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Editorial |

Drug Samples in Dermatology:  Out of the Closet, Into the Dustbin

Kenneth A. Katz, MD, MSc, MSCE1; Erika E. Reid, MD2; Mary-Margaret Chren, MD3,4
[+] Author Affiliations
1Department of Dermatology, The Permanente Medical Group Inc, Pleasanton, California
2Department of Dermatology, University of Pennsylvania, Philadelphia
3Department of Dermatology, University of California, San Francisco
4San Francisco Veterans Affairs Medical Center, San Francisco, California
JAMA Dermatol. 2014;150(5):483-485. doi:10.1001/jamadermatol.2013.9711.
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Is drug sampling—when physicians give samples of prescription medicines provided by pharmaceutical companies to their patients—good or bad? Is the answer different for dermatologists than it is for other physicians?

Many dermatologists have already answered those questions: “bad” and “no.” Numerous institutions have banned or sharply restricted drug sampling, including the Veterans Health Administration, the US military, many universities, and Kaiser Permanente. Many private clinics have done so as well. Other organizations, including the Association of American Medical Colleges, the American Society of Health-System Pharmacists, the Institute of Medicine, and the Joint Commission, have also recommended curtailing and/or controlling drug sampling. But those questions linger in other medical settings, including many private practices not subject to institutional antisampling policies.

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Not time to throw out the samples yet
Posted on June 18, 2014
Steven R. Feldman, MD, PhD, Alan B. Fleischer, Jr, MD
Department of Dermatology, Wake Forest University School of Medicine
Conflict of Interest: No specific funding for this work.Fleischer:Investigator (Grants to instititution): Regeneron, Abbvie, Eli Lilly, GaldermaConsultant (honoraria): Galderma, CelgeneEmployment (salary): MerzFeldmanGalderma, GSK/Stiefel, Leo Pharma, Celgene, Pfizer, Valeant, Abbott, Amgen, Astellas, Janssen, Lilly, Merz, Novartis, Taro, National Biological Corporation, and National Psoriasis Foundation. I am founder and majority owner of www.DrScore.com. I am a founder and part owner of Causa Research, a company dedicated to enhancing patients’ adherence to treatment.
1. While adapaline and benzoyl peroxide are available individually as generic products, there is no generic adapaline-benzoyl peroxide combination product. 2 separate agents are not equivalent to a single product that includes both agents.12. Acne guidelines support using two drugs, a topical retinoid and a topical benzoyl peroxide.2 The academic center’s practice of prescribing them as two separate agents is not a clearly better gold standard. Giving separate drugs may be better for some patients but worse for others. Showing that samples correlates with use of a combination product for samples is not evidence that sampling is bad.3. Do we have evidence that pharmacists are providing critically important input to patients with respect to topical acne or other dermatologic therapy? Even if pharmacists are counseling our patients, sampling does not circumvent the pharmacist when the prescription is filled. Moreover, for the needy patients who do get a full course of therapy in the form of samples, they otherwise would not have had the benefit of the medication at all, much less the involvement of a pharmacist in their choice of treatment. 4. The black box lymphoma warning for topical calcineurin inhibitors that appeared after the products’ launch doesn’t tell us that new medications are bad, as the data do not support an increased risk of lymphoma with topical calcineurin inhibitors.3-5 On the contrary, topical calcineurin inhibitors are safer than topical corticosteroids, have lower oncogenic risk, and are not associated with the atrophy, telangiectasias, and even potential HPA axis suppression associated with topical corticosteroids. Topical calcineurin inhibitors can cause stinging, so letting the patient try a sample of them before purchasing them is particularly helpful.5. A controlled trial found that having acne patients sample treatment at the office visit may increase adherence to that treatment. 6 The suggestion that sampling’s benefits can be achieved with Crisco is not yet supported by evidence. A major barrier to adherence is fear,7 and applying Crisco to patients may not get them past the fear of applying a drug. Moreover, many products can’t be demonstrated adequately using Crisco, including foams, sprays, shampoo, and tape formulations. Moreover, the sample of Crisco will not show patients if the medication is tolerable for them; patients who may have discovered intolerability had they had a sample may, in a sample-free world, end up buying expensive medications that they cannot use.6. The desire to see patients get the best care at the lowest cost is good, but the available evidence does not support the idea that emptying the closet of samples promotes cost-effectiveness. Sampling may drive some prescribing behavior in dermatology (so far, only association has been demonstrated), but it may be that sampling encourages use of better drugs. Even if samples sometimes encourage the use of a less than ideal treatment, it may be that a better solution would be to add samples of generic medications to our sample closets rather than losing the benefits of the samples we currently have.1. Yentzer BA, Ade RA, Fountain JM, Clark AR, Taylor SL, Fleischer AB Jr, Feldman SR. Simplifying regimens promotes greater adherence and outcomes with topical acne medications: a randomized controlled trial. Cutis. 2010 Aug;86(2):103-8. 2. Nast A, Dréno B, Bettoli V, Degitz K, Erdmann R, Finlay AY, Ganceviciene R, Haedersdal M, Layton A, López-Estebaranz JL, Ochsendorf F, Oprica C, Rosumeck S, Rzany B, Sammain A, Simonart T, Veien NK, Zivković MV, Zouboulis CC, Gollnick H; European Dermatology Forum. European evidence-based (S3) guidelines for the treatment of acne. J Eur Acad Dermatol Venereol. 2012 Feb;26 Suppl 1:1-29. 3. Margolis DJ, Hoffstad O, Bilker W. Lack of association between exposure to topical calcineurin inhibitors and skin cancer in adults. Dermatology. 2007;214(4):289-95.4. Tennis P, Gelfand JM, Rothman KJ. Evaluation of cancer risk related to atopic dermatitis and use of topical calcineurin inhibitors. Br J Dermatol. 2011 Sep;165(3):465-73. 5. Arellano FM, Wentworth CE, Arana A, Fernández C, Paul CF. Risk of lymphoma following exposure to calcineurin inhibitors and topical steroids in patients with atopic dermatitis. J Invest Dermatol. 2007 Apr;127(4):808-16. 6. Sandoval LF, Semble A, Gustafson CJ, Huang KE, Levender MM, Feldman SR. Pilot randomized-control trial to assess the effect product sampling has on adherence using adapalene/benzoyl peroxide gel in acne patients. J Drugs Dermatol. 2014 Feb;13(2):135-40. 7. Brown KK, Rehmus WE, Kimball AB. Determining the relative importance of patient motivations for nonadherence to topical corticosteroid therapy in psoriasis. J Am Acad Dermatol. 2006 Oct;55(4):607-13.
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