He Could Have Used Ibuprofen

by GoozNews ~ 11 Mar 2009 11:24am

Those were the days. New pain relief medications known as Cox-2 inhibitors had just received Food and Drug Administration approval and the post-approval research money was flowing. Merck (Vioxx or rofecoxib) and Pfizer (Celebrex or celecoxib) lined up dozens of physicians -- orthopedic surgeons, dentists, general practitioners -- to do small studies (usually a few hundred patients or less) showing that these new drugs, no different in analgesic effect than ibuprofen or other over-the-counter medications, worked in their areas of practice.

Such trials are called "seeding trials" because their real goal is to get articles about the drugs published in specialty medical journals, which can then be delivered by drug salespersons to specialists in their community practices. I'm intimately familiar with that literature because in early 2005, I reviewed all of it for a study showing the extent to which both Merck and Pfizer engaged in seeding trials to push their new Cox-2 inhibitors. The point of doing my study was to show that the companies had little interest in pursuing the more serious question of cardiovascular risk from the drugs, which had been signaled in the very large trial that won rofecoxib (Vioxx) FDA approval. They were much more interested in seeding trials.

Now it turns out that at least one of the "thought leaders" they turned to conduct those seeding trials was himself little interested in accuracy or honesty. This morning's Wall Street Journal reports that last month, the journal Anesthesia & Analgesia retracted 10 of 11 studies on rofecoxib and celecoxib authored by Baystate Medical Center's chief of acute pain, Scott S. Reuben. The journal Anesthesiology has retracted another three articles.

The journals accused Reuben of faking the data used in the studies, which appeared between 1996 and 2008. Speaking through his attorney, Reuben suggested "extenuating circumstances" led to the scientific fraud and said he was cooperating with the journals' investigation.

Here's a typical example of his studies. Reuben and colleagues administered rofecoxib to patients about to undergo arthroscopic knee surgery. According to the now withdrawn study, those given the drug had less need for stronger painkillers after the operation.

One has to wonder: why didn't Reuben try the same experiment with ibuprofen, a commonly available non-steroidal anti-inflammatory drug that is available over-the-counter? A quick search of PubMed finds no studies authored by Reuben that tested this common painkiller.

No, it would appear that it was only the availability of drug industry funding that fueled his intellectual curiosity. After completing the trials, he not only promoted the drugs for one of the companies but urged the FDA not to restrict their use.

Someone needs to replicate his experiments using ibuprofen and celecoxib (the one Cox-2 still on the market) to see if there actually is any benefit from using these drugs in that context. It needs to be both so physicians, patients and payers have comparative data that will allow them to choose the cheapest, most effective alternative.

And if it turns out that patients given rofecoxib before operations actually had no benefit, then thousands of people undergoing minor surgery were needlessly exposed to cardiovascular risk without hope of benefit.

Comments

It is obvious Dr. Reuben's "scientific" efforts were being guided by a desire for financial gain.  As a physician (otolarlyngology), I certainly would like to see a articles looking at older NSAIDS to suppliment or reduce the need for narcotics in the post-op period.  I'm not sure that I would use iboprofen due to its platelet inhibition, but how about a couple of other NSAIDS that in their days of active marketing were touted as having little anticoagulation effects,  nabumetone and salsalate.  Now that they have 'gone generic', everyone has forgotten about them.
 
Drug company claims about the safety benefits of a given drug are certainly not always reliable, and a better source of information would be helpful.  Ketorolac has been claimed to be a good drug for postop pain control, but several studies actually showed the post-tonsillectomy bleed rate shot up to 17% - 19% when  used.  That is not acceptable, and it would certainly make me more that suspicious that ibuprofen, which is know to aggravate perioperative bleeding. It continues to be widely used by general surgeons, but the tonsillectomy bleed rates make me wonder if there isn't some post-operative intra-abdominal bleeding that goes unobserved.

Here lies the problem however: research is inherently labor intensive and time consuming.  Further, research subjects in prospective studies usually expect to be compensated in some way for their participation.  So who will pay for this when the drug that needs more investigation is a generic drug that would not be generating a wide profit margin for the manufacturer.  Certainly over at NIH, they are really only interested in the cutting edge of science, not the boring, low-glamour work of verifying cost efficiencies from old science. Should tax-payor dollars be applied to this?  Probably, but who will administrate it, and at what cost?

Phil Anderson, M.D.

Conflicts of interest undermine public trust in and support for scientific research, endangers research subjects and patients, and boosts medical costs by encouraging physicians and patients to use new treatments that are no better than cheaper alternatives.

Collaborations between academia and industry has clearly brought discernible influence on clinicians, bringing with it erroneous results, suppressed data, or harmful side effects from these drugs. The sophistication, greed and political influence of big pharma has gotten way out of control.

D.F. Horrobin published a commentary in JAMA on the peer review process.

"Peer review can be performed successfully only if those involved have a clear idea as to its fundamental purpose. Most authors of articles on the subject assume that the purpose of peer review is quality control. This is an inadequate answer. Peer review must aim to facilitate the introduction into medicine of improved ways of curing, relieving, and comforting patients. The fulfillment of this aim requires both quality control and the encouragement of innovation. If an appropriate balance between the two is lost, then peer review will fail to fulfill its purpose."

Please, see the most vicious and continuing for 22 years research fraud:
"University of Toronto Fraud"
http://ca.geocities.com/uoftfraud/

Michael Pyshnov