When the at-home medication of a hospitalized patient is not on the hospital formulary or a national shortage limits the availability of a medication, Northwestern Medicine uses therapeutic interchange to ensure the patient receives a therapeutically equivalent treatment.
What is therapeutic interchange? Therapeutic interchange is the substitution of another available medication for an unavailable medication at a dose regimen that achieves therapeutic equivalence. To be therapeutically equivalent, the replacement medication and dose regimen, on average, should achieve comparable intended benefit at no greater risk.
Therapeutic equivalency and dose equivalency are determined through extensive literature review and approved by the hospital Pharmacy and Therapeutics (P&T) Committee.
What is a P&T committee and a hospital formulary? P&T committees, operating on behalf of the medical staff, determine what medications and dose forms should be routinely stocked at a hospital to meet inpatient needs based on the populations served. In addition to physicians, P&T committees also include members from disciplines such as nursing and pharmacy.
The hospital formulary is the aggregate list of routinely stocked medications and dose forms. Well-managed formularies include a portion of marketed medications within each pharmacologic class, generally those most commonly prescribed and those with unique clinical indications. Overly inclusive formularies result in significant disadvantages for acquisition, storage and maintenance without increasing clinical benefit.
Therapeutic interchange in Epic If an order is placed through the Epic Admissions tab to continue a patient’s home medication and the medication is nonformulary, Epic will notify the ordering provider and guide the provider through the therapeutic interchange process to identify an equipotent dose of an acceptable equivalent medication. On some occasions, a provider may determine that a patient should continue a nonformulary medication. The provider may place an order that allows the patient to use their home supply of the medication in accordance with hospital policy.
During the medication reconciliation process at discharge, Epic will list the prior-to-admission medication and the therapeutically interchanged medication adjacent to each other, highlighting the need to choose one of these options for the discharging provider. Generally, the prior-to-admission medication is selected. However, if the provider decides the interchanged medication should be continued instead, patients must be instructed not to resume using any of the older medication supply still at home.
Northwestern Medicine System P&T Committee The NM System P&T Committee held its first meeting in September. The system committee includes the pharmacy director of each NM hospital and the physician chair of each hospital’s P&T committee. The remaining membership consists of nursing directors, pharmacy clinical managers and coordinators, Drug Information staff and Quality representatives from across NM.
The committee will establish system standards for medication use across NM, which includes developing the NM System Formulary and determining medications acceptable for therapeutic interchange. Achieving system standards will simplify inventory management and greatly reduce the parallel effort to build and maintain medication orders in Epic.
Pharmacy and therapeutics resources The pharmacy directors and P&T committee chairs of individual hospitals are good resources for local question or concerns. For questions or concerns at the NM system level, email David Cooke, MD, vice president of quality at Northwestern Memorial HealthCare, or Tom C. Krejcie, MD, associate chief medical officer.