Latest Drugwonks' Blog

Penalty Box

  • 05.18.2006

The MSM is so predictable. Rather than reporting on the success of Part D enrollment the stories are now all about “the penalty.” As Bob Goldberg has mentioned (see below) this draconian measure averages out to between about $2-$5 a month. But this fact, not surprisingly, hasn’t been reported. The issue that the media, lawmakers, and pundits have missed is that when you don’t have a deadline people who are eligible and entitled to Federal programs don’t sign up. A spot-on example is CHIP. As mayors and governors nationwide have bemoaned — if all of the CHIP-eligible families in the US were actually using the program, the numbers of children without health care coverage would plummet. But, there’s no deadline so there’s no urgency.

And that’s the ultimate penalty.

West Virginia Governor Joe Manchin has decided not to formally respond to a recent column in the Charleston Gazette by Dr. Alan Sager of Boston University critical of the state’s efforts to implement a 2004 state law intended to curb soaring prescription drug costs.

In the April 27 column, Sager complained that the provisions of the act are being implemented “much too slowly.”

Comment from the Governor’s office …

“We think they’re moving in the right direction,” said Lara Ramsburg, the Governor’s communications director. “We’re not going to spend of lot of time worrying about responses.”

Well I did respond and here’s my letter (which appeared in the May 14 edition of the Gazette)

Drug comparison useless and wrong
May 14, 2006

Editor:

In his commentary in the April 27 Charleston Gazette, Dr. Alan Sager makes the obscene argument that since the street price of heroin and cocaine has decreased four-fifths between 1981 and 2000, so too should the costs of prescription pharmaceuticals.

His comparison couldn’t be more useless — or more wrong. He points out that in 1981 the “average retail price per pharmaceutical” was $9.50 and that in 2000 the average rose to $40.11. But this is a useless statistic because, one, it begs the question, what’s an average pharmaceutical?; and, two, it supposes that we’re dealing with the same basket of similar products.

In 1981 there were far fewer effective medications for almost every disease (most notably hypertension, high cholesterol and diabetes) and biologic therapies for cancer, multiple sclerosis, etc., were more science fiction than science. We’ve come a long way from bench to bedside in those years, and millions of Americans are leading healthier, more productive lives because of these advances.

In 1981, my parents gave me an electric typewriter for my birthday. It cost $125. Using Sager’s logic, I could make the argument that in 1981 a “word processor” cost $125 and in 2000 it cost $2,500. But would anyone accept that a typewriter and a laptop computer are comparable? I think not.

Peter J. Pitts

Scott Hensley is one of the country’s best health care reporters and his article on the risks and benefits of drugs for RA proves it. Scott’s piece is fairly balanced, however as I noted in an email to him: Not bad as far as most pieces of this genre…but if you had delineated between cancers and put this study into the context of other similar projects if would have made people rest easy rather than give the Grassleys and Sid Wolfes of the world more red meat for slowing down drug development.

For instance, ” Patients with rheumatoid arthritis (RA) are at increased risk of lymphoma, and standardised incidence ratio (SIR) is greatest for those treated with anti-tumour necrosis factor (anti-TNF) therapies; however, differences between therapies are slight, and data are insufficient to establish a causal relationship between RA treatments and the development of lymphoma, a new report indicates.

It has previously been reported that methotrexate (MTX) and anti-TNF therapies might be independently associated with an increased risk of lymphoma. However, small sample sizes and selected study populations in these studies could not confirm this association.

To investigate this issue further, Frederick Wolfe, MD, and Kaleb Michaud, MS, with the National Data Bank for Rheumatic Diseases, Arthritis Research Foundation, in Wichita, Kansas, United States, prospectively studied 18 572 enrolees in the National Data Bank for Rheumatic Diseases (NDB).

Patients were surveyed twice a year. Reported cases of potential lymphoma were further investigated. The expected number of cases of lymphoma was determined by using data from the Survey, Epidemiology, and End Results (SEER) cancer data resource.

Overall, 88 lymphomas were identified, 59 of which occurred prior to NDB enrolment and 29 of which occurred after NDB enrolment and during the period of intensive follow up.

The overall SIR for lymphoma, regardless of treatment, was 1.9. For patients receiving biologics, SIR was 2.9 (95% CI 1.7-4.9). For those taking infliximab, with or without etanercept, the SIR was 2.6 (95% CI 1.4-4.5). For etanercept, with or without infliximab, the SIR was 3.8 (95% CI 1.9-7.5). The SIR for MTX was 1.7 (95% CI 0.9-3.2), and for those not receiving MTX or biologics, the SIR was 1.0 (95% CI 0.4-2.5).

Lymphoma was associated with increasing age, male sex, level of education, and comorbidities. The Cox regression hazard ratios and 95% CIs for these variables were 1.58 per 10-year increase in age (95% CI 1.16-2.18); 3.70 (95% CI 1.79-7.68) for male sex; 1.16 (95% CI 0.99-1.37) for education; abd 1.30 (95% CI 1.10-1.54) and for comorbidity.

“The results of this study show that lymphoma is increased in RA compared with the general population,” Dr. Wolfe and colleagues conclude. However, even a sample of more than 18 500 patients could not demonstrate significant differences among the studied groups, because of the rarity of lymphoma, they note.

“It seems possible that the apparently increased rates of lymphoma are, in fact, reduced by therapy, and that the ‘increase’ may reflect channelling bias whereby patients with the highest risk of lymphoma preferentially receive anti-TNF therapy,” the researchers conclude.

“It appears that neither clinical trial data nor data from the current study are sufficient to establish a causal relationship between RA treatments and the development of lymphoma,” they add.

Arthritis Rheum 2004;50:1740-1751. “Lymphoma in rheumatoid arthritis: The effect of methotrexate and anti-tumor necrosis factor therapy in 18,572 patients”


There is also this study http://www.arthritis-research.org/Documents/breast_ca_ACR2005.ppt

and this one http://www.arthritis-research.org/Documents/lung%20cancer_ACR2005.ppt


PS. The fact that drug companies support research does not make the research wrong. If that were the case, then no drug would work since all research submitted to the FDA is done by drug companies…

From a Washington Post Story: ” Grassley said the bill would make up for an estimated $1.7 billion in lost penalty revenue over five years by reducing a “stabilization fund” aimed at helping private managed-care health plans take care of older Americans. “

So let’s see….penalize seniors who sign up early by taking away their discount and take money away from an effort to keep seniors healthy in order to save laggards $2-5 a month? This is election year grandstanding of the worst sort….

ON THE HEALTH CARE FRONT: Yesterday, according to Mark McClellan, administrator for the Centers for Medicare and Medicaid Services and the hardest working man in health care, about 40,000 to 50,000 people were on the agency’s Web site site at any given moment.

“We’ve seen a real surge,” McClellan said. “The deadline is making a difference.”

WHILE ON THE POLITICAL FRONT: According to an AP story, Representative. Nancy Johnson (R, CT) took a swipe at Democrats, saying she believes the program has been quite successful, and enrollment might have been closer to 100 percent “if the Democrats had put the welfare of our seniors ahead of their own political ambition.”

You go girl.

A PAP Gap?

  • 05.15.2006

The OIG stance is typically government: make a straightforward program that works well in the private sector a cumbersome and daunting process that discourages consumer participation and then makes any corporate deviation from the regulations or their interpetation by Asst. US attorneys or self-styled consumer groups grounds for criminal investigation or litigation.

Which goes to show you what life would be like if the government took direct control of the Medicare drug benefit….bad enough the nit-wits in OIG have screwed this one act of charity up…what would happen if every part of the pharmaceutical business was under government control?

Going for the Gold

  • 05.15.2006

Excellent article in today’s Financial Times about the impact the rapidly declining cost and increasing precision of clinical informatics is having on prescribing decisions and the Pharma model of simply marketing a drug based on FDA data. The article describes how health plans are developing better post market and predictive decision-making models on who gets what within the framework of disease managment. And it will soon be possible to integrate clinical data with some genomic data as well. Where is Pharma on all this? According to the FT article: “in a world where whoever controls the gold often rules, drugs companies no longer have a firm grasp on the most precious commodity: information.” See the article below..

I have been saying for years that Pharma has to get into the trenches and start looking at how their products actually work and where they work best to stay in the game and stay ahead of the price control crowd. What they spend on traditional marketing should be spent on developing sophisticated data mining and data analysis systems…it would deliver better value to both company and customers alike.

It’s PDUFA reauthorization time and the usual suspects are trotting out the usual evasive gabble.

PDUFA MYTH #1: Since drug companies provide about 40% of FDA funding via PDUFA, the agency is “beholden” to Big Pharma.

TRUTH: How can FDA be “in the pocket of the pharmaceutical industry” when the industry has nowhere else to go? Where’s the leverage? It’s FDA or nothing pal. The leverage is on the other side.

Proper retort to ignorant comment — “Industry pays FDA to approve drugs.”

Wrong! FDA gets paid to review drugs. (And they certainly don’t all get approved now, do they?)

More myth-busting to follow.

Send me your favorite PDUFA myths and I’ll post them. I can be reached at ppitts@cmpi.org.

Dumb and Dumber

  • 05.14.2006

Here’s a question: In the case where a life is on the line and you need a doctor who would you choose: someone who is world reknown, an expert in saving lives and treating the disease that threatens it but is under scrutiny by the mainstream media and the Left for consutling with drug companies or an untested doctor with no track record by who has done no consulting for biotech or drug firms? Only a dumb person — or a pure ideologue (an oxymoron) — would choose the latter.

Now apply this logic to banning people — regardless of their insight, clinical gifts or peer recognition — from advising the FDA because they consulted for the NIH or private companies. Merrill Goozner argues that there are plenty of oncologists for example that have not consulted for private firms that could serve the FDA. The question is: would excluding those that have consulted advance the public health. Applying the Goozner rule would exlude:
one of the world’s experts in prostrate cancer, one of the pioneers in using biomarkers to measure angiogenesis, a leader in the design of clinical trials for stomach cancer, one of the nation’s leading researchers dedicated to finding drugs that actually stop the progression of bladder cancer., and a Nobel Prize winner to boot…

This is dumber.

Peter and I have a better way that will increase the number of smart people helping the FDA as opposed to proposals that make them feel like criminals.

TGIF

  • 05.12.2006

I am suffering from hypocrisy and stupidy overload….apart from the patently biased reporting on Pfizer’s clinical trials and cancer drug pricing in the WP and WSJ respectively we now have the double standard on the coverage of RU-486 safety. According to recent research, 1 in every 80,000 women who have a medical abortion die. 1 in every 1,000,000 women who have a surgical abortion die. I am not a math whiz but that means that RU-486 increases your risk of death 10 times. If Vioxx had done that, it would have been the subject of a Charles Grassley media orgy. And lost in the reporting is the fact that many of the deathrs attributed to RU-486 recently are linked to off-label use (vaginal vs. oral use). Or was this fact conveniently buried even as the press beats up on other forms of off-label use?

Meanwhile, the AP had this misleading headline : Paxil May Increase Suicide in Teens, FDA and GlaxoSmithKline Warn

Actually, the FDA said that nearly 15,000 patients treated with both Paxil and dummy pills revealed a higher frequency of suicidal behavior in young adults treated with the drug, according to the letter.

The FDA reported that there were 11 suicide attempts — none resulting in death — among the patients given Paxil in the trials. Just one of the dummy pill patients attempted suicide.

Given that small number, the results “should be interpreted with caution,” the FDA said. Eight of the 11 attempts were made by patients between the ages of 18 and 30. All trial patients suffered from psychiatric disorders, including major depression.”


Left unsaid of course is that people suffering from major depession are likely to exihbit suicidal behavior and that all medications are associated with an elevation of suicidadility and that use of antidepressants is associated with a decrease in the incidence of suicide among teens.

Meanwhile, USA today ran a story discussing whether Oprah is a modern day Billy Graham.

All of this reminds me of what Thomas Jefferson said: “The man who reads nothing at all is better educated than the man who reads nothing, but newspapers. “


CMPI

Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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