Lie to me

Once upon a time we used to let drug reps feed us, bring us tchotchkes, and generally use our time.  The staff liked the free food, and our patients liked the free drug samples.  But we didn’t like how it made us feel.  The pharmaceutical companies have stopped giving out pens and such, and we have stopped allowing them to bring us lunches.  There are a few samples which are still useful, especially respiratory drugs which aren’t available as generics.  To this, we give in, and we do allow reps to stop by the office with samples, occasionally taking a bit of our time.

Studies show that these interactions affect prescribing patterns.  I’m not happy about it, but it’s hard to get some drugs for my patients.  The reps know me well enough to know that I don’t like to be detailed and that I’m pretty easily annoyed.  They’re tenacious beasts though.  A new one stopped by today.

She was trying to get me to prescribe a drug called Glumetza (Santarus, Inc.).  It’s a diabetes drug.  In fact, it’s a really good diabetes drug.  Not only is it a good diabetes drug, but it’s laughably cheap, although not under that name.

Glumetza is metformin—a drug also branded as Glucophage—in an extended release form.  Metformin costs about 4.00 USD per month.  The extended release version costs about 10-15 USD per month.  Glumetza costs about 250 USD per month.  This must be some sort of uber-metformin, right?  At that price it better lower your sugar and wipe your ass for you.

And that’s basically what it claims to do.  One of the problems with metformin is that it can cause some stomach upset, especially diarrhea.  In nearly all patients, this wears off in a few days, and when it doesn’t, changing to the extended release form (10-15 USD/mo, remember?) usually does the trick.  What does Glumetza claim?

Unlike immediate-release metformin, GLUMETZA uses a special advanced polymer technology that delivers the medicine slowly and steadily over several hours.5 This delay in the release of the medicine may result in fewer stomach-related side effects, such as nausea, in the 1st week of taking the medication.4

I don’t doubt that the company has a proprietary drug delivery system.  But what about the other claims?

The footnotes point to:

  1. The Glumetza package insert
  2. An inaccurate citation, but allows me to track down a journal article about extended-release metformin, not Glumetza specifically
  3. A patent summary
  4. A study that compared Glumetza, extended-release metformin, and immediate release metformin.  What did it find? We’ll get to that.
  5. A footnote leading nowhere.

Footnote 4’s study found that:

Even with a 1,000-mg q.d. starting dose, the overall incidence of gastrointestinal adverse events during the 1st week of dosing was low and comparable among treatment groups (Table 3). There was a higher incidence of nausea in the immediate-release metformin group than in the extended-release metformin groups (P = 0.05). In addition, there were more adverse events of nausea and diarrhea causing treatment discontinuation in the immediate-release metformin group than in the extended-release metformin groups. The overall incidence of adverse events considered possibly or probably related to the study drug was similar for all treatment groups; the only such events reported for >5% of patients in any treatment group were gastrointestinal events.

In other words, all forms of metformin were well-tolerated.  Even so, there was a measurable difference between the immediate release form and the extended release forms.  There was no convincing evidence that Glumetza was better than the cheaper, generic extended release metformin.  The discussion tries to be convincing, but the data don’t back any other conclusion:  Glumetza is different than generic metformin—it costs more money.

The lesson here isn’t that medicine is bad.  Metformin is a terrific drug, and cheap.  But the marketing of predictable and high-priced knock-off drugs does nothing to contribute to our health.  And plenty of physicians and patients fall for the not-so-cheap marketing.

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  1. I must be one of the outliers, because I never got over GI issues with metformin until I started Byetta, and I’ve been taking it since 2002. Generic Met XR did not work as well as Glumetza (my doc gave me some samples, but I can’t justify spending $60 a month on the stuff). Luckily, regular met and Byetta seem to cancel each other out.

    The other advantage to Glumetza and Fortamet is the availability of 1000mg tablets. A small thing, but if you’re on 2000mg a day the tablets add up.

    I think Glumetza and Fortamet are overhyped, but they seem to work better for a small subset of patients.

  2. Dianne

     /  January 30, 2012

    Ok, here are my thoughts on this issue…

    1. Whoever came up with the name “Glumetza” needs a quick course in how to not give your drug a name that will make people snicker. Not that glucophage is much better: it makes me think of a viral phage with diabetes, but Glumetza really sounds like something that can’t wipe your butt but is going to try at the worst possible moment anyway.

    2. I’m uncomfortable with drug companies giving out gifts if they affect patient care. However, I’m more worried about what they’re going to do if that avenue is blocked. Merck’s already gotten caught publishing what looks like peer reviewed journals that are really nothing but journal length Merck ads. Who knows what else they’re up to. I’d rather have them make their pitch at a time and place where I know that these are representatives of a drug company and I can take that into account properly when evaluating their claims.

    3. $250 a month? That’s not bad. It’s not real money until it costs more than $10,000 a dose. Ok, so I sound like I work for the Pentagon or something, but in the total scheme of health care costs, an extra order of magnitude cost on cheap drugs isn’t all that much. I’m pretty sure the drug companies are counting on this to keep the insurance companies from getting on their cases too much. (The insurance companies, meanwhile, are too busy harassing hemophiliacs and cancer patients to bother with minor things like whether diabetics are overspending on outpatient drugs.)

    4. There should be a fourth point, but I’ve forgotten what it was.

  3. Thanks for the education on Metformin.

  4. JustaTech

     /  January 31, 2012

    What gets me are the universities and research centers that won’t let vendors bring in food unless there are more than 2 vendors (in which case it’s a “product show” which is different). Yes, I understand that we’re not supposed to let them bribe us with food to buy their stuff, but when, say, Invitrogen is the only vendor of a reagent, you’re going to buy from them anyway, why not let them buy you pizza?

  5. There’s an (dwindling, unfortunately) generation of people who dress up a little to go to the doctor. Something between jeans and church clothes. And the clothes, purchased several decades ago, are extremely well-cared for. The cut and style links to important historical events in my mind. There’s an inherent courtesy and pride about them which I admire.

    Maybe ten or fifteen years ago I was in line behind one of these men at a pharmacy. He was ancient. His plaid shirt was meticulously pressed and tucked into his spotless creased khakis. He had the look of a veteran, probably WWI. And he was visibly upset. He was at the pharmacy because of something terrible.

    When he got to the counter, he asked for his wife’s prescription. The total was over six hundred dollars, and he could not afford it. It was absolutely wrenching. The pharmacist spent a lot of time with him, writing down less expensive options to discuss with the doctor. It sounded like there were a number of avenues for generic, or different dose to cut in half, or coupons from the manufacturer. I think he left with a one-week supply, which was still close to two hundred dollars, and a promise to take the pharmacist’s notes to the doctor. I still wonder WTF doctor sent this poor man on a fixed income, whose wife was probably dying, to fill a six hundred dollar prescription.

  6. I think I may be the small percentage that disagrees with you on this. I have tried all forms of metformin: immediate release, extended release, generic, brand name. I had bad to horrible GI side effects no matter the dose, time of day, food eaten, and so on. I did it all, for two years I might add. The 1000mg advanced polymer technology has been a game changer for me. I don’t get any GI side effects from it. I can take it on an empty stomach or with any food I like.

    I take it for PCOS and it has also been a game changer for me on improving my PCOS symptoms. Trust me, when as a woman notice that your facial hair is significantly lessened you know it is working. Also, I don’t get what I call “PCOS acne” anymore. I could go on. Oh, and my periods are for once in my life regular and less than 30 days apart.

    So, I am a believer. Whether it helps everyone to the extent it has helped me I can’t answer that. For me, it is godsent.

    • kellysmum

       /  August 15, 2012

      As in the above post, I could not tolerate metformin no matter what the type or when I took it. It got to the point I could not leave the house due to digestive issues and stomach pain. I wound up having a colonoscopy, upper endoscopy, and CT scan-all to figure out why my diarrhea and stomach pain would not cease. Finally my GI doc and I figured out it was the metformin. So we’re trying Glumetza instead and I pray that it works for my PCOS. I hope I can be a believer, too.

      • I hope it works for you too! Metformin in all the other forms killed my GI system like you. Make sure you take the 1000mg tablets of glumetza. The 500’s aren’t the same as the 1000’s. I am on 1000mg twice a day.

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