Sir, According to most authorities, phenoxymethylpenicillin is the drug of first choice for the treatment of infection with Streptococcus pyogenes. A 10-day course is recommended, to give the best chance of eradicating the organism and minimising the risk of glomerulonephritis and/or rheumatic fever. However, the PBAC listing is for only 25 tablets. Therefore, to provide a 10-day course, it is necessary to prescribe a repeat. This is often not obtained by the patient, and if it is, there is the problem of disposal of the leftover tablets at the end of the course. Would the PBAC consider providing a course of 40 tablets (or a 200 mL bottle in the case of mixture) to address this problem?

Carol Lawson
General Practitioner
Bundoora, Vic.

PBAC response

At its recent meeting, the Pharmaceutical Benefits Advisory Committee (PBAC) considered whether the current listing of phenoxymethylpenicillin as an unrestricted pharmaceutical benefit should be amended.

The PBAC recommended that the unrestricted listings be amended to provide for a maximum quantity of 50 (for all tablet and capsule forms) and 2 x 100 mL (for both oral suspensions). The current provision for a repeat which applies to these listings is to be removed.

Warfarin tablets

Sir, I would be grateful if you could explain why we have two brands of warfarin available, Marevan and Coumadin, both made by the Boots Company, when their respective doses are not bioequivalent.

Surely it would make sense to have only the one brand registered and to prevent the continual confusion between the two. Since they are made by the same company, the manufacturer would not be at a disadvantage.

D.F. Healey
General Practitioner
Inglewood, Vic.

PBAC response

Prior to 1 April 1992, a range of strengths of warfarin were available as pharmaceutical benefits as Coumadin (manufactured by the Boots Company) and Marevan (manufactured by Glaxo Australia Pty Ltd). However, after this date both brands of warfarin were listed as Boots' products. This followed the acquisition by Boots of a number of Glaxo products (including Marevan).

The discontinuation by Boots of Coumadin tablets 2.5 mg, 7.5 mg and 10 mg (and consequent deletion on 1 August 1993 of these items from the Schedule of Pharmaceutical Benefits) resulted in some rationalisation of the product range.

It is recognised that the product duplication which remains may, under some circumstances, cause confusion. Since Coumadin and Marevan are not bioequivalent, the anomalous situation has been highlighted by the introduction of the brand substitution policy. However, maintenance of the two brands would seem desirable, since to withdraw one brand would seriously disadvantage those patients who are stabilised on it. Furthermore, Government policy does not discourage the listing of alternative brands.

Broken packs

Sir, The PBAC's reply to Professor Kamien (Aust Prescr 1995;18:41) explains the procedure for pharmacists' reimbursement for quantities less than the maximum listed in the Schedule of Pharmaceutical Benefits. However, it ignores the financial loss incurred in most cases. Of the 3 instances mentioned by Professor Kamien, the prescribing of 56 bismuth subcitrate tablets (or similar expensive or infrequently prescribed drugs) presents the main problem.

An original pack of 112 bismuth subcitrate tablets costs the pharmacist $22.20 and, using the wastage factor table, the amount payable for 56 tablets is $15.13 excluding dispensing fee. Most pharmacists' shelves are dotted with expensive unused drugs rapidly reaching their expiry date. Pharmacists are expected to subsidise these losses from the 10% markup on cost which the Pharmaceutical Benefits Scheme allows.

John Bryant
Mosman, N.S.W.

Sir, I believe the PBAC response to Professor Kamien regarding the losses incurred by pharmacists dispensing less than maximum quantities on the PBS requires further elaboration.

While it is correct to state that a wastage factor of 12% applies to the pricing of half of a maximum quantity under the PBS, this still leaves the pharmacist in a loss situation and providing a subsidy on behalf of the PBS. Given that there is no compensation available for unused Schedule 4 products requiring a prescription, this more often than not is the reality. In the example of bismuth subcitrate, the application of 62% leaves the pharmacist $7.06 short of the wholesale cost of the 112 original pack. After adding the dispensing fee, the loss remains and becomes exactly $3.

Pharmacists agree with the necessity to prescribe only the quantity that the patient requires. However, there is no justification for them to lose financially when this commonly occurs. Broken quantity pricing arrangements should protect this situation, so that all health professionals are correctly remunerated when providing a service on behalf of the Government.

John Mullins
Pharmacy Guild of Australia (N.S.W. Branch)
Sydney, N.S.W.

PBAC response

Some pharmacists are concerned that dispensing less than the quantity in a commercial pack may leave them with unusable broken packs of medicines.

Prescribing of broken packs is infrequent because the sizes of manufacturers' packs are generally chosen to reflect the quantities needed for normal treatment regimens. If there are examples where the sizes of manufacturers' packs are frequently inappropriate, then this should be raised with the pharmacy organisations or the suppliers.

A situation where odd quantities may be required is where the patient is being tried or initiated on another treatment. Manufacturers identified this as one reason for the need to supply sample packs to prescribers.

In other cases, pharmacist remuneration arrangements provide a loading for broken packs. For dispensing under the Pharmaceutical Benefits Scheme, the loading is determined by an independent tribunal which takes account of the overall commercial risks associated with broken packs.