Scenario

Counter assistant Mandy comes into the dispensary with a question for pharmacy technician Vicky. “Are we out of stock of Motilium 10? I can’t find it anywhere and I’ve got a customer asking for it. I know we don’t sell loads of it, so maybe someone sold it and forgot to put it on the order. Anyway, that’s not the point at the moment: if I order it now, do you think we’ll have it in this afternoon for this woman? She says she can pop back.”

Answer

Motilium 10, which is indicated for the treatment of nausea, bloating and heartburn, contains domperidone. In May 2014, evidence came to light that domperidone could increase the risk of serious cardiac side effects such as arrhythmias, particularly in people aged over 60 years, those on regular high doses of the drug and people who took other medicines that interact with it. The chance of someone suffering such a side effect is very low, but because it can be so serious – it may lead to death – the Commission on Human Medicines, an independent body that advises the UK drug regulator, recommended that medical supervision was needed for domperidone to be taken safely. As a result, in September of this year, Motilium 10 was withdrawn from OTC sale.

Mandy needs to explain to her customer that Motilium 10 is no longer available without a prescription. It would be sensible for her to briefly describe the reasons why this change has been made, taking care not to unduly worry the customer, and advise her to seek advice from her GP if she wishes to continue taking it. Furthermore, if the customer has taken any recently and experiences symptoms such as dizziness, fainting, shortness of breath, extreme fatigue, chest pain or palpitations, she needs to seek urgent medical care as she may be suffering a side effect as a result of taking domperidone.

The bigger picture

Domperidone has been withdrawn from the OTC market, but it is still available on prescription. However, due to the safety concerns described, its use has been restricted to the relief of nausea and vomiting and it is contraindicated in people with underlying cardiac conditions or risk factors for cardiac side effects. If it is needed, it should only be prescribed at the lowest effective dose for the shortest time possible (in adults, this is usually 10mg three times a day for no more than a week), although exceptions may be made if there is a significant clinical need. For example, some people with Parkinson’s disease use domperidone to control the side effects of their treatment because of the drug’s anti-dopaminergic effect, which counteracts the dopaminebased medication they take to control their condition.

The use of domperidone in children is currently being investigated, but the recommended dose in those weighing less than 35kg is 250mcg/kg up to three times daily. This requires careful calculation using the child’s actual weight and not an estimation, and a graduated oral syringe should be used for administration rather than a medicine spoon in order to make sure that the dose given to the child is accurate. The restrictions that have been placed upon the prescribing of domperidone do not apply to palliative care patients.

Extend your learning

• The withdrawal of Motilium 10 limits the availability of OTC treatments for nausea. Have a look at your pharmacy shelves and see what other products are licensed for this indication, when they may be used, and who may use them
• A drug that may be prescribed instead of domperidone for nausea and vomiting is metoclopramide, but this is also not risk-free. Find out about who should and shouldn’t take metoclopramide by reading the information in section 4.6 of the British National Formulary (BNF)
• The information above states that the prescribing restrictions that have been put in place for domperidone do not apply to palliative care patients. Why do you think this might be?
• People who take drugs that interact with domperidone are more likely to suffer side effects. Familiarise yourself with the likely candidates by reading the relevant section of Appendix 1 of the BNF.