Sunday 30 April, 2006

Beware of drug reps bearing gifts

Posted in General Practice, Michael Tam, Rants, Wards at 17:19 by Michael Tam

Original article by: Michael Tam :: Printer friendly

Big pharma

“Big pharma” only loves your
prescribing power

“Big pharma” spends billions of dollars each year on advertisements to doctors, and they are not doing so out of charity. Every doctor you speak to will think that they are not influenced by the pharmaceutical industry and this is the great swindle of our profession. Drug advertisements are so pervasive that it is sometimes hard to know where they end and where real medical education and trial results begin.

Part of the problem is that drug representatives are invariable really nice people so it is almost impossible to turn them away. They develop good if not great rapport with most doctors and what they say always seems to make perfect sense. Never forget, however, that they are still working for a big multinational whose goal is to make money; and their way of making money is to convince you to prescribe their most expensive drugs to as many people as possible.

Although it may have been novel to collect drug company pens as a medical student, now that you are a fully fledged doctor it is time to give pause and think. Every drug company pen you use is free advertising if you use it around your place of work. The drug companies already advertise heavily in our medical journals and sponsor most of our lunches and conferences. It may be hard to see their effects at a “coalface” level, but their advertisements most certainly do work. For example, you will find a hell of a lot of people on non-generic ACE inhibitors or angiotensin-2 receptor antagonists for hypertension. These cost a lot more than their generic counterparts but don’t work any better. Care to guess why? Other examples include esomeprazole versus omeprazole and escitalopram versus citalopram. The new drugs are only a minor change from the old and have only minimal clinical benefits but cost much more.

We doctors are more than overly enthusiastic in preferentially using these newer agents considering their minimal practical gain. Try to buck the trend. There have been more than a few occasions when the pharmaceutical industry has hoodwinked the majority of the medical profession though we like to think we are evidence based. The withdrawal of rofecoxib, aka “Vioxx” (and other highly specific COX-2 inhibitors in the US market) and scandal with buried research data with the use of SSRIs in children are only two recent examples.

DO

  • prescribe generically and not promote the use of trade names;
  • preferentially prescribe off-patent drugs in the class (e.g., simvastatin for statins, lisinopril for once-daily ACE-Is, omeprazole for PPIs);
  • view studies sponsored by the pharmaceutical company that “prove” the benefits of the newer agent over the old with suspicion (e.g., in the esomeprazole vs omeprazole trial, it was 40 mg of esomeprazole vs 20 mg of omeprazole!);
  • realise that most new drugs are not revolutionary and most old drugs are not terrible;
  • read the independent literature (e.g., National Prescriber Bulletin) as it will give you a better appreciation of the limitations and adverse effects of newer agents;
  • be wary of changes in formulation of off-patent drugs that stops them from being generic (e.g., modified or slow release formulations);
  • attend drug company sponsored education sessions but view it with suspicion.

DO NOT

  • provide free advertising for drugs by using branded pens or other gadgets in the work place (though drugs taken off the market like “Vioxx” are okay for the sadistic);
  • accept information and data given to you by drug reps at face value;
  • prescribe something new just because it new or trendy or “there”;
  • assume that you are immune to the advertisements of drug companies;
  • prescribe new drugs outside of approved indications (check them, they may be more limited than you think);
  • put weight on “biological plausibility” in your prescribing as drugs have a much more complex action on the body than we may be aware (e.g., the COX-2 inhibitors did not revolutionise traditional NSAIDs and arguably, are not any better than them in the longer term);
  • “sell” or “pitch” a new drug to your patients just because you may be enthusiastic;
  • however, be too stubborn to realise that some new drugs are good and have a real improvement over the older ones.
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