14. Sick Versus Slick: 1. Testosterone, Differential Diagnosis, and Marketing

Between 2002 and 2005, prescriptions for testosterone replacement in the US increased from 1.8 million to 2.5 million.  As of 2011, testosterone prescriptions have surpassed 5.5 million per year.  Not yet close to the 30 million estrogen prescriptions written for women annually in the 1990s.  Still, testosterone replacement for men does appear to be growing rapidly.

Yet, its growth is somewhat puzzling.

There has been no sudden outbreak of low testosterone in the past decade. There has been no publication of any reputable study that strongly suggests that all men of a certain age must be on testosterone replacement.  Most physicians, in fact, are less than comfortable with testosterone replacement therapy and tend to associate testosterone replacement more with its risks than its potential benefits.  Similarly, routine laboratory screening for low testosterone is neither recommended or advised.

If the medical profession is neither promoting testosterone replacement or regularly screening for low testosterone, then how is it that testosterone replacement prescriptions are increasing?

Because of marketing, baby.  Sweet marketing.

Abbott Laboratories maker of Androgel 1% and Androgel 1.62% testosterone gels, have been running a fairly effective consumer advertising campaign operating under the guise of educating men about low testosterone.  Snuggled comfortably with Abbott’s edu-tisement is a checklist of symptoms of low testosterone.  The idea is that men complete this checklist and then take the results to their family doctor.  Abbott also provides men with a series of questions that they can ask their family doctor.

Abbott’s direct-to-consumer approach is one of injecting itself into the relationship between patient and physician and potentially influencing the process of differential diagnosis.

Differential what?

Differential diagnosis.  Or the method that most health professionals use to determine likely disorders that might be causing a patient’s symptoms.  For example, blurry vision in the morning?  Could be that you need to have your eyes checked or you could have diabetes. The role of differential diagnosis is to take a careful history of symptoms and slowly move down the diagnostic path via induction and the elimination of unlikely diagnoses.  Ideally, at the end, one arrives at hopefully a small set of probable diagnoses.

Good diagnosticians understand that people are complex and that we rarely have all the information we require to exclude all possibilities. Experience does not lead to confidence.  It leads to humility.

Pharmaceutical companies are well aware that doubt is a strong factor in the differential diagnosis process.  They are also well aware that providing consumers with a list of to-be-asked questions may push the diagnostic process down avenues that health care providers may not normally entertain.

Is it wrong for pharmaceutical companies to use this strategy?  Well, it is not illegal as long as the marketing focus is on the consequences of low testosterone and not the specific product that is being sold as a remedy.  At least that was the decision rendered by regulatory bodies that had been asked to censor Abbott Laboratories for its  marketing campaign.

Pharmaceutical products, however, are not widgets.  They are not consumer items as consumer items are traditionally understood.  Instead, pharmaceutical products are regulated and restricted in how they are approved, acquired, and their terms of use.  This operates ostensibly as a public good.

Is it in the public’s best interest for pharmaceutical companies to try to influence these restrictions?

Now, that is an interesting question.

Your Friendly Druggist

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