The Pen is Mightier Than the Jab

Pharmac is almost universally hated by GPs. The incomprehensible funding decisions. The endless “special authorities” designed only to stop you prescribing a drug. The sudden unexpected loss of control of a patient’s disease because of a change to a cheaper brand. The dwindling choice of drugs which becomes horribly apparent when you try to prescribe drugs for overseas visitors (I have managed to find only four exact equivalents of the last 20 drugs from lists overseas patients have brought me). All of these things combine to make the average GP seriously homicidal about Pharmac decision makers.

None of this is very surprising. Pharmac simply does not have the same philosophy as mainstream medicine. Doctors are thinking “what can I prescribe to my patient that will give the best result?” Pharmac is thinking “What is the cheapest drug I can use for this condition?” Admittedly, doctors are notorious for being lead around by drug reps who are adept at persuading us that their drug is the best, with the lowest side effects and the strongest action. Pharmac is not so easily persuaded, needing hard evidence to convince them.

That last sentence is not quite true. Pharmac seem extremely easy to persuade that a cheaper drug is the exact equivalent of a more expensive one or, worse still, that a cheaper drug does “as good a job” as the more expensive one. Part of the reason for this is the division between itself and Medsafe – the body that approves drugs. Medsafe is only concerned with the safety of drugs, not their bio-equivalence (whether the drug is absorbed in the same way). Consequently, Medsafe will declare a drug “the same” without ever testing whether it is absorbed at all, let alone absorbed at the same rate as another brand. Pharmac will then buy the brand because it is cheaper, without testing its efficacy. Small wonder that sometimes the new drug is simply not bio-equivalent. Small wonder that Mrs. B’s blood pressure suddenly goes through the roof after ten years of stable readings.

Perhaps the most overtly ridiculous example of Pharmac’s idea of equivalence is their steadfast refusal to fund the EpiPen. The Herald today carries two articles – one on a little boy called Finn who carries an EpiPen with him everywhere and one on the renewed call for funding for EpiPens following the death of an 8-year-old boy from an acute allergic reaction to cashew nuts. It is highly likely that an EpiPen could have saved his life. Pharmac believes that providing a patient with a syringe, needle and ampoule of adrenaline is the equivalent of an EpiPen – an auto-injection device that contains the exact amount of adrenaline needed. Adrenaline injected at the earliest opportunity in anaphylaxis (collapse from allergy) is a life-saving action. Pharmac thinks that:

1. carrying around a syringe, needle and glass vial, breaking the vial and drawing up the required dose; then plunging the needle into your leg and pressing the plunger; is the equivalent of 
2. carrying around a neat pen, taking the cap off, putting it against your leg and pushing the button.

You might think this madness is purely temporary while Pharmac is struggling a little for funds, but you would be wrong. Pharmac have stuck to this position since 2005. Here is the New Zealand Medical Journal article that pleads for full funding of the EpiPen. Here is the reply from Pharmac in the NZMJ. For those of you who like summaries, the gist of Pharmac’s argument goes ” People don’t know how to use the EpiPen properly and don’t carry it with them – so we will only fund an “equivalent” that is more difficult to use and harder to carry around”.

Yeah. I can’t follow their logic either.

Apparently, it does not occur to Pharmac that the simple solution to the poor use statistics of the EpiPen (which is still 10 times better than the syringe/vial combo) is to ensure that people are trained properly in its use.

• Provide it only to GP practices.
• Fund a nurse consultation to ensure that holders of the EpiPen and parents can use it properly (this does not add a lot to the overall cost of the EpiPen).
• Have a recall system in place so that people come in and replace their Epipen at no charge – and get another “refresher” from the practice nurse.
• Add training in the use of the EpiPen to all the first aid courses.

I am willing to bet within a couple of years at least 50% of all episodes of anaphylaxis will get treated with an EpiPen in the community. And we won’t have 8-year-old boys dying from an eminently treatable condition because Pharmac is too busy funding chocolate flavour condoms.

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