Drug 'probably killed thousands':Vioxx

[cal04]

An arthritis drug withdrawn on safety grounds last year probably killed many thousands of patients, a new study suggests. Researchers said the drug Vioxx may have caused between 88,000 and 140,000 serious heart problems in the United States alone since its introduction in 1999.

With heart disease death rates in the US running at 44%, many of these cases were likely to have been fatal, it was claimed. Vioxx, which has the scientific name rofecoxib, was prescribed to 400,000 patients in the UK. It was taken off the market at the end of September after a three year trial linked it to an increased risk of heart disease events.

The study published on-line today by the Lancet medical journal analysed data from 1.4 million Californians who had used various kinds of non-steroidal anti-inflammatory drugs (NSAIDs). Among them were 27,000 patients who had been taking Vioxx, which belongs to a family of drugs known as Cox-2 inhibitors.

A total of 40,000 were given another Cox-2 inhibitor, Celebrex, while others were taking ibuprofen or naproxen. The investigators, led by David Graham from the US Food and Drug Administration's Office of Drug Safety, found that 8,143 had suffered from serious heart disease between 1999 and last September. Of these, 1,508 died suddenly from a heart problem.

http://icteesside.icnetwork.co.uk/0100news/0200national/tm_objectid=15112290&method=full&siteid=50081&headline=drug--probably-killed-thousands--name_page.html
http://health.dailynewscentral.net/content/view/000333/53/

[fryguy]

1. quick......cap litigation awards before it hurts the drug companies....

/sarcasm off/

[LynnTheDem]

2. And bush wants to FURTHER DEREGULATE the drug industry

And the food industry...and the US nuclear plant safety regs...and and and.

Yep, bushCartel continue to "make us safer" by the day.

[Journeyman]

3. Deregulate. . . then get rid of the lawyers. . .

no laws to protect us, no lawyers to fight for us, no hope for any of us.

[LynnTheDem]

4. Well...'cept for the "good" lawyers, such as Gonzales and all RW lawyers

and...hmmm...get rid of all non-republican lawyers.

And after that, kill off all non-republican Americans.

But gosh, who WILL the poor whiney rightwingnuts have to blame for their own stupidity when no one's left but for themselves???

[nolabels]

7. Ah shucks, let's just get rid of all professional people

and go back to livin like cave men :crazy:


http://www.slycraft.com/mousecatapult.htm

[LynnTheDem]

11. but but but...even accountants??? Such as...me???!!

*sniff*

If it's gotta be then it's gotta be. *sniff* Can I have an ocean-front cave? :D

[depakid]

22. and let's not forget the so called "mainstream" Dems

who I submit- are even WORSE, voting for Gonzales being only latest example.

Whatever rationalizations they may give, won't change the fact that they've been more than complicit in all that's happened.

History will probably more correctly view them as cowards- because that's EXACTLY what they are- and it's why when they "choose their battles," so many people don't believe in them. Who want's to follow cowards?

Getting back to Vioxx- and other phamaceuticals- guess who controlled Congress in 1992 when the Prescription Drug User Fee Act- the "expidited process" that brought you all vioxx and phen-fen was passed?

Guess who was president when the FDA gave Phamaceutical companies the authorization to pollute the public airwaves with misleading ads about Celebrex, Paxil and whatever else lined their pockets at your expense?

I'm sorry, but this isn't a 2 party partisan issue. This is a matter of honesty and integrity. It's a matter of courage. It's a matter of standing up and doing what's right for a freakin' change.

Granted, Republicans are stupid. That's a given. Witness Bill Thomas (R- California) statements about women and social security on "Meet the Press" last Sunday. The Chairman of the Ways and Means Committee obviously hasn't read word one about gender difference in retirement. Not word one.

Democrats, on the other hand, are smarter than that- and in my mind, that makes them even more culpable- they sell out their constituents- they take the money (or "prestige") and turn the other way or maybe they cower in the face of ignorant bullies. Who can say why they do it?

All we can say- all we can see, are the outcomes.

[Spike from MN]

30. I agree

The spineless Dems do us no favors by "reaching across the aisle" and caving in to the Repugs every chance they get. I've had it with them. They can go Cheney themselves as far as I'm concerned. ;)

Back to the OP. I was on Vioxx for 3 years and was switched to Celebrex when Vioxx was pulled off the market. I have always had a history of chest pains but lately I noticed they were getting worse. Since that wasn't a good sign, I quit Celebrex about 3 weeks ago to see what would happen and I haven't had a chest pain since. Now I'm left wondering whether or not either of the drugs did any long-term damage. Oh great. Thanks a lot FDA. I hope you got a good kickback on the deal.

[lovuian]

5. Why did it take so long to figure out all these people were

dying!!!

[98geoduck]

6. You can only hide so many under the rug!

[girl gone mad]

8. Because the drug companies and the fda kept the link..

between heart problems and Vioxx hidden.

If doctors and patients had been informed early on that a link might exist, they would have been able to spot problems immediately. Correlation does not necessarily mean causation, and the uninformed had no reason to assume FDA approved Vioxx was causing this problem.

[Straight Shooter]

9. Follow the money. Whoever had most to lose, that's who hid the bad info.

Also, many patients probably had complications, doctors get busy, don't want to file reports. Then Sue talks to Jane, who talks to Betty, who talks to her lawyer, he begins to investigate, and there you have it. The cover-up is exposed.

Don't forget that the head of the FDA is Mark McClellan, whose brother Scott McClellan is bush's mouthpiece. I don't know if he's to blame or not, but it sure makes for strange *ahem* bedfellows.

[DRoseDARs]

15. Because Big Pharma drugs don't kill people, lawyers do. n/t

.

[customerserviceguy]

31. Yes, there's an unhealthy relationship

...between the drug makers and the FDA, but people DO have a choice. If those of you who distrust the pharma companies just stick to your herbal remedies, then you avoid this. I don't trust American car manufacturers, so I buy Japanese. I have to believe that some people really were spared debilitating pain by use of the COX-2 drugs, and while it's sad that the side effects of these drugs were not properly researched, again, people have a choice to take the risk of a new therapy having unforseen consequences, or to stay on the old regimes.

Seeing lawyers with giant billboards all around the Salt Lake City area with the word, "VIOXX" and a phone number on them is no better than thinking about rich pharma executives. Both are in the business of making money from people who fail to look before they leap.

[daleo]

33. People need knowledge, to know whether to leap or not

They depend on regulatory agencies, doctors, and drug companies to provide that knowledge. It is a proper function of the courts to provide damages if that knowledge is withheld, which ensures that drug companies act responsibly. The makers of VIOXX had good reasons to suspect that the pill had dangerous side effects. I suspect they thought that the profits to be made exceeded the damages they would have to pay out, so they downplayed the risks and withheld this knowledge.

[customerserviceguy]

34. Okay

Given that we know that the FDA is bought and paid for by the drug co's, then people have to either do their own research (I read articles in "The New Yorker" about COX-2 inhibitors years ago, describing them as wonder drugs), or they just have to stand on the sidelines and wait for the gullible and/or desperate to be the guinea pigs.

I'm not against making pharma company executives criminally responsible for their misdeeds, indeed, lethal injection would be a fitting punishment. I just have big problems with lawyers ambulance-chasing "victims" whenever something looks like it might have gone amiss. Making a bunch of shysters wealthy while they throw a few crumbs to the survivors of the deceased is not justice, either. Putting CEOs in the "test" group to try out new drugs might be.

[gratuitous]

38. A word about ambulance-chasing shysters

Our office isn't handling any VIOXX claims, but it looks like it will be extraordinarily difficult to prosecute these products liability lawsuits. Bringing a lawsuit of this nature costs a minimum of $100,000 out of pocket for the attorney, and those costs don't get reimbursed by the client, who is either too sick to work anymore or too dead to care about costs. Meanwhile, those costs are treated by the IRS as "receivables" and are taxed like any other business loan for as many years as the costs are outstanding. Wow, I can't imagine why every lawyer in the country isn't running to sign up for firm-busting costs that may never be reimbursed and are taxable events!

Not to mention the amount of attorney time devoted to researching and interviewing patients, relatives, experts, doctors and everyone else tangentially involved in such a matter means less time to spend on other cases. For the 500 hours a lawyer might spend in a year on one VIOXX-related matter that may or may not pan out, that's time not spent on a case with a better chance of winning. No money comes in when you aren't working other cases.

In addition to the time and expenses, deceased patients probably have a medical history of difficulties, and tracing the cause of their particular deaths to taking VIOXX will be very hard. All the best doctors are lined up on the side of the pharmaceutical companies, and the most knowledgeable folks about any potential side effects will have already been paid by the company for their input and expertise, and will thus not be available to the estate of the dead person for testimony. There may be a statistical correlation based on the percentages of persons taking VIOXX and deaths from heart disease, but proving an individual's demise was due to VIOXX and nothing else is a pretty tricky proposition.

While a billboard may be unseemly or distasteful, medical records are not readily available to the public, and state bar associations uniformly have rules against "soliciting" clients - that is, contacting people on the chance that they might have a claim. Despite Hollywood depictions to the contrary, one of the fastest ways for a lawyer to get his bar ticket pulled is to call on someone directly. It's up to someone who has been civilly wronged to decide to contact an attorney. If someone you loved had died while on VIOXX, how would you know or even find out about any legal recourse?

[customerserviceguy]

45. Interesting to hear

from somebody who makes a living in the lawsuit business, but apparantly a goodly number of Salt Lake City area lawyers seem to think that it's worth their time and money. I imagine that billboards, broadcast TV ads (I don't get cable or satellite), and newspaper ads aren't cheap. Nice to know that your office has more of a "sure thing" kind of business.

If someone I loved died while on Vioxx, then I would have regarded it with the same sadness that I would have if they had died in a car accident. Everyone takes a chance when they get into a motor vehicle, and on to a public road. Especially here in Utah, I just moved here less than a month ago, and everybody drives like a bat out of hell. I'm surprised that lawyers have to advertise for clients, it would seem that there would be so many negligent driving cases out there.

Hmm, maybe that's the stuff your office does.

[daleo]

41. Here are a few items from the British Medical Journal

Note some of the dates. This didn't come out of a clear blue sky for Merck, and they have made billions on this drug since the first indications of trouble showed up. Unfortunately, the legal standard of proof can be much higher than that required in the scientific community, so criminal punishment seems unlikely. That just leaves tort law.

A sample made up of CEOs is an interesting thought, but I don't think it would be scientifically valid even if you could arrange it. The sample frame is too restricted (age, race, sex, socio-economic status, educational background, health status, etc.).


In brief
BMJ, Apr 2002; 324: 994.
...ordered drug manufacturer Merck to put a warning label on the cyclo-oxygenase-2 (COX-2) inhibitor rofecoxib (Vioxx) stating that it can raise blood pressure and may increase the risk of heart attacks;...

Deborah Josefson
FDA warns Merck over its promotion of rofecoxib
BMJ, Oct 2001; 323: 767.
...to the pharmaceutical company Merck for misrepresenting the safety of their blockbuster anti-inflammatory drug, rofecoxib (Vioxx)....
...risk of stroke was found in an analysis of a large study, dubbed the VIGOR (Vioxx gastrointestinal outcomes research) trial, which compared 50 mg a day of rofecoxib with 500 mg...

Scott Gottlieb
COX 2 inhibitors may increase risk of heart attack
BMJ, Sep 2001; 323: 471.
...placebo group was 0.52% This compared with 0.74% (P=0.04) for the COX 2 inhibitor rofecoxib (Vioxx) in the Vioxx gastrointestinal outcomes research (VIGOR) study and 0.80% for the inhibitor celecoxib (Celebrex)...

In brief
BMJ, Aug 2002; 325: 236.
...investigated: The European Medicines Evaluation Authority is investigating the arthritis drugs celecoxib (Celebrex) and rofecoxib (Vioxx) to find out how often they can cause heart attacks and gastrointestinal events....

Efficacy, tolerability, and upper gastrointestinal safety of celecoxib for treatment of osteoarthritis and rheumatoid arthritis: systematic review of randomised controlled trials
BMJ, Sep 2002; 325: 619.
...Recently the VIGOR (Vioxx gastrointestinal outcomes research) trial of rofecoxib has raised concerns about serious cardiovascular effects with the...

[Tsiyu]

10. While marijuana killed no one

and folks are being incarcerated for having small amounts, Pharm companies can KILL PEOPLE and they get rewarded.

How does this administration sleep at night, making up the rules as they go along, with neither the consent of nor in the best interest of the People they are held to protect?

[Occulus]

12. They DON'T sleep!

Ghouls don't need sleep!

[pokercat999]

18. It's not just administration

I am not defending *ush and Co however this "system" has been in place for years and our Democratic admins and congress's have done the same. This "war" like most, is between the corporations and the people.

We will eventually need to take up arms against their private armies to prevent being openly enslaved by corporations. My grandchildren (if my son would get busy) and their children will be fighting this fight unless we take action NOW!

[ernstbass]

26. Good point

the dems don't appear to care much for this issue either. . . of course, they take major money from drug companies too.

[ernstbass]

25. Well said!

[Tsiyu]

29. Thanks, ernest T

You ol' coot...:)

[Hissyspit]

13. "The Bush Administration Tried To Kill My Mother"

was the title of an email I sent out to friends when this story first broke.

The sad thing is that it was literally true. Refuckingpublican greed...

[daleo]

14. Analysts will look on this as a "buy" opportunity

Watch for it.

[thecrow]

16. Merck wanted to get the product on the market so badly

that they rushed through the testing (and said that these results didn't show up in the animal testing) and applied to the FDA to get the product approved. You see, Pfizer had it all over them with Celebrex at the time and they wanted to get a similar product into the market. The very day that the FDA approved Vioxx, it was all ready packaged and ready to go on the shelves at the nation's pharmacies. They made BILLIONS in their first year. Billions!
It's all about the money.

[JohnOneillsMemory]

17. Yikes. Looks like healthcare is now a WMD..

Maybe that's why the neo-cons want to give healthcare to the Iraqis, to kill them.

[jbnow]

19. A bigger scandal will come

with the statin drugs. The disabling Myopathy and Neuropathy and fatal side effects (including heart failure) are due to the quick and ongoing depletion of Coenzyme Q-10. (What blocks the liver mechanism that manufactures cholesterol also blocks the synthesis CoQ-10, which declines in age too) There have been warnings and letters written to the FDA imploring them to include a bold warning on packaging and to doctors warning them that supplements must be taken. merck actually made a form that included CoQ-10 since the 80's as have other companies since...but the delay in marketing is that it would be admitting there is a problem.

Other countries do carry the warning. Statins are so effective and being more widely prescribed but not a single person I know taking statins was advised about this by their doctor (and most of them get very irritated when their patients have brought it up at my urging)

Most doctors don't care or believe if the FDA doesn't tell them it's true. You can bet the FDA will not be encouraging doctors to give out what is not a prescription drug.

[Ernesto]

24. I think you called it on this one jbnow

When questioned about all the satins PR last summer, my young MD just rolled his eyes. He agreed with me that the new lower cholesterol "standards" smelled like a marketing ploy to him. I guess I'm just lucky to have an honest skeptic in my corner.

[happynewyear]

28. jbnow I agree with you!

I've heard these statin drugs are risky but no doctor will come out and tell me exactly what the potential "real" risks are.

Finally I asked, "What in my chance of having a heart attack or a stroke if I do not take these drugs?" Reply was: 3 in 100 within the next 10 years. What are your chances of having a heart attack anyway without high cholesterol? NO ANSWER. People drop dead of heart attacks all the time and they do not have high cholesterol nor high blood pressue. Where do these people figure into these "statistics" I query?

Seriously ...

Next ... Now new guidelines for blood pressure too. Everyone with a reading above 120/80 is hypertensive and requires drugs now and they aren't cheap either. :grr:

What is the reality of any of this?

I think the doctors are in on this SCAM with the drug companies! And, yes, I really do believe this! All of those "free" samples - yeah my ass! :grr:

:kick:

[jbnow]

43. In defense of the doctor

Statins do have real benefit, they are effective in a host of areas. I suspect they are a good drug (if only the side effects didn't kill you) If doctors knew about the Q-10 depletion through official means (unfortunately the FDA) I'm sure they would be shouting it out to their patients.

On the other hand, niacin is quite effective at lowering bad cholesterol and raising the good kind and I don't know why that has just been dropped. There are particular forms that are better then others but it is inexpensive and very effective...compares well to the statin drugs.

Oh wait, I know, it's that problem with OTC herbs and vitamins not being FDA tested because who would pay the millions to do the FDA required testing on something they can't profit on?
Europe has a different standard for herbs and vitamins so the testing is affordable and the less toxic natural remedies are often prescribed. In fact Co-Q-10 is given there quite apart from statins, it has so many benefits, including the heart, blood pressure and gum health.
Or the mineral selenium...very cheap, with SO many benefits...is something doctors should be pushing. They are likelier to now if men have had prostate cancer but it should be widely suggested for cancer prevention, cardiovascular issues and so on.

The depleted soil we grow our foods in or the processing leaves us short on trace minerals so diet alone isn't enough.

OK, this is just one of my pet peeves and I will stop now.

[barb162]

36. do you have any link for this as a friend of mine takes a statin

and I would like to send something. I don't know crap from or about this coenzyme you're talking about here. Thanks in advance.

[jbnow]

42. Here are some links

But I also want to note when you buy OTC you don't always know what you are getting. CoQ-10 is not cheap and many brands tested don't contain what they say they are. I prescribe to Consumers Lab, an independent testing lab. Nature Made brand passes and is often on sale at Walgreens or such stores at buy 1 get 1 free. I can offer more brands that passed.

Here are the links with bits of what is included. This issue makes me SO angry! (And I don't even take it)

http://homodiet.netfirms.com/otherssay/chd/statin_cardiomyopathy.htm

3. Statins kill people - lots of people - and they wound many, many more. All patients taking statins become depleted in Coenzyme Q10 (CoQ10), eventually - those patients who start with a relatively low CoQ10 levels (the elderly and patients with heart failure) begin to manifest signs/symptoms of CoQ10 deficiency relatively rapidly - in 6 to 12 months. Younger, healthier people who's only "illness" is the non-illness "hypercholesterolemia" can tolerate statins for several years before getting into trouble with fatigue, muscle weakness and soreness (usually with normal muscle enzyme CPK tests) and most ominously - heart failure.

In my practice of 17 years in Tyler, Texas, I have seen a frightening increase in heart failure secondary to statin usage, "statin cardiomyopathy". Over the past five years, statins have become more potent, are being prescribed in higher doses, and are being used with reckless abandon in the elderly and in patients with "normal" cholesterol levels. We are in the midst of a CHF epidemic in the US with a dramatic increase over the past decade. Are we causing this epidemic through our zealous use of statins? In large part I think the answer is yes. We are now in a position to witness the unfolding of the greatest medical tragedy of all time - never before in history has the medical establishment knowingly (Merck & Co., Inc. has two 1990 patents combining CoQ10 with statins to prevent CoQ10 depletion and attendant side effects) created a life threatening nutrient deficiency in millions of otherwise healthy people, only to then sit back with arrogance and horrific irresponsibility and watch to see what happens - as I see two to three new statin cardiomyopathies per week in my practice, I cannot help but view my once great profession with a mixture of sorrow and contempt

http://www.stopfda.org/feb2004_awsi_01.htm
Cardiologists Overlook Lifesaving Discovery

William Faloon

Impressive research published in 2003 indicates that coenzyme Q10 may have broader clinical applications than originally identified. These new human studies further validate the efficacy of coenzyme Q10 in the adjuvant treatment of cardiovascular disease.1-9

In particular, a study of heart attack patients showed that compared to placebo, supplementation with 120 mg a day of coenzyme Q10 reduced secondary cardiac events by 45% and significantly reduced the number of cardiac deaths. Many of these heart-attack patients were prescribed a “statin” drug to lower cholesterol levels. The major adverse effect of statin treatment was fatigue that occurred in 40.8% of the placebo group, whereas only 6.8% of the patients supplemented with coenzyme Q10 experienced fatigue.2

In newly published findings over the past year, positive results were shown when coenzyme Q10 was tested against disorders including macular degeneration, Parkinson’s disease, viral myocarditis, and hereditary neurodegenerative diseases.10-21 Additional studies indicate that coenzyme Q10 deficiency is linked with disorders such as infertility and brain atrophy.22-23

<snip>
The “Forgotten” Merck Patents
Pharmaceutical companies have long been aware that statin drugs can wreak havoc on cardiac patients and that taking coenzyme Q10 along with the statin drug would eliminate these side effects.

The evidence supporting coenzyme Q10 as an antidote to statin drug complications is so clear that in 1989 and in 1990 Merck patented the use of coenzyme Q10 in combination with statin drugs to both prevent and treat these complications. However, Merck has neither exercised these patents nor educated physicians or patients about the necessity of taking coenzyme Q10 along with statin drugs. One of the two Merck patents states that:

“Since Coenzyme Q10…is of benefit in congestive heart failure patients, the combination with HMG-CoA reductase inhibitors (statin drugs) should be of value in such patients who also have the added risk of high cholesterol.”34

This patent was filed on behalf of Merck & Co on June 12, 1990. Now, almost 14 years later, most doctors and their patients remain ignorant that those taking statin drugs should also supplement with coenzyme Q10

http://www.tishcon.com/overview.html
Abstract:
The clinical experience in cardiology with CoQ10 includes studies on congestive heart failure, ischemic heart disease, hypertensive heart disease, diastolic dysfunction of the left ventricle, and reperfusion injury as it relates to coronary artery bypass graft surgery. The CoQ10-lowering effect of HMG-CoA reductase inhibitors and the potential adverse consequences are of growing concern. Supplemental CoQ10 alters the natural history of cardiovascular illnesses and has the potential for prevention of cardiovascular disease through the inhibition of LDL cholesterol oxidation and by the maintenance of optimal cellular and mitochondrial function throughout the ravages of time and internal and external stresses. The attainment of higher blood levels of CoQ10 (>3.5microg/ml) with the use of higher doses of CoQ10 appears to enhance both the magnitude and rate of clinical improvement. In this communication, 34 controlled trials and several open-label and long-term studies on the clinical effects of CoQ10 in cardiovascular diseases are reviewed.

[RebelOne]

20. My next door neighbor died of a heart attack

at the age of 54. She was taking Vioxx.

[Quakerfriend]

21. I designed portions of the phase I study of Vioxx

done in one of the NIHs 70 + general clinical research centers around the country.

I said randomized, placebo controlled, cross over study with 4 wk washout period, Merck changed it to a much shorter pre test post test design, to save money.

I said 5-7 days for sodium washout, Merck changed the protocol to say 3 days.

As is so often the case, the drug co. cares nothing about anything but rushing their products to market and the bottom $$$. And, Merck was first in line with Vioxx.

Academic medical schools cannot be allowed to lie down with the drug companies. THIS MUST CHANGE! Our medical system puts people in GRAVE DANGER, by cont'g to allow this. Scientific review boards cannot be the stopgap. WE MUST HAVE LAWS IN PLACE!

[nashville_brook]

39. doctors loved prescribing vioxx b/c it got them off the hook w/opiods

when the federal govt and justice dept started targeting doctors who treat pain w/opiates, vioxx suddenly got real popular.

[complain jane]

23. Yeah but that damn Sponge Bob!

[jilln]

27. good thing those animal tests are so reliable ....

NOT!!!

[hedgehog]

32. What I haven't heard is about stomach bleeds

my daughter was put on Vioxx by an ER doctor for her arthritis and ended up back in the ER a week later with a stomach bleed - exactly what Vioxx is supposed to prevent. When she finally was able to see a rheumatologist, he didn't go near the stuff.

[barb162]

35. when the hell is the FDA going to be reformed?

If this doesn't get Congress to move their sick (pharma lobbied/monied) GOP asses, what will? FDA has to be TOTALLY independent of the pharma lobbies and industry. Get rid of Frist first.

[cthrumatrix]

37. don't look for MSM to educate people on this .... look to lawyers

it's sad either way.

We can't rely upon anybody for truth...it's all about conn'ing people.

[Demeter]

40. Please Tell Me They're Mistaken, or Joking

This is gross incompetence!

[CAG]

44. If its newer and more expensive its better

That is the common subconscious and sometimes conscious mantra of physicians. I know, my job is to evaluate what drugs are on our formulary at our medical center.

For brand-name drugs, they (and we) are constantly barraged from very slick, often very attractive drug reps, offering all types of extras such as free lunches, office supplies, and access (front-row tickets, etc), and speakers fees and the worst crime, "consultant" fees made to appear that the drug company thinks your one of the experts who they just HAVE to get input from. The physicians fall for this one because it gives them direct cash (often $500-2000) and it makes their egos thrive, they don't realize the drug companies are just using them to spout the company line to their colleagues.

The public isn't much better. Just look what direct to consumer advertising has done; its made billions for big pharma for no good public health reason whatsoever.

Just once I would like for someone to give a firm a few million dollars to advertise cheap generics such as hydrochlorothiazide, bactrim, and lasix.