Wednesday, May 21, 2014

The Ballad Of The New Oral Anticoagulants, Or The Blood Thickens

Today's blog-post by the Down Under physician/essayist, Karen Hitchcock, MD/PhD, mentioned an anti-coagulant solely by its chemical hame (dabigatran). This blogger consulted Dr. Google and learned that the brand name of this med is Pradaxa (in Australia, Europe, the USA, and Canada) and it is the product of the German pharmaceutical giant, Boehringer Ingelheim. Dr. Google also alerted this blogger to the legal problems associated with Pradaxa. This blogger takes a daily dose of one of Pradaxa's competitors: Xarelto (pronounced as if starting with Z). There is no free lunch in the anti-coagulant biz: Xarelto has potential nasty side-effects, too. When this blogger demanded a non-rat-poison anti-coagulant and presented his cardiologist with the top 3 brand names: Pradaxa, Eliquis, and Xarelto, X (pronounced like a Z) hit the spot. If this is (fair & balanced) circulatory reasoning, so be it.

[x The Monthly]
Big Pharma
By Karen Hitchcock

Tag Cloud of the following piece of writing

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It was midnight and I was lying awake in bed, thinking that I should have been a surgeon. If something went wrong, I could cut it out. No nonsense, a clear cut. We physicians just sit around trying to protect organs with a bunch of drugs. Protecting organs is like being a soldier in peacetime. You hang out, doodling on script pads, deterring attacks with your presence and with wishful thinking.

Most of our drugs are barely better than wishful thinking, I was musing. The giant global pharmaceutical research enterprise is dedicated to a program of small-scale risk fiddling. Where’s the new, heroic life-saving drug? Where are all the new anti-microbial agents? There aren’t any, and it’s all big pharma’s fault. There’s major money in tweaking what we already have: turning a 3% risk into a 2.8, making something more consumer-friendly or more expensive. And we pretend this is progress, when really all we do is spin round and round. We pretend our interventions are huge. We pretend we’re at war and every decision is life and death. Mostly we tinker at the edges, sweating over drug X versus drug Y. Drug companies urge us to choose X, please choose X. It’s 0.001% better.

Such were my ruminations when a registrar called me to say that the emergency department had referred us a young guy with big fat blood clots blocking the flow of blood to half of his lungs. I stopped feeling sorry for myself and started issuing instructions.

Clots wreak havoc. They block the flow of blood to your heart (resulting in a heart attack) or brain (a stroke). They stuff your deep leg veins, turning them into blood pudding that can tear off and lodge in your lungs (a pulmonary embolism). They stuff the fibrillating atrium of an irregularly beating heart and fly up into your brain. The terminal event in most cancer patients is a clot blocking something vital. Clots can kill you, but we can treat clots.

For decades we’ve been using a drug called warfarin for all kinds of clots, particularly to stop ones that form in a fibrillating heart from reaching the brain. Our patients jokingly refer to it as rat poison, because that’s exactly what it is. And it works. Physicians all have a feel for it: to whom we should give it, from whom we should withhold it. It has an antidote if you take too much. But in the past year a bloom of expensive new drugs that “thin the blood” has hit the Pharmaceutical Benefits Scheme, promoted heavily by gangs of drug company reps bearing shiny briefcases filled with glossy brochures.

We’ve talked about clots in journal club for the past three weeks in a row. And it’s on again this week. We can’t rely on drug company salespeople for information. We have to review the research ourselves: all those sparkling multi-million-dollar drug company trials, featuring thousands of patients who are younger and healthier than ours.

Drug company reps will buy you lunch, dinner, business-class plane tickets if you want. I had coffee with a drug company rep once. She gave me a textbook I’d wanted. In exchange, I sat and listened as she peppered her sentences with the company’s name. I stopped hearing what she was saying. Was she keeping count? Had she done this for so long she now did it without thought? “How are your twins?” she asked. Good memory. She’d seen me lumbering around the wards heavily pregnant a few years before.

To me, the reps all look the same: very pretty women wearing suits, great-looking guys who belong to weekend triathlon clubs, twinkling their ten-years-younger-than-me eyes. It’s a seduction. One by one they try to touch us with their food and their flattery and the name of their drug till it’s as familiar as family, till we trust it and them, till we choose X over Y.

Drug company reps play on doctors’ uncertainty, on our anxiety that we do not know. They play on our fear that we will do the wrong thing, the not-so-good thing, the out-of-date thing. They’ll buy you lunch, dinner, business-class plane tickets if you want. I don’t want. I won’t eat their food, answer their calls, read their propaganda or take their money. I don’t think racketeers have any place in a public hospital.

The new drugs they’re promoting (or “representing”, as they say) aren’t rubbish. Read the reports of the trials and you’ll see the drugs are more or less equivalent to our trusty old rat poison. Too much and you might end up collapsed under your table, bleeding out like a rodent. Not enough and you may clot up like a sausage. The main benefit was supposed to be that, unlike warfarin, the new drugs didn’t need to be monitored by frequent blood tests.

They’re expensive drugs and took some time to be approved. One drug company launched a website encouraging people to write to their member of parliament to protest the delays in approval. It bypassed the specialists and aggressively promoted its drug, dabigatran, to GPs, flooding consulting rooms with free starter packs and lunch. Patients loved it — no blood tests — and GPs prescribed it like crazy. But it turns out that dabigatran offers less protection against heart attacks than warfarin. And then one of the company’s own reports concluded that some patients who were taking dabigatran may need a bit of monitoring after all, just to check their blood wasn’t too thin and they wouldn’t bleed to death.

Some of the company’s employees sought to have the information quashed. “Can’t this be avoided?” one wrote. The in-house researchers were asked to please check again if the monitoring recommendation was really warranted. If doctors knew there was less protection against heart attacks and on top of that some patients needed blood tests after all, they might stop prescribing it! In the name of the dollar and of marketing something shiny-glossy new, in the name of sales achievements and your end-of-year bonus, can’t these facts be avoided, please? Ω

[Karen Hitchcock is both a physician (medical registrar at the John Hunter Hospital and a lecturer in Medicine at the University of Newcastle) and a writer (PhD in English/Creative Writing at the University of Newcastle). Her first book Little White Slips (2009) won the 2010 Steele Rudd Award in the Queensland Premier's Literary Awards.]

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