WHERE DO ALL THE TABLETS GO?

1237

,

separate from hospital doctors than they previously were. Despite its avowed aims the recent reorganisation 9 has distanced them still further, and recent documents’ leave no doubt that it is primary care which is gaining the advantage. It is disturbing to find that tests of costeffectiveness seem to be more consistently applied to acute hospital services than to the areas which are to benefit from the proposed redistribution of resources. The Scottish paper comments on "the need to cut back on the less essential aspects of care and to rationalise some existing services"; naturally "opportunities for rationalisation lie mainly in the hospital field, particularly in the acute and maternity services". To justify expanding resources for primary care, however, it blandly quotes the supposed success of the health-team approach (doctor, nurse, health visitor) which has been possible since reorganisation, and which "gives the patient the advantage of a multi-disciplinary approach to his health problems". Is there any evidence that patients appreciate the advantages of the new system in primary care: have its efficiency and its effectiveness been measured as critically as hospital activities often have been? It has been comparatively easy for family doctors to argue a coherent political case, because their problems tend to be similar. By contrast the acute hospital sector is "an arena in which specialists compete with the capabilities of their respective disciplines". That is presumably why there has been no organised response to the threats so explicit in these documents. Perhaps a benefit of the present crisis will be to bring the acute specialties together, to set aside traditional disciplinary differences and competing claims, and to identify the contribution of the acute hospital sector to the Health Service as a whole-a role previously considered self-evident but now

being challenged. CONCLUSION

Recent Health

Department documentsl give the impression that those anxious to reduce what they regard as the disproportionate influence and expense of the acute hospital specialties are using the present financial situation as a good opportunity for expediting their plans, under the guise of promoting the common good. Perhaps this is why Professor Knox described the English paper as a manipulative document.8 It seems that insufficient attention has been paid to the probable effects of actively dismembering that part of the Health Service

’

of which the country has least reason to be ashamed. Certainly there are activities in the acute hospital sector which are wasteful and expensive, but these are mostly the inappropriate use or undue prolongation of rescue procedures. Most hospital doctors are well aware of this, but find it difficult to withold or withdraw treatment unless there is a consensus of support among colleagues in their own and other disciplines, and among Health Service administrators. Until there is a policy to limit rescue procedures, the effect of restricting resources will be to reduce still further the availability in hospitals of cost-effective curative treatment. Institute of Neurological Sciences, Southern General Hospital, Glasgow G5 4TF

7. Snaith, A. H. ibid. 1976, ii, 8. Knox, E. G ibid. p 790.

BRYAN

JENNETT

1014.

9. Priorities for Health and Personal Social Services; H M. Stationery Office, 1976.

a

Consultative Document.

The Fate of Medicines WHERE DO ALL THE TABLETS GO? K. T. EVANS

G. M. ROBERTS

Department of Radiology, Welsh National School of Medicine,

Cardiff Barium sulphate tablets, identical in size and shape to those of aspirin, were given to 98 consecutive patients during routine radiological studies of the upper gastrointestinal tract. In 57 patients the tablets remained in the oesophagus for longer than five minutes. Delay in passage of the tablets was particularly likely to occur in patients with hiatus hernia and reflux and if defects of peristalsis in the œsophagus were observed.

Summary

INTRODUCTION

IT is commonly assumed that swallowed tablets pass without let or hindrance into the stomach unless an œsophageal stricture is present. However, the sensation of tablets "sticking" in the oesophagus is relatively common. It is not known how often this occurs or the site where such tablets are delayed. One of the authors developed dysphagia following ingestion of the antimalarial proguanil hydrochloride (’Paludrine’) though there had been no previous œsophageal symptoms. This study was undertaken to determine the ability of 98 patients to swallow specially prepared barium sulphate tablets. PATIENTS AND METHODS

Barium sulphate tablets were prepared by granulating barium sulphate with a 10% solution of polyvinyl pyrollidone in water. The wet mass was forced through a 2 mm sieve and dried at 60°C, and the 350-500 µm-size fraction separated. This was mixed with magnesium stearate 1% and compressed on a single-stroke tablet press. The tablets were identical in size and shape to aspirin. 98 consecutive patients (56 males and 42 females) undergoing routine radiological studies of the gastrointestinal tract were studied. Patients whose symptoms suggested organic œsophageal obstruction of recent onset were omitted from the study. 3 patients included in the study complained of longstanding dysphagia attributed to reflux oesophagitis and 1 patient had symptoms of carcinoma of the hypopharynx. After the radiological studies each patient swallowed two barium sulphate tablets with just sufficient water to assist swallowing (about 15 ml). The patients lay down immediately and were fluoroscoped at intervals in the supine position. If the tablets remained in the oesophagus for longer than five minutes the patients stood up and were examined at intervals of ten minutes until the tablets had reached the stomach. The site where the tablets rested was recorded and particular care was taken to determine whether oesophageal peristalsis was normal. Patients showing retention of tablets in the oesophagus were questioned as to whether they were aware of this. RESULTS

Delay Barium sulphate tablets remained in the oesophagus for longer than five minutes in 57 of the 98 patients examined. Occasionally one tablet passed into the stomach, the other remaining in the oesophagus.

Site In 43

patients

the tablets

were

delayed

in the lower

1238 sometimes within a hernial sac. In 10 patients the tablets were discovered in the oesophagus at the level of -the aortic arch and in 4 patients delay occurred both in the middle third of the oesophagus and

oesophagus,

at

TABLE III-PATIENTS WITH TABLETS RETAINED IN OESOPHAGUS

the lower end.

Presence

of Oesophageal Abnormality (table I) of tablets.-There were radiological features indicating an cesophageal abnormality in 21 patients associated with delay in the passage of the tablets. 16 patients had evidence of hiatus hernia with gastro-cesophageal reflux and in 2 of these strictures of the oesophagus were demonstrated. 11 patients had abnormal peristalsis, 5 with defective primary peristaltic waves, and in 6 tertiary contractions were recorded. With retention

TABLE IV-RELATIONSHIP BETWEEN DELAY AND ABNORMALITY OF THE OESOPHAGUS

TABLE I-RELATIONSHIP BETWEEN OESOPHAGEAL ABNORMALITY

into the lower lodged there.

AND RETENTION

oesophagus successfully

removed tablets

DISCUSSION

Some

patients

had

more

than

one

abnormality

shown

radiologically.

TABLE II-FINAL RADIOLOGICAL DIAGNOSIS

No delay.-In 8 of the patients without delay hiatus hernia with reflux was demonstrated. Only 3 had abnormal peristaltic activity.

This investigation has shown that barium sulphate tablets similar in size and shape to aspirin can remain in the (Esophagus for up to ninety minutes after ingestion. Retention can occur even in those without symp-’ toms or signs of oesophageal disease. The incidence of retention is however increased by more than two-fold in those with radiologically demonstrated oesophageal abnormalities (table iv). The time for which tablets remained in the oesophagus might have been greatly increased if the patients had remained supine during the whole period they were being observed. Presumably drugs given in tablet form may also remain in the oesophagus. We have evidence that smaller tablets than those used in this study and barium-filled capsules are similarly retained in the oesophagus. The latter slowly melt releasing their contents (see accompanying figure). Evidence is accumulating that certain drugs, particularly the anti-inflammatory group, produce symptoms of oesophagitis in some patients. Oesophageal abnormalities have been reported following treatment with oral potassium therapy.1-3 Partial

Symptoms of Obstruction Only those patients with cesophageal strictures were aware that the tablets had remained in the oesophagus. Final Radiological Diagnosis Apart from a greatly increased incidence of retention of tablets in patients with reflux and hiatus hernia there

significant difference in the primary two groups (table II). Time of Delay was no

tern

disease pat-

in the

There was considerable variation in the time for which barium sulphate tablets remained in the oesophagus (table III). In 14 patients tablets remained in the oesophagus longer than ten minutes and in 9 patients between ten and twenty minutes. 1 patient retained a tablet in the upper oesophagus for forty-five minutes. No

oesophageal abnormality was demonstrated radiologically in this patient. 1 further patient with an oesophageal stricture secondary to reflux oesophagitis retained the tablet above the stricture for ninety minutes. In some patients drinks of quite large volumes of water failed to dislodge the tablets. In others reflux of barium

A)

Two barium sulphate tablets held up in the (esophagus at the level of the aortic arch; B) Capsule containing barium suiphate slowly disintegrating in the lower cesophagus.

1239

obstruction due to an enlarged left atrium in mitral stenosis delays the passage of potassium with the result that the potassium is released in a high local concentration. This is sufficient to cause ulceration. Oesophageal ulceration has also been reported in association with tetracycline and its derivative doxycycline .4In these reports the antibiotics were taken immediately before lying down to sleep and the patients were awakened by severe pain in the chest. Both groups considered that the strong temporal relationship between taking the antibiotics and the onset of symptoms was such that these agents were the cause of the ulceration observed endoscopically. Patients frequently feel able to take tablets without an accompanying drink. This study has shown that tablets may remain in the oesophagus in normal patients and may be more likely to do so when the tablet is taken without a drink. However, in those with abnormalities of oesophageal movement retention of tablets is ex-’tremely common. Elderly patients particularly those who are recumbent are particularly at risk of retaining potentially harmful drugs in the oesophagus. We suggest that tablets should be taken either before or during a meal and not afterwards as often advised. Alternatively at least a tumblerful of water should be taken with tablets. Further work is in progress on the effects of various anti-inflammatory drugs on the oesophageal mucosa.

,

We wish to acknowledge the help we received from Dr N. A. Armstrong and Mr Brian Evans who kindly prepared the barium sulphate tablets and capsules.

Requests for reprints should Diagnostic Radiology, Welsh

be addressed to K.T.E., Department of National School of Medicine, Heath

Park, Cardiff CF4 4XN. REFERENCES 1 Pemberton, J. Br. Heart J. 1970, 32, 267. 2. Howie, A. D , Strachan, R. W. Br. med. J. 1975, ii, 176. 3 McCall, A. J. ibid. 1975, iii, 230. 4. Bokey, L., Hugh, T. B. Med. J. Aust. 1975, i, 236. 5. Crowson, T. D., Head, L. H., Ferrante, W. A. J. Am. med. Ass. 2747.

The survey was carried out at a 520-bed general hospital in Suffolk. Over a three-month period 1000 items, consisting of 40 000 tablets and capsules and 650 injections, were returned to the pharmacy. All items which would otherwise have been discarded were examined-i.e., those from patients visiting the pharmacy, from patients admitted to the hospital, from peripheral hospitals, and expired items. All relevant information was recorded. Pricing was carried out by means of data from MIMS, the Generic Price List, and The Red Book ; in all cases the trade price was calculated as this is the actual cost to the N.H.S. RESULTS

The total cost of all drugs examined over three months was £ 1104, of which only z40 worth could be put back into stock. The annual values would be z4416 and 162 respectively. From these figures which relate to a hospital in a not very large town, a national figure of 1 150 000 was estimated, assuming that the cost rises in direct proportion to the number of beds served in the N.H.S. The survey revealed that antibiotics are potentially a major source of waste. Although just over 10% of antibacterials were returned they were worth nearly 20% of the original total value of such drugs. The figure of 10% was surprisingly low in view of the fact that the collection was made in a general hospital with many acute cases which often required admission to hospital before the course was completed. Preparations which had reached their expiry date accounted for 36% of the total waste bill. Among the 1049 items surveyed were 27 which had reached their expiry dates one to five years previously. Short-dated antibiotics were responsible for the greatest wastage and peripheral hospitals were generally involved in the most outstanding cases of waste; preparations returned from these hospitals were invariably in poorer condition than

average. 1976, 235,

WASTAGE OF PHARMACEUTICALS F. S. V. MARSHALL R. J. HART Suffolk Area Health Authority, Ipswich District

Wastage of pharmaceuticals was studied for three months at a 520-bed hospital in Suffolk. Drugs worth £1104 were brought to the pharmacy for destruction. Only £40 worth could be put back into stock. It is suggested that the use of blister-packing together with conservative prescribing, supply, and suitable storage of medicines could lead to important savings of drugs discarded each year in English hospitals, which from this study were estimated to cost in excess of £1 million. Summary

INTRODUCTION

DRUGS

Zv1ETHOD

prescribed by general practitioners in the East Anglian Region from April 1, 1974 to March 31, 1975 cost 5 million more than their salaries. More responsible management in the supply of pharmaceuticals would undoubtedly lead to important savings.

quarter of medicines returned from all sources major faults, such as tablets broken or discoloured, moisture present, or a mixture of drugs present. Over 20% of labels were unsatisfactory. The labelling of preparations supplied by dispensing doctors was much below average, failure to indicate the name of the preparation, the date of issue, the identity of the supplier, or to write the directions all in words were common. Unsatisfactory storage conditions were reflected by the condition of the medicine. The quality of dispensing by local branches of Boots was generally above average; the preparations were always in good Over showed

a

condition, and the labelling doubt by the

use

was

always clear, helped

no

of large labels.

patients produced remarkable of medication, quantities obviously accumulated because of over-prescribing or a lack of compliance with instructions. The habit of prescribing in round 100s is one of the main causes of expensive stockpiling by the patient. This could be avoided if doctors were to request a drug supply in days rather than absolute numbers, and leave the pharmacist to do the necessary calculations. In several instances

DISCUSSION

The projected national wastage figure of [1 150 000 equals about 23% of the cut in drug expenditure proposed by the Government, and since the waste drugs reported on here are only a small proportion of the un-