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“Prescription adaptation services” refers to the ability of a pharmacist to autonomously “adapt” an existing prescription when the action is intended to optimize the therapeutic outcome. Adaptation services typically fall into 2 categories: (1) renewals and (2) changes. Renewals ensure continuity of care for patients and may be emergency renewals (typically 72 hours) or continuation-of-therapy renewals (typically 90 or more days). Changes include therapeutic substitutions or changes to quantity, formulation, route of administration, dose/interval, and completing missing information. With an appropriate framework in place, adaptation services can safely optimize medication therapy outcomes while promoting efficiencies.

Background: Automatic therapeutic substitution (ATS) is the act of therapeutic interchange, in which patients are transitioned from a nonformulary preadmission medication to an equivalent formulary medication upon admission. ATS protocols are able to provide several benefits; however, if medications are unreconciled at the time of discharge, then use may lead to duplication or omission resulting in adverse outcomes. The objective was to assess the impact of preidentified ATS protocol use during admission on duplication and omission postdischarge. Methods: This study included adults who received a preidentified ATS upon admission. The primary outcome was the incidence of duplication or omission at the time of discharge. The secondary outcome was the incidence of duplication or omission at the time of discharge in moderate-to-high readmission risk patients with completed transitions of care (TOC) services compared with incomplete TOC services. Results: A total of 689 encounters were assessed for appropriate reconciliation, duplication, or omission at time of discharge. The incidence of duplication or omission at the time of discharge was 9% (n = 62). Of the 689 encounters, 287 were assessed for the secondary outcome. The rate of duplication or omission at the time of discharge was 10% (n = 19) in the complete TOC services group and 8% (n = 8) in the incomplete TOC services group (P = .6763). Conclusion: This study identified a high rate of appropriate reconciliation of ATS protocols at the time of discharge, which illustrates ATS protocols are a safe medication use management strategy if implemented as intended.

A very large part of India’s population fulfils its healthcare needs from government run healthcare delivery system which is free, contributory or highly subsidised. Use of medicines forms a large part of healthcare facility. As the number of medicines and brands are ever increasing in today’s market, it is usual for pharmacy to substitute a generic instead of the prescribed brand or a different brand if the prescribed brand is not available. Depending on the type of substitute, it could fall under ‘generic’ or ‘therapeutic’ substitution. For any condition, there may be numerous medicines existing, some of which probably got introduced more recently, may be more expensive and erroneously perceived to act better than the earlier known medications for the same ailment. Also, due to very high number of medicines that are approved and available for use in the market, it is impossible to stock all the medicines in any pharmacy. Generic and therapeutic substitutions should be formalised and implemented by institutions, with the consent and cooperation of all the stake holders as guided by World Health Organisation. The advantages and limitations of medicine substitutes are discussed in the review.

Purpose The purpose of this study was to evaluate the impact of switching from branded to generic statins on medication compliance. Methods In this historic cohort study, we identified patients taking branded statins between January 2003 and December 2012 from Sutter Health's electronic health records in Northern California. Patients with ≥2 consecutive pharmacy claims for generic statins after initiating branded statins were classified as switchers. Switchers and non-switchers were matched 1:1 on the propensity for switching. Medication possession ratio (MPR) was calculated as the sum of days supply of therapy divided by treatment duration. We assessed between-group differences in compliance (MPR ≥ 0.80) by logistic regression. Results Among 16,364 patients meeting eligibility criteria, 8470 were retained in the matched cohort. No significant differences in compliance with statin therapy were observed for non-switchers versus switchers, overall, or versus patients switched from a branded to generic statin of the same agent (generic substitutions). Patients switched from a branded to generic statin of a different agent (therapeutic substitutions) more frequently received less potent statin dosing relative to those with generic substitutions (42.2% vs.

A new antimicrobial stewardship program can be overwhelmed at the breadth of interventions and education required to conduct a successful program. The expression "low-hanging fruit," in reference to stewardship, refers to selecting the most obtainable targets rather than confronting more complicated management issues. These targets include intravenous-to-oral conversions, batching of intravenous antimicrobials, therapeutic substitutions, and formulary restriction. These strategies require fewer resources and less effort than other stewardship activities; however, they are applicable to a variety of healthcare settings, including limited-resource hospitals, and have demonstrated significant financial savings. Our stewardship program found that staged and systematic interventions that focus on obvious areas of need, that is, low hanging fruit, provided early successes in our expanded program with a substantial cumulative cost savings of $832,590.

Background: Pharmacists' scope of practice has been steadily expanding across Canada to encompass clinical activities. In January 2009, pharmacists in British Columbia (BC) were given the authority to adapt prescriptions for renewals; change in dose, formulation or regimen; and therapeutic substitutions. This study evaluated the labour costs associated with pharmacy adaptation services in BC. Methods: Ten high-adapting pharmacies participated in the study. Through workflow observations, we measured the time incurred for adapted and nonadapted prescriptions. Results: We observed 91 adapted prescriptions and 1081 nonadapted prescriptions. The total average time to provide adapted prescriptions was 6:43 minutes (SD 3:50) longer than to provide nonadapted prescriptions. The total average cost of an adapted prescription was $6.10 greater than a nonadapted prescription. Renewals took the least amount of time to complete, and therapeutic substitutions took the most time to complete. Discussion: Through workflow observations, it was determined that 10 stages of activity occur when adapting a prescription, with the most time being expended during the documentation and processing phases. Labour costs associated with adapted prescriptions were higher than for nonadapted prescriptions.

Therapeutic substitutions are common at the level of ministries of health, clinicians, and pharmacy dispensaries. Guidance in determining whether drugs offer similar risk-benefit profiles is limited. Those making decisions on therapeutic substitutions should be aware of potential biases that make differentiating therapeutic agents difficult. Readers should consider whether the biological mechanisms and doses are similar across agents, whether the evidence is sufficiently valid across agents, and whether the safety and therapeutic effects of each drug are similar. This article uses a problem-based format to address the biological mechanism, validity, and results of a scenario in which therapeutic substitutions may be considered.

Cost containment-driven drug substitution, whether generic or therapeutic, is defined as switching to another drug because it is cheaper. So far, such substitutions have drawn their public legitimacy from the general belief that they would not compromise the clinical interests of patients and certainly not violate their right to decline them if they did. This article does not enter the debate on whether or not such substitutions must give exclusive priority to the patient’s interests and choices in order to be ethical. Indeed, it acknowledges the plurality of views on this matter. It simply argues that when such substitutions involve a cheaper drug that is known to have different effects and side effects, or even a drug whose effects and side effects are unknown, they are potentially deleterious to the patient, and that no competent and well-informed patient would ever consent to them. Such substitutions are thus unethical in their very own terms.

State regulatory agencies were surveyed to determine their views concerning hospital policies that allow therapeutic substitution. A questionnaire consisting of 10 close-ended questions was sent to the executive secretary of each board of pharmacy in the 50 states and District of Columbia. Agencies were contacted by telephone in four weeks if they did not respond. Of the 51 jurisdictions surveyed, 34 answered all of the questions, 13 answered some, and 4 did not respond. None of the 13 partial respondents expressed their views concerning the legality of therapeutic substitution in the institutional setting. Fifteen agencies indicated they would view this practice as illegal, 17 said it is in accordance with policies established by the P & T committee and therefore not subject to state or federal regulation, and two agencies gave qualified responses. Seven agencies indicated enforcement procedures would be initiated if they were to learn that therapeutic substitution was being practiced in a hospital within their jurisdiction. Three states were uncertain about what action would likely be taken, 23 indicated no action would be taken, and two gave qualified responses. All 39 agencies responding to the question indicated they had never taken action against the practice of a formulary system that allows therapeutic substitution. Few state laws address the practice of therapeutic substitution, and opinions of regulatory agencies vary. Moreover, the opinions rendered have not been tested in the courts.

To the Editor.— I would like to reply to the editorial by Dr Ballin entitled "Therapeutic Substitution—Usurpation of the Physician's Prerogative." 1 The author states rather broadly that therapeutic substitution is a practice in which the pharmacist can substitute any drug believed by the pharmacist to have a similar therapeutic effect as the drug prescribed by the physician. He gives the impression that the pharmacist acts totally independently of the physician in deciding which drug to substitute. I feel that this is misleading for several reasons. First, pharmacists are not authorized, in any state, to make therapeutic substitutions without physician approval. Second, in all the examples cited by Dr Ballin, the pharmacist is making substitutions only with the authorization of the physician or the institution. The example of how pharmacy and therapeutics committees determine therapeutic substitutions best represents the cooperative effort between physicians and pharmacists. Rational decisions are made by