Seroquel . . .XR . . . SR . . .CR . . .whatever . . .

All right, here I am, first day back from vacation . . . and one of the first messages handed to me by my secretary is . . . “a drug rep wants to set up a lunch to discuss Fizzilrexcrap XR . . . a new version of Fizzilrexcrap”.  . . OK, OK it wasn’t about Fizzilrexcrap, but it might as well have been.  It was about Seroquel . . . actually, the new IMPROVED Seroquel.  “Improved in what way????” you might ask.  Believe it or not, the Eisensteins at AstraZeneca pharmaceuticals actually reformulated Seroquel (most often given as a once a day medicine) so that you only need to take it . . . well . . . once a day!  WWWOOOOOWWW.  Now, ordinarily, I might get excited about this news, but, being a bit underexcited about returning to work, I was underwhelmed . . . and declined the lunch.

While there are certainly extended release products that do make sense, there has been a pattern over the last 10 years by the pharmaceutical industry to create new products from old ones by modifying the delivery vehicle by which the medicine gets to you.  By that, I mean the pill structure.  By slowing or controlling the way the pill dissolves, you turn an immediate release medicine into an sustained release (SR), controlled release (CR), controlled delivery (CD) or extended release (XR) formula.  Another trick is to take a pill and turn it into a dissolvable tablet that can be taken without water (like there is someone in the developed world who doesn’t carry a water bottle or have access to a water fountain)  The patent gets extended and profits continue. Pharmaceutical companies are happy . . . your 401k is happy . . . your stock broker is happy . . . everyone is happy . . . right?  RIGHT???

No.

While certain sustained release medications make sense and are truely beneficial for the patient (most notably the sustained release preparations of stimulant medication and some antidepressant medications), others are thinly disguised veils for making profits.  At the risk of angering the pharmaceutical industry, I will describe . . .

Seroquel XL . . . like I said, when it is used for it’s antipsychotic properties, it is mostly given as a once, maybe a twice a day product.  When it is given during the day, it is mostly used for it’s sedative properties. To identify the “new” product as an inovation is a stretch, to say the least.

Zyprexa Zydis . . . dissolvable tabs.  Get a drink.  Take the pill.  Skip the Zydis.

Paxil CR . . . an oldie but goodie.  I didn’t understand this from the get-go.  The SSRI’s as a group are a once a day medicine.  To take Paxil and turn it into a CR product was, at the time, genius from a business standpoint . . . but of minimal clinical value.

Wellbutrin XL . . . OK, some value . . . for those who can’t remember twice a day dosing (I certainly could not), but I also understand the hesitancy of the insurance companies to fund it . . . oooooppppppssss! went generic! (at least the 300 mg tab, which is the important one anyway).

Effexor XR . . . in general, a good product.  The rate of people having trouble with plain old Effexor is high enough to justify the extended release version. 

Ambien CR . . . how can you possibly improve the best sleeping aid . . . they tried to do it.  While it is a good idea for a small goup of patients who are not able to get through the night with regular ambien, it hardly means that we have to prescribe it for everyone who needs a sleeping aid . . . especially now that regular ambien has gone generic.

Klonopin Wafers . . . dissolvable . . . waste of time.  Get a drink of water.

 Xanax XR . . . nice try . . . already went generic.

Ok, now that I have irritated the largest industry outside of the military, let me explain.

First and foremost, the duty of the doctor is to treat the patient with whatever is the most relevant medication for the presenting illness.  While this means that some of these extended release products are clinically important and helpful, it does not mean that they should be used just because they exist.  They do have a role in a very small section of the mental health population who, for whatever unusual reason, cannot or will not take the standard pill form.  In an era where the cost of care is escalating, and the outrage of the public is rising against under/un-insured people and insurance execs with million dollar salaries, I do feel that it is my duty . . . AND THE PATIENT’S DUTY . . . to try to minimize their health care expenditures.  Not at the expense of clinical care.  That is the first priority.  But do I really need to use the new improved once a day medicine with the old once a day version worked quite well???  

What do you think?

–Dan Hartman, MD