Any pharmacists out there

[mandmsmummy]

Hi
I'm on diclofenic for ankylosing spondylitis 3x50mg daily. Rheumy prescribed despite my local pharmacy attached to the surgery refusing to let me have it as it's dangerous. When the pharmacist heard I was on it she said as long as it's in your notes that rheumatology gave it to you and not us if your heart goes funny you can't blame us. This has really upset me that she could be so flippant about my health. I have been told conflicting things about it and that worries me x

Everyone's a bit twitchy about diclofenac at the moment, risk:benefit ratio seems to be shifting towards 'avoid unless absolutely necessary'.

The cardiac risks work out as something like 3 extra heart attacks/strokes per 1000 people per year being caused by diclofenac (and you can't easily guess from someone's cardiac risk profile whether they're likely to be one of the three) so the doctors are trying to prescribe safer alternatives for everyone.

Naproxen has lower risks attached, did the pharmacy/GP surgery not suggest switching to that instead? The rheumatologist might think diclofenac is clinically necessary for you but equally might just be prescribing it through force of habit in spite of recent recommendations.

Definitely worth speaking to GP/rheumatology again to get reassurance or have it switched. Also, have you been prescribed omeprazole or similar to protect your stomach?

Thanks pharmacist, I expressed my concerns to the rheumy as this has been going on a long time. He wasn't concerned at all. I tried naproxen but had breathing issues while on it but might not have been linked. Gp/pharmacy just don't want me on it whereas two other gps can't see the risk.
So am I at risk then? 37 fairly healthy apart from AS. I was under the impression that it was long term use that the risk was at?

Yes on omeprazole

Sounds like the rheumatologist has weighed up the risks and tried the safer option first so I'd say go with his opinion on it rather than the others, they don't have the full picture.

The risk is additive so a week's course = no problem, 5 years constant use = more of a problem but the risk is still small. I presume you're likely to be on them for a while?

If naproxen has caused problems and you don't have major cardiac risk generally (smoking, weight, high blood pressure, cholesterol, family history) then you'll probably be advised to carry on taking them. Bit more information here.

Thanks
I don't want to be on them for ages because of what I've been told.
I don't smoke have perfect blood pressure etc family history of angina, mild heart failure I think.

Good advice from pharmacist.

From what I recall offhand, one of the problems was that diclofenac was very widely used (in 2008 in accounted for 44% of all anti-inflammatory prescriptions) and the withdrawal was intended to get patients off it for whom it is not essential. We had a lot of patients on it who had been given it by GPs over the years just as a first line pain reliever. Patients who got it via a rheumatologist have been given the option to remain on it at our surgery after a conversation about the risks so they could make an informed decision.

I went to a meeting at the time the risks were highlighted and the presenter stated that diclofenac was reasonably safe for someone younger with no risk factors but each risk factor doubled the chance of a CV event (bearing in mind we are talking very, very small numbers here so they are still small even after doubling) but by the time you had an overweight smoker, over 65, with high BP, cholesterol and every other risk you could think of (as a significant number if users were) you were getting into chancy territory. He then pointed out that the "chancy" risk was still lower than that of dying in a car accident yet most of us get in cars every day.

I'm quite shocked that a flippant comment like that was made by a professional. You are entitled to a proper discussion of risks and benefits to allow you to make that decision properly. I would say if the rheumatologist is happy with it and you are too I would stick with that unless your risk factors increase.

Thanks, I had my blood pressure checked this morning and it's quite a lot higher than usual.