Pharmaceuticals

Americans swarm to Canada’s cheaper prescription drugs

Thousands of American seniors are crossing over into Canada and Mexico to stock up on affordable prescription drugs. For example, the stomach acid medication, omeprazole costs US$129 for 30 pills, but only US$53 in Canada. Overall, the 10 most commonly prescribed drugs cost 64% less in Canada than in Washington state. CMAJ 2000;162(13):1869-70.

b-Blockers get in line

A researcher reviewed the evidence for the effectiveness of b-blockers in the management of hypertension. Data from comparative trials demonstrate that the reduction in systolic blood pressure is significantly greater with thiazides (2.3 mm Hg) than with b-blockers. The mean rate of treatment withdrawal due to adverse drug reactions was significantly higher among patients given b-blockers than among those given thiazides (10% v. 6.9%, p < 0.001). Even the least expensive b-blockers are much more expensive than the least expensive thiazides. The author concludes that b-blockers should not be considered first-line drugs for most people with hypertension. CMAJ 2000;163(2):188-92.

Digging for gold

The practice of compiling, or "mining," prescribing information from retail pharmacies that is then sold to drug companies is a common and growing business in Canada. Concern over the right of companies such as IMS Canada to collect this data reached a peak in 1996 when many physician organizations, including the CMA, questioned the practice of collecting physician-prescribing information for profit. Three Kingston researchers outlined the issue as it developed and reported that even though the CMA developed principles to govern the collection and sale of physicians’ prescribing data in 1997, the data-mining practices of IMS Canada are "currently at variance with all five principles." The authors state that the right of physicians to be made aware of and consent to their prescribing information being mined must be better balanced against the intrinsic value of this data to policy-makers, researchers and practitioners. They also recommend that the CMA enforce its guidelines. "We contend that enforceable regulations are needed and that health care professionals should be the overseers of prescription data mining," state the authors. CMAJ 2000;163(9):1146-8.

Drug coverage: federal and provincial discord

One of the exceptions to the universality of Canada’s health care system is the coverage provided for prescription drugs, which varies by province. This author reviews the distinct federal and provincial roles and policies. In 1987 amendments to the Patent Act were introduced that guaranteed patent-holding firms a 10-year exclusivity period before a generic firm could import or manufacture patented products. Since then federal and provincial governments have been moving in opposite directions. Although Ottawa regulates drug prices and patent terms, it is the provinces and the public who pay the costs. CMAJ 2000:162(4):523-6.

Following up on fenfluramines

Fenfluramines were withdrawn in 1997 because of suspected associations with pulmonary hypertension and valvular heart disease. However, a careful review of the evidence raises questions about these associations. There were important inconsistencies among the reports of associations with pulmonary hypertension. Also, almost none of the numerous studies since the initial reports of valve disease have identified a significant excess of mitral valve disease. Since patients deserve to know the truth, the author believes regulatory agencies should apply the same thoroughness in following up major adverse drug reactions as they do in their initial evaluation of the drug. CMAJ 2000;162(2):209-11.

Freebies to MDs targeted as drug industry starts publicizing CME fines

Canada’s drug companies are now getting their knuckles rapped publicly if they violate industry rules concerning the CME events they sponsor. Several rulings made by the Marketing Practices Review Committee of Canada’s Research Based Pharmaceutical Companies (Rx&D, formerly the Pharmaceutical Manufacturers Association of Canada are published in the latest issue of the organization’s newsletter, Update. President, Murray Elston says the organization, which represents 63 drug firms, is publishing the detailed reports because it wants to be more transparent about the committee’s work. CMAJ 2000;163(6):749.

Insomnia and benzodiazepines

Insomnia, which is a symptom rather than a disease, is often due to common underlying conditions. Benzodiazepines remain a popular treatment choice for insomnia, but uncertainty over adverse effects has also raised doubts concerning the appropriate level of use. Researchers conducted a meta-analysis of 45 randomized controlled trials comparing benzodiazepines with alternate therapies or placebo. Benzodiazepines were associated with a small improvement in sleep duration (mean 61.8 minutes [95% CI 37.4–86.2]) that was countered by a number of adverse effects, such as lightheadedness, drowsiness, dizziness, memory loss and a decline in cognitive function. The authors recommend more research to help patients accurately weigh the extra minutes of sleep they may get through benzodiazepine use against the possibility of cognitive impairment or dependence. CMAJ 2000;162(2):216-20, 225-33.

International comparison of drug approval times

Although the time taken to approve new drugs in Canada has decreased considerably since the early 1990s, approval continues to take longer than in countries that take comparable approaches. This is the conclusion drawn in a comparison of application and approval dates of 219 new drugs in Canada, Australia, Sweden, the UK and the US during 1996–1998. Canada’s median drug approval time of 518 days was similar to that of Australia (526 days), but it was significantly longer than median times in Sweden (371), the UK (308) and the US (369). The author concludes that even though the length of the approval process may be affected by numerous factors, these times should be reasonably similar in countries with similar scientific approaches to drug approval, such as those considered in this study. CMAJ 2000;162(4):501-4.

Multiple sclerosis and interferons

Multiple sclerosis is the most common disabling neurological disorder among young Canadian adults, with a prevalence estimated at one in 1,000 to one in 500. Treatment was purely symptomatic and largely empirical until the arrival of interferons, whose effectiveness in preventing relapse has now been established. Although they have unpleasant side affects, are only partially effective and are very expensive, interferons provide a lifeboat until the true rescuer arrives. CMAJ 2000;162(1):83-4.

Reducing drug errors

The tragic death of an infant in a Toronto-area hospital that involved the mistaken administration postoperatively of morphine instead of meperidene raises the disturbing issue of medication errors. The death was considered a homicide. Two major initiatives to reduce the likelihood of medication errors in Canada have been introduced: a new Canadian standard for drug labels and the establishment of a Canadian agency for reporting medication errors. But physicians must go even further to help prevent medication errors, writes a commentator. "If health care professionals do not demand, on behalf of their patients, reasonable safeguards to reduce the likelihood of medication errors, no one else will." The author says the misidentification of poorly designed labels on drug ampoules or vials is an important cause of medication errors. The new drug label standard should help eliminate confusing labels, but the author worries that compliance cannot be assured since use of the standard is still voluntary. Likewise, the creation of a national reporting program for medication errors is also a positive step, but the author urges physicians to provide their input into the program’s development. CMAJ 2000;162(8):1150-1.

Viagra and cardiac disease

Sildenafil (Viagra) has revolutionized the treatment of erectile dysfunction. Because erectile dysfunction and cardiovascular disease often coexist, concerns have arisen about the effect of sildenafil on cardiovascular disease, or its interaction with cardiovascular drugs. Researchers a the University of Alberta reviewed the mechanism of action, indications and interaction. Sildenafil does not appear to increase the incidence of myocardial infarction or death. Its use is absolutely contraindicated in patients requiring nitrates, and relatively contraindicated in patients with active coronary ischemia, heart failure associated with borderline hypotension or low blood volume, a complicated multidrug hypertensive regimen or concomitant use of drugs that inhibit the P₄₅₀ pathway. CMAJ 2000;163(9):1171-5.

Who should pay for ACE inhibitor therapy?

Angiotensin converting enzyme inhibitors, a well-known class of drugs that can help prevent hypertension, can also slow the progress of kidney failure in patients with diabetes mellitus. Unfortunately, the high cost prevents many patients from pursuing this therapy. Researchers conducted a cost-utility study to assess whether provincial governments should pay for this therapy. The authors report that government funding for ACE inhibitor therapy would lead to an improvement in the number of quality years of life for patients, while producing an overall decrease in government costs. They also warn, however, that this cost-effectiveness strategy is very sensitive to changes in drug costs and patient compliance. CMAJ 2000;162(2):195-8.

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