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GP care of millions of people has been thrown into turmoil after the Government's drug regulator ruled the painkiller co-proxamol would be withdrawn.

Surgeries reported being swamped with worried patients after the Medicines and Healthcare Products Regulatory Agency said the risks of overdose outweighed the benefits.

GPs were acutely divided over the decision to phase out the drug over the next six to 12 months and attacked Committee on Safety of Medicines advice on alternative treatment options. They said there were no adequate alternatives and that patient care would suffer.

An MHRA consultation launched last year found there were 300-400 fatal overdoses each year from co-proxamol, 20 per cent of them accidental.

The agency was particularly concerned over the dangers of combining co-proxamol with alcohol or central nervous system depressants and said exceeding the maximum daily dose by as little as two tablets could cause death.

GPC prescribing sub-committee chair Dr Peter Fellows said he had opposed the withdrawal but sub-committee members were split. 'This is going to cost a lot of money and it is not going to benefit patients,' he said.

Dr Graham Archard, chair of the RCGP's pain management group and a GP in Dorset, said the committee's suggestion of paracetamol as an alternative would not be acceptable to patients. He also criticised the advice to move to an NSAID if paracetamol was not effective, saying: 'I am very concerned about putting patients on long-term NSAIDs because of the side-effects.'

Only last month, MHRA said NSAIDs should be used 'for the shortest period


Dr Archard said he would be moving straight to a combination of codeine and paracetamol. But Dr Fellows said codeine-containing drugs were also dangerous as they were addictive, constipating and caused headaches.

Dr Neal Maskrey, medical director of the National Prescribing Centre and a participant in the CSM discussions, admitted: 'On safety, neither option is terribly attractive.'

He advised each patient should be assessed individually before an NSAID or low-potency opioid was prescribed.

The CSM said patients should be taken off co-proxamol at their next medication review, but GPs urged prompt action before production of the drug was stopped.

CSM advice on pain management for mild

to moderate pain in adults

Acute pain

Step 1 Paracetamol

Step 2 Substitute ibuprofen

Step 3 Add paracetamol to ibuprofen

Step 4 Continue paracetamol and replace ibuprofen with an alternative NSAID

If an NSAID is contraindicated or not recommended, substitute a low-potency opioid

Where pain is not controlled on step 4, a low-potency opioid may be added

Chronic stable pain

Steps 1-4 as above

Step 5 Low-potency opioid added to full dose of NSAID or paracetamol

Step 6 Therapeutic trial of tricyclic antidepressant or anticonvulsant

By Cato Pedder

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