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Points for Consideration by the Physician

• When you prescribe narrow-therapeutic-window drugs that require periodic blood level, be certain that blood sampling is done after the drug has reached its steady state (usually five half-lives). Understand which level is preferable to measure: "peak" level (as for theophylline), "trough" level (as for digoxin), and "peak and trough" for aminoglycosides (such as tobramycin). Many clinical pharmacists (the author included) will willingly calculate the best dose and interval for you, and make a consultative recommendation.
• Give due consideration to the patient's prior experience with other drugs similar to the one you are considering and prescribe accordingly. Prescribing a second drug from the same drug class from which a patient already had an allergic or adverse drug effect that. required discontinuation of therapy or provided no therapeutic benefit is not prudent.
• Remember individual patient factors such as age, education, and cultural factors (including genetic effects on medication elimination). • Think about the desired extent of effect (systemic or local).
• If drug treatment fails after a reasonable trial with good adherence, change to a drug of another chemical class, or consider combination therapy with two medicines with different mechanisms of action. For example: if viral load decreases for a time, then increases in an AIDS patient, you MUST change treatment.
• Select the drugs you prescribe critically, utilizing independent, objective reviews of available information. The "most frequently prescribed" drug is not necessarily the best drug within its class. Slick, glossy detail pieces should always be confirmed by primary literature.
• Even "drugs of choice" in objective reviews can be poor choices when you consider the characteristics of individual patients. A renally compromised patient may better tolerate an "alternate drug" with dual elimination (hepatic and renal) than a "drug of choice" that is limited to renal elimination.
• Remember the pharmacokinetic and pharmacodynamic changes that occur in those over 65 can lead to accumulation and excessive responses to "normal" doses and dosing intervals.
• Be objective and discerning as you review the claims made for a newly released drug within a sizable class of drugs already available. Only 20 percent of newly approved drugs each year are classified by FDA as truly innovative or more advantageous than similar drugs in current use. The remaining 80 percent are largely "me too" drugs with a limited history of use and a potential for "surprises" after a period of general use. It is best to select drugs with established records showing them to be the best in their class.