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If you look at the following image from Pharmacy2u, this box of Loperamide Tablets is POM (See the POM in a rectangle on the left).

enter image description here
Image from Pharmacy2u

When you consider that

  • this box of 2mg Loperamide Tablets costs private prescription holders 10p
  • patients in the UK have to pay the pharmacy the standard NHS prescription charge if the prescription is an NHS prescription (£8.80 per pack)
  • it costs about £2.50 here in the UK for Imodium capsules
  • both have 2mg Loperamide and no other active ingredients
  • you can split tablets for 1mg doses for better dosage control but you cannot split capsules

why would the tablets be POM medication when Imodium capsules are considered safe as OTC medication?

Definitions within this question

POM: Prescription Only Medication
OTC: Over The Counter Medication sold without need of prescription

  • 3
    Probably the overall mass of Loperamide in the package. The POM has 60 mg total of Loperamide, while the OTC has 36 mg at most (18 capsules being the largest package size I saw for Imodium). I don't know what is the mass threshold between POM and OTC medications in the UK, but it's probably between those two numbers (perhaps even closer to 36 mg total weight). Sometimes the decision between POM and OTC is the toxicological potential if someone accidentally (or not) swallows the entire package at once. – Don_S Jul 19 '18 at 11:27
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As Don_S mentioned in comments:

Probably the overall mass of Loperamide in the package. The POM has 60 mg total of Loperamide, while the OTC has 36 mg at most (18 capsules being the largest package size I saw for Imodium). I don't know what is the mass threshold between POM and OTC medications in the UK, but it's probably between those two numbers (perhaps even closer to 36 mg total weight). Sometimes the decision between POM and OTC is the toxicological potential if someone accidentally (or not) swallows the entire package at once.

This is one possible explanation for the general case. But for example in my jurisdiction 200mg pack of acetylcysteine powder is POM and 600mg tablet is OTC, giving a massively larger dose for the OTC variant. There are certainly some idiosyncrasies to observe. In this case: there is something else at work here.

First of all, Imodium is a brand name and those are usually quite a bit more expensive when compared to generics like the one you linked to.

And there we get closer to the nature of this beast:

The NHS is great service provider and quite tough negotiating with pharmaceutical companies over the prices for drugs.

AMENDMENTS TO THE DRUG TARIFF – March 2018 – For the UK, March 2018 Basic prices of drugs lists loperamide in "Part VIIIA" on page 204

You already mentioned the price. That's the reason. If needed for prescriptions, you1 get the NHS negotiated rebate for the drug in its cheap generic form. Without that prescription the manufacturer of the brand name drug is free to charge what he thinks he can get away with.

Or to turn that around, you need a prescription to get the cheaper drug which is subsidised. It's not about the ingredients or the dangers. It's poltics of price and availability.

There is a culture of secrecy and shame concerning primary care rebate schemes but there are really no good reasons why they should not be adopted in the NHS.
A robustly administered rebate scheme will not have any impact on clinical decision making in the local NHS and can only support the legal requirement for PCTs to make arrangements which are “necessary and expedient” to supply medicines to patients, according to the NHS Act 2006 and the NHS (Pharmaceutical Services) Regulations 2012. As Paul Jerram, head of medicines management at the former Isle of Wight PCT, put it: “As I help GPs manage a budget which is public money I believe that I am ethically obliged to source at the best price. Therefore … I have to support rebates.”
However, in practical terms, NHS bodies are not always willing to consider pharmaceutical industry rebate schemes. Some are concerned that participation in a rebate scheme may undermine their credibility as a healthcare body. Others will not enter rebate schemes because of the generic prescribing agenda in the NHS in general.
For example, some rebate schemes will not be recommended by prescribing optimisation service PrescQIPP because they might advocate branded prescribing, even in cases where branded prescribing is clinically appropriate. Some will claim that rebates are at odds with local formulary and guidance recommendations.
Stephen Goundrey-Smith: "Primary care rebate schemes: win-win partnerships for industry and the NHS", The Pharmaceutical Journal 29 MAY 2013.

Or:

Appendix 1: DH view on Rebate schemes: an extract from an email sent to colleagues on the UK Pharmaceutical Advisors Group November 2012
The Pharmaceutical Price Regulation Scheme (PPRS) is the UK-wide voluntary scheme agreed between Government and the Association of British Pharmaceutical Industry to control the prices of branded medicines supplied to the NHS. Under the terms of the 2009 PPRS agreement (see paragraph 3.4 of the agreement), it states that the Department of Health does not support additional or alternative initiatives by health authorities in respect of the pricing of branded medicines in primary care.
The pricing arrangements under the 2009 PPRS aim to secure value for money for the NHS whilst providing companies with the right incentives to invest in new and effective medicines for the future. The Department's concern is that local rebate schemes potentially undermine the PPRS pricing arrangements but also, it is possible that companies will seek to make good lost revenues from rebate schemes elsewhere, for example by increasing the wholesale price on other medicines or not offering as much discount to community pharmacies. Both of these scenarios could have implications for the community pharmacy contractual framework funding arrangements or lead to higher growth in the NHS drugs bill. In view of this, Primary Care Organisations (PCO) should look critically at the wider ramifications of any potential rebate schemes on NHS budgets and future NHS service provision before entering into local agreements. The PPRS does not extend to non-branded medicines or other items which may be prescribed on the NHS; this includes POM medicines. Depending upon the detail of the rebate scheme, it will be important to consider other relevant issues. If a company is offering an arrangement that is of added value to a PCO, for example, it supports implementation of one of the PCO’s prescribing policies, or optimises patient’s use of their medicines, there may be a benefit.
Pharmaceutical Rebate Schemes


1: "You" in this context means someone looking at the database of prices, this is not necessarily the patient in general. It is the cost incurring for the system, that is here: the NHS.

| improve this answer | |
  • Interesting reading and some good literature finds – Chris Rogers Jul 19 '18 at 21:37
  • Looks like there is a lot of strength to your answer. If you look at the British National Formulary (BNF) Information, it lists the different forms and amounts available POM or OTC (Listed as GSL or P - General Sale List or Pharmacy Only - See this page for legisative info.). – Chris Rogers Jul 20 '18 at 10:18
  • @ChrisRogers First link doesn't work for me. 403 forbidden for the entire site. (Although Google confirms that URL exists and in that form?) If you like to, please add it in directly. Thx. – LаngLаngС Jul 20 '18 at 12:48
  • The BNF Information at bnf.nice.org.uk/medicinal-forms/… works for me and I have no special access agreements with them. Maybe they have a block on anyone outside the UK? I cannot see that being the case but you never know. There is a # reference at the end so try it without it which would lead to bnf.nice.org.uk/medicinal-forms/loperamide-hydrochloride.html – Chris Rogers Jul 20 '18 at 12:59
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    Just thought I would add a side note. The fact that Loperamide costs 10p to the NHS does not mean the patient pays 10p. If the prescription is an NHS prescription, the patient has to pay the standard NHS prescription charge which is more than the cost of OTC Loperamide. – Chris Rogers Jul 26 '18 at 8:25

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