Rheumatology Advance Access originally published online on January 10, 2008
Rheumatology 2008 47(3):375; doi:10.1093/rheumatology/kem281
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LETTERS TO THE EDITOR |
Co-proxamol: where have all the patients gone?
Musculoskeletal Unit, The Freeman Hospital, Newcastle-upon-Tyne, Tyne and Wear, UK
Correspondence to: D. J. Walker. E-mail: d.walker{at}ncl.ac.uk; david.walker{at}nuth.nhs.uk
SIR, The Committee on Safety of Medicines (CSM) advised withdrawal of co-proxamol in January 2005 as it was judged that the risk of accidental death by overdose and the drug's frequent use in suicide outweighed its benefits as a painkiller. We were struck by the number of patients who seemed to be coming to the clinic complaining that they were unable to find an effective alternative. A typical complaint would be that they had been on co-proxamol for 20 yrs and found it very satisfactory. They had been tried on co-codamol and tramadol without nearly as good a benefit and wanted their co-proxamol back. We felt that an audit of what had happened to all the patients on co-proxamol was necessary to see if the impression that they were dissatisfied with the alternatives was true.
The aim of this audit was to assess if patients had transferred to an alternative painkiller, how satisfied they were with their change in medication as compared with co-proxamol and whether they would like their co-proxamol back. The standard that we chose to audit against was that all subjects should have found an alternative that they were happy with or they should be allowed to continue their co-proxamol.
The department database was searched for all patients who were current users of co-proxamol in January 2005. A postal questionnaire was sent out in February 2006 to all patients, seeking information on whether they were indeed taking co-proxamol in January 2005 and which drugs they had tried and were currently taking. We asked how effective and tolerable they rated their co-proxamol and whatever drug they were currently taking on visual analogue scales (VAS). We also asked about how they had heard of the imminent withdrawal of co-proxamol and sought information relating to suicide risk using standard questions.
Eighty-one patients were identified from the database and 60 replies were received (response rate 60/81 = 74%). Thirteen males (21.6%) and 42 females (70%) responded, with an average age of 59.1 yrs. Five respondents (8.3%) did not indicate sex or age. Rheumatoid arthritis was the commonest indication for taking co-proxamol with 34 patients (56.6%), followed by osteoarthritits with 21 patients (35%). The remaining 13 patients (8.4%) were taking co-proxamol for psoriatic arthritis, systemic lupus erythematosus, enthesitis, spondyloarthropathy, ankylosing spondylitis and tenosynovitis.
Fifty-six of these confirmed that they were taking co-proxamol in January 2005 (93.3%). Seventeen (30.4%) were still taking co-proxamol at follow-up. Of these, only six had tried alternative analgesics since the announcement (most commonly co-codamol and tramadol). Of those patients who had changed from co-proxamol (39), 27 would choose to return to co-proxamol, given the chance (current drug: co-codamol 15; paracetamol 7; co-dydramol 2; codeine 4; tramadol 3; DF118 1; MST 1). There were 12 patients who were content on a new analgesic (current drug: paracetamol 4; codeine/paracetamol 4; DF118 2; co-dydramol 1; tramadol 1). Of the patients who had changed from co-proxamol to an alternative painkiller, a significantly higher level of effectiveness (P < 0.01) and satisfaction (P < 0.01) on the VAS was found for co-proxamol compared with the current drug. Twenty-seven of the 39 people no longer on co-proxamol (69%) would choose to return to co-proxamol if they had the choice.
General practitioners were most likely to have communicated the withdrawal of co-proxamol (58.9%). The population was at very low risk for suicidal intent 4/60 (6.6%) and thoughts of overdose 2/60 (3.3%).
In total, of the 56 patients confirmed as taking co-proxamol in January 2005, 17 (30%) were still taking it; 27 (48%) were unhappily off it and 12 (21%) were content on a new drug. Forty-eight per cent therefore fail our standard that they should have found a suitable alternative.
Previous work has suggested that up to 65% of people who die from co-proxamol overdose have a chronic physical disease, with approximately half of these being due to a skeletal or muscular disorder, often widespread chronic pain [1]. This case series also found a history of depression in 55% and an undefined mental illness in a further 21%. Chronic alcohol abuse was also a significant factor, being found in up to a third of co-proxamol deaths. We would argue that our patients are at low risk of overdose as they have a well-defined rheumatological condition, and we found little evidence of depression, suicidal intent or ideation in this population.
This selected group of patients experience significantly better pain relief with co-proxamol than with alternative analgesics. We would suggest that more note should be taken of what are effectively n of 1 studies and that more patients should be allowed to continue to take what is the best drug for them.
Disclosure statement: The authors have declared no conflicts of interest.
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- Dywer PS, Jones IF. Fatal self-poisoning in the UK and the paracetamol/dextropropoxyphene combination. Hum Toxicol (1984) 3(Suppl.):145–74S.
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