STANDARDISED DOSING VS PERSONALISED DOSING

Victor Okunola, operations and quality assurance pharmacist at Specialist Pharmacy, looks at the pros and cons of a personalised approach to aesthetic medication

Personalised approaches to medicines have been gaining traction and awareness over recent years, transforming healthcare as we currently know it.1

Too often we hear accounts of dissatisfaction and regret from patients following cosmetic procedures or treatments, and studies have shown that the most common reasons for discontent across all treatments assessed are ineffectiveness and complications.2–5 Our aesthetic goals and what we consider to be an ideal treatment experience are personal, therefore treatments that aim to assist individuals in achieving said goals should also be personalised to this end.4,6 In essence, personalisation aims to improve the outcomes of treatments while concomitantly reducing the occurrence and severity of adverse events by considering the individual and adjusting treatment regimens to meet their specific needs.7,8 For this to be effective, an individual must be thoroughly considered, and gaining an understanding of unique factors that may influence therapy such as medical and family history, lifestyle, and socioeconomic background is paramount to getting a full picture of who is being treated and what they need.9 Unfortunately, the most common medical practices and treatments contrast this and generally adopt a one-size fits all philosophy for the majority of patients.7,8 Standardised treatments have plenty of advantages, but licensing and guidelines for the dosing of medicines can often be restrictive in nature, and though it is not the sole driver, the widespread use of a standardised treatment regimen is largely due in part to low treatment costs, as more cost-effective treatment plans can be more easily recommended as guidelines for large-scale use in healthcare services such as the NHS.9–12 Such factors that result in the endorsement of therapy are critical when a practitioner or a patient is considering treatment options.

The goal of an aesthetic treatment should be to achieve patient satisfaction with minimal complications.2,3,5 One advantage of standardised dosing is that there is extensive safety data from clinical trials that reports adverse events and their occurrence, therefore allowing healthcare providers to make an informed decision on the risk-benefit of a treatment for their patients.10,12  This data also gives practitioners reassurance when treating patients, as thousands of people have used the medication in the same way previously. Clinical trials must hence be highly controlled to limit the influence of variables on the results; however, this means it is not feasible to test the use of multiple medications in varying doses on a large pool of people.13 Therefore, when personalising therapy or even when using standardised therapies in combination, professionals must rely more on their interpretation of researched, theoretical, and anecdotal evidence, using their professional judgement to determine the safety and efficacy of said treatments. To become qualified as a healthcare professional, one must train studiously for years, which may incline them to be conservative in their treatment styles in efforts to ensure they do not make mistakes that could compromise their qualification.14 It could be suggested that, as there is more responsibility on the practitioner when personalising medication, they must be confident in the efficacy of the treatments as opposed to following set guidelines. Frequent follow-ups and consultations are key to ensuring the minimisation of side effects while on personalised therapy, as it allows for more dynamic management of the patient. This is especially noticeable when micro-adjustments are made to the dosing of medicines which may not otherwise be possible using licensed formulations. However, this contributes to the cost of personalised treatments generally being more expensive than standardised medicine, as preparations can be made bespoke for patients, and this can act as a deterrent.

Rosacea and acne treatments are good examples of a condition where there are a variety of drug classes (retinoids, antibiotics, dicarboxylic acids etc) available with different actions that can work in synergy to provide therapy.15–17 The causes for one individual’s acne can be different to another’s, yet they may present with similar symptoms. Ideally, treatment should be targeted to different sites of action.15,17 In the UK, acne patients are recommended to be treated first with a single medication such as adapalene, despite it being well documented that monotherapy is rarely effective.16,18 However, using a multitude of dermatological preparations will often result in poor adherence, as it is undesirable to use numerous products at various times throughout the day.5–18 Additionally, the issue of compatibility also arises when using multiple products. For example, a skincare routine that consists of serums, creams, gels and sunscreen, and the ingredients that hold each product together can clash, making for an unstable result, which can diminish the intended effects of the products.19,20 Combining multiple medical and cosmeceutical ingredients into a single, stable preparation solves the issue of compatibility and adherence, thus improving the overall treatment experience for the patient; as instead of using and having to purchase multiple items, only one needs to be accounted for. In the UK, compounding pharmacies such as Specialist Pharmacy can fulfil such requests and prepare bespoke formulations on a case-by-case basis for each individual patient. The clinical decision over the ingredients that go into such a tailor-made preparation only comes after the patient has been assessed by a skilled practitioner, followed by subsequent check-ups to ensure patient safety and treatment efficacy.9,12,18 This enables healthcare providers to customise a treatment regimen based on an individual’s response to treatment even after it has commenced, either increasing dosages and/or adding ingredients when ineffective; or decreasing dosages and/or removing ingredients in the event of side effects. Personalising medications in this manner could mean that patients are better managed initially, and therefore are prevented from stepping up treatment to more intense therapies where adverse events are potentially more severe. There are also more choices available to patients should they wish to amend things such as a cream base, for example, if they were to prefer a more or a less moisturising cream that is better suited to their drier or oilier skin type.

Consumer-directed health care is vital in providing a holistic, effective service and acknowledges that the patient is ultimately the one affected by treatment once commenced, therefore should be central to decisions that are made.12,21 For a treatment to successfully be personalised to a patient, a level of input and collaboration is required with the practitioner throughout the entire duration of treatment. Generally, reports have shown that patients desire to be more involved in treatment selections, and overall, are participating in these decisions far less than they would wish to. By patients understanding the available options and what they entail, they can have a better-educated discussion with their healthcare providers and a collaborative decision can be made to select therapies that best suit the individual undergoing treatment.1,21,22 It has been suggested in the literature that involving patients in some elements of decision processes and offering them choices increases trust in practitioners, which ultimately influences the likelihood of reusing their services and referring friends.5,21 Additionally, it is important to note that with the growing popularity of lifestyle movements such as organic lifestyles and veganism, it is favourable for healthcare professionals to be able to offer natural treatments and organic alternatives, thereby facilitating increasing demands with effective options.

Personalised medication adopts a holistic approach to treating patients, and for some patients that are looking for aesthetic medicines, this can include treatment areas such as thyroid function or menopause. Even if a patient were to present with concerns over their appearance, as previously mentioned, they should be examined to assess their overall well-being. Physical appearance is largely influenced by bodily processes, and changes in an individual’s hormones can cause marked differences in how they look.23–25 In menopause, this can present as dry, slack skin and thinner hair; and in the case of thyroid insufficiency, dry skin, facial puffiness, weight gain etc can occur often changing gradually over months.25,26 To treat hormonal insufficiencies, a personalised approach is crucial, as treatment generally focuses on hormonal replacement, therefore hormone levels must be ascertained by regular blood tests and check-ups. The standard treatment for menopause usually consists of administrating synthetic hormones that have a different chemical structure to the natural hormones but mimic their action.26 In comparison, bioidentical hormone replacement therapy focuses on replenishing diminished hormone levels with natural hormones. 23This can be personalised further by targeting areas of concern with formulations such as facial creams that incorporate bioidentical hormones with hyaluronic acid and other cosmeceuticals to achieve enhanced skin moisturisation and appearance; with some studies reporting increased collagen expression and over 60% improvements in plumpness, fine lines and wrinkles.24,27 A review of the literature also suggests that bioidentical progesterone carries less risk of breast cancer compared to synthetic progestins; while bioidentical oestrogens and progesterone indicate a reduced risk of blood clots compared to their synthetic counterparts.23,26

In conclusion, personalising the approach towards medication, particularly for aesthetic treatments, is a recent advancement in therapy that aims to optimise patient outcomes while minimising complications. Both standardised and individualised approaches have their place in patient management but considering that the motivation for aesthetic medication is usually cosmetic, ensuring that adverse events are kept to a minimum severity must be a priority. Provided that both patient and practitioner are happy to pursue the personalised route, it can lead to excellent results that cannot be replicated by other therapy options. Although routine and very basic cases may not require in-depth personalisation, practitioners must remind themselves that even for standard therapies, they must consider the individual seeking treatment and work to optimise their management.