Bad Seed: the ADVANTAGE Trial of Vioxx

An article in the Annals of Internal Medicine by Hill et al(1), and the accompanying editorial by Sox and Rennie(2) have created quite a stir in the media and blogsphere. Even so, it seems worth reviewing the main points, and adding some comments.

Hill et al address the ADVANTAGE trial, published in the Annals in 2003.(3) This was a randomized controlled trial that compared rofecoxib (Vioxx, by Merck) to naproxen for patients with osteoarthritis. 600 investigators each enrolled a few (target 6) patients. The trial failed to show that rofecoxib had any advantage of naproxen in terms of pain relief (see our discussion here). Long after the trial report was published, it turned out that its first author had no involvement in the study until Merck presented him with a copy of the manuscript written by company authors describing it, making it one of the more prominent recent examples of ghost-writing (see post here).

Hill et al obtained access to numerous internal Merck documents that only came to light in response to discovery requests filed in litigation. They appear to show that the ADVANTAGE trial was actually a "seeding" trial, designed to market the drug by putting "its product in the hands of practicing physicians, hoping that the experience of treating patients with the study drug and a pleasant, even profitable interaction with the company will result in more loyal physicians who prescribe the drug." In support of that, they found these themes in the documents they examined.

- "The trial emerged from the marketing division with a marketing objective;"
- "Merck's marketing division collected, analyzed, and disseminated both the scientific and the marketing data; and"
- "Merck did not reveal the marketing purposes of the trial to participants, physician-investigators, and institutional review board members."

Remarkably, an internal Merck memo made these further points:

First, the trial was targeted to a select group of critical customers.

[These were] primary care physicians. The ADVANTAGE trial utilized this important group as investigators.

Second, the design of the trial focused on demonstrating the value of VIOXX to this important audience

So, the study was designed primarily not to answer a clinical or scientific question, but to target certain physicians as "customers."

Third, execution of the trial ... [involved] integration of the field, marketing, and CDP [Clinical Development Program].

Thus, the study was really run by marketers, not scientists of clinicians.

Also,

Finally, the results of the trial are being carefully tracked. An analysis performed at 6 months post launch demonstrated a significantly higher level of prescribing for VIOXX among primary care ADVANTAGE investigators compared to a control group of VIOXX 99 prescribers....

Thus, the primary subjects of the trial were really not the patients, but the "investigators." Really, this was a trial that showed that involving primary care physicians as "investigators" in a seeding trial caused them to prescribe the supposed study drug more often than physicians not involved in the trial.

Nonetheless, informed consent forms for the trial did not inform subjects of its underlying marketing objectives.

This article appears to be the first to provide evidence that pharmaceutical companies may deliberately disguise marketing efforts as clinical research. This is a real achievement, since obviously the companies involved make every effort to hide what they are doing, and it only through discovery during litigation did the facts come out.

The authors conclude that

At least 3 elements of seeding trials are harmful to science and society. First, full informed consent is not possible without disclosing the full purpose of the trial. Physicians and patients participating in ADVANTAGE were informed of the scientific objectives of the study, but the research protocol and informed consent templates indicate that they were not told about the key role of Merck's marketing division in the trial or the true purpose of the trial. Second, good research practice is at risk when the marketing division designs and conducts a study. In a seeding trial, in order to fulfill strong marketing objectives, the recruitment of several research sites with fewer patients per site may result in less quality control from investigators and use of sites that have less research experience than academic centers or community physicians' offices, which may be more accustomed to hosting clinical trials. Quality control and rigorous research conduct may not receive adequate attention when marketing is the primary purpose of the study. Third, the study may have little scientific merit. Around the same time as ADVANTAGE, Merck launched the VIGOR (Vioxx Gastrointestinal Outcomes Research) trial to be the definitive study of gastrointestinal toxicity. The FDA required Merck to conduct VIGOR before putting claims of improved gastrointestinal safety on the Vioxx label. Thus, the purpose of ADVANTAGE was neither to seek a new indication nor to perform postmarketing surveillance.

Additionally,

Failure to disclose the primary purpose of a trial has ethical ramifications for patients, physicians, and the design of clinical trials. Seeding trials like ADVANTAGE, in which the study medication has yet to receive FDA approval, may cause patient injury for marketing purposes.

The primary marketing objectives of seeding trials are hidden from the public, the medical profession, and institutional review board members, preventing them from making a fully informed decision about the balance of benefits and harms to themselves and society.

The importance of the article by Hill et al, in my humble opinion, goes beyond its clear demonstration that seeding trials do exist. The article demonstrates how clinical research may be twisted into marketing. The article demonstrates how an ostensibly scientific endeavor may be based on deception, when science is supposed to be about the pursuit of truth. The article demonstrates how the ethos of the huckster has replaced that of the physician in large organizations once regarded as ethical.

Once again, this is a reminder that patients, physicians and policy makers must be extremely skeptical of clinical research sponsored by organizations which have something to gain if the research turns out a certain way. Furthermore, it is a reminder to physicians that generous offers from organizations selling products, services or ideologies do not arise from altruism.

As Sox and Rennie suggest, physicians should "just say no" to seeding trials. Maybe it is time for society to "just say no" to letting those with products to sell run experiments on humans to test them.

See also comments on Alison Bass' blog, Clinical Psychology and Psychiatry, GoozNews, PharmaLot, Retired Docs Thoughts, See interviews with authors of the Annals article on the Carlat Psychiatry Blog and PharmaLot.

ADDENDUM (25 August, 2008) - See also comments by Dr Howard Brody on the Hooked: Ethics, Medicine and Pharma blog.

References

1. Hill KP, Ross JS, Egilman DS, Krumholz HM. The ADVANTAGE seeding trial: a review of internal documents. Ann Intern Med 2008; 149:251-258. Link here.

2. Sox H, Rennie D. Seeding trials: just say "no." Ann Intern Med 2008; 149: 279-280. Link here.

3. Lisse JR, Perlman M, Johansson G, Shoemaker JR, Schechtman J, Skalky CS, et al. ADVANTAGE Study Group. Gastrointestinal tolerability and effectiveness of rofecoxib versus naproxen in the treatment of osteoarthritis: a randomized, controlled trial. Ann Intern Med 2003;139:539-46. [Abstract/Free Full Text]