GP will not increase to 2x 300mg per day

[DOT COTTON]

Im currently on 400mg of lyrica per day, I seen my GP yesterday and she refused to increase it. She says 400mg per day is the max for GAD, She said the health board do not like GPs to pescribe this. had anyone else had this problem?

[SarahH]

the reason why GPs find this difficult to prescribe is the cost. It is still under patent to the original pharmaceutical company. BUT Nice guidelines show that it can be prescribed for GAD since 2007.. However, if your GP is prescribing 2x200mgs a day the cost will be the same as 2x300mgs a day. Its the number of prescriptions that cost more i.e. 3x200mgs will cost more. Your GP can prescribe you 2x300 and the cost will be the same. 600mgs a day is the maximum for GAD.
Each prescription costs the NHS £90 a month. I had this conversation with my GP yesterday!She said that some GPs do not have enough knowledge about drugs for psychiatric use. to be fair I was first put on it in a psychiatric unit so she is only just realising it can be used for GAD after 35 yrs as a GP.
Sarah

[hanshan]

Hello Dot,

As Sarah says, the maximum is 600 mg per day, and reasons for limiting prescribing pregabalin are often based on cost, not health (when it is NHS licensed for a particular condition).

Does your GP know about your previous addiction problems? If so, she may be very wary if you come in asking for a prescription increase.

If you are female and average weight, then 400 mg per day should be a more than adequate maximum dose for GAD. Many (most) people are taking less. Taking more is soon counter-productive, as you have discovered.

[DOT COTTON]

Thanks for your advice, I did get into a heated discussion with my GP About, they say its 'in the interest of patient safety', absolute rubbish its the cost, always about the dam money!

[KK77]

Yes, as Sarah said, the cost should be the same for 2x300mg so perhaps your GP has another reason. Some just don't like prescribing max dose but every patient is different. Maybe you could see another GP in your practice?

[DOT COTTON]

Thanks for all your advice guys

[hanshan]

I'm not familiar with the UK system for prescriptions, but the picture I seem to be getting is that the practice gets charged for the prescription.

Is that right? If so, doctors will be under pressure to prescribe cheaper medications, even if a more expensive but more effective medication is available.
To complicate matters, from what I can gather, it doesn't matter what strength of a medication is prescribed, the cost is the same. Is that also right?

Australia has a licensing system similar to the UK, but the cost of licensed medications is subsidized by the government when you visit the pharmacy.
Low income earners (people on pensions, etc) pay around two UK pounds for a month's supply of a licensed medication, but regular income earners have to pay about 15 UK pounds for a month's supply. It's totally separate from the doctor's practice, so doctors aren't under any financial pressure.

If the medication isn't licensed for a particular condition, you have to pay the full cost. Unfortunately, pregabalin isn't licensed for GAD in Australia, so people there have to pay the full cost themselves for GAD. I believe this is also true in the US and Canada.

[MyNameIsTerry]

This sounds like a GP who is unaware of the correct use of this medication.




As seen in this document http://www.kmpt.nhs.uk/Downloads/Tru...-in-Adults.doc

. the maximum dosage is 600mg split into 2. It can also be seen that the charge to them is the same over a 28 day period whether at sizes 75mg (the starting dose), 150mg and 300mg. It also states that after commencing at the starting dose of 150mg per day (split into 2 doses) it can be increased at intervals of 150mg daily. It is available in lots of mg sizes, presumably to manage tolerance issues so GP's may be choosing to make a starting dose less and work up through different intervals but its clear that the Kent & Medway NHS Trust do not agree with your GP.

Sussex NHS Trust seem to have the same view http://www.sussexpartnership.nhs.uk/...nish/2030/7005 on cost, starting and maximum dosage. They give slightly more information on intervals and have a close review policy on anything over 450mg due to a question mark over greater efficacy in some studies.

Merseycare NHS Trust http://www.merseycare.nhs.uk/Library/What_we_do/Clinical_Services/Pharmacy/AnxietyDisorders-Finalv3.pdf
agree with the other trusts.

South Yorkshire NHS Trust http://www.southwestyorkshire.nhs.uk/documents/1038.doc
agree with the other trusts.

If you want to see the view of NICE, it also recommends the maximum of 600mg but gives some slightly different advice because they have split it between the different conditions it can be used for http://www.evidence.nhs.uk/formulary...lin/pregabalin

Here is also is a detailed document by EMA Europe (The European Medicines Agency based on London) http://www.ema.europa.eu/docs/en_GB/...C500046602.pdf which also breaks it down into condition specific advice which agrees with the above dosage information.

Here is a Patient Information Leaflet (PIL) taken from http://www.medicines.org.uk/emc/PIL.14707.latest.pdf which agrees with all of the above and was updated 3rd September 2014. These are what they put in the boxes, so does this match yours? It says up to 600mg for GAD in this so if it matches yours, you could easily show this to your GP.

So, I think thats enough evidence to prove that your GP is incorrect. The local trust or 'health board' as she has put it don't like using this medication at all due to cost but NICE clearly set the guidelines for why this is sometimes required and there is no cost issue here because you are already on it and there is no difference in cost between mg.

NICE don't cover all of the UK, Scotland for instance have their own version (and they seem woefully behind as they didn't cover anxiety disorders at all last time I looked for someone!)

Regardless of cost GP's should be accurate and truthful. This GP is either inaccurate in their dosage advice or misleading their patient if making it a cost argument. It would be a different matter if they were trying to move them to a cheaper medication or refusing to prescribe this due to cost if not already on it, however NICE guidelines are there to indicate when this should be used which is if SSRI/SNRI's cannot be tolerated.

Hanshan - in the UK we get reduced single price prescription costs or no prescription costs at all. It depends on which country patients are in.

[KK77]

Problem is that generics are so cheap now compared to brand names. Eg, Effexor in UK (Venlafaxine) is twice the price of comparable prolonged release Venlafaxine tabs and in this case I can understand their concern. But in the case of Pregabalin, they want most patients to swap it to Gabapentin which is similar in terms of neuropathic pain control (but not approved for fibromyalgia). Or in the case of GAD/anxiety, to SSRIs/SNRIs. There probably is a very small difference in cost between doses of Pregabalin but it's not significantly relevant if a patient is already taking it.

I think in Dot's case, his GP doesn't want to play around with dose as they want him off it. So the GP in question doesn't want to get flak for increasing his dose when she is probably under pressure to take him off it. I think you have to stand your ground if the med is helping. If not, then it's probably wise to look at alternatives.

[SarahH]

Good post MyNameIsTerry!

2x150mgs is cheaper for NHS as two prescriptions whereas 3x100mgs is three therefore costs the NHS £90 a month more.It makes no difference what strength they are, its the number of tabs a day that are required.

Hanshan, each prescription is £8.05,(I think the maximum number of meds on one GP presciption is 3) but you can buy payment cards to reduce the cost (about £120 a year)So for me as I about 3 presciptions a month on average that's a third of the cost.

I hope that makes sense.

Sarah