Prescribing of quinine and drugs that induce crampBMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7035.912c (Published 06 April 1996) Cite this as: BMJ 1996;312:912
Study did not consider several factors
EDITOR,—Margaret A Mackie and John Davidson imply that general practitioners (particularly those in “high prescribing practices”) prescribe quinine too frequently and before considering iatrogenic causes of the symptoms for which it is being used.1 They also suggest that quinine is of equivocal efficacy.
The authors attempt to draw conclusions about prescribing costs from the cost or number of prescriptions issued per 100 patients. They make no reference to the age-sex profiles of the practices, which obviously influence prescribing and, as we are told anecdotally that “prescriptions for quinine were predominantly issued to women patients over 65,” could be an explanation for the findings. In addition, the assumption that practices that prescribe more than 90 items per 100 patients are high volume prescribers fails to take into account the number of tablets issued per prescription. General practitioners who review their patients more regularly and issue fewer drugs per visit are erroneously labelled high volume prescribers.
The authors conclude that “a review of the need for and dosage of current drugs may be all that is required to alleviate the problem.” They fail, however, to inform us of the proportion of patients in whom this course of action was considered or tried and in whom it was decided that agents that induce cramp could not safely be stopped (which the authors concede would be an indication for prescribing quinine).
Finally, the authors make no assessment of patients' symptomatic relief or the prevalence of symptoms in the practices that they imply are prescribing inappropriately compared with low prescribing practices. Possibly such practices have a particular interest in their elderly population and therefore detect more problems. In many areas of general practice the simplest way to keep prescribing costs down is to fail to recognise or detect a problem.
While I fully endorse efforts to rationalise prescribing, surely the above factors should have been considered. General practitioners often receive advice about prescribing that attempts to draw conclusions from poor studies. I am amazed that this article was published in its current form.