Medication safety risks to be managed in national implementation of automatic substitution of biological medicines: A qualitative study

Hanna M. Tolonen, Marja S.A. Airaksinen, Päivi Ruokoniemi, Katri Hämeen-Anttila, Kenneth M. Shermock, Pekka Kurki

Research output: Contribution to journalArticlepeer-review


Objectives To explore relevant Finnish stakeholders' perceptions on the automatic substitution of biological medicines with particular focus on medication safety and issues that need to be considered to create an appropriate model for automatic biological product substitution. Design Qualitative interview study. Methods Data were collected in semistructured individual (n=17), pair (n=7) and group (n=8) interviews (32 interviews, 62 participants) in 2018. Participants represented a wide range of stakeholders involved in the pharmacotherapy process: community pharmacists (n=8 interviews), authorities (n=7), prescribers (n=7), pharmaceutical industry and wholesalers (n=6), patients/customers (n=2), hospital pharmacists (n=1) and nurses (n=1). Inductive content analysis was performed. Results Benefits of automatic substitution were identified as cost savings, more patients receiving biological treatments and enhanced continuity of treatment. Six major risk categories were identified: (1) the patient's medication is interrupted or complicated temporarily or permanently, (2) the patient uses two products with the same active substance, (3) the traceability of the product is compromised, (4) the patient cannot get into healthcare in case of problems, (5) the patient does not receive substitution-related advice from a pharmacy and (6) the patient is distracted by the support material he/she receives. Several risk mitigation measures were commonly mentioned: medication and device counselling by pharmacists (n=23), infrequent substitution interval (n=15) and better knowledge on biosimilars among healthcare providers (n=13). Conclusion Automatic substitution of biologics is associated with risks that should be prospectively managed before implementing the procedure. The substitution also introduces new tasks and communication needs to those involved in actual medication use process, particularly to community pharmacists who will be responsible for substitution and counselling the patients.

Original languageEnglish (US)
Article numbere032892
JournalBMJ open
Issue number10
StatePublished - Oct 1 2019


  • automatic substitution
  • biological medicines
  • biosimilars
  • interchangeability
  • medication safety

ASJC Scopus subject areas

  • Medicine(all)


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