Carbocisteine is a popular medication which is commonly used in the management of chronic obstructive pulmonary disease (COPD). Recently, carbocisteine became short in supply with some pharmacies not being able to dispense carbocisteine to patients. Additionally, unfavourable wholesaling prices for carbocisteine created more supply difficulties. Although not commonly prescribed, some carbocisteine alternative drugs are available on the market.
Is carbocisteine out of stock?
Carbocisteine 375mg capsules has been out of stock in November (2022) with limited availability of the drug in some pharmaceutical wholesalers. Very often pharmaceutical manufacturers and wholesalers increase the price of the drug when it is short in supply. Unfortunately, the outdated reimbursement system for payments covering the cost of each drug supplied by pharmacies does not help in drug shortage situations. At this time the price of carbocisteine increased about six times. With the current carbocisteine price, a pharmacy makes a loss of about £15 per box supplied to patients. Many pharmacies will not dispense carbocisteine due to the potential loss they are facing.
What to do when carbocisteine is out of stock?
Towards the end of the month. Department of Health and Social Care (DHSC) publishes the list of drugs for which payments to pharmacies change (increase). This allows pharmacies to supply a drug to patients without making a financial loss. Despite price changes, DHSC does not always include all drugs affected by the increase in price. Patients who have a stock of carbocisteine sufficient to cover their use till the end of the month may choose to wait. Unfortunately, DHSC fails time and time again to pay the correct price for the drugs to pharmacies affecting supply to the patients. A good example of a similar situation is an ongoing shortage of aripiprazole this year and inadequate reimbursement by DHSC.
Patients who need carbocisteine more urgently can check for availability in different pharmacies. Some pharmacies (possibly larger chains) may not follow the price changes and continue to supply the drug at loss. Prescriptions which are issued electronically (EPS) may be easily dispensed in another pharmacy, providing that no other items are dispensed by any pharmacy.
Prescriptions with partly-supplied items (collected by the patient) cannot be ‘transferred’ to another pharmacy. In this case, a patient needs to ask GP surgery to reissue a new prescription for a drug which is needed.
What is carbocisteine?
Carbocisteine is a drug classified as mucolytic. Carbocisteine reduces the thickness (viscosity) of mucus, which can be helpful in a condition characterised by the presence of an excessive amount of sputum, such as chronic obstructive pulmonary disorder (COPD).
Carbocisteine is usually recommended as adjunctive therapy in the management of COPD. A NICE guide on the management of COPD recommends using mucolytics only for people with chronic, productive cough. Therapy with mucolytics should be continued if the improvement is seen (NICE, 2019).
What is the best carbocisteine alternative drug?
1. Different forms of carbocisteine
Carbocisteine 375 mg capsules are mainly affected by the shortage. Carbocisteine is available as higher strength capsules – carbocisteine 750mg capsules. These have some availability, however the spike in prices also affected carbocisteine 750mg capsules. Other carbocisteine 375mg capsules alternative include:
- Carbocisteine sachets 750mg/10ml
- Carbocisteine sugar-free syrup 250mg/5ml
- Carbocisteine sugar-free syrup 750mg/5ml
2. Acetylcysteine: licensed alternative
At the moment there is only one other mucolytic licensed in the UK for use in people with chronic obstructive pulmonary disease (NICE, 2021). Acetylcysteine also known as N-acetylcysteine (NAC) is the only (licensed) carbocisteine alternative drug which could be considered as an optional treatment.
There is only form of acetylcysteine are effervescent tablets called NACSYS®. NACSYS® effervescent tablets can be prescribed to reduce sputum (mucus) viscosity.
Acetylcysteine: availability without a prescription
It may come as surprise, but acetylcysteine is available without a prescription. Acetylcysteine can be purchased online as a supplement. Websites including Amazon.co.uk sell different forms of acetylcysteine, for example Troo NAC Supplement 600mg capsules and NAC N-Acetyl-Cysteine 600mg capsules.
3. Erdosteine as carbocisteine alternative
Erdosteine is another mucolytic drug available in the UK. As previously discussed acetylcysteine was the only recommended carbocisteine alternative drug by NICE, however, erdosteine can be used in the management of productive cough associated with COPD (short-term use).
What is erdosteine used for?
Erdosteine is licensed in the UK for the symptomatic treatment of acute exacerbations of chronic bronchitis. Chronic bronchitis is characterised by a daily productive cough which lasts for longer than 3 months for a least two consecutive years (NHS, 2022) and it is one of the main symptoms of COPD.
Erdosteine is available in form of capsules under a branded Erdotin. Each Erdotin capsule contains 300mg of erdosteine.
What is the main difference between carbocisteine and erdosteine?
Erdosteine is not commonly prescribed in the UK. The licensing recommendation for erdosteine limits its prescribing. Erdosteine is recommended in acute exacerbations of chronic bronchitis in COPDS with a twice-daily dose of 300mg for up to 10 days only (BNF, 2022). Carbocisteine on the other hand is prescribed to patients ongoingly.
What is the most popular mucolytic in the UK?
It is clear from prescribing information that carbocisteine is by far the most common mucolytic prescribed in the UK.
Items prescribed (last 12 months*)
*source: OpenPrescribing.net, Last 12 months (Sep ’21—Aug ’22)
To sum up, at the moment carbocisteine is short in supply. The difference between the price of carbocisteine vs repayment value to pharmacies for supply is significant, making it more difficult to supply carbocisteine to patients.
BNF (2022). Erdosteine: Indications and dose. Available at: https://bnf.nice.org.uk/drugs/erdosteine/#indications-and-dose Accessed on 20/11/2022.
NHS (2022). Bronchitis. Available at: https://www.nhs.uk/conditions/bronchitis/ Accessed on 20/11/2022
NICE (2019). Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Available at: https://www.nice.org.uk/guidance/ng115/evidence Accessed on 20/11/2022
NICE (2021). Chronic obstructive pulmonary disease: mucolytics. Available at: https://cks.nice.org.uk/topics/chronic-obstructive-pulmonary-disease/prescribing-information/mucolytics/ Accessed on 17/11/2022