Medicine wastage is a significant problem in New Zealand, with large quantities of subsidised medicines dispensed, but
never used. People who are prescribed multiple medicines or who are initiated on medicines where response and tolerance
may vary significantly, e.g. antidepressants, antihypertensives and analgesics, are at the greatest risk of accumulating
large quantities of unused medicines. A survey of 452 people in New Zealand found that 62% had leftover, unused or unwanted
medicines in their homes.1 The most commonly reported reasons for this were resolution of symptoms (29%),
change of treatment (17%), excess quantity supplied (16%), medicines past expiry date (15%) and adverse effects (15%).1
Unused medicines contribute not only to wastage but can also lead to problems such as confusion over which medicines
should be taken, dose errors, using expired medicines, sharing with family/whānau or friends and safety risks, e.g. children
A strategy to improve safety, reduce medicine wastage and prevent “piles of pills” from accumulating in patients’ homes
is to initially prescribe a medicine for a trial period. This might be appropriate when a new medicine is initiated or
a dose is adjusted, and it is uncertain if it will be tolerated or effective in terms of the goals of treatment.
For further information on medicines wastage, see: www.bpac.org.nz/bpj/2015/august/pills.aspx
Prescribers can specify a trial period for a newly initiated medicine or the first prescription following a dose alteration.2 There
are several examples where initiating pharmacological treatment for a patient is a “trial and error” process, e.g. managing
hypertension, depression or pain, prescribing laxatives for constipation, an emollient for dry skin or special food supplements.
This can lead to medicine wastage when a 90-day supply of a new medicine is dispensed, but the dose or choice of treatment
needs to be changed within a week or two.
How to prescribe a medicine for a trial period
To allow a medicine to be dispensed as a trial, clinicians must:2
- 1. Specify “trial” or “trial period” on the prescription
- 2. Indicate the quantity or period of supply of the medicine being trialled
If a prescription contains multiple items, indicate the above for each item on the prescription that is intended to
be dispensed as a trial. If the medicine is not dispensed stat, i.e. all-at-once, ensure that any repeats are listed on
the prescription to avoid additional dispensing fees for the patient should they continue with the medicine after the trial.
For further information on stat dispensing, see: www.bpac.org.nz/bpj/2015/august/pills.aspx
An example of how to prescribe a medicine for a trial period using Medtech* is shown in Figure 1. In the example, a
patient is initiated on cilazapril, 0.5 mg, once daily. Typically, cilazapril is dispensed as a three-month stat supply;
a 90-day supply is shown in Figure 1. However, patients may develop adverse effects when initiating or increasing doses
of an antihypertensive which results in a change in their treatment plan, such as the development of postural hypotension
in an older patient, which can place them at increased risk of falls. In the example shown, the clinician enters “14”
into the “Initial Dispensing Period” field and the resulting prescription specifies that the medicine is to be dispensed
initially as 14 days’ supply (14 tablets). Pharmacists can then dispense the initial quantity set out for the trial period and set up the remaining supply as a repeat.
* Medtech was used for the example as it is the most commonly used patient management system (PMS) in New Zealand; if
you are using a different PMS, enquire with your PMS support team if you are uncertain how to use the trial period function.
When prescribing a medicine for a trial period, it is important to discuss with the patient how the outcome of the trial
will be assessed, i.e. what will determine the trial to be a “success” and who will make this decision. This will vary
depending on the type of medicine being prescribed and the goals of treatment.
If the trial of treatment is a success, the patient can return to the pharmacy to have the remainder of the prescribed
medicine dispensed; this is at no additional cost to the patient provided the medicine is fully subsidised.
Best practice tip: When prescribing a medicine for a trial period, make a note of when the trial will end and schedule
a follow-up phone call by a nurse at your practice to ensure that the appropriate action has been taken, i.e. the remainder
of the prescription has been collected or a follow-up appointment has been made.
Figure 1: How to prescribe a trial of 14 days’ supply of cilazapril in Medtech