How do you handle stepping on someone else's toes?
Two recent posts of mine have dealt with bad information, and both times I've wondered what the accepted protocol is for addressing it. Obviously "Hey dumbass, go read some medical literature," doesn't cut it. I addressed one instance — the cholesterol one — quietly, after it happened. It wasn't life-threatening misinformation, so immediate intervention didn't seem necessary.
I didn't bother to say anything about the antibiotic shenanigans.
The trouble with this is addressing something someone does without stepping on their toes. If I do something stupid, I'd like someone to smack me upside the head and tell me I'm wrong. Pussyfooting around the issue is for people with no self-confidence. I don't have that problem — after all, I write on the Intarweb, and think people actually care about what I have to say, don't I? 
— so just come right out and tell me I'm wrong.*
Not everyone is that resilient, however, and I'm sensitive to this.
Recently I've heard a pharmacist say she was going to take lots of Vitamin C and echinacea to get over a cold. I've seen pharmacists recommend Airborne for cold on more than one occasion. I've heard a pharmacist recommend a homeopathic remedy for migraine. I said nothing — these suggestions aren't harmful, but they certainly aren't helpful, either. In these cases, it's just not worth the effort. Besides, Father Time and the body's own defenses will clear these problems up on their own. (And in the case of the migraine, I suspect it was psychosomatic anyway.)
When someone says something boneheaded to a patient, how do you handle it? Especially if it's a pharmacist colleague? I would imagine doctors and nurses run into this problem from time to time as well, even if they practice alone now.
* I'm happy to say that this hasn't happened in a very long time, which can be viewed as either a good thing (I'm SMRT!) or a bad thing (I work with a bunch of idiots). Which one I lean towards is dependent on where and who I am working with, naturally.
And thus it begins: Xyzal
The money being wasted on pointless research, that is. Xyzal (levocetirizine), is beginning to have some money spent on research proving that it's a good drug. I have no doubt it's a good drug. They've isolated the active isomer and decided to market it since the patent on Zyrtec (cetirizine) is running out.
Let's review, SAT-style:
Zyrtec:Xyzal::Claritin:Clarinex
Expect Zyrtec to go OTC as a means of ensuring continued profitability through marketing. (More people buy brand name Tylenol than the generic — same story for Claritin.)
Here's the bottom line: everything that Zyrtec works for, Xyzal will work for, and vice versa. Same side effects, too. And because this is so, you will never see a head-to-head study comparing Xyzal with Zyrtec, because the results will prove that it's just a waste of money. Like Clarinex. Oh sure, there will be a few isolated cases where Xyzal is 0.5% better for 0.1% of the study population, and these studies will be trumpeted, but remember that they're actually meaningless. You'll also see studies that show Xyzal is effective for some obscure condition that Zyrtec was never studied for. Just remember that this is done to make Xyzal seem like something more than a me-too drug, and that if someone bothered to spend the money, Zyrtec would work just as well.
So if you like to waste your time doing PAs or you feel an insane need to throw your patients' money away, prescribe Xyzal. Otherwise keep on using Zyrtec.
What the GSK man asked, and what he fears
These were drop-shipped yesterday afternoon:
A couple of weeks ago, I was detailed by GSK. Unlike The Angry Pharmacist, I don't hate drug reps. The GSK guy isn't a busty blonde who brings us cannolies and only visits at lunchtime. He's actually a genuine human being, and he's probably old enough to be my dad.
But on his last visit, he did something that rubbed me the wrong way: he asked me to fill out these cute little forms and send them to the doctors to get them to switch to the controlled released versions of carvedilol:
Yeah okay, buddy. How about no? I like you well enough, but geeeeze. Your form is pretty, but a reversal of it would be more useful: seniors sure do like those generics that're covered even during the donut hole…
Needless to say, I threw the stack of forms in the trash without showing anyone else. As the person who makes the most therapy recommendations, no one but me would have a use for them anyway. Even if they weren't complete bullshit.
–
On a related note, I'm waiting for the day drug companies get a clue and make writing the original, IR version of a drug more troublesome to prescribe than the inevitable extended-release forms. Call it "Coreg IR" the first time around, and then call your extended-release, patent-protected, evergreened, overpriced bullshit version plain old "Coreg." As though it were Coreg As It Was Meant To Be — like that marketing crap Sanofi-Aventis tried with Ambien. (Zomg, we should never have made Ambien because Ambien CR is soooooo much better. Ugh.)
That'll work better than your fancy brochures, ridiculous therapy change forms, and formulary negotiations combined.
[tags]GSK, Coreg, carvedilol, marketing[/tags]
How are your potassium levels?
Do zey need adjusting?
Heh heh…
Claritin + Singulair = ???
Merck and Schering-Plough are in bed together, again. (One wonders if a merger will be the climax of their collaborations somewhere down the line?) This time it's their new combination of loratadine (Claritin) and montelukast (Singulair) which was accepted for review by the FDA on August 28. In my opinion, it's only a matter of time before the two companies are given the green light to start selling it.
This combo is not unlike their Vytorin arrangement, which is actually a pretty decent combination both therapeutically and financially: Vytorin is no more expensive than Zetia by itself, which makes it a good deal for consumers and insurers alike. (And there's also the more mundane fact that there's one less pill to take, and the fact that ezetimibe is of questionable value when prescribed alone.)
Because Claritin is now OTC, it is simultaneously more and less valuable to Schering-Plough. Less valuable because you can't charge as much for it as you could when it was Rx-only because no one would buy it — and more valuable because you've got a potential market limited only by the number of people in the United States. I know I recommend (generic) Claritin pretty regularly. It works well for most people, myself included.
If the pricing is done following in the footsteps of Vytorin — which I suspect it will be — it'll be a nice little niche drug for the two companies, and it'll save consumers money, if not insurers. I don't ever see it being a blockbuster like Vytorin, for obvious reasons.
The inobvious
One thing struck me about this deal after some thought, and it's the new reciprocity between the two companies: Vytorin is inherently more valuable to Schering-Plough because their drug ezetimibe (Zetia) is still protected by patent, whereas Merck's contribution — simvastatin — is not. With this new drug, the roles will be reversed. I don't know what this means in terms of dollars and cents, but Merck's got to be breathing a bit easier now that they're on more equal footing with their partner.
[tags]Merck, Schering-Plough, Claritin, Singulair[/tags]
I'm still not impressed with Tekturna (aliskiren)
One of my more popular posts has been "Do we need Tekturna (aliskiren)?". The comments have been varied, but I still stand by my doubts over its usefulness. Other medbloggers have expressed their doubts as well. And I should state right now that I think Tekturna being on the market is a Good Thing™. I am not against the drug's existence.
In fact, I'm not arguing how efficacious it is. I'm sure it works. If it didn't, it wouldn't be approved. I'm merely questioning its place in current treatment paradigms. To explain what I mean, I'm going to use a crude analogy to compare angiotensin II receptor blockers (ARBs) and aliskiren, the only direct renin inhibitor (DRI).
Think of a sink. For whatever reason, you want to keep liquid from going down the drain. Does it make more sense to keep the sink turned off, or to plug the drain directly?
Well obviously if the goal is keeping the drain dry, you'd plug the drain. This is what ARBs do. They prevent specific and non-specific binding at the angiotensin II receptor sites. Tekturna just keeps the sink from turning on and does nothing to block the drain directly. This means there's still going to be non-specific binding at the angiotensin II receptor site. (Incidentally, this non-specific binding is not merely theoretical; if it were, ACEis would be more effective as a class than the ARBs, but instead they are merely comparable.)
Back to my point: Tekturna is more expensive than the ARBs, and it will be for a long time. I don't think having aliskiren as an option is a bad thing. I just question how valuable the drug truly is with less expensive ACE inhibitors and ARBs. Sitting here, it doesn't seem to have a real niche. Would I try Tekturna if nothing else worked? Of course I would. If I were targeting the RAAS, would I reach for it as first-line therapy? Hell no I wouldn't. I'd go for an ACE inhibitor in most cases.
I'm not going to delve into the heated debates about reactive renin production and other similar topics because I suspect that the reality lies somewhere in the middle ground, as it usually does.
In the meantime, I think don't think Tekturna has a meaningful place in current drug therapy. If ARBs do not work, it is unlikely that a DRI will, either. The only time I see it perhaps being useful is if a patient cannot tolerate ACEis or ARBs.
[tags]Medicine, pharmacy, Tekturna, aliskiren, hypertension[/tags]
What does $5,256.08 look like?
It looks a little something like this:
