Common Lab Tests Guide

• The comments under each laboratory test and monitoring suggestions are not exhaustive. 
• This guide is intended to serve as a general overview of recommended laboratory tests for conditions and medications commonly encountered by pharmacists. It is NOT intended to guide treatment decisions or provide in-depth knowledge of lab tests. 
• Pharmacists are encouraged to refer to the references provided, the USask CPE Laboratory Tests for Medication Management Course, clinical practice guidelines, expert guidance, and other high-quality evidence-based resources for more information.

Urinalysis (basic)

Urinalysis¹ (basic)

• Evaluate for urinary tract infection (UTI).
• Monitor treatment of diabetes, kidney stones, UTI, hypertension, renal, or liver disease, and other conditions.
• Screen for liver and kidney diseases.

Test (SHA reference range in adults unless otherwise noted)	When to Monitor
Urine protein2,3,4,5  (Zero-trace) If protein is found during screening or routine analysis: perform 24-hour protein test to obtain specific levels of protein. Results showing 1+ protein or greater may require further investigation with protein/creatinine ratio.	Adult patients without risk factors for kidney disease: annual screening >60yrs. Adults with risk factors for kidney disease (such as diabetes or hypertension ): annual screening along with albumin creatinine ratio (ACR). Pregnancy: detect preeclampsia. Assess UTI. Monitor effects of medications that may cause kidney damage.
pH1,6  (4.6 – 8.0)	Identify and manage UTI. Assess and manage kidney stone formation.
Blood and hemoglobin1,6  (negative) Further investigation, including urine microscopy, is required if positive.	Patients passing blood in the urine. Symptoms of bladder/lower UTI. Patients with renal failure. Possible kidney stones/crystals. Trauma. Patients with rash and joint pain.
Glucose and Ketones5  (none) High levels of ketones require urgent referral for treatment. Glucose in the urine should be further evaluated. Note that persons taking SGLT2 inhibitors will test positive for glucose.	Patients at risk of ketoacidosis due to : cyclical vomiting, extreme exercise, extremely low carbohydrate diet, malnutrition, diabetes.  Patients with Type 1 and Type 2 Diabetes : check urine ketones: when blood glucose is >15 mmol/L for a prolonged period, during illness with nausea and vomiting, acute infection, traumatic injury, periods of stress, pregnancy. Patients with symptoms  of early ketosis: excessive thirst and urination; vomiting +/- abdominal pain; fruity breath
Nitrites6,7,8,9  (negative) Leukocyte Esterase  (negative to trace)	Diagnosis of UTI in patients who are symptomatic (both would usually be positive).   Males with suspected UTI. Not usually necessary in patients with symptoms of UTI who have had a UTI before. Note that a negative result in this scenario would not rule out infection and management would not change. Asymptomatic bacteriuria should only be treated if the patient is pregnant, immunocompromised and at risk of asymptomatic septicemia, or prior to certain urological procedures.
Urine Albumin Creatinine Ratio (ACR)	Refer to Renal Function Section

Electrolytes

Electrolytes^11,12

• Assess health status, clinical condition, disease progression.
• Investigate conditions that cause electrolyte imbalances.
• Evaluate efficacy of treatment of electrolyte imbalance.
• Determine if a medication is disrupting electrolyte balance.  

Test (SHA reference range in adults unless otherwise noted)	When to Monitor
Sodium13,14 (135 - 146 mmol/L ) Identify the possible cause of hyponatremia and assess for further evaluation or treatment. Refer patients with concerning symptoms: nausea and vomiting; irritability; headache; altered consciousness; seizures.	Electrolytes should be measured 10-14 days after initiating or increasing the dose of a diuretic. When performing medication reviews for patients taking medications or with conditions known to cause sodium abnormalities, watch for trends in sodium values.
Potassium12,15,16 (3.5 - 5.1 mmol/L) Consider the possibility of pseudohyperkalemia. Hypomagnesemia and hypokalemia coexist; correct  hypomagnesemia first. Levels >6 mmol/L should always be managed.	Patients taking medications  that could cause hyperkalemia: measure 3 and 7 days after starting or changing dose, at 4 weeks, then every 6 months once stable (measure serum creatinine [SCr] as well). Patients taking medications that affect potassium. Evaluate renal function; persistent nausea/vomiting. Patients with ischemic heart disease. Patients taking digoxin.
Chloride12,17 (100 – 110 mmol/L)	Interpret with sodium to evaluate fluid balance. Interpret with carbon dioxide (CO2) to evaluate acid-base balance.
Magnesium12,18,19,20 (0.70 – 1.10 mmol/L) Hypomagnesemia often coexists with hypokalemia or hypocalcemia. Correct hypomagnesemia first.	Patients with signs/symptoms of hyper- or hypomagnesemia and are taking medications known to affect magnesium levels. Monitor the effectiveness of magnesium and/or calcium supplements. Patients taking medications known to affect magnesium levels. Patients with kidney disease or uncontrolled diabetes, to ensure the patient is not excreting or retaining excessive amounts of magnesium (along with kidney function tests such as BUN and creatinine).
Calcium12,21,22 (2.10 - 2.55 mmol/L) Calculate corrected calcium if the lab does not measure or calculate ionized calcium. Total calcium is usually a good reflection of calcium status in otherwise healthy  patients. Interpreted with phosphate levels. Refer any noted abnormalities for further evaluation and treatment.	Evaluate efficacy of treatment of hypo- or hypercalcemia. Patients who are taking medications that affect calcium levels (such as denosumab, diuretics).
Phosphate12,23,24 (0.87 – 1.45 mmol/L) Interpreted with calcium  levels.	Patients with conditions that affect phosphate (kidney disease, hypoparathyroidism, hypothyroidism, diabetes).  Patients taking medications that affect phosphate (e.g., acetazolamide, calcium carbonate, bisphosphonate, certain laxatives, diuretics).

Renal Function

Renal Function

• Identify and classify kidney disease (in addition to Urine Albumin/Creatinine as described above).
• Monitor effects of medications with nephrotoxic potential.
• Ensure appropriate dosing and use of medications cleared by the kidneys.

Test (SHA reference range in adults unless otherwise noted)	When to Monitor
Serum creatinine (SCr)10 (Females: 45 – 90 µmol/L) (Males: 60 – 104 µmol/L) In patients taking an ACEI or ARB, consider an alternate agent if SCr increases >30% from baseline.	Baseline prior to starting drugs known to affect renal function. Measure 5-10 days after starting or increasing dose of drug known to affect renal function. Patients with known or risk factors for renal dysfunction. Monitor for nephrotoxicity. Use to calculate creatinine clearance to guide dosing of medications cleared by the kidneys.
Urea/Blood Urea Nitrogen (BUN)25,26 (3.7 – 7.0 mmol/L)	Assess kidney function (along with SCr and other tests). Monitor side effects  of medications that can affect the kidneys.
Creatinine Clearance (CrCl) (estimate)10,27 Decline in GFR is seen before increase in SCr. Calculations are not accurate in patients with unstable renal function. Stage 1 (normal or early kidney damage or increased GFR): >90 mL/min Stage 2 (Mild CKD): 60 – 89 mL/min Stage 3 (Moderate CKD): 30 – 59 mL/min Stage 4 (Severe CKD): 15 – 29 mL/min Stage 5 (Kidney failure): <15 mL/min	Guide dosing of medications cleared by the kidneys. Determine if a medication is safe to use given the patient’s current renal function.
Urine Albumin/Creatinine Ratio (ACR) 10  ≥ 30 g/mol for longer than 3 months is an indicator of kidney damage.	Used with estimated glomerular filtration rate (eGFR) for staging of chronic kidney disease.

Liver Function

Liver Function

• Evaluate liver function/ability to synthesize proteins.
• Assess liver damage/injury in the context of symptoms suggestive of liver disease.

Test (SHA reference range in adults unless otherwise noted)	When to Monitor
Albumin28,29,30 (35-52 g/L)	Patients at risk of albumin abnormalities (malnutrition, liver disease, kidney disease, chronic inflammatory conditions). Patients on medications affected by albumin levels. Used to calculate Child-Pugh score to guide dosing of medications cleared by the liver.
International Normalized Ratio (INR)30,31 (0.8-1.2)  Therapeutic range is either 2-3 or 2.5-3.5	Patients using warfarin. Used to calculate Child-Pugh score to guide dosing of medications cleared by the liver.
Aspartate aminotransferase (AST)29,32 (Females: 10-35 U/L) (Males: 10-40 U/L)	Assess with ALT to evaluate liver injury. Patients using medications known to cause liver injury.
Alanine aminotransferase (ALT)29,33 (Females: 5-45 U/L) (Males: 8-60 U/L)	Assessed with AST to evaluate liver injury. Patients using medications known to cause liver injury. 3 months after starting statin therapy.48
Alkaline Phosphatase (ALP)29,34 (30-110 U/L)	Assessed with GGT to evaluate cholestatic disease.
Gamma-glutamyl transferase (GGT)29,35 (Females: 10-35 U/L) (Males: 10-50 U/L)	Assessed with ALP to evaluate cholestatic disease.
Bilirubin (Total)30,36,37,38 (2-22 µmol/L)	Used to calculate Child-Pugh score to guide dosing of mediations cleared by the liver.  Assess with ALT, AST to evaluate liver injury.
Bilirubin (Direct)37,38 (0-5 µmol/L)	Assess with ALP and GGT to evaluate cholestatic disease.
Lactate Dehydrogenase (LDH)39 (120-230 U/L)	Assess presence of liver disease (along with other liver injury markers such as ALT).
Total Protein40 (60-80 g/L) Noted abnormalities should be referred for further evaluation and management.	Routine health screening. Evaluate nutrition status. Monitor kidney and liver function.

Endocrine

Endocrine

Test (SHA reference range in adults unless otherwise noted)	When to Monitor
Blood Glucose – random5 (3.6-10.0 mmol/L) ≥ 11.1 mmol/L  is diagnostic for diabetes; refer  to primary health care provider. (Diabetes Canada)	Patients using medications known to affect glucose levels. Patients at risk for diabetes.
Blood Glucose – fasting5,41 (3.6-6.0 mmol/L) ≥ 7.0 mmol/L is diagnostic for diabetes; refer to primary health care provider. Target range for most people with diabetes: 4.0-7.0 mmol/L (Diabetes Canada)	Monitor glycemic control in persons with diabetes. Patients at risk for diabetes.
Hemoglobin A1C,41 (HgA1C or A1C) (4.6-6.5%)  Target for persons with diabetes is individualized:  ≤ 6.5 to ≤ 8.5. (Diabetes Canada)	Patients at risk for diabetes. Monitor glycemic control in persons with diabetes: Every 3 months if not controlled. Every 6 months if controlled.
Thyroid Stimulating Hormone (TSH)42,43,4,45,46,47 Non-pregnant: 0.27 -4.20 mIU/L Pregnant people:       1st trimester: <2.5 mIU/L       2nd and 3rd trimester: <3.0 mIU/L        (RxFiles) If patient is out of range: assess adherence and drug interactions. Note that if TSH is out of range, Free T4 and Free T3 will be reported from the same sample, reducing the need for further testing. Free T3: 3.90-6.70 pmol/L Free T4: 11.1-22.0 pmol/L	Screening asymptomatic, non-pregnant people is not recommended. Note that TSH levels can vary up to 50% between tests.  Patients taking medication for hypothyroidism: baseline then 6-8 weeks after starting or changing levothyroxine dose or brand, then annually once euthyroid. Pregnant and not treated for hypothyroidism: screen if symptomatic or have risk factors for hypothyroidism (e.g., Type 1 Diabetes, age >30 years, ≥ 2 pregnancies, history of miscarriage, taking medications that affect thyroid hormone levels ).  Pregnant and taking medication for hypothyroidism: test once pregnancy is confirmed, then every 4 weeks during the first half of the pregnancy, at least once between 26- and 32-weeks’ gestation, and 4-6 weeks postpartum.

Lipids

Lipids^48,49,50,51

• Determine cardiovascular risk.
• Assess whether hyperlipidemia therapy should be initiated or changed.
• Assess impact of medications and lifestyle changes.
• Repeat 4 weeks after initiating or changing dose of statin. 

Test (SHA reference range in adults unless otherwise noted)	When to Monitor
Total cholesterol (3.20 – 5.20 mmol/L) Used to calculate Framingham Risk Score.	Routine health check in patients with cardiovascular risk factors.  Use of statin: baseline and 4 weeks after starting or changing dose. If TG <1.5 mmol/L, monitor treatment using LDL-C, non-HDL-C or ApoB (fasting or non-fasting) If TG ≥1.5 mmol/L, monitor treatment using non-HDL-C or ApoB (fasting or non-fasting) Refer if TG ≥ 10 mmol/L
High-density Lipoprotein Cholesterol (HDL-C)   (1.0-1.6 mmol/L) Males: ≥ 1.0 mmol/L preferred Females: ≥ 1.3 mmol/L preferred  Used to calculate Framingham Risk Score.
Triglycerides (TG) (0.45 - 1.70 mmol/L) Fasting state preferred, especially if  TG > 4.5 mmol/L
Low-density Lipoprotein Cholesterol (LDL-C)   (1.60-3.50 mmol/L) Calculated using TG Initiate statin therapy if ≥ 3.5 mmol/L and low or intermediate risk. Consider add-on therapy if ≥ 2.5. mmol/L  or < 50% reduction in LDL (intermediate or high risk)
HDL/Total ratio Ratio >6 associated with increased risk of CVD
Non-HDL-C Calculated from total cholesterol and HDL-C levels Initiate treatment if ≥ 4.2 mmol/L and low or intermediate risk. Consider add-on therapy if ≥ 3.2 mmol/L and intermediate or high risk.	Patients with TG >1.5 mmol/L (instead of LDL-C for screening)
Apolipoprotein B (ApoB)   Target is ≤ 0.8 g/L Initiate statin treatment if ≥ 1.05 g/L and low or intermediate risk. Consider add-on therapy if ≥ 0.85 g/L and high risk.	Patients with TG >1.5mmol/L (instead of LDL-C for screening)

Creatine Kinase (CK)

Creatine Kinase (CK)

Test (SHA reference range in adults unless otherwise noted)	When to Monitor
Creatine Kinase (CK)  (30-300 U/L) Refer to primary care provider if CK > 10 times ULN.	Baseline in patients starting statin therapy (along with ALT and SCr). Patient develops muscle pain while taking a statin.

Hematology

Hematology

• Assess health status, clinical conditions, and disease progression.
• Identify effects of medications on RBC or WBC balance; Vitamin B12 levels; or iron indices.
• Evaluate drug treatment for anemia or other hematologic disorders.

Test (SHA reference range in adults unless otherwise noted)	When to Monitor
Red Blood Cell Count (RBC)52,53 (Females: 3.20-5.40 x 1012/L) (Males: 4.60-6.20 x 1012/L)	Assess anemia or conditions that affect red blood cells.
Hemoglobin (Hgb)53,54 (Females: 110-160 g/L) (Males: 135-180 g/L)	Assess patients at risk of anemia (renal disease). Patients taking medications  that can increase risk of deficiency (of iron, folate, or vitamin B12) or bleeding. Evaluate efficacy of treatment of anemia.
Hematocrit (Hct)53,54 (Females: 0.330-0.480 %) (Males: 0.405-0.546  %)
Mean Corpuscular Volume (MCV)53,54 (Normocytic: 79-99 fL)
Mean Corpuscular Hemoglobin (MCH)53,54 (27-32 pg)
Mean Corpuscular Hemoglobin Concentration (MCHC)54,54 (320-360 g/L)
Vitamin B1254 (138-781 pmol/L)	Patients treated for macrocytic anemia or B12 deficiency. Patients using medications known to lower B12 levels. Folate levels should be assessed as well (note that pharmacists are not able to order folate levels).
Platelets (Plt)55 (150-400 x 109/L)	Patients using medications that can increase risk of bleeding (steroids, anticoagulants, SSRIs, antiplatelets).
White Blood Cell Count (WBC)56,57 (4 - 11 x 109/L)	Patients using medications that can affect WBC/neutrophils. Evaluate response to antibiotic treatment.
Neutrophils (Neut)57,58 (1.5-7.5 x 109/L) Neutropenic: <1.5 5 x 109/L Agranulocytosis: <0.1  5 x 109/L Refer patients with neutropenia for urgent care.	Patients using medications that lower neutrophils (e.g., chemotherapy; clozapine).
Eosinophils (Eos)59 (0.0-0.6 x 109/L)	Patients using medications that can cause eosinophilia. Efficacy of medications used to lower eosinophils.
Basophils (Bas) and Monocytes (Mono)56 Refer patients who are out of range for further evaluation.	Not specifically ordered by pharmacists – part of WBC and Differential
Lymphocytes (Lymph)60 (1.5-4.0 x 109/L) Extremely high levels, rapid increases, or the presence of red flag symptoms warrants referral for further evaluation and management (unexpected weight loss, anorexia, night sweats, swollen lymph nodes/spleen).

Iron Indices

Iron Indices^53,61,62

Test (SHA reference range in adults unless otherwise noted)	When to Monitor
Ferritin (20-200 µg/L) (Royal College of Physicians and Surgeons of Canada)  Level is impacted by  inflammation, infection, pregnancy, or obesity; interpretation in the appropriate context is important. Medications that may impact ferritin levels include iron, oral contraceptives, ethanol (increase), erythropoietin, methimazole (decrease).	Assess patients at risk of iron deficiency. Assess patients at risk of bleeding. Patients treated for iron deficiency anemia.
Iron (Females: 10-29 µmol/L) (Males: 13-33 µmol/L)
Total Iron Binding Capacity (TIBC) (45-72 µmol/L)
Transferrin (2.0-3.6 g/L) (Medical Council of Canada)  Levels are affected by inflammatory conditions.
Iron Saturation/Transferrin Saturation (Females: 14-51%) (Males: 25-56 %)

Serum Drug Levels

Serum Drug Levels^63,64,65

• Medication initiated or dose changed.
• Interacting medication starts, stops or dose is changed.
• Therapeutic effect not achieved.
• Patient experiences apparent medication toxicity.
• Change in clinical situation (e.g., acute illness).

Test (SHA reference range in adults unless otherwise noted)	When to Monitor
Digoxin65,66 (1.1-2.2 nmol/L) (Heart Failure: 0.6-1.3 nmol/L)61 Sample at least 6-8 hours after last dose. Sample anytime if toxicity is suspected.	Patients  with questionable adherence. Other patients who may benefit from close monitoring include: the elderly, patients with poor kidney function or low body weight, patients requiring higher doses for heart rate control. Evaluate clinical deterioration (after prior good response). Increase in digoxin dose. Increase in diuretic dose. Stopping/starting interacting medication (amiodarone, quinidine, verapamil, etc.) Changing kidney function.
Lithium65,67 (0.60-1.20 mmol/L) Acute therapy: 0.8-1.2 mmol/L Maintenance: 0.6-0.8 mmol/L Maintenance (elderly): 0.4-0.6 mmol/L Sample 12 hours after last dose.  Sample anytime if suspected toxicity.	At treatment initiation every 1-2 weeks until desired therapeutic level is reached, then every 2-3 months for 6 months. Dose change. Addition/discontinuation/change in interacting medication. Dehydration (infection, excessive sweating, diarrhea).
Phenobarbital and primidone 65 Phenobarbital: 65.0-170.0 µmol/L Primidone: 23-55 µmol/L Primidone is metabolized  in part to phenobarbital. Primidone reaches steady state in about 2 days: phenobarbital in 10-25 days in adults. Sample just before next dose for routine monitoring; anytime if toxicity is suspected.	Suspected adverse events/toxicity related to drug level. Persistent seizures. Establish individual target level in patient who is well-controlled. Dose adjustments during pregnancy. Addition/elimination of interacting drug. Suspected non-adherence. Acute illness.
Phenytoin65,68 (40.0-80.0 µmol/L) Assess 7-10 days after initiation or dose change or when another drug is added or stopped. Use corrected phenytoin level in low albumin or renal function. Sample just before next dose for routine monitoring or if inadequate dose suspected. Sample anytime if suspected toxicity.
Valproic acid65,69,70 (350-700 µmol/L   )(therapeutic level in patients with epilepsy) There is not a good correlation between dose, serum levels, and therapeutic effect. Some patients with epilepsy may be controlled with levels outside of the above range. In patients using valproic acid for behavioral or psychiatric applications, levels are used to monitor for toxicity (rather than to achieve therapeutic level). Levels will be higher if albumin levels are reduced. Sample anytime if suspected toxicity.  Sample just before next dose for periodic monitoring.

References

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 Updated November 2023