Nexium is a prescription medication used to treat gastroesophagal reflux disease (or heartburn, as it is more commonly known). It does this by inhibiting a proton pump, or in other words, by stopping the stomach from secreting stomach acid. By many reports, it is quite good at that, and has relatively minimal side effects. Although heartburn might seem like a minor condition, it can become quite serious if untreated, so Nexium can be a quite important medication.

The two above writeups covered much of the pharmacology of Nexium, and I thought they covered everything that needed to be said on the matter. But by serendipity, right after reading them, someone posted about HeadOn, a chapstick like medicine that suggests, without stating, that it cures headaches, even though it provides no mechanism for doing so. This inspired me to write a little bit on the economics and sociology of Nexium.

Nexium is, as of 2013, the second most prescribed drug in terms of sales and the 5th most prescribed drug in terms of units. Yearly sales of Nexium in the United States ran to 5.97 billion dollars, which is greater than the GDP of Liechtenstein, and thus of 44 other independent countries with a GDP less than that of Liechtenstein. 5.97 billion dollars is also 50% greater than the cost of a Nimitz Class Aircraft Carrier. It is enough to buy eight B-2 Stealth Bombers, and is more than twice the cost of the Curiosity rover program. I could come up with more examples, but the point that 6 billion dollars is a lot of money doesn't need much embellishment.

As was mentioned in the above write-ups, Nexium is a derivative of Prilosec. Prilosec is a drug with the same indications and action as Nexium. The difference is that Nexium is one of the specific isomers contained in prilosec, which is a mixture of slightly different forms of the same structure. The Nexium form is the most active (or only active form), so by taking it, you get the same effect with a smaller dosage. But that leads to the question of how much difference there is between taking a certain dose of Nexium and the same dosage contained in Prilosec. And that question has been answered,through a scientific study: after five days of treatment, Nexium had shown a benefit in 68.4% of patients, versus 62% of patients who were taking Prilosec. That means that if you have a group of sixteen patients, 10 of them will show a benefit from Prilosec but 11 of them will show a benefit from Nexium. Although this is statistically significant, it is probably not therapeutically significant for most patients.

With this rather narrow difference, there are a lot of questions about why exactly Nexium is so popular. The obvious answer is that the company that owns the patent on Nexium (Prilosec being out of patent) has marketed quite aggressively both to the public and to medical professionals. It is not cynical to take this as an example of how marketing has corrupted the practice of medicine, and not in a small degree either: 6 billion dollars a year is, as stated, a lot of money.

The 6 billion dollar figure also only covers the direct cost of the medication. Nexium, despite having the same effects, the same side-effects, and the same toxicity, is a prescription drug, while Prilosec is an Over The Counter medication. This means that Nexium has added costs, the cost of needing to visit a doctor and get a prescription. So we can imagine parallel circumstances: someone with a full time job with health insurance sees a commercial for Nexium, and decides to ask their doctor about it. Meanwhile, someone who works in an uninsured job or otherwise has no health insurance sees an ad for Prilosec (featuring, in a demographically telling moment, Larry the Cable Guy) and goes down to the local Walgreens and buys some Prilosec. Ironically enough, the first person has been rewarded with resources that can only be exchanged for something that is symbolically better than what the second person has. It is situations like this that make the already confusing debate about health care costs even more confusing, because there is an undeniable symbolic and psychological element in how people use pharmaceuticals.

There is no problem with Nexium: it seems to be a useful medication without many downsides that can treat a serious condition. On the other hand, the success of this medication leads to many questions about the economic costs and benefits of prescription medications.