Tuesday, May 8, 2007

WHO list of essential medications

Have you heard of the WHO list of essential medicines, and if so, have you bothered looking at it?

It is a list of truly necessary, not replaceable, basic ("essential") medicines. If you were about to be dropped of in Durfur to establish a general purpose clinic, that is what you would take with you.

Let's look at the birth control pills, which is something that I, as an ObGyn, can talk about: You will find just two, the combinations of EE and norethidrone, to us known as Necon and the combination of EE and levonorgestrel or Levora.

That's it. And let me tell you, it is enough, even for the US. With Necon you have an OCP with a progestin component that has little androgenic side effects, is very well tolerated, generic and dirt cheap. With Levora you have an OCP with a more androgenic profile with excellent bleeding control, which we use in Levora, Seasonale (just a re-packaged Levora, no misteries there), Plan B and Mirena. Also generic, also dirt cheap.

How come there are over 100 OCPs o the market? All "Me too" products, nothing revolutionary new, maybe, but only maybe, Jasmin. So why do the parmaceutical reps fill your ears with "information" about their fabulous new pill with oh-so-great bleeding pattern, side effect "profile" and other utter nonsense?
Plain profit making. Nothing else.

We do not need most of the medications that are not on the "essential list", or we need them only for extremely specialized purposes. We really do not need over 100 different oral contraceptives, since the only thing that makes a difference between them is the individual response of a woman's body to any given birth control pill. And that, dear pharma rep, was, is and will remain unpredictable. You just have to try. During my first residency, many years ago, I asked one of my attendings about what to do if a woman did not like her birth control pill. His answer was: "Just give her any, but really any, other pill". Back them I thought he was rude and maybe even stupid. Now I have experienced that it is in fact true.

Another example: I still prescribe good old Ibuprofen for pain. It is cheap and it works every time. And the fact that I never prescribed those fancy new cox-2 inhibitors saved me a few sleepless nights when some of them were withdrawn from the market.

My other rule about prescribing medications is:
If I see it on TV I don't prescribe it. My patients would just be paying for the TV ads. Also, if a phrama rep comes to my office and pitches a medication, I don't prescribe it. It has to be expensive, if not they would not pay for a rep to come over. And of course, most of the meds they pitch are "now tier 2, and only with such and such insurance tier 3, but we are working on that"...

So, take a look at the WHO list of essential medications and see which meds in your field are essential! And which ones you can do without.

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