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GP view: Ranitidine shortages are improving relations with pharmacists

"Managing patients on ranitidine seems to be a good use of pharmacists' skills"

Ranitidine shortages are triggering collaboration between pharmacists and GPs through reviewing medication, says GP Toni Hazell

It’s me, talking about shortages – again. Sorry. One of these days I’ll find something original to write about.

The latest instalment in the medicine shortages box set is ranitidine. If I’m being honest, it’s not a medicine that I usually give much thought to. Ranitidine is useful for those with reflux and gastritis, and it’s cheap and well tolerated. It isn’t something that has given us much hassle. Until now.

The headlines started to hit in early October, when a Medicines and Healthcare products Regulatory Agency recall was issued for certain batches of ranitidine-containing medicine due to possible contamination with carcinogen N-nitrosodimethylamine (NDMA).

Initially, this only affected Zantac. But it was shortly followed by an alert that all oral preparations of ranitidine were out of stock, with no date for resumption of supply. This action was taken even though, according to the U.S. Food and Drug Administration, the levels of NDMA in ranitidine barely exceed that found in many foods. Perhaps we should also ban bacon and whisky.

This shortage seems to be different from some of the previous ones. So far, shortages have been caused by different brands of a medicine going in and out of stock, so prescribers have to fiddle around changing allergic patients from Jext to Emerade and back again, or our patients taking hormone replacement therapy products from a patch to a gel and then to a tablet.

This is the first time that an entire class of medicine has effectively gone out of stock, as there are few other H2 antagonists on the market. Those that are available are also in short supply, so much so that we have been asked not to switch to them for fear of exacerbating those shortages.

From adversity comes opportunity though, and this is at least a trigger for GPs and pharmacists to work together in a way that will hopefully become more common in the future. Increasing numbers of practices have pharmacists who conduct medication reviews and other tasks previously given to GPs. Managing patients on ranitidine seems to be a good use of their skills.

Pharmacists have the knowledge to review the notes for the indication and then speak to the patient. Some patients been taking it for years after a short episode of reflux and don’t need it anymore. Others will need switching to omeprazole or Gaviscon.

The occasional patient might need to be discussed with gastroenterology or paediatrics. Drug shortages are a pain in the posterior, but if they improve GP-pharmacist communication and multi professional working then at least some good will have come out of the situation.

Toni Hazell is a GP based in a practice in London

5 Comments

Simon Ingham, Superintendent Pharmacist

I don't understand why its alright for anyone to continue supplying Ranitidine.  Looking at the issue it appears the carcinogen NDMA is being produced from the drug in the body as it is broken down, under high environmental heat or when exposed to other chemicals. 

Maybe certain batches had higher amounts in them due to manufacturering processes but there is still a risk with every tablet supplied.  It seems unethical to be supplying any Ranitidine regardless of recall status until the extent of the risk has been calculated.  Unless we can be sure the doctor has weighed up the patient's risk of GI symptoms vs cancer risk (for which they have no data whatsoever) how can we be happy to dispense?

Personally I feel negligent supplying it with the knowledge it might be increasing my patients' chances of developing cancer.

 

 

Tired Manager, Community pharmacist

Can someone help me.... is there actually a shortage or not? I have seen the recalls but as yet no problem ordering from Alliance etc...? 

Joan Richardson, Locum pharmacist

Patient marches up to the counter in the pharmacy yesterday and asks if the ranitidine prescribed for them has arrived yet.  Upon being told that there is no available stock and that the GP has been contacted regarding an alternative they reach into their coat pocket and, with a flourish, produce a pack of ranitidine 75mg that they have just purchased in a local bargain store.  Earlier this week there was a recall notice issued for certain batches of this make of 75mg tablets but there is no way of being sure if the pack in the patient's hand is one of them.

Patient tells staff that they obviously have no idea how to order tablets and leaves pharmacy in triumph having got one over on the incompetant staff.

Meanwhile the pharmacist sinks down to the floor in the corner of the dispensary and sadly begins to rock back and forth............

True story apart from the last sentence!!!

Leon The Apothecary, Student

I found the best-run prescription management tends to be ones where both pharmacy and surgery talk on a regular basis.

Joan Richardson, Locum pharmacist

Falling about laughing here!  Tried speaking to GP's when all this first started and was told to send patients to a certain multiple that had plenty of stock.  Now there seem to be more and more brands affected - note the new recall today for certain brands of  75mg tablets.  What could have been a gradual, phased process is now likely to become  chaos!

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