Cheaper Can Be Better

By ANDREW PURVIS

The new heart drug hit the market in 1987 in a blinding flash of pitchmen, promotion and public relations hoo-ha. The product of biotech breakthroughs, TPA was touted as clearly superior to the competition, a clot-busting drug called streptokinase, on the market for 15 years. Though TPA (for tissue plasminogen activator) is 10 times as expensive as the older drug, the majority of U.S. doctors bought the pitch, and the new drug became the favored method of breaking up clots in heart-attack victims. Then last week an international team of researchers reported what some doctors had suspected all along: the fancy new medication appears to be no better at saving lives than plain old streptokinase. In fact, it seems to carry a slightly greater risk of causing strokes.

The saga of TPA is a glaring example of what some experts believe is a pervasive problem in American health care: how high-pressure marketing tactics by drug companies combine with the lure of a glamorous high-tech product to persuade doctors to adopt the latest medication, even when it offers no clear advantage. "Doctors are enamored of new technologies," says Dr. Stephen Schondelmeyer, director of the Pharmaceutical Economics Research Institute at Purdue University. "We have this attraction to 'new is better,' even though that is not always true."

Usually, the added cost of a new drug is justified by an obvious benefit. Second- and third-generation antibiotics, for instance, can work when older, cheaper antibiotics like penicillin fail. In other cases, a costly new drug may break new ground, as AZT did in treating AIDS.

But with TPA, the price difference was extreme -- about $2,500 a treatment vs. $220 for a dose of streptokinase -- while the advantages were murky. Several studies showed that the new drug worked more quickly to open up blocked arteries, but whether that really made a difference in patient survival was unclear.

Then why were U.S. doctors so quick to adopt the medication? For one thing, cost is still not a primary concern for many U.S. doctors. In Canada and Europe, where cost constraints and rationing of health care are a matter of course, TPA did not enjoy great success; streptokinase plus ordinary, cheap aspirin remain the standard anticlotting therapy. In addition, pervasive fears of malpractice suits in the U.S. add to the pressures on doctors to use the latest technique.

But the biggest reason TPA took off was the aggressive promotional campaign launched by its manufacturer, Genentech. The worldwide market for anticlotting agents, or thrombolytics, is estimated at $600 million a year. To get a substantial piece of the action, Genentech relentlessly promoted its product not just to doctors and patients but to researchers as well. "I have never seen anything like it," said Dr. Charles Hennekens, U.S. coordinator for the study released last week.

Genentech, Hennekens says, refused to participate in the international study, which compared TPA with streptokinase and a third thrombolytic called anistreplase, so a British-made version of TPA was used instead. Moreover, Hennekens says, when he tried to recruit doctors to participate, he found that some had been told by Genentech salesmen that using the other drugs in the trial could endanger their patients. Streptokinase, they were told, could cause cerebral bleeding, and anistreplase, which is derived from human plasma, was alleged to carry a risk of AIDS infection. Neither danger is significant, said Hennekens. Genentech denied any direct meddling in the trial and disputes the study's findings on methodological grounds.

Though TPA is a dramatic example, many heavily promoted new drugs offer only subtle advantages over cheaper alternatives. Dr. Sidney Wolfe, an outspoken consumer advocate in Washington, says that 70% to 90% of newly approved drugs are not important therapeutic advances. One example: substances called lower osmolarity contrast mediums, introduced in 1986. Used in taking diagnostic pictures of internal organs, they are believed to be only marginally safer than existing agents but are sold at up to 12 times the price.

Overzealous marketing practices in the drug industry have attracted attention in Washington. At a Senate hearing in December, critics cited a litany of abuses that seemed to cross the line between advertising and bribery. Roche, for example, paid doctors $1,200 to prescribe a new antibiotic to 20 hospital patients in exchange for minimal information on the results of the therapy. Another company offered free mileage on American Airlines for using Inderal LA, a hypertension drug. Last week the recently appointed FDA commissioner, Dr. David Kessler, told the committee that regulating drug promotion would be a top priority in the coming year.

In an era when health-care costs in general are growing out of control, it is becoming increasingly difficult for the government, insurance companies and doctors to ignore the cost factor in medicine. And as patients bear more and more of the costs, they should realize that the latest, slickest new treatment is not always just what the doctor should order.