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Health Trends

Prescription Drug Sales Continue Upward Trajectory

A proliferation of new products, coupled with growing prescription drug use by managed care companies, will continue to fuel double-digit growth of prescription drug sales through the year 2000. This projection, which continues a trend of the past two years, was released last month by IMS America Ltd., a health care and pharmaceutical information company.

"We see double-digit real (excluding inflation) growth through the year 2000," said Rich Fehring, vice president of U.S. client relations for Plymouth Group, an IMS consulting unit.

According to IMS, prescription drug sales rose at a real growth rate of 10.1% in 1997, the same growth rate as 1996. Total prescription sales grew 12.6%, to $81.2 billion, in 1997.

IMS collects data on prescription drug sales from community pharmacies, hospitals, clinics, long-term care facilities, and health maintenance organizations.

Prilosec, marketed by Astra-Merck, Inc., for the treatment of ulcers, had the highest sales of any prescription drug in the United States in 1997. Prilosec sales rose 31% in 1997 over 1996 levels, to $2.3 billion. Eli Lilly's antidepressant Prozac ranked second, with 1997 sales of $1.9 billion, up 12.2% from 1996 levels.

A Cellular Fountain of Youth

Researchers at the University of Texas Medical Center in Dallas are conducting laboratory experiments that indicate a particular enzyme may help human cells avoid the normal aging process and correct or slow some of the ravages of time, including skin wrinkling, some types of blindness, and cardiovascular disease.

"We're not saying this will give people something to make them live longer," said Jerry Shay, MD, coauthor of a study on the cell discovery that appeared in the January 14 issue of the journal Science. However, according to Shay, the work confirms that cells can be kept youthful far beyond their normal life span by keeping them alive and dividing.

Shay and his fellow researchers prevented the death of normal cells by inserting a gene that allows cells to maintain a normal chromosome length. Typically, a human cell divides about 70 times over a lifetime; each time it divides, the protective end of the chromosome, called the telomere, shortens.

Eventually, when the telomere becomes too short to protect the chromosome, the cell can no longer divide, and it dies. In effect, the telomere acts as a biological clock that stops cell division and leads to manifestations of aging.

Shay and his colleagues reported that when they transferred a gene that makes telomerase-an enzyme that keeps the telomere from shortening-into human cells, the cells continued to divide long after the normal 70th-generation span. "These cells are now up over 100 population doublings, and they show no evidence they will slow down," Shay said in his report.

In their research, the scientists used pigmented epithelium cells, which are involved in the age-related disorder macular degeneration. They also used skin fibroblast cells, which help maintain the proper level of collagen in the skin; the death of these cells is linked to skin aging and wrinkling.

Though the researchers saw no immediate practical application for their research, they speculated that the technique may eventually be used to treat patients for some disorders by removing aging cells, treating them with telomerase, and then restoring them to the patient's body. They also speculated that telomere research may eventually lead to techniques for treating aging arteries in patients with heart disease, methods to grow skin for graft and burn patients, and ways to grow bone marrow cells for treating cancer and blood disease.

Short-term Care Policies Enter the Marketplace

A few insurers are beginning to add a new type of policy to the options offered to consumers: the short-term care (STC) facility policy. These plans pay for care in a nursing facility, just as long-term care policies do, but care is covered for a limited time, typically ranging from 90 to 360 days.

One recent entry into the STC market is Central States Health and Life Co. of Omaha, Nebraska. Central States, which also sells long-term care policies, is marketing its new STC offering in five states: Nebraska, Missouri, Colorado, Wyoming, and Mississippi.

Central States' base contract offers 90-, 180-, 270-, or 360-day benefit periods for nursing facility and assisted living care; daily benefit options range from $50 to $150, and benefit eligibility is based on loss of two to five activities of daily living (ADLs) or cognitive impairment.

Central States' STC policies target middle- to low-middle-income consumers who have less than $50,000 in assets, excluding their homes, say Joseph Amato, director, senior life and life markets for the company. The policies are designed to appeal to seniors with fixed incomes who don't have significant assets to protect, according to Amato.

"Such individuals will find STC prices more affordable than LTC prices," predicted Amato, "and they'll like the policy's ability to help them remain independent in their later years."

New Report Suggests at Least Four Nutritional Supplements a Day

Daily use of four nutritional supplements-vitamin E, vitamin C, calcium, and a multivitamin with folic acid-can produce dramatic improvements in long-term health, according to a report released on March 31 by the Council for Responsible Nutrition (CRN), an association representing the dietary supplement industry.

KEY FINDINGS OF NUTRITION REPORT The following are some of the key findings from studies and surveys cited in the recent Council for Responsible Nutrition (CRN) report Optimal Nutrition for Good Health: The Benefits of Nutritional Supplements. Among the elderly, the routine use of multivitamin and mineral supplements could improve immune function and reduce the incidence of infectious diseases. In a recent year-long, double-blind, placebo-controlled trial conducted in Newfoundland, researchers found that men and women over 65 years of age who took a modest multivitamin and mineral supplement reported only half as many illnesses as a placebo group. Recent epidemiological studies involving more than 100,000 people found those taking at least 100 international units (IU) of vitamin E every day reduced their risk of heart disease by 40%. Study results published in the February 1998 issue of the Journal of the American Medical Association indicated that using multivitamins with folic acid lowered homocysteine levels and reduced the risk of heart disease in women by 45%. The appropriate use of supplements could substantially reduce health care costs: more than $10 billion could be saved annually if people took at least 100 IU of vitamin E on a regular, long-term basis to reduce the risk of heart disease; the use of antioxidant vitamins C and E to reduce the incidence of cataract operations could save $3.5 billion annually. Most vitamins and minerals appear to be safe within a wide range of intakes. Reports of adverse effects from vitamin or mineral supplements are relatively rare. Optimal Nutrition for Good Health: The Benefits of Nutritional Supplements is available for $10 from CRN, 1300 19th St., Suite 310, Washington, DC 20036.

No Observed Adverse Effect Level (NOAEL) and Lowest Observed Adverse Effect Level (LOAEL) for Vitamins and Minerals   Vitamin NOAEL LOAEL Vitamin A 10,000 IU 21,600 IU Beta-carotene 25 mg None established Vitamin D 800 IU 2000 IU Vitamin E 1200 IU None established Vitamin K (phylloquinone) 30 mg None established Vitamin C Over 1000 mg None established Thiamine (B-1) 50 mg None established Riboflavin (B-2) 200 mg None established Nicotinic acid 500 mg 1000 mg Nicotinamide 1500 mg 3000 mg Pyridoxine (B-6) 200 mg 500 mg Folic acid 1000 mcg None established Vitamin B-12 3000 mcg None established Biotin 2500 mcg None established Pantothenic acid 1000 mg None established   Mineral NOAEL LOAEL Calcium 1500 mg Over 2500 mg Phosphorus 1500 mg Over 2500 mg Magnesium 700 mg None established Chromium III 1000 mcg None established Copper 9 mg None established Iodine 1000 mcg None established Iron 65 mg 100 mg Manganese 10 mg None established Molybdenum 350 mcg None established Selenium 200 mcg 910 mcg Zinc 30 mg 60 mg (Daily Intake Levels) Source: Council for Responsible Nutrition

Taking these four supplements every day could cut peoples' risk of having heart attacks by 40%, protect vision during the aging process, prevent 50,000 hip fractures annually, and reduce by more than half the number of babies born every year with neural tube birth defects like spina bifida, according to studies cited in the report. In addition, multivitamin use could substantially reduce the incidence of infectious diseases in the elderly.

"We now have a substantial body of data showing that if everyone took a few supplements every day, they could significantly lower their risk of a multitude of serious diseases," said David Heber, MD, PhD, director of the UCLA Center for Human Nutrition at the University of California, Los Angeles. Heber spoke at a press conference in Washington, where the report was released.

Optimal Nutrition for Good Health: The Benefits of Nutritional Supplements is a compilation of the most recent scientific data on vitamins, minerals, fiber, carotenoids, fish oils, and other nutritional supplements. Studies cited in the document demonstrate that supplements may be helpful in protecting against chronic diseases and conditions such as osteoporosis, birth defects, heart disease, stroke, infectious disease, macular degeneration, and cataracts.

The report's author, Annette Dickinson, PhD, is CRN's director of scientific and regulatory affairs. She called upon the Department of Health and Human Services to "more fully" recognize the role of supplements in the next revision of Dietary Guidelines for Americans, and urged the United States Department of Agriculture to drop its prohibition against using food stamps to buy nutritional supplements.

Attending to Proper Medication Management in Assisted Living Facilities

A team of researchers at the University of Minnesota is exploring the way medications are managed in board-and-care and assisted living facilities. Their study of 98 facilities throughout Minnesota showed wide variations in the way medications are stored and administered, prompting them to strongly urge that there be some level of training for those who administer medications in assisted living facilities.

The study was authored by Judith Garrard, PhD, a psychologist with the School of Public Health at the University of Minnesota; Susan Cooper, a pharmacist currently working with HealthPartners, Inc.; and Christine Goertz, a doctoral student in the Division of Health Services Research, University of Minnesota School of Public Health. The study was published in the December 1997 issue of The Gerontologist.

Of the 98 facilities surveyed, 86% provided medication storage, 83% gave medication reminders, and 69% administered medications to one or more residents. However, six of the 98 facilities reported that a resident had been hospitalized because of an adverse drug reaction or medication overdose.

In a follow-up interview with 64 of the 98 facilities, "We found that one or more residents were allowed to manage their own prescription medications in one third of the facilities," the researchers noted.

"We believe that there should be some minimum regulation of medication storage and administration in board-and-care facilities," continued the researchers, "because many of the residents are elderly, frail, and vulnerable, and society has a responsibility to assume some oversight of their welfare in these facilities." The researchers noted that their study convinced them that "specific standards should be established requiring a minimum level of training for staff who set up or administer medications."

Internet Webzine "Between Rounds" Looks at Physician Entrepreneurs

The April edition of the Internet Webzine "Between Rounds" (www.betweenrounds.com), an electronic publication sponsored by Astra Merck, Inc., explored issues surrounding physician entrepreneurs and managed care. Articles included:

• "Forecasting the Voyage Out," in which a panel of health care experts predicted a rise in provider-sponsored organizations as growing numbers of physicians seek the benefits and protections provided by unions. The experts also predicted new technologies that would help contain costs while boosting quality of care, improvements in the management of chronic diseases such as diabetes and multiple sclerosis, and growth of individually based health insurance systems.

• "Apostle of Outcomes," the story of a physician who believes that clinical practice will benefit from techniques learned in business school. The physician has developed outcomes measurement tools and clinical practice guidelines to help assess the cost-effectiveness of health care delivery systems.

• "Risky Ventures," a look at the successes and failures of physicians trying to establish their own managed care organizations, including the difficulties encountered by doctor-owned groups as they try to overcome the financial advantages enjoyed by managed care organizations.

AAN Highlights New Information on Alzheimer's Drugs

Highlights of the American Academy of Neurology's 50th Anniversary Annual Meeting April 25-May 2 in Minneapolis included reports of several new studies on donepezil and metrifonate, cholinesterase inhibitors that show promise in treating patients with Alzheimer's disease.

Donepezil is approved for use for Alzheimer's; metrifonate has not been approved for use with Alzheimer's.

Research on donepezil presented at the meeting included:

• A study showing that donepezil improves behavioral symptoms such as apathy, hallucinations, and purposeless, repetitive movements in addition to improving cognitive symptoms, the indication for which it was approved. The study of 40 Alzheimer's patients also showed a significant reduction in the stress levels of patients' caregivers. "Any benefit regarding behavioral symptoms is important, because such symptoms often contribute to caregiver burden and nursing home placement," said neurologist Daniel Kaufer, MD, director of the Alzheimer's treatment program at the University of Pittsburgh Alzheimer's Disease Research Center.

• A study of 1,035 patients of community-based physicians showing that donepezil is as effective and safe in this population-which is more likely to represent the average Alzheimer's patient's experience-as it was in studies conducted at centers specializing in Alzheimer's research.

Research on metrifonate included:

• A 26-week study of 1,218 people with mild to moderate Alzheimer's disease found that metrifonate significantly improves patients' ability to perform basic daily activities such as dressing and eating, as well as other activities such as making a phone call or doing housework, when compared to patients who were given a placebo.

• Another analysis of the same 26-week study found that metrifonate significantly improves cognitive functioning in patients when they are compared to untreated patients. Patients who received a higher dosage of the drug (60-80 mg, based on the patient's weight) showed more improvement than those who received a lower dosage (a 50 mg fixed dose, or 30-60 mg based on weight).