Box 2.

Applying the daily drug schedule and symptom diary.

This technique corresponds to chart reviews in deprescribing,131 and can facilitate the close monitoring necessary for differential diagnosis, safe tapering, and other drug changes.132–134 We request contemporaneous hour-by-hour daily notes of symptom pattern relative to drug schedule, reported 24 h at a time, captured over several days. This will profile the baseline symptom pattern, revealing ADRs, including paradoxical effects, interdose (also known as rebound or breakthrough) withdrawal,135–137 drug interactions, or withdrawal symptoms from dosage reduction. If drugs are taken on a consistent schedule, ADRs often can be observed in a regular cycle time-bound to drug dosing or change, corresponding roughly to peak plasma, half-life, activity of metabolites, or washout of a drug.106,138,139 Unlike ADRs or relapse, withdrawal symptoms generally occur in sharp, sporadic waves unrelated to the drug schedule.13,28,32,140 To prevent paradoxical reactions, which peak after drug ingestion, or interdose withdrawal, particularly with short-acting benzodiazepines, arranging the dosing schedule or dividing doses to maintain drug plasma level more evenly over 24 h may establish a more stable symptom pattern. It is essential to do this before initiating a taper, to avoid mistaking drug adverse effects for withdrawal symptoms. A year’s drug history and a drug interactions report assist in interpretation of the symptom pattern.141–143 (see Table 1).