Pharmacist Privilege in Saudi Arabia: Pharmacist Prescribing and Therapeutic Interchange

Faisal Al-Otaibi, Ph. D, Assistant Professor, College of Pharmacy, Pharmacy Patrice Department, Shaqra University, Saudi Arabia. Mohamed Soliman Imam, Ph. D, Assistant Professor, Dean, College of Pharmacy, Shaqra University, Saudi Arabia. Randa Mansour Abdel-Sattar Ahmed, Ph.D, Biomedical Science Department, College of Pharmacy, Shaqra University, Saudi Arabia. Amsha Alotaibi, Pharm D, Clinical Pharmacist, College of Pharmacy, Pharmacy Patrice Department, Shaqra University, Riyadh, Saudi Arabia. Asma Alotaibi, Pharm D, Clinical Pharmacist, College of Pharmacy, Pharmacy Practice Department, Shaqra University, Saudi Arabia. Amal Alotaibi, Pharm D, Clinical Pharmacist, College of Pharmacy, Shaqra University, Saudi Arabia. Wesam Alsuwaid, Pharm D, Clinical Pharmacist, College of Pharmacy, Pharmacy Practice Department, Shaqra University, Saudi Arabia. Yousef Ahmed Alomi*, BSc. Pharm, MSc. Clin Pharm, BCPS, BCNSP, DiBA, CDE, Critical Care Clinical Pharmacists, TPN Clinical Pharmacist, Freelancer Business Planner, Content Editor and Data Analyst, Riyadh, Saudi Arabia.


INTRODUCTION
The profession of a pharmacist has developed over the past few years in the KSA. 1 It has changed the role of a pharmacist from the distribution phase to the patients directed care. 2 Recently, the privileges of a pharmacist has increased to provide services, including total parenteral nutrition, anticoagulant and pharmacokinetics services. [3][4][5] The pharmacy is active in prescribing medications, change orders and request laboratory tests for monitoring drug therapy. Pharmacists demonstrated excellent clinical outcomes and avoided unnecessary economic burden on the healthcare system. 3,6 Multiple international studies have shown that pharmacists have the privilege of dependent or independent prescribing. [7][8][9] Moreover, the pharmacist plays an active role as a prescriber and improves patient outcomes. 10,11 Investigations related to the pharmacist privilege of prescribing are seldom in the Middle Eastern countries. 5,12 The therapeutic intervention described the system of switching from patent to generic medications with the same chemical name or change from one drug to different drug names with the same therapeutic efficacy and safety and indications. 13,14 Therapeutic interchange is a tool used to keep all medications available 24/7 for patients, improve drug therapy adherence to hospital formulary and avoid unnecessary economic burden on the healthcare services. Various studies have shown that the pharmacist has the privilege of a therapeutic interchange system. 11,13,15,16 It could be an independent therapeutic interchange or one according to the approved guidelines of the pharmacy and therapeutic interchange system. Few studies have been conducted about pharmacist privilege with an emphasis on the therapeutic interchange system in Saudi Arabia or in Middle Eastern countries. 5 In this study, we aimed to declare the pharmacist privilege with an emphasis on prescribing and therapeutic interchange in the kingdom of Saudi Arabia (KSA).

METHODS
This is a 4-month cross-sectional survey of prescribing privilege of pharmacists in the KSA. The study consisted of two parts: First parts collected demographic information and the second part comprised questionnaire with 28 questions divided into four domains. The domains were derived from the previous literature and American Alomi YA, et al.: Privileges of Pharmacist Prescribing and Therapeutic Interchange in Saudi Arabia Society of Health-System Pharmacists (ASHP's standards and regulations. 9,[17][18][19][20] The domains were privilege management and resources, pharmacist prescribing and therapeutic interchange, clinical and administration privilege and drug monitoring and healthcare education. We used 5-point Likert response scale system with close-ended questions to obtain responses. The questionnaire was distributed in an electronic format and was distributed to the hospital director of pharmacy, deputy director and pharmacy quality management. The responders were followed-up via email and telephone after every 1-2 weeks. All primary healthcare centers, regional pharmacy administration at MOH were excluded from this study. This study discussed and analyzed the pharmacist privilege in Saudi Arabia with an emphasis on pharmacist prescribing and therapeutic interchange. All data were obtained through the Survey Monkey system and analyzed with the use of SPSS version 20 software. There were three methods of validation and more than two authors reviewed the survey independently. The pilot study was conducted and the survey data was corrected accordingly. Cronbach's alpha test for internal validity was analyzed. This survey was exempted from the international guidelines of IRB. 21

DISCUSSION
The pharmacist privilege of prescribing was started in the 1990s when the clinical pharmacists were involved in providing TPN services with full independent prescribing of TPN order in hospital practice. 4 While in the early 2000s, usually, the pharmacist had the complete authority of dispensing medications without prescription, which are called the OTC medications. The pharmacist was responsible for excellent clinical outcomes and considerable reductions in the cost of healthcare services. 3 In addition, the therapeutic interchange system was started almost in the early 2000s during the group gulf medications purchases tenders. The pharmacist can switch automatically from providing patented drug to the generic drug of the same chemical name without the approval of a physician and perform fully independent therapeutic interchange. In this study, we focused on the privilege of pharmacists with an emphasis on prescribing and therapeutic interchange. We found that about onethird of the participants responded that they had a system similar to the previous studies 7, 8 with some improvement from a previous local study. 5 Our results were less than that of a previous study because of the lag time of system implementation at different countries. 9 The pharmacist privilege in prescribing was more for OTC medications. Although the type of medication prescribed by the pharmacists were similar; however, this result differed from a previous study because the pharmacist privilege in prescribing was implemented at hospitals, whereas in this study, the pharmacist prescribing privilege was implemented at community pharmacies. 8 Moreover, majority of the responders were working at private hospitals and they had implemented the OTC system within their pharmacies. Most of the medications that had the privilege of prescrib-  ing were OTC, vitamins and minerals similar to a previous study, 5 which represented the OTC drug list approved by the Saudi Food and Drug Authority. 22 Majority of the medications used for therapeutic interchange were nonsteroidal anti-inflammatory drugs, vitamins and electrolytes similar to the previous study. 5,16 All therapeutic interchange medications were available for the aforementioned medications and much easier to switch from one product to the other one. Most of the privileges of prescribing was countersigned by a physician, which is similar to the results of previous study. 5 Our results were much better through prescribing protocol and at ambulatory clinics privileges and become resemble of previous study. 5 The pharmacist to take an active role in the independent prescribing at ambulatory care clinics. Two-thirds of the responders had the privilege of prescribing during CPOE with an emphasis on ambulatory care clinic and drug information services. This is because OTC medications are easy to prescribe and implementation of the drug information service including the formulary guidelines. 11 The pharmacists privilege of prescribing during therapeutic interchange demands certain guidelines and pharmacy law to standardize the policies and procedures between the two systems in the kingdom of Saudi Arabia (KSA).

CONCLUSION
The pharmacist have prescribing privilege and therapeutic interchange utilization in the KSA. The pharmacist plays an active role in prescribing or perform therapeutic interchange of OTC medications through pharmacy law. The electronic entry of pharmacist privilege has not reach its optimal level. Full implementation of the comprehensive pharmacist privilege system and regulations through in-depth guidelines about prescribing and therapeutic interchange is highly recommended in the KSA.

CONFLICT OF INTEREST
The authors declare no conflict of interest. Answered 36 Skipped 0 Skipped 0