- © 2007 Canadian Medical Association or its licensors
There's no doubt in the mind of clinical pharmacist Dr. Aaron Tejani, the co-ordinator of clinical research and drug information for British Columbia's Fraser Health Authority (FHA), that academic detailing has a indispensable role to play in the daily decisions that physicians and pharmacists make.
Tejani, whose duties include serving as pointman for the FHA's 12 acute care hospitals in meetings with pharmaceutical reps, says that becomes apparent many days that he meets pharmaceutical detailers. Last summer, for example, Tejani met with a Pfizer Inc. representative who pitched the use of acetylcholinesterase inhibitor donepezil (sold as Aricept for the treatment of Alzheimer's disease) to treat mild cognitive impairment (MCI), an off-label indication.
Tejani promptly hauled out a Therapeutic Letter, an academic detailing publication produced by the University of British Columbia's Department of Pharmacology and Therapeutics (April-August 2005;56). It indicated: that an unpublished clinical trial of the drug involving patients with MCI demonstrated no benefit in terms of preventing or delaying progression toward Alzheimer's disease; that several trials had suggested just 16% of people with MCI go on to develop Alzheimer's; and that there wasn't a known correlation between the 2 disease states.
“A 16% conversion rate is relatively small, so treating all people with MCI would be, in my mind, dangerous, especially when you have trials showing some of these drugs cause harm,” Tejani says.
Pfizer spokesperson Christine Antoniou says the promotion of off-label use of drugs “is not standard practice and our representatives receive a lot of training and regular reminders that off-label promotion is not at all something that we want to do. We hope it's an isolated incident and we're looking into it.”
Tejani says off-label promotion is common and described a number of similar pitches, including ones for off-label use of Recombinant Factor 7 for stroke patients, and moxifloxacin eyedrops for people undergoing cataract surgery. Pharmacy representatives have even urged FHA staff to lobby regulators to approve a drug for off-label indications, Tejani adds.
In 2005, the FHA invited drug company representatives to a forum, where expectations regarding the accuracy and quality of clinical evidence presented by drug detailers were spelled out. “We told them: ‚This is what we feel is appropriate, and this is where we think you will be crossing the line.'”
Tejani says such incidents demonstrate the value of optimal prescribing initiatives like therapeutics letters or academic detailing visits. “It [does away] with clinical opinion and bias. Instead, it simply states what we know and what we don't know about the evidence… [and] this is the kind of fact-based information clinicians and patients need to make informed decisions.”