Sample Collaborative Practice Agreement
Note to Pharmacists: The requirements for pharmacists to perform "automatic" therapeutic interchange vary by state. This document is meant only as a sample of what a protocol for therapeutic interchange might include. Please consult your state board of pharmacy regarding whether automatic therapeutic interchange by pharmacists is allowed in your state and for more information on the specific requirements to perform these duties. Also, see our chart, Collaborative Drug Therapy Management (CDTM), for more information on specific rules for collaborative practice in your state.
Therapeutic Interchange of Proton Pump Inhibitors (PPIs)
State law/board of pharmacy rule in ___________________ (insert your state) allows pharmacists to practice under a Collaborative Practice Agreement with prescribers. Pharmacists may participate in the practice of managing and modifying drug therapy on a case-by-case basis according to a written protocol between the specific pharmacist(s) and the prescriber(s) who is/are responsible for the patient's care.
By signing this document, the named prescribers agree that the named pharmacist(s) may enter into a Collaborative Practice with them for therapeutic interchange of Proton Pump Inhibitors (PPIs) according to the attached protocol. By signing this document, the prescribers agree with the therapeutic interchange protocol.
This agreement is valid for ___ years (depends on state, usually two years) but can be rescinded at any time, by any party involved, if all parties are notified in writing.
Pharmacist(s):
______________________ Date____________
______________________ Date____________
______________________ Date____________
Physician(s)/Advanced Practice Provider(s):
______________________ Date____________
______________________ Date____________
______________________ Date____________
______________________ Date____________
______________________ Date____________
______________________ Date____________
______________________ Date____________
______________________ Date____________
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Therapeutic Interchange of Proton Pump Inhibitors (PPIs)
EFFECTIVE DATE: _______________
APPROVED BY: (list prescribers here)
REVIEW DATE: (depends on requirements of your state)
PURPOSE/BACKGROUND:
A protocol for therapeutic interchange can be used to streamline the process of complying with insurance formularies, and to promote cost-effective prescribing.
POLICY:
The pharmacist will follow this written protocol, and use the attached dosing table. This protocol applies to patients under the care of the provider(s) listed.
ORGANIZATION / PROCEDURES:
The pharmacist will coordinate the therapeutic interchange process. If any questions should arise regarding the therapeutic interchange, such as __________________________________, the pharmacist will consult the prescriber.
With each therapeutic interchange the pharmacist will:
- Counsel the patient or his or her representative about the recommended drug substitution to ensure no drug allergies, drug interactions, previous adverse reactions or treatment failure, or other special needs like administration of the PPI through an enteral feeding tube or the need for dosing adjustment due to liver disease.
- Obtain patient or representative approval to substitute.
- Substitute according to the agreed protocol only.
- Inform the prescriber by fax/phone/in writing (may depend on state requirements) that therapeutic interchange has taken place within _____ hours/days.
Abbreviation: GERD = gastroesophageal reflux disease
Drug | Daily Dose Providing Similar Efficacy for GERD and/or Effects on Gastric pH1-3 | |
Dexlansoprazole (Kapidex)a | 30 mg | 60 mg |
Esomeprazole (Nexium)b | 10 mg | 20 mg to 40 mg |
Lansoprazole (Prevacid)c | 15 mg | 30 mg |
Omeprazole (Prilosec, generics)d | 10 mg | 20 mg |
Pantoprazole (Protonix)e | 20 mg | 40 mg |
Rabeprazole (Aciphex)f | --- | 20 mg |
- Consider 30 mg maximum per day for moderate hepatic impairment. No data in severe hepatic impairment.4
- Maximum dose per day in severe liver impairment is 20 mg.5
- Consider dose reduction in severe hepatic impairment.6
- Consider dose reduction in hepatic impairment.7
- No dosage adjustment necessary in mild to severe hepatic impairment. No data for doses higher than
40 mg per day in hepatically impaired patients.8 - No dosage adjustment needed in mild to moderate hepatic impairment. No data in severe hepatic impairment; use caution.9
References
- Kirchheiner J, Glatt S, Fuhr U, et al. Relative potency of proton-pump inhibitors-comparison of effects on intragastric pH. Eur J Clin Pharmacol 2009;65:19-31.
- Veterans Affairs Pharmacy Benefits Management Strategic Healthcare Group and the Medical Advisory Panel. Abbreviated drug class review: proton pump inhibitors. Updated August 2006. http://www.pbm.va.gov/Clinical%20Guidance/Drug%20Class%20Reviews/Proton%20Pump%20
Inhibitors,%20Abbreviated%20Drug%20Class%20Review.pdf (Accessed July 6, 2009). - Armstrong D, Marshall JK, Chiba N, et al. Canadian Consensus Conference on the management of reflux disease in adults-update 2004. Can J Gastroenterol 2005;19:15-35.
- Product information for Kapidex. Takeda Pharmaceuticals America, Inc. Deerfield, IL 60015. January 2009.
- Product information for Nexium. AstraZeneca Pharmaceuticals LP. Wilmington, DE 19850. June 2009.
- Product information for Prevacid. Takeda Pharmaceuticals America, Inc. Deerfield, IL 60015. May 2009.
- Product information for Prilosec. AstraZeneca Pharmaceuticals LP. Wilmington, DE 19850. March 2003.
- Product information for Protonix. Wyeth Pharmaceuticals, Inc. Philadelphia, PA 19101. May 2008.
- Product information for Aciphex. Eisai Inc., Woodcliff Lake, NJ 06766. June 2008.