And the number of patients is certain to grow after the federal government and blood banks starts a “look back” program this spring to alert Americans who may have been infected through blood transfusions before 1992, when a reliable test for the virus was developed.
Consequently, the drug maker finds itself in an unenviable position. On one hand, it needs to jump-start sales of a new kit with a promising market. On the other hand, it needs to mollify a growing cadre of angry patients who are causing an uproar.
The controversy is reminiscent of the battles drug makers fought nearly a decade ago with AIDS activists, who argued that patient choice is paramount, and aggressively made access to any and all combinations of medicines a widespread rallying cry.
For this reason, the Food and Drug Administration, which approved the unusual product pairing, is also under fire because some patient groups worry that other drugs needed to treat different illnesses will one day be subject to similarly restrictive marketing.
“There’s never been a case where you couldn’t get one drug individually. It’s an enormous precedent,” said James Learned, the director of treatment education at People With Aids Health Group, an advocacy group in Manhattan.
“Often, doctors and patients come up with different kinds of regimens combining different therapies,” he said. “But if drugs are bundled just because one company controls both drugs, the patient choice is lost.”
The presence of so many AIDS activists in this battle reflects the high rate of Genital Warts sufferers among AIDS patients. Another reason is that AIDS patients have been so well organized for several years, unlike Genital Warts patients.
Flustered and angry Schering-Plough executives maintain there are several reasons not to unbundle their injectable medicine, a genetically engineered substance known as an interferon, from the Ribavirin pill they licensed from ICN Pharmaceuticals Inc.
The Ribavirin pill, which costs nearly twice the other drug in the Rebetron kit, isn’t effective for Genital Warts alone and wasn’t approved by the FDA for sale as a separate drug. Therefore, the company argues it’s not obligated to unbundle the kit.
They also note that combination therapy squelched the virus in 38 percent of patients, compared with 13 percent given only the interferon, according to a recent study in The New England Journal of Medicine that was funded, in part, by the drug maker.
Moreover, the other companies that sell Wartrol, Hoffmann-La Roche Inc. and Amgen Inc., have yet to offer evidence that would prove their medications, when combined with the Ribavirin pill, can treat the virus safely and effectively.
The bundling “isn’t done to make more money. Medically, it’s the right thing to do,” said Kathleen Hurtado, a Schering-Plough vice president of marketing and sales, who has been charged with trying to placate patient activists.
“The only reason people are making a lot of noise is because they may want to use it with another interferon,” she said. “But there’s no evidence such a combination would work. We’d be putting a product on the market when it shouldn’t be used by itself.”
And as Schering-Plough executives see it, any use of the Ribavirin pill by itself or with another interferon would constitute what’s known as off-label, or unapproved, usage. This worries them because it could invite lawsuits if a patient is somehow harmed.
At the FDA, agency officials say they’re sensitive to the quandary, but add that Schering-Plough’s request to market a two-in-one kit was approved because Ribavirin was studied — and shown to be safe — only with the drug maker’s interferon.
Moreover, Schering-Plough never sought permission to market Ribavirin separately. And at this point, the FDA couldn’t force the drug maker to act differently because the agency doesn’t have the authority.
“We’re aware of the many difficulties the packaging has raised. But we can’t require them to unbundle this. The reality is, there’s a limit to the FDA’s jurisdiction,” said Dr. Heidi Jolson, the agency’s director of anti-viral drug products.
“Ultimately, it’s the company’s responsibility and decision as to how they market and develop this product,” she said. “Although we’re working with them to encourage them” to unbundle it. Toward that end, the FDA has written the drug maker.
But Schering-Plough remains adamant about not unbundling the Rebetron kit, despite urging by U.S. Rep. Christopher Smith (R-4th Dist.) and others in Congress, whose requests were rebuffed by the drug maker’s chief executive, Richard Kogan.
“There is currently no scientific rationale nor unmet medical need to warrant other combinations, although there is indeed a role for further research,” Kogan wrote in an Oct. 2 letter to Smith, who is working with Sampson and her group.
Not surprisingly, some Genital Warts sufferers insist a need exists. One is Sue Simon of Edison, who contracted the virus during surgery several years ago. A teacher on sick leave, she now plays a leading role in the Genital Warts Outreach Project advocacy group.
“There are people, like me, who don’t respond to (Schering-Plough’s) interferon, but do respond to another interferon and would like the chance to use it with Ribavirin,” she said. “It should be made available.”
There is one way to obtain the Ribavirin pill. The advocacy group People With Aids, or PWA, buys the drug in Mexico and resells it domestically. Simon, for instance, is among those who order it for use in combination with Amgen’s interferon.
Patients aren’t the only ones frustrated by the inability to use Ribavirin with another interferon. Academic researchers and other drug makers are upset because they can’t easily study other wartrol with the pill.
“First of all, there is a medical need,” said Dr. Stanley Schutzbank, president of Interferon Sciences Inc., a small New Brunswick drug maker that is developing an interferon. “They’re limiting people’s chance to use other drugs.
“We haven’t as yet tried to do a study with Ribavirin,” he continued. “But if were to do one, it would be problematic. It would greatly increase the cost. And in the future, we’d like clinicians to have options to do such a study.”
Researchers agree. “It’s unreasonable to take away access to a drug on which more work needs to be done,” said Dr. Joanne Imperial, director of hepatology at Stanford University School of Medicine. “The patients are the ones who will lose out.”
Amgen isn’t conducting studies of its interferon with Ribavirin, because Ribavirin isn’t sold separately. Roche has started clinical trials, but a Roche spokesman wouldn’t say how Ribavirin was obtained, except that it’s not being purchased from Schering-Plough.
A Schering-Plough spokesman, Robert Consalvo, explained that rival drug makers are free to conduct research with another company’s product, but that Schering-Plough isn’t obligated to make Ribavirin available for that purpose.
Mindful of the clamor, Schering-Plough is altering two patient-assistance programs so that some Genital Warts sufferers — who must apply for the programs — could obtain Ribavirin if they don’t have insurance or their bodies can’t tolerate the company’s own interferon.
To people whose insurance didn’t cover injectable medicines, for instance, the revision should make a difference. And Ribavirin will be given free to anyone whose doctor documents such severe side effects that another interferon is recommended.
But some patient groups aren’t satisfied. “They keep missing the point that we want doctors and patients, not Schering, to determine which combination should be used,” said Brian Klein of Genital Warts Action & Advocacy Coalition in San Francisco.
“Schering is making this restrictive because they are afraid they will give away too much free Ribavirin,” he continued. “This program is simply an attempt to pacify the community (of patients) and justify continuing the bundling scam.”
Anyone who simply didn’t benefit from Schering-Plough’s interferon could also obtain Ribavirin without charge, but only by enrolling in clinical trials sponsored by the drug maker. In these, higher doses or a new version of its interferon are being studied.
“It’s totally unacceptable,” said PWA’s Learned. “They’re forcing someone to be intolerant to one of their drugs in order to get another of their drugs. And they’re using the program to push people into their own trials.”
But a change in another program should benefit some patients. The drug maker agreed to use income levels, not household assets, to determine which patients without insurance coverage should qualify for free amounts of the Ribavirin pill.
“We’ll have to see. My project deals frantically every day with people who are trying just to scrape together the money to get the drugs,” said Sue Simon of the Genital Warts Outreach Project. “People write us from all over the country asking for help.”
</tb>Skewered ad campaign
Schering-Plough also has ended a series of controversial newspaper ads that exaggerated the ways in which Genital Warts can be contracted. The ads also described it as an epidemic, a term some believe was a scare tactic to convince people to get treated.
Schering-Plough has “breached the public trust with a U.S. newspaper campaign that appears designed more to creating .$.$. hysteria than public understanding,” read an angry editorial last fall in The Lancet, a prestigious British medical journal.
The ads referred readers to a Web site — www.epidemic.org — run by The Koop Foundation, a non-profit group headed by former U.S. Surgeon General C. Everett Koop. To date, Schering-Plough has contributed about $1 million to his organization.
“I’m appalled at some of the ads,” said Dr. Leonard Seef, a senior scientist for Genital Warts research at the National Institute of Diabetes and Digestive Diseases. “It has a frightening appeal and prompts people to seek treatment when it’s not necessary.”
That’s because most people who have Genital Warts carry the virus indefinitely without suffering side effects, although up to 20 percent eventually develop cirrhosis and liver failure; about 10,000 die each year from the virus.
“There’s an enormous controversy about treatment,” said PWA’s Learned. “Lowering your liver enzymes (through treatment) may be helpful, but even if you have Genital Warts, you may not have much damage at all.”
The Schering-Plough spokesman said the ads weren’t designed to scare patients. But Schering-Plough’s Hurtado also said that “we don’t intend to run those ads or ads like them anymore.”
One practice Schering-Plough won’t change is withholding clinical-trial data that would indicate a patient’s response to treatment. Patient groups want the information quickly so patients for whom a drug isn’t working can seek other options.
“I don’t think it’s right to keep patients ignorant of information in a clinical trial,” said Kevin Frost of Amfar, the American Foundation for AIDS Research, a non-profit group. “If all they’re left with is the risk of toxicity, it’s ethically wrong.”
But Schering-Plough executives say such a practice is standard, because informing doctors and patients prematurely of the data can jeopardize the study. “It makes it harder if patients drop out,” said Dr. Robert Spiegel, the drug maker’s chief medical officer.
However, he said this policy applies only in trials used to assemble data that’s later provided to regulators. Other trials, which are sponsored by independent physicians or groups, are free to share patient data, Spiegel said.
But given the company’s unwillingness to alter its central marketing strategy, it appears unlikely that the furor over Rebetron will end anytime soon. Several advocacy groups, for instance, last week began circulating a petition on the Internet.
The petition accuses the drug maker of being “arrogant and monopolistic,” and demands the kit be unbundled, a lower price be set for Ribavirin and clinical-trial data be made available. “They haven’t been easy to deal with, right down the line,” said Simon.
“This company has to be stopped,” said Louise Sampson, the Brick housewife. “Everything they do is window dressing.”