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The waiting game

The BNF - then and now

GP Dr Alan Begg reflects on how the BNF has changed over the past 60 years

The 1960 edition of the BNF is a gem of a publication that illustrates how much therapeutics and prescribing have changed in 60 years. The Joint Formulary Committee was established in 1946 to compile a standard prescribers’ formulary, which became known as the BNF. The 1960 edition, which was the fifth, was designed to fit easily into a white coat pocket. Infrequently prescribed items were excluded to make way for new preparations such as chloramphenicol eye drops and hydrocortisone cream. Doctors were reminded that they were free to prescribe what they considered to be best for the patient – a far cry from the restrictive formularies of today.

Read more: Pulse at 60

Antibiotics

Antibiotics that we would recognise today, such as phenoxymethylpenicillin, oxytetracycline and erythromycin, were in common use by 1960. Even then, the prescriber was warned to ensure the nature of the condition had been established and the patient would respond to the therapy. There was a warning to avoid indiscriminate use in order to prevent resistance and drug sensitivity. Antibiotics were also discouraged for minor infections such as small boils and mild tonsillitis. Does this sound familiar?

Then and now

bnf 2 cmyk

1960

  • Weighs 225g
  • 272 pages
  • Measures 17cm x 11cm
  • Nine-page infants’ section

2020

  • Weighs 1kg
  • 1,678 pages
  • Measures 22cm x 16cm
  • Separate children’s edition of 1,132 pages

Analgesics

Aspirin was considered to be relatively non-toxic, although the potential for GI upset was noted. Paracetamol was also described as ‘relatively non-toxic’. Phenacetin was later withdrawn because of its toxicity. None of the current common anti-inflammatory drugs was available in 1960. Phenylbutazone, which was later withdrawn, was documented in this edition along with most of its side-effects. The danger of addiction with morphine and its derivatives was clearly highlighted and the prescribing of these schedule IV drugs was subject to strict controls. In spite of this, prescribers have had a role in the ‘addiction’ epidemic with increasing use of codeine-based drugs and gabinoids. It is almost as if the advice in 1960 was not heeded.

Hypnotics

A hypnotic was recommended to aid sleep in pyrexial conditions. Chloral hydrate, flavoured with blackcurrant syrup, was freely used in infants and children. For insomnia, the advice was to encourage sleep with a ‘suitably flavoured’ hot milky drink before bed – advice that still holds good today. There were no benzodiazepines. Medium-acting barbiturates such as amyobarbitone kept patients asleep for up to eight hours. Longer-acting ones tended to cause a hangover. Addiction was a major problem and doctors of this period can recall the difficulty of persuading elderly patients to come off these drugs. Perhaps the advice should have been that the first prescription was already one too many.

Tonics and vitamins

Vitamin and mineral supplements are now a multibillion-pound industry. In 1960, a normal diet was felt to provide an adequate supply of vitamins, with prophylaxis recommended to prevent deficiencies at critical periods. There was a warning that the symptoms of vitamin deficiencies were non-specific and indistinguishable from common psychogenic complaints.

Tonics were used to restore the feeling of wellbeing, but it was acknowledged that many acted through psychological mechanisms. Two strychnine mixtures, containing dilute hydrochloric acid and chloroform water, acted as tonics although the one containing ferric salts was not to be used to treat iron-deficiency anaemia.

GI, respiratory and cardiac drugs

We would find this pharmacopoeia extremely limited. Antispasmodics were available but treatment of peptic ulcer was restricted to antacids and the advice to take small frequent meals. Respiratory and cardiac conditions did not warrant an explanatory section. Aminophylline, prednisolone, isoprenalin and injectable adrenaline were mainstays of treatment. Diuretics were limited but GTN, amyl nitrate and digoxin were available. High blood pressure was treated with reserpine or pentolinium – which does not appeal today.

Yet to come

We could not have imagined back then how receptor agonist and antagonist agents would change therapeutic approaches, or how statins would affect mortality. Today, the medicines we are most excited about are biologics, for the treatment of chronic conditions. Who knows what else lies ahead?

Dr Alan Begg is a GPSI in cardiology in Montrose, Scotland

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Readers' comments (7)

  • lovely Dr Begg.

    I enjoyed your article.

    thank you

    - anonymous Salaried!

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  • It’s size is now reducing its usefulness I find.

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  • Proof of what beuraucracy has done to medicine- more pen and paper pushing.

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  • Would help if font size had remained...and had it not been dumbed down!

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  • The big change is that the bnf was once useful, before the obsessives turned it into an encyclopaedia of obscure potential interactions, rare side-effects and theoretical contraindications.

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  • The book is now a tome, and the print requires my auroscope!

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  • The BNF has become so bloated its barely useable now and I have taken to using mims instead.

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