463
primarily in the urine. Three main substances in emerge the urine-the unchanged drug, its sulphone derivative, and a dihydroxylated derivative. A sulphide metabolite with a long half-life is present in plasma but not urine, probably because of extensive binding to plasma proteins. In several anti-inflammatory assays, the sulphide metabolite has been shown to be as active excreted
indomethacin. Sulindac (’Clinoril’) was the subject of a special symposium at the VIII European Rheumatology Congress, Helsinki, Finland, in June, 1975. Eighteen papers read at that symposium have now been published,’ and they deal with the pharmacology of sulindac and the efficacy of this drug versus aspirin, ibuprofen, phenylbutazone, and oxyphenbutazone. In osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, gout, and acute painful shoulder, sulindac seems to be as effective and in many instances better tolerated than the other drugs. Few reports have appeared in the U.K. journals, but one clinical triaP comparing sulindac (400 mg/day) with ibuprofen (1200 mg/day) in osteoarthrosis of the hip showed that the two drugs were much the same in terms of patient and doctor preference, effects on hip movements, and toxicity. No serious side-effects were encountered, and the analgesic properties of sulindac were superior to those of ibuprofen. Like all anti-inflammatory drugs, sulindac should be used with caution in patients with a history of gastrointestinal upset, and since the drug is excreted largely via the kidneys the dosage should be reduced in renal impairment. It is known that steroids, especially those as
containing fluorine (e.g., triamcinolone), may produce a myopathy, but no muscle cramps or myopathies have occurred during four years of clinical trials with sulindac. Side-effects do not seem to be as frequent as with indomethacin, but these are early days. The maximum dose administered to date has been 400 mg/day, but wider clinical experience may well reveal that this dose is insufficient in certain rheumatic conditions. One of the advantages of sulindac is that it need be given only twice-a-day. Each tablet of clinoril contains 100 mg of sulindac and the recommended dosage is 100-200 mg twice-a-day. The rheumatologist or general practitioner in the U.K. can be excused for taking a cautious attitude to a new anti-inflammatory agent. With so many non-steroidal anti-inflammatory drugs to choose from, and many of the patients taking more’than one preparation, it will be a long time before we know the true worth of sulindac. Existing evidence suggests that it is effective and well tolerated, and where new therapy is required sulindac may fit the bill. ,
GENERAL-PRACTICE PRESCRIBING DOCTORS need education and
guidance in the preof and medicines.3 Parish and his colscribing drugs leagues in Swansea are looking at some of the factors
that determine prescribing habits. In a cohort of doctors who entered general practice in England and Wales between July, 1969 and July, 1970, they are examining, in particular, previous medical training and experience in relation to prescribing activity, sources of drug information, and their views on drug advertisements, prescription-writing by ancillary staff, the role of the pharmacist in drug treatment, and the matter of high-cost prescribers. Unfortunately, much of the information is
obtained
by questionnaires (with their inherent limitations) rather than by personal interview, but in a preliminary report4 some potentially valuable information already emerges. Although there are now plenty of opportunities for training in general practice, most of these doctors had had no such planned training: previous postgraduate experience in general practice seemed to have been haphazard and few had been attached to a general practice as undergraduates. Nearly one in three had qualified outside the United Kingdom, and these had previously gained less experience in general practice and had completed more short-term postregistration house appointments than their U.K.-trained colleagues. Overseastrained doctors prescribed a higher proportion of proprietary branded preparations-a tendency which was less for doctors who qualified before 1960, suggesting that length of time since qualifying may be a factor here. In 90% of the doctors’ responses
drug-company representatives in making known the existence of a helpful information about usefulness seemed to come from within the profession-from partners, colleagues, consultants, and articles in medical journals and Prescriber’s Journal. Unfortunately, Drug and Therapeutics Bulletin, which has the particular virtue ’of giving some guide to cost-effectiveness of treatment,3 was little used by this group of practitioners. But it is encouraging that most practitioners in the survey looked with a critical eye upon information from drug-company representatives and placed more reliance on experience-based advice from professional colleagues and disinterested sources. A group of "high-cost" prescribers were identified who had been investigated for this reason by the Department of Health. In age, sex, and qualifications they did not differ from lower-cost prescribers, but they did include of overseas-trained doctors. Most of these high-cost prescribers felt that the Department was too concerned with prescribing costs, but they did express more eagerness than the others for further training and more information on drug prescribing. If these early observations are confirmed by the 1976 survey, which is now being analysed, the implications will be wide. The proliferation of health centres, in which general practice partners together with pharmacist colleagues are able to discuss drug treatment regimens, should make an impact on patterns of prescribing over the next few years. The influence of prean
June, 1975.NewYork,1976. 2. Dieppe, P A., Burry, H. C., Grahame, R., Perera, T. Rheumatol. Rehab. 1976, 15, 112. 3 Lancet, 1976, ii, 351.
excess
training in general practice emphasises, once graduate clinical training is just as important this specialty as in other branches of clinical prac**
vious
more, that
in 1 Clinoril in the Treatment ofRheumatic Disorders. Proceedings of a Symposiumheld attheVIII EuropeanRheumatology Congress, Helsinki, 1-7
the
questionnaire, important drug, but the most
to
were said to be
tice.
Coll Gen Practit 1976, 26, suppl. 1. 5 Committee of Inquiry into the Regulation of the Medical Profession. H.M. Stationery Office, 1975
4. Jl R.
primarily in the urine. Three main substances in emerge the urine-the unchanged drug, its sulphone derivative, and a dihydroxylated derivative. A sulphide metabolite with a long half-life is present in plasma but not urine, probably because of extensive binding to plasma proteins. In several anti-inflammatory assays, the sulphide metabolite has been shown to be as active excreted
indomethacin. Sulindac (’Clinoril’) was the subject of a special symposium at the VIII European Rheumatology Congress, Helsinki, Finland, in June, 1975. Eighteen papers read at that symposium have now been published,’ and they deal with the pharmacology of sulindac and the efficacy of this drug versus aspirin, ibuprofen, phenylbutazone, and oxyphenbutazone. In osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, gout, and acute painful shoulder, sulindac seems to be as effective and in many instances better tolerated than the other drugs. Few reports have appeared in the U.K. journals, but one clinical triaP comparing sulindac (400 mg/day) with ibuprofen (1200 mg/day) in osteoarthrosis of the hip showed that the two drugs were much the same in terms of patient and doctor preference, effects on hip movements, and toxicity. No serious side-effects were encountered, and the analgesic properties of sulindac were superior to those of ibuprofen. Like all anti-inflammatory drugs, sulindac should be used with caution in patients with a history of gastrointestinal upset, and since the drug is excreted largely via the kidneys the dosage should be reduced in renal impairment. It is known that steroids, especially those as
containing fluorine (e.g., triamcinolone), may produce a myopathy, but no muscle cramps or myopathies have occurred during four years of clinical trials with sulindac. Side-effects do not seem to be as frequent as with indomethacin, but these are early days. The maximum dose administered to date has been 400 mg/day, but wider clinical experience may well reveal that this dose is insufficient in certain rheumatic conditions. One of the advantages of sulindac is that it need be given only twice-a-day. Each tablet of clinoril contains 100 mg of sulindac and the recommended dosage is 100-200 mg twice-a-day. The rheumatologist or general practitioner in the U.K. can be excused for taking a cautious attitude to a new anti-inflammatory agent. With so many non-steroidal anti-inflammatory drugs to choose from, and many of the patients taking more’than one preparation, it will be a long time before we know the true worth of sulindac. Existing evidence suggests that it is effective and well tolerated, and where new therapy is required sulindac may fit the bill. ,
GENERAL-PRACTICE PRESCRIBING DOCTORS need education and
guidance in the preof and medicines.3 Parish and his colscribing drugs leagues in Swansea are looking at some of the factors
that determine prescribing habits. In a cohort of doctors who entered general practice in England and Wales between July, 1969 and July, 1970, they are examining, in particular, previous medical training and experience in relation to prescribing activity, sources of drug information, and their views on drug advertisements, prescription-writing by ancillary staff, the role of the pharmacist in drug treatment, and the matter of high-cost prescribers. Unfortunately, much of the information is
obtained
by questionnaires (with their inherent limitations) rather than by personal interview, but in a preliminary report4 some potentially valuable information already emerges. Although there are now plenty of opportunities for training in general practice, most of these doctors had had no such planned training: previous postgraduate experience in general practice seemed to have been haphazard and few had been attached to a general practice as undergraduates. Nearly one in three had qualified outside the United Kingdom, and these had previously gained less experience in general practice and had completed more short-term postregistration house appointments than their U.K.-trained colleagues. Overseastrained doctors prescribed a higher proportion of proprietary branded preparations-a tendency which was less for doctors who qualified before 1960, suggesting that length of time since qualifying may be a factor here. In 90% of the doctors’ responses
drug-company representatives in making known the existence of a helpful information about usefulness seemed to come from within the profession-from partners, colleagues, consultants, and articles in medical journals and Prescriber’s Journal. Unfortunately, Drug and Therapeutics Bulletin, which has the particular virtue ’of giving some guide to cost-effectiveness of treatment,3 was little used by this group of practitioners. But it is encouraging that most practitioners in the survey looked with a critical eye upon information from drug-company representatives and placed more reliance on experience-based advice from professional colleagues and disinterested sources. A group of "high-cost" prescribers were identified who had been investigated for this reason by the Department of Health. In age, sex, and qualifications they did not differ from lower-cost prescribers, but they did include of overseas-trained doctors. Most of these high-cost prescribers felt that the Department was too concerned with prescribing costs, but they did express more eagerness than the others for further training and more information on drug prescribing. If these early observations are confirmed by the 1976 survey, which is now being analysed, the implications will be wide. The proliferation of health centres, in which general practice partners together with pharmacist colleagues are able to discuss drug treatment regimens, should make an impact on patterns of prescribing over the next few years. The influence of prean
June, 1975.NewYork,1976. 2. Dieppe, P A., Burry, H. C., Grahame, R., Perera, T. Rheumatol. Rehab. 1976, 15, 112. 3 Lancet, 1976, ii, 351.
excess
training in general practice emphasises, once graduate clinical training is just as important this specialty as in other branches of clinical prac**
vious
more, that
in 1 Clinoril in the Treatment ofRheumatic Disorders. Proceedings of a Symposiumheld attheVIII EuropeanRheumatology Congress, Helsinki, 1-7
the
questionnaire, important drug, but the most
to
were said to be
tice.
Coll Gen Practit 1976, 26, suppl. 1. 5 Committee of Inquiry into the Regulation of the Medical Profession. H.M. Stationery Office, 1975
4. Jl R.
