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Healthy Skepticism AdWatch

AdWatch illuminates the logical, psychological and pharmacological techniques used in drug advertisements.


June 2004, Australia

Micardis Plus (telmisartan plus hydrochlorothiazide) from Boehringer Ingelheim

"The early morning danger zone": Micardis Plus (telmisartan plus hydrochlorothiazide) from Boehringer Ingelheim


Please note this AdWatch issue is no longer active so you can not submit answers to the questions below.

Australia June 2004

“The early morning danger zone”:
Micardis Plus (telmisartan plus hydrochlorothiazide) from Boehringer Ingelheim

Please note:  This issue of AdWatch focuses on an advertisement that has been replaced since April with a similar advertisement.

Source: Medicine Today, November 2003

What message is the advertisement sending?

The Micardis Plus advertisement is open to a range of interpretations. [more about interpretation of the advertisement]

A)  Is this the most optimistic reasonable interpretation?

Micardis Plus is more effective at preventing cardiovascular events in the “early morning” than all other antihypertensive drugs.*

* “all other antihypertensive drugs” because busy doctors may not read the footnote disclaimer.

B) Is this the least optimistic reasonable interpretation?

Micardis Plus is more effective at suppressing the increase in blood pressure in the “early morning” that its components so it may be more effective at preventing cardiovascular events.

What does the term “early morning” mean to you?

From:    To: 

What is the message that you get from the advertisement (regardless of whether you believe it or not)?

The message I get is:


How believable is the message that you get from the advertisement?

The message I take from the advertisement is:

Is the message justified by the evidence cited in the advertisement?

Blood pressure is lowest from 01:00 to 04:00 then increases slowly.  After 07:00 blood pressure increases more rapidly to peak at 09:00. [1]

The peak incidence of cardiovascular events is between 08:00 and 11:00.[2] [3]

Telmisartan alone reduces the absolute blood pressure but does not decrease and may slightly enlarge the relative increase in blood pressure in the morning.[4]

The advertisement does not cite any evidence regarding whether or not Micardis Plus:

reduces heart attacks and stoke rates

is superior in anyway over interventions other than its components alone.

[more about the evidence]

Is the message you get from the advertisement justified?

The message I get from the advertisement is:

What messages would you like to send?

Comments addressed to Boehringer Ingelheim:

Comments addressed to AdWatch:

AdWatch’s current recommendation for Australia

Therapy for uncomplicated hypertension.

First line: Lifestyle changes (including better diet[5] and physical activity) have benefits beyond reducing hypertension.

Second line:  chlorthalidone 25mg ½ daily.[6]  [our reasons]

Diabetics may benefit from additional therapy.  It not clear if any other group gains total mortality and/or quality of life benefits from additional drugs.  For the following drug classes we do not know which drug is the best in it’s class.

Third line:  Beta-blocker

Fourth line:  ACE inhibitor

Fifth line:  Long acting Calcium Channel blocker

Sixth line: A2 blocker.  A2 blockers are rarely useful except when an ACE inhibitor would be appropriate but is not tolerated because of the ACE cough.[7]


cost per year

chlorthalidone 25mg ½ daily


propranolol 40mg 1 twice a day


ramipril 5mg 1 daily


ramipril 10mg 1 daily


amlodipine 5mg 1 daily


amlodipine 10mg 1 daily


Micardis 40mg


Micardis 80mg


Micardis Plus 40mg + 12.5 mg


Micardis Plus 80mg + 12.5 mg


Comments about AdWatch’s current recommendation for Australia:

Before reading this AdWatch issue
I Micardis Plus

I now plan to Micardis Plus .

I am a

I live in

I give permission for my feedback above to be analysed for AdWatch Feedback (eg Feedback about AdWatch on Nexium), research publications and for dialogue with Boehringer Ingelheim and regulatory agencies. (If you don’t give permission then your feedback will be read but can not be used.)

Providing your email and name is optional but very helpful

We will not use your email or name unless you give specific permission below. We won’t pass your email or name to anyone else and will remove them from our records at any time on request to: .(JavaScript must be enabled to view this email address)

Please give us your email address so that if we are unsure about your feedback we can clarify it with you.


Please add my email address to the list to be notified about new AdWatch issues once a month.

Please check that your email address is correct and notify .(JavaScript must be enabled to view this email address) if your email address changes or if you don’t hear from us within two months.

If you would like to be notified of other updates to the Healthy Skepticism website then please become a Free or Paid Healthy Skepticism Subscriber.

I want my name sent with my feedback to the company and regulatory agencies. (We will not use your name for any other purpose except contacting you about AdWatch.)

My name is: 

Two extra questions just for general practitioners:

Would you be willing to participate in a pilot trial of the impact of AdWatch on prescribing?

If so, do you do at least 50% of your prescriptions on a computer that would enable you to tell us how many scripts you wrote for 1 month before and 1 month after reading AdWatch?

Feedback will be be used as a basis for dialogue with BI and regulatory agencies including the Medicines Australia Code system. We will also take feedback seriously for improving future editions of AdWatch because we believe that a complaint is a gift for quality improvement.  We need criticism to help us improve and praise to help us not change too much in response to criticism. 

AdWatch is produced by Healthy Skepticism:

Appendix: Response from Boehringer Ingelheim

25 May 2004

Dear Dr Mansfield,

MicardisPlus® Advertisement

Thank you for your recent e-mail regarding the advertisement in 2003 for

Boehringer Ingelheim believes that the MicardisPlus advertisement cited
conveys, in an arresting and interesting manner the importance of good 24
hour BP control for hypertensive patients, and the principle aim of the
message is to reinforce that MicardisPlus offers this.

Imagery such as the ‘the man in bed on the rail tracks’ conveys the notion of
sometime in the early morning, which is at the end of the 24 hour dosing
period for most people and when some once daily BP medication may no
longer be providing as effective control. This was demonstrated in the
clinical trial referenced when looking specifically at the last hours of the
dosing period.

During the morning period an increased incidence of cardiovascular
morbidity and mortality is now well recognised from the literature as you
point out.

The antihypertensive effect of MicardisPlus is greater than that of the
individual components, Micardis or hydrochlorthiazide. This additional
antihypertensive effect may be needed for patients uncontrolled on either of
the individual components.

MicardisPlus was newly introduced into the Australian market in 2003 and
the reader is alerted to this. The use of the word ‘new’ during the first year
of marketing is compliant with the Medicines Australia Code of Conduct of
the use of this word in advertising. The word ‘new’ is no longer being used
in the 2004 advertising for MicardisPlus.

At Boehringer Ingelheim we take great care in the formulation of our
advertising for all of our products, including MicardisPlus, and this
advertising campaign is in accordance with a global corporate program. All
our promotional activity is reviewed very carefully for accuracy and for
compliance with the Medicines Australia Code of Conduct. As such we are
satisfied with the MicardisPlus advertisement and believe your criticism is

Yours sincerely,
Boehringer Ingelheim Pty Ltd

Dr Rob Creek
Medical Director


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AdWatch (Australia)


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