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WHAT do acarbose, nizatidine and The Ashes have in common? Not much — but they do all appear in this article.
I recently attended a diabetes update and was bedazzled by the advances in diagnosis, classification and treatments of this common disease.
Especially interesting was the Comprehensive Diabetes Management Algorithm released by the American Association of Clinical Endocrinologists (AACE). This contrasts to the Australian guidelines.
Regular readers of this column know that I am no disciple of medicine-by-protocol as it can be too restrictive, takes away clinical autonomy and lends itself to doctor substitution.
The AACE algorithms are a breath of fresh air because they offer clinicians flexibility and aren’t motivated by governmental factors like the Pharmaceutical Benefits Scheme. Doctors spend a whole lot of time studying a whole lot of stuff, and they should be allowed to use this knowledge in its entirety for the benefit of their patients.
Acarbose appears twice in the AACE algorithms; both for diabetes and prediabetes. I thought, “Wow! That’s a drug I have not used for 7–8 years!”
Attending clinical updates, it’s easy to get swept up in all that is new, forgetting all the old tried and trusted (and often cheaper) treatments. The recent MJA article on phenytoin as an antiarrhythmic is another fantastic example of this.
There are a number of reasons why drugs go in and out of fashion — drug companies promoting newer medications; clinical guidelines that can come from a variety of institutions; peer pressure from colleagues; and how often we revise our own knowledge.
So in the spirit of The Ashes, I present my First XI of “forgotten” drugs that I believe still have a role to play in practice:
I) Nizatidine: When a proton pump inhibitor fails or is contraindicated for a patient with peptic ulcer disease, H2-antagonists still have a role to play. Nizatidine also possesses pro-motility properties.
II) Sucralfate: Most of my registrars and medical students have never heard of it, but worth thinking about as a third or fourth line drug in peptic ulcer disease.
III) Imipramine: Oscar London, author of a book on how to be the world’s best doctor, reminds us to never give psychiatrists credit for starting a patient on a tricyclic antidepressant. This class of drugs is also handy for insomnia, enuresis, neuropathic pain and urinary incontinence.
IV) Moclobemide: How long since you’ve seen a depressed patient on this drug? About 15–20 years ago it was popular; then SSRIs (selective serotonin reuptake inhibitors), SNRIs (serotonin–norepinepherine reuptake inhibitors) and new antipsychotics came to town with all their marketing and swept it away. It is effective, safer than many other antidepressants in the elderly and has easy dosing.
V) Acarbose: This drug to treat type 2 diabetes seems to play a bigger role in the US than there, but is included in our team as “an option for improving glycaemic control”.
VI) Nitrofurantoin: Our wicket-keeper is a very safe pair of hands for urinary tract infection (UTI). So many UTIs remain sensitive to it but I know of hardly anyone who gives it a run these days. I’ve seen many an urologist use it as a prophylactic antibiotic at low dose.
VII) Ampicillin: We are constantly told about antibiotic stewardship, yet hospital doctors seem to always prescribe the latest and dearest antibiotics. This all-rounder (hence batting at number seven) still has many applications, not least respiratory tract infection.
VIII) Doxycycline: With broad antibiotic properties, this drug is a rural doctor’s best friend. It covers atypicals like Q-fever and leptospirosis, as well as being effective for respiratory tract, skin and genitourinary tract infections and as a malaria prophylaxis.
IX) Co-trimoxazole: My team is big on all-rounders and this sulfur drug is not only good for urinary tract infection, but also great for respiratory tract, atypicals and skin. The syrup for children does not need to be in the fridge, which is handy for many parents.
X) Cefaclor: A small number of children get a serum sickness-like adverse reaction with this drug so many have rejected it. But it’s still a very useful and mostly well tolerated antibiotic for many patients.
XI) Soluble aspirin: Patients can buy this cheaply at the supermarket and it often gets forgotten, yet has so many uses.
This list is my opinion and in no way intended to modify your prescribing habits. I hope it will stimulate you into thinking and talking to colleagues about some of your favourite older drugs.
And please feel free to add your comments below about my XI. There may be some you want to drop from the team and add your own better performers.
I am confident my First XI performs better than our crumbling Aussie cricketers.
Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.
Nice article Aniello,
As a junior doctor I must admit I have never heard of moclobemide. However I have at some point in my career so far used prescribed First XI (except your top order II, III and IV) with good results. In particular doxycycline is such a versatile agent. In ophthalmology it is one of the few oral drugs we prescribe – at low doses for the management of inflammatory ocular surface disease.
I would add IV Verapamil for young, healthy people with paroxysmal SVT – much cheaper than adenosine, doesn’t make the person feel like they are going to die!
Great article! It makes us think about our prescribing habits and our rationale for using them. Is it just a fashion thing? In my field of anaesthetics, ketamine has been around for a long time and was fairly out of favour (in 1st world countries, that is) but has recently staged quite a come back and is acknowledged as a very versatile agent
Not quite a drug but a great antiseptic for blisters, superficially infected wounds, skin ulcers, abrasions etc. is Mercurochrome 2 or 5% aqueous solution.It is painless when applied and very cheap. It was swept away by clever advertizing for povidone-iodine but you can still buy it if you look around.
It’s good to see someone else familiar with the “Book of Medical Wisdom” that I read as an impressionable med student and has remained with me ever since.
Valuable team, BUT; Cotrimoxazole is part sulphonamide (known in my day as “sulphas” – NOT sulfurs) and has a significant adverse reaction rate with erythema multiforme and, sometimes fatal, Stevens-Johnson syndrome. The reaction has been sheeted home to the sulpha component, and any sensitivity is to all sulphonamides. There is a hazard, not well enough known: in some men it produces a sensitivity reaction in the form of an ulcer at the base of the glans penis. It heals readily with basic hygeine and is unpleasant, but if it occurs it is an absolute contraindication to any further use of the drug. I don’t know whether there is a cross sensitivity to other tetracyclines.
Watch out for allergies esp. to co-trimoxazole.
I’ve a high cholesterol and to this end trialled nicotinic acid. The side effects of flushing for me were unbearable and after reading the latest research dismissing nicotinic acids inefficacy I think caution should be urged.
As a G.P. anaesthetist, now retired, I used many of the drugs included in the list. As a patient with raised cholesterol levels I was started some years ago on the statins in combination with Nicotinic Acid. Not only did this combination bring my cholesterol levels back to acceptable levels but it also increased the HDLs and decreased the LDLs. Sadly, the medical profession in general failed to realise the great benefits that Nicotinic Acid has in facilitating these good effects and some ten years ago, Nicotinic acid was removed from the Medical Benefits Prescribing list. Whilst it is not expensive to purchase over the counter, it still remains a most useful drug in the armamentarium of the prescribing G.P. and Specialist.