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...reduced

co-proxamol prescribing by 95 per cent

With GPs now facing the task of having to get patients off co-proxamol following its withdrawal by the Medicines and Healthcare Products Regulatory Agency, Dr Peter Frith explains how he reduced the number of patients on the drug from 438 to 20

What we were up against

In 2003 we were sufficiently concerned by the published evidence of co-proxamol-associated fatalities1 that we discussed the issue with our PCT prescribing adviser.

We formulated a policy to reduce how much we were prescribing. We had considerable misgivings, and expected our patients to be opposed to what we were doing. Some were, but we were surprised by the results we achieved. We aimed for a 50 per cent reduction but were surprised when the actual reduction was 80 per cent.

We have since revisited the remaining 20 per cent of co-proxamol users to repeat the process and achieved an overall reduction of 95 per cent.

What we did

Our prescribing policy had three strands:

·Not to initiate any new co-proxamol prescribing

·To ask patients to swap to alternative analgesics when they attended for other reasons

·To systematically write to all patients and ask them to try alternative analgesics.

The policy ­ developed with great help from Chris Lawson, former prescribing adviser, and Liz Richardson, former prescribing technician of Mansfield and District PCT ­ obviously needs all the doctors in a partnership to consistently apply the first two strands.

The third strand needed more organisation, but we were fortunate to have a PCT prescribing technician working one day a week in the practice, and she did the majority of this work. The main points to the third strand were:

·To write to all patients on co-proxamol and ask them to try up to full-dose paracetamol instead of co-proxamol.

·If full-dose paracetamol did not give adequate analgesia, they could contact the surgery and ask to have codeine added to their prescription. This was 15mg initially, and could be increased to 30mg if necessary. This was not as co-codamol but in addition to paracetamol. Alternatively they could make a doctor's appointment to discuss the matter further. If patients were still dissatisfied with paracetamol and codeine we allowed them to return to co-proxamol.

·We did not write to everybody at once. We sent out 10 letters a week. This prevented us from being overwhelmed with queries and requests for appointments. In fact it made no appreciable difference to our workload.

It must be pointed out that we had the 'luxury' of allowing the remaining 20 per cent to go back on co-proxamol and of course this is no longer an option.

We used codeine as a second-line analgesic to add to paracetamol because that's what the PCT adviser suggested. I think the rationale is that co-proxamol is a combination of paracetamol plus an opiate (dextropropoxyphene). By using paracetamol plus codeine we were replacing one opiate with another ­ ie replacing like for like.

Codeine as a mild opiate is good at relieving mild/moderate pain. Its side-effects include nausea, drowsiness, constipation and headache. While significant they are not as potentially serious as the NSAIDs (see BNF for full list).

What I would do now co-proxamol has been officially withdrawn

All GPs should have received Professor Gordon Duff's e-mail/letter from the Committee on Safety of Medicines of January 31 formally announcing the withdrawal of co-proxamol over the next six to 12 months. It clearly summarised why co-proxamol is being withdrawn and contains advice on the treatment of mild to moderate pain.

The pharmalogical advice differs from what we did because it suggests the possible use of ibuprofen as a second step after paracetamol.

Ibuprofen is an effective well-tolerated NSAID. It is probably the safest NSAID, as well as being available without prescription. But as an NSAID it does potentially have some serious side-effects: dyspepsia/gastric ulceration/bleeding, wheezing in asthmatics, fluid retention and worsening of heart failure, and renal failure for people with renal impairment. These risks get higher with increasing age (see BNF 10.1.1).

I am not sure how this will work out in practice as some people will already be on NSAIDs and others will have contraindications to its use (we used paracetamol and codeine as our second step).

The CSM letter also advises that patients should be changed from co-proxamol when they next attend for a routine medication review. But I would recommend that practices approach the problem in much the same way as we did with our three-strand policy.

The first two strands remain unchanged, but I would modify the third to contain the following steps:

·Identify a member of staff who will take responsibility for implementing your policy.

·Identify all patients on co-proxamol (arrange to see those on warfarin to arrange extra INR monitoring when changing them to paracetamol or other alternatives).

·Write to all the remaining patients on co-proxamol at a number per week that will allow you to cope with queries and requests for appointments (see example letter top right).

·In the letter ask patients to change to paracetamol (up to its maximum dose).

·If full-dose paracetamol does not provide adequate analgesia, discuss other alternatives (this can be done over the phone).

The remaining challenging patients

Since Professor Duff wrote his letter we have revisited the remaining 20 per cent of co-proxamol users and taken much the same approach again. We now have a small group of about 20 patients who are having considerable difficulty finding alternative analgesia and who may be hard to help.

Considering that we originally had 450 patients on co-proxamol, this represents a relatively small and manageable number. While not detracting from the difficulties these people are facing, I don't think GPs need to feel overwhelmed by the problem.

What we achieved

Number initially on co-proxamol 438

Number who switched back to co-proxamol 87

Number patients no longer on list 10

Number no longer taking pain relief 38

Number taking alternative pain relief 303

Alternative relief breakdown

Paracetamol 187

Co-codamol 8/500 27

Co-codamol 30/500 28

Co-codamol 15/500 4

Co-codamol 30/500 plus tramadol 1

Paracetamol plus dihydrocodeine 3

Paracetamol plus codeine 15mg 10

Paracetamol plus codeine 30mg 4

Codeine 30mg 1

Co-dydramol 3

Dihydrocodeine 3

Tramadol 2

NSAID's 3

A further 26 of the 303 had subsequently stopped their analgesia after being switched over

Suggested letter to patients

Dear

You may have recently heard that the painkiller co-proxamol is being withdrawn. The chair of the Committee on Safety of Medicines has recently written to all doctors to announce this. Although co-proxamol is a popular painkiller, there have been concerns about its safety. The committee has decided that these safety concerns are sufficiently serious to justify co-proxamol being withdrawn in the next few months.

According to our records, you are being prescribed co-proxamol. It is generally accepted that paracetomol is just as effective as co-proxamol at relieving pain. We have therefore changed your repeat prescription from co-proxamol to paracetomol. When you have used your existing supply of co-proxamol, please order a prescription for paracetomol instead. You can take two tablets every four-six hours if you need to.

The maximum dose in 24 hours is eight tablets. If this dose of paracetomol does not provide you with adequate pain relief, please contact the surgery to arrange for a doctor to discuss the matter with you.

Yours sincerely

A Doctor

Reference

1. K Hawton et al. BMJ 2003: 326-1006-8

Further information

www.mhra.gov.uk

Peter Frith is a GP in Mansfield, Woodhouse, Nottinghamshire

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