BNF 01 Formulary Development

Formulary Development BNF 01 Gastrointestinal Products

Whilst working my way through the Prescription Cost Analysis figures for a project I was surprised to see how large the volume of prescriptions was in 2019 for some of the therapies available.

For example, the generic descriptor in the BNF for Alginic acid compound preparations had a total NHS spend of over £20m in 2019. Drilling down further into the figures the Drug Tariff and Dictionary of Medicines and Devices has the following generic description:

Alginate raft-forming oral suspension sugar free

This piqued my interest and I decided to investigate a bit further. There are various brands in this category, but seemingly no true generics, and the reimbursement price is based upon the pack size ordered by the prescriber. Of course, with these products a patient who is happy that their symptoms are being controlled on a particular brand is going to be resistant to change. But what about new patients?

If the prescriber is happy that the quality of the various brands available, then the prescribing cost to the NHS will vary significantly according to the pack size chosen. And will the prescriber necessarily know this from their clinical system?

If written generically then the following is how the item will be reimbursed:

Quantity PrescribedReimbursement PriceCost per Month for 50 Patients*
*Assumes one bottle per month is prescribed and dispensed

From the data above the 500ml bottle gives the best value to the NHS.

And assuming a dispensing fee of around £2 per item, and even with no discount on the 500ml bottle, dispensing income should be maintained. There could be clinical or social reasons for giving a smaller bottle, and for one off prescribing and to reduce waste, then perhaps the 300ml bottle represents a mid-price choice.

The 500ml bottle reimbursement is based on the Peptac brand from Teva, it may be worth checking to see if there is a discount scheme available on Peptac.

Another curiosity I discovered is where the prescription is written generically for:

Sodium alginate 500mg/5ml / Potassium bicarbonate 100mg/5ml oral suspension sugar free x 500ml

This is listed in the Drug Tariff at a price of £5.12 as a Category C Item based on the NHS list price of Gavisocn Advance.

However, in the dm+d the generic descriptor for Acidex Advance 500ml is the same. And with an NHS list price of £3.84 per 500ml bottle, it can be dispensed against a generic prescription and the dispensary will make a small income of £1.28 per bottle dispensed plus the c£2 dispensing fee. [Assumes no discount]. Again, for controlled patients this may not be an option, but for new patients or one-off prescriptions it is worth considering.

Moving onward, I looked at Proton Pump Inhibitors to see what opportunities there are in that category.

The table below shows the top 10 proton pumps by strength and form prescribed in England in 2019.

MedicineDrug Tariff Price*Market Price*Margin
Omeprazole 40mg gastro-resistant
Lansoprazole 15mg
gastro-resistant capsules
Omeprazole 10mg
gastro-resistant capsules
Omeprazole 20mg
gastro-resistant capsules
Lansoprazole 30mg
gastro-resistant capsules
Pantoprazole 20mg
gastro-resistant tablets
Pantoprazole 40mg
gastro-resistant tablets
Esomeprazole 20mg
gastro-resistant tablets
Esomeprazole 40mg
gastro-resistant tablets
Lansoprazole 30mg orodispersible
* Based on figures June 22nd 2021

Since most of the Proton Pumps have been off patent for years, the Drug Tariff and purchase price remains relatively stable. The clinical decision about strength and medicine must come first but following those considerations of cost to the NHS and finally income should be considered.

There is not much between the most popular choices in this category with most prescriptions being dispensed for omeprazole and lansoprazole. This information is useful to share with prescribers on an occasional basis at practice meetings.