Download Therapeutic Interchange Policy (TIP)

NHA Automatic Therapeutic Interchange Policy
(Updated Mar 2015)*
The following interchanges have been implemented to ensure rational use of select drugs, to decrease drug expenditures,
and to allow interpretation of orders when the strength or dosage form is not indicated or not available. In exceptional
clinical situations, the physician may override the interchange by writing "Do not substitute". This list pertains to adult
patients only, unless otherwise specified.
*Mar 2015 changes reflect transition to BC Provincial Formulary Therapeutic Interchange List
ADULT PATIENTS:
Drug ordered
ampicillin PO TID or QID
artificial eye lubricant drops
artificial eye lubricant ointment
beclomethasone dipropionate
INHALER 100 mcg / puff (Qvar®)
Drug Supplied
amoxicillin (same dose) PO TID
Artificial tear drop with preservative; same
number of drops and frequency
If preservative-free drop is ordered,
preservative-free will be supplied
Eye lubricant ointment with preservative at
same frequency
If preservative-free ointment is ordered,
preservative-free will be supplied
cefaclor capsule PO TID
cetirizine PO
fluticasone INHALER 125 mcg / puff (same
number of puffs and frequency)
trandolapril
See Table 10
latanoprost 0.005% drops (same number of
drops and frequency)
beclomethasone aqueous 50 mcg (1 spray)
into each nostril twice daily
See Table 3
micafungin 100 mg IV daily
cefuroxime axetil tablet (same dose) PO
BID
loratadine 10 mg PO daily
ciclesonide
fluticasone
See Table 2
cilazapril
trandolapril
See Table 10
benazapril
bimatoprost 0.01% and 0.03%
drops (Lumigan RC, Lumigan)
budesonide nasal spray
(Rhinocort AQ, Rhinocort
Turbuhaler)
caspofungin
cimetidine
clotrimazole vaginal tablet/insert
(any strength)
clotrimazole vaginal cream (any
strength)
corticosteroids, topical
desloratadine PO
Dorzolamide 2% ophth drops
EMLA®
enalapril maleate
enalapril sodium
Eprosartan
Eryc 333
ranitidine 150 mg PO BID
clotrimazole vaginal insert 200 mg PV HS x
3 days and clotrimazole 1% cream to
vaginal area PRN
See Table 9
clotrimazole vaginal cream 1%; 1
applicatorful PV HS x 6 days
See Table 9
See Table 8
loratadine 10 mg PO daily
Brinzolamide 1% ophth drops same dose and
frequency
Ametop 1.5 g applied under an occlusive
dressing for 30 minutes
trandolapril
See Table 10
Irbesartan (See chart below – Table 12)
Erythromycin 250 mg PO QID
see iPortal/Pharmacy/NHA Automatic Therapeutic Interchange Policy for latest version
Exceptions
Exception: HIV/AIDS patients on
Highly Active Anti-retroviral
Therapy (HAART)
Exception: HIV/AIDS patients on
Highly Active Anti-retroviral
Therapy (HAART)
Exception: if CrCl less then 50
mL/min, an adjustment of the
dose is recommended
ADULT PATIENTS:
Drug ordered
esomeprazole
etidronate and calcium (Didrocal)
famotidine
fenofibrate
fexofenadine PO
flunisolide nasal spray (Rhinalar)
fluticasone propionate (Flonase) or
fluticasone furoate (Avamys) nasal
spray
fluvastatin
fosinopril
framycetin dressing
Fusidic Acid cream/ointment
gatifloxacin ophthalmic drops
Insulin, Human
Ketoconazole cream
ketorolac 10 mg PO
lansoprazole
Levobunolol ophthalmic drops
Lidocaine/prilocaine cream
lisinopril
lovastatin
magnesium hydroxide and mineral
oil (Magnolax)
Metamucil (Psyllium Powder)
(for Adults)
miconazole topical cream 2%
miconazole vaginal suppository
(any strength)
miconazole vaginal cream (any
strength)
mometasone furoate monohydrate
nasal spray (Nasonex)
moxifloxacin ophthalmic drops
Drug Supplied
See Table 7
Acute care: TIP to cycle of calcium
elemental 500 mg PO daily for 76 days then
etidronate 400 mg PO daily for 14 days
ranitidine 150 mg PO BID, or ranitidine 50
mg IV Q8H
See Table 4
loratadine 10 mg PO daily
beclomethasone aqueous 50 mcg (1 spray)
into each nostril twice daily
See Table 3
beclomethasone aqueous 50 mcg (1 spray)
into each nostril twice daily
See Table 3
atorvastatin
See Table 5
trandolapril
See Table 10
bactigras dressing (same frequency)
Mupirocin oint at same frequency except
fusidic acid > TID  mupirocin TID
ofloxacin ophthalmic drops (same number of
drops and frequency)
Current formulary brand
Clotrimazole cream BID
ibuprofen 400 mg PO (same frequency)
See Table 7
Timolol same strength, dosage and frequency
Ametop (tetracaine) 1.5 g applied under an
occlusive dressing for 30 minutes
trandolapril
See Table 10
atorvastatin
See Table 5
milk of magnesia (same dose and
frequency)
Two Psyllium wafers (stores item) at the
same frequency (up to a Maximum 3
doses/24 hours) followed by a minimum of
240 mL water or other liquid (Adults)
clotrimazole topical cream 1%
clotrimazole vaginal insert 200 mg PV HS x
3 days and clotrimazole 1% cream to
vaginal area PRN
See Table 9
clotrimazole vaginal cream 1%; 1
applicatorful PV HS x 6 days
See Table 9
beclomethasone aqueous 50 mcg (1 spray)
into each nostril twice daily
See Table 3
ofloxacin ophthalmic drops (same number of
drops and frequency)
Exceptions
Exception: NG use or dysphagia
patients
Exception: Didrocal Kits are
restricted to residential care
Exception: if CrCl less then 50
mL/min, an adjustment of the
dose is recommended
Exception: HIV/AIDS patients on
Highly Active Anti-retroviral
Therapy (HAART)
Note: Stores Item
Exception: pediatric patients
Exception: HIV/AIDS patients on
Highly Active Anti-retroviral
Therapy (HAART)
Exception: Eating disorder
patients
Exception: mometasone furoate
monohydrate (Nasonex) is used
for children aged 3 to 12 years
see iPortal/Pharmacy/NHA Automatic Therapeutic Interchange Policy for latest version
Page 2 of 10
ADULT PATIENTS:
Drug ordered
Drug Supplied
Naproxen sodium 275 mg tab
neomycin+polymixin+
hydrocortisone otic drops
(Cortisporin, Cortimyxin)
nitroglycerin sublingual tablets
0.3 mg sublingual;
0.6 mg sublingual
Naproxen 250 mg tab
neomycin+polymixin+dexamethasone
ophthalmic drops (Maxitrol) (same number
of drops and frequency)
nitroglycerin sublingual spray
0.4 mg (1 spray) sublingually;
0.8 mg (2 sprays) sublingually
nizatidine
norfloxacin 400 mg PO
nystatin vaginal cream (any
strength)
nystatin vaginal suppository (any
strength)
omeprazole
pantoprazole PO
penicillin G 500,000 units PO
ranitidine 150 mg PO BID
ciprofloxacin 250 mg PO (same frequency)
clotrimazole vaginal cream 1%; 1
applicatorful PV HS x 6 days
See Table 9
clotrimazole vaginal insert 200 mg PV HS x
3 days and clotrimazole 1% cream to
vaginal area PRN
See Table 9
quinapril
rabeprazole
See Table 7
See Table 7
penicillin V 300 mg PO (same frequency)
Two Psyllium wafers (stores item) at the
same frequency (up to a Maximum 3
doses/24 hours) followed by a minimum of
240 mL water or other liquid (Adults)
trandolapril
See Table 10
See Table 7
Risedronate 5 mg daily (Actonel®)
Risedronate 35 mg once weekly
Alendronate 10 mg daily
Alendronate 70 mg once weekly
rosuvastatin
Senna glycosides 8.6 mg tablet
saxagliptin
atorvastatin
See Table 5
Senna glycosides 12 mg tablet
linagliptin – See Table 11
simvastatin
atorvastatin
See Table 5
sitagliptin
linagliptin – See Table 11
Telmisartan
Irbesartan (See chart below – Table 12)
Oxazepam X mg
Psyllium Powder (Metamucil) or
Psyllium Granules (Prodiem)
Temazepam X mg
travoprost 0.004% drops (Travatan,
Travatan-Z)
triamcinolone acetonide nasal
spray (Nasacort AQ)
latanoprost 0.005% drops (same number of
drops and frequency)
beclomethasone aqueous 50 mcg (1 spray)
into each nostril twice daily
See Table 3
Triazolam 0.125 mg
Oxazepam 15 mg (or ratio-equivalent doses)
Valsartan
Irbesartan (See chart below – Table 12)
Exceptions
Exception: if CrCl less then 50
mL/min, an adjustment of the
dose is recommended
Exception: pregnancy OR
breastfeeding
Exception: HIV/AIDS patients on
Highly Active Anti-retroviral
Therapy (HAART)
Exception: HIV/AIDS patients on
Highly Active Anti-retroviral
Therapy (HAART)
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Page 3 of 10
Interpretation of Incomplete or Ambiguous Orders
On occasion, incomplete or ambiguous orders are written. In order to avoid treatment delays, minimize the number of times
the physician needs to be contacted and to make the best use of hospital and pharmacy resources, the Medical Advisory
Committee has approved the following guidelines;
a.
Pharmacists will take the initiative for interpreting and completing orders for non-prescription drugs.
(e.g. Vitamins, minerals, laxatives, antacids, artificial tears etc…)
b.
Pharmacists will interpret/clarify on the doctor’s order sheet any order, which is obviously misstated.
Examples:
MD Orders.
penicillin G 1 g IV q6h
enteric coated ASA 5 mg PO daily
clarified/interpreted and noted by the Pharmacist on a Doctor’s order sheet as:
penicillin G 1 MU IV q6h
enteric coated ASA 325 mg (5 grain) PO daily
Signature and designation of the pharmacist
c.
Pharmacists will contact a physician for interpretation of an order for a prescription product if it is not on the list of
interpretations approved by the Medical Advisory Committee.
d.
PRN orders written without a frequency interval will be assigned an appropriate interval by the pharmacist.
e. Medication orders written with a frequency interval range will be substituted with the shortest interval by pharmacy. Eg.
Every 4 to 6 hours PRN will be substituted to every 4 hours PRN.
Therapeutic Interchange Program Tables
Table 2:
Inhaled Corticosteroids:
Inhaled Corticosteroid Therapeutic Interchange
DRUG ORDERED
DRUG DISPENSED
beclomethasone dipropionate (Qvar®) 100 mcg
fluticasone 125 mcg (same number of puffs and frequency)
ciclesonide 200 mcg inhaled once daily
fluticasone 125 mcg inhaled BID
ciclesonide 400 mcg inhaled once daily
fluticasone 250 mcg inhaled BID
ciclesonide 400 mcg inhaled BID
fluticasone 500 mcg inhaled BID
Exception: HIV/AIDS patients on Highly Active Anti-retroviral Therapy (HAART)
see iPortal/Pharmacy/NHA Automatic Therapeutic Interchange Policy for latest version
Page 4 of 10
Table 3:
Nasal Corticosteroids:
Nasal Corticosteroid Therapeutic Interchange
DRUG ORDERED
DRUG DISPENSED
budesonide Nasal Spray
beclomethasone aqueous 50 mcg (1 spray)
(Rhinocort AQ,Rhinocort Turbuhaler)
into each nostril twice daily
flunisolide nasal solution
(Rhinilar)
fluticasone propionate nasal spray
(Flonase)
fluticasone furoate nasal spray
(Avamys)
mometasone furoate monohydrate nasal spray
(Nasonex)
triamcinolone acetonide nasal spray
(Nasacort AQ)
Exception: mometasone furoate monohydrate (NASONEX) is used for children aged 3 to 12 years
Table 4:
Fenofibrates:
Fenofibrates Therapeutic Interchange
DRUG ORDERED
DRUG DISPENSED
fenofibrate regular release
As ordered
fenofibrate micronized (Lipidil Micro)
As ordered
fenofibrate microcoated 100 mg PO daily
fenofibrate micronized 134 mg PO daily
(Lipidil Supra)
(Lipidil Micro)
fenofibrate microcoated 160 mg PO daily
fenofibrate micronized 200 mg PO daily
(Lipidil Supra)
(Lipidil Micro)
fenofibrate nanocrystals 48 mg PO daily
fenofibrate micronized 67 mg PO daily
(Lipidil EZ)
(Lipidil Micro)
fenofibrate nanocrystals 145 mg PO daily
fenofibrate micronized 200 mg PO daily
(Lipidil EZ)
(Lipidil Micro)
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Page 5 of 10
Table 5:
HMG co-A Reductase Inhibitors (statins):
DRUG ORDERED
(TOTAL DAILY DOSE)
DRUG DISPENSED
fluvastatin
lovastatin
rosuvastatin
simvastatin
atorvastatin
20 mg
10 mg
-
5 mg
10 mg PO daily
40 mg
20 mg
2.5 mg
10 mg
10 mg PO daily
80 mg
40 mg
5 mg
20 mg
10 mg PO daily
-
80 mg
10 mg
40 mg
20 mg PO daily
-
-
20 mg
80 mg
40 mg PO daily
-
-
40 mg
-
80 mg PO daily
Exception: HIV/AIDS patients on Highly Active Anti-retroviral Therapy (HAART
Table 7:
Proton Pump Inhibitors (PPIs):
Proton Pump Inhibitor Equivalent Doses
DRUG ORDERED
DRUG DISPENSED
PO orders
esomeprazole 20 mg
lansoprazole 15 mg
omeprazole 10 mg
pantoprazole 20 mg PO
(at same interval as original order)
rabeprazole 10 mg
esomeprazole 40 mg
lansoprazole 30 mg
omeprazole 20 mg
pantoprazole 40 mg PO
(at same interval as original order)
rabeprazole 20 mg
NG orders* or dysphagia patients
lansoprazole 15 mg
omeprazole 10 mg
pantoprazole 20 mg
esomeprazole 20 mg NG
(at same interval as original order)
rabeprazole10 mg
lansoprazole 30 mg or 60 mg
omeprazole 20 mg or 40 mg
**esomeprazole 40 mg NG DAILY
pantoprazole 40 mg or 80 mg
rabeprazole 20 mg or 40 mg
* Exceptions: NG orders for Helicobacter pylori are exempt from this interchange and should be interchanged to esomeprazole 20
mg NG BID.
** Daily maximum esomeprazole dose for this interchange is 40 mg except for Zollinger-Ellison Syndrome
Call prescriber for any doses that fall outside this interchange.
Pediatric, pregnant and breastfeeding patients are exempt from this interchange. Lansoprazole or omeprazole may be used for
pediatric patients. Omeprazole may be used for pregnant or breastfeeding patients.
see iPortal/Pharmacy/NHA Automatic Therapeutic Interchange Policy for latest version
Page 6 of 10
Table 8:
Topical Corticosteroids





The dosage form (eg. cream, ointment, lotion) that is ordered will be dispensed.
If a dosage form is not specified, the cream will be supplied.
This interchange also applies to the topical corticosteroid component of a compounded combination order.
If betamethasone valerate is ordered with no strength, 0.1% will be supplied.
If hydrocortisone is ordered with no strength, 1% will be supplied.
This interchange does not apply to mucous membrane agents (for example triamcinolone 0.1% dental paste – ORACORT)
POTENCY
VERY POTENT
POTENT
MODERATELY POTENT
WEAK
DRUG ORDERED
DRUG DISPENSED
betamethasone dipropionate Glycol 0.05% (Diprolene Topilene)
clobetasol propionate 0.05%
clobetasol propionate 0.05% (Dermovate)
clobetasol propionate 0.05%
halobetasol propionate 0.05% (Ultravate)
clobetasol propionate 0.05%
amcinonide 0.1% (Cyclocort)
betamethasone valerate 0.1%
betamethasone dipropionate 0.05% (Diprosone, Topisone)
betamethasone valerate 0.1%
desoximetasone 0.05%, 0.25% (Topicort)
betamethasone valerate 0.1%
fluocinonide 0.01%, 0.05% (Lidemol, Lidex, Lyderm, Topsyn)
betamethasone valerate 0.1%
betamethasone dipropionate 0.025% (Propaderm)
betamethasone valerate 0.1%
betamethasone valerate 0.05%, 0.1% (Betnovate)
betamethasone valerate 0.1%
clobetasone butyrate 0.05% (Eumovate)
betamethasone valerate 0.1%
diflucortolone valerate 0.1% (Nerisone)
betamethasone valerate 0.1%
fluocinolone acetonide 0.01%, 0.025%, (Synalar, Synamol,
Fluoderm)
betamethasone valerate 0.1%
hydrocortisone valerate 0.2% (Westcort)
betamethasone valerate 0.1%
mometasone furoate 0.1% (Elocom)
betamethasone valerate 0.1%
prednicarbate 0.1% (Dermatop)
betamethasone valerate 0.1%
triamcinolone acetonide 0.05%, 0.1% (Aristocort, Kenalog,
Triderm)
betamethasone valerate 0.1%
triamcinolone acetonide 0.5% (Aristocort C)
betamethasone valerate 0.1%
desonide 0.05% (Tridesilon, Desocort)
hydrocortisone 1%
hydrocortisone 0.5%, 1%
hydrocortisone 1%
hydrocortisone 1% to 2.5% (Cortate)
hydrocortisone 1%
hydrocortisone acetate 1% (Hyderm)
hydrocortisone 1%
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Page 7 of 10
Table 9:
Topical antifungals (vaginal):
Topical antifungals (vaginal)
DRUG ORDERED
DRUG DISPENSED
clotrimazole vaginal cream (any strength)
clotrimazole vaginal cream 1%; 1 applicatorful
PV HS x 6 days
miconazole vaginal cream (any strength)
nystatin vaginal cream (any strength)
clotrimazole vaginal tablet/insert (any strength)
miconazole vaginal suppository (any strength)
nystatin vaginal suppository (any strength)
clotrimazole vaginal insert 200 mg PV HS x 3
days and clotrimazole 1% cream to vaginal
area PRN
Table 10:
Angiotensin Converting Enzyme (ACE) Inhibitors:
ACE Inhibitor Equivalent Doses
Drug
Dose*
benazapril (LOTENSIN)
10 mg
captopril (Capoten)
No substitution
cilazapril (Inhibace)
2.5 mg
enalapril maleate (Vasotec)
5 mg
enalapril sodium
4 mg
fosinopril (Monopril)
10 mg
lisinopril (Prinivil, Zestril)
10 mg
perindopril (Coversyl)
No substitution
quinAPRIL (Accupril)
10 mg
ramipril (Altace)
No substitution
trandolapril (Mavik)
1 mg
(*The total daily dose of the original ACE inhibitor order will be used to calculate an equivalent trandolapril dose for once daily
administration.)
Pediatric paients are exempt from this interchange. Enalapril is Restricted to pediatric patients.
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Page 8 of 10
Table 11:
Dipeptidyl Peptidase IV (DDP-4) Inhibitors
RESTRICTED to combination treatment for type 2 diabetes mellitus:
a) When insulin NPH is not an option AND
b) After inadequate glycemic control on maximum tolerated doses of metformin AND a sulfonylurea.
THERAPEUTIC INTERCHANGE
DDP-4 (or combination
as ordered)
Sitagliptin 25 mg , 50 mg,
100 mg
Sitagliptin/metformin
50 mg/ 500 mg
50 mg/ 850 mg
50 mg/1000 mg
Sitagliptin/metformin XR
50 mg/1000 mg
Saxagliptin 2.5 mg, 5 mg
Saxagliptin/metformin
2.5 mg/ 500 mg
2.5 mg / 850 mg
2.5 mg / 1000 mg
Linagliptin dose (plus
metformin if combination)
5 mg daily
5 mg daily with respective dose of
metformin
5 mg daily with metformin
500 mg twice daily
5 mg daily
5 mg daily with respective dose of
metformin.
Table 12:
Autosubstitution Policy for Angiotensin II Receptor Blockers (ARB’s) :
Angiotensin II
Receptor Blocker
Dose
Equivalent Irbesartan Dose
(Maximum 300 mg per 24 hours)
Eprosartan
Eprosartan
Eprosartan
400 mg PO daily
600 mg PO daily
800 mg PO daily
→
→
→
Irbesartan 75 mg PO daily
Irbesartan 150 mg PO daily
Irbesartan 300 mg PO daily
Telmisartan
Telmisartan
Telmisartan
20 mg PO daily
40 mg PO daily
80 mg PO daily
→
→
→
Irbesartan 75 mg PO daily
Irbesartan 150 mg PO daily
Irbesartan 300 mg PO daily
Valsartan
Valsartan
Valsartan
80 mg PO daily
160 mg PO daily
320 mg PO daily
→
→
→
Irbesartan 75 mg PO daily
Irbesartan 150 mg PO daily
Irbesartan 300 mg PO daily
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Page 9 of 10
This list does not apply to neonates.
PEDIATRIC PATIENTS:
Drug ordered
Drug Supplied
anidulafungin
caspofungin 70 mg/m2 loading dose (up to
max dose of 70 mg),
Exceptions
followed by 50 mg/m2 IV daily (up to max dose
of 50 mg)
caspofungin (any dose)
caspofungin 70 mg/m2 loading dose (up to
max dose of 70 mg),
followed by 50 mg/m2 IV daily (up to max dose
of 50 mg)
desloratadine PO
loratadine PO daily (dose will be based on
weight/age)
fexofenadine PO
loratadine PO daily (dose will be based on
weight/age)
micafungin
caspofungin 70 mg/m2 loading dose (up to
max dose of 70 mg),
followed by 50 mg/m2 IV daily (up to max dose
of 50 mg)
(NB – new – as of Feb 2015 – cetirizine added to formulary restricted to peds)
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Page 10 of 10