The authors propose a definition for rational multiple medication use (MMU). They then discuss how levels of diagnostic sophistication, ranging from symptomatic to syndromic to pathophysiologic to pathoetiologic, affect the ability to use multiple medications rationally. Based on this concept of diagnostic sophistication, MMU can be conceptualized dimensionally. Thus, MMU ranges from highly evolved and substantially evidence-validated approaches based on an understanding of the pathophysiological and pathoetiological nature of a disease (e.g., anti-retroviral treatment for HIV, multi-modal treatment of various malignancies), to those based on an understanding of the pathophysiology of an illness (e.g., various treatment combinations used to treat Parkinson’s disease), to less evolved or less evidence-based medication combinations based on a syndromic diagnosis (e.g., such as are often used to treat bipolar disorder). By better understanding the principles involved in rational MMU, clinicians can optimize the treatment they provide their patients. (Journal of Psychiatric Practice 2013;19:54–61).
SHELDON H. PRESKORN, MD, is Professor, Department of Psychiatry, University of Kansas School of Medicine-Wichita, and Chief Science Officer and Medical Direc tor, Kansas University- Wichita Clinical Trials Unit (KU-W CTU), Wichita, Kansas. He has more than 35 years of drug development research experience at all levels (i.e., preclinical through Phase IV) and has been a principal investigator on over 350 clinical trials—funded by industry, the federal government, or private foundations—including trials of every antidepressant and antipsychotic medication marketed in the United States over a period of 25 years. Dr. Preskorn maintains a website at http://www.preskorn.com where readers can access previous columns and other publications. AHSAN Y. KHAN, MD, is Professor, Department of Psychiatry & Behavioral Sciences, University of Oklahoma Health Sciences Center, Oklahoma City. Oklahoma
Disclosure statement: Over his career, Dr. Preskorn has worked with over 100 pharmaceutical companies in the United States and throughout the world. Over the past year, Dr. Preskorn has received grants/research support from or has served as a consultant, on the advisory board, or on the speakers bureau for the following: Abbott, Biovail, Boehringer-Ingelheim, Bristol-Myers Squibb, Cyberonics, Dey Pharma, Eisai, Johnson & Johnson, Lundbeck, Merck, National Institute of Mental Health, Naurex, Orexigen, Pierre Fabre, Pfizer, Stanley Medical Research Institute, Sunovion, and the U.S. Food and Drug Administration. Dr. Khan reports no disclosures.