When can switching drugs be justified? (Rachel Hall)

I will first like to thank Rachel Hall for a great post. This case raises a number of important clinical dilemmas, to which I would like to make the following contribution to; especially in the light of the changes going on in the NHS:

One of the most difficult decisions a clinician will be asked to make is to switch a patient's medication on cost alone - especially, as you stated, when the current medication is well tolerated. The guilt you felt is, in my view, is a reflection of that difficulty.

This is the problem the GPs have had to grapple with. My observation is that some GPs deal with it very well and others don't. It is therefore not uncommon, from my discussions with my patients, for some GPs to deflect the decision to the PCT - you know: not me gov. I feel this is counter productive. It sows a seed in the patient's mind that the change has no justification. I think the well rehearsed cost-effectiveness arguments are justified. So I always take the view that the best way to deal with it is to discuss this thoroughly with the patient. I guess increasing number of pharmacists prescriber will  have this scenario to deal with. It is not good practice to deflect responsibility for that decision (my view). In any case, GPs - as commissioners - will now have to take responsibility for cost decisions under the new proposed arrangement.

Talking about responsibility: Community pharmacists have an important role to play here. We need to support our prescriber colleagues when they make these difficult decisions. It is counter productive if when asked by a patient why a switch has been made, we encourage the notion that this is another cost cutting exercise to fester in the mind of the patient without explaining the cost-effectiveness angle. A difficult decision means we need to take extra time to explain that decision. The notion of nothing about me without me holds here.

To support this viewpoint, I wish to share my personal experience of this. In Hampshire, as part of the a cost-effectiveness and budget re-balancing exercise, all prescriptions for Movicol was switched to Laxido. A patient of mine was clearly unhappy about this switch but I explained to her as far as I could why this action was justified. I also made it clear that I will ask for a switch back if it turns out not to be suitable for her. I asked her to give the change a go. Three weeks later I asked her how she was getting on with the switch. Guess what: She said it wasn't bad after all.

The key message here is this: Whatever the intervention we make in our patients' therapy we need to keep them in the loop of the why. If we don't, we loose them and we become less effective is what we are trying to do.

So on the question of when is the switching of drugs justified: I think switches can be. It can also be difficult.  As professionals, we need to make sure we make such decisions on effectiveness evidence alone. If 2 drugs are equi-effective (more or less), then the decision will always be to opt for the cost-effective option.

A simple mathematical model of drug A is cheaper than drug B will NOT do. We need to factor in the time it will take to justify such decisions to our patients and risk of none compliance etc. In effect the cost analysis need to be robust; the same way we will expect the effectiveness analysis to be robust.

Thanks you again

Kazeem Olalekan