The Pharmaceutical Journal
Vol 279 No 7477 p528-530
10 November 2007

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• Retention fees
• Concessionary fees
• Pack sizes (5)
• Prescribing
• Controlled drugs
• Hospital infections
• Wholesalers
• Locum pharmacy
• BPC

Letters to the Editor

Pack sizes

Who do they think they are kidding?

From Mr A. T. Thompson, MRPharmS

It is sad to read the response from Sanofi-Aventis and Bristol-Myers Squibb (PJ, 27 October, p467) to criticism levelled at their decision to change pack sizes of Plavix from 28 to 30.

Aspects of the justification provided by their medical directors immediately reminds me of the explanation given when the same company decided to change the Tritace formulation of ramipril from capsules to tablets, namely “the transition from Tritace capsules to tablets is happening due to global manufacturing rationalisation within Aventis” (PJ, 25 October 2003, p578).

Unless I am mistaken, companies within the Sanofi-Aventis family have continued to manufacture ramipril capsules, and thus the central plank of that argument has been consistently undermined.

It has become predictable that companies desperate to protect valued markets increasingly resort to creative tactics such as single enantiomers, novel formulations and modified release preparations. So come on Sanofi-Aventis, stop dressing up the Plavix pack size change as anything other than the latest addition to the armamentarium of profit-maintaining techniques.

I, for one, would accept an honest declaration of that intent far more than an attempt to justify the decision on the grounds they have given.

Angus Thompson
Independent Prescribing Adviser
Ilminster, Somerset

Please do not insult our intelligence

From Mr H. Shinebaum, MRPharmS

When I read that Sanofi-Aventis was going to increase the pack size of Plavix from 28 to 30, I thought it would provoke some correspondence and that any reply from the company would side-step all the relevant issues. I was not to be disappointed: there it all was in the PJ of 27 October (p467).

So what has happened? Without any consultation with pharmacy representatives, the pack size has increased to 30 and the price by £2.52 per pack. We currently have both sizes on our shelves. They look identical. There is a good chance that some pharmacists may have already dispensed the larger size in error for 28, and lost £2.52.

The Pharmaceutical Services Negotiating Committee has informed us that Plavix has not been granted “special container” status, so contractors will only be paid for 28. This will upset the “anti-snip” brigade. The result will be lots of “snipped off” strips of two in the dispensary.

There may be a customer who will be prepared to have 14 lots of two but, hold on, what about the batch numbers and information leaflets? The end result is that stock holding can go up by at least 7 per cent on this one expensive product alone.

My local primary care trust has a large project on at the moment encouraging patients to cut down on ordering excess medicines where possible. But how many patients will not order their Plavix alongside their other regular medicines, because they get two more tablets per pack?

Also, most medicines use reviews performed result in patients’ medicines being synchronised to reduce waste. So the Plavix pack size change just complicates the situation.

Reading between the lines, Sanofi-Aventis has just increased the turnover of its best selling drug by 7 per cent. The reply from Sanofi-Aventis and Bristol-Myers Squibb’s medical directors says the new pack will have security elements to ensure the origin of the product (surely the 28 pack could have the same new packaging).

Also, GP prescribing systems will automatically default to the 30 pack. This will only work when added as a new drug and does not apply to drugs already on repeat. Their final comment is that the daily cost of Plavix has not changed. Are we not all grateful for that?

Well done Sanofi! At a time when it is changing its distribution methods and would be looking for support from pharmacists, it has just alienated a lot more. If it genuinely wanted to help pharmacists, why did the price not stay the same and then pharmacy would benefit from a bit more profit in these difficult times. If it is not a move just to make more money from its best drug, then why has another of its drugs, Zimovane, not been changed to 30s?

These questions do not need a reply from Sanofi. We are not stupid and know the reasons for the change already: extra turnover and profit, and back-slapping in the boardroom.

We can show our disapproval. Pharmacists will search out a reliable supply of parallel-imported Plavix, and look forward to the market being flooded with generics when the patent expires.

Howard Shinebaum
Sutton Coldfield, West Midlands

There must be a better way

From Mrs J. M. Walls, MRPharmS

In reply to Mike Spencer on the subject of the change of pack size of Plavix tablets from 28 to 30, Tony Whitehead and Frances Mackintosh of Sanofi-Aventis and Bristol-Myers Squibb, respectively, state that GP prescribing systems are being updated to default to the 30 pack (PJ, 27 October, p467).

Are they aware that most prescriptions for Plavix are repeats? Do they know whether the software will be able to change the quantities on these prescriptions?

Their response fails to address the point made by various correspondents that patients will be left with 28-day quantities for almost all other drugs, causing a huge synchronisation problem which will contribute to a waste of NHS resources.

There may well be a need to secure the supply chain but there must be a better way of doing this.

Jacqueline Walls
Crowborough, East Sussex

Treated with contempt

From Mr M. Stein, MRPharmS

So the 30-day pack of Plavix has the same daily cost as the 28-day pack and GP prescribing systems will now default to the 30-pack (PJ, 27 October, p467). What does that mean in response to the excellent letters querying the logic behind the change in pack size? The response from the company representatives treats us with utter contempt.

When I am finally made redundant by checking technicians and multiple pharmacy pharmacists, I think I shall try to become a new successful medical professional who is treated with respect, listened to and allowed to climb the ladder of success and enterprise. Yes, a nurse.

Malcolm Stein
Hatfield, Hertfordshire

A profit-generating exercise

From Mr A. K. Patel, MRPharmS

So Sanofi-Aventis and Bristol-Myers Squibb have come up with changing GP systems, the fact that the daily dose price of Plavix will not change and counterfeit issues to explain the change from 28-day packs to 30-day packs (PJ, 27 October, p467). I am sure extra security measures could also be put on a 28-day pack.

As John Strachan has written (ibid, p467) this has nothing to do with safety or counteracting counterfeit medicines but is simply a profit-generating exercise.

Ahmed Patel
Batley, West Yorkshire

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