BRITISH MEDICAL JOURNAI
15 OCTOBER 1977
A 68-year-old man with a history of previous surgery for peptic ulcer some 15 years before had had recurrent symptoms of duodenal ulcer over the past two years. Following a weight loss of one stone (6-4 kg) and a small haematemesis he was placed on the waiting list for further surgery. In the meantime he was given cimetidine 200 mg thrice daily and 400 mg at night with complete relief of symptoms. When reviewed at surgical outpatients he had recovered his weight loss and his operation was postponed indefinitely. Six days after the withdrawal of cimetidine after five weeks' treatment he was admitted with a small perforation of his ulcer with contamination of the peritoneal caxvity. Simple closure of the perforation was carried out. BRIAN D KI-IGHLEY Balfron. Stirlinlgshirc
1023
MRC treatment trial for mild hypertension
SIR,-Dr G H Hall, in his letter about the MRC treatment trial for mild hypertension (23 July, p 266), expresses his view that the decision on the future of the full-scale trial should be taken on the basis of the r esuilts of the pilot trial and is surprised that they were not disclosed in our report (4 June, p 1437). It is customary in the management of all such large-scale trials to restrict knowledge of the "events" in treatment and control groups to the small number of people immediately responsible for monitoring their progress; they in turn alert an ethical committee if trends approach statistical significance. Any alternative would allow the trials' future to be jeopardised by the leakage of information which might suggest trends which were of no
significance. Cimetidine and gastric ulcer healing SIR,-We were very interested to read that Dr F Frosi and his colleagues in Denmark (24 September, p 795) had shown a significant increase in the healing of gastric ulcers in patients treated for six weeks with cimetidine. However, we do not feel that the place of this drug in the management of gastric ulceration (in contrast to duodenal ulceration) is finally proved. We have been conducting a similar trial, whose design has been described elsewhere.' Although our study is larger than the Danish one (54 patients have completed the trial to date), a significant difference in healing rate between cimetidine and placebo groups has yet to emerge. The treatment period in our trial is two weeks shorter, yet the healing rate in our cimetidine group (69 ,) is very close to that in the Danish studyv The principal difference, however, lies in the placebo groups. In our study 54 of gastric ulcers healed in a four-week period, whereas only 27 ", healed in six weeks in the Danish series. High placebo healing rates have also been described in another recent gastric ulcer trial. Dr Frost and his colleagues have had to contend with all the difficulties inherent in a multicentre trial and perhaps the most important effect of these has bcen that their two groups of patients are not strictly comparable. The sex ratios vary and in the placebo group the ulcer history is nearly twice as long as in the cimetidine group-possibly an important factor in their low placebo healing rate. Studies of the treatment of gastric ulcer are inevitably beset by difficulties arising from the high spontaneous healing rate which occurs in this condition. Healing of 19 out of 20 gastric ulcers has been reported following injections of distilled water. Clearly much more work is required with larger and better-balanced trials before the place of cimetidine in the management of gastric ulceration can finally be assessed. J ROSE R J MACHELL A P DICK P C CICLITIRA J 0 HUNTER M FARTHING
of an underprivileged group such as the elderly by separating them from the rest of the human race with reserved resources or special staff may overcome some difficulties, but will in the long term create or consolidate others. If a consultant is prepared to provide comprehensive care for a defined population of elderly people does it matter whether he calls himself a geriatrician or a general physician ? Ultimately the way forward will be seen to be the disappearance of both specialties as we now understand them and the evolution of appropriately trained hospital physicians charged with providing comprehensive general medical care for all adults. This is unlikely to happen in less than a generation and to be successful it must come about bv consensus rather than by imposition, but the training recommendations of the report of the Royal College of Physicians Working Party on Medical Care of the Elderly' contain encouraging signs of possible progress. Should we not press for implementation of these recommendations as a modest development that commits nobody to anything but which might lead to more co-operation and courtesy between our jarring sects ? This would in itself reduce one of the problems Mr Cross identifies. J GRIMLEY EVANS
The working party's estimate that this trial requires the observation of 18 000 people for an average of five years is partly determined by the statistical criteria in its design. Like all estimates it is subject to error, but it is not likely to be so seriously incorrect as it would have to be if useful data on events could be gained from 1849 persons, most of whom were under observation for less than UnivcrsitN Department of Medicine (Geriatrics), two years. General Hospital, W S PEART Newcastle Newcastle upon Tvne Chairman
Medical Unit, St Mary's Hospital.
Royal College of Physicians of London, Lancet, 1977, 1, 1092.
ILondon, W2
W E MIALL Secretary, MRC Working Party on Mild to Moderate Hvpertensiton 'hlRC D)HSS Epidemiology and Medical Care Unit, Northwick Park Hospital, Harrow, Middx
Care of the elderly sick
SIR,-I do not doubt Mr V H Cross's (24 September, p 816) conclusions that the prejudice of hospital staff and the image and role of the geriatrician contribute materially to recruitment problems in geriatric medicine. I am at a loss to understand how his proposed solution would cope with the problem. Indeed, the diagram of his new scheme seems not so much a blueprint for the future as an epitome of the worst aspects of the past. If we cannot recruit British graduates into contemporary geriatric medicine with its emphasis on acute and rehabilitative care how will we recruit Mr Cross's "physicians to the elderly," doomed to oscillate eternally between domiciliary services and "chronic hospital beds" ? Two of the features which distinguish the geriatrician and which reflect particular needs of old people are his commitment to provide personally continuous and comprehensive care for his patients from acute illness through to long-term care, if necessary, and his responsibility to a defined population. It is from this last feature, which contrasts with the traditional view of a doctor's responsibility l)epartment of Medical as restricted to those persons he has chosen to Gastroenterology, Addenbrooke's Hospital, accept as patients, that both the moral glory Cambridge and the political weakness of the geriatrician Ciclitira, P J, et al, in Cimletidi'te, ed W R Burland and derive. All too often he is given the responsiM A Simkins, p 283. Amsterdam, Excerpta Medica, bility while others retain control of the re1977. 2 Multicentre Trial, in Cimetidine, ed W R Burland and sources he needs to discharge it. A Simkins, p 287. Amsterdam, Excerpta Medica, I suspect that this is one manifestation of a 1977. general principle. Attempts to help members 3Gill, A M, Lancet, 1947, 1, 291.
Joint appointments in general and geriatric medicine
SIR,-The enormous projected increase in the population aged 75 and over through the rest of this century is possibly the most serious single factor facing medical practice todavand it is by no means clear that the profession as a whole is seriously facing up to this fact. To this end the recent report' of the Royal College of Physicians Working Party on Medical Care of the Elderly (of which we were members) has proposed increasing the number of physicians practising geriatric medicine by the establishment of joint appointments between geriatric and general medicine. In some areas the implementation of such appointments is now being discussed. Their success will depend on a careful structuring of the duties of the new specialists to cover all aspects of geriatric care and also on the adequate training of such specialists in both general and geriatric medicine. The primary objective of geriatric medicine is to maintain fitness and independence to as near the end of life as possible-and to maintain old people in the community rather than in institutions. This involves careful diagnosis and medical treatment. It also requires the management of rehabilitation, day hospital care, community liaison, and, where all else fails, of long-term care. These together are the irreducible minima of geriatric medicine and clearly no specialist can accomplish this in two or three sessions a week. We therefore believe that the following three requirements are essential to the setting up of viable joint appointments in general and geriatric medicine. (1) At least half of the sessions must be in geriatric medicine (and preferably six to seven sessions a week). (2) The physician must be trained as a senior
1024
BRITISH MEDICAL JOURNAL
registrar in both general and geriatric medicine. (There are few joint senior registrar appointments in Britain at the present time and the numbers of these must be increased. Meanwhile we suggest that physicians appointed to joint appointments who have not had dual training should be required to spend the first year of their appointment on secondment in an approved senior registrar postwhether this be in geriatric medicine or general medicine.) (3) If there are already one or more whole-time geriatricians in the district where joint appointments are to be made, each of these should have the option of changing his contract (with the possibility of a year's sabbatical leave to revise his knowledge and experience of general medicine if necessary). If these three requirements are observedand of course provided adequate hospital facilities are made avrailable-we believe that these projected joint appointments will play a most ;^portant role in meeting the escalating demand for geriatric care which now faces us. J C BROCKLEHURST University of Manchester
A N EXTON-SMITH University College Hospital Medical School, London
M R P HALL University of Southamptoni
R E IRVINE Hastings, Sussex Royal College of Physicians of London, Lancet, 1977, 1, 1092.
Names of drugs SIR,-The plea by Dr M B Hay (17 September, p 774) that trade names be put in brackets when the often unwieldy and usually unmemorable official names of drugs are mentioned in the BMJ was dismissed by you, sir, in what I am bound to say was an insensitive way. You state in effect that the articles should be read vocabulary in hand, forgetting, I fear, that for doctors in practice this formulary is on their surgery desk and that for such as I, retired, the only help is a pensioned-off MIMS or an appeal to the local pharmacist. Moreover, in "Today's Treatment" the trade name is commonly supplied in parentheses. I know that this "long-standing editorial policy" is a gross irritation to even quite young doctors; to those of Dr Hay's generation and mine it is often a total bar to comprehension. There should be a booklet published-by you ?-say twice a year, giving not only the more common English trade names but those of the major continental countries and the USA in columns. Even quite old doctors travel. GODFREY D J BALL TIavistock, Devon
SIR,-Your reply to the letter from Dr M B Hay (17 September, p 774) just will not do. Surely the purpose of a journal such as the BMJ must be the communication of information and every effort must be made to ensure that it is readily comprehensible. I do earnestly suggest that the "long-standing editorial policy" be urgently reviewed and that the various proprietary names of drugs be included in brackets after the generic name so
that doctors of mean intelligence such as myself might understand what your erudite contributors are talking about. J W MALTBY Tiverton, Devon
SIR,-Your defence of the long-standing editorial policy of using only non-proprietary names for drugs (17 September, p 774) does not convince me that it is correct. The use of non-proprietary names without trade names implies the equivalence of preparations having the same non-proprietary name. But this is not always so and your choice of prochlorperazine as an example actually illustrates this point against you. The two oral preparations sharing this name in the British Nationtal Formulary are not equivalents; prochlorperazine as Stemetil is not equivalent to Vertigon, which is specially formulated for sustained release. Differences in formulation can be of great importance; the use of a different vehicle for an elixir of sulphanilamide has been reported to have caused the deaths of 100 patients.' Because the BMJ circulates widely abroad there is even more need to include the proprietary names and the names of the manufacturers and not to rely on the international acceptance of approved names. There are important differences in formulation between drugs with identical approved names in other countries. For example, fentanyl is the approved name for Sublimaze (Janssen) used in the UK and for Sublimaze (McNeil) used in the USA. The Janssen product contains methylhydroxybenzoate and propylhydroxybenzoate, whereas the McNeil product does not. Nathan and Sears2 have shown that these additives are not inert and state that their presence should be taken into account in both experimental and therapeutic situations. Another example showing the need to know the name of the manufacturer is that of morphine. Morphine sulphate injection (NMacarthys), a UK preparation, contains chlorocresol 02",, and sodium metabisulphite 01",, whereas morphine injection (Lilly) a USA preparation, contains chlorobutanol 0 5 ",, and sodium bisulphite 01P,. If the morphine injection (Macarthys) available to me at this hospital were used for high-dose morphine anaesthesia as used in some North American centres toxic amounts of chlorocresol, a phenolic derivative, would be given. The effect of chlorobutanol is very different as it is a mild sedative and analgesic with an action similar to that of chloral hydrate; it has been used to check sea-sickness and other forms of motion sickness.' Could this be one of the reasons high-dosage morphine anaesthesia appears to be more popular in the USA than in Britain ? There have been problems with heparin injections of different manufacturers, some preparations containing chlorocresol, some chlorobutanol, and some no preservative. Adverse reactions have been reported with heparin injections containing chlorocresol' and the absence of adverse reactions to heparin injections containing chlorobutanol has been
claimed.'; When methotrexate injection is described it is necessary to know the proprietary preparation because the intrathecal use of one preparation containing methylhydroxybenzoate has been followed by paraplegia. Even sodium chloride injections may contain additives; Craig and Habib have reported the occurrence of severe flaccid paralysis following the
15 OCTOBER 1977
epidural injection of 0-9 ",, sodium chloride; the particular preparation used contained 1 5 benzyl alcohol as a preservative. Drugs with the same approved name but with different proprietary formulations are in daily use in anaesthesia. Further examples are suxamethonium chloride, neostigmine, pethidine, and atropine sulphate. With each of these drugs there is a preparation which will produce an adverse reaction in a patient sensitive to cresols and another preparation with the same approved name which will be safe for these patients. This information is not available in the British Nationial Formulary, Briti'sh Pharmacopoeia, British Pharmacopoeial Codex, Martindale's Extra Pharmacopoeia, or even MIMS. In Britain the information as to what drugs our ampoules actually contain is obtainable only from the manufacturer. Will you please abandon this long-standing .ditorial policy and ask your contributors to state at the beginning of their papers not onlv the non-proprietary name but also the proprietary name, for formulation, and the name of the manufacturer ? I am hopeful because already your editorial practice sometim.s differs from your policy. In the same issue as your defence of this policy you have allowed the authors of the most interesting paper from Cardiff (17 September, p 735) to state the proprietary names, names of manufacturers, and formulations as well as the non-proprietary names. EDWARD MATHEWS Anaesthetics Department, Queen Elizabeth Hospital, Birmingham
Martin, E WI, Hazards of Medica tion. Philadclphia and Toronto, Lippincott, 1971. 2Nathan, P W, and Sears, T A, Nature, 1961, 192, 668. Stanley, T H, et al, Anesthesiology, 1973, 38, 536. Martinldale: The Extraz Pharmacopoei,u ed N W! Blacow, 26th edn, p 1528. London, Pharmaceutical Press, 1972. Ainley, E J, et al, Lancet, 1977, 1, 705. Marsh, B T, Lancet, 1977, 1, 860. Saiki, J H, et al, Cancer, 1972, 29, 370. Craig, D B, and Habbib, G G, Anesthesia anid Analgesial, 1977, 56, 219.
** *See leading article at p 980.-ED,
BMJ.
The drug bill SIR,-We are all aware of the need to prescribe drugs economically and efficiently. We are urged to prescribe drugs, so far as is feasible, by their British Nationial Formular?, name. Chemists may then dispense the least expensive drug. Many doctors would follow this advice but do not do so for two reasons: (1) they find it difficult to remember the non-proprietary name of a particular drug but they remember easily the proprietary name; (2) frequently the actual writing of the non-proprietary name is a deterrent because of its length or complexity. This problem could be overcome by a simple modification of form FP10/EC10. At the top of the form a box similar to the existing "NP" box should be printed, marked "E," meaning a therapeutically equivalent drug. If the doctor prescribes a proprietary drug and wishes this drug only to be dispensed, then he should put a cross in the box alongside the E, in the same way as he puts a cross in the box alongside NP if he does not want the name of the drug to be put on the label of the drug container. If, however, he prefers the patient to have the most economical equivalent, then he leaves this box open. The chemist must then dispense the most economical drug. Every chemist should be provided with a list
15 OCTOBER 1977
A 68-year-old man with a history of previous surgery for peptic ulcer some 15 years before had had recurrent symptoms of duodenal ulcer over the past two years. Following a weight loss of one stone (6-4 kg) and a small haematemesis he was placed on the waiting list for further surgery. In the meantime he was given cimetidine 200 mg thrice daily and 400 mg at night with complete relief of symptoms. When reviewed at surgical outpatients he had recovered his weight loss and his operation was postponed indefinitely. Six days after the withdrawal of cimetidine after five weeks' treatment he was admitted with a small perforation of his ulcer with contamination of the peritoneal caxvity. Simple closure of the perforation was carried out. BRIAN D KI-IGHLEY Balfron. Stirlinlgshirc
1023
MRC treatment trial for mild hypertension
SIR,-Dr G H Hall, in his letter about the MRC treatment trial for mild hypertension (23 July, p 266), expresses his view that the decision on the future of the full-scale trial should be taken on the basis of the r esuilts of the pilot trial and is surprised that they were not disclosed in our report (4 June, p 1437). It is customary in the management of all such large-scale trials to restrict knowledge of the "events" in treatment and control groups to the small number of people immediately responsible for monitoring their progress; they in turn alert an ethical committee if trends approach statistical significance. Any alternative would allow the trials' future to be jeopardised by the leakage of information which might suggest trends which were of no
significance. Cimetidine and gastric ulcer healing SIR,-We were very interested to read that Dr F Frosi and his colleagues in Denmark (24 September, p 795) had shown a significant increase in the healing of gastric ulcers in patients treated for six weeks with cimetidine. However, we do not feel that the place of this drug in the management of gastric ulceration (in contrast to duodenal ulceration) is finally proved. We have been conducting a similar trial, whose design has been described elsewhere.' Although our study is larger than the Danish one (54 patients have completed the trial to date), a significant difference in healing rate between cimetidine and placebo groups has yet to emerge. The treatment period in our trial is two weeks shorter, yet the healing rate in our cimetidine group (69 ,) is very close to that in the Danish studyv The principal difference, however, lies in the placebo groups. In our study 54 of gastric ulcers healed in a four-week period, whereas only 27 ", healed in six weeks in the Danish series. High placebo healing rates have also been described in another recent gastric ulcer trial. Dr Frost and his colleagues have had to contend with all the difficulties inherent in a multicentre trial and perhaps the most important effect of these has bcen that their two groups of patients are not strictly comparable. The sex ratios vary and in the placebo group the ulcer history is nearly twice as long as in the cimetidine group-possibly an important factor in their low placebo healing rate. Studies of the treatment of gastric ulcer are inevitably beset by difficulties arising from the high spontaneous healing rate which occurs in this condition. Healing of 19 out of 20 gastric ulcers has been reported following injections of distilled water. Clearly much more work is required with larger and better-balanced trials before the place of cimetidine in the management of gastric ulceration can finally be assessed. J ROSE R J MACHELL A P DICK P C CICLITIRA J 0 HUNTER M FARTHING
of an underprivileged group such as the elderly by separating them from the rest of the human race with reserved resources or special staff may overcome some difficulties, but will in the long term create or consolidate others. If a consultant is prepared to provide comprehensive care for a defined population of elderly people does it matter whether he calls himself a geriatrician or a general physician ? Ultimately the way forward will be seen to be the disappearance of both specialties as we now understand them and the evolution of appropriately trained hospital physicians charged with providing comprehensive general medical care for all adults. This is unlikely to happen in less than a generation and to be successful it must come about bv consensus rather than by imposition, but the training recommendations of the report of the Royal College of Physicians Working Party on Medical Care of the Elderly' contain encouraging signs of possible progress. Should we not press for implementation of these recommendations as a modest development that commits nobody to anything but which might lead to more co-operation and courtesy between our jarring sects ? This would in itself reduce one of the problems Mr Cross identifies. J GRIMLEY EVANS
The working party's estimate that this trial requires the observation of 18 000 people for an average of five years is partly determined by the statistical criteria in its design. Like all estimates it is subject to error, but it is not likely to be so seriously incorrect as it would have to be if useful data on events could be gained from 1849 persons, most of whom were under observation for less than UnivcrsitN Department of Medicine (Geriatrics), two years. General Hospital, W S PEART Newcastle Newcastle upon Tvne Chairman
Medical Unit, St Mary's Hospital.
Royal College of Physicians of London, Lancet, 1977, 1, 1092.
ILondon, W2
W E MIALL Secretary, MRC Working Party on Mild to Moderate Hvpertensiton 'hlRC D)HSS Epidemiology and Medical Care Unit, Northwick Park Hospital, Harrow, Middx
Care of the elderly sick
SIR,-I do not doubt Mr V H Cross's (24 September, p 816) conclusions that the prejudice of hospital staff and the image and role of the geriatrician contribute materially to recruitment problems in geriatric medicine. I am at a loss to understand how his proposed solution would cope with the problem. Indeed, the diagram of his new scheme seems not so much a blueprint for the future as an epitome of the worst aspects of the past. If we cannot recruit British graduates into contemporary geriatric medicine with its emphasis on acute and rehabilitative care how will we recruit Mr Cross's "physicians to the elderly," doomed to oscillate eternally between domiciliary services and "chronic hospital beds" ? Two of the features which distinguish the geriatrician and which reflect particular needs of old people are his commitment to provide personally continuous and comprehensive care for his patients from acute illness through to long-term care, if necessary, and his responsibility to a defined population. It is from this last feature, which contrasts with the traditional view of a doctor's responsibility l)epartment of Medical as restricted to those persons he has chosen to Gastroenterology, Addenbrooke's Hospital, accept as patients, that both the moral glory Cambridge and the political weakness of the geriatrician Ciclitira, P J, et al, in Cimletidi'te, ed W R Burland and derive. All too often he is given the responsiM A Simkins, p 283. Amsterdam, Excerpta Medica, bility while others retain control of the re1977. 2 Multicentre Trial, in Cimetidine, ed W R Burland and sources he needs to discharge it. A Simkins, p 287. Amsterdam, Excerpta Medica, I suspect that this is one manifestation of a 1977. general principle. Attempts to help members 3Gill, A M, Lancet, 1947, 1, 291.
Joint appointments in general and geriatric medicine
SIR,-The enormous projected increase in the population aged 75 and over through the rest of this century is possibly the most serious single factor facing medical practice todavand it is by no means clear that the profession as a whole is seriously facing up to this fact. To this end the recent report' of the Royal College of Physicians Working Party on Medical Care of the Elderly (of which we were members) has proposed increasing the number of physicians practising geriatric medicine by the establishment of joint appointments between geriatric and general medicine. In some areas the implementation of such appointments is now being discussed. Their success will depend on a careful structuring of the duties of the new specialists to cover all aspects of geriatric care and also on the adequate training of such specialists in both general and geriatric medicine. The primary objective of geriatric medicine is to maintain fitness and independence to as near the end of life as possible-and to maintain old people in the community rather than in institutions. This involves careful diagnosis and medical treatment. It also requires the management of rehabilitation, day hospital care, community liaison, and, where all else fails, of long-term care. These together are the irreducible minima of geriatric medicine and clearly no specialist can accomplish this in two or three sessions a week. We therefore believe that the following three requirements are essential to the setting up of viable joint appointments in general and geriatric medicine. (1) At least half of the sessions must be in geriatric medicine (and preferably six to seven sessions a week). (2) The physician must be trained as a senior
1024
BRITISH MEDICAL JOURNAL
registrar in both general and geriatric medicine. (There are few joint senior registrar appointments in Britain at the present time and the numbers of these must be increased. Meanwhile we suggest that physicians appointed to joint appointments who have not had dual training should be required to spend the first year of their appointment on secondment in an approved senior registrar postwhether this be in geriatric medicine or general medicine.) (3) If there are already one or more whole-time geriatricians in the district where joint appointments are to be made, each of these should have the option of changing his contract (with the possibility of a year's sabbatical leave to revise his knowledge and experience of general medicine if necessary). If these three requirements are observedand of course provided adequate hospital facilities are made avrailable-we believe that these projected joint appointments will play a most ;^portant role in meeting the escalating demand for geriatric care which now faces us. J C BROCKLEHURST University of Manchester
A N EXTON-SMITH University College Hospital Medical School, London
M R P HALL University of Southamptoni
R E IRVINE Hastings, Sussex Royal College of Physicians of London, Lancet, 1977, 1, 1092.
Names of drugs SIR,-The plea by Dr M B Hay (17 September, p 774) that trade names be put in brackets when the often unwieldy and usually unmemorable official names of drugs are mentioned in the BMJ was dismissed by you, sir, in what I am bound to say was an insensitive way. You state in effect that the articles should be read vocabulary in hand, forgetting, I fear, that for doctors in practice this formulary is on their surgery desk and that for such as I, retired, the only help is a pensioned-off MIMS or an appeal to the local pharmacist. Moreover, in "Today's Treatment" the trade name is commonly supplied in parentheses. I know that this "long-standing editorial policy" is a gross irritation to even quite young doctors; to those of Dr Hay's generation and mine it is often a total bar to comprehension. There should be a booklet published-by you ?-say twice a year, giving not only the more common English trade names but those of the major continental countries and the USA in columns. Even quite old doctors travel. GODFREY D J BALL TIavistock, Devon
SIR,-Your reply to the letter from Dr M B Hay (17 September, p 774) just will not do. Surely the purpose of a journal such as the BMJ must be the communication of information and every effort must be made to ensure that it is readily comprehensible. I do earnestly suggest that the "long-standing editorial policy" be urgently reviewed and that the various proprietary names of drugs be included in brackets after the generic name so
that doctors of mean intelligence such as myself might understand what your erudite contributors are talking about. J W MALTBY Tiverton, Devon
SIR,-Your defence of the long-standing editorial policy of using only non-proprietary names for drugs (17 September, p 774) does not convince me that it is correct. The use of non-proprietary names without trade names implies the equivalence of preparations having the same non-proprietary name. But this is not always so and your choice of prochlorperazine as an example actually illustrates this point against you. The two oral preparations sharing this name in the British Nationtal Formulary are not equivalents; prochlorperazine as Stemetil is not equivalent to Vertigon, which is specially formulated for sustained release. Differences in formulation can be of great importance; the use of a different vehicle for an elixir of sulphanilamide has been reported to have caused the deaths of 100 patients.' Because the BMJ circulates widely abroad there is even more need to include the proprietary names and the names of the manufacturers and not to rely on the international acceptance of approved names. There are important differences in formulation between drugs with identical approved names in other countries. For example, fentanyl is the approved name for Sublimaze (Janssen) used in the UK and for Sublimaze (McNeil) used in the USA. The Janssen product contains methylhydroxybenzoate and propylhydroxybenzoate, whereas the McNeil product does not. Nathan and Sears2 have shown that these additives are not inert and state that their presence should be taken into account in both experimental and therapeutic situations. Another example showing the need to know the name of the manufacturer is that of morphine. Morphine sulphate injection (NMacarthys), a UK preparation, contains chlorocresol 02",, and sodium metabisulphite 01",, whereas morphine injection (Lilly) a USA preparation, contains chlorobutanol 0 5 ",, and sodium bisulphite 01P,. If the morphine injection (Macarthys) available to me at this hospital were used for high-dose morphine anaesthesia as used in some North American centres toxic amounts of chlorocresol, a phenolic derivative, would be given. The effect of chlorobutanol is very different as it is a mild sedative and analgesic with an action similar to that of chloral hydrate; it has been used to check sea-sickness and other forms of motion sickness.' Could this be one of the reasons high-dosage morphine anaesthesia appears to be more popular in the USA than in Britain ? There have been problems with heparin injections of different manufacturers, some preparations containing chlorocresol, some chlorobutanol, and some no preservative. Adverse reactions have been reported with heparin injections containing chlorocresol' and the absence of adverse reactions to heparin injections containing chlorobutanol has been
claimed.'; When methotrexate injection is described it is necessary to know the proprietary preparation because the intrathecal use of one preparation containing methylhydroxybenzoate has been followed by paraplegia. Even sodium chloride injections may contain additives; Craig and Habib have reported the occurrence of severe flaccid paralysis following the
15 OCTOBER 1977
epidural injection of 0-9 ",, sodium chloride; the particular preparation used contained 1 5 benzyl alcohol as a preservative. Drugs with the same approved name but with different proprietary formulations are in daily use in anaesthesia. Further examples are suxamethonium chloride, neostigmine, pethidine, and atropine sulphate. With each of these drugs there is a preparation which will produce an adverse reaction in a patient sensitive to cresols and another preparation with the same approved name which will be safe for these patients. This information is not available in the British Nationial Formulary, Briti'sh Pharmacopoeia, British Pharmacopoeial Codex, Martindale's Extra Pharmacopoeia, or even MIMS. In Britain the information as to what drugs our ampoules actually contain is obtainable only from the manufacturer. Will you please abandon this long-standing .ditorial policy and ask your contributors to state at the beginning of their papers not onlv the non-proprietary name but also the proprietary name, for formulation, and the name of the manufacturer ? I am hopeful because already your editorial practice sometim.s differs from your policy. In the same issue as your defence of this policy you have allowed the authors of the most interesting paper from Cardiff (17 September, p 735) to state the proprietary names, names of manufacturers, and formulations as well as the non-proprietary names. EDWARD MATHEWS Anaesthetics Department, Queen Elizabeth Hospital, Birmingham
Martin, E WI, Hazards of Medica tion. Philadclphia and Toronto, Lippincott, 1971. 2Nathan, P W, and Sears, T A, Nature, 1961, 192, 668. Stanley, T H, et al, Anesthesiology, 1973, 38, 536. Martinldale: The Extraz Pharmacopoei,u ed N W! Blacow, 26th edn, p 1528. London, Pharmaceutical Press, 1972. Ainley, E J, et al, Lancet, 1977, 1, 705. Marsh, B T, Lancet, 1977, 1, 860. Saiki, J H, et al, Cancer, 1972, 29, 370. Craig, D B, and Habbib, G G, Anesthesia anid Analgesial, 1977, 56, 219.
** *See leading article at p 980.-ED,
BMJ.
The drug bill SIR,-We are all aware of the need to prescribe drugs economically and efficiently. We are urged to prescribe drugs, so far as is feasible, by their British Nationial Formular?, name. Chemists may then dispense the least expensive drug. Many doctors would follow this advice but do not do so for two reasons: (1) they find it difficult to remember the non-proprietary name of a particular drug but they remember easily the proprietary name; (2) frequently the actual writing of the non-proprietary name is a deterrent because of its length or complexity. This problem could be overcome by a simple modification of form FP10/EC10. At the top of the form a box similar to the existing "NP" box should be printed, marked "E," meaning a therapeutically equivalent drug. If the doctor prescribes a proprietary drug and wishes this drug only to be dispensed, then he should put a cross in the box alongside the E, in the same way as he puts a cross in the box alongside NP if he does not want the name of the drug to be put on the label of the drug container. If, however, he prefers the patient to have the most economical equivalent, then he leaves this box open. The chemist must then dispense the most economical drug. Every chemist should be provided with a list
