A higher figure is better

These drugs are classified as ‘less suitable for prescribing’ in the British National Formulary (BNF) by the Joint Formulary Committee. Examples of these drugs include diuretics containing potassium supplements, compound inhalers, and various drugs of limited clinical value. Although these drugs are not drugs of first choice, their use may be justifiable in certain circumstances. Where a drug is less suitable for one indication and not another, the drug is not included in this percentage figure.

The increased use and experience of a narrow range of drugs for particular conditions should reduce the incidence of side effects and dangerous interactions¹. The range of drugs prescribed is calculated by counting the number of different main item codes (i.e. first five digits of the CSA code). This means that each proprietary, generic and branded generic are classified as separate drugs. So for example, amoxicillin, Galenamox^® and Amoxil^® would be three drugs not one. However, different strengths and forms (e.g. tablet/syrup) of the same drug are classed as one drug.

1. McCarthy M, Wilson-Davis K, McGavock H. Relationship between the number of partners in a general practice and the number of different drugs prescribed by that practice. British Journal of General Practice 1992; 42: 10-12.

Many patients with gastro-oesophageal reflux disease can be adequately controlled on lower doses of proton pump inhibitors (PPIs) than currently prescribed and this is one of the main messages from the NICE guidelines on the use of PPIs¹.

1. Anon. Guidance on the use of proton pump inhibitors in the treatment of dyspepsia. National Institute for Clinical Excellence Technology Appraisal Guidance no.7 www.nice.org.uk 2000.

This indicator has been taken from the Delphi consultation study¹. The indicator was judged to be a valid indicator for cost minimisation.

1. Campbell SM, Cantrill JA, and Roberts D. Prescribing indicators for UK general practice: Delphi consultation study. BMJ 2000;321:425-428.

This comparator adds a volume component to the prescribing of ulcer-healing drugs.

When used in the treatment of hypertension, bendroflumethiazide 5mg daily does not reduce blood pressure more than 2.5 mg daily but the 5mg dose has a higher incidence of side effects¹. However, the higher dose may be required in the treatment of heart failure.

1. Carlsen JE, Kober L, Torp-Pedersen C, Johansen P. Relation between dose of bendrofluazide, antihypertensive effect and adverse biochemical effects. BMJ 1990; 300: 975-978.

Potassium-sparing diuretics are rarely necessary for the routine management of hypertension¹.

1. Anon British National Formulary (BNF) 45 March 2003.

The latest British Guidelines on the management of asthma state that nebulisers have not been shown to be superior to standard metered dose inhalers plus a spacer device for delivering inhaled steroids in chronic asthma¹.

1. British Thoracic Society and The Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Thorax 2003; 58 (Suppl 1) i1-i94.

Co-codamol effervescent 8/500 is no more effective than the non-soluble version (and unlikely to be any more effective than paracetamol alone). There are also concerns that effervescent tablets contain high amounts of sodium¹.

1. Department of Health advice on sodium content of soluble co-codamol and paracetamol tablets. Issued by Area Board Prescribing advisers 2002.

There is little evidence at present that combinations containing low doses of opioids with paracetamol are more effective than paracetamol alone and full doses of opioids are likely to produce adverse effects¹.

1. National Prescribing Centre. The use of oral analgesics in primary care. MeReC Bulletin 2000; 11: 1-4.

There is no difference in gastric toxicity between enteric coated and standard formulations of aspirin¹.

1. Kelly JP, Kaufman DW, Jurgelon JM, et al. Risk of aspirin-associated major upper gastrointestinal bleeding with enteric-coated or buffered product. Lancet 1996; 348: 1413-6.

Studies suggest a 50% reduction in serious gastric complications with rofecoxib¹ and celecoxib² but no anti-inflammatory drugs are without gastric adverse effects. NICE has advised restricting their use to those at high-risk of developing a GI event. NICE has also highlighted concerns regarding the cardiovascular safety of these agents and the fact that any gastric benefits are lost in patients also taking low-dose aspirin³.

In Northern Ireland, the rate of increase in the prescribing of rofecoxib and celecoxib is 4 times the magnitude of the rate of decrease in prescribing of 'older' NSAIDs. The volume and cost of anti-inflammatory prescribing in Northern Ireland has increased by a staggering 26% and 60% respectively between 1999 (before the introduction of rofecoxib and celecoxib) and 2002⁴.

1. Bombardier C, Laine L, Reicin A, et al. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. N Engl J Med 2000; 343 1520-8.

2. Silverstein FE, Faich G, Goldstein JL, et al. Gastrointestinal toxicity with celecoxib versus nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis: the CLASS study: a randomized controlled trial. JAMA 2000; 284: 1247-55.

3. Anon. Guidance on the use of cyclo-oxygenase (Cox) II selective inhibitors for osteoarthritis and rheumatoid arthritis. National Institute for Clinical Excellence 2001. www.nice.org.uk

4. Girvin B, Rafferty T, Stevenson MR, et al. Uptake of COX-2 selective inhibitors and influence on NSAID prescribing in N Ireland. Pharmacoepidemiology and Drug Safety 2004;13:153-157.

• Cost of peripheral vasodilators
• Cost of topical NSAIDs

• DDDs /1000 NIPUs for benzodiazepines
• DDDs /1000 NIPUs for zolpidem, zopiclone and zaleplon
• DDDs /1000 NIPUs for dihydrocodeine
• Items /1000 NIPUs for antibiotics

A larger figure is better

• Penicillin V, flucloxacillin, amoxicillin and erythromycin items as a % of total antibiotic items
• 500mg amoxicillin items as a % of (250mg + 500mg items)

A smaller figure is better

• Quinolones items as a % of total antibiotic items
• Co-amoxiclav items as a % of total antibiotics

The number of prescription items (rather than DDDs) has been used as a measure of the quantity of antibiotic prescribing since most antibiotics are prescribed as a short course of treatment.

The more effective use of antimicrobial agents has become a national priority due to the increasing problem of resistance. Strategies have included advice to reduce the overall prescribing of antibiotics - particularly for simple coughs, colds and sore throats¹.

The four antibiotic indicators are concerned with formulary choices. The prescribing of first-line agents (e.g. penicillin V, flucloxacillin, amoxicillin and erythromycin) is recommended over second-line agents such as quinolones and co-amoxiclav as detailed in the Public Health Laboratory Service guideline². (These recommendations are intended for consultation and adaptation according to local resistance patterns). The prescribing of high strength 500mg of amoxicillin rather than 250mg will be necessary for some infections such as community acquired pneumonia³.

Further information regarding ongoing strategies in Northern Ireland to tackle the problem of antimicrobial resistance can be found in the Antimicrobial Resistance Action Plan (AMRAP)⁴.

1. Standing Medical Advisory Committee Subgroup on Antimicrobial Resistance. The path of least resistance. Department of Health 1998.
2. Public Health Laboratory Service. Management of infection guidance for primary care: draft for consultation and local adaptation. www.phls.co.uk
3. MacFarlane J, Boswell T, Douglas G et al. BTS guidelines for the management of community acquired pneumonia in adults. Thorax 2001; 56 (Suppl IV) iv1-iv64.
4. Antimicrobial Resistance Action Plan (AMRAP) 2002-2005.www.dhsspsni.gov.uk

• DDDs /1000 NIPUs for co-codamol 8/500
• DDDs /1000 NIPUs for co-codamol 30/500
• DDDs /1000 NIPUs for co-dydramol
• DDDs /1000 NIPUs for co-proxamol