Wednesday, May 27, 2009

Online Docs Give Advice About...Generics?!?


I am minding my own business, trying to keep up with my general infectious disease knowledge by following a link to a brief 15-minute video lecture on Clostridium difficile infection (subscription required) at the website Medscape. For those unacquainted, Medscape is a website designed to provide information for physicians about recent studies, with expert commentary, internet roundtables, and chat rooms for docs to anonymously cross-talk about a variety of professional topics. It's got a nice layout, the links are good, I'm a fan. A similar website that is also extremely popular among the medicine crowd is Up To Date, though its layout has a slightly different purpose, being more of an online textbook rather than a sort-of internet physician magazine as Medscape is modeled.

One of the critical and important differences between the two is that Up To Date generates its revenue by selling subscriptions, likely making the bulk of its money by package subscriptions to hospitals and medical schools. No commercial advertising can be found at the website. By contrast, Medscape's business model relies on commercial sponsors to generate revenue, and while I have no doubt that the editorial policies of the company are designed to create a firewall between pharmaceutical manufacturers and the physicians providing expert commentary, from my standpoint their corporate organization is inherently more prone to commercial influence than that of Up To Date. I don't consider Medscape out-of-bounds as a consequence--and I don't necessarily mean to imply that the creeping influence of drug companies is absent at Up To Date, but I do view the Medscape commentaries, particularly when it involves discussions of newer, patented drugs, with particular skepticism.

Which was why I was surprised to hear some refreshing commentary from Dr. David Johnson of the Eastern Virginia School of Medicine as he weighed in on the treatment of Clostridium difficile. Only a little tedious detail is needed here to explain matters. "C diff" infection is one of the most common causes of diarrhea in the US; standard treatment involves using a drug called metronidazole, but relapses in this disease are common, and the gold-standard medication for relapse is oral vancomycin. Vanco is an old-time drug, still incredibly useful, used most commonly in IV form. In that IV form it's pretty cheap. However, the pill form of it--and only the pill, not the IV, form of vanco is effective against C diff--is very expensive: a two-week course can run anywhere from just under $650 to more than $1700 depending on the dose. And oral vanco has but one manufacturer, ViroPharma Inc (annual sales approx $232 million in 2008, which makes it a small player by industry standards).

Given that, Dr. Johnson's advice perked up an otherwise thorough-but-staid academic discussion:

For oral vancomycin, I'm going to give you a tip: When you send the patient to the pharmacy for vancomycin, 125 mg every 6 hours for 14 days, that's about a $1200 ticket for that oral therapy. That pill or capsule is actually a nongeneric and it is something that's extremely expensive. It's anywhere from $15 and upwards per capsule. Now, the tip is to work with your pharmacy. Get them to compound this. Take the IV vancomycin -- take a gram. Have them compound that in a liquid formulation. It doesn't taste very good, but they can put some sweetener in this. They can then take a gram and make 8 doses of this in a liquid formulation. The half-life or shelf life of this you'll have to work with your pharmacy in compounding, but that dose now costs approximately a dollar.

If you're not doing this, you really need to be. Think about the cost savings. We have about a 15-fold-plus cost reduction per dose. Patients now take this incredibly cheap medication, oral vancomycin, as an IV formulation compounded, delivered over the course of the same timeframe. If you're not doing this, you really should be. It's a tremendous savings and certainly of equal efficacy. [my emphasis]

I am not trying to pick on ViroPharma, which for all I know is a perfectly respectable corporation trying to bring useful drugs to the marketplace. But I am saying that vanco has been around for a long time as a drug, well past the expiration of its patent, so there is no reason why a doc shouldn't be proud of pushing a cheaper form of the medication and doing so in the patient's best interest. For we are in theory supposed to act solely on their behalf and not on those of a multimillion dollar corporation. If both interests can be dovetailed, that's fine, but I am now a fan of Dr. Johnson because his little digression makes it entirely clear where he places his loyalties.

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