04 Jan 2018 [108] Drugs to avoid
In two previous Therapeutics Letters we presented Clinical Pearls from Prescrire International.1,2 Prescrire is one of a small number of drug bulletins in the world, which reports on prescription drugs and is completely independent of industry influence. The front page of Prescrire International states, “Funded by subscribers. No advertising, no grants, no shareholders.” The inside jacket documents the large number of contributors and the processes whereby they prevent conflicts: “Members of the Prescrire Editorial Staff sign a yearly declaration of absence of conflicts of interest, in accordance with Prescrire’s ’Non merci…’ Charter.”
In April 2017 Prescrire published their latest “Drugs to avoid: 2017 update”.3 This update represents an assessment, based on a rigorous procedure, of the harm-benefit balance of drugs and indications. This fifth annual review of drugs to avoid includes all medicines examined by Prescrire between 2010 and 2017 and authorized in the European Union. It identifies 91 drugs that are more harmful than beneficial. The full 10-page version is freely available.4
The Tables provided here include only the drugs on the Prescrire list that are currently available in Canada. The Tables also include the indications, a summary of the reasons to avoid and Prescrire’s suggestions of better alternatives. For ease of reference we have divided the list into drugs prescribed for prevention (Table 1) and drugs prescribed for treatment (Table 2).
Table 1: Drugs to avoid prescribed for prevention
| Drug (Brand) | Indication | Reason(s) to avoid | Better alternative(s) |
|---|---|---|---|
| Aliskiren (Rasilez) | High blood pressure | Not shown to reduce cardiovascular events | Thiazide, ACE inhibitors |
| Bezafibrate (Bezalip) | Elevated lipids | Not shown to reduce cardiovascular events | Gemfibrozil |
| Fenofibrate (Lipidil) | Elevated lipids | Not shown to reduce cardiovascular events | Gemfibrozil |
| Dronedarone (Multaq) | Anti-arrhythmic | Less effective than amiodarone | Amiodarone |
| Ivabradine (Lancora) | Heart failure | Toxicity such as myocardial infarction and severe bradycardia; no advantages | Beta blockers |
| Olmesartan (Olmetec) | High blood pressure | Possible sprue-like enteropathy | Other angiotensin receptor blockers |
| Gliptins: Alogliptin (Nesina), Linagliptin (Trajenta), Saxigliptin (Onglyza), Sitagliptin (Januvia) | Type 2 diabetes | Unfavorable adverse effect profile such as anaphylaxis and pancreatitis | Metformin, sulfonylureas |
| Flozins: Canagliflozin (Invokana), Dapagliflozin (Forxiga) | Type 2 diabetes | Adverse effects such as hypotension and genital infections | Metformin, sulfonylureas |
| Pioglitazone (Actos) | Type 2 diabetes | Adverse effects such as heart failure and bone fractures | Metformin, sulfonylureas |
| Orlistat (Xenical) | Weight loss | No long-term effectiveness; adverse effects such as severe diarrhoea and malnutrition | Diet and exercise |
| Denosumab (Prolia) | Osteoporosis | Modest efficacy; disproportionate adverse effects such as back pain and serious infections | Weight bearing exercise |
Table 2: Drugs to avoid prescribed for treatment
| Drug (Brand) | Indication | Reason(s) to avoid | Better alternative(s) |
|---|---|---|---|
| Domperidone | Vomiting, upper GI hypomotility | Cardiac dysrhythmias | Metoclopramide |
| Prucalopride (Resotran) | Chronic idiopathic constipation | Uncharacterized adverse effect profile | Other laxatives |
| Moxifloxacin | Bacterial infections | Serious toxicity such as liver and cardiac disorders | Ciprofloxacin, ofloxacin |
| Donepezil (Aricept), Galantamine (Reminyl), Rivastigmine (Exelon), Memantine | Alzheimer’s and other dementias | Minimal efficacy; disproportionate adverse effects such as severe vomiting and syncope | Support from caregivers and family |
| Alemtuzumab (Lemtrada), Natalizumab (Tysabri), Teriflunomide (Aubagio) | Multiple sclerosis | Disproportionate adverse effects such as infections and liver damage | Interferon beta |
| Olaparib (Lynparza) | Advanced ovarian cancer | Not shown to prolong survival; serious adverse effects | Appropriate supportive care |
| Trabectedin (Yondelis) | Ovarian cancer, soft-tissue sarcoma | No tangible efficacy; severe adverse effects such as diarrhoea and liver damage | Appropriate supportive care |
| Duloxetine (Cymbalta) | Depression | Unacceptable risk of cardiac and liver toxicity | Other antidepressants |
| Citalopram (Celexa), Escitalopram (Cipralex) | Depression | Risk of QT prolongation | Other antidepressants |
| Venlafaxine (Effexor) | Depression | Risk of cardiac disorders | Other antidepressants |
| Bupropion (Zyban) | Smoking cessation | Risk of neuropsychiatric disorders | Nicotine |
| Oral or Nasal Decongestants: Pseudoephedrine, Naphazoline, Phenylephrine | Allergic or viral rhinitis | Serious cardiovascular disorders | Conservative measures |
| Omalizumab (Xolair), Mepolizumab (Nucala) | Severe asthma, chronic idiopathic urticaria | Disproportionate adverse effects | Corticosteroids |
| Nintedanib (Ofev) | Idiopathic pulmonary fibrosis | No survival benefit; serious liver damage and thromboembolism | Symptomatic treatment |
| NSAIDs: Celecoxib (Celebrex), Diclofenac (Voltaren), Ketoprofen, Piroxicam | Pain and inflammation | Unacceptable additional adverse effects such as myocardial infarction and skin reactions | Acetaminophen, Ibuprofen, Naproxen (lowest dose for shortest period) |
| Glucosamine | Osteoarthritis | Not effective; rare allergic reactions | Appropriate exercise |
| Capsaicin topical) | Pain | Limited effectiveness; irritations and burns | Other analgesics |
| Methocarbamol (Robaxin) | Muscle relaxant | No proven efficacy; gastrointestinal and skin adverse effects | Acetaminophen |
| Quinine | Muscle cramps | Poor efficacy; risk of life-threatening adverse effects | Regular stretching |
Prescrire’s conclusions
- “91 authorised drugs more dangerous than beneficial”
- “This review lists drugs that have an unfavourable harm-benefit balance in all their authorized indications, in other words drugs that should be removed from the market on account of their toxicity.”
From a Canadian perspective the good news is that 44 (48%) of the 91 drugs to avoid are available in Europe and are not available in Canada.
References
- Therapeutics Initiative. Clinical pearls from Prescrire. Therapeutics Letter. 2006 (Oct-Dec); 60:1-2. [LINK]
- Therapeutics Initiative. Clinical pearls from Prescrire. Therapeutics Letter. 2012 (Jan-Mar); 85:1-2. [LINK]
- Prescrire Editorial Staff. Drugs to avoid: 2017 update. Prescrire Int 2017; 26 (181):108-111. [LINK]
- Prescrire Editorial Staff. Towards better patient care. Drugs to avoid in 2017. Rev Prescrire 2017; 37 (400): 137-148. [LINK]
Hugh Paton
Posted at 08:23h, 05 JanuaryGreat information, helpful to me as a benefit plan consultant, thank you very much!
Bob Paddock
Posted at 09:08h, 05 JanuaryWhy only one Fluoroquinolone on the list? FDA says they have killed 3000 and injured 200000. That is believed to be only one percent of the real numbers.
Please have issue #109 address Fluoroquinolones. Please.
Thank you.
n
Posted at 23:28h, 21 June10 yrs after short course on cipro, and achilles tendon damage still a big problem.
Hans Baer
Posted at 11:18h, 05 JanuaryGreat information! Thanks.
Peter Boronowski
Posted at 19:52h, 08 JanuaryThank you for this list. I subscribe to “Best Pills Worst Pills” and it is good but not like Prescrire.
Ben Addleman
Posted at 15:19h, 11 JanuaryInteresting they list most meds for T2DM except metformin and sulfonylureas. I’m not convinced sulfonylureas do much good for the patient with diabetes since there’s evidence of increased cardiovascular events. I also do see some very commonly prescribed meds (olmetec, Cymbalta, Effexor, citalopram and its popular but unnecessary enantiomer escitalopram). This list could ruffle some feathers!
Richard Bray
Posted at 00:37h, 01 FebruaryYes, I agree with Mr. Addleman that Cymbalta, Effexor, Celexa, and Ecsitalolpram will most certainly ruffle many feathers in my workworld!
A must read for anyone interested in the many dangers of industry is: Deadly Medicines and Organized Crime. A very valuable scientific piece of work!
David Kendler
Posted at 14:38h, 11 AprilDenosumab for the prevention of osteoporosis?? This is not an indication anywhere in the world! This product is indicated for the treatment of patients at high risk of fracture (including men, women, glucocorticoid, aromatase inhibitor, androgen deprivation). Clinical trials do not substantiate any increases in overall infection or back pain. Where is the TI or Prescrire review of evidence of exercise efficacy in the prevention of fracture? Certainly this evidence is much less robust than that achieved by large randomized controlled drug trials!
Alan Cassels @ TI
Posted at 16:04h, 23 JulyA very good suggestion. I think that reviewing the literature on the efficacy of exercise in preventing fractures is a very worthwhile goal.
cheers, Alan Cassels, Communications Director.