This blog is written in the light of the article (
http://www.downtoearth.org.in/content/harmful-combo-drugs-flood-market) published in the magazine 'Down to earth'.
Combination drugs have always been a major issue in the Indian subcontinent. The major reasons for the popularity of combination drugs are quite a lot. I tried jotting down many of my thoughts on this issue which has been a bane to practicing medicine in India.
The foremost reason for the high popularity of combination drugs has been the fact that most of the doctors recieve their practical pharmaceutical education from medical representatives. I very much remember our days during internship when we had no clue on why we wrote a certain brand of iron or calcium tablets or even an antibiotic. Basically, there was a major gap between pharmacology classes in the second year and the medicines which were available in the market.
As I read through the article in 'Down to earth', I remember how one medical representative tried to convince me of the great advantages of a combination drug of diclofenac and ranitidine. Another drug - 'Dexorange' is an absolute favourite with many doctors and patients. I know couple of families who are regular customers of this tonic. Even well meaning doctors write this syrup very regularly for their patients. Very few of them realise that it's the alcohol within the syrup which makes them feel good.
The most flagrant misuse of all such combinations is most in the management of diarrhoea. I recently found out that there are companies who have started coming out with lactobacillus in ORS (oral rehydration solution) preparations. When we know that the most common cause of diarrhoea is viral - it is very unfortunate to find pharmaceutical companies trying push down all sorts of combination down the patient's throat - Ciprofloxacin+Tinidazole, Metrogyl+Norfloxacin, Ofloxacin+Ornidazole... The list is inexhaustive.
Another reason for this situation is the aggressive marketting of drugs in the Indian subcontinent and the huge profits which are at stake. The image of the generic drugs which were supposed to bring down pharmaceutical costs to quite a large extent has been badly tarnished. Generic drugs were potrayed as something sub-standard. I was shocked when my previous store keeper told me about 'unethical drugs' being kept in my store. I could not believe my ears when I realised that medical representatives had taught him that generic drugs are actually unethical drugs.
Since I started my second stinct in NJH, on many occasions I've realised that sometimes it is actually difficult to get a cheaper basic variety of a drug than a costlier 2nd or 3rd choice drug for a particular condition. A typical example was the availability of Hydrochlorothiazide (HCT). I had so much difficulty convincing my suppliers that this drug was the first choice for the management of hypertension. Couple of suppliers went to the extent of making fun at me. They told me that Losartan and Amlodipine AT are the latest medicines. A strip of 10 tablets of HCT 25 mg cost 4 rupees whereas Losartan cost 50-60 rupees. One can imagine the margin you can get from the latter. And we talk about cost effective management of non-communicable diseases.
To find out more about this is to request any doctor friend of yours to rummage through the drugs they recieve as samples. You may be surprised to find that there would be very few sample medicines which are commonly used and which are cheap. Most of them would be quite expensive medicines and there would not be enough to cover a complete course - especially when it comes to antibiotics. The game is simple - you give some of them free. Then you have buy the rest. I recently heard that this was the same ploy that the English used to popularise drinking of tea in the Indian subcontinent.
The story goes that when the English established tea estates, they found out that there was quite a lot of wastage as they only used the high quality tea dust. They somehow realised that that the low quality tea dust which was thrown out was also tasty. So, they organised free tea stalls for the local population. And as soon as drinking of tea became quite a popular past-time among the locals, the low quality tea dust was available at the cost - thereby ensuring that there was a revenue. (No idea on how true the story is. I heard it on a recent visit to Bangladesh)
Drug resistance especially with antibiotics is a major issue. Nowadays, it is very uncommon to see anyone prescribing antibiotics like septran or amoxycillin. Augmentin, Levofloxacin etc rules the roost and that too for a one day fever. A very simple medicine for urinary tract infection is Furulic Acid or Nitrofurantoin. Very few medical practitioners knows that this is the best antibiotic for community acquired urinary tract infection. In addition, there are only few companies who produce the tablet form which comes very cheap. And it is not very easy to get.
Whatever said and written, the bottomline is that the pharmaceutical industry has made a mockery of medical science in the country. I hope that the latest initiative from the planning commission will bring in some amount of control in the manufacture and sale of drugs whereby ethical preparations are available at a cost which the poorest of the poor can afford.