From: "Steve Harris" <sbharris@ix.RETICULATEDOBJECTcom.com>
Subject: Re: all about HMOs
Date: Fri, 12 Apr 2002 12:06:36 -0600
"amp_spamfree" <firstname.lastname@example.org> wrote in message > Here's another
quote I love:
> "Expensive drugs called calcium channel blockers, for example, are
> routinely prescribed for patients with high blood pressure, even
> though studies show that cheaper beta-blocker and diuretic drugs can
> work as well or better."
> Has this author ever looked at the medical data? How about the little
> problem of impotence? Or maybe hypokalemia is a problem for some of
> these patients? If Docs are prescribing Ca blockers, are they just
> plain stupid? or maybe its medically a better decision?
Yep. For his penance we need to put the writer of this article on generic
propranolol until his pulse is 60, and see how he feels.
It probably is true that not enough HCTZ is used as a separate med. Alone,
it costs almost nothing as a generic, and at this dose (or even half this
dose) has minimal effects on K+ or cholesterol. Studies show it's effective
on mortality, and it's additive to almost everything else. It's only
technically a diuretic-- the blood pressure effect is something else and
continues long after any diuretic effect ends. Generally it's not enough as
a single drug-- but it can be. There's also a generic HCTZ-triampterine.
Some old generics aren't used enough. There's a generic captopril and even a
generic captozide (captopril-HCTZ). But it's twice a day-- so copays are
definitely needed to make people understand that convenience costs money.
Societies also have to confront the nasty problem of the fact that people
will sometimes do something that's very good for them and preventive (which
saves society money on stroke and MI), if it's once a day, but *won't* do
something that's good for them if it's twice a day. Go figure. So should
society pay the difference in cost, since it costs them less in the long
run? In America our answer has generally been "no" and we pay for it in
ESRD for poor people in renal failure, and our huge costs for stroke-rehab
and CABG surgery.
Multiple combinations aren't used enough, for those people willing to put up
with them. The effect of most drugs is linear on dose, but the side effect
profile is J-shaped, which means you can often get the same effect with low
doses of 4 drugs that you can on high doses of two. That's important,
because many people can tolerate the high doses of only the fanciest and
latest drugs, where as even low-dose cheap beta blockers (atenolol, etc) are
tolerated quite well, as additive combo features.
In the US, the patent system and the FDA and Medicare and insurance
reimbursement to doctors all have a hand in the fact that there is a general
failure in use of tricky low-dose combos for hypertension. When the patent
ends, so does incentive to do clinical research on a drug, including
research to see who combos of it and other off-patent drugs. Patent
protection needs to be extended if we want to see information about any of
this. Fed research clinical dollars should also be specifically and
deliberately targeted at off-patent-drug (and nutrient!) clinical research.
Next, the FDA requires separate NDA application for combinations even when
the separate drugs are approved and perfectly legal and accepted practice to
give together (go figure) so there's a huge DISincentive to develop them.
You'll never see that generic captopril+HCTZ+low-dose-atenolol. This
stupidity needs to stop-- it's an experiment to use these things in combo on
every patient who first tries them, and the experiment is done all the
time-- but we have no good formal way of collecting the side effect data!
The price to a company that wants to market a combo of previously approved
drugs should merely be heightened collection of such data, as after new
market release of a new drug. Finally, working your way through multiple
combos of cheap generic drugs to find an individual fit for hypertension
takes time and clinical money, and insurers aren't willing to pay it to
doctors in fee-for-service private systems. So expensive drugs end up as
substitutes for clinical time, in much the same way MRI money substitutes in
part for good neurological followup, and so on. The problem is that, since
these things tend to be used for a lifetime, a little more clinical time up
front can be over all cheaper.