Rare Afflictions: Medicine or Markets - 02

This post subtitles: 2 Steps, 1 Leap

Hopkins, I’d call him Hoppy, was an old-fashioned chemist. Which was to say that his all seasons brown suit, check shirt and braces belonged more in the plant offices of industrial chemical processing than sharp new organic and biological laboratories. But Guinness liked him and his respectable cut held more for their North London venture’s management than any of the new crowd. From PM Wilson’s scientific future flock. 

A quantitative professional, measure to his mind superior to mere chemical presence. And the reason he sat behind his desk in a corner of the second floor premise. North of Western Avenue and Walls sausages where, gossip held, a future Maggie Thatcher had commenced minion career in an experimental ice-cream shack. 

In his room without a view Hoppy acquired a crafty skill. Rather than admit ignorance he would nod. I was to term it the not-nod. Not for him an understanding of novel gas chromatography to separate small volumes of fats. Not for him my nouveau recollections of titrating hydrofluoric acid in I.C.I. fume cupboards.  Hairs rose on the back of necks at such exploits, but if they did with Hoppy it was lost to the nod. At the job interview so fascinated was I with it that I missed the look in his eyes at relating my ambition to make better iron absorption possible for anaemic patients.

Thusly I was surprised to receive an interim job offer several weeks later. Just back from my first OE and pretty broke I took it. To realise how his ignorance was my gain in having a free hand to R&D inorganic iron onto saccharide(sugar) transfer complexes. The one haematinics option of its time and place to gain a good look. And soon resulting in healthier and bigger pigs.

Hoppy smiled more, doubtless thrilled with his office’s well-taken praise from firm overseers and management. Pork, bacon and foods market revenues were well worth having in addition to their excellent beverage as Europe recovered and its populations began to bulge. Besides which patented properties accrued for their holders both across the Atlantic and later the world. Big business indeed, as Virginia’s joy -  - in recent days has shown. 

Smiling, however, does not make the vet-lit and the past was to resettle on Hoppy as soon as I’d left to pursue med-lit mentions for myself. Plus salting away any spare cash I could muster at evening dinner tables - eat your heart Abel* - into sure things. 

Yet to Hoppy I am impelled to attribute a very solid lesson regarding parental administration of chemical substances. In short: WHAT GOES IN HAS GOT TO COME OUT. And no, not as a bloody rash at the site of injection! As he put it so very well.

* Protagonist in the novel Kane & Abel.

Step UP

In relating that small step back I believe readers are more able to register several aspects of last week’s post ( qv below ). And in returning to chloramphenicol for what it was capable of inside the body of a patient for whom aplastic anaemia was never intended.

First a moment to clear up what this term means. Collins dictionary has the literal(ex Latin) prefix meaning - without plasticity. Unhelpful.

Better is Miller Keanes’s Medical dictionary— aplastic [a-plas´tik] - pertaining to or characterized by aplasia( = bone marrow failure); having no tendency to develop into new tissue…[ note: with my underlining ] This may be due to:—

•  chemical factors such as drugs, 
• physical factors such as radiation,
• infection by a virus, or 
• idiopathic congenital defects of the stem cells of the bone marrow. 

It is characterized by a reduction or depletion of hemopoietic(blood) precursor cells with decreased production of white blood cells (leukocytes), red blood cells(erythrocytes), and platelets.

Added to which - and relating to upcoming content on the treatment for PNH mentioned earlier - I’d like to widen context of recorded findings in respect of contemporary doctors checking the immune system for proteins called antibodies. They say, “Antibodies in the immune system that attack your bone marrow cells may cause aplastic anemia.”  

What was it about this inexpensive, rapidly absorbed and distributed bacteriostatic (inhibits bacteria as distinct from bactericides which kill) antibiotic whose 250mg capsules were easily taken by mouth..?

Relative that is to aplastic anaemia's(AA) rarity. Back in the day, 1 case in 50K, was held to be the U.K. incidence. That is 1 case in 50K chloramphenicol courses of treatment. Hardly noticeable you might conclude correctly. In fact twas some 3 years from its introduction before serious blood disorders were reported. Recipe for rarity was large city populations, widespread prescribing and broad spectrum application. Thence to children, in whom a greater and closer parental scrutiny was I daresay taken.

But this rarity in reality was part of the problem. Witness Gairdner’s case (BMJ, 1954, 2, 1107). “A girl of 4 years” presenting “on attack of bronchitis and asthma for which she received 1gm daily for 4 days. Six months later she developed a sore throat, treated with a further course of 1gm daily for 4 days. Three days after completing this course a purpuric(blood) rash appeared and in spite of blood transfusion she died two weeks later”.  AA was found at necropsy.

Suggests, does it not, how the first course whilst presumably working also found and ‘occupied’ a vulnerability in the patient’s body. Made worse and much more obviously SIX MONTHS LATER!

Bringing us back to the question of what was going on inside the patient?

Answers came after a fairly brutal trial in premature babies. At the time routine chemoprophylaxis(antibiotic cover) was prevalent. [ Recall if you will the 1920s period Downton Abbey drama whereby watchers saw the medical debate around Lady Sybil’s delivery. Caesarean, they argued, could kill both mother and child—we have no treatments to use—].

3 decades on the trial allocated 4 treatment groups of approx. 30 babies each:—

1.  no drug, 
2. chloramphenicol(C), 
3. penicillin(P) + streptomycin(S), and 
4. P + S + C. 

Resulting in: First and third groups ~20 percent died. Chloramphenicol groups, 60-70 percent died.

Cause of death was circulatory collapse with high chloramphenicol plasma concentrations due to a failure of the liver to conjugate, and kidney to excrete, the drug.

What WAS GOING IN WAS STAYING IN. Not changing, as with older and competant organ development, but damaging by its continued presence.

Yes, biochemical investigation in the fate of drugs in the IMMATURE can predict safe dosage schedules, but point is made that UNCONTROLLED chemoprophylaxis with its loss of life is not to be tolerated by clinicians. 

Indeed uncontrolled anywhere, anytime and over time is to be avoided wherever possible.

Leap.

Fifty years + later I was to see an aging lady with one very swollen and angry toe. No, she recalled to her doctor’s question, she had not “banged” it in the garden. Yet ohh.. hadn’t she stubbed it on a bedpost. He stooped, leaned, looked, felt then washed his hands. Talking all the while to put her mind at ease. 

“Classic case.. you ask me.. You are asking me aren’t you.. thought so.. and for classic cases - I’d take a photo if I hadn’t seen so many like it in my time. Yes, you’re bigger than many but not so big that my classic treatment with its life of efficacy wont polish it orf in next to no time… Now quiet please while I get this newfangled computer to print out your very own prescription..”

In thrall she pulled a large stocking back over her foot and took the print out with her. As I looked at the screen in some astonishment.

“Well, said he to me with a grin, “some of your questions I can’t answer—too special for a GP like me, but I know gout when I see it and… and I do know how to treat it. Stubbed it, came up real fast right.. I say Staph aureus.. and that’s how you deal with it. Do you know the people who make this antiobiotic held it back for years.. and years. Keep it in your bag, doc, their rep would tell me, you never know when.. blah blah. What’s funny, whaddya smiling like that for..?”

“Life of efficacy,” I said. And he grinned again. Then, not wishing to explain himself, said, “ This time tomorrow she’ll be right. But I must get nurse to call and make sure she finishes the course.”

And she was, and she did. Erythromycin had made the leap.

Rare Afflictions: Medicine or Markets - 01

My initial interest in the topic began in the 1960s.

On a wet blustery morning I was sitting in a company Ford whilst the driver went into ground-floor rooms of a high terraced property across the road.

Suddenly, beside my head, a tap on the window. I turned to see bare knuckles, white cuffs, dark-suited and over coated, and a decidedly pale-faced man asking me to let the window down.

"Sorry," he said when I did so, "thought you were Ken. His car isn't it? Gone, has he?"

"None.. of those," I answered carefully, "who are you?"

"George, PD if ya wanna know."

"Parke Davis."

"That's the one.. you?"

"You know. You know Ken, so I'm with his firm right now—"

"Gottit! Manager, huh. Course, ya would be, sitting in the passenger seat an' all."

"Actually—"

"Doesn't matter, ya don't have to explain. Look, I only stopped by on a hope and if Ken's in there with doc Harris he sure won't want to see me today."

"You're the pharmacist aren't you, " I asked, remembering Ken's earlier conversation related to the reason I was there in the first place. "Australian—"

"New Zealander, actually. Yeah, PD are pretty good like that. But yes you're right, pharmacist makes a big difference. Hey, I see Ken coming. Nice to meet you, I'll be off."

And he was, jogging back to the rear and soon out of sight.

Ken confirmed my impressions, adding in his pedantic former teacher way, "Almost prescient really. Good we got to Harris first. Given what's happened and his attitude to prescribing stuff. Parke Davis do do chloromycetin don't they..?"

"Chloramphenicol," I replied with a brief practice of the antibiotic's generic name, "though it would help knowing if Harris got the problems in adults or children."

"Both. I mean, he was for everyone and everything. Broad spectrum, the greatest and best ever. Nothing to touch it. Now, well, with aplastic anaemias—that was what you said wasn't it—he's got to rethink his.. and I.. I for one don't see it coming easily.. if at all."

"Not me," I said easily as he started up and drove off, "not why I'm here. We do an alternative, but not broad spectrum, as you know. Paediatric, too, again not all-and-sundry. And yes, self-regulation like ours.. y'know from your rep training.. means it has a life. Efficacy for life. Sure other drugs will come along yet for now someone needs hold the reins."

Enthused, Ken sang, "Oh yes, erythromycin is very good when used properly. Kept in reserve and all. Now listen, Norm, before we do my next call, Harris has agreed to lunch. Says he'll meet us first, then decide where. I couldn't do better than that. But I could look out for us if you don't get anywhere with him. He won't like you telling him what you've just told me and I know the chemists around him pretty well so if you think I should cover the scrip supply issue I'll get onto it straightaway."

"Thank you, Ken, good thinking. But let's do lunch first. Let's hope he's still receptive to our ethics and can take in your commercial front plus my R&D.."

Doctor Harris did, as it happened, and so in this single case sense the transatlantic corporate boards ratification of avoiding drugs misuse by unwarranted prescription remained intact.

Tom Meades made medical literature with his study of doctor prescribing and drug use competence.  In the 1950s. Yet even ten years later  serious side-effects of continued drug use were being reported. In patient population clusters(ie cities) this can result in great difficulties tracking down and remediation.

Been a While..

SINCE I posted here.

But I do need say something - LOBBY - and other spots are not appropriate.

Soon I intend making a submission IMPORTANT for why a government agency, which has been reported to reject an efficacious biopharmaceutical, would do so. And for equally significant reasons to its very high treatment costs.

Concerns to balance pertinent matters in reaching my conclusion will be recalled and recounted.

Today I'd like begin with the first of those. Recalling a past event will most certainly state where I am coming from. Though I hasten to add that readers seeking only what they want to hear would be wise not to presume anything more than what is presented.

Let's entitle this series of posts RARE AFFLICTIONS: MEDICINE or MARKETS?

006: Meet M/S No Messing!

A cannabinoid mimics cannabis. Aka synthetic cannabis, tho I personally think this misnomers. However, it seems that workplace usage thereof has entered our community consciousness.

Elsewhere ingredients were at issue. Noted as contaminant the prescription (viz controlled use) drug phenazepam present. Whose presence was what I'd refer to as a likely story( viz excuse).

How come..? What of controls.? Is it one thing to legislate for controlled substances and quite another to expect satisfactory knowledge in commercial profitmakers from such substances? In whom are satisfactory use standards mandated and/or obligatory?

More than interesting is what the New Zealand Drug Foundation director, Ross Bell, had to say on the subject:—

"The trouble with our drug laws is..the onus is on the government to prove a new product is harmful, rather than a manufacturer prove it is safe."

Looks a market-ready recipe for make and sell..what the hell!

Then a surprise when a commenter told of how NZ was the only other country (cf USA) to operate DTC (direct-to-consumer) advertising on non-prescription, or controlled, drugs.

If true, then free market practices have hit upon one major obstacle in the form of uncontrolled and, as the case may be, unacceptable drugs demand.

For myself, a smoking quitter now at least two decades mature, I'd call unacceptable. For reasons related to how consequential costs shall fall upon others in need of health dollars in a very zero sum budgetary scheme of things post-recession and/or recession-strapped.

Okay, so for me there's a case to answer. How does one do this..?

Tell them about the Hearing.. y'know Woodcock—no not Woodstock—I said Doc Woodcock didn't I.. go on..!

Yes, Perjjo, you were rather impressed with her weren't you.. okay..I'll mention it though I can't remember all the points..

She's the point, just remember that—

At the Energy and  Commerce subcommittee Hearing this last week on "Medical Innovation, Jobs and Patients". S/Committee members Dingell and Waxman ready, willing and able to follow through in respect of patient safety.

Backstory to the meeting included in part the heparin crisis of 2008. Briefly:—

The discovery of a contaminant* in batches of heparin throws into stark relief the difficulties, not only for the US Food and Drug Administration, but also for international regulatory agencies, to ensure the safety and quality of active pharmaceutical ingredients.

Riven with political partisanry and polarisations the US in recent years has made little progress on such matters. Added to which Republicans have backed aggressive budget cuts to FDA, whilst requiring it relax scrutiny of new drug approvals and conflicts of interest.

Before them a bill - HR 1483 - the Drug Safety Enhancement Act. Needed was informed evidence on where the FDA was at so as to close gaps. Related, I gather Tom had spotted a p/release and jotted the salient, and to the extent of expanding what the agency would be about in broad global collaborations, I think the proceedings useful. 

On message Rep. Waxman said: “It is in no one’s interest to have a weak FDA.. If Americans lose confidence in the FDA, they will lose confidence in the pharma industry as well. The FDA needs the resources to protect us for(sic) unsafe drugs, and to be sure these drugs work.”

Firm for the FDA, Dr. Janet Woodcock, positively shone:—
".. the agency's job is to keep patients safe, and make sure drugs work.. It is an important piece of the innovation pipeline, not an impediment".

Wow! Whoever would have thought responsible regulation in the food and drug industry was an impediment? No, don't tell me, let me guess ;-)

Far from overcome by the insight several Hearing members argued that a "dry drug pipeline" was the FDA's problem. Woodcock countered immediately, "Safety problems were not the sole province of generic drug makers.. "Heparin was not a generic drug.. This is not a generic drug problem–this is a pervasive drug quality problem".

Hi, Perjjo again: I've gotten the feeling this lady sees the past as a foreign country.. know what I mean? Roll on the future..

She was not done either. Rep Dingell explained to all present how the next session would be rapid fire Q&A—like he was rapid Q and she rapid A..

His first ten getting short solid noes. Because this frames the nature of HR 1483 I'll include five of them as follows...

Do you have —

• ability to control the safety of pharma imports into the US?
• necessary resources to ensure raw materials suppliers do GMP**
• authority to recall drugs you believe to be substandard or unsafe
• power to refuse suspected adulterated imports at the border
• ability to share matters with trusted regulatory partners

Then wry smiles as staccato paused on the humorous note of her two yesses..

So.. let me see, saith Rep. Dingell — it's a nine year frequency for visiting foreign drug manufacturing facilities.. and a one year frequency for dog food making facilities.?

Yes.

Do you(FDA) need these additional authorities and would HR 1483 have afforded you need to deal with the heparin problem?

Absolutely, yes.

Do it America, and collaborate internationally without getting too hung up over drug "counterfeiting" etc. This needn't mean a return to the  - lucky you! - trade protection regime that so very fortunately avoided much thalidomide tragedy - but needed is to re-enable capability for demanding responsible and obligations-led pharmaceutical and biopharmaceutical global business.

*  The heparin was made in China, which like the melamine contamination of milk had prior 'approval' because ** good manufacturing practices were not or had not been observed and a critical number of casualties in the market took time to build up and get noticed.

005: III - Trilogy

Also upholding the Michigan Court’s decision was a major surprise in the form of Circuit Judge Sutton.

President G. W. Bush’s appointee in 2003. [ Recall if you will this was the same year the President signed $400 bn for pensioners pharmaceuticals package into Medicare so as to secure his second term from their otherwise sizeable democratic constituency. ] Firmly conservative, strong on states rights and legislation, he also came with worthies backing an astute mind ( having time served in SC Justice Scalia’s office ) for future Supremes nomination.

As if speaking directly to Judge Graham’s powers of federal force he argued:—

In most respects, a mandate to purchase health insurance does not parallel these other settings or markets... Regulating how citizens pay for what they already receive (health care), never quite know when they will need, and in the case of severe illnesses or emergencies generally will not be able to afford, has few (if any) parallels in modern life. Not every intrusive law is an unconstitutionally intrusive law.

So.. in the order of things person-2-patient acceptable rule would be: find, treat(remedy), set upon upon recovery and process payment for service rendered

This compassionate conservative then appeared join Judge Martin on the economic component with — "Call this mandate what you will -- an affront to individual autonomy or an imperative of national health care -- it meets the requirement of regulating activities that substantially affect interstate commerce”.

Enough said. For a majority 2-1 decision at anyrate.

But Judge Graham had flashed a beacon to followers. Most of whom were stunned by a majority going against them. Appalled, as they saw things, that one of their own should back the President. Politics, politics, their wherewithal, when law and its relevance was at issue.

Spotting the light from among them, however, the libertarian Cato’s constitutional studies fellow, Ilya Shapiro blogged: “... it is shocking that an avowed constitutionalist like Judge Sutton requires Congress to show only a rational basis behind what it does.. to survive constitutional scrutiny. Under such logic, Congress can do anything it wants so far as it is essential to a larger regulatory scheme. That cannot be the law.”

Which of course overstates Judge Graham’s point. Besides, who would seriously abide “cannot”s pertinent the law in this case. And with these people.

Elsewhere though highly relevant—never mind the law—those Republican legislators went yesterday, there’s a debt problem and regardless Americans polled willingness to take cuts or afford more(premia or taxes) so as to sustain Medicare, we say cut $600bn from that government expense! What Congress gives(2003 qv) Congress can take away!

High-handed Big GovT ( from hypocritical republicans ) wouldn’t you say.?

As for Shapiro et al I think the unmentionable is due.

Larsson is a fine Swedish writer and knows well enough the libertarian mind. Yes, even the American libertarian mind. As readers of The Girl Who Played With Fire realise. Heroine Salander has been severely abused by her father and a second male state-appointed lawyer guardian, Bjurman. Knowing this her first-appointed guardian(stroke-sufferer recovering with her able assistance) discusses with his doctor her decision to ‘go after’ the two men still scourging her existence. The doctor declares himself surprised at Palmgren’s “libertarian aspect” insofar as his endorsement of her depravity, not to mention that she could kill herself in the endeavor. The lawyer then admits: “Yes, so am I.”

The only conclusion a reader can draw for his support is that emotion is/was the driver. Libertarians thus, and most certainly between themselves, are no less irrational than the remainder of human beings when push comes to shove.

Shapiro’s “rational” accusation upon Judge Jackson’s logic is both mistaken. And misplaced.

To wrap, Law Prof. Jost(Washington & Lee) said the Appeal Court had undertaken “a much more sophisticated opinion than we’ve seen before; a more thorough examination of the precedents”.

Not putting words into mouths, but lifting their game is where it is at for Affordable Care Act opponents

Already heard, two further appeals awaited. Will they result in a Supreme Court decider.? Who knows. Yet politics, politics, so messy, might not money + mouthiness meet more minds.!

If so, then sadly, the wrong expense.

005: II — Trilogy

Given the intervention later yesterday it was clear that a break was called for. No politics, the contention. Difficult to avoid, I argued, since material to follow arose directly from the minds and majority decision of former US presidential appointees to the judiciary, that third bastion of US democracy. Whereupon silence, our group constituting this no ordinary meaning and specialist politics, as it were, trumping the vulgaré

So, today we continue in the second part regarding the Appeals Court decision which weighed into the constitutionality of health care overhaul by the AFFORDABLE CARE ACT.

The Act, aiming to provide medical coverage for more than 30 million UNINSURED Americans, holds major impact for the health sector — health insurers, pharmaceuticals manufacturers, devices and hospitals

Given that Republicans have attacked it as a form of intrusive government power, it is likely to be a major issue through presidential and congressional elections in 2012.

Heard in the 6th Circuit's Cincinnati court, a 3 judge panel ruling separate opinions. Hence interest in unanimous or majority decisions and, given the particular nature of this panel, how much weight might go to the outcome.

The Appeal arising from a case brought by Thomas More Law Center in Michigan on the day the President signed it into law. Arguing that Congress could not regulate how Americans pay for healthcare services and insurance. A federal judge in Michigan upheld the law as legal and the Center appealed.

So..  upholding the Michigan court ruling President Carter's 1979 appointee, Judge Martin. Said by his opponents to be a liberal and anticipating Congress being able to order anything. In the event, this Judge wrote: "The activity of [forgoing] health insurance and attempting to cover the cost of health care needs by self-insurance is no less economic than the activity of purchasing an insurance plan."

Affirming the Michigan ruling.

Importantly, IMO, is how this provision aka the individual mandate brings the Affordable Care Act front and center America's concern. Person-2-patient responsibility presumed existent in respect of costs, as required, and  authorised by Congress.

At first I thought dissenting Judge Graham was addressing this very point of inaction or inactivity, with its overrun costs aspect. A President Reagan appointee(1986) and strong views about "runaway healthcare costs being a national problem" I'll admit to being disappointed when he switched to [ runaway costs ] "does not mean that Congress can try and solve them in any fashion it pleases".

Wants debt reduction or doesn't he!—mebbe he doesn't want President Obama's means to this end.?

Clearer: "If the exercise of power is allowed and the mandate upheld, it is difficult to see what the limits on Congress's Commerce Clause authority would be. What aspect of human activity would escape federal power?"**

Ah, that's it then, Conservative obsesses over powers, more makes for Big Govt. But what of the unconscious life-threatened guy in the middle of the road? Treat or don't treat?

Economic view, yes; macro no, surely? Be that as it may my double asterisk note above reveals in the next part Judge Graham as the wouldbe beacon for opponents.

Score: 1-1

Reuters - has coverage fyi tho not the great unmentioned(qv later)

Part 3: Surprises galore! Including the great unmentioned by those oh so objectivized opponents..

005: Today, Tomorrow & the Next Day - a trilogy

Upon good advices received from Just Muppo(qv) today's blog relates a procedure which in this theater's vernacular is termed scraping bones. You will understand, and accept I hope, my metaphor insofar as footing the soil above those bones has already taken place.

So.. what do we have here.? ( o/c: sayeth medz muse: Along the way to a thoroughgoing differential one ought to discern the parts..)

Ah yes, immediately I see several parts and shall take them in order.

Concerning the first we have a news item by Pollack upon the Medicare decision to continue fund treatment to existing patients a chemotherapeutic which the Federal Food and Drug Administration (FDA) recently declared non-approved for breast cancer.

At a single stroke the FDA thus took Avastin 'off-label' - (non-approved removes this indication from the drug's labelling) - yet in no wise eliminated off-label use. Which physician-administered course is both privately practised and Medicare funded.

Personally and unlike this decision's strenuous and overly sharp critics, who to a man (strangely most government-opposed!) declare the FDA did it because of the money!—meaning that Genentech's price at ~USD88,000 p.a. is too much to pay—I see the wisdom of prudent arms-length twixt government agency and manufacturer in operation.

Meaning truly good news for Big Pharma as it sustains the manufacturer's freedom to target their drug's market - thus upholding marketshare and revenues - via pricing. They have, as it were, retained the freedom(thus right) of decision. Herein with its greater value of sustainability. Surely?

Put simply: the higher the price the fewer the patients; the fewer the patients the less likely abuse and/or overuse. Thus, rather obviously, the longer its life.

To those oh so price-conscious critics one sees the squeal of $88 grand 'off-label' hitting purse and pocket as Recession bites upon perhaps their constituency's costly choices. Cries for help has never been their thing, whereas contention that taxes ought claw back costs reigns uppermost.  Yea, regardless taxpayers in general.

Ho.. whoa.! Don't go there, don't talk about general taxpayers, that's political. See! And political in these times is a way out of.. of taking ownership.  Responsibility..? Yes, mostly individual responsibility.
...

When I started out folks, a trilogy blog was no way envisaged. Now I don't see myself avoiding it. I thus encourage you stay the course, for its space and time holds value for all who do.

...

Tomorrow, the second part—AFFORDABILITY..