Thursday, May 29, 2008

Vytoringate keeps hurting Vytorin sales

Vytoringae keeps punishing... Schering-Plough's SEC filing shows a continuing drop of Vytorin prescriptions. No bottom in sight.

Based on our health care market research via online physician surveys of cardiologists, internists and GPs who prescribe cholesterol drugs, we predict at least a 50% drop in Vytorin/ Zetia sales. Our recent physician survey in April-May 2008 shows that 50% of doctors have stopped prescribing Vytorin or have reduced prescriptions. This, despite the fact that most doctors thought Vytorin is effective and would prescribe it for themselves and family members. How ironic, good will squandered by pharma missteps.

Click here to view this survey for details.

Our surveys also reveal that the reason doctors are reducing Vytorin prescriptions is related to poor communications with Merck and Schering-Plough, and negative media reports which have a growing influence on doctors’ prescribing decisions in the absence of good communications between doctors and the pharmaceutical companies.

For an in depth analysis of our survey results see Vytoringate: A Failure to Communicate with Doctors. We even suggest a way for pharma to stop it's self inflicted slippery slope and restore trust.

As we previously mentioned, John McCain joined this controversy (see Wall Street Journal Blog). Senator McCain’s physicians seem to also have made their treatment decisions based on the same influences that affected doctors in our survey.

As long as medical companies fail to communicate with their most important customers— physicians—the media and other external forces will have increasing control over prescription sales and pharmaceutical company profits.

Robert Cykiert, M.D.

Tuesday, May 27, 2008

Pilots and smoking

Federal regulators ruled that Pfizer’s smoking-cessation drug Chantix can't be used by pilots and air-traffic controllers. See more details at the Wall Street Journal Blog

Chantix has been under scrutiny for a while for psychiatric side effects. A report this week also suggested that the drug may be associated with physical problems including seizures. Pfizer has said such potential problems are rare, and are already noted on the drug’s label. More than five million people have taken Chantix in the U.S., Pfizer said.

Smoking and smoking cessation have a high association with depression and suicide - So, is it the Chantix or the cigarettes? Smoking is also the leading cause of heart disease, heart attacks and strokes -
So, is it the cigarettes or the Chantix? Smokers also have increased risks of seizures and more dangerous consequences of their seizures - So, is it the cigarettes or the Chantix?

Clearly, for the vast majority of people, Chantix is a far better option and much lower risk than cigarettes. However, no drug is perfect, and no drug is for everyone. Glaxo has offered free Commit nicotine lozenges to pilots. That’s a reasonable alternative option for pilots and good PR for Glaxo, while Pfizer is taking a hit and until we get more data on Chantix.

Lets hope Altria-Philip Morris doesn’t take Glaxo’s lead and offer free Marlboros to pilots.

Robert Cykiert, M.D.

John McCain and Vytoringate

John McCain is now part of the Vytorin controversey, called Vytoringate by the media! He was apparently switched to generic statin (simvastatin) after the Vytorin study was presented at the American College of Cardiology meeting. See more details and discussion at Wall Street Journal Blog.

Looks like McCain’s doctors were as confused as most cardiologists, internists and family practitioners are about Vytorin, the ENHANCE study, and the American College of Cardiology expert panel’s recommendations. Poor communications with physicians and mixed signals from Merck and Schering-Plough resulted in much media hype, and now many physicians, including McCain’s, are confused about how to treat elevated cholesterol and LDL.

For two decades it’s been assumed that lowering cholesterol and LDL reduces the risk of heart attack and stroke. This has been documented with outcome studies for Mevacor, Lipitor, Zocor and other drugs. From the ENHANCE study we know Vytorin reduces lipids better than simvastatin alone. However, the ENHANCE study introduced a new controversey when it was shown that Vytorin does not reduce carotid artery plaque better than Zocor alone. Checking for reduction of carotid artery plaque using ultrasound was something that had not been done in previous studies, but somehow everyone expected to correlate reduction in lipids with reduction in artery plaque. Failure to show the correlation between reduction in artery plaque and cholesterol raised many questions about over 20 years of assumptions on the role of cholesterol and cholesterol lowering drugs (a multi-billion dollar industry).

Luckily, the ENHANCE study did NOT show that Vytorin is in any way harmful or worse than Zocor alone.

The simmering new scientific questions about heart disease and the role of cholesterol combined with suspicious behavior by two large pharmaceuticals has resulted in Vytoringate, a media feeding frenzy, and confusion by doctors who treat heart disease. The two pharmaceutical companies failed to communicate with their most important customers: the doctors who prescribe their medications! Needless to say, those doctors stopped prescribing on a large scale and sales dropped about 50% and billions of dollars of share holder equity for the two companies vanished almost overnight. performed healthcare market research via an online physician survey of physicians who treat high cholesterol First in Jan 2008 and then in May 2008, and found that approximately 50% of doctors stopped prescribing Vytorin since the ENHANCE study and the media’s Vytoringate coverage. You can view the results of this public survey here. Note there is also an analysis of the two surveys as one of the links on that page.

So, I wonder what possible rationale could there be for MCain’s doctors to replace his Vytorin with simvastatin and allow his LDL cholesterol to rise from 83 on Vytorin to 123 without Vytorin?

Was it confusion? Risk aversion? You be the judge.

Robert Cykiert, M.D.

Thursday, May 22, 2008

Full disclosure is coming

Everyone seems to be supporting a new bill backed by Senator Chuck Grassley (R-Iowa) and Senator Herb Kohl (D-Wisc.) that will require companies to disclose payments to doctors who received $500 or more from a single company over the course of a year, starting in 2011. More on this in Jacob Goldstein's WSJ blog.

This is a good law, but why wait till 2011? What Doctors Think performed an online physician survey of over 100 orthopedists and general surgeons in February 2008, and asked them “Should medical companies publicly disclose their consulting agreements with physicians, and specifically indicate what payments or inducements they give to physicians?” (See question #12).
Not surprisingly, 78% of doctors answered YES to this question. Doctors and medical companies should have nothing to hide regarding their business deals. Our healthcare market research confirms that.
Robert Cykiert, M.D.

Saturday, May 17, 2008

Tour de Tobacco

Lance Armstrong, seven-time winner of the Tour de France is on a warpath against cancer with his 5th Livestrong Day, He is doing a yeoman's job in fighting cancer, but he could do a lot more relatively easily by leveraging his access to the media to publicize how cigarettes are the leading cause of cancer by far, and by putting pressure on the tobacco companies to stop all marketing of their deadly products. In Lance's editorial in the Wall Street Journal,, he states that the public should "Ask your local, state and national lawmakers what steps they'll take against tobacco, the number one cause of cancer..." Unfortunately, the public has insufficient clout with legislators to enact changes, and more importantly the public does not have the media access that Lance has, as witnessed by his ability to author an editorial in the Journal. Imagine how effective Lance could be if he appeared on Oprah, Letterman, Leno, Larry King, etc., spoke out against tobacco companies, and put pressure on legislators to ban all tobacco advertising. The US government in its NIH web site, , (page 7) states that Tobacco use is the leading preventable cause of premature death in the United States. Each year, more than 440,000 Americans die of tobacco-related disease, accounting for 1 in every 5 deaths. Cigarette smoking is responsible for more than 30 percent of cancer deaths annually in the United States. Smoking also contributes substantially to deaths from heart disease, stroke, and chronic obstructive pulmonary disease... From 1995 to 1999, estimated annual smoking-attributable economic costs in the United States were $75.5 billion for direct medical care for adults and $81.9 billion for lost productivity." According to the US federal Trade Commission,, tobacco "Advertising and promotional expenditures… (were) $15.15 billion in 2003… $14.15 billion in 2004, and… $13.11 billion in 2005." In contrast, according to the National Cancer Institute,, “the Nation’s principal agency for cancer research… The NCI’s total budget for Fiscal Year 2005 was $4.83 billion. The NCI will invest an estimated $4.79 billion during Fiscal Year 2006. The budget is expected to decrease to $4.75 billion in Fiscal Year 2007.” The tobacco companies are therefore spending three times as much on tobacco advertising than the government spends on cancer research. Additionally, tobacco companies have so far donated $2.5 million to federal candidates and parties for the 2008 election. Go to for donation details by company and politician. It’s no wonder that we’re losing the war on cancer. Lance is one of the few people that can single-handedly end the insanity. Doing that would be a greater accomplishment than winning the Tour seven more times!

Robert Cykiert, M.D.

May 16, 2008

Thursday, May 8, 2008

Bedside Manner vs. Medical Talent

In a recent Wall Street Journal Health Blog, Jacob Goldstein discusses the importance of doctor etiquette referring to Harvard psychiatrist Michael Kahn's New England Journal of Medicine article that proposes 6 rules for doctor behavior.

Etiquette should be at the bottom of the list of what patients want when they are in the hospital. The #1 priority while you’re in a hospital is to be discharged as soon as possible in a healthier state than when you were admitted. You need a smart, diligent, caring, hard-working, talented physician in charge of your care and/or surgery. The doctor could have the best etiquette in town, but if s/he doesn’t have the skills and determination then you are in trouble.

Etiquette may make your hospital stay more appealing, but it is not the benchmark you want to measure. I know some physician colleagues who have great etiquette skills, but I wouldn’t have them take care of me, and then I know some others who have no “bedside manner” at all, but take incredible care of their patients.

Lets not forget our priorities. If the doctor has proper etiquette then that’s icing on the cake. You can’t always have your cake and eat it too.

Robert Cykiert, M.D.

Tuesday, May 6, 2008

Pharma shifts to eDetailing and doctors like it

As pipelines shrink, patents expire, generics grow (see story), the FDA becomes more cautious and conservative, consumer groups complain more about drug prices, the government investigates marketing practices, and stockholders get more angst, the pharmaceutical companies have no choice but to reduce their costs to compete and survive. Sales reps will be cut first because they are much more expensive than new web-based technologies that can offer a higher ROI.

In a January 2008 "What Doctors Think" performed an online physician survey of 230 doctors in various specialties. 44% of surveyed doctors said that ‘email with web site links’ pharma-marketing was the least intrusive on their practice and time. Only 6% of doctors said that sales rep detailing was least intrusive. 9% said that meals with sales reps was least intrusive.

As doctors’ incomes slide, and they spend much less time with sales reps, eDetailing (email and the web) is clearly the strategy for pharmaceutical companies to shift to. It’s far less expensive, much more effective and is more socio-economically acceptable--think green.

When asked what was the most effective way for a pharmaceutical company to notify a doctor of a new FDA drug approval, 57% of polled doctors said ‘email with link to web site’, whereas only 37% said a ’sales rep visit’. When asked “what form of medical company marketing would LEAST escalate national health care costs,” 64% said ‘email with links to web sites’ whereas only 5% said ’sales reps’.

The full healthcare market research survey can be viewed

An analysis of the shift from detailing to eDetailing can be found

Merck is seeing the prescription-writing on the wall. Other pharmaceutical companies will shortly follow the growing trend.

Robert Cykiert, M.D.
Robert Cykiert, M.D.

Thursday, May 1, 2008

No Smoking

According to the American Cancer Society (ACS) there will be 1.4 million new cases of cancer in the USA in 2008. ( Go to">
and download the excellent Powerpoint presentation for detailed cancer statistics). Lung and bronchial cancer will account for 14-15% of these new cases. Additionally, the ACS predicts 566,000 deaths from cancer in 2008. Lung cancer will account for 26% of all cancer deaths for women, and 31% of all cancer deaths for men. The ACS also says that “Smoking is responsible for about 87% of lung cancer deaths” and that “Cigarettes kill more Americans than alcohol, car accidents, suicide, AIDS, homicide, and illegal drugs combined” — see

Simple arithmetic shows that approximately 20% of Medicare’s cancer expenditures, or $4 billion, are for lung cancer caused by cigarettes. (Medicare’s expenditures for treating heart disease and emphysema secondary to cigarettes is probably another $10 billion, based on ACS data for heart and emphysema related deaths). Medicare Trustees recently reported that “Medicare hospital insurance spending is forecast to exceed tax revenues for 2008 and all future years and the fund will be exhausted in 2019″ And that’s just Medicare! Health insurance and out of pocket expenses for treating lung cancer, heart disease and emphysema in people under Medicare age probably accounts for another $10-15 billion dollars in cigarette related expenditures. Clearly Medicare spending on tobacco related diseases is the main reason for Medicare’s hastened insolvency.

How long are we going to allow tobacco to bankrupt Medicare and the healthcare system? The high cost of cancer drugs is minuscule compared to the damage being done by cigarettes.

Why are the presidential candidates not discussing tobacco--the leading cause of disease, death and healthcare expenditures in the USA by far?

Robert Cykiert, M.D.
Comment by Robert Cykiert, M.D.