The Pharmaceutical Journal
Vol 268 No 7195 p568-572
27 April 2002

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Letters to the Editor

Prescribing

Evidence base must take precedence over marketing

From Mr P. D. Burrill, MRPharmS

The top 10 most costly drugs prescribed in the National Health Service in 2001 (PDF* 50K) reveals the many influences on prescribing (PJ, 20 April, p528). The prescribing of simvastatin was first stimulated by the Standing Medical Advisory Committee guidance back in 1997 but there has definitely been a resurgence since the National Service Framework for Coronary Heart Disease. Simvastatin has a strong evidence base and is licensed for secondary prevention.

Is it justifiable to substitute another statin, atorvastatin, which does not have the same evidence base nor the required licensing, simply because it is potentially cheaper? The Drug and Therapeutics Bulletin does not think so.¹ Do the prescribers who have raised atorvastatin to the heights of number three in the top 10 realise that they are mostly prescribing "off-licence"? Interestingly, Pfizer has recently been reprimanded for inappropriate promotion of unlicensed medicines and off-licence indications, including atorvastatin.²

By all means, release scarce resources by substituting an evidence-based but cheaper drug for one that consumes a large proportion of your budget. A good example from the top 10 is amlodipine, described by Dr Brian Curwain as being "sold well to prescribers" (PJ, April 20, p528). Why not use felodipine, which has arguably a stronger evidence base and costs a third less? Another example from the top 10 is paroxetine, when fluoxetine is now likely to be a much more cost-effective selective serotonin reuptake inhibitor.

The inclusion of doxazosin in the top 10 is of concern and prescribing continues to increase. Many prescribers seem unaware that the doxazosin arm of ALLHAT was discontinued prematurely because of worse outcomes compared with the thiazide diuretic.³ Given that thiazides, beta-blockers, ACE inhibitors, some dihydropyridine calcium channel blockers, and now losartan have an evidence base in the management of hypertension, doxazosin should be required only rarely. If an alpha-blocker becomes necessary, why not use the much cheaper prazosin?

Long-acting beta₂-agonists, such as salmeterol, are an important option in the management of asthma. However, their use too early can lead to underdosing with inhaled steroids. There is a dose-response curve for inhaled steroids but it is important to achieve an effective dose before considering adding in a long-acting beta₂-agonist. The recently updated north of England guideline suggests this will be in the region of 1,000µg of beclometasone daily.⁴

Pharmacists must continue to promote evidence-based and cost-effective drugs in preference to those that are well marketed. As the Drug and Therapeutics Bulletin said nearly 10 years ago, "a drug should be prescribed because of the weight of evidence in its favour, not because of the weight of the manufacturers promotional effort behind it".⁵ It is possible to reduce the influence of the pharmaceutical industry on prescribers and change the top 10 mostly costly drugs to a more appropriate selection.

Peter Burrill
Specialist in Pharmaceutical Public Health,
North Derbyshire Public Health Network

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