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Boehriner Ingelheim Atrovent (ipratropium bromide)

May 1999

Vol 17 Issue 5/6 Boehringer Ingelheim promotes Atrovent (ipratropium bromide) in Russia as first line for chronic bronchitis.

Boehringer Ingelheim promotes Atrovent (ipratropium bromide) in Russia as first line for chronic bronchitis.

MaLAM Home Page

A request from Russia

On 9 December 1998 we received the following e-mail from Russia:

Dear Peter,
In Russia long time Boehringer Ingelheim advertise Atrovent (ipratropium bromide) using the chess board image and question: ‘Chronic bronchitis:
your first step? e2-e4 Atrovent’.
I think that it is not correct advertisement, Atrovent is not the agent of first choice for the initial treatment of all types of chronic bronchitis.
Is it good target for MALAM action?

Vasiliy Vlassov Dr. Med. Sci., Professor
Saratov State Medical University

A copy of the advertisement for Atrovent in Russia appears below.

Pharmaceutical marketing in Russia

In 1997 the Russian pharmaceutical market was one of the fastest growing markets in the world and reached US$ 3.5 billion.  That was 25% more than the previous year.[1]  This rapid growth rate may reflect increased use of promotion to doctors who are not accustomed to it.

In August 1998 the Russian economy crashed.  Responses from drug companies have varied.  For example:

“Eli Lilly have continued to distribute life saving pharmaceuticals, such as insulin, despite non-payments from distributors.”


“Smith Kline Beecham increased it budget for advertising and promotion of its products, increased prices, and declared no intention to withdraw from Russia.” [1]

Boehringer Ingelheim

According to Boehringer Ingelheim’s web site the company ranks among the top 20 pharmaceutical companies in the world. It reported revenues exceeding DM 8.75 billion in 1998.

Boehringer Ingelheim’s “Vision statement on Value” is interesting regardless of whether or not the company’s staff take it seriously:

“Value will be our competitive advantage, our customers demand more for less.

Our customers are objective, professional and analytical. They have a balanced view of purchasing. The value of our customers’ demands is changing and will continue to change. We need to anticipate the value our customers will place on our products and services now and in the future. We will only be able to exceed our customers’ expectations by being closer to them. We have to share their values, aspirations and problems. We need to understand how they use our products, how we can make our products more efficient and effective, and how our products answer the needs of our customers. The closer we all are to our customers, the easier it will be. We have to remove the barriers between them and us and between ourselves. We have to be one group with a shared objective.”


June 1999

Dr Heribert Johann

Chairman of the Board

Boehringer Ingelheim GmbH
Binger Strasse 173
D-55216 Ingelheim am Rhein

re: the promotion of Atrovent (ipratropium bromide)

Dear Dr Johann,

Professor Vasily Vlassov of the Saratov State Medical University, Russia, has asked MaLAM [1] to write to you about an advertisement for Atrovent (ipratropium bromide) published in his country.  The advertisement uses the image of a chess game and some small but very active dancers and asserts:

“Chronic bronchitis:
  your first step? 

We understand from Professor Vlassov that Russian doctors are likely to take away from that advertisement the message that Atrovent alone is always the best choice for the initial treatment of all types of chronic bronchitis.  We are also concerned that the image of tiny dancers in the advertisement may lead to an association (perhaps subconsciously) between Atrovent and dramatic improvement so that patients gain the capacity for vigorous physical activity.  The advertisement fails to provide any safety information.  Consequently the advertisement could lead doctors to believe that Atrovent may be used by all types of patients without any safety concerns.

Question 1:  Are those the messages that your company intends to send?
Question 2:  What is your best evidence to support those messages that are intended?
Question 3:  What steps will be taken to ensure that unintended messages are not sent in the future?

Comparison of those messages with initial conclusions based on the expert opinion available to MaLAM, summarised below, raises some questions.  This letter is intended to give you the opportunity to express your point of view so that we can assess whether or not your promotion of Atrovent assists appropriate therapy.  We hope that you will either provide evidence to support your advertisement or reconsider the way you promote Atrovent.  We are optimistic that dialogue can lead to improvements in drug promotion to the benefit of the public, health professionals and your company in accord with your company’s “Vision statement on Value”.[2]

Initial conclusions from expert opinion.

The first step in therapy for chronic bronchitis is avoidance of causative factors such as smoke dust and fumes. Assistance with overcoming nicotine addiction is the only intervention that has been shown to slow progression of chronic bronchitis.[3]

“Used alone [Atrovent] is not a powerful bronchodilator.  However its effects are additive to those of commonly used doses of b2-adrenoceptor agonists, so it is usually used in conjunction with b2-adrenoceptor agonist therapy.”[4]

Atrovent may provide a modest benefit for patients who have continuous symptoms.  However, for patients with intermittent symptoms the 1998 guidelines from the Canadian Respiratory Review Panel recommend using a beta-2 agonist without Atrovent.[5]  If there is increased cough and dyspnoea together with increased sputum volume and/or purulence then antibacterials (eg amoxycillin or doxycycline) may be beneficial.[6]  For very severe exacerbations intravenous corticosteriods are recommended.[4]

While Atrovent may be better than placebo, it rarely restores respiratory function to normal values.  Furthermore there are many patients for whom Atrovent provides no clinically important benefit.[7]

Atrovent is generally considered to be a safe drug but experience with pregnant and lactating women is limited.  On rare occasions Atrovent may cause urinary retention and acute angle closure glaucoma [3] and therefore should be used with caution in patients with or at risk of either of those two conditions.

Additional questions

Question 4:  Does your company believe that advertisements for drugs should include safety warnings?
Question 5:  What methods does your company have for monitoring the quality of promotion by subsidiaries?


Yours sincerely,

Dr Joel Lexchin MD, CCFP (EM), DABEM

Secretary, MaLAM Inc

MaLAM Home Page

June 1999

Dr Heribert Johann

Chairman of the Board

Boehringer Ingelheim GmbH
Binger Strasse 173
D-55216 Ingelheim am Rhein

re: the promotion of Atrovent (ipratropium bromide)

Dear Dr Johann,

I have read the MaLAM International edition about the promotion of Atrovent by your company in Russia.

(Please tick where appropriate)

I am a:        doctor                        




and would appreciate receiving a personal copy of your reply.         

Yours sincerely,


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