Year : 2014 | Volume
: 5 | Issue : 4 | Page : 143--144
Comparisons are odious
Boehringer Ingelheim India Private Limited, Mumbai, Maharashtra, India
C-35, Rose Blossom, Sitladevi Temple Road, Mahim, Mumbai - 400 016, Maharashtra
|How to cite this article:|
Suvarna V. Comparisons are odious.Perspect Clin Res 2014;5:143-144
|How to cite this URL:|
Suvarna V. Comparisons are odious. Perspect Clin Res [serial online] 2014 [cited 2019 Jul 20 ];5:143-144
Available from: http://www.picronline.org/text.asp?2014/5/4/143/140540
Doctors often ask companies which drug is better. This is because companies try to promote that their drug is better than competitor drugs. However quite often, among the so-called me too drugs within the same class there are no adequately powered, well-designed, head to head, clinical comparative studies. In the absence of such data, how fair is it to compare? Why will we not have such head to head studies with other members in the same class? Is it because the difference between these drugs is so small that one would need 1000's of patients to show that one drug is better than the other? And even if one is able to show that the difference is statistically significant, can we always say that the difference is clinically significant? Plus one may end up spending a lot of time, money and effort and still run the risk of the competitor being better, or that the study may be prematurely terminated for reasons of futility? So then what do companies resort to? Indirect comparisons. Why? It's because all the new kids on the block have been compared to the standard of care. However, such indirect comparisons have obvious limitations as study designs and patient populations may be different. Meta-analyses (regression/network) are done but are again fraught with the same limitations. 
Plus the disease is heterogeneous, for example each patient can experience a stroke or diabetes differently. Number needed to treat (NNT) or number needed to harm (NNH) is sometimes calculated, but the same patient may experience benefit and harm. Hence, people have come up with NNT unqualified success (how many patients must I treat before one experiences benefit without experiencing harm) and NNH unmitigated failure (how many patients must I treat before one experiences harm without experiencing any benefit).  Still one is not able to compare. Don't despair. Dare (to be different). Naturally, it makes sense, not to compare, but to focus on our own product, look into our own database, identify patient clinical characteristics that correlate with optimal safety and/or efficacy outcomes, and use this to help doctors to maximize the appropriate number of patients who should be on our product.
Klastersky wrote in an NEJM editorial, "the real issue is no longer the choice of the "best" agent, but rather the identification, on a rational basis, of the population of patients who will benefit from a given agent the most."  In other words, it is not that one drug is better than another. It is about finding out, which patient responds best to which drug/regimen. Companies may find the former relevant. For doctors, the latter is relevant. In the spirit of competitive collaboration, companies can come together and facilitate practical or pragmatic investigator initiated trials that address clinically relevant questions.
For example, companies marketing products for hormone responsive breast cancer could have facilitated pragmatic trials in women with hormone responsive breast cancer that are estrogen receptor and/or progesterone receptor positive, where investigators try and match a patient subset to the right treatment, in sequence or in combination, viz., tamoxifen, or aromatase inhibitors or inactivator or fulvestrant.
Even when we do a head to head parallel group study comparing two drugs, patients in one arm are not exposed to the other drug, and hence one does not know how these patients would have responded to the other drug.
In other words, let us focus on our customer's needs and help them match the right patient to the right drug, instead of comparing in the absence of appropriate data. This approach may apparently shrink the market, but ultimately one gains by having the right patient on the right drug for life (in chronic conditions), thus increasing the length of a prescription and ensuring customer life-time value. And one's credibility is enhanced in the eyes of the customer and consumer. Remember we too can be patients 1 day.
|1||Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: A meta-analysis of randomised trials. Lancet 2014;383:955-62.|
|2||Schulzer M, Mancini GB. 'Unqualified success' and 'unmitigated failure': Number-needed-to-treat-related concepts for assessing treatment efficacy in the presence of treatment-induced adverse events. Int J Epidemiol 1996;25:704-12.|
|3||Klastersky J. Antifungal therapy in patients with fever and neutropenia-More rational and less empirical? N Engl J Med 2004;351:1445-7.|