The Pharmaceutical Journal
Vol 268 No 7181 p55-58
19 January 2002

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Letters to the Editor

Prescribing (3 letters)

Levonorgestrel confusion

From Mr J. Mason, MRPharmS

Your readers, particularly those employed in primary care organisations, may be interested to learn of a situation that has come to light following a recent review of one of my GP practice's PACT data.

While trawling through the practice's PACT catalogue I noticed that there were entries for both Levonelle-2 (the POM product) and Levonelle (the P product). I asked our data analyst to perform a search of ePACT for all Levonelle-2, Levonelle and levonorgestrel 750µg items prescribed by our GPs from January 2001 onwards. Up to March 2001, all prescriptions for levonorgestrel 750µg tablets were for either Levonelle-2 or the generic, and there were no prescriptions for Levonelle. From April 2001, there were 43 prescriptions for Levonelle. This represents an additional cost to our primary care group of more than £250. If this was extrapolated across the country it would represent a considerable expense to the health economy — approximately £125,000 at a rough estimate.

I was interested to find out why all prescriptions for Levonelle should have been written after April 2001. Acting on a hunch, I checked with one of our practices how frequently their computer system is updated. The practice confirmed my suspicion that its system is updated quarterly and that Levonelle was added to the drug dictionary at the beginning of April. A quick check on the system showed that the drug dictionary defaults to Levonelle rather than the POM product or the generic.

As a result of these findings, we have written to all of our GPs reminding them that there are two branded levonorgestrel 750µg products and that they should be careful which one they select from the drug dictionary. We also suggested that, if possible, they should remove Levonelle from their formulary. We have also included an article in our prescribing factsheet.

We wrote, too, to all of our community pharmacists asking them to return prescriptions for Levonelle to the GP for amendment to Levonelle-2. To assist this process we produced a leaflet for pharmacists to attach to returned prescriptions. Readers who would like copies of the letters or the leaflet can contact me by e-mail.

This situation raises an interesting question as to how the NHS can gain redress for such unnecessary expenditure. I am tempted to write to each of the computer system suppliers involved with an invoice requesting payment for the difference in cost between the POM and the P product. These suppliers need to be more careful when adding new drugs to their drug dictionaries and should think twice about adding new P products when the POM version remains available.

Jonathan Mason
Prescribing Adviser
Canterbury and Coastal Primary Care Group
(Jonathan.Mason@ekentha.nhs.uk)

Who's to blame?

From Ms M. Y. Sharma, MRPharmS

I have revisited hospital pharmacy after working in primary care for some time. It has amused me to note that, while general practitioners tend to blame their hospital colleagues for some prescribing (eg, enteric-coated aspirin, high-cost products) but remain reluctant to make any changes, too often, when questioned as to the rationale for prescribing certain drugs, hospital doctors respond with the comment "well, they came in on that". Where does this leave the patient, and indeed the pharmacist?

Monica Sharma
Dewsbury, West Yorkshire

Usefulness or otherwise of new formulations

From Mr D. S. Reece, MRPharmS

In response to Mohammed Hussain's letter (PJ, 5/12 January, p17) may I offer my thoughts?

Where a long-acting sulphonylurea is indicated, the most cost-effective one is glibenclamide. Hypoglycaemia, particularly in older patients, is a well-known adverse effect of long-acting sulphonylureas. It is common practice to switch patients experiencing hypoglycaemic episodes associated with glibenclamide to a shorter acting drug, such as gliclazide. Therefore do patients need a modified release gliclazide? I think not.

One of my tasks as a locality pharmacist is to update the locality formularies that have previously been developed. The issue of loratadine has been discussed with several general practitioners. The options in this situation are to switch patients to either desloratadine or a different drug entirely. Probably the most sensible option is to switch to desloratadine and, once a generic loratadine becomes available, switch back. This may involve the practices in a little more work but it would eventually reduce the practice budget. If this is carried out across the country it may, perhaps, dissuade companies from indulging in manipulation of the market.

The situation with doxazosin is more complex, but the same strategy is feasible. The real issue here is whether or not alpha-blockers should be prescribed as commonly as they are when there is so much high-quality evidence for the cardiovascular benefits of thiazides, beta-blockers and ACE inhibitors.

David Reece
Locality Pharmacist
North Eastern Derbyshire Primary Care Trust

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