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Year : 2004  |  Volume : 36  |  Issue : 3  |  Page : 178--179

Therapeutic substitution: A hidden irrationality

Vishal Tandon, BM Gupta, V Khajuria 
 Departments of Pharmacology and Therapeutics, GMC, Jammu (J&K) - 180001, India

Correspondence Address:
Vishal Tandon
Departments of Pharmacology and Therapeutics, GMC, Jammu (J&K) - 180001

How to cite this article:
Tandon V, Gupta B M, Khajuria V. Therapeutic substitution: A hidden irrationality.Indian J Pharmacol 2004;36:178-179

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Tandon V, Gupta B M, Khajuria V. Therapeutic substitution: A hidden irrationality. Indian J Pharmacol [serial online] 2004 [cited 2023 Mar 24 ];36:178-179
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It cannot be denied that irrationality is widely prevalent in the field of medicine. Doctors with wrong practices, pharmaceutical companies with their promotional tactics, patients indulging in self-medication and the government's inability in implementing an effective and efficient drug control system are some of the known apparent factors responsible for irrational drug therapy. But one of the serious factors on the part of the pharmacist is drug substitution, which still remains hidden and can contribute significantly to the irrationality. When a prescription is written for a proprietary product, the pharmacists must, under the law, dispense that product only, unless they persuade the doctor to alter the prescription. Under such circumstances they can substitute a generic product for the proprietary formulation prescribed by the doctor (Generic Substitution[1]. But indulging in therapeutic substitution is a serious irrationality on the part of the pharmacists where a drug belonging to same class but with a different chemical structure is deemed to be pharmacologically and therapeutically equivalent and is used as a substitute.[1] This can cause serious adverse therapeutic outcomes and therapeutic failures. This also denies the doctors' right to prescribe their priority drug for a given indication as well as denies the patients' right to have chemically same drug prescribed by a doctor. Therefore, it also has legal implications.

Drug substitution is done quite often by the pharmacist and studies had not been carried out on this aspect in the past. Therefore, a prospective study was carried out by collecting 200 prescriptions from patients/relatives who, after attending the OPDs of different departments, had visited different chemist shops near the Government Medical College, Jammu to purchase prescribed drugs. The prescribed drugs in the prescriptions were compared with the actual drugs received by the patients/relatives from the chemist shops for evaluating the total drug substitutions, generic substitutions and therapeutic substitutions in the prescriptions. The incidence of each group of drugs in prescriptions showing generic substitution and therapeutic substitution was also worked out. The present study was irrespective of the total number of drugs substituted in one prescription and the number of visits of patients/relatives. An interview or questionnaire study of the patients/relatives and chemists to ascertain the cause of drug substitution was not done as diverse answers and reactions were expected. Moreover, lack of cooperation on the part of the chemists interfering with the outcome of study was feared. Doctor-patient interactions were also not studied; the present study concentrated only on therapeutic transactions.

The results are shown in [Table:1]. In the present study 28.5% of the total prescriptions showed drug substitution. Out of these prescriptions 19.5% were found to be substituted generically whereas 9% of these prescriptions showed therapeutic substitution. The incidence of each group of drugs in prescriptions showing generic substitution and therapeutic substitution was observed. It was the maximum with antibiotics (46.15%) and (44.44%), followed by drugs for peptic ulcer disease (20.5%) and (16.66%), and analgesic/antiinflammatory drugs (10.25%) and (27.77%) respectively. Drug substitution was also seen with preparations like vitamins, minerals and hematinics, antihistaminics, antianxiety drugs, antihypertensives and cough syrups as shown in [Table:1]. The patients/relatives were very cooperative but there were mixed reactions from the chemists while conducting the study. The present study indicated drug substitution to be quite prevalent in the society. Using non-proprietary names to prescribe drugs can be cost-effective to the patients and can also tackle the problem of the “Therapeutic Jungle”.[2] We suggest that therapeutic substitution could also be curtailed by writing non-proprietary name of the drugs in prescriptions.

In conclusion, the drug control system of the government must recognize this serious hidden irrationality on the part of the pharmacist in the overall interest of the society.


1Laurence DR, Bennett PN, Brown MJ, editors. Clinical Pharmacology. 8th ed. New York: Churchill Livingstone; 1999.
2Nies AS. Principles of therapeutics. In: Hardman JG, Limbird LE, Gilman AG, editors. Goodman & Gilman's the pharmacological basis of therapeutics. 10th ed. New York: Mcgraw-Hill; 2001. p. 45-66.