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http://www.nytimes.com/2002/12/18/health/18DRUG.html?tntemail0

Diuretics' Value Drowned Out by Trumpeting of Newer Drugs

By MELODY PETERSEN

any experts have told doctors for years that diuretics, a type of medicine that costs just pennies a day, are the best drugs to treat high blood pressure.

But those recommendations have been nearly drowned out by the major drug companies, which have poured hundreds of millions of dollars into marketing their newer and higher-priced blood pressure medicines, particularly calcium channel blockers and ACE inhibitors.

Analysts say that the results of the government study that were announced yesterday were likely to have little effect on sales of the newer drugs, in part because drug makers will continue to urge doctors to prescribe their medicines as additional treatments for heart patients who need more than one drug to control their blood pressure.

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The study, the largest hypertension trial ever, found that diuretics work better than the newer medicines to treat high blood pressure and also prevent some forms of heart disease.

The study specifically included Norvasc, a calcium channel blocker sold by Pfizer, which is expected to bring in nearly $4 billion in sales this year, and lisinopril, an ACE inhibitor sold as Prinivil by Merck & Company and as Zestril by AstraZeneca. Lisinopril lost its patent protection in June and sales are now declining.

Dr. Curt D. Furberg, an author of yesterday's study, said that over the years, companies have heavily promoted the newer drugs as being superior. "They also bashed the diuretics," he said, "more based on opinion than fact."

Because diuretics are generic drugs sold by companies that do not spend money on marketing, he said, there was no promotional effort to counter the claims of the drug makers selling the new treatments.

"We find out now that we've wasted a lot of money," said Dr. Furberg, a professor of public health sciences at Wake Forest University. "In addition, it has probably caused harm to patients."

Researchers have conducted numerous studies that suggest that the heavy marketing of the brand name drugs may be leading doctors to underuse diuretics.

Drug companies have marketed their medicines by advertising them in medical journals, by inviting doctors to meetings and dinners where studies paid for by the companies are discussed and by hiring sales representatives to knock on physicians' doors.

A 1995 study showed that diuretic use declined to 27 percent from 56 percent of antihypertensive prescriptions between 1982 and 1992. If the prescriptions had stayed at the 1982 level, the study said, the health care system would have saved $3.1 billion.

Another study, published in The New England Journal of Medicine in 1998, reviewed 70 medical journal articles that discussed calcium channel blockers and found that 96 percent of the authors who supported the drugs had financial relationships with the drugs' makers. Among the researchers who published work critical of the drugs, only 37 percent received financial support from the companies making the products.

In 1999, researchers at Massachusetts General Hospital reported that calcium-channel blockers were the most heavily advertised drug in the New England Journal of Medicine in 1996, while there were no ads for diuretics.

Officials at drug companies said yesterday that their marketing efforts had not induced doctors to prescribe the wrong drugs.

"Physicians still are in control," said Christopher Loder, a spokesman for Merck. "Doctors will not prescribe a medicine unless it delivers value."

Drug industry executives said they agreed with the latest study's finding about the importance of prescribing diuretics. But they said many patients find that their blood pressure is not controlled with a single medication, leaving an important place for their products. The companies also said that some patients cannot tolerate the diuretics.

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