| Obtain feed-back from prescribers about pharmaceutical advertising. | |
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We received a range of comments about pharmaceutical advertising in general. As in the last three examples above one of the main issues discussed was whether or not doctors are influenced by promotion.
"I agree doctors are very swayed by Drug Com. reporting. I am particularly concerned about our use of antibiotics for obvious viral infections… [Re Augmentin:] As with all of these ads. I think they are fairly insulting to GPs. What other professionals have such childish images put forward to them." (HS V2N2 satisfaction score 7)
"I do not look at advertisements at all." (HS V2N2 satisfaction score 4)
"Not read. GP’s are not stupid as you infer." (HS V2N2 satisfaction score 1)
"… who reads the ads anyway?… a waste of time. Drs in general very sceptical about colour ads! Sometimes too sceptical (as I may seem in these answers.)" (HS V2N2 satisfaction score 1)
"Obvious. – doctors are not idiots." (HS V2N2 satisfaction score 2)
"You may not have noticed if you check your New Ethicals Compendium that the drug information it contains mostly use the Trade name when referring to positive effects & the generic name when referring to side effects- scepticism is important – very clever marketing."
"Good to have all the issues exposed. Drug companies need to be more accountable in their drug advertisements & in the information presented when reps call. Not all that info is accurate."
We asked readers to comment on the advertisement regardless of their assessment of the antibacterial and some of the feedback was specifically about the appropriateness of the advertising.
SKB’s advertisement for Augmentin
(amoxycillin/clavulanate) is:
1=Inapropriate
7=Appropriate
U=Unspecified
Augmentin:
"It is pushed as the "for any infection" drug."
"As with all of these ads. I think they are fairly insulting to GPs. What other professionals have such childish images put forward to them."
"I see many GP’s using Augmentin as a 1st line drug in older children for viral infections. This ad encourages use (without thought) for just about anything."
Lilly’s advertisement for Ceclor
(cefaclor) is:
1=Inapropriate
7=Appropriate
U=Unspecified
Ceclor:
"Very naughty advertising – does it contravene the consumer protection act?"
"I try and never Tx bronchitis in children but that isn’t a common occurance. They encourage misuse of a drug with this ad."
"I find Ceclor has a number of side-effects (it is not gentle on patients) and I rarely use it for the reasons listed in your article."
BMS’s advertisement for Diclocil
(dicloxacillin) is:
1=Inapropriate
7=Appropriate
U=Unspecified
Diclocil:
Comment from a paediatrics trainee: "I don’t know much about Tx wound infection or Diclocil. This ad would have made me think about using this. Healthy Scepticism is good for educating me."
Astra’s advertisement for
Helicosec (omeprazole, amoxycillin, metronidazole) is:
1=Inapropriate
7=Appropriate
U=Unspecified
MSD’s advertisement for Noroxin
(norfloxacillin) is:
1=Inapropriate
7=Appropriate
U=Unspecified
Noroxin:
"This one really pisses me off. The idea that I’m a cruel doctor if I risk severe pain for my patient if I don’t prescribe norfloxacin I find deeply offensive."
"Very effective ad. Didn’t know trimethoprim was 1st line."
"I was aware of the overdramatic presentation. I wondered if it implied she had pyelonephritis! This in itself is misleading."
"I agree – I can’t remember any patient "doubled up" like this with cystitis."
"I totally agree – not first line therapy & over the top emotional content."
However the qualitative feedback suggests that when answering the questions above most GPs were more focused on assessing whether or not they should use the drug rather than assessing the advertising. This is understandable given that the former is their primary role. For example many readers scores varied in association with statements defending or attacking the use of the antimicrobial. These statements should be addressed. Some readers requested more information to assist their decision making.
General feedback:
"Problems remain in deciding clinically when to diagnose bacterial vs viral infection. Very common problem, needs more/better research."
Augmentin:
"NZ cannot afford (both financially + microbiologically) to overuse Augmentin. Should you have included use of Augmentin for gingivitis or is penicillin/metronidazole still recommended?"
"I have overused this antibiotic in the past and am trying to decrease use. It is very good for skin infections."
"We still have a major problem with GPs using Augmentin as 1st chioce when they shouldn’t."
Diclocil:
"In a situation where one would use flucloxacillin, dicloxacillin is perhaps a safer alternative."
Ceclor:
"Ad supports a very common misconception. In practice it would be very difficult to distingiush viral/bacterial clinically. How strong is support for no Ads in acute bronchitis?" Attached note: "I think MaLAM is great. Would be nice if PreMeC or Pharmac could produce PreMeC type prescriber info eg ‘choice of antibiotic / no antibiotic in common conditions’ or ‘strategies for reducing antibiotic resistance’ as back up for the MaLAM topics. Best wishes with it."
"Expensive drug (despite the advert.) compared to more appropriate Atb’s which have a better track record."
"It’s ok. Ceclor is well tolerated in children especially."
Helicosec:
"Your comment does not take into consideration the patient part charge for clarithromycin." (This statement is entirely correct. The primary author of Healthy Scepticism didn’t know about it!)
"Clarithromycin regimes impractical due to cost."
Clarithromycin packs should be available. Alternatively clarithromycin could be made available for the specific indication of H.P. erradication."
"Given that clarithromycin is too costly this does look the best option – AS STATED IN RECENT PREMEC BULLETIN!! Please reply this to me." (original emphasis.) ( The primary author of Healthy Scepticism has not yet seen that bulletin. In future MaLAM Adelaide must have access to such relevant NZ publications prior to drafting HS NZ editions.)
Noroxin:
"Never a first choice in UTI."
"As a locum I am shocked at the way Noroxin is now prescribed it seems very commonly for simple UTIs."
"Each of this type of info received causes one to pause & reflect – the danger of n of 1 episodes say of failed "simple" Rx for UTI influencing further prescribing."
A reader who rated HS V2N2 7, rated
intention to change prescribing 6 and rated all the advertisements 1 or 2 except Noroxin
rated 4 wrote:
"Clinical experience suggests a lower than acceptable hit rate with trimethoprim
and this may be the reason norfloxacin is used so much. Nitrofurantoin is probably not
used enough."
"I try hard to stick to triprim, nitrofurantoin and Amoxyl (the later has the highest success rate here). Have never needed to use Noroxin."
"A lot of the UTI bugs in our area are resistant to trimethoprim & sensitive to Augmentin (in the Petri dish!)" (HS NZ V2N2 had mentioned the difference between effectiveness in the Petri dish vs clinical effectiveness. It appears the point got across to this reader.)
"Having had a trimethoprim resistant E.coli UTI & felt exactly the way depicted [in the advertisement] I was irritated that I didn’t know 20% E.coli were resistant & would use norfloxacin again personally." MaLAM's response is: Immobilising pain from UTIs requiring house calls, narcotic analgesia and/or hospitalisation does occur but most UTIs are less severe. Women with less severe UTIs are likely to recover with trimethoprim even if their infection is resistant to it. If norfloxacin is used 1st line for all UTIs then resistance will increase and there may be no effective therapy for those who suffer immobilizing pain.
"Norflox is appropriate for more severe UTIs when one cannot risk using inappropriate empirical Rx. It does not preclude the use of simpler regimens in milder cases." That is a very reasonable hypothesis that deserves testing with a clinical trial. Meanwhile MaLAM is not aware of any controlled trial evidence to support or refute that hypothesis. (This reader’s HS NZ satisfaction score was 1 = Very dissatisfied.)
"No thought given to emergence of resistance to norfloxacin. Unfortunately, ad. reinforces belief of many local GPs."
"Agree norfloxacin isn’t first line but seeing so much resistance to trimethoprim & UTIs are painful. I’ve been doubled over on the couch like that before – I give norfloxacin as a backup scrip to be filled if Triprim not helping + after MSU taken to test sensitivities."
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