A Saturday morning request for an emergency supply of prednisolone for a dog makes me question the need for the cascade
Last Saturday morning while I was working as a pharmacist at a village pharmacy, I was asked if I could provide an emergency supply of oral prednisolone that had been prescribed for a dog. The owner (a doctor) had run out of the tablets and wondered whether he could get an emergency supply of generic prednisolone from the pharmacy.
In an emergency, under certain conditions, the Human Medicines Regulations allow a pharmacist working in a registered pharmacy to supply a prescription-only medicine if requested by a prescriber or the patient. I wasn’t sure about emergency supplies of veterinary medicines and so I called the National Pharmacy Association’s Drug Information service for advice. I learned that there is no legal provision for emergency supply of medicines on the request of a veterinary surgeon or animal owner.
Even if it had been possible to make an emergency supply, I would not have been able to supply an appropriate product that day. The cascade states that I must supply a product that is authorised for the animal species, if one is available. We didn’t stock any of the prednisolone preparations authorised for dogs (two brands and two generic formulations are listed in the VMD product database). We did have human generic prednisolone, but the cascade rules would have prohibited me from supplying that.
Some people believe the cascade is a good thing: that it provides guidance and structure for vets on what to prescribe and that it helps to give clients confidence in the vet’s prescribing decision by ensuring that authorised veterinary medicines with proven efficacy and safety are used as a first treatment.1 However, the cascade doesn’t necessarily ensure that the most effective and safest treatment is prescribed. Perversely, it can mean that the treatment with the most evidence for efficacy and safety is prohibited if it is not an authorised medicine.
Existence of the cascade may be an incentive to pharmaceutical companies to prove the efficacy of treatments and it ensures that their products are prescribed. But it may also increase the cost of treatment, which is then passed on to clients and can limit the choice of treatments that can be offered.
Some think the cost of medicines should be allowed to be considered as a factor when choosing which veterinary medicine to prescribe and that it should be possible to prescribe human generic medicines on cost grounds.1
There is perhaps scope for introducing more flexibility into the cascade by allowing an unauthorised medicine to be prescribed as first-line treatment where there is evidence to support the choice. The growing evidence base and increased availability of evaluated and comparative information on veterinary medicines might increasingly show the cascade as it stands to be a restrictive and disadvantageous tool.
1. Veterinary Medicines Directorate. Survey of veterinary surgeons cascade prescribing practices: summary of responses. May 2014.