Saturday, May 19, 2007

£100m worth of drugs wasted each year

The BBC and the Guardian have both run a story about £100m worth of drugs being wasted each year by patients. I'm shocked. Shocked that it's only £100m per year. The real figure is going to be far higher. I have returned medicines collected every couple of months by a contractor. They normally take away seven or eight sackfuls of drugs - thousands of pounds worth. As an example, I have had two boxes of Casodex (at £240 per box), two seretide 250/25 inhalers (£75 each) and 30 diamorphine ampoules returned recently. Once something has left the pharmacy it can't be reused. There are two reasons for this. Firstly I don't know how it has been stored, and secondly I have already claimed payment for the drugs.

Some waste is unavoidable - people die, patients react badly to certain drugs. But waste can be reduced. The easiest way to reduce waste is to prescribe a months worth at a time. This also has the useful benefit of training the patients in how long it takes a prescription to be generated - they tend to forget if they only have to do it once every three months. Two or three monthly prescribing falls down because patients stockpile drugs and GPs don't always change their records. For example, someone is started on a new blood pressure tablet and is given 28 days supply (which is reasonable enough). They tolerate this new drug and their blood pressure comes down to target. However, the surgery forget to change the quantity to three months on the repeat screen. So Mrs Smith ends up with 28 days of bendroflumethiazide, 84 days of ramipril, 56 days of simvastatin, 84 days of omeprazole and 100 aspirin on her repeat prescription. And these all get ordered every month because Mrs Smith ticks all the boxes (or doesn't tick any and the surgery issue everything). This doesn't get picked up by the GP signing the prescription, and is tough for the pharmacist to pick up as well - I deal with 10,000 items per month; I don't have the time to look at every patient's records to see when they last had their drugs.

28 day prescribing also saves money - it stops people going to their GP for prescriptions for hayfever treatment for example. It is cheaper to pay the £6.85 prescription charge for two or three months worth of cetirizine than to buy it over the counter. If the prescription is only for 28, it is cheaper to buy it over the counter. I have been seeing lots of prescriptions recently for 90 cetirizine or 2 beconase nasal sprays, and it irritates me greatly.

Also mentioned in the above stories was the fact that £200m was wasted by GPs prescribing branded drugs over generic ones. The National Audit Office looked at prescribing of statins, ACE inhibitors, PPIs and clopidogrel, which account for 20% of prescribing costs between them. There are cheap and effective generic statins, ACE inhibitors and PPIs available. For example, simvastatin 40mg daily reduces cholesterol by about the same as 10mg atorvastatin daily. But simvastatin costs £3.50 per month while atorvastatin costs £18 per month. So it makes sense to use simvastatin, other than in those patients who genuinely can't tolerate it. There is also more evidence to support the use of simvastatin than atorvastatin, such as the Heart Protection Study. Clopidogrel is more interesting. It does the same job as low dose aspirin, and is often used in combination with aspirin for a year after a heart attack. Except that the combination often carries on for more than a year. Clopidogrel is also used as an alternative to aspirin for those who can't take aspirin. However, clopidogrel is actually quite similar in terms of side effects when compared with aspirin. Clopidogrel costs around £30 per month, while aspirin costs around £1 per month.

For some reason I decided to read the comments on the BBC website. That was a bad move. It is just as well I am young, otherwise I may have had a heart attack, though I definitely feel the need to bash my head against a brick wall. My neighbours may be worried about me given the amount of abuse that was coming out of my mouth, and there were times I felt like chucking my laptop out of the window. Just to address one major point that came up. There is (virtually) no difference between generic and brand name drugs. It is not unusual for them to be manufactured by the same company - Merck owns Generics UK for example. There are certain drugs which should be prescribed by brand name, and there are a few people who are sensitive to different excipients in generics, but the vast majority of patients have no problem with generics. Generics should be used whenever possible because they are far cheaper than the original brand.

Wednesday, May 09, 2007

Coeliac disease

Coeliac disease awareness week is coming up soon. Hence this story on the BBC website.

As it says, coeliac disease is a gut disease caused by gluten intolerance and the only treatment is a gluten free diet. So what? What is gluten? Gluten is a protein that is found in wheat, barley and rye. People with coeliac disease can't tolerate gluten - they may get diarrohea, bloating and weight loss . The presence of gluten causes an inflammatory reaction in the gut, leading to reduced absorption of nutrients and so the failure of a child to thrive may be due to coeliac disease.

But why is this a problem? Well, standard flour, as used in bread, cakes, pastries and so on is made from wheat. Therefore people with coeliac disease have to eat special gluten free products. Although some supermarkets carry a gluten free range they are more expensive than standard products, and so most coeliac patients get their foods on prescription. There is a wide range of gluten free foods available on prescription, ranging from long life breads to freshly baked breads. Pasta, biscuits, cake mixes and flours are also available on prescription.

Prescriptions for these products do occasionally cause problems. A typical prescription might read "Juvela gluten free wheat free white fibre loaf sliced". Juvela also do brown loaves, non-fibre loaves, non-sliced loaves, and so on. At least their products are long life though. Bigger problems arise when you order freshly baked products and are told they will arrive on a certain date. Of course you relay this information to the patient so they know when to collect their prescription. But then the bread does not turn up on the date you were given and you have to placate an irate patient...

Coeliac UK have a very useful website with lots of information on coeliac disease and gluten-free products and services.