Recent statistics suggest that the number of hypertensive patients controlled at goal blood pressures, as defined by national committees, has not significantly improved over the past several years; yet millions of dollars and enormous effort have been expended on promoting new treatment strategies and educating physicians and patients. But is the type of ongoing education aimed at increasing the number of patients controlled at goal pressure, or is it aimed too frequently at convincing patients and physicians to change to newer therapies? Is there an appropriate balance between these two efforts?
Tremendous strides have been made by the pharmaceutical industry in developing newer, effective, and well‐tolerated antihypertensive medications. In addition, there have been some major attempts by industry to increase awareness of the importance of systolic blood pressure, the importance of treating more diabetics, and in disseminating national recommendations. Yet, as competition has become more intense, more of the effort has been expended on product promotion. Is this a shortsighted approach to a major problem?
Let us assume that only 30%–40% of patients with hypertension are presently controlled at goal blood pressure levels of <140/90 mm Hg or even lower in diabetics. This represents approximately 15–20 million people. There are, therefore, about 30 million more who require a more energetic or different approach to diagnosis and therapy. If we are to accomplish our objectives in these individuals, the message to physicians and patients alike should not always be “my drug is better than your drug.” The message should be “we have many effective medications which can be used for different patients in different situations.” If more people are treated and attempts to reach goal blood pressure levels are pursued more vigorously, it is obvious that medication use will increase. “A rising tide lifts all boats.” If a medication is effective and well tolerated, it will, by definition, gain more users. If a company has a good product, use of that medication will increase.
It is a sad commentary that once a medication loses its patent and is available generically, it disappears from the radar screen. This has occurred with numerous excellent antihypertensive medications, i.e. diuretics, some of the β blockers and some of the angiotensin‐converting enzyme inhibitors. It is natural that promotional efforts decrease when a drug goes “off patent,” but many of these agents are highly effective. Many patients have been controlled with these medications, but the pressures of symposia, monographs, promotional meetings, and detailing often result in a change of medication for the sake of change or “being up‐to‐date” rather than maintaining a therapy that had worked. Of course, in some cases, a new medication is clearly indicated and does result in a better outcome, but there have been numerous occasions when the promotion of newer agents resulted in changes in physician behavior that were not always appropriate.
This is clearly indicated by the story of diuretic use. Despite numerous clinical trials that repeatedly demonstrated benefit and the repeated recommendations of national committees that these agents should remain as first‐step therapy, their use declined steadily in the 1970s and 1980s. They were off patent. There was no constituency to advocate their use. When statements regarding their potential harmful effects were made, responses were muted in contrast to responses following studies suggesting that calcium channel blockers were less effective than other medications. Editorials written by opinion leaders defending these agents appeared in abundance. Calcium channel blockers are useful antihypertensive drugs, but if they had been off patent, there would have been little response to the publication of these articles.
Pharmaceutical companies have been active and generous in supporting medical education. A great deal of medical education in this country is now supported by industry; this is to be encouraged. Many of the educational programs are of high caliber with good scientific content. But, in recent years the content of sponsored medical meetings has become more skewed toward a particular product or procedure. In addition, as noted in previous editorials in The Journal of Clinical Hypertension, as well as in other major medical journals, too many papers are now being written by science writers who are part of industry and signed off by leading physicians. If a physician is involved in a research project, even if it is a protocol driven short‐term clinical trial, he or she should have the responsibility of summarizing the data and getting the paper published. Unfortunately, this is occurring less frequently. Many papers submitted to journals reflect a slight but evident bias toward positive results of a new therapy or procedure. Oftentimes, articles expressing a different opinion about data are not cited—not errors of content, errors of omission. Oftentimes, any possible deficiency of an older therapy is highlighted and problems with a new drug are minimized. It should not be necessary to “knock an old treatment” when advocating a new one.
Drugs off patent, i.e. some of the combination therapies that had been used successfully for years but are no longer being promoted, should not be abandoned; yet a check of journals or medical lectures rarely turns up a mention of these. It is becoming more and more difficult for medical journals to present balanced reports. The pressures to publish are considerable both on the part of industry and physicians who are asked to write or participate in writing summaries of data on specific products or procedures. It is appropriate for industry to fund educational efforts; without this kind of support important information would not be made available to many practicing physicians. But a better balance is necessary. We must be vigilant in order to prevent the kind of promotional infringement that has begun to infiltrate scientific literature and medical education efforts.
There is a great difference between attending a nonpromotional grand rounds lecture or attending a symposium sponsored by a specific pharmaceutical company. In the latter case one expects to hear about a new drug or procedure; one expects to be brought up‐to‐date about new studies that have been carried out with a particular medication. There can be little objection to this type of program. However, there are far too many product messages at some of the other types of lectures that are intended to convey balanced opinions.
One answer to this dilemma has been a series of “Updates in the Management of Hypertension” symposia that have been held over the past 5 years in more than 30 cities in the United States and have involved more than 75 different speakers. These symposia are supported by contributions from a consortium of six to eight pharmaceutical companies that have no input into content, choice of speakers, or site of the meeting. The concept works and the audience is assured of a totally unbiased presentation. The objective is to improve the management of hypertension. This model is one that should be utilized more frequently.
The potential conflicts of industry and academia have been pointed out in numerous editorials in many journals. The Journal of Clinical Hypertension is concerned about these conflicts and will make every effort to keep the content of the journal as free of commercialism as possible while recognizing the important role that industry has and should continue to play in medical education.