One more thing on micro-titration that took me far too long to see: the two figures people quote are not measuring the same quantity. Once you notice that, the apparent contradiction disappears.
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Practice · Dosing & titration · continued
Micro-titration: a disputed topic, argued properly posts 91–111
This is a continuation of a long topic, addressed by post number rather than by page. Start at post 1 · go to the accepted answer.
a.almeida, post #50: I have no financial interest in anything named in this thread and I want to say so before I comment on micro-titration, because it is the sort of subject where it matters. Go to post
The arithmetic in post #90 is right; the assumption feeding it is the part to check.
Concentration and dose get conflated constantly in this subcategory. Changing how much diluent you add changes the volume you draw and changes nothing about the dose.
Take it as a starting point and not as a specification.
Helpful, and short, which on this subject is harder than long.
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Reaching a dose and staying there for a year: the question of whether a stable dose remains effective over years is mostly answered by the withdrawal trials and by real-world reports. The dose does not seem to stop working, but the longest trials are not indefinitely long.
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an.zamora, post #63: The failure mode on micro-titration is boring rather than dramatic. It is almost always the step everyone assumes was done correctly because it is too simple to get wrong. Go to post
Since micro-titration keeps coming up, it should probably be a maintained page rather than a recurring thread. I am happy to draft it if someone with more direct experience will review it.
methods_draft, post #85: Micro-titration: the concept of increments smaller than the labelled steps. It has no evidence base from trials but is described by some people. The downside is that very small increments are hard to measure accurately with a syringe. Go to post
Concentration and dose get conflated constantly in this subcategory. Changing how much diluent you add changes the volume you draw and changes nothing about the dose.
Post #98 is right about the mechanism and I think understates the practical bit.
The most useful reply I ever got about micro-titration was a request to state my units. It sounds like pedantry and it has saved me twice.
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j.falk, post #53: Holding a dose indefinitely: the trials did not study indefinite holding at a non-maximum dose. The trials escalated to a target and then held that. What happens if you stay at an intermediate dose for years is not formally studied and extrapolation is the best available reasoning. Go to post
Counterpoint on micro-titration, offered without confidence: the same observation is consistent with a much duller explanation, and nobody has ruled the dull one out.
s.leclerc, post #74: Everything in post #70 holds. The case it does not cover is the one I have. Concentration and dose get conflated constantly in this subcategory. Changing how much diluent you add changes the volume you draw and changes nothing about the dose. I would be glad to be shown a cleaner way of putting this. Go to post
Adding the measurement that post #100 says would settle it.
Splitting a weekly dose in two: the pharmacokinetic argument against is that you want the benefit of long half-life, which gives a slowly changing plasma level from a weekly dosing schedule. Splitting it flattens the curve further but loses the convenience of once-weekly dosing. The trade-off is convenience versus a slightly flatter concentration curve.
Not a conclusion. A place to stand while looking for one.
On micro-titration: the maintained page in the documentation commons covers the general case with citations and a review date, which is more reliable than any reply here including this one.
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SHermansen, post #87: Concentration and dose get conflated constantly in this subcategory. Changing how much diluent you add changes the volume you draw and changes nothing about the dose. That is what the documentation says. What happens in practice is usually close. Go to post
A titration plan written down in advance is easier to stick to and easier to abandon deliberately. An improvised one becomes a series of decisions made on the worst day of each week.
Two people can read the same figure differently here and both be reasonable.
s.dziedzic, post #7: The starting dose in most of these programmes is a tolerance step and produces little effect by design. Judging the compound at the starting dose is judging the wrong thing. Go to post
Answering the micro-titration question as asked, then the question I think is meant. As asked: yes, with the qualification below. As meant: it depends on how the first measurement was taken.
My experience of micro-titration contradicts the reply above. I am posting it as a data point rather than as a refutation, because one person's experience is exactly that.
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Practical note on micro-titration: write down what you expect before you look. The number of times I have found what I went looking for is higher than chance would allow.
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c.ostergaard, post #18: Where the micro-titration reasoning breaks down for me is the step from the group result to the individual case. That step is almost never argued for. Go to post
Micro-titration is one of those subjects where the general answer and the answer for a specific case diverge, and the thread will go in circles until someone says which one is being asked for.
e.mensa, post #10: Concentration and dose get conflated constantly in this subcategory. Changing how much diluent you add changes the volume you draw and changes nothing about the dose. I looked this up rather than remembered it, which is the right order. Go to post
Where I part company with post #109, and it is a narrow parting.
Nothing here is medical advice, and a titration question is one of the few where a prescriber can genuinely answer in a minute what a thread will take a week to circle.
Anyone with a larger sample, please post it.
This topic was referenced in
- Follow-up: Where the four-week escalation interval comes from, and what it is notPractice › Dosing & titration · 147 replies
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