How to save the NHS - First cut the drug bill

NB - THIS BLOG IS NOT HEALTH ADVICE FOR INDIVIDUALS - PLEASE TALK TO YOUR DOCTOR BEFORE TAKING ANY ACTION BASED ON THIS POLEMICAL ARTICLE. 

I had a look at the list of high cost drugs for our practice the other day, and was shocked.

Not by the million or so pounds that we spend on medication in a year, as I already knew that figure.

I am used to the fact that we spend more on drugs than on all the other costs for the practice put together.

What shocked me was how little benefit our patients get from the drugs on the list : by how poor the evidence for their effectiveness is, and how many of them have definite harmful effects.

Top of the list comes various inhalers for COPD (Chronic Bronchitis and Emphysema). We spend £77500 in the practice which is about 5.5% of our total.   Each inhaler costs around £30-60 for a months supply and many patients have 2 different ones. I have yet to meet a patient who has said ' Thanks doc for that great inhaler which is so much better than the Ventolin you gave me first off' . The evidence that any of them benefit patients significantly is weak, and they neither prolong life nor delay the progression of the disease.  And there are definite risks of Pneumonia for inhaled steroids, and concerns about an increase in the risk of heart attacks.Inhaler risks

Many patients are started on them after a hospital admission, and they are never stopped in outpatients because of lack of benefit.

2nd come so called sip feeds or food supplements for undernourished patients at an annual cost of £45000. All doctors know these from visits to nursing homes. They come in small cartons with a straw at the bedside of patients who have given up and stopped eating for various reasons. They are the ultimate UHT food. Sticky liquids full of preservatives and empty of freshness or taste or of anything that might be described as tempting.

They do contain nutrients, but often they contain less than are found in full cream milk. They do persuade relatives (who don't see them being tipped in the bin), that something is being done, but there is very little evidence that they are of any benefit in the categories of patient (terminal cancer, and severe general frailty) in whom they are mostly  used.

Next comes Pregabalin (Lyrica), which was developed for epilepsy but is now used for chronic pain. We spend £35400 per year. This is odd as few of the doctors in the practice admit to having ever started this drug. It costs around £100 per month for a typical dose, around 10 times as much as the main alternative gabapentin (to which it is very similar), and around 50 times as much as the standard treatment amitriptyline. It was advised by NICE (the national institute for health and care excellence) in 2013 for neuropathic pain in spite of the analysis showing that the clinical benefit of the drugs was very limited, and that no one treatment was superior to the others.NICE CG173

It is also used by psychiatrists treating patients with anxiety and personality disorder, which seems inadvisable as it works in a similar way to Valium and other Benzodiazepines which have caused huge harm because of addiction and other adverse effects and it also has been shown to have a  a large abuse potential. This is so bad that pharmacies have been broken into and this has been the only drug that has been taken.Guardian review

Fourth is Rosuvastatin (Crestor). We spend £25580  per year on this variety of statin. If patients were treated with Atorvastatin, which has similar potency, we would save 95% percent of this money. In this case we are the ones responsible. We started using it a few years ago when we were trying to get patients total cholesterol down below 5 in order to get our QOF (Quality and Outcomes Framework) money. We were also persuaded that getting cholesterol levels right down benefitted patients with arterial disease. Since that time other statins have got a lot lot cheaper, and we have tried to swap patients, but many were not keen, and we didn't push it. Although Rosuvastatin is arguably more dangerous than other statins drugwatch.com, we were worried that if a patient who was changed against their will then suffered a bad event ( as some are bound to do), we would get complaints and hassle etc.

  

5th comes human insulin at about £24000  Note the human. Insulin has been available for 80 years and was formerly extracted from pigs pancreas. More recently genetic engineering means that it can be made from yeast. One would think that this would make it much cheaper to produce. Instead the makers, who now form a sort of worldwide Triopoly, consisting of the Danish Novo and the US Eli Lilly,  together with the French Sanofi, have withdrawn the cheaper brands.  Patients have had to be transferred to the modern versions that cost much more. One example is the withdrawal of a popular insulin made by Novo which was estimated to cost the NHS £9m annually as patients were switched pharmaceutical-journal.com. Cheaper insulin is available in India etc. but is not licensed in the uk, and it would be against Gmc guidelines anyway.

6th comes co-codamol, a combination of codeine and paracetamol. One of the most widely used painkillers, this used to be cheap as chips.

The evidence that either paracetamol or codeine is actually helpful long term for patients with chronic joint pain is actually very very poor. NICE (the national institute for clinical excellence) recently suggested removing paracetamol from its recommendations for osteoarthritis.  They only stopped short of doing this when it was pointed out that this would lead to a rise in opioid use pulsetoday.co.uk.

7th are antidepressants. These are now being taken by around 9% of adults in England according to Eurobarometer comparison survey results .The main drugs increase the amount of a chemical called serotonin at nerve endings in the brain. Depressed people suffer a deficit of this chemical and the drugs correct this. Sounds logical doesn't it? Except for the fact that the serotonin theory of depression never fitted the facts and is now completely discredited thepsychologist.bps.org.uk.  In fact one of the newer antidepressant treatments agomelatine, actually antagonises serotonin. Patients and doctors think that the drugs 'work' because there is a huge tendency to natural recovery from depression. Simply going to the doctor and taking a pill every day helps hugely. Similarly, stopping the drugs is tricky, because they affect neurotransmission in the brain and the body has self correcting mechanisms that attempts to counteract the effects. When patients have a bad week from drug withdrawal shortly after stopping (which is likely to happen), they are likely to restart treatment.

According to NICE (cg90), drug treatment is likely to be ineffective ( I.e. Of no benefit) in patients with situational stress, and mild to moderate depression. According to the bnf the common drugs, so called SSRIs, are dangerous when taken with anti inflammatory medication like ibuprofen because they cause gastric bleeding. Yet only a tiny minority of patients are aware of this risk, and ibuprofen is on sale in supermarkets. That so many patients can be taking so much useless and potentially dangerous medication costing so much money demands an explanation. The explanation seems mainly to be that psychiatrists are in the pocket of the drug industry to a much greater extent than other sorts of doctors according to researchers including Peter Goetsche who heads the Nordic Cochrance Centre for Evidence Based Medicine theguardian.com.

8th comes acid reducing drugs (PPIs) like omeprazole. These on the other hand are very very effective drugs for heartburn and indigestion. So it is not surprising that around 15% of our patients age 50 and above are on them.  But we should not need them, because almost all of the patients could cure themselves by altering their lifestyle, or by taking safe drugs  like antacids and ranitidine.  These drugs cause thinning of the bones and vitamin b12 deficiency and chronic kidney damage, and can cause serious illness from magnesium deficiency. They also make patients vulnerable to the hospital superbug C. difficile physiciansweekly.com.

9th on the list are tablets for controlling sugar levels in type 2 diabetes. Costing around 2% of the total we spend around £20000 on these. Our patients generally feel no benefit from them.  Most patients have very few symptoms anyway and if they do then the lowering of blood sugar with the drugs is small, and of trivial benefit. They are prescribed in the hope that reducing sugar levels will prevent the dreaded complications of diabetes such as amputation and blindness. No such beneficial effect on outcomes has been shown for any of the newer drugs, perhaps because such problems are very rare in the typical patient. In fact the diagnosis of this form of diabetes was recently shown to be associated with an INCREASE in life expectancy, for patients diagnosed after 60 and without kidney damage www.efpia.eu. While the benefits are doubtful, the hazards are not, with potentially deadly cases of pancreatitis caused by some of the new drugs at the top of the list. There is also considerable concern that they may cause pancreatic cancer www.drugwatch.com.

If we cut our prescribing of these drugs, which use up around 20% of our budget, by 90% we would save around £135000 per year for our practice which is probably typical for the UK. If this was replicated across the country the saving would be around £1.2bn – roughly one percent of present NHS costs. Worth doing – but we need leadership from the NHS, the specialist Royal Colleges, and the Government, and who of those is not getting money from big pharma?