing tubes (sample collection systems), follow the instructions of the tube
the rate of the aggregation process. Antibody bound to sample drug is no manufacturer.
longer available to promote microparticle aggregation, and subsequent Centrifuge samples containing precipitates before performing the assay.
particle lattice formation is inhibited. Thus, a classic inhibition curve with A specimen should be collected 612hours following the last oral dose of
respect to digitoxin concentration is obtained, with the maximum rate of digitoxin.2 By this time, serum digitoxin levels are expected to be in
aggregation at the lowest digitoxin concentration. By monitoring the change equilibrium with tissue levels and should correlate with pharmacologic
in scattered light or absorbance, a concentration-dependent curve is effects.
obtained.
Prior to analysis, the serum may be stored refrigerated (28C) for 24hours
Reagents - working solutions or at 20C for 12weeks.3 Specimens should not be repeatedly frozen and
thawed.
R1 Antibody reagent
Anti-digitoxin monoclonal antibody(mouse) in buffer with Invert thawed specimens several times prior to testing.
preservative. Any additional clotting or precipitation which occurs due to the freeze/thaw
treatment should be removed by centrifugation prior to analyzing the
SR Microparticle reagent digitoxin concentration of that sample.
Conjugated digitoxin derivative microparticles, human-sourced Materials provided
material, and preservative. See Reagents working solutions section for reagents.
R1 is in positionB and SR is in positionC. Assay
Precautions and warnings For optimum performance of the assay follow the directions given in this
Pay attention to all precautions and warnings listed in document for the analyzer concerned. Refer to the appropriate operators
Section1/Introduction of this Method Manual. manual for analyzerspecific assay instructions.
Reagent handling Application for serum and plasma
COBASINTEGRA400plus analyzers COBAS INTEGRA 400 plus test definition
The cobasc pack has to be mixed daily before use. Place the cobasc
pack on the Cassette Mixer and mix for 1 minute. Measuring mode Absorbance
COBASINTEGRA800 analyzers Reaction mode R1-S-SR
The reagent is automatically mixed for 2minutes after cobasc pack
puncture and for half a minute during Begin of Day. Wavelength A 659 nm
Reading cycle blank/test 34/65
Unit ng/mL

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DIGIT
Digitoxin Therapeutic drug monitoring

Pipetting parameters Follow the applicable government regulations and local guidelines for
quality control.
Diluent (H2O)
Note
R1 105 L 6 L Controls should be assayed within 2hours after placing on-board the
Sample 4.5 L 6 L instrument.
SR 38 L 6 L Calculation
COBASINTEGRAanalyzers automatically calculate the analyte
Total volume 165.5 L concentration of each sample. For more details, please refer to Data
Analysis in the Online Help (COBASINTEGRA400plus/800 analyzers).
COBAS INTEGRA 800 test definition
Conversion factor: ng/mL 1.31 = nmol/L
Measuring mode Absorbance
Limitations - interference
Reaction mode R1-S-SR See the Analytical specificity section of this method sheet for information on
Wavelength A 659 nm substances tested for cross-reactivity in this assay. There is the possibility
that other substances and/or factors may interfere with the test and cause
Reading cycle blank/test 45/98 erroneous results (e.g., technical or procedural errors).
Unit ng/mL Specimens with assay values greater than the highest calibrator (65ng/mL,
85nmol/L) are flagged by the system. To obtain a specimen digitoxin
Pipetting parameters concentration value if this occurs, dilute the original specimen manually with
the PrecisetTDMII diluent (0ng/mL), reassay, and multiply the result by
Diluent (H2O) the appropriate dilution factor.
R1 105 L 6 L Certain samples have been observed to cause nonspecific microparticle
Sample 4.5 L 6 L aggregation in the COBASINTEGRA Digitoxin assay. As a precaution,
samples flagged as <3.0ng/mL (<3.9nmol/L) TEST RANGE on all
SR 38 L 6 L COBASINTEGRA analyzers should be re-assayed and the absorbance
unit change (A) obtained. Refer to the COBASINTEGRA systems User
Total volume 165.5 L Manual, Operation-Results for instructions regarding how to access raw
Calibration data. The observed A of the sample should be compared to the A of the
0ng/mL calibrator. Samples with absorbance unit changes(A) of 0.023
Calibrators Preciset TDM II above the 0ng/mL calibrator rate should be retested by another established
method before reporting digitoxin results.
Calibrators A-F
Uzara, potassium canrenoate and spironolactone were identified to cause
Calibration mode Logit/log 4 falsely elevated digitoxin values at concentrations of the recommended
Calibration replicate Duplicate recommended daily dose.
Hydrocortisone does not interfere at concentrations of the recommended
Deviation low/high <10%at7.5ng/mL(9.8nmol/L) daily dose, however, at higher doses, as administered in life-threatening
Calibration interval situations, hydrocortisone may cause elevated digitoxin values.
COBAS INTEGRA 400 plus Each cobasc pack, every 1week and The manufacturer of Digoxin Immune Fab (Antibody fragment therapy) has
stated that no immunoassay technique is suitable for quantitating digitoxin
analyzers as required following quality control in serum from patients undergoing this treatment.4
procedures As with many mouse monoclonal antibody-based immunoassays, the
COBAS INTEGRA 800 Each lot, every 12weeks and as COBASINTEGRA Digitoxin test may experience interference with samples
analyzers required following quality control containing human anti-mouse antibodies (HAMA). Samples suspected of
containing HAMA (e.g., from patients with history of mouse monoclonal
procedures antibody exposure) should be tested by an alternate method.
A calibration curve must be prepared using the Preciset TDMII calibrators. Serum/plasma
Calibrators must be placed from the highest concentration (F)first, to the
lowest (A)last, on the CAL/QC rack. This curve is retained in memory by Criterion: Recovery within 10% of initial value at a digitoxin concentration
the COBASINTEGRA systems and recalled for later use. of 12.3ng/mL (16.1nmol/L).
Traceability: The Preciset TDMII calibrators are prepared to contain known Icterus:5 No significant interference up to a bilirubin concentration of
quantities of digitoxin in normal human serum and are traceable to USP 325mol/L or 19mg/dL.
reference standards. Hemolysis:5 No significant interference up to a hemoglobin concentration of
Note 621mol/L or 1000mg/dL.
Calibrators should be assayed within 2hours after placing on-board the Lipemia:5 No significant interference up to a triglycerides concentration of
instrument. 1112mg/dL.
Total protein: No significant interference up to a total protein concentration
Quality control of 12g/dL.
Quality control Roche-TDM OnLine Digitoxin Specimens containing bilirubin, triglycerides, and/or hemoglobin at levels
Controls above those listed above should be diluted with the Preciset TDMII diluent
(0ng/mL), assayed, and the results multiplied by the appropriate dilution
Control interval 24hours recommended factor.
Control sequence User defined For diagnostic purposes, the results should always be assessed in
Control after calibration Recommended conjunction with the patients medical history, clinical examination and other
findings.
For quality control, use control materials as listed in the Order information ACTION REQUIRED
section. In addition, other suitable control material can be used. Special Wash Programming: The use of special wash steps is mandatory
The control intervals and limits should be adapted to each laboratorys when certain test combinations are run together on COBASINTEGRA
individual requirements. Values obtained should fall within the defined analyzers. Refer to the CLEAN Method Sheet for further instructions and for
limits. Each laboratory should establish corrective measures to be taken if the latest version of the Extra wash cycle list.
values fall outside the defined limits. Where required, special wash/carry-over evasion programming must
be implemented prior to reporting results with this test.

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DIGIT
Digitoxin Therapeutic drug monitoring

Limits and ranges Intermediate precision Mean SD CV

Measuring range ng/mL (nmol/L) ng/mL (nmol/L) %
565ng/mL (6.685.2nmol/L) (defined by the limit of detection and the Level 1 15.2 (19.8) 1.71 (2.24) 11.3
upper limit of linearity).
Lower limits of measurement Level 2 33.3 (43.3) 1.52 (1.99) 4.6
Limit of blank (LoB), limit of detection (LoD) and limit of Level 3 47.4 (62.1) 1.39 (1.82) 2.9
quantitation/functional sensitivity (LoQ) Method comparison
Limit of Blank =3ng/mL (3.9nmol/L) Digitoxin values for human serum samples obtained on a
COBASINTEGRA700 analyzer using the COBASINTEGRA Digitoxin
Limit of Detection =5ng/mL (6.6nmol/L) reagent(y) were compared with those determined using a commercially
Limit of Quantitation =6ng/mL (7.9nmol/L) available FPIA method(x).
The Limit of Blank and Limit of Detection were determined in accordance FPIA
with the CLSI (Clinical and Laboratory Standards Institute) EP17A
requirements. Number of samples 231
The Limit of Quantitation was determined using the result of functional Range of values min. 0.57ng/mL
sensitivity testing. max. 45.3ng/mL
The Limit of Blank is the 95th percentile value from n60 measurements of
analytefree samples over several independent series. The Limit of Blank Slope 0.935
corresponds to the concentration below which analytefree samples are Intercept 1.36ng/mL
found with a probability of 95%.
Correlation coefficient 0.968
The Limit of Detection is determined based on the Limit of Blank and the
standard deviation of low concentration samples. Analytical specificity
The Limit of Detection corresponds to the lowest analyte concentration The following cross-reactive substances were evaluated on the
which can be detected (value above the Limit of Blank with a probability of COBASINTEGRA systems in normal human serum spiked with digitoxin at
95%). 25.8ng/mL(33.8nmol/L). Each substance was tested at 10times the
The Limit of Quantitation is the lowest analyte concentration that can be highest concentration for its therapeutic or normal range, as per the
reproducibly measured with a betweenrun coefficient of variation of protocol described by NCCLS.11 The imprecision of the assay was taken
20%. It has been determined using low concentration digitoxin samples. into account when determining cross-reactivity. Cross-reactivity was
designated as not detectable (ND) if the obtained value was less than the
Note: For COBASINTEGRA analyzers, values between 3.05.0ng/mL sensitivity of the assay.
(3.96.6nmol/L) will not be flagged by the instrument.
Expected values 100(analytical result-analyte concentration)
Cross-reactivity (%) =
Accurate determination of a patients sample digitoxin concentration is concentration of interferent
encouraged due to the narrow therapeutic range of this drug. In addition,
the significant variability of patient response even under similar dosing Level tested Cross-reactivity
regimens often produces unpredictable levels of serum digitoxin Drug ng/mL %
concentrations.
Digoxin 25 ND
Extensive data are available which demonstrate a relationship between
serum digitoxin levels and therapeutic effectiveness.6 Therapeutic effects Digoxigenin 5 ND
are seen with concentrations between approximately 1030ng/mL Digoxigenin-mono-digitoxoside 25 13.4
(1339nmol/L). Serum digitoxin concentrations above 35ng/mL (46nmol/L)
are associated with symptoms of toxicity, while concentrations below Digoxigenin-bis-digitoxoside 5 ND
10ng/mL (13nmol/L) are generally not effective.6,7,8 However, analysis of Dihydrodigoxigenin 25 ND
serum concentrations alone is not efficient for optimization of digitoxin
therapy. Additional factors such as age, thyroid condition, electrolyte Digitoxigenin 25 309
balance, hepatic and renal functions, and other clinical symptoms must be
considered.9 Digitoxigenin-mono-digitoxoside 25 156
Each laboratory should investigate the transferability of the expected values Digitoxigenin-bis-digitoxoside 25 129
to its own patient population and if necessary determine its own reference Dihydrodigitoxigenin 25 12.2
ranges.
Ouabain 1000 0.4
Specific performance data
Representative performance data on the COBASINTEGRA analyzers are Testosterone 25 ND
given below. Results obtained in individual laboratories may differ. Prednisone 25 ND
Precision ND = Not Detectable
Precision was determined using controls in accordance with the NCCLS Any modification of the instrument as set forth in this labeling requires
EP5T210 requirements with repeatability (n=80) and intermediate validation by the laboratory.
precision (2aliquots per run, 2runs per day, 20days).The following results
were obtained on a COBASINTEGRA400 analyzer: References
1 Moe GK, Farah AE. In: Goodman LS, Gilman A, eds. The
Repeatability Mean SD CV Pharmacologist Basis of Therapeutics. New York, NY: MacMillan
ng/mL (nmol/L) ng/mL (nmol/L) % Company 1970.
Level 1 15.2 (19.8) 1.41 (1.85) 9.3 2 Jacobs DS, Kasten BL, DeMott WR, et al. eds. Laboratory Test
Handbook. Stow, Ohio: Lexi-Comp Inc 1990.
Level 2 33.3 (43.3) 0.93 (1.22) 2.8
3 Valdes R Jr, Jortani S, Gheorghiade M. Standards of laboratory
Level 3 47.4 (62.1) 0.88 (1.15) 1.9 practice: cardiac drug monitoring. Clin Chem 1998;44(5):1096-1109.
4 Digibind Product Information. Burroughs Wellcome Co. Research
Triangle Park, NC 1990.

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Digitoxin Therapeutic drug monitoring

5 Glick MR, Ryder KW, Jackson SA. Graphical Comparisons of

Interferences in Clinical Chemistry Instrumentation. Clin Chem
1986;32:470-475.
6 Smith TW. Pharmacokinetics, bioavailability and serum levels of
cardiac glycosides. J Am Coll Cardiol 1985;5:43A-50A.
7 Doherty JE. Digitalis glycosides. Pharmacokinetics and their clinical
implications. Ann Internal Med 1973;79:229-238.
8 Perrier D, Mayerson M, Marcus FI. Clinical pharmacokinetics of
digitoxin. Clin Pharmacokin 1977;2:292-311.
9 Physicians Desk Reference 48th Edition Montvale, NJ: Medical
Economics Data Production Inc 1994;1215-1216.
10 National Committee for Clinical Laboratory Standards. User Evaluation
of Precision Performance of Clinical Chemistry Devices; Tentative
Guideline. Villanova, PA.: NCCLS;1992;4(12). NCCLS Publication
EP5-T2.
11 National Committee for Clinical Laboratory Standards. Interference
Testing in Clinical Chemistry; Proposed Guideline. Villanova, PA.:
NCCLS; 1986;6(13). NCCLS Publication EP7-P.
A point (period/stop) is always used in this Method Sheet as the decimal
separator to mark the border between the integral and the fractional parts of
a decimal numeral. Separators for thousands are not used.
Symbols
Roche Diagnostics uses the following symbols and signs in addition to
those listed in the ISO 152231 standard.
Contents of kit
Volume after reconstitution or mixing

FOR US CUSTOMERS ONLY: LIMITED WARRANTY

Roche Diagnostics warrants that this product will meet the specifications
stated in the labeling when used in accordance with such labeling and will
be free from defects in material and workmanship until the expiration date
printed on the label. THIS LIMITED WARRANTY IS IN LIEU OF ANY
OTHER WARRANTY, EXPRESS OR IMPLIED, INCLUDING ANY IMPLIED
WARRANTY OF MERCHANTABILITY OR FITNESS FOR PARTICULAR
PURPOSE. IN NO EVENT SHALL ROCHE DIAGNOSTICS BE LIABLE
FOR INCIDENTAL, INDIRECT, SPECIAL OR CONSEQUENTIAL
DAMAGES.
COBAS, COBASC, COBASINTEGRA, PRECISET and ONLINETDM are trademarks of Roche.
All other product names and trademarks are the property of their respective owners.
Significant additions or changes are indicated by a change bar in the margin.
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