The risks around prescribing of nitrofurantoin have been flagged by the UK’s Medicines and Healthcare products Regulatory Agency (MHRA), and in this issue we have a clinical article detailing the potential risks around pulmonary and hepatic adverse drugs reactions. There is always risk with any prescribing, though some medications have proven more alarming than others. In my time I have prescribed, in good faith: co-proxamol, sibutramine, rimonabant, ranitidine, rosiglitazone, and cisapride. All of these have been withdrawn from the UK market. Anti-obesity medications such as sibutramine and rimonabant have a chequered past and another, the GLP-1 agonists, are surging so one might reasonably assume reports of adverse events could soon see an uptick.
Co-proxamol, an analgesic combining paracetamol and dextropropoxyphene (a weak opioid), will be unknown to a younger generation of GPs, but was commonplace in pain management. Unfortunately, it was ludicrously dangerous in overdose, though that would go unnoticed in most GP careers so no one was clamouring for change. The bigger picture was clearer and the MHRA put in place a phased withdrawal that was completed by the end of 2007. A 6-year follow-up of impact estimated that there had been 500 fewer deaths between 2005 and 2010 than there would have been if co-proxamol was still available.1 (And there was no evidence of an uptick in deaths with other analgesics.)
It’s worth lingering on the harrumphing by the medical profession at the time. One letter in the BMJ condemned the co-proxamol withdrawal as ‘illogical’ and ‘How am I to explain to my older patients with arthritis that a useful painkiller they have used for years is to be withdrawn because younger folk irresponsibly overdose on it?’2 (In itself, a revealing comment on the stigmatisation of mental health problems 20 years ago.) An article in the BJGP managed to suggest, perhaps tongue-in-cheek, that the withdrawal ‘may relate more to the politics that surround Dr David Kelly’s suicide’.3 Kelly was the Gulf War weapons expert who died in 2003, with co-proxamol implicated in his death, amidst the scandal around a dossier detailing possible Iraqi weapons of mass destruction used to justify war.
Sometimes, it is hard to change prescribing habits. It used to be relatively commonplace to prescribe steroid depot injections for hayfever. Severe hayfever can be horribly debilitating but the side effect profile, unsurprisingly, makes for grim reading and in most cases the risk/benefit argument was not ideal. That fell out of favour and is no longer available on the NHS. So, despite prescriber reticence to change habits we shift, albeit grudgingly on occasions.
Issue highlights
Prescribing or, more pertinently, discontinuation of the prescription of HRT is covered in an editorial this month. As well as an Analysis article on overprescribing, we also have research focusing on medications. We cover prescription duration for long-term conditions, direct oral anticoagulant–statin drug interactions, low-dose amitriptyline and mirtazapine in insomnia, and antidepressants and postural hypotension. Beyond the drugs we have important editorials on violence against women and girls, the ethics on recruiting an international healthcare workforce, and another Analysis article on building research workforce capacity in academic general practice. And, of course, all the wonderful voices and opinions in Life & Times.
The MHRA, thank goodness, continues to give us plenty to consider: propranolol, another medication that is worryingly toxic in overdose; fluoroquinolones with their alarming set of side effects; finasteride, which can cause psychiatric side effects including suicidal thoughts and sexual dysfunction that can be persistent; and aripiprazole and the risk of pathological gambling with all its devastating consequences. It can be challenging balancing these risks but, as prescribers, let’s be grateful we are forewarned.
- © British Journal of General Practice 2025
