By O. Elber. Oklahoma Panhandle State University.
This form of innovation placed value on the art of combining or the art of presenting known – and often complex – substances buy biltricide 600mg amex. As shown by the case of Dausse biltricide 600mg free shipping, such industrialization mobilized chemical tools as a means for concentration purchase 600mg biltricide free shipping, control, and standardization, as well as marginally as a source of isolated substances. Complexes seemed especially valuable and important to preserve when plant extracts came under consideration. The industrialization of plant and organ extracts therefore relied on mechanics on the one hand and physiology on the other. The model of professional regulation advanced in our introductory chapter should therefore be amended to take into account this diversity of know-how, beyond the mere mobilization of pharmacological modeling. As illustrated here, biological testing systems were not just important elements in the industrial practice of standardization and quality control. In parallel, academic pharmacists used them to perform physiological functions and make them manifest, meaning that they became tools to explore and signal the synergies and complexities that remained central to the culture of preparations. If there is a caricature of German history to parallel the image of the French industrial state, it is the idea of a rapidly growing chemical industry that colonized the entire pharmaceutical sector after the 1890s. One major interest of the history of plant extracts is to show the importance of these practices, which made a subset among German frms comparable to their French counterparts living off of the exploitation of specialties registered in the pharmacopoeia. The history of Madaus thus reveals a culture of preparation that shares many aspects with the practices at Dausse, including the organization of plant collection and breeding, mechanical innovations, a deep interest in physiological tools, and research. The social and intellectual landscape within which the frm blossomed was not the French professional order, but a rare combination of industry and alternative medicine. Madaus’s holistic approach of the living, which nurtured a system of correspondences among plants, animals, and human beings, than the integration of alternative medical practices – homeopathy, as well as the use of plants and organ extracts – into the industrial regulatory order and its values of productivity, standardization, and homogeneity, all of which were taken as synonymous of quality and effectiveness. The consequences were not only the prominent role attributed to mechanics and processing, but the mobilization of pharmacology and chemistry 63 Jean-Paul Gaudillière for quality control. As a company looking for a more scientifc form of popular and biological medicine, Madaus paradoxically engaged in the development of as many standards and assays as more molecularly oriented frms like Schering or Hoechst. The tensions brought about by this transformation of therapeutic agents previously associated with forms of medical practices stressing the individual and constitutional nature of disease into mass-produced and prescription- ready pills are easy to perceive, but remain to be analyzed. Similarly, comparison between Madaus and Schering highlights the commonalities of the industrial regulation of drugs. Both frms developed in-house research facilities focusing on physiology, both focused on biological assays as privileged tools of intervention, both invented relations with physicians and local practitioners that linked science and marketing. The correlate of standardization and quality control within the frms was a pattern of state interventions that echoed and reinforced entrepreneurial interventions (a situation powerfully illustrated with the regulation of sera) but did not constitute an autonomous administrative way of regulating. While substantiating the idea of an industrial way of regulating, such parallels do not make the differences between the innovation culture of both frms less real. Even when investigating cellular metabolic pathways, Schering’s strategy remained to turn extracts and sex-hormone preparations into pure molecules, while Madaus’s ambition was to make the biological complexity visible, relying on ecological investigations, mélanges, and the mobilization of local healers’ therapeutic experiences. In the end, this pervasiveness of industrial regulation in Germany provides a possible explanation for what is otherwise diffcult to understand, namely the contrasted fate of herbal medicine in both countries. The 1936 reform granting Heilpraktiker a legal status is usually understood as an example of profession building that mimicked the history of school medicine, benefting from a peculiar political window originating in the Nazi’s initial love for alternative, supposedly popular health practices, where healers were able to negotiate partial but effective institutionalization. Hence, even if after World War I French herbalists expressed their acceptance of a status as second-rank drug makers, the pharmacists’ corporate bodies blocked the path toward the recognition of a full-fedged profession, pleading for the 1941 ban. The need to take into account cognitive and material practices when analyzing drug regulation, however, points to a different path of interpretation. Pharmacists’ and herbalists’ ways of understanding the nature of drugs as well as their mode of preparation were much less dissimilar than what is traditionally assumed, a feature that reinforced the administrative nature of their competition within the system of professions. The fact that the German reform persisted once its national-socialist birth context vanished might therefore be seen as a consequence of both the declining infuence of professional regulation and the successful industrialization of “alternative” therapies in the interwar period. Following this line of analysis, the success of French pharmacists might well be rooted in the herbalists’ delayed industrialization, which left the former to think they were the only legitimate actors in trading and regulating medicinal plants. Hüntelmann The diphtheria serum was a major therapeutic innovation at the end of the 19th century. As a new form of therapy, the diphtheria serum marks the starting point for other sera like the one for tetanus or veterinary sera like red murrain. The new serum therapy promised not only a cure for diphtheria and other fatal infectious diseases, but also large profts for manufacturers who could stabilize the production process and produce serum in large quantities at industrial plants. Because detailed information about the research was freely available in well-known medical publications, health professionals trained in bacteriology could reconstruct the experiments and, there being no patent on the diphtheria serum, legally produce serum. The ambiguous legal situation, the production of serum in a free market, the prospect of large profts for the serum industry, earlier public health scandals triggered by tuberculin, the novelty of serum therapy, and the lack of information about its long-term effects – all of these factors attracted the intense interest of state offcials who hoped to minimize the potential public health risks. One of their responses was to implement and institutionalise a system of state control. In this paper I will analyse the network of actors involved in the procedures of standardization, such as test and host animals, serum, scientists, producers, state authorities, and technical arrangements. I will describe the expansion of the concept of evaluation and the standardization of veterinary sera like anthrax and red murrain. Afterwards I will describe the processes by which a serum became a state approved remedy (or not), the introduction of a new serum, the evaluation, standardization, and the institutionalization of this process. I will illustrate this with the example of the evaluation of red murrain serum and the diffculties that could be encountered in this process. The Institute for Experimental Therapy as the institutionalization of evaluation After a short period of discussion and preparation in February 1895, the “Control Station” for diphtheria serum was founded as part of a series of preventive measures, including serum 1 The paper was written as part of the research project „Vaccines and sera between laboratory, production and bureaucracy. Quality control procedures as a dynamic regulatory system between serum research, serum industry and public health policy 1890-19. Engstrom, Volker Hess, Christoph Gradmann, Ulrike Kloeppel and especially Jonathan Simon. Hüntelmann price-fxing, regulating its distribution in pharmacies, and imposing a prescription requirement. Locally the process of serum production was permanently monitored by a medical offcial and centralized in a state-run institute. At the „Control Station“ the samples were tested simultaneously and independently by two medical offcials. The evaluation procedure was highly technical, involving the injection of a very precise dilution of toxin and serum, and afterwards an observation of the absence of any swelling at the injection site on a guinea pig. After the offcial results of the evaluation process had been sent to the producer, the serum was bottled into phials and distributed to the pharmacies. The phials were sealed and bore the label ‘Inspected by the State’ on their labels.
Yet adult weights vary two to threefold cheap biltricide 600mg on line, while a large fat mass can store large excess of highly lipid soluble drugs compared to lean patents of the same weight buy 600mg biltricide overnight delivery. Adolescents may oxidize some drugs relatvely more rapidly than adults discount biltricide 600mg without a prescription, while the elderly may have reduced renal functon and eliminate some drugs more slowly. Iron prep- aratons and other haematnics are exceptons to this rule because of the blood lost by women during menstruaton. There is a possibility that males metabolize benzodiazepines, estrogen containing preparatons and salicylate at a faster rate than females. Tolerance The therapeutc efects of some medicatons are lessened in individuals over a prolonged period of use. Thus, a patent who has been using a drug for longer tme, requires a higher dose so as to obtain the same therapeutc efect as produced by the drug when taken for the frst tme. Opioids, benzodiazepines, β2 agonists, cafeine, cocaine, amphetamines, and barbiturates fall into this category. Cross- tolerance develops when the use of one drug causes a toler- ance to another. Alcoholics, barbiturate and narcotc addicts develop a cross-tolerance to sedatves and anaesthetcs. These individuals require very large amounts of anaesthetcs before surgical anaesthesia can be atained. Synergistc Efect Several drugs when combined may show synergistc acton in the form of either additve or supraadditve acton or poten- taton. Resistance Development of resistance to drugs is a common problem with antmicrobial agents (anttuberculosis drugs, antleprotc drugs, antmalarial drugs etc). Ratonal prescribing and in turn compliance by the user will prevent the emergence of resist- ance. Medicine absorpton rates may vary widely between individuals and in the same individual at diferent tmes and in diferent physiological states. Drugs taken afer a meal are delivered to the small intestne much more slowly than in the fastng state, leading to much lower medicine concentratons. In pregnancy gastric emptying is also delayed, while some drugs may increase or decrease gastric emptying and afect absorpton of other drugs. Hence variaton in plasma albumin levels, fat content or muscle mass may all contribute to dose variaton. With very highly albumin bound drugs like warfarin, a small change of albumin concen- traton can produce a big change in free medicine concen- traton and a dramatc change in therapeutc acton of a medicine. Metabolism Medicine metabolic rates are determined both by genetc and environmental factors. Medicine acetylaton shows genetc polymorphism, whereby individuals fall clearly into either fast or slow acetylator types. Medicine oxidaton, however, is poly- genic, and although a small proporton of the populaton can be classifed as very slow oxidizers of some drugs, for most drugs and most subjects there is a normal distributon of medicine metabolizing capacity, and much of the variaton is under envi- ronmental control. Renal disease or compettve tubular secreton of drugs can therefore slow down the excreton of certain drugs. Pharmacodynamic Variables There is signifcant variaton in receptor response to some drugs, especially central nervous system responses, for example pain and sedaton. Some of this is genetc, some due to tolerance, some due to interactons with other drugs and some due to addicton, for example, morphine and alcohol. Disease Variables Both liver and kidney disease can have major efects on medicine response, chiefy by the efect on metabolism and eliminaton respectvely (increasing toxicity), but also by their efect on plasma albumin (increased free medicine also increasing toxicity). Heart failure can also afect metabolism of drugs with rapid hepatc clearance (for example lidocaine, propranolol). Environmental pollut- ants, carcinogens, tobacco smoke, alcohol, anaesthetc drugs and pestcides can also induce metabolism. For example, in infantle malnutriton and in malnourished elderly populatons medicine oxidaton rates are decreased, while high protein diets, charcoal cooked foods and certain other foods act as metabolizing enzyme inducers. Sedatve and hypnotcs induce sleep beter in calm environment and when administered at night. Pharmacogenetc variaton will afect the medicine response, by 4-6 fold among diferent individuals. All major determinants of medicine response such as transporters, metabolizing enzymes, and receptors are controlled genetcally. These factors in certain cases may result in toxicity- for example toxicity caused by inhibi- tory efect of isoniazid on phenytoin metabolism seems to be more signifcant in slow acetylators of isoniazid than in those patents who metabolize the drug more rapidly. The Appendix 10 summarizes the pharmacogenetc variaton, the frequency of occurrence, drugs involved and the outcome. Unfortunately this is very ofen not the case, and physicians overlook one of the most important reasons for treatment failure that is poor adherence (compliance) with the treatment plan. The medicine may be poorly tolerated, may cause obvious adverse efects or may be prescribed in a toxic dose. Failure to adhere with such a prescripton has been described as ‘intelligent non-compliance’. Bad prescribing or a dispensing error may also create a problem, and regarding which patents may have neither the insight nor the courage to queston. Factors may be related to the patent, the disease, the doctor, the prescripton, the pharmacist or the health system and can ofen be avoided. Low-cost strategies for improving adherence increase efectveness of health interventons and reduce costs. Health care providers should be familiar with techniques for improving adherence and they should employ systems to assess adherence and to determine what infuences it. Patent Reasons In general, women tend to be more adherent than men, younger patents and the very elderly are less adherent, and people living alone are less adherent than those with partners or spouses. Patent disadvantages such as illiteracy, poor eyesight or cultural attudes (for example preference for traditonal or alternatve drugs and suspicion of modern medicine) may be very important in some individuals or societes, as may economic factors. Doctors should be aware that in most setngs less than half of patents initated on anthypertensive medicine treatment are stll taking it a year later. Similarly, in epilepsy, where events may occur at long intervals, adherence is notoriously unsatsfactory. The Doctor-Patent Interacton There is considerable evidence that this is crucial to concordance. If they are in doubt or dissatsfed they may turn to alternatve optons, including ‘complementary medicine’. There is no doubt that the medicine ‘doctor’ has a powerful efect to encourage confdence and perhaps contribute directly to the healing process.
You are further dictating by fat medical practice and to make matters worse buy 600 mg biltricide with visa, you are using an unpublished study which has no logic cheap 600 mg biltricide overnight delivery, inadequate statistics and improper evaluation best 600 mg biltricide. In the past, your direction has been to have the drug company release a news letter to physicians regarding dangerous or untoward side effects of drugs when they have been proven. The focus of this paper is not to resolve whether Orinase reduced or increased the cardiovascular mortality of its consumers – now that Orinase has been replaced by newer generations of antidiabetic agents – this question has become largely irrelevant. Nor am I interested in tracing the terms of the debate as a confict over clinical trials knowledge, as othershavealready done. Rather, I would like to suggest that the trials of Orinase in the 1970s 3 David L. Gina Kolata, “Controversy over Study of Diabetes Drug Continues for Nearly A Decade,” Science 203 (1979): 990. The relationship between the regulation of pharmaceuticals and the regulation of medical practice is central to this narrative. A drug is not regulated merely as a good in its own right, but always as a commodity tied to a set of knowledge regarding its production and its consumption. As we shall see, these forms of knowledge are far easier to regulate before a drug hits the market. Once a drug has developed broad use in practice, the multiplicity of economic, social, and cultural forms called into being by the daily practice of pharmaceutical consumption form an unruly terrain that is much more diffcult for any single regulating agency – whether state- based, profession-based, or industry-based – to control. Granted, this case is narrated in a late- 20th century American context, which implies a strong state based regulatory agency coupled with a rhetoric of individual liberty and a poitics of consumer advocacy that is not necessarily applicable in other national contexts. First, that postmarket pharmaceutical regulation is a far more contested – and less formally-governerd – process than premarket regulation. Second, that unlike premarket regulatory debates, which tend to focus on the qualities of the drug itself as concrete and the patient populations as hypothetical, the theoretical purity of postmarket debates is always muddled by the existence of actual consumers who have been taking the medications at hand, and who now have incorporated the pharmaceutical consumption into their identities as patients. Third, that at stake in these debates are not only the availability or withholding of a drug product, but also of the information and the avenues to knowledge surrounding a drug product. Finally, and perhaps most evidently, the narrative of diabetes and Orinase in the 1960s and 1970s highlights the role of mutually-defning relationships between drugs and diseases in the regulation of therapeutic practice. Progress of Experiment: Science and Therapeutic Reform in the United States: 1900-1990, Cambridge: Cambridge University Press, 1997. Meinert and Susan Tonascia, Clinical Trials: Design, Conduct and Analysis, New York: Oxford University Press, 1986, pp. Sondik and Dana Gilbert, “Clinical Trials and Established Medical Practice: Two Examples,” in: Biomedical Innovation, ed. Greene Origins of the Tolbutamide Crisis The diffculty of regulating drugs for new diseases – or for diseases with changing boundaries – is central to this story. For the most part, as late as 1950, it was diffcult to be diagnosed with diabetes without exhibiting symptoms (popydipsia, polyuria, autophagia) or signs (glycosuria) of the disease. As I have written elsewhere, by the late 1960s the numerical diagnosis of “mild” or asymptomatic diabetes – detected on the basis of blood sugar levels alone – had become common in practice due in part to the infuence of oral hypoglycemics. The study would address three layered questions: (1) did tolbutamide have a favorable impact on vascular disease? By 1961, the study protocol was approved with seven different research sites; subjects with diabetes newly-diagnosed by screening laboratory tests were recruited and randomly assorted into four treatment arms. By 196 , fve more sites had been added, and by 1965 the full patient complement of 1,0 7 patients – roughly 00 to each arm – had been enrolled. Greene, Prescribing by Numbers: Drugs and the Defnition of Disease, Baltimore: Johns Hopkins, 2007. Tolstoi, “Treatment of diabetes with the ‘Free Diet’ during the last ten years,” in: Progress in Clinical Endocrinology, New York: Grune & Stratton, 1950, pp. Six years into the study, coordinators noticed that more deaths were appearing in the tolbutamide group than in any other group, including placebo, chiefy from cardiovascular causes. His frst response was to search for baseline differences might explain the difference in mortality. By that point, the study coordinator was convinced that even if tolbutamide was not harmful, there was no longer any possibility of demonstrating beneft; therefore the study arm could not be continued in an ethical fashion. Differences in medical management among the study’s sites, some thought, might account for the differences in mortality. Unfortunately for those concerned, the press leak occurred one day before their scheduled meeting. Crisis, Publicity, and the Regulation of Medical Information The tolbutamide controversy achieved publicity at a pivotal moment in the relationship between therapeutic research and its multiple publics. Marks, Interview with Christopher Klimt, May 16, 1984, as cited in Marks, Progress of Experiment, p. Greene were a period of crisis for the paternalistic model that had characterized relations between the American medical profession and its patient public for at least a century. Media coverage was consumed (as well as produced) in a divergent fashion by the industrial, professional, and consumer publics. That the frst public news of tolbutamide’s risks occurred not as a general press release or article in the science section of the newspaper, but as a report overthe fnancial newswire, is highly signifcant. The frst public for the tolbutamide controversy was the broader fnancial community surrounding the pharmaceutical industry, whose concern for the welfare of the drug itself – as a product – could be easily differentiated from a broader concern for the welfare of the diabetic patient. It is now common to see clinical trials results receive their frst publicity in the business sections of newspapers, but this was a relatively recent development. Over the second half of the twentieth century, as a smaller number of patented, brand-name, large-market drugs came to dominate the interests of the pharmaceutical industry, and as the industry grew to comprise a larger portion of the national economy, the impact of one clinical trial could affect the portfolios of thousands of investors. As a direct consequence of this transformation, by 1970 detailed information on ongoing clinical trials was broadly sought by fnancial analysts, traders, and individual investors. Knowledge of the progress of a clinical trial itself became a valuable currency which circulated through a private-sector information economy. Management of this knowledge became a priority for industry publicists and Upjohn execturives. For an analysis of the rising critique in the 1970s of the autonomous, paternalistic model of medical authority, see David Rothman, Strangers at the Bedside, A Story of How Law and Bioethics Transformed Medical Decision-Making, New York: Basic Books, 1991.