Selecting a Medication From Within a Therapeutic Class of Psychotropic Medications
Choosing the right psychotropic medication within a therapeutic class can be complex, but Raj K. Kalapatapu, MD, PhD, an associate professor of psychiatry at UCSF, offers a practical framework to simplify the decision-making process. In this article, Dr Kalapatapu introduces the “P” categories—Prescription, Patient, and Provider—which guide clinicians through essential considerations like dosing, patient history, and provider expertise.
How Do I Know Which Medication to Select From Within a Therapeutic Class of Medications?
By applying the following structured approach, prescribers can make informed choices that align with both clinical guidelines and individual patient needs. Within a therapeutic class of psychotropic medications, deciding which specific medication to prescribe to a patient is a challenging task. Using “P” categories (Prescription, Patient, Provider), this PEARL gives examples of questions to ask oneself when deciding which medication to select from within a therapeutic class of medications.
10 Prescription Categories
- Prescribing Information: Is this specific medication FDA-indicated for the diagnosis being treated, or is it an off-label use? Any boxed warning? Have pharmacokinetics and pharmacodynamics been considered?
- Clinical Research: What is this medication’s evidence for efficacy and/or effectiveness for the diagnosis being treated? How will this medication impact the prognosis of the diagnosis?
- Treatment Goal: What is this medication’s goal? What outcome am I expecting? How mild or severe is the diagnosis? For how long is the patient estimated to take this medication?
- Dosage: How slowly or quickly can the dose be titrated? Does titration depend on the clinical setting?
- Dosing Frequency: How frequently should this medication be dosed? How easy or difficult is dosing?
- Form: Does this medication come in tablet, liquid, long-acting injectable, etc.?
- Interactions: Are there specific interactions with other medications, food, supplements, alcohol, etc.?
- Monitoring: Are laboratory or other studies recommended or required initially or continuously?
- Route: Will this medication be administered orally, intravenously, intramuscularly, or via another method?
- Side Effects: What side effects (beneficial and harmful) or safety concerns are associated with this medication?
5 Patient Categories
- History: Has the patient's age, weight, gender, allergies, comorbid medical history, substance use history, social history, medication adherence pattern, etc., been considered?
- Family: Does the patient have family members where this medication was, or was not, effective?
- Preference: Which medication, if any, does the patient prefer? Does the patient have any prior experience with this specific medication? If so, why or why not try this medication again?
- Cost: Can the patient afford this medication? Is this medication on the patient's insurance, hospital, and/or pharmacy formulary? Does the patient's insurance require prior authorization? Brand or generic?
- Setting: Is the patient in an emergency, outpatient, inpatient, jail, residential, etc., setting? Are they in the private or public sector?
5 Provider Categories
- Expertise: Do I have expertise with this medication? Have I previously prescribed this medication? If so, how frequently? Or, do I have zero prior experience with this medication?
- New vs. Continuation: Am I starting this medication brand new, or am I continuing this medication that was already prescribed by a previous clinical provider?
- Clinical: Is this medication generally acceptable by my professional society’s clinical practice guidelines, colleagues or specialist consultants in my clinical setting, and/or a consultant clinical pharmacist?
- Education: What or who has shaped my education about this medication? Continuing education seminar, society meeting, journal article, advertisement, pharmaceutical representative, pamphlet, supervisor, etc.?
- Bias: Am I compensated financially, or have I received gifts, from a specific pharmaceutical company? Was I given free samples of this medication? Any other source of bias or conflict of interest?
References
Denig P, Haaijer-Ruskamp FM, Zijsling DH. "How Physicians Choose Drugs". Soc Sci Med. 1988;27(12):1381-1386.
Nutescu EA, Park HY, Walton SM, et al. "Factors that Influence Prescribing Within a Therapeutic Drug Class". J Eval Clin Pract. 2005;11(4):357-365.
Hartjes MG, Richir MC, Cazaubon Y, et al. "Enhancing Therapeutic Reasoning: Key Insights and Recommendations for Education in Prescribing". BMC Med Educ. 2024;24(1):1360.
Raj K. Kalapatapu, MD, PhD, is an associate professor of psychiatry at the University of California San Francisco School of Medicine. He works clinically as an attending psychiatrist in Psychiatric Emergency Services at the Zuckerberg San Francisco General Hospital and Trauma Center, California.
Contact Information:
1001 Potrero Avenue, San Francisco, CA 94110
Phone: 628-206-8125
Fax: 628-206-5733
Email: Rajkumar.Kalapatapu@ucsf.edu
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