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To the Editor: Generic substitution policies are financially attractive.¹ Although several studies have found no clinically important effects of switching to generic warfarin formulations,² some observational studies have found an increase in warfarin dosages³ or frequent and substantial changes in international normalized ratio (INR).⁴ Few studies have been sufficiently large to examine clinical outcomes, and none have done so in a large-population setting.

On June 7, 2001, the provincial drug benefit plan in Ontario, Canada, instituted a policy requiring pharmacists to substitute either of 2 generic warfarin formulations (Apo-warfarin and Taro-warfarin) for Coumadin (Bristol-Myers Squibb Canada Inc, Montreal, Quebec). Physicians were advised of the policy a week before implementation.⁵ Patients could still receive Coumadin by paying the difference between it and the lowest-priced generic or by providing evidence of an adverse event during treatment with generic warfarin.

We performed an ecological study of trends in warfarin prescribing, INR testing, and . . . [Full Text of this Article]

Methods

J. Michael Paterson, MSc
paterson@ices.on.ca

Muhammad Mamdani, PharmD, MA, MPH; David N. Juurlink, MD, PhD
Institute for Clinical Evaluative Sciences
Toronto, Ontario

Gary Naglie, MD
Department of Medicine
University of Toronto

Andreas Laupacis, MD, MSc; Thérèse A. Stukel, PhD
Institute for Clinical Evaluative Sciences

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