Middle ground

It was with some amusement that I read “Rebuttal: Are Drugs too Expensive in Canada?”^1,2 which featured a debate between Joel Lexchin, self-proclaimed pharmaceutical industry watchdog, and Russell Williams and Jean Marion from the pharmaceutical industry.

In my opinion, neither of these people have the correct view. The truth, as with a lot of things, lies somewhere in between. Dr Lexchin makes a very simplistic argument that only 10% of new drugs brought to market offer any substantial therapeutic value over existing medications. He cites the example of the older diuretics, such as hydrochlorothiazide, as being superior to or just as good as angiotensin receptor blockers (ARBs) and calcium channel blockers that are more costly. What he does not tell you is that this finding depends on the age group. Elderly patients with systolic hypertension, especially, seem to tolerate diuretics much better than young patients with essential hypertension. Young people will not thank you for administering a diuretic for their hypertension; they complain of malaise and lack of energy, and will tell you they feel better without taking the drug. However, when these same younger hypertensive patients are given ARBs, especially, or sometimes calcium channel blockers, they will tell you that they feel wonderful, they will report absolutely no symptoms, and their hypertension will usually be well controlled. The ARBs as a class probably have one of the best side effect profiles of any class of drugs discovered to date. What Dr Lexchin also does not mention is that many patients require 2 or 3 medications to treat their hypertension to target; thiazides might be part of this puzzle but not the whole picture. Often patients have concomitant medical conditions, such as diabetes. Then the drugs of choice are angiotensin-converting enzyme inhibitors and ARBs, as they offer renal protection. If patients have congestive heart failure as well as hypertension, you would be unlikely to prescribe hydrochlorothiazide or indapamide as part of their treatment.

Dr Lexchin is right when he says that companies charge what they think the market will bear. For example, drugs used for erectile dysfunction are $15 a pill because this is the vanity market. Medications like these are simply unaffordable in my practice area, and I am constantly being bombarded by patient requests for samples. Another classic example is the drug finasteride: when used for benign prostatic hypertrophy, it is much cheaper than when used in a lower dose for male pattern baldness. Dr Lexchin is also quite right that the costs of new biologics, such as trastuzumab, are outrageous and beyond the reach of just about everybody. When drugs come off patent protections and generics appear, name brand companies do not seem to alter their prices. They don’t sell much of the name brand product once generic products are available, however, so it is a moot point.

All medications have side effects. There is no such thing as a perfect pill; whether it is in the generic form or the brand form, there will be side effects. You have to weigh the benefits against the risks for every medication.

Name brand pharmaceutical companies should be doing a lot more research and development in Canada. Far more molecules should be discovered in this country. There should be some kind of reward system for companies that are actually manufacturing in Canada and, therefore, providing jobs, as opposed to foreign multinationals whose Canadian locations merely package their finished products, which are produced in their plants elsewhere. Some foreign multinationals in Canada are nothing more than warehouses stocking products from overseas.

The cost of our research and development, whether quoted in worldwide figures or not, has to be recouped by the inventing company, but once that has occurred they should be able to drop their prices on existing molecules. Companies that market name brand products should be encouraged to manufacture more products in Canada, rather than import from elsewhere. Too many of our new medications have been discovered overseas, and the company in Canada is just the licensee for this country.

The bottom line is that drugs in Canada are more expensive than they should be, but not as expensive as those in the United States and some other countries. Practising family physicians must weigh all the pros and cons when prescribing medication. The cheapest drug is not necessarily the best choice, nor is the most expensive drug necessarily the best agent. The truth is somewhere in the middle.