Is bigger better? An argument for very low starting doses

For years, we and others have advocated starting treatment of chronic indolent conditions at doses lower than those typically recommended in the product monographs.1 The approach we recommend is to use a very low dose when starting a new medication if the condition is not life-threatening or producing severe symptoms. Unfortunately, this approach is not used that much in practice.

First, we should define “very low dose.” The “start low, go slow” approach when starting medications — which entails starting with the lowest available dose — is generally well accepted in the medical community, especially for elderly patients. However, our approach is different. We are suggesting that it is reasonable in many cases to start with half the lowest marketed dose for older, established products. For newly marketed medications, we suggest starting with half or even one-quarter the lowest available dose, because dose–response studies have either not been done or their findings have not been incorporated into the product monograph. In addition, often only one or maybe two doses are marketed initially.

Our approach has several important advantages over the use of initial doses recommended in many product monographs. The use of a very low starting dose (a) would further decrease the risk of adverse effects; (b) engage patients in determining the best dose for them; and (c) would still provide a placebo effect, if present, and mitigate the ethical issues associated with the use of placebos.