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Clinical Consequences of Generic Warfarin Substitution: An Ecological Study
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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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