Ethics—with a side of scruples, please
Normally, if your doctor gives you medicine, you probably trust that his recommendation is based on what he feels is best for you. You may not always agree, or you may question the side effects (which you always should!) but you usually trust that he’s only doing what he feels is right for you.
Now what if I told you that he might be giving you the medicine because it offers the best rebate—back to him?
It may sound outrageous, but it’s true.
If you’re being treated for cancer or kidney disease, be cautious about any anemia drug prescription your doctor may give you.
The safety of anemia drugs (known as epoetin and darbepoetin, or EPO) and their commonly used doses is now being looked at more closely than before. It seems these drugs are being used at very high doses—much higher here in this country than in many other places, including much of Europe—and that is considered to be an unsafe practice, due in part to the rebate programs offered to doctors.
An FDA report says there is no evidence supporting the contention that these medicines at high doses improve the quality of life or extend the lives of patients taking them. In fact, several studies show that these drugs can shorten a patient’s life at such high doses!
Anemia drugs have become a runaway train with oncologists and kidney-dialysis centers. Thanks to generous rebate programs by competing drug companies, practitioners can purchase these medicines and be reimbursed for a portion of the cost. This translates into some steep profits for those doctors.
In addition, there’s an opportunity for the unscrupulous to double-dip. They not only can receive rebates from the drug companies but also can receive reimbursement from Medicare or insurance companies. To top it off, the doctor has usually marked up the cost—overhead, you understand.
The doctor also sets the amount of the dose. Not surprisingly, the more that’s used, the better the rebate deal. And if a doctor deals exclusively with just one of the competing drug companies—the financial rewards are especially great!
And that’s where the real problem comes in.
It’s been estimated that about half of all current dialysis patients receive a high enough dose of one of these drugs to raise their red-blood-cell counts beyond the level that’s considered risky (greater than 12 grams).
Anemia drugs are helpful for patients who have severe anemia, but there is little to support the contention that these drugs make a difference for patients who have only mild to moderate anemia.
About 10 years ago, one of the drug companies conducted a trial that highlighted just how dangerous this issue really is to patients. Looking to show that patients on dialysis would benefit from having their hemoglobin levels raised to that of a healthy person (a level of 14), the researchers found instead a greater risk of heart attacks and death than in those patients for whom the aim was for a level of 12.
No one has yet studied and confirmed what would be the best hemoglobin level for dialysis patients. Also, a higher dose has not been proven to be better just because a patient hasn’t responded to a lower dose. If anything, overdoing the doses can cause toxicity—which is where the higher risk of a heart attack or stroke comes in.
These patients can be treated with more iron and by having their hemoglobin levels monitored. My main plea here is that when an oral iron supplement is used, choose a gentler, better-absorbed form such as iron glycinate or iron gluconate. The commonly used iron sulfate form is rather harsh on the system, poorly absorbed, and can cause stomach problems and constipation. This often leads to additional medication to treat the side effects. Also, iron is a pro-oxidant, meaning it promotes the formation of health-harming free radicals. It’s always a good idea to take extra vitamin C with iron in the form of a supplement (250 to 500 mgs once or twice per day) or by making sure you get enough iron from food in the form of extra servings of fruits and vegetables.
