AUTH/1803/2/06 & AUTH/1804/2/06 - Proctor & Gamble and Sanofi Aventis v Roche and GlaxoSmithKline

Bonviva once monthly slide kits

  • Received
    22 February 2006
  • Case number
    AUTH/1803/2/06 & AUTH/1804/2/06
  • Applicable Code year
    2003
  • Completed
    20 April 2006
  • Breach Clause(s)
    7.2 (x 3) and 7.4 (x 3)
  • Sanctions applied
    Undertaking received
  • Additional sanctions
  • Appeal
    No appeal
  • Review
    Published in the August 2006 Review

Case Summary

Procter & Gamble and Sanofi-Aventis complained jointly about two Bonviva Once Monthly (ibandronate) slide kits issued by Roche and GlaxoSmithKline. Procter & Gamble and Sanofi-Aventis supplied Actonel (risedronate).

Procter & Gamble and Sanofi-Aventis noted that slide 6 in the slide kit entitled ‘Osteoporosis, bisphosphonates and Bonviva (ibandronic acid)’ correctly described ibandronate as a bisphosphonate. Slide 11 stated that the National Institute for Health and Clinical Excellence (NICE) recommended bisphosphonates as first-line therapy in the secondary prevention of osteoporotic fragility fractures. Only alendronate, etidronate and risedronate, and not ibandronate, had been evaluated by NICE. By not excluding ibandronate, slide 11 misled the health professional to believe that NICE had recommended ibandronate as well. The NICE recommendation was based on an analysis of the cost effectiveness of medicines. Ibandronate was not licensed, nor had it demonstrated efficacy, in preventing hip fractures, the key cost driver in osteoporosis health economic evaluations. Efficacy of ibandronate in preventing nonvertebral fractures, another costly treatment, had also not been demonstrated. It should therefore not be implied that NICE would group ibandronate with the other bisphosphonates. Indeed during the evaluation of the available evidence the Scottish Medicines Consortium concluded that a grouping of ibandronate with other bisphosphonates in terms of hip and non-vertebral fractures was not appropriate. The omissions made in this slide kit were alleged to be in breach of the Code.

Slide 11 also claimed that bisphosphonates in clinical trials had demonstrated vertebral and non-vertebral fracture reduction efficacy. The slide inferred this was also true for Bonviva, which was not the case, as specifically and unambiguously noted in the Bonviva Once Monthly summary of product characteristics (SPC). These claims were alleged to be in breach of the Code.

The Panel noted that according to the SPC, Bonviva was indicated for the treatment of osteoporosis in postmenopausal women in order to reduce the risk of vertebral fractures. Efficacy on femoral neck fractures had not been established. Bonviva was first authorised in September 2005 ie eight months after the NICE guidance was published.

The NICE Technology Appraisal 87, dated January 2005, was titled ‘Bisphosphonates (alendronate, etidronate, risedronate), selective oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. Page 47 of the document defined certain terms and it was stated that bisphosphonates included alendronate, etidronate and risedronate. In the Panel’s view it was thus clear that even when the NICE document referred to ‘bisphosphonates’ it referred only to those three medicines.

The Panel noted that slide 11 referred to bisphosphonates and that they had ‘… been recommended by NICE as first-line therapy in the secondary prevention of osteoporotic fragility fractures’. This statement was referenced to the NICE Technology Appraisal 87. Section 1.1 of that document, however, stated: ‘Bisphosphonates (alendronate, etidronate and risedronate) are recommended as treatment options for the secondary prevention of osteoporotic fragility fractures [in certain groups of women].’

The Panel considered that in a presentation entitled ‘Osteoporosis, bisphosphonates and Bonviva’ which cited the NICE guidance it was misleading not to state clearly which bisphosphonates the guidance covered. Bonviva had not been assessed by NICE.

The Panel considered that slide 11 implied that ibandronate had been included in the NICE guidance which was not so. Slide 11 was misleading in this regard and not capable of substantiation.

Breaches of the Code were ruled.

The Panel noted that slide 11 stated that vertebral and non-vertebral efficacy with bisphosphonates had been demonstrated in clinical trials. The Panel that the statement implied that all bisphosphonates, including Bonviva, had demonstrated both vertebral and non-vertebral efficacy; given the licensed indication for Bonviva this was not so. Breaches of the Code were ruled.

Procter & Gamble and Sanofi-Aventis noted that slides 29-43 of the slide kit entitled ‘Slides for hospital sales force Bonviva (ibandronic acid) monthly for postmenopausal osteoporosis’ presented data from the Monthly Oral iBandronate In LadiEs (MOBILE) study which had compared daily and monthly ibandronate. The main conclusion was that ‘Once-monthly ibandronate can provide an effective, well-tolerated and practical alternative to daily and weekly oral bisphosphonates’ (slide 43). This suggested that a comparison to other once weekly bisphosphonates was made which was not the case and was thus grossly misleading. It further suggested that the study demonstrated similar efficacy between all bisphosphonates, which was clearly not the case as there were no head-to-head fracture studies between Bonviva and the other bisphosphonates. On the contrary all the data so far published on ibandronate differed from alendronate and risedronate by having failed to show fracture risk reduction efficacy at both the hip and non-vertebral sites. Roche and GlaxoSmithKline argued that despite this lack of head-to-head evidence the claim was still justified, but they failed to provide any scientific rationale or support. The claim was alleged to be in breach of the Code.

The Panel noted that slide 44, headed ‘MOBILE Study: Conclusions’, stated that ‘Once-monthly ibandronate can provide an effective, well-tolerated and practical alternative to daily and weekly oral bisphosphonates’. The MOBILE study compared once monthly ibandronate with once daily ibandronate not daily or weekly bisphosphonates.

It was thus misleading to make a statement comparing once a month ibandronate with daily and weekly bisphosphonates under the heading ‘MOBILE Study: conclusions’. The statement was inaccurate in the context of the heading. Breaches of the Code were ruled. The Panel did not consider that the statement per se was outside the Bonviva marketing authorization or inconsistent with the SPC and thus in this regard no breach of the Code was ruled.