Therapeutic Substitution: Usurpation of the Physician's Prerogative

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