Doctors should question the value of most heavily promoted drugs

Top promoted drugs are less likely than top selling and top prescribed drugs to be effective, safe, affordable, novel, and represent a genuine advance in treating a disease, argue US researchers in The BMJ today.

Tyler Greenway and Joseph S Ross, based at Yale University, say clinicians "should question the value of drugs being most heavily promoted by pharmaceutical manufacturers before prescribing them."

US physicians receive billions of dollars each year from drug companies as part of drug promotion. Yet studies have shown that greater contact with drug sales representatives is associated with an increased likelihood of prescribing brand name medications when cheaper alternatives exist.

And more recent studies have shown that payments from drug companies are associated with a greater likelihood of prescribing promoted drugs.

However, since August 2013, legislation has required the industry to publicly disclose all payments to physicians of $10 (£8; €9) or more or $100 in aggregate. This led to the Open Payments Database, which archives all industry payments to individual physicians and teaching hospitals.

Greenway and Ross therefore decided to assess the health "value" of drugs being most aggressively promoted to physicians to better understand implications of pharmaceutical promotion for patient care.

They identified the 25 drugs associated with the largest total payments to physicians and teaching hospitals from August 2013 to December 2014, including all direct and indirect payments, such as speaker fees for education lectures, consulting fees, and honorariums, as well as payments in kind, such as the value of food and gifts.

However, they excluded research payments, royalties, and licensing fees, which are typically not promotional.

Next, they estimated drugs' value to society using five proxy measures: innovation; effectiveness and safety; generic availability (a measure of affordability); clinical value (inclusion on the WHO list of essential medicines); and 'first line' status (recommended as a first line therapy).

They also determined the top 25 drugs by 2014 US sales and the top 25 most prescribed drugs in the US during 2013.

Not all the differences were significant. But one that was showed that top selling and top prescribed drugs, not top promoted drugs, are more likely to represent the ideal drug that is effective, safe, affordable, novel, and represents a genuine advance in treating a disease.

For example, only one of the top promoted drugs was on the WHO essential medicines list, compared with nine top selling drugs and 14 top prescribed drugs.

Fewer top promoted drugs were considered 'first line' treatments than top prescribed drugs, while generic equivalents were available for 15 (63%) top promoted drugs, eight (32%) top selling drugs, and all top prescribed drugs.

These findings raise concerns about the purpose of pharmaceutical promotion and its influence on patient care, say the authors.

They say efforts are needed to better evaluate the value of drugs, ensuring that this information is readily available at the point of care so that it can inform clinical decision making, promoting use of higher value medicines.

And they suggest that clinicians should consider taking steps to limit their exposure to industry promotion and consider engaging with non-commercial educational outreach programmes that provide evidence based recommendations about medication choices.