Table 1 “Drugs to avoid” marketed in Australia and listed on the PBS
From: “Drugs to avoid” to improve quality use of medicines: how is Australia faring?
Therapeutic area | “Drugs to avoid” listed on PBS | Reasons to avoid | Rates of use (DDD/1000 population/day in 2015 unless otherwise indicated) |
|---|---|---|---|
Cardiology | Olmesartan (alone or in combination with hydrochlorothiazide or amlodipine) | No more effective than other sartans but can cause severe sprue-like enteropathy [23, 24] | 11.60 |
Fenofibrate | No proven efficacy, cutaneous, haematological and renal adverse effects | 7.14 | |
Ivabradine | Lack of benefit other than symptomatic for angina and heart failure, visual disturbances, cardiovascular disorders (including myocardial infarction), potentially severe bradycardia and other cardiac arrhythmias | 0.17 | |
Nicorandil | Lack of benefit other than symptomatic for angina and heart failure, risk of severe AE | 0.01 | |
Diabetes | Dipeptidyl peptidase-4 inhibitors (DPP-4): alogliptin, linagliptin, saxagliptin, sitagliptin, vildagliptin | Efficacy on diabetes complications has not been demonstrated, risk of severe adverse effects: hypersensitivity reactions (Stevens–Johnson syndrome, anaphylaxis, bullous pemphigoid), infections, pancreatitis, intestinal obstruction | Alogliptin 0.03 Linagliptin 1.15 Saxagliptin 0.57 Sitagliptin 3.99 Vildagliptin 1.20 In July 2016, around 208,000 people were taking a gliptin, i.e. 22% of all patients treated for diabetes [19]. Gliptin use has doubled since 2012 and became the third most common treatment (alone or in combination) in 2016 |
Pioglitazone | Risk of heart failure, bone fractures and bladder cancer | 0.60 | |
Alzheimer’s disease | Cholinesterase inhibitors (donepezil, galantamine, rivastigmine), memantine | Transient and small benefit, risk of serious adverse effects and interactions including digestive, neuropsychiatric and cardiac adverse effects with the three cholinesterase inhibitors | Donepezil 1.23 Galantamine 0.28 Rivastigmine 0.17 Memantine 0.12 In 2014, 52,012 patients were dispensed an anti-dementia drug, a 19% increase since 2009 [20]. Most were treated for over 6 months: around 70% taking acetylcholinesterase inhibitor and 64% of people on memantine |
Multiple sclerosis | Alemtuzumab | Risk of infusion-related reactions, infections, autoimmune disorders | 0.02 |
Natalizumab | Risk of progressive multifocal leucoencephalopathy, serious hypersensitivity reactions, liver damage | 0.09 | |
Teriflunomide | Infections, liver damage, peripheral neuropathy | 0.03 | |
Depression | Citalopram, duloxetine, escitalopram, venlafaxine | QT prolongation and torsades de pointes with citalopram and escitalopram, risk of cardiac disorders hepatitis and severe cutaneous hypersensitivity reactions such as Stevens–Johnson syndrome with duloxetine, risk of cardiac disorders (hypertension, tachycardia, arrhythmias, QT prolongation) with venlafaxine | Citalopram 6.89 Duloxetine 4.94 Escitalopram 18.30 venlafaxine 12.06 In 2015, citalopram, escitalopram, venlafaxine and duloxetine represented 44% (42.2 DDD/1000 population/day) of use of SSRI/SNRI antidepressants in Australia [17] |
Respiratory | Pholcodine | Antitussive that may cause sensitisation to neuromuscular blocking agents used in general anaesthesia | NA_OTC |
Oxymetazoline, pseudoephedrine | Decongestants for oral or nasal use with risk of serious and even life-threatening cardiovascular disorders, including hypertensive crisis, stroke and arrhythmias, as well as ischaemic colitis | NA_OTC | |
Inhaled mannitol | Lack of convincing evidence of efficacy in cystic fibrosis with risk of bronchospasm and haemoptysis | 0.0026 | |
Nintedanib | No convincing evidence of efficacy in idiopathic pulmonary fibrosis, risk of serious adverse effects including: venous thromboembolism, bleeding, hypertension, gastrointestinal perforations and impaired wound healing | NA | |
Gastroenterology | Cimetidine | H2 antagonist with multiple drug interactions increasing the risk of dose-dependent adverse effects of combined medicines | 0.02 (0.5% of the H2 antagonist usage) |
Domperidone | Indicated for intractable nausea and vomiting, risk of arrhythmias and sudden death | 1.43 | |
Osteoporosis | Denosumab | Limited efficacy, risk of serious adverse effects such as musculoskeletal pain, severe infections, QT interval prolongation associated with hypocalcaemia, osteonecrosis, multiple fractures after discontinuation | 8.73 The 8th drug by PBS spending in 2017–2018 with 648,197 prescriptions, a 24% increase compared to 2016–2017 [21]. Around half of initial osteoporosis treatment was with denosumab in 2015 (35,260 patients); with the rest of use (47,303 patients) in previous users of at least one other osteoporosis medicine [22] |
Pain | Celecoxib | Greater risk of cardiovascular adverse effects (including myocardial infarction and thrombosis) and skin reactions than other NSAIDs | 5.62 (25.5% of PBS prescriptions for non-steroidal anti-inflammatory drugs) |
Diclofenac/piroxicam | Greater risk of gastrointestinal and cutaneous disorders (including toxic epidermal necrolysis) than other NSAIDs | NA_OTC* | |
Weight loss | Orlistat | Gastrointestinal disorders, liver damage, hyperoxaluria, and bone fractures in adolescents | 0.00044 |
Smoking cessation | Bupropion | Neuropsychiatric disorders, potentially severe allergic reactions (including angioedema and Stevens–Johnson syndrome), addiction, and congenital heart defects in children exposed to the drug in utero | 0.04871 |
Skin/allergy | Promethazine injection | Thrombosis, skin necrosis and gangrene following extravasation or inadvertent injection into an artery | 0.0377 |