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Prescriptive Authority for Saskatchewan Pharmacists
Update #3 – November 9, 2010
What is Level II Prescriptive Authority?
The bylaws divide pharmacists as prescribers into two levels, I and II. Level II, characterized as advanced, leverages advanced skills of some of you and is more applicable to more highly functioning or more sophisticated interdisciplinary collaboration or teams. For example, many pharmacists have advanced training in managing disease states that would allow an expanded role for you to prescribe drugs for those disease states. The original legislative framework further divided Level II prescribing authority into Parts A and B. Part A describes when a pharmacist is able to prescribe through credentialing processes (similar to Emergency contraception prescribing). Part B describes situations where prescribing is performed under a collaborative practice agreement. Part A
1. Provision of oral contraception 2. Lifestyle and/or health promotion
These categories of prescribing have been deferred pending further study. In particular it has been identified that our educational objectives for Part A are inadequate. For example, they do not recognize when oral contraceptives may be prescribed for indications other than contraception. While we have identified Zyban for smoking cessation they do not recognize all of the possibilities for prescribing lifestyle drugs. Nevertheless, prescribing can occur within collaborative practice agreements described next. We will publish an update later. Part B - Collaborative Prescribing Agreements
3. Altering dosage and /or dosage regimen
1) Initiate Drug Therapy - Once a collaborative practice agreement is in place, you may prescribe medications within the limits specified under such agreements. For example, the physician makes the diagnosis and you have authority to select and prescribe medications, monitor the patient’s response to the medication and adjust doses as authorized in the agreement. As a further example, you have additional training as a certified diabetes educator. Within collaborative practice agreements with local physicians, they refer their newly diagnosed diabetics to you for selection of appropriate drug therapy and monitoring. You prescribe and dispense the appropriate insulin, home blood glucose monitoring device and work with the patient to monitor therapeutic response until the patient is stabilized on the right insulin and dosage.
2) Therapeutic Substitution - Requires that the practitioner is aware of the policies on therapeutic substitution and has endorsed the policy. Therapeutic substitution occurs in consultation with the patient, and takes into consideration many factors including the patient’s response to therapy, adverse reactions, allergies and sensitivities and financial needs. This will only be permitted where credible authorities declare that different molecules within the same therapeutic category are clinically equivalent, or in the absence of such authorities established processes within controlled environments where the organization accepts responsibility for clinical equivalence. For community pharmacy practice, we intend to rely upon credible authorities such as government mandated formulary committees or the Canadian Agency for Drugs and Technology in Health (CADTH). For hospitals, current practices sanctioned under Regional Health Authority policy will be recognized. For example, the patient requests a less expensive proton pump inhibitor. In conducting your assessment, you discover that CADTH has recognized that all drugs within that category are clinically equivalent for the indication for which the patient is using the more expensive brand. You prescribe and dispense a less expensive alternative and monitor the patient for therapeutic success. 3) Altering Dosage and/or Dosage Regimen – In this situation, you would already have a prescription for a drug, but under one of these agreements, you alter the dose or dosage regimen to achieve the therapeutic goal. Community warfarin dosage adjustment programs are an example of this type or prescribing. Under collaborative practice agreements, community pharmacists adjust the dosage of warfarin for their patients based on INR blood tests. Once the bylaws come into force, Level II prescribing will only be permitted pursuant to collaborative practice agreements (i.e. Part B only). For further information on the definitions and conditions under which such prescribing is permitted, please consult sections 23(1)(a)(i) and 23(4) of the bylaws at: It is important to note that such agreements must be in writing and executed either by individual pharmacists and practitioners, or responsible persons on their behalf who have the legal authority to bind them or within Regional Health Authority facilities according to the RHA policy. For further details, please consult the framework guidance document at: and draft template agreement at:
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