e/c NSAIDS

[mm45]

A pharmacology lecturer recently told me that prescribing of e/c NSAIDs was just a waste of money compared to normal NSAIDs as they have no benefit to protecting the stomach as the drug still enters the system and acts on the stomach.

I just wondered if people agree with this...

[pharmatron]

It's not a case of whether people agree or not - it's fact!

Aspirin (salicylic acid) is a weak acid: it's local irritant effect is negligible in the acidic environment of the stomach (hydrochloric acid, pH~2). However, it has a profound effect on prostaglandin synthesis (permanently acetylates the cyclo-oxygenase enzyme).

PGs are essential for maintaining microvasculature and lining of the mucosa - hence aspirin causes GI irritation. This is a systemic effect not a local one consequently enteric coating will not prevent its occurence.

(The same is true for other ulcerogenic drugs e.g. prednisolone - EC will not solve the problem despite what many prescribers think!)

[johnep]

My wife was precribed Celebrex for her arthritis. worked well but started suffering from stomach ache and had GI bleed. Could not believe that Celebrex to blame and she ended up with a sigmoidoscopy. This found a bleeding point (not a cancer as feared) and after stopping celebrex and a course of omeprazole--all Ok. She now takes ibuprofen but still needs an omeprazole.

I had problems after a combination of aspirin plus a whisky, so now I am on lansoprazole as keeping aspirin 300mg and Ibu 400mg going to relieve arthritis.

when I was young prided myself on my 'cast iron' stomach.

johnep

[mm45]

yeah I relise the fact that NSAIDs inhibit PG synthesis and mucous secretion etc. But if e/c are no more benefitical then normal NSAID why are so many doctors prescribing them, surely it could save the nhs money if they just stuck to the normal coating...

[admin]

Originally Posted by mm45

yeah I relise the fact that NSAIDs inhibit PG synthesis and mucous secretion etc. But if e/c are no more benefitical then normal NSAID why are so many doctors prescribing them, surely it could save the nhs money if they just stuck to the normal coating...

I have always thought that these drugs also have a local irritant effect on the stomach, as well as the systemic effect. As well as enteric coating tablets, this can also be reduced by using the drug in another forrm - e.g. Diclofenac suppositories. I'm sure there must be studies to show that using e/c tabs, suppositories or even injections have less GI side effects then plain oral tablets.

[Zoggite]

Trust me, even diclofenac suppositories can give you stomach pains!
Maybe the e/c coating helps reduce irritation of the GI tract upstream of the stomach, i.e. the mouth, throat, & gullet; also coatings often mask the bitter taste of a tablet...
I don't think cost has anything to do with the formulation any more: why is omeprazole 20mg capsules so much cheaper that 10mg-capsules or 20mg-tablets?
While we're on the subject: has anyone else noticed the multiplication of scripts for aspirin 75mg dispersible, and on the same Rx omeprazole 20mg caps. "take one daily as on aspirin"? This leaves me very confused! What a back-to-front way of doing things!

[mm45]

yeah I have noticed this problem to. Just curious if you were able to influence prescribers what would you suggest to the aspirin 75mg Rx?

While I was working at a pharmacy, im only a student, I noticed a Rx for simvastatin 10mg two a day, I pointed out to the pharmacist that a Rx for 20mg once a day would be cheaper the pharmacist just said yeah and that was that. I just feel that even if we were to contact the prescriber and be taken seriously to suggest a change to 20mg once daily woud save the NHS money. Ok it would be huge amount of money but it would be a start.

[Zoggite]

Well, this is where those blessed MURs come in quite handy: not only do surgeries actually take notice of them (if you send the forms to their practice pharmacist), but you also get paid for doing so, the GPs get their QoF-points, AND the patient thinks you've actually done something for them! an all-round "win-win" situation!

[admin]

Originally Posted by Zoggite

Trust me, even diclofenac suppositories can give you stomach pains!
Maybe the e/c coating helps reduce irritation of the GI tract upstream of the stomach, i.e. the mouth, throat, & gullet; also coatings often mask the bitter taste of a tablet...

I know systemic diclofenac can still cause stomach problems via the mechanism already mentioned, but my point is that the e/c tablets or the suppositories must cause less irritation?

You can just sugar coat a tablet to mask the taste - cheaper to do then e/c coating.

I understand all the strange pricings in the drug tariff, but to an individual company production time is very expensive, so they would always rather reduce this, and thus save on costs.

[admin]

Originally Posted by mm45

yeah I have noticed this problem to. Just curious if you were able to influence prescribers what would you suggest to the aspirin 75mg Rx?

While I was working at a pharmacy, im only a student, I noticed a Rx for simvastatin 10mg two a day, I pointed out to the pharmacist that a Rx for 20mg once a day would be cheaper the pharmacist just said yeah and that was that. I just feel that even if we were to contact the prescriber and be taken seriously to suggest a change to 20mg once daily woud save the NHS money. Ok it would be huge amount of money but it would be a start.

I don't understand the pharmacist in this situation. I have contacted surgeries lots of times about statins, and they usually welcome any advice that saves THEIR budget - not the NHS. I find it's quite a good way to make first contact with them, as you are phoning up to save them money and not to just moan about something.