THE GREAT ANTIBIOTIC RIP-OFF 1.17.02, 8:00 AM ET - Matthew Herper Are doctors prescribing new drugs when alternatives are much cheaper and equally effective? http://tm0.com/forbes/sbct.cgi?s=125424045&i=448728&m=1&d=2204288
That's somewhat been going on for years, partly due to good (or too good) marketing, or samples you have on hand already that you can give the Pt. to take stat and write a follow up Rx for, also the physician's interest in the best care for the Pt. and the most rapid and effective cure, etc. There's no mean and nefarious conspiracy behind it; if anything, prescribers these days (physicians, PA's, NP's, etc) can really get beat up by HMOs and other managed care situations; in fact, the pressure is a little too great now in the other direction, where price is more important than efficacy.I think the news that shocked the world, or at least a piece of it, that is, the emergence of strains resistant to Eli Lilly's Vancomycin, which was always supposed to be held in reserve as last resort, kind of jolted everyone into realizing the newer antibiotics should be reserved for use when first line defenses fail, and you better have your trenches well dug and plans for if the Enemy breaks the first perimeter.I also hope it brings a renaissance of in-office susceptability testing, or, sending it out, though that costs more to everyone.Years ago, when my Stepfather was actively practicing, if he had an acute "strep" or ENT infection patient, or an apparent skin or other infection, gather swab samples, swipe the (very easy to use, even a Doctor can do it! (ducking) culture media), drop an array of disks impregnated with micrograms of various antibiotics as well as swabbing a couple different culture media.Then he'd prescribe a few days worth of the most conservative antibiotic that he thought PROBABLY was on target, to get the poor pt. started on something, as well as of course other meds, for pain, cough, expectorants, decongestants, whatever; and of course an ointment or cream for apparent dermal infection as well as P.O. meds.When the culture results were done, if he found what he prescribed wouldn't help kill the germ nearly as well as something else, or maybe not at all, he'd call in the different med; if he was on track, he just called in 2 weeks worth of whatever, alerted the patient either way, and had them come in for an OV in a week, or call or come in sooner if things got worse.Of course, if NOTHING appeared to be efficacious, it was time for the labs, consulting with whoever, and ensuring he wasn't completely off the railroad tracks.He probably was the hardest sell for drug route salesmen/saleswomen; usually samples mailed to us at home or the office, or brought in by the reps ended at home in a great big box our dishwasher came in. Stuff he thought was really good for the right pt., we glommed all the starter doses together in batches for a full course of therapy for a patient, and he saved these for the uninsured, indigent patients that didn't have the resources to afford the medicine.He also bought things like ampicillin, tetracycline, erythromycin, other commonly used drugs by the 1M bottle (1000 doses) from generics people, and dispensed them to patients who couldn't afford the medicine on their own, at no charge. (The stuff cost pennies to him.)To be fair, the samples that worked really well, he did prescribe. Dubious things built up in the Box and were used by the family when appropriate. (Can you imagine they used to send out diet pills in the mail, to our house? God help us if someone decided to open our mailbox right by the side of the road.)After being given Talwin for the pain from a severe ear infection, after I got done vomiting the 2nd or third time, I suggested "maybe this isn't the right medicine for everyone; I'd rather die from this pain than take another one of those pills."These days, I wonder how many doctors practice medicine the same way my Stepfather did, and whether that's a good or a bad thing. I do think most prescribers are not mindless drones who pick the newest, most expensive pill or drug to prescribe, though.RSH.
RSH---"I think the news that shocked the world, or at least a piece of it, that is, the emergence of strains resistant to Eli Lilly's Vancomycin, which was always supposed to be held in reserve as last resort, kind of jolted everyone into realizing the newer antibiotics should be reserved for use when first line defenses fail, and you better have your trenches well dug and plans for if the Enemy breaks the first perimeter."Agreed ,the overuse of antibiotics is a danger which only may get worse.Some other links touching on this are:http://www.fda.gov/fdac/features/795_antibio.htmlhttp://www.fda.gov/oc/opacom/hottopics/anti_resist.htmlhttp://www.sciam.com/askexpert/medicine/medicine15.htmlhttp://whyfiles.org/038badbugs/;o)
Oh, I know Vanco wasn't the watershed.The first watershed, I think was when Elizabeth Taylor or Sophia Lauren or whoever was hostpitalized in the early 1960's for a resistant staph that escalated into a dreadful toxemic mess; if the methicillin derivatives hadn't been available in time (I believe she was an experimental patient), whichever one of them would have surely died.This was resistance developed to penicillin that resulted in a new infectious, non-hospital acquired infection; hospital acquired germs of course have more experience.That should have been good enough warning, but regrettably, it was not.RSH.
There are more articles here on "superbugs" than i have time to read and/or digesthttp://www.google.com/search?q=superbugs&btnG=Google+Searchregards;o)
The other thing you have to remember with ALL new drugs that come out is that many doctors can't wait to play with their new toys! Everytime a new product comes out, the doctors write for it in droves. Then, when they discover the "black box warnings" (to non-medicals, a black box warning is a statement at the beginning of the package insert that comes with every drug package. The "black box" warns of any major side effects/adverse reactions that could be serious or even fatal!) or (shudder) even read the package insert to see how it is supposed to be used, then they stop and realize it isn't for everyone they see in the office/hospital that day.Example:When a new antipsychotic medication came out, nearly every patient on our psych floor got it. Then one of our patient's coded and died due to a major side effect of the medication. Amazingly, the number of patients on the medication dropped of rapidly...The big danger when new antibiotics come out, especially the 3 new ones that are for the bugs that are resistant to Vancomycin, is that many doctors still want to "play with the new toys." That's why many hosptials, like ours, really try to only let them be used for there specific purpose, and not for Aunt Matilda's latest sore throat.Rational use is the answer. But tell that to the public who seem to think that the new wonder-sludge they saw on TV is the new drug just for them.....Just a view from the trenches...Robert A. Dowd, Pharm.D. (Doctor of Pharamcy)AKA KYHawkeye
Example:When a new antipsychotic medication came out, nearly every patient on our psych floor got it. Then one of our patient's coded and died due to a major side effect of the medication. Amazingly, the number of patients on the medication dropped of rapidly...The big danger when new antibiotics come out, especially the 3 new ones that are for the bugs that are resistant to Vancomycin, is that many doctors still want to "play with the new toys." That's why many hosptials, like ours, really try to only let them be used for there specific purpose, and not for Aunt Matilda's latest sore throat.Rational use is the answer. But tell that to the public who seem to think that the new wonder-sludge they saw on TV is the new drug just for them.....Just a view from the trenches...Robert A. Dowd, Pharm.D. (Doctor of Pharamcy)AKA KYHawkeye Sorry I missed this earlier. LU, T & JNJ have embroiled my attention of late.You have one of the jobs I wanted (other than the one I have), you dog! I wanted to be a clinical pharmacologist (MD type); be able to prescribe as well as to review and control hospital mayhem and teach. That doesn't mean I don't keep my hand in, anyway.I have always been against TV or magazine or other ads for Rx meds. (Remember the term "ethical drugs", the non Rx but OTC stuff that wasn't advertised? I haven't heard that term in years.)I'm not fond of media ads for doctors or lawyers, either. The latest ambulance chasing issues are Mesothelioma (that is heartless and mean-spirited and directed obviously at the WTC workers and survivors), and, Serzone.I'm still angry about the Pondimin, Phen-Phen, and Redux stuff; my stepfather prescribed Pondimin for years and years, since AH Robins came out with it a generation or more ago. No EPH in any of his patients. I also think the DEA had a nerve putting it on C-IV; I never heard of anyone abusing or becoming habituated to the drug; it worked, was good in patients where because of heart disease, blood pressure, an aggressive pressor / cardioactive diet drug would be a bad idea.Mixing (dl) phenfluramine and phentermine to counter the drowsiness of the racemic form sounded loopy at the time (Phen-Phen), but boy those clinics sure advertised for patients and weren't overly picky about screening patients for risk factors.And when the d-isomer of phenfluramine was discovered not to cause drowsiness and seemed to be the isomer that suppressed appetite, well Redux came out; no drowsiness, minimal abuse potential, it worked.But all of a sudden, we hear of EPH in 'droves', and class action and individual suits being printed on mimeographs.Was it just that this drug became so enormously popular (along with the witche's brew I won't dignify) that we had a large enough cadre for a rare side effect to be uncovered (see my tirade about chloramphenicol and chloroquine etc over on JNJ); or, were patients likely to contract EPH on their own admitted to the pool of treated patients?I don't know of any longitudinal studies on high-risk CV obese patients given any of these drugs with controls; particularly when they were handed out like candy at Halloween.And lost in all this flurry of lawsuits and press overdramatized press coverage was a question I was asking myself, "Could drugs that affect the serotonin system non-selectively (i.e., not just the CNS, but the whole body) be a key to understanding diseases of the cardiovascular - pulmonary organ system?"Ah, well.There's a pt. here put on Cordarone for what clearly is AFIB, not an indication; let alone the fact the AFIB was not "life threatening", no prior drugs were tried, and it's the wrong drug to begin with.Life is fun; it's nice when we can keep more of it around.RSH.
Reply to rshunter2:My husband practices medicine the way your stepfather did. Slow to try the new hyped-up version of a drug until it is proven. The reps love him for the same reason his patients do--he is very kind. Too bad the HMOs make it hard to practice the way he loves to. Medicine is in CRISIS, with no really good solution in sight.
Re: Painter99My husband practices medicine the way your stepfather did. Slow to try the new hyped-up version of a drug until it is proven. The reps love him for the same reason his patients do--he is very kind. Too bad the HMOs make it hard to practice the way he loves to. Medicine is in CRISIS, with no really good solution in sight. Medicine is not in a terminal crisis, but it is in what one might conservatively call perhaps a collapse into ineffective bureaucratic stasis, snarled up with so many regulations and so many vulture trial lawyers and dial 1-800-SUE-DOCTOR people, my stepfather was right. I suppose my stepfather saw farther than I did with my myopic eyes. Many things must change soon unless we want another dogfight in Congress and with the FDA and all parties concerned.The true R&D pharma companies need their 17 year patents, fully usable by the people that spent billions to develop often entirely new vectors of therapy, such as the "statins" (Mevacor, et al) that suppress a key liver pathway that introduces unneeded cholesterol into the body and where it lands in the worst places, such as as a clogging factor leading to heart attack and to ischemic stroke (as opposed to a CVA, the traditional brain hemmorrhage), intermittent claudications and so forth. The new platelet drugs such as Plavix show promise in preventing or ameliorating the IC symptoms Churchill suffered, although aspirin or aspirin and dipyramidole might be somewhat effective or at least not harm.Drug companies, researching partners at Universities and even the NIH and the military, deserve to at least break even. I am not suggesting that they not do more than that, but some things I have been seeing going through both local and Federal channels suggest a total ignorance of just what it takes to get a drug on the market. I had a discussion with one of our State Representatives tonight that took my breath away. I might suggest to the industry at large that more effort be given to cost breakdowns, and "why does this pill cost $2 and whose fault is it?" than in other lobbying methods, or doctor goodies.PMA and everyone should be involved in this effort, and an active and aggressive advertising campaign would not hurt, that more precisely explains how medicines are discovered, researched, and finally approved; I'd be happy to write the material myself.Painter, I am glad your husband has the chance to diagnose, study, prescribe, and heal. It is a rare privilege to be able to save a life, or to at least improve the quality of lives as best can be done. I do that by proxy when I can; it is not the same. But, as some solace, I suppose, I can do things in research and statistics that might help others. It still is not the same as curing a child's sore throat or ear ache or diagnosing Ca early enough to be caught in an individual patient. And I will also always miss medical and forensic pathology, and criminalistics (now they call it Forensic Science).The general public needs to be more aware of how the medical system works and how. I would sooner see fewer ads for Rx antihistamines, antifungals and the like, and more industry-focused, case-oriented material. How much it costs to get a pill on the market.How much physicians and others pay in malpractice insurance.President Bush clearly has other things on his mind at the moment, but the healthcare of the nation ought to be brought to his attention at some point.RSH.
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