E-drug: New WHO Model List on the web (cont'd)
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Dear e-druggers,
A few comments on the new EDL.
Antihypertensive drugs
I was very pleased to see several ancient drugs go and to see
captopril replaced by a squared boxed enalapril.
Lipid lowering drugs
Simvastatin loses its patent this very month (at least in the UK),
hopefully the price should come down soon.
Hormones (or their analogues):
I don't understand why fludrocortisone has been deleted. Although
Addison's disease as an auto-immune condition is extremely rare,
hypoadrenalism secondary to TB is less so. Anyway even if
uncommon, it is eminently treatable and often requires a
mineralcorticoid alongside the glucocorticoid. Desmopressin has also
been deleted. I agree pituitary diabetes insipidus is very rare, but why
shouldn't its treatment be regarded as essential? Neither
fludrocortisone nor desmopressin can be used without proper patient
education, but this is the case for many other drugs in the EDL, so
this cannot be the reason. If rarity of these diseases is the problem,
then hypoandrogenism is just as rare, and contrary to Addison's
disease and diabetes insipidus is not life threatening, and yet the EDL
includes testosterone 200 mg injection.
Antidiabetic drugs
I was very sorry to see the disappearance of the square box from
glibenclamide, the only sulphonylurea in the EDL. Although this is
cheaper than the shorter acting gliclazide, glibenclamide is the
sulphonylurea more commonly associated with severe
hypoglycaemia, ie requiring hospitalization (fatal cases have also
been reported). The problem is glibenclamide's long duration of
action, which cannot be offset by lower doses without the drug
losing the required therapeutic effect. In the UK Prospective Diabetes
Study (UKPDS, a study of over 5000 patients followed for average 10
years), the risk of hypoglycaemia was equal between glibenclamide
and chlorpropamide but both are long acting sulphs. Moreover, the
UKPDS patients were seen at three montlhly intervals in a very
specialized hospital clinic setting where they received all the medical
attention and all the education about diet and drug side effects they
needed. Hardly a developing country situation...On top of this,
glibenclamide cannot be used in any degree of renal impairment,
something which also may represent a problem as kidney failure is
the most frequent diabetic complication in the developing world.
Antidepressants
The only one in the list is amitryptiline. I think one of the SSRIs
(selective serotonine reuptake inhibitors)should have been included
because of their superiority in terms of side effects, although not in
efficacy. Fluoxetine, now off patent, could be a good choice for a
future EDL.
Apologies for this long message. I hope this critique is constructive.
Valeria
--
Dr Valeria Frighi
Diabetes Trials Unit
Oxford Centre for Diabetes Endocrinology and Metabolism
Churchill Hospital, Old Road
Oxford OX3 7LJ
UK
tel -44-1865-857248
fax -44-1865-856286
e-mail valeria.frighi@dtu.ox.ac.uk
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