The premise for Dr Miller’s letter in the September issue [BCMJ 2012;54:327] appears to be a recent decision by the BC Health Authorities Pharmacy & Therapeutics (BCHA P&T) committee regarding dabigatran, prasugrel, and ticagrelor.
To set the record straight, the first three references in this letter refer to requests for stakeholder input and are not a decision by the BCHA P&T committee. In fact, the BCHA P&T committee made a decision at the 24 May 2012 meeting to add ticagrelor to the formulary with restrictions.
While prasugrel was excluded from the formulary, the committee decided to add dabigatran to the formulary. It should be noted that the BCHA P&T committee has also subsequently aligned its decision for the ticagrelor formulary addition with the Pharmaceutical Services Division. The letter further speculates on the methodology used by the committee for decision making, and attempts to make an association between the statistical analysis that was considered by the BCHA P&T committee in making a decision and the Therapeutics Initiative (TI), with which the author has referenced some historical disagreements.
To be clear, the BCHA P&T committee has no association or relationship with the TI. The BCHA P&T committee considers many factors in making formulary decisions, and statistical methods are only one of these factors. To state that a particular methodology is being used to keep what might be useful drugs out of your hospital completely ignores the opposing and balanced view that the same methodology—one that may be prone to type II error but considers serious adverse events and mortality—may in fact save patients from harmful effects of drugs that have only marginal benefit over currently available medications.
Although there is room for limitless discussion on the benefits and risks of any particular statistical methodology, the BCHA P&T committee’s consideration in some instances of an “overall net benefit” as one of many factors in decision making, may align most logically with, and be familiar to physicians as, the sentiment embodied in the Hippocratic Oath: “Primum non nocere,” or “First, do no harm.”
—Dana Cole, BScPharm, ACPR, PharmD
—Darryl P. Samoil, MD, CCFP(EM), FCFP
Co-Chairs, BCHA , P&T Committee
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