Doubtful benefits

A major group of patients who come to us are those with non- communicable diseases being treated elsewhere who just cannot bear the cost of treatment. Of course, most of the extra expenses are a result of multivitamins and latest combination drugs which are expensive.

However, I was quite surprised to meet a well off gentleman who came to me last week. He was diagnosed to have diabetes and hyperthyroidism elsewhere. He was incurring a cost of 7000 INR every month just to purchase the medicines. Doctor consultation costs and blood tests were extra. He had met another doctor who told him that there was no need for so many medicines.

He came for a second opinion.

His original treating doctor was no small man. He was a senior cardiologist in a NABH accredited hospital in a state capital city of our country.

The best I could do was to call up one of my friends in the respective speciality.

The below snap shows the medicines he had with him. In the foreground is the medicines he absolutely needs and behind it are the medicines he could do without, which has not much evidence of significant benefit.

A close up of the medicines we stopped. The protein powder and the sucralfate syrup is included.

Now, this is a patient who can afford to spend 7000 INR. One can only imagine the plight of the poor who are given a similar prescription . . .

Well, I hope you looked at the second snap, which shows the medicines he stopped a bit close . . . In that bunch of medicines, I hope you noticed Tab. Faropenem 200 mg. The gentleman was having it twice a day since the last 10 days. I could not find any evidence of any sort of infection in the papers he had nor did he give any history of the same. 

So much for evidence based medicine and the dangers of antibiotic resistance that we talk about . . . 

Interesting . . .

Since the lastweek, The Hindustan Times has been doing a feature on the billionaire Indians. 

I found this table along with the last article on it.

To have 28 billionaires (18 in pharmaceuticals and 9 in healthcare) who made to the list by making a business out of caring for the sick and dying is a bit disconcerting to me.

I wonder if this statistics bothers anybody else . . . 

Fixed Drug Combinations

It was about couple of weeks back that the store in-charge at our place informed us that a commonly used medicine - Doxycycline was not available for purchase anywhere. Instead, a Fixed Drug Combination comprising of Doxycycline with Beta-Cyclodextrin was available at almost 3 times the price of simple Doxycycline.

It was unfortunate. Along with Septran, Doxycycline is an antibiotic we regularly use. Contrary to popular thought, they are quite effective in managing bacterial infections at least in remote locations of the country. 

Today, there was this article in the Times of India about an article in The Lancet about India's Drugs Act aiding proliferation of harmful combination drugs. And of recent, me and my colleagues were debating about use of combination drugs in diabetes. To be frank, I'm yet to see even one diabetic patient treated elsewhere who is not on a combination drug. 

I'm glad that this issue has come in print. It seems meaningless to try to educate the pharmaceutical industry and the healthcare community about the vagaries of Fixed Drug Combinations. As I mentioned in one of earlier posts, the major challenge is that most doctors get information from the pharmaceutical representatives. 

I think that the only solution is to educate the public about the issue. 

Couple of other medicines with which we've had this issue is Hydrochlorothiazide, the first line drug for Systemic Hypertension and Butylscopolamine (Buscopan), one of the best drugs for abdominal spasms and cramps. Both very cheap medicines coming under the Drug Price Control. No supplier wanted to stock them as there was no margin. 

The issue is all the more serious for us since the prohibitive costs of medicines accounts for a major proportion of costs in healthcare. One can imagine about how much costs increase with FDCs when combination of doxycycline is 3 times the cost of plain doxycycline. 

One can only hope that the government takes up this issue seriously. 

Well, before I sign off, just a gentle reminder on how rich the pharmaceutical industry has grown. I quote a recent news item - 'India has leapfrogged Russia and the UK to third place with 97 billionaires, 27 more than 2014. Manufacturing and Pharma are the preferred sectors with 23 and 14 billionaires respectively. Combined wealth of the Indian billionaires comes to $266 billion. Mumbai is headquarters to most of the Indian billionaires.'

Ethical prescriptions . . . taught by pharmaceutical companies . . .

I was prompted to write this blog after few minutes I gave to one of the pharmaceutical representatives to 'educate' me. I was amazed at the audacity of the efforts being taken by these representatives of the pharmaceutical industries, small and big, to go to any extent to promote their medicines. Well, what did this fellow had to offer me rather insisting that I store it in our pharmacy? 

The antibiotic called 'Linezolid'. I have only read about it. Has never seen it, forget about using it. I remember to have read about it being used as a last resort. Later, Dr Titus enlightened me about it being used in MRSA. It was appalling. This fellow wanted me to try it out for patients who do not respond to routine antibiotics. And, if I'm not mistaken, one is not supposed to use it without a culture and sensitivity test. 

There is no point crying over antibiotic misuse if we can allow unscrupulous pharmaceutical companies to market their products in this manner. Many of the people in the leadership level may be great men of integrity, but things are quite different in the grassroot level. 

2 incidents which I should narrate. Both told to me by acquaintances few years back who had worked earlier in the pharmaceutical industry. The first one was about this guy who used to tell me about training sessions that he used to undergo as he prepared for a career in pharmaceutical promotion. The first 90% of the time was spent on learning all the merits of the company and the technical details of the popular drugs which the company produced. The next 10% involved discussions with some of the most successful representatives of the company and the ways and means to 'trap' leading clinicians into prescribing 'our brands'. He left the profession as he did not fit in. 

The second one was about this guy whose wife was suffering was terminal cancer. He was invited to a gala dinner by his colleagues and it turned out to be celebration party for achieving year end target of the same anti-cancer drug which his wife was on. You can imagine his predicament. 

Fast forward to a meeting I had with an organisation who provides drugs to not for profit hospitals in Ranchi last week. The staff of this group was explaining to me about the difficulty in getting medicines which are under the Essential Drug List of the government. The reason - there is a drug price control on such medicines, and therefore nobody was interested in neither manufacturing, marketing or purchasing this medicine. 

And that is true. When, I took over NJH, it was surprising to find that there was no thiazide diuretics readily available. The store keeper informed me that it was too difficult to obtain from the market. Can you imagine that? The first line of management in uncomplicated and few types of complicated hypertension was difficult to obtain in the market. But, it was quite easy to get the costlier forms of antihypertensive medication. Losartan, telmisartan, ramipril etc. are quite easy to obtain. And you won't believe - it remains the same. I raised this issue with one of our major supplier. He asked me, 'Sir, why are you so interested in thiazide? It hardly brings you any margin'.

I was told that one of the best pre-operative antibiotics in clean cases is Injection Cefazolin. I have not yet found a supplier who could get it for me. I was surprised when one supplier told me that he was finding it difficult to provide 'Hyoscine butylbromide' - popularly called Buscopan. He could give me a combination medication which contains an unethical combination of dicyclomine and diazepam. 'Works the same as buscopan' according to my 'tutor'. 

I'm not sure how long we should be mere spectators to this sort of machinations of the pharmaceutical industry. I'm sure that somewhere the government needs to step in and ensure that medicines which are there  in the essential drug list are easily available in the market. However, that does not absolve the clinical care community from taking strong ethical stands regarding prescription of medicines in defiance of the arm twisting and lucrative deals from the pharmaceutical industry. . .