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Unfractionated heparin (UFH) has been in clinical use for over 50 years and extensive clinical trials have demonstrated its effectiveness in the prevention and treatment of thrombotic disease. In the last 2 decades, low molecular weight heparins (LMWHs) have been developed and subjected to extensive laboratory and clinical studies. In clinical comparison with UFH in the treatment of venous thromboembolism, LMWHs appear to offer a superior benefit-risk profile. In addition, the ease of drug administration and lack of drug monitoring associated with LMWHs are attractive clinical features. We calculated the overall costs of UFH and LMWH therapy using recently published clinical data and local cost information. Although the acquisition costs of LMWHs are higher than for UFH, LMWHs are more cost effective in surgical prophylaxis of deep venous thrombosis (DVT) if the costs of failed prophylaxis are considered. The costs of using subcutaneous (SC) LMWH as therapy for established DVT are lower than those of UFH administered by intravenous infusion. The financial benefit of using LMWH treatment becomes more pronounced when the rates of antithrombotic failure and bleeding complications are incorporated. If UFH is given by SC injection, however, the cost differential favouring LMWH for the treatment of DVT is not so great. If current trials demonstrate that LMWH treatment can be given on an ambulatory outpatient basis, the economic advantages of LMWH will be considerable. However, the extent of this will vary from place to place depending on local funding arrangements.

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The 'limited list' or 'formulary' concept has been used to promote rational use of drugs and to set standards for drug use. Recently the concept has been aimed more toward containment of drug costs. Effective hospital formulary systems assist in purchasing and inventory management. Application of the formulary concept has resulted in savings within specific classes of drugs and in total hospital drug costs. Key features which promote effectiveness are development of policies by prescriber consensus and continued education along with feedback on drug usage. The formulary concept also provides a foundation for appropriate use of drugs in hospitals. In the community setting, limited lists can achieve cost savings and can assist in the rational use of drugs. National limited lists have been less successful in controlling overall drug costs, probably because they have focused on economic effects, rather than education, feedback or user participation. Properly organised drug rationalisation policies embracing the limited list concept can improve health outcomes by promoting rational drug use. They can also contain or reduce drug costs.