Caffrey AR, Borrelli EP. The art and science of drug titration.
Ther Adv Drug Saf 2021;
11:2042098620958910. [PMID:
33796256 PMCID:
PMC7967860 DOI:
10.1177/2042098620958910]
[Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023] Open
Abstract
A “one-size-fits-all” approach has been the standard for drug dosing, in
particular for agents with a wide therapeutic index. The scientific
principles of drug titration, most commonly used for medications with
a narrow therapeutic index, are to give the patient adequate and
effective treatment, at the lowest dose possible, with the aim of
minimizing unnecessary medication use and side effects. The art of
drug titration involves the interplay of scientific drug titration
principles with the clinical expertise of the healthcare provider, and
an individualized, patient-centered partnership between the provider
and the patient to review the delicate balance of perceived benefits
and risks from both perspectives. Drug titration may occur as up-,
down-, or cross-titration depending on whether the goal is to reach or
maintain a therapeutic outcome, decrease the risk of adverse effects,
or prevent withdrawal/discontinuation syndromes or recurrence of
disease. Drug titration introduces additional complexities surrounding
the conduct of clinical trials and real-world studies, confounding our
understanding of the true effect of medications. In clinical practice,
wide variations in titration schedules may exist due to a lack of
evidence and consensus on titration approaches that achieve an optimal
benefit-harm profile. Further, drug titration may be challenging for
patients to follow, resulting in suboptimal adherence and may require
increased healthcare-related visits and coordination of care amongst
providers. Despite the challenges associated with drug titration, it
is a personalized approach to drug dosing that blends science with
art, and with supportive real-world outcomes-based evidence, can be
effective for optimizing pharmacotherapeutic outcomes and improving
drug safety.
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