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The daily work of pharmacists and pharmaceutical-technical staff is often characterized by obstacles because of the balancing act between what the doctor has prescribed and what the patient wants to take and what not must be done. Regulatory measures, such as a general prohibition on the exchange of drugs, which the Federal Joint Committee has laid down in a keyword list „substitution exclusion list“, are added to this, as well as the dispensing of certain discount drugs that the health insurance funds want. It is not always easy to do justice to everyone. For example, there are also drugs that are exempt from the substitution obligation because they are not subject to discount contracts. This then also applies to emergency and night services. Certain thyroid hormones, anticoagulants, antiepileptic drugs, cardiac glycosides, immunosuppressive drugs and opioid analgesics fall into this category because their therapeutic range would quickly lead to under- and overdoses (Part B Annex VII of the AM-Directive). Manufacturer, drug substance, dosage form, therapeutic area and also the patient are to be considered as critical factors. However, the pharmacist may express his concerns if the safety of the therapy is at risk. There are many examples of this in practice, for example, if the patient complains about the dosage form because he cannot swallow the tablets because of their size, or if the intake is at risk because the shape of the tablet does not match the swallowing difficulties of the patient. The risk of confusion is also a major issue, for example, when different tablets that the patient has to take every day look the same. However, it is not only the dosage form that can become a problem, but also the patient himself, because allergies to active ingredients and excipients are not uncommon, just like lactose intolerance. Capsules made of gelatine cannot be taken by people of certain religions either. The list is long, but if possible, the doctor should always be consulted first. Pharmaceutical staff are usually good at doing the splits when difficulties arise. The Pharmacy Operating Regulations also stipulate that in the event of unsolvable questions and concerns, the drug may not be dispensed on the present prescription. Since July 2019, however, there has been a so-called special PZN 02567024 with new factors that can justify various dispensing situations, such as the unavailability of a discount medicine, urgently needed medicines on the night and emergency service or the dispensing of medicine requested by the insured. Pharmacists must also provide detailed advice in order to be able to identify factors that could endanger therapy (tablet too large, etc.), of which the doctor may not or cannot be aware.

Source: apotheke-adhoc.de