Of course, this essay appears at the website of a health insurance company, which has a vested interest in consumers not being prescribed the latest (and most expensive) new medications. But I largely agree, and I both regularly educate my patients and have written here at FmH in the past about the opposite trend, prescribers whose only source of information about the medications they prescribe is the manufacturers who profit from their use, and the questions you should ask your prescriber when s/he proposes a change to a newer medication because it is supposedly “better.”

I sit on the pharmacy and therapeutics committee of my hospital, where decisions about what medications the hospital will have in its formulary are made. This week, we discussed in exasperation the growing pressure from patients and families who demand to be treated with a new asthma medication they have seen advertised on television, which is 7-10 times more expensive than the standard of care, and according to the scientific literature is no more effective and no more tolerable. It is not only credulous doctors you have to worry about, but consumer-driven prescribing pressures.

People should be aware of one particular pharmaceutical industry scam which is increasingly widespread and insidious. Many medicinal copmounds have molecules with chirality, i.e. they are asymmetrical and thus exist in several different isomers which differ only in which way the bonds within the molecules twist. Often, the different isomers differ in biological activity. Thus, for example, 20 mg. of an antidepressant might contain around 10 mg of the leftward-twisting (levo- or L-, also referred to as S-) version of the molecule and around 10 mg of the dextro- or D-isomer. One of them is biologically active and the other is essentially an inert ingredient. So a company figures out how to efficiently separate the two isomers and patentsa a new medication consisting of one of the stereospecific forms. It is easy to see that 10 mg of the new medication is for all intents and purposes equivalent to 20 mg of the old one (and will probably be a pill of about the same size, by the way!), yet it will be marketed as new and improved, as more effective or more side-effect-free. It obviously sounds like a more powerful drug to a lay person, because 10 mg does what it took 20 mg of the old drug to do. And it costs some multiple of the cost of the old drug, as well as being protected by patent rights for many more years while the older drug enters the public domain where generic versions can be offered. One example of this is the antidepressant Lexapro, which is escitalopram (“S-citalopram”), the S-isomer of citalopram, which is the older antidepressant Celexa. Lexapro has been around for a few years now and is shaping up to have no advantages over Celexa, except in profit margin to the manufacturer.

It seems to me that the trend of capturing and maintaining market share with stereoisomeric forms of older medications is all the rage in Big Pharma these days; in fact, that is the case with the asthma medication we discussed in P&T this week. And I am sure we should believe the manufacturers’ claims in some instances that the ‘inert’ ingredient in the mixed version was not inert at all, but contributed to side effects or changes in the metabolism of the drug in comparison to the stereospecific form. But the literature, when you can get an unbiased study not paid for by the interested industry party, often says otherwise.

So…not so fast.

PS: the P&T committee voted to add the new asthma medication because the pulmonologists swear they would not be able to handle the P.R. fallout from not meeting patient requests for it, and don’t have the time or the inclination to better educate the public about its lack of advantages over the older medication it is meant to supplant. Supposedly, patients will have to jump through hoops, such as nonresponse to other measures and prior approval by a ‘gatekeeper’ specialist, to get the new drug. We’ll see how firm and how long the gates stand…