Rheumatoid Arthritis: Old School vs New

It's a sad state of affairs that physicians are susceptible to the marketing ploys of Big Pharma, try as we might to claim that we're better than the rest, much like Lake Wobegon, where all the children are above average.  So one would hope that we would put the interests of the patient first, in essence, and serve as his/her healthcare fiduciary.  But if that's the case, why is it that Big Pharma is still making money off branded medications when the generic version is available?  And why do we continue to prescribe medications for which there is no proven clinical benefit?

It will be interesting to see how this randomized double-blind trial published early online this week in the New England Journal of Medicine will affect our prescribing habits.  In the trial, the authors compared 353 participants with active rheumatoid arthritis, a very painful & debilitating condition, who had failed methotrexate, half of whom were given an additional sulfasalazine & hydroxychloroquine, both generic, vs etanercept, available by brand only as Enbrel.  

Whether sulfasalazine & hydroxychloroquine were added to methotrexate or etanercept was added to methotrexate, both groups demonstrated improvements within 6 months.  However, about one in four didn't respond and thus was randomized to either remain on the same treatment or switch to the other.  Here again, those who switched noted improvement.  At the end of 48wks, triple therapy was no worse than dual therapy in demonstrating benefit & improving symptoms.

So why should this matter to you & me?  Cost.  Yes, that ugly 4 letter word.  Value.  Which is calculated as benefit divided by cost.  Fiduciary duty to our patient and to some extent, our tax payers.  It turns out that triple therapy only costs $1,000/yr vs $25,000/yr for Enbrel.  I suppose you could argue that this was a small short study and only the first of its kind to compare generic to brand.  But perhaps I'm too cynical & jaded to think that our prescribing habits will be swayed by this study, if we can't even write more generic statins.  

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