I would like to clarify a point made in Dr Ian Griffiths’ recent letter ‘Opponents of DTCA need the objectivity they expect of advertisers’ (http://www.nzma.org.nz/journal/116-1183/641/).1

He is responding to a letter published in a previous edition of the NZMJ, ‘Direct-to-Consumer advertising is more profitable if it is misleading’ (http://www.nzma.org.nz/journal/116-1182/610/), in which Dr Peter Mansfield and Barbara Mintzes state that GlaxoSmithKline’s ‘advertisement does not explain that Flixotide [fluticasone] is more expensive than appropriate doses of the alternatives’. In his response Dr Griffith’s suggests that. fluticasone is the same price as other inhaled corticosteroids, with improved outcomes. The reference quoted for pricing information is the Pharmaceutical Schedule available online at www.pharmac.govt.nz/schedule.asp as accessed October 2003.

While Dr Griffiths is correct in saying that the (current) price of fluticasone is the same as other inhaled corticosteroids, he forgot to say that this was not the case before February 2003. This was when PHARMAC reference priced inhaled corticosteroid (ICS) metered dose inhalers (MDIs), based on equivalent beclomethasone (BDP) dose – where fluticasone is generally accepted to be twice as potent as both BDP and budesonide.3 Given that Mansfield and Mintzes’ comment related to the time at which the advertisement was running, April to October 2002, ie, before fluticasone reference pricing, their comment is valid.

At the time that GlaxoSmithKline’s advertisement was running, the subsidy payable for Flixotide 25 mcg per dose MDI was $0.03, or 69% per dose more than the subsidy payable for Becotide Junior. Likewise, for Flixotide 50 mcg MDI it was $0.02 (34% more than Becotide 100); Flixotide 125 mcg MDI, $0.08 (68% more than Becloforte); and Flixotide 250 mcg MDI, $0.12 (54% more than the equivalent dose MDI for Becloforte).

Up until reference pricing, fluticasone was an expensive drug relative to other ICSs. Not only was it more expensive dose to equivalent dose, but also it was (and is) prescribed at daily doses higher than equivalent doses of BDP or budesonide,4,5 while conferring no extra benefit at higher doses.6 The weighted average cost of fluticasone per patient between April 2002 and January 2003 was $347 per year, compared with $207 for BDP (68% more).

We also dispute the claim that fluticasone ‘has a substantial body of evidence for improved outcomes’.Based on the findings of the relevant Cochrane Review, there is no clear evidence for fluticasone being superior to beclomethasone at equivalent doses for most patients.7

Perhaps there may still be varying shades of objectivity?