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BOOK REVIEW

‘Blood Feud’ by Kathleen Sharp

By Dennis Rosen
Globe Correspondent / September 19, 2011

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The last few years have seen a surfeit of high profile cases of corporate malfeasance and practices, which blithely trampled ethical and legal boundaries. Lehman Brothers; Enron; Madoff: all shared a culture of greed in which collateral damage to individuals or society at large was either deemed inconsequential or ignored entirely.

Some businesses profess to hold themselves to a higher standard, and the pharmaceutical industry is one of them. Despite a large number of books and articles chronicling questionable practices, sometimes resulting in injury and death, it always seems to come as a shock to discover just how amoral and callous the actions of some within this industry appear.

Journalist Kathleen Sharp’s “Blood Feud’’ focuses on one such a case: that of the development and aggressive marketing of a blockbuster anemia drug despite eventual evidence that it could prove dangerous or even deadly under certain circumstances.

The book tells three stories simultaneously. The first involves the 1984 discovery of epoetin alfa (also known as Procrit, Epogen, and Aranesp), a medication used to stimulate red blood cell production in patients with anemia from kidney disease and chemotherapy. Pushed by two drug companies, Amgen and Ortho (a subsidiary of Johnson & Johnson), annual sales surged, topping $5 billion in 2001. Yet alongside its success in treating anemia, it had significant side effects that started to become known in the 1990s, which were largely ignored by the two companies.

One study published in 2003 found that its use in patients with head and neck cancers increased death rates by 39 percent. A 2006 study in the New England Journal of Medicine found that when epoetin was given to increase red blood cell levels beyond those recommended by the FDA, there was a 34 percent higher incidence of heart attacks and death. Yet according to Sharp, both Amgen and Ortho aggressively promoted its use to reach the higher, more dangerous levels.

The second story involves the ways physicians were enticed to prescribe the drug and to use it at high doses, thereby turning higher profits for the drug companies.

Especially troubling was the liberal provision of vouchers for free product (in one case, $80,000 worth) that opened up a wide avenue for Medicare fraud, with many physicians and hospitals using them to acquire product at no cost and then billing Medicare to receive “reimbursement’’ for 95 percent of the average wholesale price of drugs they had paid nothing for.

The third story is the personal one of Mark Duxbury, former star sales representative for Ortho who gradually came to doubt the ethics of aggressively promoting epoetin as instructed. After losing his job, he joined a whistleblower suit against Ortho, until his untimely death.

The first two parts of the book are thoroughly researched and wildly successful in describing the depths to which those responsible for marketing the off-label use of epoetin sank despite being aware of the risks to the health and lives of countless patients, and the complicity of many physicians in this. It makes a very strong case for strengthening the regulatory oversight of the pharmaceutical industry and for even closer monitoring of its interactions with doctors.

The attempt to bind so much of the narrative to the personal story of Duxbury, tragic though it may be, is not as successful. By focusing the book more tightly on the other two story lines, and editing down the portion dedicated to Duxbury, the pace of the book might have been better sustained. Likewise, the abruptness with which the book ends, without a clear summary of the current status of epoetin use or of where the legal proceedings against Ortho stand, left this reader dissatisfied with the many unanswered questions that remained.

Dennis Rosen is a pediatric pulmonologist and sleep specialist who practices in Boston. He can be reached at dennis.rosen@childrens.harvard.edu.

BLOOD FEUD: The Man Who Blew the Whistle on One of the Deadliest Prescription Drugs Ever

By Kathleen Sharp

Dutton, 424 pp., $27.95