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ANGLETON, Texas - Merck & Co.'s marketing team targeted doctors viewed as unfriendly toward Vioxx to bring them into the fold, neutralize or discredit them, the plaintiff's lawyer in the nation's first Vioxx-related lawsuit to go to trial alleged Tuesday.
Houston litigator Mark Lanier questioned Nancy Santanello, head of Merck's epidemiology department, about an internal list of 36 doctors identified as "physicians to neutralize" in an e-mail circulated two months after the popular painkiller went on the market in 1999.
"Attached is the complete list of 36 physicians to neutralize with background information and recommended tactics. You will notice that some have already been 'neutralized,' " the e-mail said. It also said a previous e-mail had a subset of the 36 physicians "we would like to get involved in Merck clinical research" and that the e-mail's recipient should "be aware of our most challenging (and also most vocal) national and regional physicians."
Santanello said the term, "neutralize" was a marketing strategy to educate doctors about Vioxx.
"I'm not a marketing person, What the marketing people do is ask the scientists to meet with the physician and explain the data to them," she told jurors.
Santanello is Merck's corporate face among the company's team of lawyers and continued absorbing verbal punches from Lanier Monday regarding the ethics of Merck's marketing and commitment to safe drugs.
Lanier pressed her about written recommendations to gain each doctor's support for Vioxx. In one case, the document said, "Show me the money" and then noted Merck had provided him with $25,000 to support a program to examine treatment of arthritis. In another case, the document said "discredit" next to the name of a doctor allegedly deemed unwilling to be swayed.
Santanello said such grants from pharmaceutical companies are common. She also said "discredit" meant providing an alternate viewpoint, and doctors who expect their views on drugs and treatment to be heard can be critical if they perceive that a company ignores them.
"They definitely consider themselves thought leaders, and they want to be included," she said.
On Monday Santanello testified that an in-house training game for Vioxx sales representatives dubbed "Dodge Ball" wasn't about learning to dodge questions from doctors about the drug's safety.
In the case, the widow of a man who took the drug for about eight months before he died in his sleep alleges that Vioxx caused his death, and that Merck knew the drug was dangerous years before voluntarily pulling it from the market in September.
Merck says the company acted responsibly, disclosed Vioxx research and voluntarily removed the drug from the market last year when a study showed it doubled the risk of heart attack if taken for a year and a half or more.
Lanier presented an internal memo Monday laying out the "Dodge Ball" training and asked Santanello why trainees could only move on to the next round of the card game if they gave Merck-approved answers to possible doctors' questions about Vioxx safety or dodged such questions altogether.
"The point is, you never had to answer the question if you dodged it?" Lanier asked.
"Basically you're trained to answer questions from physicians ? not to dodge questions," Santanello said, noting participants couldn't win if they dodged all the questions.
Lanier also highlighted warning letters Merck received from the Food and Drug Administration about misrepresenting or downplaying Vioxx safety concerns in aggressive marketing that included glitzy television ads.
Merck added warnings about cardiovascular risks to Vioxx's label in 2002. About 20 million people took Vioxx before it was pulled from the market.
The trial centers on the May 2001 death of Robert Ernst, a 59-year-old produce manager at a Wal-Mart in Cleburne, near Fort Worth. Ernst also ran marathons and worked as a personal trainer. He died in his sleep next to his wife, Carol.
His autopsy report says he died of an arrhythmia, or irregular heartbeat, secondary to plaque buildup in two major arteries.
Whitehorse Station, N.J.-based Merck argues that no studies link Vioxx to arrhythmia, so the drug couldn't have caused Ernst's death. Lanier's legal team argues that arrhythmia is most often caused by heart attack, but Ernst died too fast for his heart to show damage.
The nature of science is one of debate. No matter what you publish or claim, there are bound to be critics.
-------------------- ...the whole experience is (and is as) a profound piece of knowledge. It is an indellible experience; it is forever known. I have known myself in a way I doubt I would have ever occurred except as it did.
Smith, P. Bull. Menninger Clinic (1959) 23:20-27; p. 27.
...most subjects find the experience valuable, some find it frightening, and many say that is it uniquely lovely.
Osmond, H. Annals, NY Acad Science (1957) 66:418-434; p.436