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RxCowboy
05-05-2009, 02:34 PM
If I were head of the FDA I would do away with DTC Rx advertising altogether. It does nothing but increase the cost of medications.

DTC ad spending decreased last year
Apr 27, 2009
By: Fred Gebhart, Contributing Editor
Drug Topics E-News

Drugmakers cut consumer advertising for prescription drugs by 8 percent in 2008. The retreat from $4.8 billion in 2007 to $4.4 billion last year is the first reduction in direct-to-consumer Rx spending since the late 1990s.

DTC spending was flat in 2007, according to market research firm TNS Media Intelligence. Drug industry watcher John Mack, principal consultant for VirSci Corp, predicted a further 11 percent decline in DTC spending for 2009.

“There is a lot of highly visible spending in DTC,” Mack said. “When the economy goes bad, that visible spending is one of the first areas to be cut, along with the number of drug reps, which has also been slashed. Drug makers are cutting costs across the board.”

Manufacturers are also seeing Rx sales slow as more consumers decide not to fill scripts and move instead to generics. Both changes make brand advertising an easy target for cost cutting. “Consumers are just not buying as much,” said Chicago-area independent pharmacist Dennis Bryan, incoming president of the Illinois Pharmacists Association.

“Sales are hurting as food trumps meds. Everybody is taking a hit.” Recession is just one reason drugmakers are cutting their DTC budgets. Blockbuster drugs typically drive DTC advertising, Mack noted, and blockbusters have been few and far between the past two years.

Even fewer blockbusters seem poised to enter the market anytime soon. “Current drug approvals are largely extensions of existing products,” said David Kweskin, senior vice president and practice leader in brand and communications, TNS Healthcare. “Take Cymbalta (duloxetine, Lilly). They got a new indication for fibromyalgia, which is good for sales, but you’re not going to put a ton of money behind a new indication.”

Declining DTC spending is just part of the story. Pharmaceutical companies are also changing their advertising mix. Less money is going to print ads in magazines and newspapers and more money is going into television and online ads. “The pullback was much stronger in print than in other media,” said John Busbice, principal, commercial effectiveness practice, IMS Health. “And there was more pullback in lower-volume areas than in the top 25 DTC advertisers.”

The top 25 DTC advertisers accounted for 62 percent of total DTC spending in 2008, $2.7 billion, Busbice said. Another 100 or so products pitched direct to consumers accounted for the remaining $1.7 billion. The top 25 brands cut DTC spending by about 5.5 percent, IMS reported. Smaller brands cut spending much more.

The smaller brands had the right idea, he continued. Brands with sales of less than $750 million generally had a lower return on their DTC investment than brands with sales above $750 million. Busbice said the large brands went too far. The top 25 brands should have increased their ad spending by about four percent. IMS estimates they could have maximized sales by cutting $40 million from network television and adding $50 million each to print, cable TV, and syndicated TV.

IMS reported that the typical return on DTC investment ranges from 1.9 for syndicated TV to 1.4 for network television. Network TV audiences are falling, Busbice said. Viewers are moving to cable and syndicated programs. And they are moving online. “We see a significant migration online,” said West Shell, president and CEO of HealthLine, an online health site based on consumer information searches.

“Recent data shows an ROI of five to one for online DTC because online ads are better targeted than print or TV. The Internet audience is as big as the TV audience and still growing, while TV is shrinking. Consumers are moving online and advertisers have to follow them. Pharma is relatively late to the game and lags other sectors in online DTC.”

TNS Media Intelligence agrees. Jon Swallen, TNS senior vice president, research, said that online Rx DTC spending moved from two percent in 2007 to three percent in 2008. U.S. advertisers overall spent seven percent of their ad dollars online.

“Online DTC is going to be one of the very last channels to be cut,” predicted Didi Discar, partner, MedAccess, a pharma-focused advertising and marketing agency in Southern California. “Online is significantly less expensive than other channels and today’s medical consumer is very web savvy.” That bodes well for pharmacy, said Jeremy Shane, president and COO of HealthCentral.com, a consumer health information Web site.

“The pharmacist remains an important consumer touchstone,” he said. “People don’t want to buy blindly, they want advice. The pharmacist is the source they trust and want to touch as a part of the treatment and buying decision.”

steross
05-05-2009, 04:47 PM
I agree.

Rx, I find Prilosec interesting. A few years back, it was the drug to have. Everyone on Pepcid or Zantac had to switch to Prilosec even though it was expensive because it worked so well. As I recall from the time it was the biggest DoD drug expenditure by far. I was on our utilization review committee and we spent a lot of time looking at Prilosec prescriptions.
Now, it is over the counter and relatively cheap. Patients now tell me all the time it doesn't work and they want Nexium/Aciphex/Prevacid. So, do you think that the stomach's proton pumps have developed an omeprazole resistance over the years or is the $$$ of the drug and the need for an Rx part of the placebo effect that make it work better?

RxCowboy
05-06-2009, 05:21 AM
Omeprazole is a racemic mixture. Nexium, esomeprazole, is the s-enantiomer (chemically it's s-omeprazole, cute, huh). So, when patients take Prilosec they are taking Nexium too (they take both the r- and s-enantiomer). There is no reason on the planet that Nexium should work better than Prilosec, there is no real clinical advantage, there has never been a study that I'm aware of that has shown Nexium to be clinically superior at anything. But I hear that from patients all the time too. I think it is by and large a placebo effect. If Nexium were OTC it wouldn't work as well.

RxCowboy
05-06-2009, 05:24 AM
Just imagine cutting $4.4 billion from the cost of prescription drugs. All the sudden they are a lot more affordable. Over night. Instantly.

steross
05-06-2009, 09:46 AM
I knew Nexium was very similar but I didn't know it was just one of the enantiomers. Wow, that is pathetic.

And you are right on the reduced cost by cutting out DTC ads. But, these companies are fighting over fractions of market share, and will do anything to increase theirs. The worst ones to me are the ones that medicalize life's irritants. I know there are people real restless leg and people with real dry eyes(who should be worked-up for Sjogrens). But I do not think that there are enough of these people that really have these problems severe enough that we should all be watching ads about it ever night. The power of suggestion is strong, and instead of someone buying artificial tears they now believe they have to put cyclosporine in their eyes to feel better.

RxCowboy
05-06-2009, 08:26 PM
I knew Nexium was very similar but I didn't know it was just one of the enantiomers. Wow, that is pathetic.

Yup.

And you are right on the reduced cost by cutting out DTC ads.

It's one of those things that really gets under my skin. It doesn't help anyone.

But, these companies are fighting over fractions of market share, and will do anything to increase theirs.

That's the thing, there is very little evidence that DTC can actually affect market share. Pharma A does it because Pharma B does it. Once upon a time it was illegal. We need to roll back the clock.

The worst ones to me are the ones that medicalize life's irritants. <snip> The power of suggestion is strong, and instead of someone buying artificial tears they now believe they have to put cyclosporine in their eyes to feel better.

What gets to me is that people expect pills to cure the little aches and pains we accumulate through life. We simply can't... and we're finding out the medications we use for that might be pretty dadgum harmful. I've recommended to the internists I work with that they use glucoseamine for oa/djd first... it might not help, but it won't kill them.

Donnyboy
05-07-2009, 08:02 AM
Omeprazole is a racemic mixture. Nexium, esomeprazole, is the s-enantiomer (chemically it's s-omeprazole, cute, huh). So, when patients take Prilosec they are taking Nexium too (they take both the r- and s-enantiomer). There is no reason on the planet that Nexium should work better than Prilosec, there is no real clinical advantage, there has never been a study that I'm aware of that has shown Nexium to be clinically superior at anything. But I hear that from patients all the time too. I think it is by and large a placebo effect. If Nexium were OTC it wouldn't work as well.

I read an article on this not from a medical standpoint but from a patent law perspective. It was the first time that the molecule was for lack of a better term "flipped" and given a new patent. Dose cut in half...molecule flipped....wha-lah Prilosec OTC.

Donnyboy
05-07-2009, 08:08 AM
While we have an audience with two smart guys from two aspects of the medical field....

I am on board with you RX that drug ads just raise price....but I'll go one farther. I think the majority of healthcare ads just add costs. I get it for the local group of peditricians....or ortho guys where client choice is the driver. But how do hospitals justify ads. I mean do people really "choose" a hospital at all. Childbirth...yes. Pretty much everything else...no at least from my limited view.

I mean most people IMO go to the hospital for emergencies or because their doctor sent them there. Where is the billboard in that equation.

Am I way off here? There is a billboard for a hosptial every 100 ft here in the Metroplex and in primo locations....it has to be expensive....do you all feel there is a return?

steross
05-07-2009, 08:31 AM
It does matter for hospitals, I do believe. Obstetrics is the obvious one, but for emergency care it matters, too. Many hospitals that are "Chest pain centers" have done only minor cosmetic changes to how they care for chest pain. Yet, if the advertise as a "Chest pain center" more people come in for that reason. Put up a picture of a smiling kid with a otoscope in his ear- more kids.

I'm not claiming that it is a good idea or that it makes a big change in the overall market share similar to what Rx mentioned for drugs, but the ads do bring people in.

Donnyboy
05-07-2009, 08:41 AM
It does matter for hospitals, I do believe. Obstetrics is the obvious one, but for emergency care it matters, too. Many hospitals that are "Chest pain centers" have done only minor cosmetic changes to how they care for chest pain. Yet, if the advertise as a "Chest pain center" more people come in for that reason. Put up a picture of a smiling kid with a otoscope in his ear- more kids.

I'm not claiming that it is a good idea or that it makes a big change in the overall market share similar to what Rx mentioned for drugs, but the ads do bring people in.

Okay so let me peel the onion a little more. Ob...kids...makes all the since in the world. Chest pain center is what I was wondering about.

So the next question is....are the ads targeted acturately IYO? In otherwords are the borderline hypchondriacs with insurance running to the "chest pain center" and the medicaid folks going to whats close.... so while the ads may bring in a small portion of the overall number of patients they bring in the profitable ones? Or are they doing the opposite and bringing those that don't pay for their care so they go where they want...no insurance network restrictions for example....thus having an adverse affect. More patients may not be a good thing.

Thoughts?

steross
05-07-2009, 09:05 AM
Okay so let me peel the onion a little more. Ob...kids...makes all the since in the world. Chest pain center is what I was wondering about.

So the next question is....are the ads targeted acturately IYO? In otherwords are the borderline hypchondriacs with insurance running to the "chest pain center" and the medicaid folks going to whats close.... so while the ads may bring in a small portion of the overall number of patients they bring in the profitable ones? Or are they doing the opposite and bringing those that don't pay for their care so they go where they want...no insurance network restrictions for example....thus having an adverse affect. More patients may not be a good thing.

Thoughts?


My guess would be that overall the ads bring in more insured.

Most medicaid just see the ER as "going to the doctor" so I don't think they would be differentiating the CP centers.

The wife of the guy who never goes to the doctor but complains about his chest after work one day will take him to the chest pain center and demand that every test known to man be done right then to make up for the lack of effort on his part over the past 20 years. See it everyday.

RxCowboy
05-07-2009, 10:49 AM
I read an article on this not from a medical standpoint but from a patent law perspective. It was the first time that the molecule was for lack of a better term "flipped" and given a new patent. Dose cut in half...molecule flipped....wha-lah Prilosec OTC.

I'm not sure what you mean by "flipped." Chemically, Prilosec Rx and Prilosec OTC are identical.

Donnyboy
05-07-2009, 10:59 AM
I'm not sure what you mean by "flipped." Chemically, Prilosec Rx and Prilosec OTC are identical.

I'm no chemist so I could screw this up...

But to make a stab at my understanding lets say Prilosec is made of three parts and they bond in the shape of a triangle... now picture said triangle with points A and C as the base and point B at the top pointing north. They took A and C and left them alone but slightly changed the bonding such that now B is pointing south. It's still A,B and C as the make up....but the bonding is different so it's a "new" molecule and thus a new patent. The article said this was done to stop generics. A generic was about to be available so as opposed to losing Rx market share to generics they re-patent it under the new molecule at a lower dose and put it OTC. And I may be way off but I thought Nexium begat Prilosec OTC in this case. It was the Nexium molecule that was manipulated slightly to create Prilosec OTC....does that sound right? Maybe they were expressing the similarties....it's been sometime since I read it.

This is a difficult medium with for me to explain this. The content of the article was less about the drug and more about the logistics it creates for companies to protect patented products by reinventing the same thing.

RxCowboy
05-07-2009, 11:00 AM
I mean most people IMO go to the hospital for emergencies or because their doctor sent them there. Where is the billboard in that equation.

Thinking back over my life and the times I've gone to the ER, it has never once been because my doctor sent me there. In fact, I've chosen physicians because of the hospitals where they've had admitting privileges. You're right that it does add to the costs of healthcare, but hospital ads really do have the ability to influence choice, whereas patients simply cannot choose their prescription medications.

RxCowboy
05-07-2009, 11:18 AM
It was the Nexium molecule that was manipulated slightly to create Prilosec OTC....does that sound right? Maybe they were expressing the similarties....it's been sometime since I read it.

You're confusing Prilosec OTC and Nexium. Prilosec OTC is omeprazole, which is identical to prescription Prilosec, chemically identical. Nexium is esomeprazole, which is the s-enantiomer omeprazole, which is a racemic mixture (contains an r- and s-enantiomer). Nexium allowed them to extend the patent life and market a new drug. Happens all the time. The asthma drug albuterol (Proventil) is a similar mixture. Now there is Xopenex or levalbuterol which is levo-albuterol whereas albuterol itself is a mixture of dextro- and levo-albuterol. The other thing drug companies love to do is make a sustained release dosage form. This happened recently with Ambien CR, which doesn't make a lick of sense. But it allows the company to extend the patent life, and physicians who don't understand the pharmacokinetics involved will prescribe it.

steross
05-07-2009, 11:29 AM
There may be some benefit of the levo-albuterol over the racemic. A couple of studies have shown a lower admission rate with the levo, hence making it cost effective. I'm not completely convinced but can't say I don't order it from time to time when I am more concerned. Our hospital pharmacy tried to drop racemic albuterol completely until we threw a fit about it.

Donnyboy
05-07-2009, 11:39 AM
I'm butchering this somehow with the drug details... I know it was Prilosec and the message was that there was essentially no change in product but a new patent was issued. I guess these type changes are common so maybe this was an uncommonly small change to recieve a new patent.

If you start speaking negatively about Ambien we can't be friends anymore....

RxCowboy
05-07-2009, 01:42 PM
I'm butchering this somehow with the drug details... I know it was Prilosec and the message was that there was essentially no change in product but a new patent was issued.

Right, but it was Nexium that received the new patent, not Prilosec OTC. The purpose of selling anything OTC is simply to capture a new market.

If you start speaking negatively about Ambien we can't be friends anymore....


Not Ambien, I take it myself on occasion (I have sleep apnea and every once in a while have difficulty falling asleep with the mask on). It is Ambien CR that I have a beef with. When Ambien first came on the market the big selling point was that the pharmacokinetics were perfect for a sleep agent, quick action, duration of action that ensured 6-8 hours of sleep and that didn't leave you groggy the next day. That is all pretty well true. The purpose of a CR product is to increase the duration of action, which in this case didn't need to be increased.

RxCowboy
05-07-2009, 01:44 PM
There may be some benefit of the levo-albuterol over the racemic. A couple of studies have shown a lower admission rate with the levo, hence making it cost effective.

That's what you do when you can't show a difference in effectiveness, you try to show cost effectiveness.

I'm not completely convinced but can't say I don't order it from time to time when I am more concerned. Our hospital pharmacy tried to drop racemic albuterol completely until we threw a fit about it.

Really? Wow... we're trying to limit the use of Xopenex.