3/23/2015

VyingforMarketShare,CompaniesHeavilyPromoteMeTooDrugsProPublica

Dollars for Doctors

How Industry Money Reaches Physicians

Vying for Market Share, Companies Heavily Promote Me Too

Drugs
Ourcomprehensiveanalysisofdrugcompanyspendingondoctorsinthelastfivemonthsof2013showsthemostpromotedproducts
typicallywerenotcures,breakthroughsortopsellers.
byCharlesOrnsteinandRyannGrochowskiJones
ProPublica,Jan.7,2015,3p.m.

(DavidSleight/ProPublica)

ThisstorywascopublishedwiththeNewYorkTimes'TheUpshot.
Formorethanfivedecades,thebloodthinnerCoumadinwastheonlyoptionformillions
ofpatientsatriskforlifethreateningbloodclots.Butnow,afuriousbattleisunderway
amongthemakersofthreenewercompetitorsfortheprescriptionpadsofdoctorsacross
thecountry.

Themanufacturersofthesedrugs
Pradaxa , Xarelto and Eliquis have
beenwooingphysiciansinpartby
payingformeals,promotional
speeches,consultinggigsand
educationalgifts.Inthelastfive
monthsof2013,thecompaniesspent
nearly$19.4millionondoctorsand
teachinghospitals,accordingto
ProPublica'sanalysisoffederaldata
releasedlastfall.

M M
, p
B 2014, f vm
m pm m
v mf pb p
pm
p. f
mp, v mp
. xp pp

Theinformation,fromadatabase
knownasOpenPayments,givesthe
firstcomprehensivelookathowmuch
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moneydruganddevicecompanieshave
spentworkingwithdoctors.Whatit
showsisthatthedrugsmost
aggressivelypromotedtodoctors
typicallyaren'tcuresorevenbig
medicalbreakthroughs.Somearetop
sellers,butmostarenot.
Instead,theyarenewerdrugsthat
manufacturershopewillgaina
foothold,sometimesafterfailingto
meetWallStreet'searlyexpectations.
"Theymayhavesomeuniquenichein
themarket,buttheyarefairly
redundantwithothertherapiesthatare
alreadyavailable,"saidDr.Joseph
Ross,anassociateprofessorof
medicineandpublichealthatYale
UniversitySchoolofMedicine."Many
ofthese,youcouldcallmetoodrugs."

( , J,
M , PPb)

Inalmostallcases,older,cheaper
productsareavailabletotreatthesameconditions.Companiestypicallytryto
differentiatethenewdrugsbyclaimingtheyareeasiertousecarryfewersideeffects
workfasterthancompetitorsorhavemedicaladvantages.
ThemakersofPradaxa,XareltoandEliquis,forexample,saytheirdrugsareatleastas
effectiveasCoumadinforcertainconditionsbutdonotrequireroutinebloodtestsor
limitationsonwhatpatientscaneat.(PatientstakingCoumadin,alsoknownaswarfarin,
shouldn'teatgrapefruitorcranberriesandhavetolimitgreenleafyvegetablesintheir
diet.)
OfficialsattheCentersforMedicareandMedicaidServices,whichadministersOpen
Payments,andthePharmaceuticalResearchandManufacturersofAmerica,thedrug
industrytradegroup,saidtheyhadnotanalyzedthedatainordertorankspendingby
drug.
WhentoldofProPublica'sanalysis,JohnMurphy,PhRMA'sassistantgeneralcounsel,
saiddrugmakers'spendingshouldbeseennotonlyasamarketingstrategy,butalsoasa
wayofensuringthebesttreatmentoptionsforpatients."Onpaper,adrugmaynotlook
likeitismonumentallybetterthananotherdrug,buttoanindividualpatient,itmight
be,"Mr.Murphysaid.
AccordingtoProPublica'sanalysis, Victoza ,adiabetesmedicationmadebyNovo
Nordisk,wasthedrugassociatedwiththemostpaymentstodoctors,bydollaramount.
Thecompanyspentmorethan$9milliononphysicianinteractionsrelatedtoVictozain
thelastfivemonthsof2013,excludingresearchpaymentsandroyalties,whichrelate
moretodrugdevelopmentthanmarketing.(ProPublicacreatedatoolthatletsyoulook
upanydrug,deviceorcompanyandcompareitwithanyother.)
Victoza,throughaonceadayinjection,helpslowerbloodsugaramongdiabetics,but
researchersandadvocacygroupshavesaiddrugsofitsclasscarryanincreasedriskof
thyroidcancerandpancreatitis.Dr.ToddHobbs,chiefmedicalofficerofNovoNordisk
inNorthAmerica,saidthecompany'sspendingreflectedVictoza'snewnessandtheneed
toaddresssuchsafetyconcerns.
"Wejustreceivedahugeamountof
interestandquestionsandneedfor
education,"Hobbssaid,referring
toinquiriesbyhealthcare
professionals,particularlyprimary
caredoctors."Youseethefruitsof
thatinthisreport."

20 mp P M Pm
Belowisalistofdrugsforwhichcompaniesspentthemostoninteractionswithphysiciansandteaching
hospitalsinthelastfivemonthsof2013.Thesetotalsexcluderoyaltypaymentsandresearch,whichare
relatedtodrugdevelopment.FDAalertsandwarningsmayrelatetoaproductssideeffectsorconcerns
aboutitsmarketing.

Drug

Year

Use

http://www.propublica.org/article/vyingformarketsharecompaniesheavilypromotemetoodrugs

General

FDAAlerts&

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VyingforMarketShare,CompaniesHeavilyPromoteMeTooDrugsProPublica

Eliquis,theanticoagulantjointly
marketedbyBristolMyersSquibb
andPfizer,rankedsecondinits
linktospendingonphysicians,
withnearly$8million,our
analysisshowed.Inastatement,
thecompaniessaidtheirspending
helpsensurephysicians
understandtheappropriateuseof
Eliquis.Becausethedrugis
prescribedbyphysiciansin
differentspecialties,thestatement
said,"itiscriticaltohaveaspeaker
programthatadequatelyprovides
robusteducationtothese
physicians."
Thedrugassociatedwiththethird
mostpaymentstodoctorswas
Brilinta ,adifferenttypeofblood
thinnermadebyAstraZenecathat
viesforsaleswithPlavix,whichis
nowavailablegenerically.Inan
email,AstraZenecasaidithad
identifiedBrilintaasoneofits"key
platformsforgrowth"and
increasedspeakerandresearch
spendingonit."Physiciansarealso
indispensablepartnersinour
effortstobringnewmedicinesto
patients,"thecompanysaid.

Approved

Payments*

Warnings

Victoza

2010

Type2Diabetes

$9.07M

Read,Read

Eliquis

2012

Anticlotting

$7.99M

Brilinta

2011

Bloodthinningdrug

$7.71M

Invokana

2013

Type2Diabetes

$7.16M

Latuda

2010

Schizophrenia

$7.03M

Read

Xarelto

2011

Anticlotting

$6.93M

Read

Humira

2002

Arthritis,ankylosingspondylitis,
Crohndisease

$5.58M

Read

Tudorza

2012

COPD

$5.31M

Daliresp

2011

COPD

$5.2M

AbilifyMaintena

2013

Schizophrenia

$5M

Abilify

2002

Schizophrenia

$4.77M

Read

Linzess

2012

Irritablebowelsyndromewith
constipation,chronicidiopathic
constipation

$4.59M

Pradaxa

2010

Anticlotting

$4.43M

Read

Tradjenta

2011

Type2Diabetes

$4.17M

Read,Read

Belviq

2012

Weightloss

$4.14M

Copaxone

1996

Multiplesclerosis

$4.01M

Read

Samsca

2009

Hyponatremia(lowsodiumlevelsin
theblood)

$3.89M

Read

H.P.Acthar

1952

Infantilespasms,multiplesclerosis,
endocrinedisorders,arthritis,lupus

$3.62M

Symbicort

2006

Asthma

Aubagio

2012

Treatsmultiplesclerosis

$3.5M
$3.37M

Read

Read

*Note:GeneralPaymentfiguresdonotincluderoyalties.

Source:CentersforMedicareandMedicaidServices,FoodandDrugAdministration,ProPublicareporting
ProPublicahastrackeddrug
companies'paymentstodoctors
since2009throughasearchable
databasecalledDollarsforDocs.Butthiscoversonly17companies,mostofwhichhave
beencompelledtoreleasethisinformationunderlegalsettlementswiththegovernment.
Ithasnoinformationfrommedicaldevicemakers.

Thelistofmostpromoteddrugsfeaturedmanyrecentarrivals:14ofthetop20were
approvedbytheFoodandDrugAdministrationsince2010.Sometreatsimilar
conditions,includingdiabetes,schizophreniaandchronicobstructivepulmonary
disease,sothecompetitionamongthemisfierce."They'refightingoverthesame
doctors,Iguaranteeyou,"saidRhondaGreenappleSimoff,founderofaconsultingfirm
thatadvisespharmaceuticalcompaniesinBernardsville,N.J.
Largelyabsentfromthetopofthelistweredrugsthatcuredisease,suchasanewclassof
hepatitisCtreatments,orthosethatsignificantlyextendlife,particularlyforcancer
patients.Ifadrugiseitherthefirsttotreatadiseaseorismuchbetterthanexisting
drugs,saidDr.SidneyWolfe,thefounderandnowsenioradvisertoPublicCitizen's
HealthResearchGroup,"they'sellthemselves'onthemeritsoftheiruniquebenefits."
AccordingtoProPublica'sanalysis,afewofthemostheavilypromoteddrugs,including
Samsca,whichtreatslowsodiumlevelsintheblood,haveserioussideeffectsthatcame
tolightaftertheirapprovalbythefederalgovernment.Themanufacturersofseveral
others,includingCopaxone,Latuda,Xarelto,DalirespandHumira,havebeenfaultedby
theF.D.A.forimproperpromotion.
Subsys ,approvedin2012totreatcancerpain,ranked23rdinspendingondoctors.It's
oftenprescribedforofflabel,orunapproved,usesinNovember,TheNewYorkTimes
reportedthatsomeofthedoctorspaidthemosttopromotethedrughaddisciplinaryor
legaltroubles.InastatementtoTheTimes,InsysTherapeutics,thedrug'smaker,saidits
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marketingofSubsyswasappropriate.
Themedicaldeviceassociatedwiththemost
paymentstodoctorswasIntuitiveSurgical's
daVincisurgicalrobotsystem ,whichthe
companyhasmarketedasaneffective,less
invasiveoptionforanarrayofprocedures.
Criticshavecomplainedthatthedeviceis
needlesslyexpensiveandoverused,andsayit
hasbeenlinkedtopatientcomplicationsand
deaths.
Intuitivespentnearly$12.8millionon
physicianinteractionstopromotetherobot
inthelastfivemonthsof2013,notincluding
royaltiesandresearch.Thespokeswoman
PaigeBischoffsaidinanemailthatabout
halfofthecompany'soutlaysforeducation
andtrainingwere"passthrough"spending:
Surgeonsorhospitalspaidthecompanyfor
services,andthecompany,inturn,paid
doctorstoprovidethem.
Dr.RobertTakla,anemergencyroom
physicianintheDetroitarea,earnedabout
$75,000inthelastfivemonthsof2013by
deliveringpromotionaltalksaboutseveralof
themostheavilymarketedanticoagulants
andbloodthinners,particularlyBrilinta,
accordingtoOpenPayments.

Somehighlypromotednewerdrugs"arefairlyredundantwithothertherapiesthatare
alreadyavailable,"saidDr.JosephRoss,anassociateprofessorofmedicineandpublic
healthatYaleUniversitySchoolofMedicine.(ChristopherCapozzielloforTheNewYork
Times)

Hesaidheenjoysspeakingonbehalfof
companiesandthinksheoffersadifferent
perspectivethancardiologistsandinterniststheusualprescribersofthedrugs
becausehetreatscomplicationsofbloodclotsintheemergencyroom.

Dr.Taklasaidhereviewsclinicalstudiesbeforedecidingtospeakforadrugandturns
companiesdownwhenheisn'timpressed.Hesaidhenolongerspokeonbehalfof
Pradaxabecauseofwhathecharacterizedaspublicbacklashagainstit,drivenbyaspate
oflawsuitsagainstitsmanufacturer,BoehringerIngelheim.(Thecompanyagreedtopay
$650millionlastyeartosettlethesuits.)HeacceptsfeestospeakaboutXarelto,adrug
hehastakenhimselfforadeepveinthrombosis.
"It'saveryfertileandveryrobustmarketplacerightnow,"hesaidoftheanticoagulants.
NewsapplicationsdeveloperMikeTigascontributedtothisreport.
Methodology:Howwecalculatedcompanypaymentstodoctors
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