Why do we overmedicate babies for heartburn?

How to fix health policy.
June 17 2010 9:35 AM

The Reflex To Treat Reflux

Why do we overmedicate babies for heartburn?

Man with acid reflux. Click image to expand.
Are acid blockers over-prescribed?

In an attempt to slow down use of the drug that would become the second-highest-grossing pharmaceutical in the United States, the head of Medicaid and Medicare delivered a blunt admonition to a 2003 gathering of the American Medical Association: "You should be embarrassed if you prescribe Nexium, because it increases costs with no medical benefits."

At the time, the pricey heartburn drug—widely advertised as the "purple pill"—was the latest weapon in the war on stomach acid. AstraZeneca used a $500 million marketing campaign to propel $5 billion in annual sales of Nexium. So quickly did the drug sweep the country that the doctors with whom I worked began calling it "purple crack."

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Nexium was the latest "proton pump inhibitor," or PPI, a massively profitable class of drugs that switches off the stomach's acid-producing cells. When AstraZeneca's prior PPI blockbuster, Prilosec, was on the verge of becoming available as a generic, the company hit upon a brilliant strategy. As with other medications—like albuterol for asthma—Prilosec's manufacturing process created a mixture of two molecules that were mirror images, of which only one had any effect on cells. To create Nexium, AstraZeneca tweaked Prilosec's production so only the active form was in the pill. The drugs are bio-identical but certainly not price-identical.

Critics like the former New England Journal of Medicine editor Marcia Angell often point to Nexium as an example of how unscrupulous pharma companies made health care costs skyrocket. Observe how AstraZeneca brilliantly intervened at Massachusetts General Hospital. As the Boston Globe Magazine reported, the company negotiated a "fantastic discount" on Nexium that saved the hospital hundreds of thousands of dollars each year. In exchange, the hospital administrators agreed to make it their preferred drug in its class. As journalist Neil Swidey wrote, AstraZeneca scored a coup: "[P]atients will be discharged on Nexium, residents will be trained on Nexium, and doctors across the country will be told that Nexium is the first choice of world-famous Mass General," even though an identical, cheaper generic exists.

However, shrewd marketing on the part of drug companies fails to explain the widespread use of heartburn drugs in adults and now in babies. When you examine that problem, it is clear that the crisis of prescription drug costs has little to do with the behavior of pharma companies—and everything to do with the unscientific prescribing habits of many doctors.

Last month, the Archives of Internal Medicine published five sobering articles on the overuse and risks of heartburn drugs like Nexium. Incredibly, doctors put half of all hospital inpatients on them, and 41 percent of all patients go home on them—regardless of the reason for hospitalization.

Keep in mind that, contrary to many people's beliefs, doctors don't get a cut of drugs they prescribe, and nobody is forcing or often even asking them to prescribe them. The over-prescription of acid blockers is a worldwide problem, occurring in single-payer systems like that of the United Kingdom and in largely privately insured countries like the United States. So why does everyone keep using drugs like Nexium so widely?

Let's take a step back to understand heartburn. Cells lining the stomach produce hydrochloric acid, which starts digestion and also appears to kill bacteria. Heartburn, goes the theory, is caused by the acid "refluxing" from the stomach upward into the esophagus, damaging the lining and also causing pain and discomfort. Based on studies involving more than 35,000 patients, acid blockers like Nexium can heal this damage and thus improve pain symptoms in those patients.

But there's a problem with the theory. In a study of 1,000 randomly selected healthy people who underwent endoscopy to look at the esophagus, 150 had damaged linings. Yet just 50 complained of any heartburn symptoms. The other 100 with damaged linings were doing just fine. Just as strangely, 100 of the patients without damaged linings had heartburn symptoms.

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