Billion dollar lawsuits, scientists on drug company payrolls, and endless advertising.  The ten best selling medications in the US tell quite the story.  Without further ado…

#1 Lipitor

Lipitor, a treatment for high cholesterol, comes in at number one.  Can you guess how much it makes Pfizer every year?

What it does: Lipitor works by inhibiting an enzyme in the cholesterol synthesis pathway.  So take it, and you make less cholesterol.

This is important because cholesterol tends to stick to our arteries like gum to a lead pipe, clogging them up.  Which is bad.

Concerns:  While fighting cholesterol is typically a good thing, Lipitor is part of a trend towards medicine that is very statistically based.  You may be perfectly healthy, but studies show that taking this pill will reduce your chance of ABC by XYZ, so go ahead and take it.

That’s good, right?  Well, scientists are far from perfect.  And, we’ve discussed how the cholesterol level deciding committee is essentially entirely on the payroll of big pharma.  The guys who decide how much medicine you should take are paid by the companies which make drugs.  Not so good.

The weird stuff: Pfizer used Dr. Jarvik in many Lipitor advertisements, but accidentally forgot to mention that he wasn’t actually a medical doctor.  (But since he did invent the first artificial heart, personally, I think he knows what he’s talking about!)

Sales: $13 billion annually

#2 Plavix

Plavix – my professor calls it a “wonder drug.”  Why?  I’m not entirely clear, but it certainly is popular.

What it does:  Plavix makes blood platelets less likely to form a clot.  Technically, it binds to a receptor for ADP and blocks it, which stops an important signaling pathway.  Since clots can be deadly (what do you think happens when a large piece of gunk clogs up your heart?), that’s a good thing.

It’s mostly used in the context of a heart attack.  Remember, that heart disease is the number one killer in the US by far, which explains its popularity.

Concerns:  Heavy marketing towards consumers.  The ads pretty much say that you’ll die if you don’t take Plavix.  Considering that it has serious side effects, and that it should only be used in certain types of heart attack, that’s a bad thing.

Plavix is the type of nitty-gritty drug that you should expect your doctor to know about.  And when you’re being put in an ambulance to the ER with a heart attack, the last thing you should have to think about is an ad on TV telling you that you’ll die unless your doctor gives you a specific drug.

Sales: $6 billion

#3 Advair

What it does: Advair relaxes the lungs and reduces inflammation there, mainly used for asthma.  Chemically, it’s a combination of a steroid (which reduces swelling) and a long acting beta agonist (which tells your lungs to relax).

The weird stuff:  Advair has a black box warning.  That’s the worst that can happen to a drug short of being pulled off the market.  The reason?  One of its ingredients was shown to increase your risk of dying from asthma by 400%!

(You can read why Advair is probably a safe drug.  But still scary.)

Sales: $6 billion

#4 Nexium

Aka, “The Purple Pill.”

What it does: Nexium interferes with a proton pump in the stomach.  Proton pumps are responsible for establishing concentrations of hydrogen that are acidic.  Nexium, thus, reduces acid secretion in the stomach.

Considering how common indigestion and stomach pain is, it’s quite popular.

The downsides:  Nexium is an expensive prescription drug.  What it consists of, however, is nothing more than a specific form of the active ingredient in a much cheaper drug.  Is it any better than the cheaper form?

Sales: $5 billion

#5 Norvasc

What it is used for: Heart pain and hypertension

What it does:  Norvasc blocks calcium channels.  Because calcium is an essential chemical in muscle contractions, blocking calcium channels can lead to muscular relaxation.  Muscle relaxation can lead to improved blood flow and lower blood pressure.

3 Weird Side Effects:

1) Norvasc can make certain types of your white blood immune cells go bye bye
2) It can make your gums start growing, elegantly named gingival hyperplasia.
3) Stasis dermatitis.  Blood in your legs starts pooling up, possibly popping capillaries.  Your skin can turn brown.

These are quite rare, however.

Sales: $4.8 billion

#6 Zyprexa

What it’s used for:  Schizophrenia and bipolar disorder.

The naughty stuff:  Eli Lilly, the company which makes Zyprexa, covered up the drug’s serious side effects like increased risk of diabetes.  They also pushed the drug to be used for many conditions which it was never shown to work, like senile dementia.

So the executives at Eli Lilly were fine with Grandma being put on a powerful anti-psychotic that could cause diabetes, uncontrolled movement disorders, and dizziness just so they could make more money.

Their highly unethical marketing cost them a $1.4 billion lawsuit.

If you want to learn more about Zyprexa, I’d highly recommend checking out Furious Seasons, an investigative blog that covers it and other BigPharma shenanigans.

Sales: $4.3 billion

#7 Risperdal

We’ve talked about Risperdal before.  A popular, tranquilizing antipsychotic.

What it’s used for:  Everything.  See a shrink?  You might get given Risperdal.  It’s that simple.

The bad stuff:  An antipsychotic with serious side effects is being used for every single psychiatric ailment.  Don’t believe me?

OK.  Off the top of my head, Risperdal is used for ADHD, anxiety disorders, depression, schizophrenia, bipolar disorder, OCD, dementia, autism, and eating disorders.

And that’s without checking for the endless papers with titles like, “Risperidone may show efficacy for treating shoe-eating zombies.”

But don’t worry.  Shrinks know what they’re doing, and never get compensation from drug companies for making the right choices.

Sales: $4.1 billion

#8 Effexor

What it does: Makes people feel happy, except when it makes them suicidal, that is.  Chemically, Effexor inhibits reuptake of serotonin and norepinephrine.  This may help reduce anxiety and may play a role in treating depression.

The weird stuff:  While a treatment for depression, like many other antidepressants, Effexor may increase your risk of committing suicide.

Why is it that antidepressants can cause suicidal thinking and behavior?  Dunno.  More importantly, has that stopped more than 25% of students at some colleges from taking them?  Nope!

Sales: $3.7 billion

#9 Prevacid

What it does:  A proton pump inhibitor that…wait a second, it’s basically Nexium all over again.

Next!

Sales: $3.5 billion

#10 Zocor

What it does: Like Lipitor, Zocor is a statin, and is used to lower cholesterol levels.  To spice things up…

3 Weird Side Effects:

1) Zocor can cause dermatomyositis, a type of degenerative rash, where your immune system attacks the skin
2) It can also cause chylothorx, where the body leaks fluid into the space around the lungs
3) And it can cause your body to attack the kidneys causing, well, kidney failure

Note: these side effects also apply to Lipitor.

Sales: $3 billion

What the Advair Warning Means

Asthma is pain enough by itself. Then you learn that the medications you take for it might, well, kill you.

You might be concerned because Advair, for instance, has a black box warning, the worst the FDA can do short of withdrawing a drug.

The good news, however, is that it seems that the main concerns about Advair’s safety are in one of its ingredients and is addressed by its dual formulation.

What is Advair?

Advair is a combo drug of albuterol or salmeterol, a long acting Beta agonist (LABA), and fluticasone, a steroid.

The problem comes from the salmeterol component of Advair. The chemical action of this drug is to go into the lungs and target beta receptors. By activating them, the drug causes your lungs to relax, which eases the asthma. Good, right?

Well, yes. Problems arose, however, when a researcher comparing use of salmeterol to another drug noticed that the risk of death of those using salmeterol was three times higher than the other medication. Concerned, the US government in the form of the FDA helped organize a much larger examination of salmeterol.

And what they found was pretty bad. People who used it a LABA as their sole asthma treatment were four times as likely to die as those using inhaled steroids. So how on earth can your doctor tell you to take Advair?

The biological explanation

The answer? Well, let’s step back a little.

The probable reason that salmeterol was associated with increased risk of death was because of how it works. It goes to the lungs and tells them to relax; it doesn’t, however, help control inflammation. So it might make you feel better while the serious biological problem of inflammation is happening.

It’s symptom control without controlling the underlying disease.

This is supported by the possibility that the very same study the FDA ran seems to show that, in combination with steroid treatment, LABA doesn’t significantly increase your risk of dying.  (Though that doesn’t sound very reassuring!)

To top it off, several major analyses including the Cochrane database of systematic Reviews show that use of a LABA with a steroid, dual therapy like that in Advair, is not associated with increased problems.

And dual therapy may have a slight advantage in lung function and, possibly, have less effect on growth in a child.

Conclusion

We still aren’t 100% of how safe Advair is.  That said, the logic behind its combination is solid and seems to have some good medical support.  From what I’ve seen, it makes sense not to take salmeterol by itself, which is exactly what Advair addresses.

On the other hand, it may be possible to treat asthma with steroids alone, just by increasing the dose.  Still, steroids are potent and can have significant side effects.

Thanks for reading!