Envisioning 2.0

This article is part two of an ongoing series inspired by the Seattle Times special, “Suddenly Sick.” The Times’ series examines how the pharmaceutical industry promotes medications for a range of conditions, including hypertension and obesity. Click here to read other installments of “Disease Mongering Or Saving Lives?”

One of the main pieces of evidence people point to when they say that drug companies are engaging in disease mongering is that they support or influence the development of treatment guidelines. Their argument is that the pharmaceutical industry is helping to develop guidelines that advocate for the use of medications in broad swaths of the population.

This was the contention of Duff Wilson who wrote the article, “New Blood Pressure Guidelines Pay Off – For Drug Companies” that appeared last year in the Seattle Times. Duff notes:

“In recent years, expert panels from prestigious medical research organizations such as the World Health Organization (WHO) and the federal National Institutes of Health (NIH) have called for lower thresholds for blood pressure. Behind each of those panels were the giant pharmaceutical companies that manufacture the new and expensive hypertension drugs.”

While the federal high blood pressure guidelines stop short of recommending that people with lower blood pressure levels receive medication, critics of the new guidelines have expressed concern that they will lead to the expanded use of expensive therapies. Industry opponents seemed to have their fears confirmed when it was reported that the American Society of Hypertension (ASH) had developed a new definition for high blood pressure and asked physicians to treat “high risk” patients with medication if they had cardiovascular disease – even if they only had “pre-hypertension.” In an article that appeared earlier this year, the New York Times implied that drug firms had overly influenced ASH’s efforts.

The Dirty Little Secret About High Blood Pressure Management

If asked about their motivations for recommending drug treatment for high-risk patients with high blood pressure, some experts would say that it is important to focus on the science rather than on sponsorship or the panel’s ties to industry. They might go on to argue:

1. Newer medications have been proven in clinical trials to help reduce the risk of cardiovascular disease and kidney failure due to high blood pressure

2. We are not doing a very good job of treating high blood pressure, so we need to manage it more aggressively and medications are a big help

3. Every patient is different and there is no one size fits all treatment for high blood pressure

4. Most importantly, there is a dirty little secret about high blood pressure management: lifestyle modifications don’t work for most patients, so they will ultimately require a medication

An article published in today’s New York Times provides a great example of why this is the case. It focuses on the debate about whether people with pre-diabetes should be treated with medication or asked to exercise to stave off diabetes. In the article, Gina Kolotta said:

“Should diabetes specialists even bother to advise patients to try helping themselves through diet and exercise first, before prescribing drugs? . . . A large federal study, completed several years ago, seemed to make a compelling case that they should . . . But the [study’s] diet and exercise program was nothing like what an ordinary person might expect. The participants got extensive individual counseling and group support, at a cost of $1,356 a person the first year and $672 in each subsequent year. Even so, they shed only about 12 pounds after four years, or 4 percent of their initial weight. . . If a large health plan decided to offer the same program for its members at risk for diabetes, the plan’s price for every member would rise by 1 percent . . .”

The same could be said for managing high blood pressure with lifestyle modifications or exercise. A major clinical trial that demonstrated the benefits of diet on blood pressure reduction, the DASH study, has been criticized by some high blood pressure experts as a “feeding study.” In addition, patients in the study required extensive counseling and support so that they would remain on the diet.

The Conundrum: Drug Companies Profit, But People May Live Longer

The experts developing guidelines are all too aware of the dirty little secret about high blood pressure management. They know that most people will need drug therapy, but fear not recommending diet and exercise before prescribing a drug. In some respects ASH’s efforts could be viewed as an acknowledgment of reality rather than a sign that the organization is beholden to the drug industry.

On the other hand, experts also have to contend with the fact that their recommendations are going to help some drug companies make lots of money. What should they do? Do they avoid recommending mediations they believe are effective in order to prevent profiteering? Or, should they do what they think is necessary to save lives? That’s the dilemma that faced by people charged with developing recommendations on how to manage high blood pressure and other illnesses.

There are no easy answers to this questions. Unfortunately, drug firms, physicians and medical societies have been less than willing to talk extensively about the issues

This entry was posted on October 17, 2006 at 2:47 pm and is filed under Disease Mongering Or Saving Lives?. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.