I had a medication review with my GP practice pharmacist this morning - the first in 4 years. I have always taken enteric coated pred before I go to bed on the understanding that these are 'slow release' and I then feel OK to start work in the morning. The pharmacist refused to dispense enteric coated tablets to me. She said it is no longer done (strange, as I had some in my last batch). She claimed that 20 years of experience and recent research papers demonstrated (a) that there was no beneficial effect on the digestive tract - she wants to prescribe omnezoprol for that, and (b) that they had absolutely no delayed release effect. I said that was contrary to everything I've read and been told, and that I had no digestive issues and didnt want to start taking yet another drug. She was having none of it!
Interesting "debate" with pharmacist this morning - PMRGCAuk
Interesting "debate" with pharmacist this morning
Surely it is up to your doctor what is prescribed, not the pharmacist?
Well it worked like a charm on my gastric problems which were unresponsive to Omeprazole. I was reading a paper that said EC Pred shouldn’t be prescribed for replacement for adrenal failure because of the delayed release. Perhaps next time you could say that you are so interested in this that you’d be grateful if they could dig out the papers for you.
Actually having a quick squint on t’internet, she may be right in her thinking. There do seem to be more articles agreeing with her than contradicting her -
Society for Endocrinology BES 2017 Has article headed -
Enteric coating delays the absorption of prednisolone variably and should not be used....but they are talking about people with adrenal insufficiency not PMR etc.
This is a link from NHS Special Pharmacy Service -
sps.nhs.uk/articles/is-ther...
Probably used up the last of their stock on your last prescription and not getting any more.
Will be interesting to see it it becomes common practice.
Thank you. I'm unconvinced about her statement that there is no delayed release with enteric coated tablets. It's worked for me for four years. Guess I'll have to change my regime and take the non coated ones in the morning. The problem I had when I tried that in the past, was I woke up feeling unfit for work.
Do you wake up during the early hours for loo break.....if so, you could take Pred then. The substances that cause issues are shed around 4am, so if you can take plain Pred about an hour or so before it helps fight the inflammation. If not, then as early as possible.
I do indeed! That makes sense. Not sure whether to take the omeprazole - would prefer to avoid yet another drug and associated side effects!
Not everybody needs it, take your Pred with good thick yogurt and you may be fine...try it initially, and then if you find you get reflux or stomach issues add in the Omeprazole.
Would also suggest the first morning dose you only take a smaller enteric dose the evening before....as they’re will only be a few hours between the two.
Don’t try and make last enteric dose last a day and a bit - hope that makes sense.
I have never taken Omeprazole-I sandwich my Pred ie have some food- thick yoghurt,cereal a few mouthfuls,then Pred( non enteric coated),then more food and no gastric problems?😀
Please try to avoid any PPI. They aren't supposed to be used longterm, and they are implicated in bone thinning (osteoporosis anyone?) plus they do have other side effects and don't agree with everyone. Sounds to me like someone has been told to flog more expensive drugs to as many likely customers as possible. Sorry to sound so cynical but....
If that's the case, it's outrageous she's taken it upon herself to dispense a drug that might make my osteopenia worse. I'm talking to rheumatology on Monday. It will be interesting to hear their view.
I wish I could find the website where I read that omeprazole hadn't been intended for longterm use. It was something quite official, maybe an earlier version of their website or a government website. The effect on bones has been known for a while, perhaps because the reduced stomach acid affects calcium absorption. I wonder if it has an effect on other nutrients too?
Fairly sure it does - like B12, vit C, calcium and magnesium:
pubmed.ncbi.nlm.nih.gov/250....
Wonder if our pharmacy friend knows of this article?
That’s interesting, I was given lanzaprozole to take 1 hour before taking pred. I’ve been taking since the start. Just done a search and it states.
If you take lansoprazole for more than 3 months, the levels of magnesium in your blood may fall. Low magnesium can make you feel tired, confused, dizzy and cause muscle twitches, shakiness and an irregular heartbeat. If you get any of these symptoms, tell your doctor. Should only be taken for 6 - 8 weeks.
This advice was on the link you gave me. I tried splitting the dose, half at 2/3 am then the rest in the morning. It has worked a teat, virtually, pain free for two whole days! Thank you.😀
That is b^££ - it isn't "recent" work at all and some was done in patients with Crohns with the thought that since they are absorbed much further down the gut they might have a local effect, they didn't. That doesn't mean they aren't beneficial for gastric problems. I wouldn't accept that from a pharamcist.
They don't officially have a delayed release effect - but since they have to pass through the stomach to lower down the GI tract to a different pH to be absorbed it takes much longer to get to that stage. Plain pred is absorbed immediately, within an hour usually.
ncbi.nlm.nih.gov/pmc/articl...
says absorption is "delayed".
It would be complaint time if it were me. And I might develop awful gut problems with a PPI - it is extremely common ...
Yes I'm pretty miffed tbh. I'm going to try and speak to a gp and get the pharmacist overruled.
Sounds like a new broom making themself look indispensible ... I've heard a lot of people saying they have come up against a new pharmacist who doesn't know a lot about PMR and its management,
It will be interesting to see if your doctor is willing to have his prescribing powers taken over by/overruled by a pharmacist. A pharmacist might query a prescription on safety grounds but as far as I know would have no power to overrule a doctor. In general terms a pharmacist can only prescribe POM in emergency circumstances. NHS link below.
nhs.uk/nhs-services/prescri...
In general terms a pharmacist can only prescribe POM in emergency circumstances
Not sure that’s strictly true if PIP - Pharmacist Independent Prescriber -
pharmacyregulation.org/educ...
Not saying her decision was right, but just saying it may be within her remit to do it.
Thanks for that, I hadn't realised
There are certain things they have automony to monitor - but I think the doctor can disagree, no different from between 2 doctors really.
There are MSc level courses/modules including prescribing that advanced care practitioners take to allow prescribing of all drugs licensed for a condition - i.e. not off-label - except controlled substances such as opiates and barbiturates. The pharmacist will have an equivalent qualification.
Cheap doctors ...
Just one thing I was thinking you could try if your GP is not going to go against the pharmacist, which by the way, a pharmacist review is totally new to me, is to ask your consultant, if they agree for you to have the coated version, for them to prescribe it and you collect it from the hospital, if that's not too far away for you. It infuriates me that they all have opinions on something they have not experienced. I'll be interested to hear how you get on.
Yes, my first port of call is the rheumatology department. To be honest, I think this pharmacist might be part of the GP practice rather than someone from the pharmacy itself. I think the practice has a small team who deal with repeat prescriptions etc. Makes me think the GP is likely to collude with the pharmacist.
Maybe she does have authority to change things then. Have added another reply re Omeprazole.
Never heard of it, but can see why you think that might be what happens.Definitely try the Rheumatologist then... good luck.
I was given Omeprazole and had awful side effects from the start - stomach ache, excess foul-smelling flatulence all day every day, loose stools about 4 or 5 times daily, faecal incontinence, trembling hands, dizziness. Some of these side effects I put down to Prednisolone but they all disappeared when I stopped the Omeprazole. I took it for 3 months and at one point my GP told me to double the dose to see if it helped my symptoms! I didn't. I was then prescribed Ranitidine and got the same side effects so I stopped it after a week or so. It took about 3 months for my stomach to feel completely back to normal. I take enteric coated Prednisolone along with yogurt at breakfast.
My gp perscribes it now at my request. Nothing to do with stomach probs for me, but I suddenly found that in dropping to 5mg (coated) my drop seemed much easier and no side effects. I then dropped from 4.5mg to 4mg (all coated) and same thing happened. Having been fearful of dropping under 5 due to adrenals etc, I was pleasantly surprised so will stick to them for now. Will see if I can drop to 3.5 just as easily. What floats one boat doesn't do another!
Question: What's the difference between your pharmacist & God???Answer: God doesn't make out to be a pharmacist!!
Seriously though, from my experience with Ulcers (duodenal & peptic), GERD, all variations of Thyroid & Adrenal problems and of course I must not forget my beloved PMR (from a total list of 17 diagnosed autoimmune diseases), PPIs from the very latest "AZOLES" to the more old and bold "RANITIDINES" are not the answer!!
Have you got the option to change pharmacies?
A young-sounding GP, who was totally unknown to me, was on' repeat prescription duty' rang me from the practice to tell me that she had done the prescription and she had added Omeprazole for digestive problems. I replied that I didn't have any. Her reply was - along the lines of - so it would be a good time to start taking them before - they develop. The prescription was filled, I brought them home, read the bit of paper. Didn't take any and put the box in the medicine chest where it has remained undisturbed ever since. Bless her. She meant well.Along with many others in this forum, I take live yoghurt as my gastric protector.
But she also cost the NHS the cost of the drug and the dispensing fee - not that much for one person but it adds up if she does that for everyone. Top tip: check the bag before leaving the counter and return anything you don't intend using so they can be put back on the shelf ...
Some won’t if it’s got the dispensing label on it..,and ‘been through the accounting system’ ...tried that with unopened boxes when hubby died, although they had obviously been taken out of pharmacy.
They aren't allowed to take stuff back that has left the shop - hence the bit about before leaving the counter. Also a good move to be sure they've given you the right stuff ...
I do!
What a can of worms this is! Dorset Lady is correct. Pharmacists can do extra training to become Independant Pharmacist Prescribers. It is becoming more common for GP practices to employ a Pharmacist to do the medication reviews because that frees up Doctor's time and Pharmacists are considered to be "the experts in medicines". It is a closer skill set match than getting nurses to do it, although these days nurses often do all the interventions for diabetes, asthma etc having trained at a higher level to permit prescribing. However in reality Pharmacist's knowledge tends to be very theoretical and therein lies the problem. I'm retired now but I don't think things have changed that much and every day I think "I wish I knew then what I know now". Prescribing in the NHS is now governed by NICE (National Institute for Clinical Excellence). Remember the old days when the GP would get out his MIMS or BNF and look up the medicine he was thinking of? No more. The NICE guidelines lay it all out with flow charts and protocols. So referring to your specific situation; proton pump inhibitors (PPIs) are now the drug of choice and the NICE guidelines state that they must be prescribed with steroids or NSAIDs (ibuprofen, naproxen etc). If a patient refuses them a note will be made on their notes so if a gastric bleed occurs in the future, the NHS cannot be sued.Regarding your E/C Prednisolone, as someone has already said they are not strictly delayed release. To a Pharmacist, delayed release means a medicine which has been specially formulated into a dose form which controls the rate at which the active principle is released. In practice enteric coatings do create a time lag between time of dose and release of the drug so to a patient this is delayed release. There have been reports in medical literature that the cost of EC Pred doesn't justify the benefit so once NICE enshrines this in policy, that's it.
If you don't fancy another stand off, I would accept the Omeprazole but don't take it. You could then a month later contact your Doctor and say you have side effects. There are plenty to chose from, but for us I would major on muscle pain, joint pain, insomnia and risk of osteoporosis. These four are also PMR/steroid issues. Don't be surprised if you are told these are very rare side effects. My answer to that is "it may be rare but if you are the one that is affected it is a problem".
Good plan. So, would those side effects be a justification for switching back to ec pred?
No Jontie, just an option for not having the Omeprazole.
I assume that if Nice say we can't have it then that's the end of the matter. Unless we buy it privately.
I imagine there is still a degree of discretion on the part of a GP - and sometimes rheumatologists will side with the patient. Then there is always the arithmetic - adding up the figures for 2 separate drugs is fairly convincing.
Doctors are very quick to say "They're just guidelines" when it suits them ...
With NICE it's not so much you can't have a drug over another, because some patients will have adverse reactions or there may be drug interactions with other medicines. But getting back to the EC Pred vs uncoated Pred question. If EC Pred comes off of the prescribing formularies for the NHS then there may come a point at which the manufacturers cease production because of the economics. PMRpros point of two drugs more expensive than one is very valid. However if studies have shown little benefit on clinical grounds that adds weight to prescribers saying NO to EC Pred. And yes, if you want a private prescription that should not be a problem unless the GP charges for writing one!!!!!!
Which I believe they are not allowed to do if it is part of management on the NHS ...
Jontie
Just to counteract all the negative comments about Omeprazole etc, my version.
I was prescribed lowest dose many moons before Pred, when taking a cocktail of drugs including low dose of aspirin for high blood pressure was in fashion. That was 2003 or 2004- and remained on same all through GCA/Pred years.
Omeprazole along with all the BP drugs were were stopped after knee replacement operation when BP went really low in 2018.
So about 15 years in total - shock, horror I’m still alive!
Last DEXA scan - 2019 - returned readings within normal range -
AP spine T. -0.6
Femoral Neck (left) T. -1.0,
Total Hip (left) T.-0.9, -
although classed as “at risk” (hysterectomy aged 37, 4 years + on Pred and mother’s fractured hip [although she never was diagnosed as having osteoporosis]).
I’ve had 3 replacements in last 2-3 years, never any comment of brittle bones, and a heavy fall a couple of months ago which bones came trough unscathed.
No issues from Omeprazole- ever.
Maybe I’m the exception to the rule...there’s always one apparently!
You are not the exception to the rule! I have been taking Omeprazole for 10 years with no issues to date.
Good to hear - sometimes posts get swamped with adverse comments, so we need a balanced view.
Yes, good to have another perspective. Thanks
Me too, valve been on them for11 years no problem
Likewise with me, been on them, 20mg, for many, many years suspect decades, with no problems, either stomach or bones. Last DEXA scan was excellent. I still take my Pred with a banana and yogurt though.
I happened to get horrible effects from omeprazole but plenty other people don’t get them. I just wonder why on earth she's rocking the boat and changing something that was obviously working well for you...
Maybe there is a new category of pharmacist who is able to prescribe? I haven’t heard. As far as I know it’s the doctor. Possibly take issue to doc and discuss it before taking action.
If you read my reply to Bcol higher in thread and also PMRnewbie2017 reply you find there are. Pharmacist Independent Prescriber
Are these pharmacists allowed to change a prescription a doctor made? They've introduced something here (to free up overworked GPs) where a pharmacist can prescribe several things. As far as I can tell from the website they cannot override a prescription from a doctor. Most of the items listed can be managed by a patient with otc medication, with or without a pharmacy consultation (which is NOT free btw, a dr visit is) but there are three which require prescriptions that a pharmacist can now independently prescribe: uncomplicated uti, shingles (to get an antiviral) and birth control. Thanks for warning, Jontie , about what can happen if this profession is given more power. We train our doctors for a reason and want to keep them!
PMRnewbie (retired pharmacist ) has answered your question I think.
Yes. I see now there are such people. You learn something new each day! I had been wondering why a new pharmacist at our pharmacy wanted to review my medicine when I hadn’t asked. I was rather annoyed when she began criticising the doctor. It undermines trust.
No she shouldn’t be criticising anyone...not professional.
I can see and understand that some pharmacists have the extra qualification to prescribe as do some nurses, but does that give them the right to change a doctor's prescription. Surely, at least, they should discuss the possible change with the doctor first and then explain any changes they have made with the patient.
Don’t know the answer to that, maybe it depends on what powers the GP who “employs” them has bestowed and the death of knowledge the actual pharmacist has.
I can recall some years ago (2010s) our then pharmacist (Boots employee, not attached to surgery) carrying out a medication review for both me and my late hubby and making suggestion to change medication. So it’s been going on in some places for a long time.
I suppose it depends on the history - I wouldn't take kindly to anyone changing the medication regimen I have worked out over a long period to work best for me without discussing it with me and explaining their justification. When I as a patient have tried various sorts of steroid doses and timing and found what works best for me, no-one is going to get away with a dismissive "rubbish" without some very good justification. They may manage to improve it - but that isn't the way to go about it.
To me your last sentence sums it up. I have no problem with a medication review, but if there are going to be suggested!!! changes then they need to be discussed with and a rational explanation provided to the patient. The patients own experience and history also needs to taken into account before any changes are actually made.
How depressing. I used to have so many digestive issues, including oesophageal spasms. These improved immeasurably when I started on gastric resistant Prednisalone tablets. Please could you ask your pharmacist for the reference link to the research papers for the sake of the PMR/GCA forum. We would be grateful to see it. Personally, I got a lot of unpleasant symptoms from Omeprazole . I find that my gastric resistant Pred takes about 6 hours to kick in. I take it at bedtime and feel fine in the morning.My surgery pharmacist caused me no end of trouble - he seemed to have an agenda to get patients off medication or on to cheaper medication perhaps. He would remove things from repeat dispensing without warning me. He didn’t last very long but he seemed to have an alarming amount of autonomy.
Same here. Gastro resistant has worked well for me for 4 years. Take it before bed and I'm ready for work in the morning.
Another point - some years ago there was a movement to remove enteric coated pred from the armoury for much the same reasons that is almost certainly behind the pharmacist's move. It was (at the time) felt to be cheaper to give patients plain pred plus a PPI than it was to just give e/c pred. GPs were consulted and the move was made as they didn't think there would be a problem - however, once long term pred patients like us were switched they discovered that a lot of patients developed GI symptoms and many GPs regreted supporting the move. In the meantime, the producers of plain pred thought they were safe to increase the price without risking losing sales so the price differential almost disappeared. The problem though is not just the pennies - it it the complexity of polypharmacy where 2 drugs may or may not interact - but when a patient is on several medications the interactions can become totally different, Clinical trials are rarely done on patients already taking several other drugs. It is well known that taking more than 5 drugs, especially in the older patient, is a risk factor for problems including falls and it is recommended that prescriptions be kept as simple as possible. The patient needs pred - and there is a form of pred that means they don't have GI problems and don't need additional "protection". So why use 2 different substances whn 1 does the job? It is one of the problems that leads to polypharmacy: the patient gets a prescription but develops what is assumed to be a side effect. Instead of changing the drug, they dish out another to manage the adverse effect. It too may lead to a problem - and another drug may be handed out.
Drug interactions could account for 1% of hospitalizations in the general population and 2–5% of hospital admissions in the elderly. Go into any medical ward anywhere and you will find they are filled with older patients - and a lot of them are there because of drug interactions. I don;t wish to join them - I try to keep my medication as simple as I can. It still means 4 different drugs taken at 5 times a day to reduce interactions,
Here is an update: I contacted the rheumatology advice line which is manned by specialist rheumatology nurses. The person I spoke to said she thought "I had a point" but that I needed to talk to my GP as he was the one who prescribed the medication. I had a telephone consultation with the GP today. It was the first time I've talked to him because my previous GP has left the practice. He listened to what I had to say but remained neutral. He said he would talk to the GP Practice pharmacist but could not guarantee I would get my way. It sounds like the pharmacist does indeed rule the roost here! The GP admitted that this was probably about saving money. He said enteric coated were more expensive, and omneprozol were cheap as chips. I explained that the main reason I took enteric coated ones was that, because it was slower release I could take them at night and feel ready for work in the morning. Luckily, I explained that I'm a gardener - he said that had I been an office worker, I'd basically have to put up with feeling bad for a couple of hours! He said that if the practice can save a few pence on drugs for people like me, then there is more available for people needing cancer treatment. I don't hold out much hope because I've already made my case to the pharmacist, and she wouldnt accept it. So, there we are. This is the world we live in folks. I'll let you know the outcome...
The difference in price really is peanuts when both drugs are put togetherand they might find they end up spending more when you have to attend appointments more often because of adverse events due to the PPI. But that doesn't count ...
I know. Its rubbish. I'm not intending to take the PPI anyway. I'll wake up at 4 am and take uncoated pred with yoghurt. I think various people suggested that.
Just for Info - latest prices
Latest NICE costs (Jan 2021)
This is quoted indicative cost & drug tariff price...what pharmacies charge nhs for dispensing.
All 28 tablets
Dose. Indicative price Tariff
Plain Pred
5mg £0.85-1.28. £1.77
1mg. £0.62-1.32 £0.94
EC Pred
5mg £1.68-3.79. £1.77
1mg. £5.82-7.43. £5.83
Omeprazole -
10mg - £6.58-7.90 £7.22
20mg - £6.61-7.22 £7.22
Have taken cheapest and dearest brands ....tariff is same for all brands.
So assuming prices are correct, EC works out cheaper than plain plus PPI.
Very interesting. Thanks
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