What approach should the prescriber take when determining drug treatment for a patient?

Individualize Drug Choice for the Specific Patient

The prescriber should individualize the drug choice for the specific patient 1, 2. This approach prioritizes patient-centered care by considering the patient's overall health context, functional status, life expectancy, personal preferences, and specific clinical characteristics when selecting medications 1.

Evidence-Based Rationale for Individualization

The most recent guidelines emphasize that treatment decisions must be tailored to each patient's unique circumstances rather than following rigid protocols 1. Collaborative decision-making with the patient based on side-effect and efficacy profiles should guide initial medication selection 1. This shared decision-making approach ensures that treatment aligns with the patient's values, preferences, and resources 1.

Key Factors Requiring Individualization

Patient-specific characteristics that must inform drug selection include:

• Age, body composition, organ function (hepatic and renal), and comorbidities that affect pharmacokinetics and pharmacodynamics 1, 3
• Concomitant medications, tobacco use, caffeine use, and adherence patterns that influence drug interactions and treatment success 1
• Previous treatment response, as prior positive response to a specific medication strongly predicts future response 4, 5
• Metabolic risk factors (obesity, diabetes risk, family history) that determine which agents to avoid 1, 2
• Patient goals and priorities, which may differ from outcomes measured in clinical trials—particularly in older adults who may prioritize quality of life and functional independence over life extension 1

Why Other Options Are Inadequate

Using the newest drug on the market is inappropriate because newer agents lack long-term safety data and may not offer advantages over established treatments 1. Cost and availability also limit access to newer medications, potentially reducing health equity 1.

Relying solely on clinical experience is insufficient for complex patients because it ignores the evidence base and may perpetuate outdated practices 1, 2. While experience informs clinical judgment, it must be integrated with current evidence rather than replacing it 2.

Always using evidence-based guidelines without individualization is problematic because guidelines are designed for populations, not individuals 1. The decision to treat and which drug to start should remain individualized, taking into account the amount of damage, level of disease severity, age, and other patient characteristics 1. Guidelines provide frameworks, but truly individualized drug dosage regimens cannot be developed without first setting a specific individualized target goal for each patient 5.

Practical Implementation Algorithm

When determining drug treatment, follow this structured approach:

1. Complete comprehensive psychiatric and medical evaluation to identify specific pharmacological targets versus symptoms requiring psychosocial intervention 2

2. Assess patient-specific factors: organ function, comorbidities, concomitant medications, previous treatment responses, metabolic risk, and patient preferences 1, 2

3. Engage in shared decision-making with the patient (and family when appropriate) to select medication based on individualized side-effect and efficacy profiles 1

4. Set specific individualized target goals (such as target serum concentrations or symptom reduction thresholds) rather than applying population-based therapeutic ranges 5

5. Develop treatment and monitoring plan that accounts for the patient's ability to adhere, access to care, and resources 1

6. Start with appropriate doses for the individual patient (considering age, weight, organ function) and titrate based on response and tolerability 2, 3

7. Monitor systematically using standardized tools and adjust based on individual response rather than protocol-driven timelines 2

Common Pitfalls to Avoid

Do not apply population-based therapeutic ranges rigidly—some patients respond at lower concentrations while others require higher levels 1, 5. Verify therapeutic drug levels and create patient-specific pharmacokinetic models when appropriate to optimize dosing 5.

Avoid assuming all patients within a diagnostic category require identical treatment—even patients with the same diagnosis are heterogeneous in illness severity, functional status, prognosis, and treatment options 1. Different choices may be appropriate for different patients, and the clinician must help each patient determine if the suggested course of action is clinically appropriate and consistent with their values and preferences 1.

Do not ignore patient preferences and goals—older adults may prioritize maintaining daily functional capacity and independence over outcomes measured in trials conducted in younger populations 1. Treatment goals should be established collaboratively, adapting care to the patient's goals, values, and resources 1.