On average, the substitution of the generic in the pharmacy forces the elderly patient in multiple treatments to change the brand of the drug almost two times out of three, with far from positive effects on the continuity of therapy and on the correct use of the drug. It is one of the data contained in the article that the forthcoming issue of Dialogo sui medica, the independent information magazine of the Asl 20 of Verona, dedicates to the controversial topic of substitutability. The article in Dialogue on drugs remains unrelated to the controversy, but the data it produces indirectly proves some of the theses supported by the generalists are right. The authors examined a cohort of almost 30,000 patients aged over 65 from the ASL 20, suffering from chronic pathologies and under treatment for at least a year with drugs in the categories at the highest expense, such as antihypertensives, diuretics, lipid-lowering drugs, etc. An analysis of consumption (carried out before AIFA cut the prices of off patents) revealed that the probability of replacement grows according to the number of packs taken and above all to the number of active ingredients. «A patient who consumes 7 packs of the same substance in a year» explains Maria Font, deputy director of the magazine and one of the authors of the study «suffers a replacement in 26% of cases. A patient who takes three different active ingredients, on the other hand, undergoes a substitution in 61% of cases». The study also recorded the same variability from the perspective of pharmacies: «There are principals that offer a limited number of brands per active ingredient» continues Font «and others that stock a large number of products. But what is most interesting is the variability of the substitution for the ten active ingredients examined: some, where the originator usually prevails, are replaced very little - such as furosemide, for which we record one substitution every 600 dispensed packs - others, where there is greater competition from the generic, have higher substitution rates. This is the case of atenolol, which is changed every 40 packs». The conclusion reached by the authors of the study is almost obvious: to chronic elderly patients, moreover in polypharmacy, the substitution should be offered with extreme caution. "We have not examined the effects on the reference cohort" underlines Maria Font "but experience teaches us that changing the can often disorients the frail patient and leads him into error: there are even those who double the dosage because they are led to think that two different packages mean two different drugs". The solutions? Many: "Doctors can always indicate non-replaceable in the prescription" recalls Font "or you can agree that when the prescriber indicates the brand name of the generic, the pharmacist does not replace it. Or again, pharmacies can be invited to reduce the variability of the brands treated without getting carried away by the benefits that some manufacturers offer. The important thing is to become aware of the fact that an insistent substitution in the fragile patient does not help the therapy».
Pharmacist33 – 6 July 2011
