The Things that You're Liable to Hear from Pharma Marketers, It Ain't Necessarily So

I just finished listening to the latest issue of Primary Care Medical Abstracts from my friends Rick Bukata and Jerry Hoffman, which means that I have some more recent articles from the medical literature to comment on. This time the theme is: stuff practitioners believe to be true based on the way that Pharma marketing has flooded the medical airwaves, that may actually not be true at all.

• Chapter 1: Even if the Prozac class of antidepressants are not necessarily more effective than the older tricyclic antidepressants, at least they're a lot safer. A team from Nottingham, England looked at a database of about 60,000 patients 65 or older being treated for new-onset depression. They compared the outcomes for patients on the new-generation (SSRI) vs. older (tricyclic) drugs. They found in virtually every category a higher incidence of adverse reactions among those taking the SSRI-type drugs. The risk of dying within 1 years was 8.1% for people taking the tricyclics vs. 10.6% for the SSRI patients. This is an observational study and not a controlled trial, so you can't exclude the possibility that somehow the sicker patients were given the SSRI drugs and that explains why they had worse outcomes. Still, the huge number of patients included in the study certainly suggests that the safety of SSRIs may have been greatly exaggerated. (Coupland C, Dhiman P, Morriss R, et al. "Antidepressant Use and Risks of Adverse Outcomes in Older People: Population Based Cohort Study." BMJ 343:d4551, 2011)
• Chapter 2: Alprazolam (Xanax) has unique properties as a drug for panic disorder. While alprazolam is a member of the benzodiazepine class (minor tranquilizers like Valium), company marketing has been highly successful in associating it in physicians' minds specifically with panic disorder, so that if you have a patient with that diagnosis, or who even gets excited once in a while, and you try to treat that patient with any other benzo besides alprazolam, you're an idiot. An international team of folks did a systematic review of 8 studies that compared alprazolam to other benzodiazepines in the treatment of panic disorder. They found no evidence that Xanax is superior to any other drug in that class. They did find, however, that Xanax had a worse addiction profile and many additional adverse reactions compared to its benzo cousins. (Moylan S, Staples J, Ward SA, et al. "The Efficacy and Safety of Alprazaolam versus Other Benzodiazepines in the Treatment of Panic Disorder." Journal of Clinical Psychopharmacology 31:647-652, 2011)
• Chapter 3: If you want to prevent Type 2 diabetes, reach for a bottle of pills. There's been a huge interest, almost entirely driven by Pharma marketing, in diagnosing the condition "prediabetes" and then throwing medications at it.  This group from NIH utilized a database of over 200,000 patients who were surveyed for lifestyle factors in 1994-96 when none of them had diabetes, and then compared follow-up data in 2004-6 to see which ones ended up developing diabetes. They looked at smoking, body weight, diet, exercise, and alcohol consumption. Every single one of the healthy lifestyle factors was a significant predictor of not developing diabetes later on, with lean body mass being the single most powerful one. Basically, for every additional healthy lifestyle factor that you had, you reduced your risk of diabetes by about 1/3 compared to what it was previously. The main point here is the immensity of the effect--drug companies would kill to be able to announce a drug that reduced future risk of diabetes by 5-10%. The take home message seems to be that if it takes time and energy to counsel patients on lifestyle instead of reaching for ther prescription pad, it's well worth the effort. (Reis JP, Loria CM, Sorlie PD, et al."Lifestyle Factors and Risk for New-Onset Diabetes: A Population-Based Cohort Study." Annals of Internal Medicine 155:292-299, 2011.)