"Marketing strategies masquerading as Evidence Based Medicine"

A commentary appears in the October 19,2006 issue of the New England Journal of Medicine regarding allegations about the length to which a drug company will go in influencing patient care by misleading physicians and improperly manipulating the creation of treatment guidelines. The commentary in the Perspective section is entitled " Surviving Sepsis-Practice Guidelines, Marketing Campaigns, and Eli Lilly".The authors are all from the Critical Care Medicine Department at NIH. A summary of their article can be found on the October 19 post on Health Care Renewal.

Xigris (drotrecogin, aka recombinant human activated protein C,rhPAC) is the drug, Lilly is the drug company and the condition for which treatment guidelines were said to be manipulated is sepsis. I have been concerned for some time about the degree to which Big Pharma have used ( and mis- used) the concepts of evidence based medicine to promote various medications but if the commentary accurately reflects reality this example rivals or even exceeds the gabapentin story.

This NEJM article and an earlier article in the Annals of Internal Medicine dealing with gabapentin and the disreputable techniques used to market it ( I posted about it here ) should be mandatory reading for medical students and included in the reading lists of med school courses on EBM and how EBM can be kidnapped and exploited . If the situation is, in fact, as described in the NEJM commentary, egregious is not strong enough an adjective for that type behavior. But "If" is the operative word. For a thoughtful counterpoint to the NEJM commentary to to the Oct 22, 2006 post by Dr. RW. He reminds us that criticism of guidelines or for that matter any treatment should not be based simply on the fact that a drug company may have used various techniues to promote it but should be based on logic and reference to solid evidence and in his analysis of the NEJM article the authors from the NIH fall short in that category.

No one is shocked by the fact that businesses not infrequently promote their goods or services by emphasizing the advantages and minimizing the downside of their products. However, if and when that spin puts patients well being or lives at risk I believe we move past "mere" unethical behavior. There is little room for error in the treatment of sepsis patients and underplaying or ignoring the risk of hemorrhage from activated protein C (Xigris) could well lead to patient fatalities. (The authors assert that the risk of bleeding was not properly noted in the promotional material generated for Xigris). To withhold information about serious side effects from a medication and promote its use by deceptive means included sponsoring guidelines may well move past negligence as well.

There is more .Go to the October 20,2006 post from Health Care Renewal for expression of concern about the role another drug company, Amgen, played in the development of guidelines for uses of Epogen in renal failure.

I do not know if and/or to what degree the experts who authored the two guidelines mentioned above were actually improperly influenced by the drug companies' activities and/or recommended treatments for which the evidence was insufficient but the perception that guidelines might be "usurped ...for commercial purposes" has to make physicians even more skeptical of guidelines in general particularly with such a commentary in a high impact journal. Further, when you consider the uses to which guidelines are put,including quality audits,pay for performance,arguments in legal proceedings it becomes even more important that we know how the sausages are made. And as the NEJM article asserts Xigris does seem to have found its way into performance standards even though I believe it is fair to say that the jury is still out ( or should be) regarding its efficacy and safety.