Why would doctors prescribe an inferior drug?

#1

Taking the information from here about Telmisartan being much better than Losartan for BP control, diabetes and cardio protection, I wonder why it is not the most prescribed ARB. It also has fewer side effects and is better tolerated. The price may be marginally higher (5 USD a month more).

I asked a local doctor friend why they prescribe Losartan instead of Telmisartan. He acknowledged that Telmisartan appears to be a superior drug but he didn’t know that until he did a ChatGPT comparison. He said that in the UK, both are prescribed.

He said that the hospital authority in Hong Kong chose Losartan so that’s what they prescribe. He said there’s also hospital politics which prevents the best drug from always being chosen. But he would not go into details.

My mother in the USA is also prescribed Losartan instead of Telmisartan even though she could benefit from it’s insulin and cardio protective benefits. I’ve asked my parents to talk to the cardiologist about Telmisartan.

Why would hospitals choose an inferior drug? Is it because Losartan is made by Merck and Telmisartan is made by a smaller German company? The prices are similar and they have both been around since the 1990s.

I guess it goes to show that what the doctor prescribes may not be optimal for your health. Am I missing something here because this doesn’t seem good.

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#2

I remember when I worked for a pharmaceutical company I learned doctors were more likely to prescribe Premarin because Wyeth was in the hospitals giving education, so it followed the doctors later prescribed what was most familiar to them.

I wonder if there is something to tease out from that… was losartan out first?

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#3

Losartan came out in 1995. Telmisartan came out in 1998. So it did have a 3 year lead. But, Telmisartan appears to be the superior drug to me in all aspects.

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#4

In the USA at least, it’s most likely because there’s nobody advocating for telmisartan vs other BP meds. Since it’s generic, there’s no incentive for a pharmaceutical company to pay drug reps or other medical providers to “spread the word”, unlike with newer branded-only meds. That leaves medical providers with the job of keeping up with new research studies in their area of practice, and some are better than others at doing this.

It all goes back to advocating for ourselves and going the extra mile for our own health to do our own research and then hope that our doctors will listen to us, especially in cases where we actually know more about a topic than they do because we’ve done the literature search and they haven’t. Just the other day, my doctor wanted to give me rosuvastatin to lower my Lp(a), and I had to tell him it wouldn’t work and if anything might actually raise it slightly. Nobody likes to eat humble pie, so you have to tread lightly sometimes if you want their cooperation.

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#5

I spoke with another senior doctor here and he said that there’s no difference between the different ARBs and Losartan is widely available at every hospital and clinic. Telmisartan is not as widely available.

I’ll still prefer Telmisartan and I don’t believe all ARBs are the same. I guess doctors really don’t have time to keep up on studies. But you’d think there’s someone in the hospital system who would.

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#6

Obviously not ARBs are the same and the senior doctor who said has probably both low knowledge and high ego.

So why doctors prescribe inferior drugs?

  1. Marketing: doctors are like us, they trust some brands and marketing campaigns when a drug is launched. At launch telmisartan’s superiority wasn’t obvious
  2. Time: doctors don’t follow the latest research. They don’t even follow the official guidelines. There are many papers about this. For instance the European and American guidelines have recommended single pill combinations (SPC) for hypertension for more than 15 years and yet prescription of SPC have decreased over the past 15 years.
  3. Incentives: why would doctors bother to spend time and effort to reduce some long-term outcomes and do something different than what their system does? In the best case their patients will live a few more years but nobody will be able to ascribe that to the change of drug. In the worst case there might be a problem (that might not even be related to the change) and they would suffer from the consequences.

What is more surprising to me is why the associations in charge establishing the guidelines do not recommend specific drugs instead of broad classes: I think they don’t want to be seen as defending a specific big pharma company (even after it goes generic) and because doctors already don’t follow the most basic guidelines their authors might prefer not to make them more complex with drug specific recommendations.

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#7

I like to think that doctors have the best intentions. However, the healthcare system can put the doctors in a situation that becomes very cookie cutter. In the US, insurance companies dictate pretty much everything.
My only other thought is, that Losartan is weaker at BP reduction than Telmisartan, according to what I have read. Maybe that has an influence?

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#8

From my couple years of being a pharma rep, I can promise you that a large number of doctors have no idea what the best drugs are. It’s all about what they learned first, which pharma rep did a better job educating them, which rep they like the most, what their colleagues do, which trip they got to go on… they are just people, and even the ones with the best of intentions often have no idea because only the creme de la Creme continue to research/study. I don’t mean to throw them under the bus, most truly care, but just think about how much time we spend on here and we still don’t have all the answers.

My regular vet is now treating feline kidney disease better for her other patients because I shared with her what I learned in a facebook group! She truly cares and is very smart, but she has a busy practice and no time to learn more than necessary.

To @Davin8r’s point, some hospitals etc offer xyz drug because that rep won the contract due to price or other reasons. It’s all about what is on formulary, at least when I was doing that job…. The VA, kaiser, etc…

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#9

The Different Therapeutic Choices with ARBs. Which One to Give? When? Why?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947116/

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#10

Losartan was approved by the FDA 4/1995 and Telmisartan 1998. I believe it was quite expensive until recently as compared to other ARBs.
I think it is familiarity of use and a lack of education in regard to key differences.
They are prescribing it for Htn … so it’s a lateral move for a doctor when that is the indication.
The problem is the missed opportunity of dual or triple benefit prescribing. I don’t think this is part of the thought process, and specifically treating aging is not part of the thought process.
You come to them for Htn … they pick the ARB they are most familiar with, without recognizing the missed health benefit opportunity.
I have a number of patients on other ARBs - and they often have reluctance to change things, and I have only so much bandwidth for changing multiple things at a single consult.
However, since I released my latest blog on this topic, I now have patients contact me asking - why didn’t you put me on this? So I guess I’ll need to be more proactive myself.

Thx @AnUser for putting the link below! No not self promotion as I’m on the board to participate and get “beat up” for my opinions, and learn. I usually look carefully through the board before starting to write a blog as it saves me from “eating crow” after having made a mistake. This is a great place to look at a range of evidence before going out and then searching for more.

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#11

@DrFraser Could you post a link to your blog? I’d like to check it out.

Thanks for helping your patients live healthier and longer lives.

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#12

https://www.grantfrasermd.com/post/neurocognitive-decline-series---telmisartan

RapAdmin has said it’s fine to link to relevant things and I agree (one doctor on the peter attia subreddit keeps linking inferior things, “self-promotion” becomes only a problem IMO if it wouldn’t be posted by someone else)

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#14

@DrFraser Great blog! I’ll have to read the other articles as well. It’s like Cliffs Notes for health.

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#15

I read a couple of his blogs. Good work. Tough to cram much into a few words that works for a broad audience.

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#16

That’s because most doctors that prescribe these are internists, FPs or GPs… or jack of all trades and masters of none.
The biggest influencer of which drug is chosen by a physician is not what the annoying pharma rep is trying to sell you (cutting in to doctor’s limited time to sing you their company jingle, GTFO, just let me sign for the samples and leave me alone) OR what drug is actually superior… NO none of it… THE MOST INFLUENTIAL FORCE ON DOCTOR DECISION IS…DRUM ROLL… WHAT IS COVERED BY THE THIRD PAYER… because we don’t get paid for doing PA’s and rather not deal with calls from angry patients stating that the drug we prescribed is $$$$ while getting accused of being on big pharma’s pay roll. (Look up anti-kick back laws and Sunshine Act)

However, as a subspecialist (Clinical Immunology/Allergy) I can bore you to death in subtle differences between intranasal steroids or antihistamines. From my experience there is really no superior drug, there is just a drug best suited for every individual. The really inferior drugs just don’t survive the market.

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#17

@Dr.Bart Makes some great comments there. Everyone here should be aware of. 1. Most physicians are not influenced by drug reps. I haven’t spoken to one in probably 20 years.
2. Which drug is covered by insurance is a huge factor. Pharmacist have become so busy they often no longer call a physician to work out a drug that is covered. I just get a fax saying not covered. This is time consuming so we stick with drugs we know are covered.
You have to do your homework so you can work with your doctor to use the drugs that are best for you.

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#18

Then the issue is that the insurance companies need to do their homework and cover the best drugs. After all, it’s in their best interests to keep their clients healthy. They need that win-win scenario.

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#19

You and Dr Bart make great points.

Sounds like things have changed a lot. Back in my day, as one of the first people working at TAP, many doctors were making 5-6 figures using our drug so most would see us and wanted the education, but, to your point @Dr.Bart, t’s not the Wild West any longer, and unless it’s a particularly cutting edge drug, I would imagine that what you both say makes sense.

But yeah, being on formularies/covered by insurance, would remain key.

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#20

Maybe it would be helpful if doctors started using ChatGPT to compare drugs. Here’s one for Losartan and Telmisartan.

Losartan and telmisartan are both medications classified as angiotensin II receptor blockers (ARBs), used primarily to treat high blood pressure (hypertension) and, in some cases, heart failure. Despite their similar mechanism of action, there are several differences between them:

Pharmacokinetics:

Losartan: It has a shorter half-life of about 2 hours, and its active metabolite has a half-life of 6 to 9 hours. This often necessitates more frequent dosing, usually once or twice daily.
Telmisartan: It has a longer half-life of about 24 hours, allowing for once-daily dosing, which can improve patient adherence.
Metabolism:

Losartan: It is metabolized in the liver by the cytochrome P450 system, specifically CYP2C9 and CYP3A4 enzymes. This means it has a higher potential for drug interactions.
Telmisartan: It is minimally metabolized by the liver and does not significantly interact with the cytochrome P450 system, reducing the risk of drug interactions.
Elimination:

Losartan: It is excreted in both urine and feces, with about 35% of an oral dose excreted in urine and about 60% in feces.
Telmisartan: It is primarily excreted unchanged in feces (about 97%), with minimal renal excretion.
Efficacy and Usage:

Both medications are effective in lowering blood pressure, but some studies suggest that telmisartan may have a slightly longer duration of action and more consistent blood pressure control over a 24-hour period due to its longer half-life.
Telmisartan has also been shown to have some additional benefits in terms of cardiovascular protection and potential improvement in insulin sensitivity, which can be advantageous for patients with metabolic syndrome or type 2 diabetes.
Side Effects:

Both medications share common side effects such as dizziness, fatigue, and gastrointestinal issues. However, due to its longer half-life and more consistent blood levels, telmisartan might be associated with fewer fluctuations in side effects compared to losartan.
Clinical Studies and Indications:

Both medications are indicated for hypertension and can be used to reduce the risk of stroke in patients with hypertension and left ventricular hypertrophy.
Telmisartan has additional indications for the reduction of cardiovascular events in patients who are at high risk due to atherosclerotic disease.
In summary, while losartan and telmisartan are similar in their primary function as ARBs, telmisartan’s longer half-life, reduced potential for drug interactions, and additional cardiovascular benefits may make it a preferable choice for some patients. However, the choice between the two should be tailored to the individual patient’s needs and medical history, and a healthcare provider should make the final decision.

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#21

I would love to have an assistant AI… but that would never get thru regulations… .HIPAA, medical liability, boards etc. etc. etc. I have to google old fashioned way.

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