Important: I am not a doctor, pharmacist or medical professional. This article is intended to raise awareness, not to diagnose anyone or tell anyone whether they should take a prescribed medicine. Never stop or change medication without speaking to an appropriately qualified healthcare professional—unless you develop the emergency warning symptoms described in the official patient leaflet, in which case seek urgent medical help.
Most British people living in Spain will eventually encounter a medicine they have never heard of back in the UK.
One of the most common is Nolotil.
You may be prescribed it after an operation, for severe dental pain, kidney stones, an injury, intense back pain or a high fever that has not responded to other treatments.
In Spain, Nolotil is neither an obscure alternative remedy nor something handed out secretly under the counter. It is a licensed, prescription-only medicine which has been used in the country for more than 50 years.
However, it also carries a rare but potentially life-threatening risk that British patients need to understand.
This is not about creating panic. It’s talking about Nolotil in Spain and why you need to be aware of this prescribed drug. It is not an over the counter medicine, it needs to be prescribed.
It is not about telling people to refuse treatment.
It is about making sure that, when a medicine is offered, patients understand what it is, why it is being prescribed and which symptoms must never be ignored.
What exactly is Nolotil?
Nolotil is a brand name for metamizole, also known in some countries as dipyrone.
It is a non-opioid painkiller with pain-relieving, fever-reducing and antispasmodic properties. Spain’s official patient information says Nolotil may be used for moderate or severe acute pain following surgery or trauma, colicky pain, pain associated with tumours and high fever that has not responded to other measures or medicines.
Metamizole medicines are authorised in a number of European countries, although their approved uses and restrictions vary. In September 2024, the European Medicines Agency concluded after a major review that the benefits of metamizole continued to outweigh its risks, but it ordered stronger and clearer safety warnings throughout the European Union.
That distinction matters.
The official European conclusion was not that Nolotil must be withdrawn everywhere.
Nor was it that the safety concern had been invented.
The conclusion was that metamizole remains useful, but patients and healthcare professionals must be better informed about a serious known adverse reaction.
Why is Nolotil unfamiliar to British patients?
Metamizole is not routinely available as a human medicine in the UK, so many British patients arrive in Spain having never encountered it.
That can create two opposite reactions.
Some people assume that because a Spanish doctor prescribed it, there can be no meaningful risk.
Others hear alarming stories online and assume that taking a single capsule will inevitably cause a medical emergency.
Neither position is sensible.
All medicines have potential benefits, side effects and contraindications. The question is whether the medicine is appropriate for the individual patient, whether safer or more suitable alternatives exist and whether the patient understands the warning signs.
The issue that has generated the most concern around metamizole is agranulocytosis.
What is agranulocytosis?
Agranulocytosis is a sudden and severe reduction in granulocytes—particularly neutrophils—which are white blood cells needed to fight infection.
When their number falls dramatically, the body can become dangerously vulnerable to infections. These infections may progress quickly and can be life-threatening or fatal.
The European Medicines Agency describes metamizole-associated agranulocytosis as a known, serious adverse effect. It may occur during treatment or shortly after the medicine has been stopped. It can also occur in someone who has previously taken metamizole without any problem.
Crucially, the reaction is considered idiosyncratic.
In everyday language, that means it is unpredictable and does not simply happen because someone took too large a dose.
The risk is not dose-dependent, so taking the correct prescribed amount does not completely remove it. Equally, taking a higher dose does not appear to be the straightforward trigger in the way people might expect from a conventional overdose.
The reaction is regarded as rare or very rare in product information, although the precise frequency is difficult to calculate and varies between studies, populations and countries. The fact that it is uncommon does not make it unimportant: the concern is the severity of what can happen when it does occur.
What are the warning signs?
The official Spanish Nolotil leaflet tells patients to stop taking the medicine and seek immediate medical attention if they develop symptoms that may suggest agranulocytosis.
These include:
- Fever
- Chills
- Sore throat
- Painful ulcers or sores in the mouth, nose or throat
- Painful sores in the genital or anal area
- A sudden infection or feeling seriously unwell
Other concerning signs described in the leaflet include persistent fever, inflammation in the mouth or throat, unusual bruising, bleeding or marked paleness.
These symptoms can sound like an ordinary infection, which is part of the danger.
Someone may assume they have picked up a cold, throat infection or minor virus and simply continue taking the painkiller.
However, official European advice is clear: if these symptoms arise while taking metamizole, or shortly after stopping it, the medicine should be stopped and urgent medical assessment sought. A blood count, including a differential white-cell count, should be performed immediately. Treatment should not continue while waiting for the results.
If agranulocytosis is confirmed, the person must never be given metamizole again.
Symptoms may be hidden
There is another important complication.
Metamizole is sometimes given to reduce fever. Yet fever may also be one of the first signs of agranulocytosis.
This means the medicine could partially suppress the very symptom that should alert the patient to a problem.
Antibiotics may also mask some of the early warning signs. The EMA therefore warns that patients and clinicians need to remain particularly alert when metamizole is being used for fever or alongside an antibiotic.
Are British people at greater risk?
This is where the subject often becomes exaggerated or oversimplified online.
In 2018, Spain’s medicines regulator, the AEMPS, reviewed metamizole after cases of agranulocytosis were reported, particularly among patients of British origin.
That review led to additional recommendations for healthcare professionals, including using metamizole for short periods, prescribing the lowest effective dose, taking a detailed medical history and ensuring patients understand the warning symptoms.
However, the AEMPS did not conclude that British nationality itself had been proven to cause a higher risk.
It said that greater susceptibility among northern European populations had been discussed for years and genetic factors had been studied, but the evidence available could neither confirm nor rule out an increased risk among particular ethnic populations.
In 2023, the Spanish regulator revisited the issue. It noted that the earlier cluster of cases had been reported particularly in British patients by the same notifier and that the number of reported cases had risen alongside increased use of the medicine in Spain. It maintained its safety recommendations rather than announcing that British people had been conclusively shown to be genetically vulnerable.
That is the balanced position.
There is enough history to justify awareness among British patients.
There is not enough evidence to state as fact that every British person is uniquely or automatically more susceptible.
Being British should prompt a proper conversation with the doctor or pharmacist—not panic, certainty or self-diagnosis.
What did the European review decide?
The European Medicines Agency began a major review in 2024 after serious cases continued to be reported in Finland despite strengthened precautions.
The review considered scientific studies, European safety reports, information from pharmaceutical companies and the views of specialists in haematology, pain management, general practice and pharmacy, as well as a patient representative.
The EMA’s safety committee concluded that the benefits of metamizole remained greater than its risks.
However, it required stronger warnings designed to help patients and clinicians recognise agranulocytosis earlier.
The European Commission issued a legally binding EU-wide decision in November 2024.
The updated guidance emphasises that:
- Agranulocytosis can occur at any point during treatment.
- It can also begin shortly after treatment has stopped.
- It may occur even after previous trouble-free use.
- It is not related to the dose taken.
- Patients must know the symptoms.
- Suspected cases require immediate blood testing.
- Metamizole must not be restarted if agranulocytosis is confirmed.
- People with certain blood or bone-marrow disorders must not take it.
Interestingly, the EMA review did not support routine blood-count monitoring for every patient as an effective way of detecting the reaction early. Because agranulocytosis may develop suddenly, recognising symptoms and acting immediately remains essential.
Who should not take Nolotil?
The official Spanish leaflet lists several situations in which Nolotil should not be taken.
These include people who have previously experienced agranulocytosis caused by metamizole or related medicines, people with bone-marrow disorders or diseases affecting blood-cell production, and those who have previously experienced certain serious allergic, blood or skin reactions to metamizole.
Other contraindications or important precautions include certain reactions to painkillers, acute intermittent porphyria, glucose-6-phosphate dehydrogenase deficiency and the final three months of pregnancy. The full list is longer, which is why the prescriber needs an accurate medical history and the patient should read the current leaflet supplied with the medicine.
Tell the doctor or pharmacist about:
- Previous reactions to metamizole, dipyrone, Nolotil or similar medicines
- Blood or bone-marrow disorders
- Chemotherapy or immunosuppressive treatment
- Medicines known to affect blood-cell production
- Serious allergies to painkillers
- Pregnancy or breastfeeding
- Kidney or liver problems
- All other medication and supplements being taken
Do not assume the doctor automatically has access to your complete UK medical record.
Are there other serious risks?
Agranulocytosis receives the most attention, but it is not the only serious reaction listed for Nolotil.
The official patient leaflet also describes the possibility of severe allergic reactions, including anaphylactic shock; serious skin reactions such as Stevens–Johnson syndrome and toxic epidermal necrolysis; kidney inflammation or reduced urine production; severe reductions affecting several types of blood cells; and gastrointestinal bleeding.
These reactions are not presented here to suggest that they are common.
They are mentioned because “I have taken it before and felt fine” does not guarantee that every future course will be uneventful, and because sudden serious symptoms should never be dismissed.
Emergency symptoms such as breathing difficulty, swelling of the face or throat, collapse, widespread blistering or peeling skin, or a rapidly worsening illness require immediate medical assistance.
In Spain, the emergency number is 112.
What should British patients ask?
Being offered Nolotil does not mean that the doctor has made a mistake.
It also does not mean you must accept it without understanding what you are taking.
Reasonable questions include:
What is the medicine being prescribed for?
How long am I expected to take it?
Is this the lowest effective dose?
Are there alternatives that may be suitable for me?
Do any of my medical conditions or medicines increase the risk?
Which symptoms mean I must stop taking it and seek help?
Should I have any follow-up or blood tests in my particular circumstances?
A good healthcare professional should not be offended by those questions.
They are part of informed consent.
Do not borrow or share Nolotil
Nolotil is a prescription medicine in Spain.
The official leaflet specifically says that it has been prescribed for the named patient and should not be given to another person, even if that person appears to have the same symptoms.
That matters because social media groups are full of well-meant advice such as:
“I have some left over—you can have mine.”
Please do not do that.
A person offering the capsules cannot check your blood history, allergies, pregnancy status, interactions or contraindications.
A medicine being common in Spain does not turn it into a casual household remedy.
What if you are already taking it?
Do not panic simply because you have read this article.
The recognised adverse reaction is serious, but it is uncommon, and European regulators continue to consider that metamizole has a favourable benefit–risk balance when used appropriately.
Read the leaflet in your box.
Take it only as prescribed.
Do not extend the course or increase the dose yourself.
Remain alert for fever, chills, sore throat, painful mouth or mucosal sores, or a sudden infection during treatment and shortly afterwards.
If any of those symptoms occur, follow the official advice: stop taking the medicine and obtain urgent medical assessment.
For a non-urgent concern, speak to the prescribing doctor or a pharmacist rather than relying on comments under a Facebook post.
Awareness without alarm
Nolotil is a perfect example of why moving to another country means learning a new healthcare system as well as a new language.
A medicine may be completely normal in Spain while unfamiliar in Britain.
Different countries may reach different regulatory decisions based on their assessment of benefits, risks, prescribing culture and available alternatives.
That does not automatically make one country careless and the other correct.
What matters is that the medicine is prescribed appropriately, that your individual risk factors are considered and that you are told what to watch for.
The message is not:
“British people must never take Nolotil.”
The evidence does not support such a blanket claim.
The message is:
“British patients should know what Nolotil is, understand the rare but serious risk of agranulocytosis and seek professional advice before taking it.”
Ask questions.
Mention your medical history.
Read the leaflet.
Know the warning signs.
Never take someone else’s prescription.
And never assume that a medicine is harmless simply because it is commonly used.
That is not fearmongering.
That is informed healthcare.
