Patients and Physicians should BOYCOTT Zetia and Vytorin: Forcing MRK and SGP to come clean with the data

You wouldn't believe it - or would you? The NYT reports today that SGP has data from a number of - go figure - unpublished studies that may contain important data about increased [and previously undisclosed] risks of liver toxicity with Zetia and Vytorin: http://www.nytimes.com/2007/12/21/business/21drug.html Unproven benefits, undisclosed risks? If I were a patient, I would want to be taken off this drug and be put on atorvastatin or simvastatin or a similar agent. If teh medical community would get on board and take patients off of this unproven and perhaps risky drug, that might at least force the companies to come clean with their data.

In fact, I'm astonished at the medical community's reluctance to challenge the status quo which is represented by widespread use of drugs such as this and Avandia, for which there is no proof of efficacy save for surrogate endpoints, and for which there is evidence of harm. These drugs are not good bets unless alternatives do not exist, and of course they do. I am astonished in my pulmonary clinic to see many patients referred for dyspnea, with a history of heart disease and/or cardiomyopathy who remain on Avandia. Apparently, protean dyspnea is not a sufficient wake-up call to change the diabetes management of a patient who is receiving an agent of unproven efficacy and which is known to cause fluid retention and CHF. This just goes to show how effective pharmaceutical marketing campaigns are, how out-of-control things have become, and how non-normative physicians' approach to the data are.

The profit motive impels them forward. The evidence does not support the agents proffered. Evidence of harm is available. Alternatives exist. Why aren't physicians taking patients off drugs such as vioxx, avandia, zetia, and vytorin, and using alternative agents until the confusion is resolved?

Are Merck and Schering-Plough "enhancing" the ENHANCE data?

I'm from Missouri, "The Show-Me State," and like many others, I'd like Merck and Schering-Plough to show me the ENHANCE trial results. I'd like them raw and unenhanced, please. This expose in the NYT last week is priceless:

http://www.nytimes.com/2007/11/21/business/21drug.html?ex=1353387600&en=2d41b634a5c553df&ei=5124&partner=permalink&exprod=permalink

I just learned that Matthew Herper at Forbes reported it first in an equally priceless article:
http://www.forbes.com/home/healthcare/2007/11/19/zetia-vytorin-schering-merck-biz-health-cx_mh_1119schering.html

In a nutshell: Sinvastatin (misspelling intentional) recently lost patent protection. Sinvastatin (Zocor) has been combined with ezetimibe (Zetia) to yield combination drug Vytorin. This combination holds the promise of rescuing Sinvastatin, a multi-billion dollar drug, from generic death if doctors continue to prescribe it in combination with ezetimibe as a branded product. There's only one problem: unlike sinvastatin, ezetimibe has never been shown to do anyting but lower LDL cholesterol, a surrogate endpoint. That's right, just like Torcetrapib, we don't know what ezetimibe does to clinically meaningful outcomes, the ones that patients and doctors care about. (The drug compaines care about surrogate outcomes because some of them are sufficient for FDA approval - that subject is a blog post or two in itself.)

So Merck and Schering-Plough designed the ENHANCE trial, which compares 80 mg of simvastatin to 80 mg of simvastatin + 10 mg of ezetimibe on the primary outcomes of carotid intima-media thickness and femoral artery (IMT). Note that we still don't have a clinically meaningful endpoint as a primary outcome, but we're getting there. A trial assessing the combination's effects on meaningful outcomes isn't due to be completed until 2010. Of course a big worry here is that ezetimibe is like torcetrapib and that in spite of creating a more favorable cholesterol profile, there is no clinically meaningful outcome improvement; i.e., the cholesterol panel is a merely cosmetic result of ezetimibe.

(Regarding the ongoing trials evaluating clinical outcomes: Schering-Plough is up to some tricks there too to rescue Sinvastatin from generic death. The improve-it study [they need a study to "prove-it" before they embark on a mission to "improve-it," don't you think?] design can be seen here:
http://clinicaltrials.gov/ct/show/NCT00202878
In this study, ezetimibe is not being compared to maximum dose sinvastatin, nor is a combination of ezetimibe and sinvastatin being compared to maximum sinvastatin alone. If one of those comparisons were done, important information could be gleaned - doctors would know, for example, if ezetimibe is superior to an alternative (one that is now available in generic, mind you) at maximum dose, or if its addition to maximum dose sinvastatin has any additional yield. But such trials are too risky for the company - they may show that there is no point to prescribing ezetimibe because it is either less potent than max dose sinvastatin, or that it has no incremental value over max dose sinvastatin. So, instead, sinvastatin 40mg+ ezetimibe 10mg is being compared to sinvastatin 40mg alone. The main outcomes are hard clinical endpoints - death, stroke, MI, etc. Supposing that this trial is "positive" - that the combination (Vytorin) is superior to sinvastatin 40mg. Should patients now be on Vytorin (sinvastatin 40mg+ ezetimibe =patent-protected=expensive) instead of sinvastatin 80 mg (=generic=cheap)? Well, there will be no way to know based on this trial, which is exactly the way Schering-Plough wants it. You see, this trial was designed primarily for the purpose of securing patent protection for simvastatin in the combination pill. Its potential contribution to science and patient care is negligible. So much so in fact, that I think this trial is unethical. It is unethical because patients volunteer for research mainly out of altruism (although in this case you could argue it's for free drugs). The result of such altruism is expected to be a contribution to science and patient care in the future. But in this case, the science sucks and the main contribution patients are making goes to the coffers of Schering-Plough. Physicians should stop allowing their patients to participate in such trials, so that their altruism is not violated.)

The NYT article makes some suspicious and concerning observations:

• The data, expected to be available 6 months ago (the trial was completed almost 2 years ago!), will not be released until some time next year, and then only a partial dataset analysis, not complete data analysis.
• The primary endpoint was changed after the trial was concluded! (Originally it was going to be carotid IMT at three places, now only at one place - a change that is rich fodder for conspiracy theorists, regardless if an outside consulting agency suggested the change.)
• Data on femoral artery IMT are not going to be released at all now

Matthew Herper's Forbes article also notes that the trial was not listed on http://www.clinicaltrials.gov/ until Forbes asked why it was not there!

For the a priori trial design and pre-specified analyses, see pubmed ID # 15846260 at http://www.pubmed.org/ . In that report of the study's design, I do not see mention of monitoring of safety endpoints such as mortality and cardiovascular outcomes. But I presume these are being monitored for safety reasons. And Merck and Schering-Plough, who have claimed that they have not released the IMT data because it's taking longer than anticipated to analyze it, could certainly allay some of our concerns by releasing the data on mortality and safety endpoints, couldn't they? It doesn't take very long to add up deaths.

The problem with pre-specifying all these analyses (carotid IMT at 3 locations and femoral IMT) is that now you have multiple endpoints, and your chances of meeting one of them by chance alone is increased. That's why the primary endpoint holds such a hallowed position in the heirarchy of endpoints - it forces you to call your shot. I liken this to billiards where it doesn't matter how many balls you put down unless you call them. And none of them counts unless you first put down your first pre-specified ball - if you fail that, you lose your turn. In this case, if you check a bunch of IMTs, one of them might be significantly different based on chance alone - so if you change the primary endpoint after the study is done, we will rightly be suspicious that you changed it to the one that you saw was positive. That's bad science, and we and the editors of the journals should not let people get away with it.

I have a proposal: When you register a trial at http://www.clinicaltrials.gov/ , you should have to list a date of data/analysis release and a summary of the data/analyses that will be released. Should you not release the data/analysis by that pre-specified date, your ability to list or publish future trials, and your ability to seek or pursue regulatory approval for that or any other drug you have is suspended until you release the data. Moreover, you are forbidden from releasing the data/analyses prior to the pre-specified date - to prevent shenanigans with pre-specified list dates in the remote future, followed by premature release.