Gray Lady On-Line Letters

• 10.25.2007

In the spirit of full and open dialogue, here are two letters-to-the-editor from today's on-line edition of the New York Times ...

Opinion

LETTERS

Testing New Drugs
Published: October 25, 2007

Re “A Test of Bad Health” (Op-Ed, Oct. 18):

To the Editor:

Peter Pitts’s criticism of the proposed Center for Comparative Effectiveness exemplifies the scare tactics used by the pharmaceutical industry to protect its interests.

While he cites one example of delayed drug approval in Britain, he doesn’t mention the many cases in which comparative effectiveness studies have fostered timely and appropriate decisions to adopt or not adopt new drugs and other medical advances.

The use of government-sponsored studies to inform drug coverage decisions by government agencies is not “an inherent conflict of interest,” but rather the judicious exercise of government resources to serve the public interest.

Sadly, the casualties of President Bush’s veto of the State Children’s Health Insurance Program bill include not only the millions of children left uninsured, but also the hundreds of millions of Americans and their doctors who need better information to make the best possible decisions about their health care.

Alan B. Cohen
Boston, Oct. 18, 2007
The writer is a professor of health policy and management and the executive director of the Boston University Health Policy Institute.

To the Editor:

Peter Pitts warns that a proposed Center for Comparative Effectiveness to test new drugs would be dangerous because “conducting these studies is so tricky, their findings are regularly overturned or modified by further research.” Yet he would have us accept the company’s clinical trials showing the drug to be safe and effective?

One wonders why it is so tricky for the government to do this research, yet so simple for his pharmaceutical financiers to do the same.

Kevin Carlsmith
Hamilton, N.Y., Oct. 18, 2007

After all, everyone's entitled to their opinion.

Getting It Right on Clinical Trials: Honesty is the Best Policy

• 10.25.2007

Sanofi's conduct in the testing of Ketek underscores the importance of trust in shaping perceptions of risk. The relationship between drug companies and consumers must change. It will have to be more honest, more transparent, more individualized and enduring. It can't end after the FDA approves a product either.

According to the WSJ the FDA said it was "unable to find evidence" that the company either fixed the problems or threw the problematic doctors out of the study and told the FDA. The FDA also faulted Aventis for failing to make sure the study was properly conducted and for allowing unqualified investigators to participate in the trial.

These problems are rare and will happen. However when they are detected they should be reported promptly and the unqualified investigators should be barred from participating in clinical trials as a matter of industry policy.

http://online.wsj.com/article/SB119328145497070973.html?mod=googlenews_wsj

Stark Raving Anti-Semite...

• 10.24.2007

Who says sorry seems to be the hardest word? Here's a sample of some a Pete Stark's other gentle musings about those who differ with him on healthcare policy issues... From Jonathan Weisman of the Washington Post (get a look at the photo the WP selected for the article..)


2003: As Stark belittled House Ways and Means Chairman Bill Thomas (R-Calif.), then-Rep. Scott McInnis (R-Colo.) told him to "shut up."

"You think you are big enough to make me, you little wimp?" Stark taunted. "Come on. Come over here and make me, I dare you. You little fruitcake."

2001: At a Ways and Means subcommittee hearing on abstinence promotion, Stark referred to then-Rep. J.C. Watts (R-Okla.) as the "current Republican Conference chairman, whose children were all born out of wedlock."

1995: In a private meeting, Stark called then-Rep. Nancy L. Johnson (R-Conn.) a "whore for the insurance industries."

"He didn't call her a 'whore,' " defended Stark press secretary Caleb Marshall. "He called her a 'whore of the insurance industry.' "

1991: Stark singled out "Jewish colleagues" for blame for the Persian Gulf War, referring to then-Rep. Stephen Solarz (D-N.Y.) as "Field Marshal Solarz in the pro-Israel forces."

1990: Stark called then-Health and Human Services Secretary Louis Sullivan, who is African American, "as close to being a disgrace to his race as anyone I've ever seen."

http://www.washingtonpost.com/wp-dyn/content/article/2007/10/23/AR2007102302165.html

Evidence of an Evidence-Based Double Standard at CMS

• 10.24.2007

Maybe someone can explain the difference between the risks of off-label use of drug-eluting stents -- which CMS will still cover -- and the risks of appropriate ESA use -- which CMS will is banning. In both cases there is no evidence from randomized controlled trials demonstrating safety or quality of life benefit which CMS claims is the standard for reimbursing things these days.

Last time I checked there was no randomized placebo controlled study of aspirin with safety being the primary endpoint. Maybe Medicare should not pay for that either.

http://online.wsj.com/article/SB119318921736669347.html?mod=health_home_stories

People Leak When They Are Losing or it is When They Are Losers?

• 10.24.2007

Gee, I wonder who leaked this to the WSJ...Let's see, when you don't have the science or the facts on your side, presenting the sort of observational data in public to defend your position that you derided as evidence in support of the safety of other drugs and when everyone else in the agency is pretty much responsible...my guess is David Graham and that it is part of a well-orchestrated effort. We know it's not the European Medicine Agency which just tighted prescribing data. Let's hope with better post market data we won't have this hysteria in the future. My guess is, with tort lawyers and web-based interest groups profiting from fear we will see more of this, not less.

http://online.wsj.com/article/SB119318921736669347.html?mod=health_home_stories

Andy's Legacy

• 10.24.2007

Andy von Eschenbach comments on the issue of "legacy drugs" via a letter in today's edition of the New York Times ...

To the Editor:

The Food and Drug Administration thanks you for emphasizing our continued efforts to protect the public and raising consumers’ awareness that certain drugs are marketed without F.D.A. approval. In June 2006, the F.D.A. announced its renewed emphasis on solving the problem that many drugs lack F.D.A. approval, often because they were introduced into the market long before the F.D.A. had its current regulatory authority.

To deal with the unapproved drugs that remain in use, we give highest priority to drugs that have safety concerns, lack evidence of effectiveness or are health frauds. This approach is carried out without imposing undue burdens on health care and is applied uniformly against all companies, large and small, that market these drugs.

The F.D.A. is committed to proactive action to assist companies with finding opportunities to legally market their products. As part of this commitment, the F.D.A. appointed an unapproved drugs coordinator and conducted a full-day workshop in January 2007 to educate companies about the drug approval process, the over-the-counter monograph process and user fee waivers. Our unapproved drugs coordinator consults frequently with companies, and many of them have begun the approval process for their products.

Some refer to these unapproved marketed drugs as “legacy drugs.” A legacy is not a substitute for drug approval. Individual experience, anecdotal evidence and marketing history are insufficient bases for concluding that a drug is safe and effective. In fact, experience demonstrates that unapproved drugs are often unsafe, ineffective, inappropriately labeled and poorly manufactured. This is not the legacy that we want for our families.

I, and the entire F.D.A., remain committed to ensuring that safe and effective drugs are available to protect and promote the health of the American people.

Andrew C. Von Eschenbach, M.D.
Commissioner of Food and Drugs, Food and Drug Administration
Washington, Oct. 22, 2007

FDA Cough Medicine Decision Puts Pediatricians In Silent Mode

• 10.23.2007

Here's the bottom line reason pediatricians love the decision to ban cough medicines: fewer 2 AM phone calls from parents about dosing, less anxiety about lawsuits...

Benjamin Brewer MD who blogs for the WSJ on medicine:

The dose provided some relief — the boy’s sniffles and cough abated long enough for the Brewers to get some shuteye. “I have found that the advice to hold off on a kid’s cold medicine is much easier to give than it is to heed,” Brewer writes.

The crackdown on cold medicines for kids may have an unintended benefit for the doctor. “With infant cold medications off the market, I won’t miss the parents calling in the middle of the night for recommendations on how much to use,” he writes. “I won’t miss meticulously documenting how many tenths of a milliliter I advised a person to give or the liability risks associated with my advice.”

Thanks for the dose of honesty doc.

I just wish the FDA experts were as freaked out about MRSA and diminishing antibiotics to treat them as they were about cough medicines. Ironically, the "safety uber alles" movement has made it likely kids will see fewer antibiotics for killer bugs or coughs. Reminds me of when I was a kid. It would make me feel a little bit better if Mickey Mantle were still batting clean up for the Yankees.

http://blogs.wsj.com/health/2007/10/23/a-taste-of-his-own-medicine/

For those who want to see Mantle's stats as opposed to the number of kids who died from infectious diseases in the 1960s...

http://www.baseball-reference.com/m/mantlmi01.shtml

Bone Débarras

• 10.23.2007

Just in from the Beeb ...

Bone drug rationing 'must end'

Campaigners are appealing against a decision they claim is restricting doctors from prescribing osteoporosis drugs on the NHS.

Currently only one drug - alendronate - is approved by the National Institute for Health and Clinical Excellence. But the drug can cause a severe reaction in a quarter of patients.

The National Osteoporosis Society (NOS) says hundreds of thousands of people are missing out on potentially life-saving treatment as a result. NOS says the decision by NICE to recommend the cheapest drug is a false economy and leaves many patients at increased risk of painful and life-threatening fractures.

Professor Ignac Fogelman of the NOS said: "We are challenging the financial model that was used to look at the cost effectiveness of the various treatments for osteoporosis." GP Rosemary Leonard said: "Alendronate is the one osteoporosis drug which is now off patent so it is a lot cheaper than the others which is why there is this push to prescribe it. "But unfortunately one in four people who are on it can get bad reactions to it, particularly inflammation of the oesophagus.

"There is a choice available but NICE guidelines say that primary care trusts only have an obligation to provide alendronate."

Postcode lottery

In some primary care trusts, this means alendronate is the only drug choice offered, she said.
"We are heading for a postcode lottery."

Professor Tim Spector, a consultant rheumatologist at St Thomas' Hospital, London said: "It is vital for clinicians and patients to have alternative treatments available so we can maximise patient choice, reduce avoidable drug side effects and reduce the risk of osteoporotic fractures."

NICE has not yet released its final guidance.

It said in a statement: "It is disappointing that the appeal will delay final guidance on use of drugs for osteoporosis and delay publication of our clinical guideline which will then set out the best use of drugs and non-drug treatments."

A spokeswoman said NICE would report back in due course once the appeal had been heard.
Osteoporosis literally means "porous bones" and makes it more likely for them to fracture as they lose their density.

Over 1m women in the UK have been diagnosed with the disease, although experts say many more probably suffer from the condition.

Is this what we really want in the US? That's just, well, SiCKO.

March of the Paternalists

• 10.22.2007

Seichel. In Hebrew it means discretion and in Yiddish it means "common sense" or as Joseph Aaron puts it...good sense, street smarts, the kind of wisdom you don’t get from getting a Harvard diploma.

Seichel tells you what’s right and what’s smart better than any book or guide or intellectual.

Or any FDA panel.

Seichel tells you that when millions of parents over 40 years have used cough and cold medicines responsibly they have a better handle of their kids needs than the media seduced know it alls who gathered in Rockville.

Did any of them consider that, because of the ban, parents will simply water down or dose adult cough meds to help their kids stop coughing or sniffling? Or that they will turn to even less effective or untested "natural" remedies that may be even more dangerous?

No, because the panel and the American Academy of Pediatric were not guided by seichel but by the "safety uber alles" principles pushed by the trial lawyers (websites now coming to a computer near you) have pushed medicine past science and common and into the panic room.

The decisions we make out of fear and to eliminate risk completely will always lack common sense and reek of mob rule.

Et tu, Bernie?

• 10.22.2007

The Junior Senator from Ben & Jerry’s, Bernie Sanders, has just introduced a bill that would replace our current patent system for pharmaceuticals with a “Medical Innovation Prize Fund.” Here we go again.

It’s not a new idea. The “prize” model has been used in the past – in the old Soviet Union. It didn’t work. The Soviet experience was characterized by low levels of monetary compensation and poor innovative performance. The US experience isn’t much better. The federal government paid Robert Goddard (“the father of American rocketry”) $1 million as compensation for his basic liquid rocket patents. A fair price? Not when you consider that during the remaining life of those patents, US expenditures on liquid-propelled rockets amounted to around $10 billion.

Certainly not what Schumpeter had in mind when he wrote about “spectacular prizes … thrown to a small minority of winners.” Creative destruction indeed!

Senator Sanders wants to replace a patent system that has allowed the average American lifespan to increase, over the past 50 years, by almost a full decade with a prize program that has a solid record of complete failure.

As Joe DiMasi (Tufts University) and Henry Grabowski (Duke University) have argued, under a prize program, pharmaceutical innovators would lack the incentive to innovate. To quote DiMasi and Grabowski, “The dynamic benefits created by patents on pharmaceuticals can, and almost surely do, swamp in significance their short-run inefficiencies.”

In other words (and to paraphrase Winston Churchill) our pharmaceutical patent system is the worst way to stimulate and support health care innovation – except for every other system. On a list of 100 ideas for ways to improve innovation and access, a prize program shouldn't even on the list.

Who could support such a crackpot idea? Nobody? Wrong! Dangerously wrong. Again, as DiMasi and Grabowski presciently observed in 2004, “The main beneficiaries in the short-term would be private insurers and public sector purchaser of pharmaceuticals … Governments and insurers are focused myopically on managing health care costs. They are not likely to be strong advocates for funding new drug development that can increase individual quality of life and productivity."

Cui bono indeed.

Here is a link to the legislation(courtesy of one of its biggest supporter, Jamie Love):

http://www.keionline.org/misc-docs/SandersRxPrizeFundBill19Oct2007.pdf

Those who support this idea are so blinded by their own propaganda, that they view it as a solution to all the world’s health care ills. Consider some of the following statements:

Merrill Goozner (CSPI), “Research is risky, new drugs are too expensive, and
industry focuses far too much of its effort on drugs of minimal medical significance. The prize fund solves all these problems by disconnecting the incentives for generating breakthroughs from the price that individual patients or their insurers must pay."

Sorry Merrill. Wrong on all counts.

Jamie Love (KEI), “By separating the markets for innovation from the markets for the physical goods, the Prize Fund would ensure that everyone, everywhere, could have access to new medicines at marginal costs.”

Er, Jamie – time for some remedial economics classes.

And the timing of Senator Sanders’ bill is interesting too. It coincides with the upcoming meeting of the WHO’s Intergovernmental Working Group on Public Health, Innovation and Intellectual Property (IGWG in short) whose goal is "to prepare a global strategy and plan of action on essential health research to address conditions affecting developing countries disproportionately.”

As Meir Pugtach (Haifa University) and Helen Disney (Stockholm Network have argued:

After all, how can we expect that an international body will be able to secure the implementation of recommendations, such as "promote the active participation of developing countries in innovation", "provide support for national health research programmes in developing countries through political action and long-term funding", "promote transfer of technology and the production of health products in developing countries" and "monitor the impact of intellectual property rights and other factors on innovation and access to health-care products"?

The truth of the matter is that the promotion of innovation and the creation of new medicines for the sake of developing countries cannot be based on a top-down process. Rather they should be based on bottom-up solutions by the actual players involved in this process - companies, research institutions, and the regulatory and IP authorities.

Clearly Senator Sanders and the Jamie Love-ites do not concur. They want the philosophy of the IGWG to become the law of the land in the United States -- hard facts, economic theory, and historical precedents not withstanding.

Hopefully the US delegation in Geneva will strongly argue against this philosophy and refuse to enter into “consensus.”

A prize in every box does not a Crackerjack idea make.