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Introduction to the formulary
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Introduction to the formulary

Now let move to another main part of
the medication management: formulary management.
Firstly, let talk about the evolution of the formulary system. In the beginning, the original formulary was developed by the military in 1940’s. Later the American medical association stated laws for pharmacists to guide them developed policies to dispense generic equivalent drugs when a specific brand-name drug was prescribed. In 1960’s, Hospital formulary became legal and announced by several pharmacy related associations including American society of health system pharmacists, American hospital association, American medical association and American pharmacist association.
There were two events occurred at 1965: first, the Medicare listed formularies as a reimbursement eligibility requirement, second, the Joint Commission included an active P&T committee in its accreditation requirements. From then, Formularies no more than a list of drugs stocked by the pharmacy. In 1980’s, Literature called the emerge of the clinical and economic value of formularies. Later in 1994, American Medical Association’s official policy on drug formulary was first published. Now, The Formulary System become an essential tool for health care units.
What is the definition of the formulary? The formulary is a continuously updated list of medications with related information, representing the clinical judgment of pharmacists, physicians, and other expert in the diagnosis and/or treatment of disease and promotion of health. Formulary system define as an ongoing process which methodologically evaluates medications on an ongoing basis for inclusion or exclusion, establishes guidelines for optimal medication use, and develops policies and procedures for prescribing, dispensing and administer medications.
Formulary is the foundation of the formulary system. In the simplest form, the formulary is a list of medication available for use at a hospital or health system. This list includes dosage forms, strengths and package sizes of each of the medications on it. Formularies can be categorized by their access to medications as open or closed. An open formulary has no limitation to access to medications. A closed formulary may limit drugs to specific physicians, patient care areas, or disease state via formularies restriction. Formularies restriction do not necessarily translate to optimal medication management. For example, limitation of an antibiotic to a restricted status may result in shifting to a different antibiotic.
While sometimes this change is desirable, that may not always be the case. The new agent of choice may be more expensive or less safe than the restricted agent. Careful consideration of the impact of the formulary product selection and/or restriction is critical to the process.
As I mentioned before, the P&T committee is an organized team which recruit multidisplinary experts is responsible in formulary management. All of the review process on formulary should base on the evidence-based clinical, ethical, legal, social, philosophical, quality-of-life, safety, and economic factor. The management of Formulary System like a seesaw between evidence based medicine drug selection and limiting medication items. P&T committee need to evaluate the advantage and disadvantage of selecting or removing drug items into the formulary system. Item restriction may reduce the cost on inventory and system management but may cause some disadvantage. For example, it may reduce the quality of care by limiting access to clinically indicated medications.
Diligent management of formulary has both patient and financial implications. Patient care considerations include medication efficacy and safety. Financial consideration are the cost of the drug as well as the costs associated with stocking the medication such as shelf space, drug outdates, and handling. What are the roles for pharmacist in formulary management? Pharmacist is responsible for the quality, quantity, and sources of all medications, chemical, biologicals, and pharmaceutical preparations used in the diagnosis and treatment of patients. Many health systems provide pharmacists with the authorization to use a formulary therapeutic alternative in place of a non-formulary medications or a non-preferred formulary medications without having to contact the prescriber. With agreement, some institutions allow pharmacists to change medications by the approved guideline.
The guideline or agreement must include dosage strength, dose frequency, and route of administration for the interchange. In Taiwan, the pharmacist is not allowed to change medication without getting approval from the prescriber. Only if the prescribed medication is in shortage, without having to contact the prescriber, the pharmacist can change the medications if the chemical name, dosage form and strength all are the same.
In Taipei Veterans General Hospital, as drug is in shortage, we will assign a pharmacist to evaluate the possible alternative medicines in the formulary. In this evaluation form, the evaluator need to make a ranking list of all the alternatives based on their therapeutic similarity and reimbursed price. This is the pulp-out screen as the physician prescribing a medication in shortage. The pharmacy department will put the shortage review report on the screen to show the reason for the shortage or formulary change, make suggestions for alternatives and guide the physician to choose alternative drugs from the list.

Formulary management is another key component of medication management. Chang will explain the history, rationale, and design behind formularies. He also describes how the pharmacist is involved in this process.

Key points

Formulary is a list of medications available for use at a hospital or health system. Formulary also includes the different dosage forms, strengths, and package sizes of each recorded medication.

An open formulary has no limitation to medication access, while a closed formulary may limit drugs to specific physicians, patient care areas, or disease states.

Formulary reviews should be evidence-based, taking the clinical, ethical, legal, social, philosophical, quality-of-life, safety, and economic factors into account. PTC needs to evaluate the pros and cons before making every decision. Item restrictions reduce the cost of inventory and the need for system management but may also reduce the quality of care.

It is the pharmacist’s responsibility to make sure the quality, quantity, and sources of all medications, chemicals, biologicals, and pharmaceutical preparations used in the diagnosis and treatment of patients are correct.

Occasionally pharmacists are authorized to use non-formulary medications or non-preferred medications without contacting the prescriber. However, this must be regulated by detailed guidelines specifying the dosage strength, dose frequency, and route of administration for the interchange.

In Taiwan:

According to Taiwanese regulations, pharmacists are not allowed to change medication without the approval of the prescriber, unless there is a shortage. In that case, the pharmacist can dispense an alternative with the same chemical name, dosage form, and strength.

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How often is your hospital formulary updated?

How are you informed of the changes?

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Good Pharmacy Practice: Medication Management

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