“Evergreening” and other stories . . .

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f3869 (Published 25 June 2013) Cite this as: BMJ 2013;346:f3869

“Evergreening” is the name given to the strategies used by pharmaceutical companies to keep their market share for a product after the 20 year period of exclusive manufacturing rights has expired. A typical strategy is to create slightly modified follow-on drugs, typically entaniomers such as escitalopram and esomeprazole in place of generic citalopram and omeprazole. And there are a number of other ways to persuade prescribers to stick with named brands or to avoid generics. Most health systems try to combat this with the use of restricted formularies, and Geneva in Switzerland is no exception. But a cost evaluation analysis in PLOS Medicine (2013, doi:10.1371/journal.pmed.1001460) finds that these strategies achieve limited success. The researchers calculate that had all brand and follow-on drugs been replaced with generics, Geneva alone could have saved €30.3m (£25.7m; $40.3m) over an eight year period.

The problem of drug pricing is at its most acute with novel agents for cancer. More than 100 experts in the treatment of chronic myeloid leukaemia speak out about the unsustainable cost of treatment in Blood (2013, doi:10.1182/blood-2013-03-490003). Their carefully considered analysis includes a chart of regional variations in cost, showing a more than threefold variation in the cost of the three main agents for chronic myeloid leukaemia, with annual treatment with a single agent varying from $24 000 to $123 500. Unaffordable pricing extends to many drugs that produce much smaller increases in survival in other cancers, as they point out. “We propose to begin a dialogue by organizing regular meetings, involving all parties concerned, to address the reasons behind high cancer drug prices and offer solutions to reduce them.” Minerva wishes them well and suggests that interested readers should contact: hkantarjian{at}mdanderson.org.

Arguments about the costing of new drug treatments extend across the whole of medicine. Minerva takes a sceptical view of modelling studies of cost effectiveness, but recognises that decision makers sometimes have to use these methods, and never more so than in the field of anticoagulation. Expensive, new, fixed dose agents jostle for sales, and for the prevention of stroke in atrial fibrillation, we now have reasonable evidence about rivaroxaban, dabigatran, and apixaban in comparison with warfarin. Much depends on the control of the international normalised ratio and on the local pricing for these drugs. In Stroke (2013, doi:10.1161/​STROKEAHA.111.000402), a Markov decision analysis model suggests that all these agents can be considered cost effective by normal criteria based on quality adjusted life years, although warfarin remains much the cheapest.

Aberdeen deserves fame in the annals of medicine, because it was there that Alexander Gordon (1752-99) first discovered that hand washing could prevent the spread of puerperal fever, many decades before Oliver Wendell Holmes and Ignaz Philipp Semmelweis. Gordon looked back at his own cases and bewailed the fact that he had unwittingly killed so many women. Aberdonians continue this noble tradition of outcomes research with a case series study of all the operations for Graves’ disease carried out there between 1986 and 2008 (Journal of Otolaryngology - Head and Neck Surgery 2013;42:37, doi:10.1186/1916-0216-42-37). As it became clear that subtotal thyroidectomy was almost always followed by thyroid failure, there was a switch to total thyroidectomy, eliminating the need for lifetime follow-up. There was just one case of permanent laryngeal nerve palsy, and no deaths. Gordon would stand amazed.

“The benefit of implantable cardioverter-defibrillator (ICD) therapy depends upon appropriate evaluation of a persisting risk of sudden death and estimation of the patient’s overall survival,” begins a discussion paper comparing implantable with wearable cardioverter defibrillators in the European Heart Journal (2013, doi:10.1093/eurheartj/eht167). Once a patient has an ICD implanted, it is generally only removed for malfunction, and decisions about deactivating it are difficult. On the other hand, wearable defibrillators provide flexibility, at the expense of a certain amount of external wiring.

Endometriosis is a well known cause of impaired fertility, and it has also been known for some time that daughters of women with endometriosis have an increased risk of getting it. A large and thorough population study from Denmark explores the risk of endometriosis in daughters and its effects on fertility (Human Reproduction 2013, doi:10.1093/humrep/det231). Sure enough, daughters have twice the risk of endometriosis if their mothers have it, but surprisingly they are as fertile as the daughters of women without endometriosis.

Self harm is a troublesome category for historians, philosophers, and psychiatrists, as Sander L Gilman discusses in “From psychiatric symptom to diagnostic category: self-harm from the Victorians to DSM-5” (History of Psychiatry 2013;24:148-65, doi:10.1177/0957154X13478082). Gilman traces a continuum of “moral panic” about self mutilation that connects modern discourse with the Victorians. Diatribes about poor parenting, children who stay indoors, the pernicious effect of popular media, and the stresses of modern life appeared regularly in the 19th century—just as now, in relation to self cutting, eating disorders, and of course, in those far-off times, masturbation. It may be a sign of progress that in 2013, DSM-5 fails to deal with the last of these.


Cite this as: BMJ 2013;346:f3869


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