Profits of Fear
Every closet in my medical office is suddenly filled with samples of Ciprofloxacin, an ordinary antibiotic intended primarily for use with bladder infections. This week, every patient phone call I receive and almost every patient visit to my office includes a request for this antibiotic. Physicians as well as patients are stockpiling the drug. One of my patients returns home to his wife, and she relays to me that instead of reassuring her with news of his normal test results, he instead brags, "I've got it. I've got it," brandishing his hoard of Cipro samples that he must have smuggled from my closet. Another patient calls me from Philadelphia to ask whether she can take Cipro to prevent anthrax. "Not unless you live by a certain building in Boca Raton," I reply. Five minutes later she calls me back frantic--her neighbor is returning from Boca wheeling her possibly contaminated luggage down the hall. "No," I groan. "No Cipro."
Bayer, the Cipro manufacturer, is stoking this frenzy and playing into public hysteria by promoting the drug. The drug reps drop off hundreds of sample cartons at my office without saying what for, though I can see them frowning when they hear me say, "I am not prescribing Cipro for anthrax."
Why Cipro? What the drug company is not telling either patient or doctor is that Cipro was originally tested as an alternative treatment for anthrax only for penicillin-allergic patients. Antibiotics have never been properly tested for prophylaxis, so Cipro's usefulness for prevention is speculative, though there is clearly some rationale for prophylaxing patients with close exposure. But doxycycline, a generic, is just as effective and costs one-tenth of what Cipro costs. A month's supply of Cipro costs more than $300; the equivalent amount of doxy is $32. In fact, there are multiple antibiotics available with similar efficacy, many of which are cheaper.
Which is not to say that any of these antibiotics should be prescribed. Prolonged use of Cipro, for example, without a real treatment target or reasonable endpoint, could cause significant side effects--including diarrhea, rash, colitis, gastrointestinal bleeding and insomnia--in a large population. Insomnia affects 5 percent of Cipro users, a fact that may be of interest to the drug rep for Ambien who follows the Cipro rep into my office to encourage me to prescribe more sleeping pills.
Another problem is drug resistance. Cipro, a milestone drug when it first appeared, has already lost some effectiveness because of excess use over the years and has largely been replaced by other drugs in its class, such as levofloxacin. I worry that continued unnecessary use will further cripple Cipro until people who really need it, for conditions ranging from the most minor kidney infection all the way to life-threatening cystic fibrosis, could find it useless.
Plus, if all the antibiotics stores are used up by a panicking though healthy public, people who really need the drugs for life-threatening conditions may find that they are out of luck. If antibiotic prophylaxis on a small scale does become necessary, then doxycycline or other relatively inexpensive antibiotics will represent a more cost-effective approach.
Most of all, I am concerned about a perpetuation of unsavory sales practices. In contrast to the altruism and heroism that rescue and healthcare workers have shown in the wake of the disaster of September 11, many of them working through the night without sleep or food, a drug company is attaching itself to the exact fear that is crippling us. The well-dressed Cipro rep whose territory includes my office and who plies me with "free lunches" is justifying the fear by pretending that there is a treatment for it. With the drug industry returning to what it knows best, parasitism, we find our dread exploited by a monolith that can't resist an opportunity to make more money.