Physician – Pharmacist Collaborative for Therapeutic Interchanges St. Vincent’s Ambulatory Pharmacy Services 7.1.2015

Learning Objectives: Identify the benefits of a physician-pharmacist therapeutic interchange collaborative. Determine who qualifies to participate in a collaborative agreement. Recognize the difference between therapeutic substitution and therapeutic interchange and choose references to validate interchanges. Perform patient monitoring parameters prior to implementing a therapeutic interchange. Utilize a therapeutic interchange grid, considering any restrictions involved. Learning Objectives

Improving the responsible use of medicines is an urgent priority across health systems worldwide. Avoidable Costs in US Healthcare 2013 www.theimsinstitute.org Retrieved December 4,2013

Avoidable Costs in US Healthcare 2013 www.theimsinstitute.org Retrieved December 4,2013

Avoidable Costs in US Healthcare 2013 www.theimsinstitute.org Retrieved December 4,2013

Benefits of a Therapeutic Interchange Collaborative Dispense approved medications on patient’s initial visit Provide a consistent supply of medications to most patients Increase patient adherence Increase monitoring and decrease poly-pharmacy use by providing more medications from Hope Dispensary

Benefits of a Therapeutic Interchange Collaborative Establishes a formulary to increase patient access to medications Provide cost savings for patients (meds provided for free) Provide cost savings for suppliers (less expensive glucose meter and supplies) Be a dependable source of information & medication for both patients and healthcare providers

HOW DOES HAVING A THERAPEUTIC INTERCHANGE COLLABORATIVE AGREEMENT IMPACT HEALTHCARE? Increase patient adherence by providing medication on the initial visit to the pharmacy. Lower costs for both the patient and healthcare by allowing medications to be dispensed from an approved formulary. Monitor for drug and disease interactions and adverse events through patient interviews and use of one primary pharmacy. Provides dependable information for both patients and healthcare providers by pharmacist interactions as part of the healthcare team. All of the above.

Credentialing of Pharmacist for Collaborative Practice

WHO CAN ESTABLISH A COLLABORATIVE WITH A Qualified PHARMACIST? In the state of Connecticut, Only a PHYSICIAN (MD. or DO.) can enter into a collaborative agreement with a pharmacist

Forms are filed in the patient medical record. Notification of the physician of the therapeutic interchange needs to be within 3 business days. Forms are filed in the patient medical record. COLLABORATIVE DRUG THERAPY MANAGEMENT AGREEMENT (00246946-2) 6.2013

Who can enter into a collaborative practice agreement? A Pharm D and an APRN working in the same clinic A pharmacist with 12 years experience and a veterinarian as long as the collaborative is restricted to animal medications A physician from Bridgeport Hospital and a pharmacist certified in diabetes management from St. Vincent’s Medical Center A physician licensed in Connecticut and a pharmacy resident licensed in New York All of the above Both physician and pharmacist are licensed in CT.

A Therapeutic Interchange Collaborative Practice Agreement

THERAPEUTIC INTERCHANGE The authorized exchange of therapeutic alternates in accordance with previously established and approved written guidelines or protocols within a formulary system. Changing over to an alternative drug that is not chemically the same as the original prescribed medication but is expected to have the same therapeutic effect and safety profile. THERAPEUTIC SUBSTITUTION The act of dispensing a therapeutic alternate for the drug product prescribed without prior authorization of the prescriber, such as substituting brand name medications with generic versions. Council on Scientific Affairs. Impact of Drug Formularies and Therapeutic Interchange on Health Outcomes. http://www.ama-assn.org/resources/doc/csaph/a04csa2-fulltext.pdf. Updated June, 2004. Accessed November 22, 2011. Nystrom SV, Stover K, Crain WM. An Estimate of the Annual Incidence of Therapeutic Interchange in the Commonwealth of Virginia During 1998. Fairfax, VA: The Department of Medical Assistance Services; 1998.

How are Therapeutic Interchanges Determined References include Approved Pharmacy & Therapeutics lists from area hospitals Recognized sources Pharmacist’s/ Physician’s Letter, UpToDate Lexicomp

Patient Monitoring parameters prior to an interchange Current medications and disease states Review for drug interactions Review for disease interactions, particularly renal or hepatic

Patient Monitoring parameters prior to an interchange Prior history of medication use Response to use Evaluation of prior adverse reactions (Dose or disease related?)

Consent for Therapeutic Interchange I, ______________________________, __________, understand that my prescriber, PRINT PATIENT NAME DATE OF BIRTH _________________________, has agreed to therapeutic interchange. PRINT PRESCRIBER NAME I attest that the information provided to Hope Dispensary of Greater Bridgeport regarding my current medications and health conditions is accurate to the best of my knowledge. I will notify Hope Dispensary of any adverse reactions or changes in medication or health conditions prior to further dispensing or refilling of medication. _________________________________________________ _______________ SIGNATURE OF PATIENT OR AUTHORIZED REPRESENTATIVE DATE ________________________________________________ RELATIONSHIP (IF AUTHORIZED REPRESENTATIVE) ________________________________________________ _______________ PHARMACIST DATE Therapeutic Interchange: ______________________________________ TO _______________________________________ _______________________________________ _______________________________________ Medication/strength/directions Medication/strength/directions Medications presently taking: __________________________________________________________________________________________________________________________________________________________________________ Allergies to medication: _________________________________________________________________ Patients are interviewed for a current medication and disease state history. COLLABORATIVE DRUG THERAPY MANAGEMENT AGREEMENT (00246946-2) 6.2013

Do you have an allergy to ________________________________ (interchange med) or any similar medication? Yes No Have you ever taken _______________________________________ (interchange med)   Did you have any adverse reactions? If so, what? Did this medication help you? Do you have any kidney or liver disease? Any present health conditions? If so, what? Interview includes questions regarding prior use of interchange medication. COLLABORATIVE DRUG THERAPY MANAGEMENT AGREEMENT (00246946-2) 6.2013

therapeutic Interchange Making the therapeutic Interchange

Glucose Meters Accu-Chek Glucose Meter/Control Solution Test Strips **If patient is given a prescription for insulin the Collaborative Practice Pharmacist can include the following items: Insulin Syringes (pending vial) Insulin Pen Needles (pending insulin pens) Glucose meter, control solution, teststrips & lancets – Testing 2-4 times a day as directed by physician. Accu-Chek Glucose Meter/Control Solution Test Strips Lancets One Touch Free Style On Call GE 100 Meter Under the collaborative, whatever glucose meter is prescribed by a collaborative physician, the collaborative pharmacist may dispense the glucose meter available.

DPP4 Inhibitors/Metformin Linagliptin/Metformin (Jentadueta) 2.5 mg/500 mg BID Linagliptin 5 mg daily and Metformin 500 mg BID Sitagliptin/Metformin (Janumet) 50 mg/500 mg BID Sitagliptin (Januvia) 100 mg daily and Metformin 500 mg BID Sitagliptin/Metformin (Janumet ER) 100/1000 mg daily Linaglipin/Metformin (Jentadueta) 2.5 mg/1000 mg BID 1000 mg BID 50 mg/1000 mg BID Metformin 1000 mg BID 50/1000 mg 2 tabs daily   50/1000 mg daily Sitagliptin 50 mg daily and Sitagliptin 100 mg daily and Within the collaborative, the pharmacist has the flexibility to choose the medication or combination that is available and still therapeutically equivalent & appropriate . Changes need to be thoroughly explained to the patient and should be kept to a minimum.

A patient has a prescription for Janumet 50/500 mg 2 times daily A patient has a prescription for Janumet 50/500 mg 2 times daily. You do not have any in stock. The collaborating pharmacist could: Dispense Sitagliptin 100 mg daily and Metformin 500 mg 2 times daily Dispense Sitagliptin 50 mg and Metformin 500 mg 2 times daily Dispense Sitagliptin 100 mg daily and Metformin 1000 mg ½ tablet (500 mg) 2 times daily Tell the patient that you will have the med available for them in 10 days with the next order All of the above All are correct, but “D”, having the patient wait 10 days, is not a good choice.

Inhaled steroid/beta-agonist combinations Adults and children ≥ 12 years Children < 12 years consult product information Advair Diskus 100 mcg/50 mcg, 1 inhalation BID 250 mcg/50 mcg, 500 mcg/50 mcg, Advair HFA 45 mcg/21 mcg, 2 inhalations BID 115 mcg/21 mcg 230 mcg/21 mcg Symbicort 80 mcg/4.5 mcg 160 mcg/4.5 mcg, Dulera 100 mcg/5 mcg , 200 mcg/ 5 mcg, Interchanges are made within the restrictions of the collaborative. This interchange is restricted by patient age.

Any dose of either medication may be ordered. Evidence-based oral beta-blockers for treating HEART FAILURE currently on formulary are Carvedilol and Metoprolol succinate. Any dose of either medication may be ordered. Metoprolol tartrate 12.5 mg tablet PO BID Metoprolol succinate 25 mg tablet PO daily Carvedilol 3.125 mg tablet PO BID Metoprolol tartrate 25 mg tablet PO BID Metoprolol succinate 50 mg tablet PO daily Carvedilol 6.25 mg tablet PO BID Metoprolol tartrate 50 mg tablet PO BID Metoprolol succinate 100 mg tablet PO daily Carvedilol 12.5 mg tablet PO BID   Metoprolol succinate 200 mg tablet PO daily Carvedilol 25 mg tablet PO BID This interchange is based on a disease state, In this case, only used for HEART FAILURE, not blood pressure.

Angiotensin Converting Enzyme (ACE) Inhibitor Therapeutic Interchange-total daily dose (once daily or ½ dose 2 times daily) Lisinopril and all other ACE-I EXCEPT FOSINOPRIL require dosage adjustment in renal dysfunction CrCl < 30 ml/min. benazepril 5 mg 10 mg 20 mg 40 mg 80 mg enalapril   fosinopril lisinopril moexipril 3.75 mg 7.5 mg 15 mg 30 mg 60 mg perindopril 2 mg 4 mg 8 mg 8-16 mg quinapril ramipril 1.25 mg 2.5 mg trandolapril 0.5 mg 1 mg The ACE Inhibitor interchange allows for flexibility in dosing (total daily dose as once or twice daily dosing.) There is a restriction based on renal function.

Insulin Insulin lispro (Humalog) Insulin aspart (Novolog) – same instructions for use Insulin human R (Humulin R) Insulin human R (Novolin R) – same instructions for use Insulin human isophane Suspension (Humulin N) Insulin human isophane Suspension (Novolin N) – same instructions for use Insulin 75/25 lispro protamine/lispro (Humalog Mix 75/25) Insulin 70/30 aspart protamine/aspart (Novolog Mix 70/30) – same instructions for use Insulin NPH/Regular 70/30 (Humulin 70/30) (Novolin 70/30 – same instructions for use Insulin glargine (Lantus) Insulin detemir (Levemir) – same instructions for use Insulin pens (Kwikpen, Flexpen, Solostar, FlexTouch pen) 100 units/ml Insulin Vial 100 units/ml – same instructions for use Insulin of the same concentration (100 units/ml) can be interchanged from one device to another. Changing from one type of insulin to another (E.g. basal to intermediate) requires physician intervention.

If you dispensed HumAlog 75/25 insulin 100 units/ml for Novolog 70/30 Insulin 100 units/ml it would be: Therapeutic Substitution Therapeutic Interchange Though therapeutically equivalent, the 2 insulins are different concentrations.

When using the interchange grid, the pharmacist needs to consider: Patient age Patient renal status Patient current medications and disease states Past medication experience All of the above

Before entering into a collaborative agreement: Read the COLLABORATIVE DRUG THERAPY MANAGEMENT AGREEMENT and understand what you are signing. Review the Therapeutic Interchange Grid to increase familiarity with use and restrictions. Know where to access references to verify any interchanges you make.

Physician – Pharmacist Collaborative for Therapeutic Interchanges Thank you for completing this competency. To pass you need to get 90% on the quiz. St. Vincent’s Ambulatory Pharmacy Services 9.2017