in sickness and in health

The CDC released its 2007 National Diabetes Fact Sheet recently. Among the notable findings, 24 million Americans suffer from diabetes, with another 57 million in a pre-diabetic state. 90-95% of these are type 2 diabetes, also known as non-insulin dependent or adult-onset diabetes. It is by and large a preventable form of the disease.



While pre-diabetics don't always progress to diabetes, a very significant percentage do. Type 2 diabetes is strongly associated -among other things- with being overweight and being physically inactive. Many people with type 2 diabetes can control their blood glucose by losing weight, following a healthy meal plan, and exercising. In most cases, their doctors will add a blockbuster oral drug for good measure. If all that fails, insulin is the only option.

However, even when treated appropriately with all the life-saving medications the pharmaceutical industry can offer, diabetes is nasty killer. Its victims suffer increased infections, blindness, limb amputations, kidney disease that may lead to dialysis, heart attacks, strokes, and other ills. It is not a pretty picture.

Diabetes is more common in certain ethnic groups, many of whom also happen to suffer from very high incidences of obesity. There is little doubt that, in many instances, diabetes is a life-style disease. You could say, it is part of the price we all pay for cheap oil. A tax on gas so to speak.

You may have seen those anti-smoking ads that the State of California put out recently. In it they take down the glamorous Marlboro man image to that of a sick person, sitting in a wheelchair with oxygen supply lines in their nostrils. For now at least, smokers are free game. Not so for the overweight and the sedentary. At least not yet. However, it would not be hard to imagine a similar ad that takes down the image of the successful macho SUV driving male to a similarly more realistic representation.

take two of those and see me in a week

The best selling drug in America is Pfizer's Lipitor. It sold over $6B last year. Lipitor is a cholesterol lowering medication. It is, in essence a preventive drug. It is there to prevent heart attacks and possibly stroke. It is also a pharma company's darling. You take it for life, no matter how good or bad you feel. High cholesterol is almost always a no-symptom condition and Lipitor does not treat any symptom or subjective problem. It just lowers your cholesterol and may or may not produce some unwanted side-effects. Once you hit a magic number on the cholesterol scale, you are stuck for life. Apart from Lipitor there are a few other cholesterol lowering medications that had over $1 billion in sales last year. These include Vytorin, Zetia, and Crestor.

Despite these high sales, we had to confront a rather unpleasant reality. Tim Russert, a well-known journalist died suddenly of a heart attack at age 58. Mr. Russert, the moderator of Meet the Press on NBC, took high cholesterol pills, aspirin, and high blood pressure pills we are told. The latter, also blockbuster drugs treat another no-symptom condition that is diagnosed in the doctor's office. Another preventive medicine class with members in the top 100 best selling drug list for the year. We are told Mr. Russert was also in the good care of well-known cardiologists. He was given check-ups and stress tests and he always passed with flying colors. His cholesterol was normal and his blood pressure a stellar 120/80. Yet he died suddenly, with no warning and no symptoms. That was unsettling.

Mr. Russert is not alone of course. He is only the best known member of a class of 300,000 people who die suddenly of heart attacks. And about 150,000 of those have no symptoms whatsoever. They just drop dead one day, good cholesterol and all. With or without medication. So much for taking drugs all your life. But let's go back to the bestsellers for a moment.

Number two on the best seller list is Nexium, the purple pill. At $4.4B a year, another stellar performer. And one most people ask for no doubt. Because there are older and equally effective medications in the generic arsenal. Nexium is another darling of the industry. For a different reason though. Nearly everyone can take it. And many people do. Most take Nexium for the occasional indigestion or a bit of acid reflux. They take it so they can go to McDonalds and have a big mac with fries without getting an upset stomach. Or maybe, because they had too much to drink.

Number three on the list is Advair Diskus, a medicine for asthma. Asthma too can be a rather serious condition, but once again most people taking Advair are using it for the occasional nasty wheeze. Advair is a bronchodilator that has been around for a long time in generic form, combined with a steroid, all in a nice package to inhale easily. Advair Diskus is good for almost $3.4B a year.

Next on the list is Prevacid, a competitor to Nexium. $3.3B to cure more heartburn and indigestion. Maybe we need to look at what we eat instead of popping pills? Over $7 billion for heartburn. It is likely to give one heartburn just thinking about it.

Rounding out the top five is another drug Mr. Russert could have used. Plavix, a high prized competitor to lowly aspirin when it comes to heart attack prevention. Plavix is usually given after a heart attack or stroke to prevent recurrence. That is, of course, if the first heart attack or stroke doesn't kill you right away.

All in all the top five generate over $20 billion in sales in the US alone. None of them seem particularly impressive at what they do.

Rounding out the top ten, we find Singulair, another asthma drug, Seroquel, an anti-psychotic, Effexor XR and Lexapro, two anti-depressants, and Actos, a medication for type 2 diabetes. All of these drugs have over $2 billion of sales per year each.

Apart from more wheezing drugs, and a medication for overweight people who develop diabetes, there are the mental health medications, that feature so prominently on the rest of the best-seller list. Here we encounter Risperdal, Abilify, Cymbalta, Zyprexa just to name a few.

These are the life-saving drugs that make America tick. Their main impact it seems, is on the share price of pharmaceutical companies.