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Propecia and the question of "advertised" pharmecu

Guest Hal9000

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Guest Hal9000

Had an interesting conversation the other day:


I played badminton with a doctor friend and we got talking about meds. He had a patient ask him to prescribe propecia for his receding hairline. My MD buddy talked to this patient for a long while and eventually gave him an Rx for the drug. In his opinion, the efficiacy of the drug is questionable but the patient was adamant.


So, what are the ethical consequences of prescribing meds that are patient directed?

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Guest UWOMED2005

I think, in this case, the prescription is ethical if:


a) It is inconceivable the drug will harm the patient (ie prescribing

B) The patient is paying for the drug and not 'the system'

(ie gov't OR drug plan)

c) You discuss fully your feelings about the lack of evidence for the drug.


Once considerations a, b, and c have been addressed, in my opinion it really is up to the patient to decide.


But I think this is one of those gray areas where once a, b, and c have been addressed either course of action would be appropriate.

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Guest CoconutSmasher

Hey guys,


To start with, this is a quote from the College of Physicians and Surgeons Resource Manual for Physicians Clinical Practice Guidelines.


"The provision of a prescription to a patient is a medical act. It is the result of a clinical decision made by a physician subsequent to a comprehensive evaluation of the patient by that same physician. This evaluation should be based on a face-to-face encounter with the patient which includes the usual elements of clinical assessment such as the taking of a history, conducting a physical examination and any necessary investigations, and reaching a provisional diagnosis. Patient records should clearly reflect that the pertinent elements of the patient evaluation have been completed and documented."


I include this as a starting point since I think that this topic can easily morph into larger-scope issues.


This guideline only speaks to the process for arriving at a prescription of medication for a patient. In your example, we all assume that there is an identifiable problem (the hairloss) and that the evaluation was done by the doc. So I see the basic issue being the clinical efficacy of the medication. There are many medications that are government approved, but have questionable efficacy. I'm not 100% sure of the legalities, but if the process is followed then the clinical decision lies with the doctor.


1. Educate the patient about the medication.

2. Give a professional opinion on the appropriateness of the medication

3. Make a final decision about whether you want to prescribe or not.


This simplified approach has a few assumptions. First is that there is no "obvious" contraindication for the mediation. Prescribing a medication that may harm the patient for example. Second, is the responsibility portion of the equation. Although not illegal, prescribing antibiotics for viral infections is generally considered irresponsible as it contributes to resistance.

So, assuming that the medicaition has some indication for the issue at hand, the doctor has a decision to make. Is the medication appropriate and does it have possible benefits. The patient cannot direct the doctor to prescribe. He/she is still legally responsible for all prescription that he/she signs.


The ethical question is: is the doctor being responsible? Is the doctor capitulating to patient's requests to keep them as a patient? Are they being lazy? Do they want to avoid conflict?The patient may decide to seek a prescription elsewhere if the doctor denies the request. Or, is the doctor prescribing for benefits from pharmaceutical companies or research grants?


If, as in your example, there has been education, discussion, and the medication has indication for the ailment (albeit the physicians "opinion" questions the effects), then it may be an option to prescribe if other alternatives have been explored. Remember, sometimes doctors need to be pushed to investigate further by their patients as a counterbalance to being medically and fiscally responsible and not over-prescribing or ordering tests.


This is the art of medicine. But throw in personal beliefs in the context of medicine, and away we go...




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Guest rabbit

In response to the previous response, the conditions that must be satisfied in order for a prescription to be deemed ethical seem rather stringent.


With regards to point (a), a prescription for ANY medication carries with it conceivable (perhaps rare) complications to the patient. The ethical issue here is whether these risks (including potential allergic reactions) are explained appropriately to the patient.


With regards to point (B), governments and insurance providers set guidelines for the drugs they will cover. If this drug is prescribed according to the label and it is covered by a drug plan, I'm not certain why this would be unethical.


I agree with point ©. Obviously, it is important to describe the reported efficacy of a drug in relation to its risks and your feelings as the prescribing physician.


I think the interesting issue here is the effect of advertising on patient requests for medications. Because of advertising patients now have unparalleled access to health information (including drug effects) empowering them to actively take part in their own health care and be better health consumers.


On the other hand, patients may seek out prescriptions for ailments by relying on consumer information alone. In the scenario originally provided, one can imagine such a patient paying out-of-pocket for a drug that has questionable efficacy and potential risks (as all drugs do) leading to possible financial and health consequences. I can envision a similar scenario with regards to drug costs in which patients request and pay for brand name drugs due to the influence of marketing when low-cost generics are available.

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Guest druggist



Opportunity cost must also be considered in conjunction with the previous statements. For example, explain to the patient that clinical trials have shown that patients taking minoxidil for male-pattern baldness experience hair-growth at the vertex and not at the hairline (or very little). Money spent on minoxidil (as it is not usually covered on most formularies) could be spent on other more effective treatments, such as hair transplantation/restoration. The money he/she spends on the minoxidil for X period of time will accumulate, and eventually he may opt for these treatments regardless. I have found that this route sometimes works.



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