Eyeworld

24 Ophthalmology Business • September 2017 If a medicine is switched by the pharmacist without the doctor's knowledge, Dr. Martins do Vale said the doctor might report an adverse effect associated with his originally prescribed medicine when the patient was really taking a dif- ferent medication provided by the pharmacist. Dr. Graalum said her experience is that the pharmacist will work collaboratively with the physician to find the safest, most effective, and most affordable option with the least chance of an adverse reaction to the patient. "In the spirit of collaborative patient care, the pharmacists should communicate with a physician if changes need to be made and close the loop of communication by send- ing a 'chart note' to the physician when an agreed upon change has been made, with the description of the final product sent home with the patient," Dr. Graalum said. OB References 1. Federal Trade Commission. Generic drugs and switching prescriptions: Health information for older people. www.consumer.ftc.gov/ articles/0324-generic-drugs-and-switching- prescriptions-health-information-older-people. Accessed July 17, 2017. 2. Gray T, et al. Guidelines for therapeutic interchange—2004. Pharmacotherapy. 2005;25:1666–80. 3. National Consumers League. Consumers' Views on Therapeutic Substitution Survey. 2008. 4. Candisky C. Controls sought on drug switch- es. The Columbus Dispatch. Oct. 25, 2007. 5. Martins do Vale F. Re: Pharmacists may be allowed to change prescriptions without con- sulting prescriber. BMJ. 2011;343:d7067. Editors' note: The sources have no finan- cial interests related to their comments. Contact information Graalum: tatianas@gradybritton.com Newsom: hunter@newsomeye.net Rafie: srafie@ucsd.edu situation as switching one prescribed medication to one in the same ther- apeutic class for the same condition but not the chemical or generic equivalent, dubbing it "therapeutic substitution." "For some conditions and treat- ments, it may make good financial or medical sense to swap out one prescription for another," Sally Greenberg, NCL executive direc- tor, said in a press release. "But as consumers reported in our survey, it's essential for them to be a part of this process, to know their doctor is aware and supportive of the switch, and to feel confident that their health and treatment—not financial incentives— are top priority." While negative reactions to a change in prescription might be rare, one story published in The Columbus Dispatch in 2009 gave an example of the possible consequences of such a practice. It described two cases where epilepsy patients who had their condition controlled on one prescription saw seizures return after the pharmacy changed their prescrip- tions without their or their doctor's knowledge. 4 A response to proposed leg- islation in the U.K. published in the British Medical Journal in 2011 expressed the view that changing a doctor's prescription without his or her knowledge could be "ethi- cally improper" with the potential to "compromise pharmacological vigilance." 5 "Two medicines with the same drug may have different toxicity and effectiveness, because the process of chemical synthesis and produc- tion of pharmaceutical formulation determines the degree of purity of the active ingredient, the presence of impurities or contaminants, and even the dosage of the active ingredient, which all may affect the effectiveness and safety," Fernando Martins do Vale, MD, Institute of Pharmacology and Neuroscience, University of Lis- bon, Portugal, wrote in his response. vs. the other, so we'll always try to accommodate," Dr. Rafie said. If the pharmacist needs to change from one type of drug to another, they make a call to the phy- sician's office, Dr. Rafie said. "If the physician prescribes one statin but the insurance wants a dif- ferent statin or different medication within the same class to be covered, then we would call the physician and say, 'The patient's insurance covers this one, can we switch it?'" Dr. Rafie said. Diana Graalum, PharmD, clinical pharmacy manager, MedSav- vy, Portland, Oregon, said that per Oregon statute ORS 689.515, in some cases it could be within a pharma- cist's legal scope to change the mode of delivery for a drug, depending on the circumstance. For example, if a child were prescribed an antibiotic, it could be changed from a pill to a suspension or chewable tablet of the same drug at the same strength. Dr. Rafie said they might also change quantity depending on insurance coverage. For example, if a doctor prescribed a 1-month supply with 12 refills but insurance covers a 3-month supply at a time, pharma- cists could defer to the latter. The American College of Clin- ical Pharmacy (ACCP) released its position statement on the Guidelines for Therapeutic Interchange in 2004, supporting the practice as a "syner- gistic combination of the expertise and knowledge of pharmacists and physicians whose common goal is to ensure optimum patient care." The guidelines, however, "should not be interpreted as 'bestowing indepen- dent prescribing authority on phar- macists,'" the statement read. 2 A survey by the National Con- sumers League (NCL) in 2008 found that nearly three-quarters of people taking prescription drugs said they would be concerned if a pharmacy changed their doctor's prescription to another medication for the same condition. 3 The NCL described the continued from page 23

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