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Hospital formulary, Therapeutic drug monitoring


b) Hospital formulary
Definition, contents of hospital formulary, Differentiation of hospital formulary
and Drug list, preparation and revision, and addition and deletion of drug from
hospital formulary.
c) Therapeutic drug monitoring
Need for Therapeutic Drug Monitoring, Factors to be considered during the Therapeutic DrugMonitoring, and Indian scenario for Therapeutic Drug Monitoring.

Types of formularies
• National formularies (e.g. British National
Formulary (BNF))
• Hospital formularies
• Local formularies
• Joint hospital–local formularies.
• Open formulary system: the formulary
recommends drugs and non-formulary drugs are Still routinely available
• Closed formulary system: restricted drug list:
only medicines included in the formulary may be used. Benefits of a formulary
• Cost-effective prescribing
• Rational prescribing
• Use of a restricted range of drugs results in better knowledge of drug use
• Better stock management
• Improvement in communication between prescribers and pharmacists
• Promotes seamless care between hospital
practitioners and primary care
Objections to development of a
• Deprives the prescribers of the freedom of
• Allows for purchase of inferior quality drugs
• Does not always reduce the cost to the consumer.
Formulary development
• Team work approach is required
• Decision whether to adapt another formulary or
develop a completely new formulary
• Instil a culture of willingness to accept change
• Should be flexible and adapt to ongoing needs of prescribers and patients.
Formulary system
• Inclusion and exclusion criteria
• Process to monitor drug use and establish
policies on drug use
• Adverse drug reaction reporting activities
• Provision of reference material on drugs included in formulary.

Formulary management system
• Has to be flexible and dynamic
• Regular updates to reflect current practice (e.g. biannual or annual editions)
• Inclusion of new drugs released on the market:
consider issue of safety, cost, indications, me-too drugs
• Withdrawing drugs: discontinued drugs, drugs
no longer prescribed
• Procedure to meet non-formulary requests.
Content of a formulary
• Introduction
• Follow a basic drug information system (e.g. reference to British National Formulary)
• Use a classification system (e.g. pharmacological or symptomatic)
• Include drug costs and cost of treatment
• Notes on inclusion criteria and selection of drugs.
Formulary presentation
• Pocket sized
• Binding: loose-leaf allows for flexible adaptations but may present problems with long-term use
• Use colour to facilitate presentation of material
• Cover: durable and attractive design
• Font size to make appropriate reading
• Availability in electronic format.
Inclusion criteria
• Efficacy
• Side-effect profile and contraindications
• Interaction profile
• Pharmacokinetic profile
• Patient acceptability: taste, appearance, ease of
• Generic availability, cost.
Ethical implications of developing
a formulary system
• Interfering with non-pharmacological basis for choice of product
• Formulary system may provide for generic substitution or therapeutic substitution
• Interactions with the pharmaceutical industry may influence the formulary system.
Non-pharmacological basis of
therapeutics At the macro level, prescribing trends that influence the individual prescriber include:
• cost
• availability of product
• traditions and education of society (e.g. may influence dosage form selection)
• health issues
• stability and power of pharmaceutical industry
• medical teaching.
At the micro level, the individual prescriber is
influenced by:
• peer groups
• society
• control measures and regulations by health authorities
• pharmaceutical industry.
Generic substitution
This is the dispensing of a different brand or an unbranded drug product for the drug product prescribed.
Therapeutic substitution
This is the dispensing of a particular drug entity in place of a therapeutically similar but chemically different drug product.

Definition of formulary and formulary system The formulary is a continually revised compilation of pharmaceuticals
(plus important ancillary information) that reflects the current clinical
judgment of the medical staff. The formulary system is a method whereby the medical staff of an institution, working through the pharmacy and therapeutics committee, evaluates, appraises, and selects from among the numerous available drug entities and drug products those that are considered most useful in patient care. Only those so selected are routinely available from the pharmacy.
The formulary system is thus an important tool for assuring the quality of drug use and controlling its cost.
The formulary system provides for the procuring, prescribing, dispensing, and administering of drugs under either their nonproprietary or proprietary names in instances where drugs have both names Benefits of the formulary system
The potential benefits of a formulary system are threefold:
(l) Therapeutic. (2) Economic. (3) Educational.
The therapeutic aspect of a formulary system provides the greatest benefit to the patient and physician in that only the most efficient products are listed and available.
The economic merit also has a double benefit in that the formulary eliminates duplication thus reducing inventory duplication and the opportunity for volume purchasing means lower charges to the patient.
The educational benefit is also significant for the resident staff, nurses
and medical students because many good formularies contain various prescribing tips and additional drug information of educational value.