A Country Doctor Writes:

There were two “suits” and several boxes of free pizza in the lunchroom when I stopped in to grab some coffee the other day. The enthusiastic young drug “rep” spoke rapidly while our staff ate. His regional manager watched and listened.

Drug “reps” are the only people you ever see in a doctor’s office around here wearing suits. The younger man’s three-button narrow-lapel suit was black and a little shiny, his permanent press point collar shirt a classic French blue, but his striped tie definitely too large for his narrow collar. His senior colleague wore a pinstriped double-breasted dark gray suit with a white spread collar shirt, a perfectly tied half Windsor knot and tasseled loafers.

The two men seemed very out of place in our rural clinic, and so did the medication they were promoting.

The new drug, first in its class, won’t make patients feel any better, live any longer or breathe significantly better. Statistically, it will help reduce the number of exacerbations of chronic obstructive lung disease in patients already on maximum medical therapy.

Most insurance companies don’t even cover the drug, but the fast-talking young “rep” rattled off several things we might want to write down on Prior Authorization requests in order to get it approved. He suggested we refer to the GOLD treatment guidelines, which mention the new drug class without specifically recommending it.

“Side effects? Some people – excuse me for mentioning this while you are eating – experience diarrhea, and some get psychiatric symptoms, which would be a reason to stop the drug.”

At that point I almost choked. Not that I am the least bit squeamish about the mention of bodily functions while I eat or drink, but because of the overly casual mention of the risk of psychiatric side effects.

If a medicine for chronic bronchitis with an unknown mechanism of action can make patients suicidal, it seems to me that a small group of country doctors in remote, rural America should not be among the first ones to prescribe it. It sounded to me as if we must have been the second choice for a drug launch because the pulmonologists downstate wouldn’t pay enough attention to the “suits” representing it.

I excused myself and went back to my office.

I racked my brain. Medical school was a very long time ago. Phosphodiesterase? Cyclic AMP? Viagra, what else? My computer had some more answers.

Phosphodiesterases (PDE’s) were first isolated in rat brains forty years ago.

Xanthines like caffeine and theophylline (an almost outdated COPD drug with a lot of toxic side effects) are non-selective phosphodiesterase inhibitors.

Sildenafil (Viagra) is a PDE-5 inhibitor, and it has found some use in severe pulmonary disease (Revatio).

The new drug is the first PDE-4 inhibitor in clinical use. Earlier compounds in the same class were shown to have severe psychiatric effects and never turned into useful medications.

PDE-4 inhibition stimulates pyramidal cells in the brain, but it is not exactly known what the clinical effect of that might be. People have looked for psychiatric uses for this type of chemical, but the results of that research are still inconclusive.

I also found a less than flattering review on an internal medicine website that summed it all up nicely for me.

So there I was, having listened to a sales pitch for a drug that essentially does very little for only the sickest of COPD patients but might be opening Pandora’s box as far as brain chemistry goes. Not my cup of tea.

I turned to the pile of mail on my desk. On top was a faxed sample offer for a new drug to treat travelers’ diarrhea. I turned to my computer again: Average retail price $300. I stopped right there and tossed the piece of paper in my wastebasket.

By that time it was one o’clock and my first patient of the afternoon, a 75-year-old man with severe COPD, was ready to be seen.