Reviews Web

Website launched to expose “tricks” of drug ads

BMJ 2003; 327 doi: http://dx.doi.org/10.1136/bmj.327.7420.936 (Published 16 October 2003) Cite this as: BMJ 2003;327:936
  1. Melissa Sweet, freelance journalist specialising in health and medicine in Australia (sweetcom{at}tig.com.au)

    Esomeprazole campaign is first to be scrutinised

    Doctors are being duped by an effective but misleading advertising campaign for a new proton pump inhibitor, says a new watchdog on pharmaceutical advertising.

    The founders of Adwatch (www.healthyskepticism.org/adwatch.asp), an interactive web based analysis of “the logical, psychological and pharmacological tricks” of drug advertisements, have called on Astra Zeneca to amend its promotional claims for esomeprazole (Nexium). They say the advertising is based on unfair dose comparisons and also fails to compare the drug with appropriate alternatives, including non-drug therapies such as elevation of the head of the patient's bed.

    Since its launch in Australia in August last year, esomeprazole has captured more than 10% of the rapidly expanding market for proton pump inhibitors, which treat gastro-oesophageal reflux and other acid-related problems. The number of scripts for proton pump inhibitors dispensed under Australian government-funded subsidy schemes has almost tripled over the past four years, reaching 9.2 million in 2002-3.



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    The Adwatch site is likely to be closely watched by the drug industry and advertising agencies

    Esomeprazole contains the most effective component of market leader omeprazole, which is S-omeprazole (esomeprazole) and its mirror molecule, R-omeprazole. Many observers believe such drugs are being developed as a commercial response to omeprazole's patent expiration.

    The advertisement analysed by Adwatch claims that “Nexium 40 mg offers greater healing power than either omeprazole or lansoprazole.” However, its fine print reveals that the doses used of the latter drugs were less than 40 mg.

    Adwatch says there is no evidence that esomeprazole is superior to equivalent doses of other proton pump inhibitors. When proton pump inhibitor treatment is appropriate, prescribers should use the cheapest one in the lowest dose that controls symptoms, it says.

    Astra Zeneca said the claims in its advertisement were “accurate, balanced and correct” and that the Adwatch critique was “highly subjective.” In a letter to Adwatch, the company's director of sales and marketing for primary care, Mark Bull, said the campaign had twice been judged not to breach the industry's code of conduct for marketing.

    But the National Prescribing Service (NSP) believes Adwatch's concerns are warranted. “Nexium has had pretty strong uptake for a drug that probably doesn't offer a lot more,” said NPS chief executive officer Lynn Weekes. “I suspect a lot of patients have been swapped across unnecessarily.”

    Professor Lloyd Sansom, who chairs the Pharmaceutical Benefits Advisory Committee, which recommends prescribed medicines for government subsidies, said there was no significant difference between omeprazole and esomeprazole “on a dose for dose basis.” The data suggested that the majority of patients could be managed satisfactorily with the less expensive 20 mg dose of omeprazole, he said.

    Associate Professor Peter Katelaris, of the University of Sydney, who has been involved in industry trials and education about proton pump inhibitors, said the market growth reflected a move towards “step down” therapy–starting patients on proton pump inhibitors, rather than first attempting a trial with H2 antagonists. This strategy was likely to relieve symptoms and heal oesophagitis in more patients with significant reflux disease than a “step up” strategy, he said.

    He added that a new class of drugs, acid pump antagonists, were likely to become available in future as patents began to expire for the newer proton pump inhibitors, raising similar questions for clinical practice.

    An international team, including specialists, pharmacologists, and general practitioners, contributes to Adwatch, but the driving force is Adelaide GP Peter Mansfield, who has campaigned against inappropriate drug marketing for 20 years. He founded the Medical Lobby for Appropriate Marketing (MaLAM) after being shocked by pharmaceutical marketing while in Bangladesh as a final year medical student.

    The organisation initially pushed for withdrawal of harmful drugs but was renamed Healthy Skepticism (http://www.healthyskepticism.org/) last year, signifying a change of focus. Dr Mansfield said this stemmed from the realisation that “companies do whatever the market rewards, so we need to stop rewarding them for doing the wrong things.” He said, “Promotion is a mirror on our souls that tells us how we really make decisions.”

    The organisation's new name is from a 1963 speech by a drug advertising executive, Pierre R Garai, who challenged doctors to develop a “healthy skepticism” and stop blaming drug companies for misleading drug promotion. The doctor “must cultivate a flair for spotting the logical loophole, the invalid clinical trial, the unreliable or meaningless testimonial, the unneeded improvement and the unlikely claim,” Mr Garai said. “Above all, he must develop greater resistance to the lure of the fashionable and the new.”

    Adwatch was partly inspired by an Australian television programme, Media Watch, which highlights media blunders. Judging by how much journalists dread starring on Media Watch, Adwatch is likely to be closely watched by industry and advertising agencies. Astra Zeneca made contact soon after Adwatch's launch. But the impact of Adwatch on prescribers may be more difficult to judge.