Detailing Dr. House: Promotion or Risky Prescribing?

A superstar baseball player is rushed to the hospital with a broken arm. Tests show the athlete is also suffering from numerous other symptoms, including kidney failure, liver damage, hallucinations, and hypogonadism.

Enter Gregory House, the misanthropic, diagnostic genius and protagonist of House, the hit TV medical drama. In House's cynical worldview everyone lies. And so when the baseball player says he's never used steroids, House doesn't believe him and treats his hypogonadism with Lupron.

Lupron?

Even for House, who is renowned for prescribing drugs that will as easily kill the patient as save him, this treatment choice seems puzzling.

"Ludicrous," wrote Scott Morrison in his blog "Polite Dissent" the morning after the show aired. Morrison, a doctor, TV critic, and avid House-watcher, parses and rates every episode. He gave this particular show a D for the medicine. "Admittedly, this area of medicine isn't my specialty, but this makes no sense. Lupron suppresses the production of sex hormones, something the patient is already low on. He is causing hypogonadism in a patient who already has that problem."

Dr. House (played by Hugh Laurie) in search of a diagnosis

Dr. House's Lupron treatment also raised the eyebrows of Dominick Frosch and Sony Ta, UCLA medical researchers and authors of "Pharmaceutical Product Placement: Simply Script or Prescription for Trouble?" published last May in the Journal of Public Policy & Marketing (see accompanying article in this issue).

Frosch and Ta found the use of Lupron (leuprolide, from Abbott) and the four mentions of the drug on the show "suspicious," and wondered if they weren't a paid product placement (also called stealth or subliminal advertising)—the insertion of a product or service into a script or scene of a TV show, usually for a price negotiated with the network, producer, or scriptwriter.

"The doctors were using the product to treat hypogonadism, which is not a FDA-approved indication for this medicine," wrote Frosch. "Indeed, Lupron is traditionally used to suppress testosterone production as a treatment for prostate cancer." Further, they noted "a newer pulse-dose Lupron is currently being evaluated as a treatment for hypogonadism in a FDA-registered clinical trial. The off-label use of this product in this show and the concurrent FDA trial appear more than coincidental."

ALL PHOTOS COURTESY OF FOX

PROMOTION OR PART OF THE STORY?

House (played by British actor Hugh Laurie) bears more than a little resemblance to Sherlock Holmes. Both are unconventional, both are drug addicts (Holmes to cocaine, House to Vicodin), and both are driven by unconventional means to solve cases: For Holmes, it's about catching a criminal; for House, it's about diagnosing a disease.

Each episode of House follows basically the same pattern: A patient is rushed to the hospital; House takes on the case; his team misdiagnoses the disease; the patient almost dies; a light bulb goes off in House's mind; he figures out the problem and the patient lives (usually). The disease is almost always arcane. In the case of the baseball player, it turns out to be colchicine poisoning. (Don't ask.)

The character of House, with his risky, high-prescribing habits, makes the show fertile ground for all kinds of drug mentions—more so perhaps than any other medical TV show. Overall, drug mentions have doubled on TV in the last two years, according to Nielsen Product Placement.

So what gives? Was the use of Lupron on House a product placement for promotional purposes?

"Absolutely not," says Harley Liker, medical adviser to House. The show, he says, which attracts 20 million viewers weekly, contains no paid pharmaceutical product placements.

"Zero, zero, none," says Liker. "I talked about this with the writers. Their reaction was that it was almost the opposite: They try to avoid mentioning specific brand names whenever possible, partly because of potential legal issues."

Liker, who holds both medical and business degrees and serves on a global advisory board for AstraZeneca, functions as a consultant on House. "I'm not on the set every day. I get a script, or I talk about an idea with someone. I make sure that the vernacular is appropriate and that the story line makes sense."

Lupron was not his idea. "It was not my detailing," says Liker. "Many people come up with ideas, including a doctor who is a full-time writer on the show."

Liker attributes House's off-label use of Lupron on the show more to House's character than the drug.

"House is very untraditional. He is a risk-taker, constantly thinking outside the box. He is actually more likely to use a drug off label than he is on-label. It has more to do with who Doctor House is and the way he approaches medicine."

CUTTING-EDGE WRITERS

As for the apparent knowledge of Lupron's off-label indication, the clinical trials, and the testing of Lupron for hypogonadism for FDA approval, Liker credits the writers who, he says, are very aware of what is going on in the medical world. "When we're doing cutting-edge stuff, we'll say, 'We're going to try this new drug that's been developed.'" Liker, however, stresses that it's the disease and not the drug that determines what drugs are mentioned.

"We think about how we are going to treat the disease, or condition, or symptom, not the other way around. It's not 'OK, how can we highlight Drug A, B, or C.' It's never part of the discussion. Never.

"We basically start with the diagnosis that we're going to be exploring, and work our way backwards. It's not like, 'Oh, well, let's go down this path and this is where we're going to end up.' It's actually, 'Here's where we're going to end up with this weird diagnosis of, say, neurocystercercosis?' And 'OK, well, how many things look like neurocystercercosis that we can try and masquerade as potential diagnoses before getting to neurocystercercosis.' We don't want to get to the final diagnosis until the final act, right? Otherwise you give it away," says Liker.

"For example, let's say someone had a tumor in their lung, and they presented with chest pain. Well, if they came in to the Emergency Room and they were having chest pain, we would give them nitroglycerin because that's what you do. So the thinking is never, 'Oh, we need to incorporate nitroglycerin into the story.' One of the diseases that can often masquerade as other diseases are autoimmune processes. So if you look at House, one of the most commonly used drugs is probably prednisone because someone's always thinking that it's autoimmune. Every patient on House seems to have a form of lupus. But, again, in terms of our thinking process, it's almost never, 99 times out of 100, it's never driven by the drug."

THE POWER OF TV

Frosch says in his paper that it is almost impossible to determine whether drug mentions are promotional or just part of the story line. The potential for pharma product-placement advertising is there, however, and Frosch's concern is the power of TV to influence consumers.

A drug mention is certainly powerful enough to prompt viewers to go to the Internet to find out more about the drug, and possibly to the company's branded Web site, which in and of itself is a marketing triumph. (Branded Web sites are the most effective form of online pharmaceutical marketing).

This was in evidence on a recent episode of House when a generic drug, amantadine, was prescribed to treat Parkinson's. The next morning online searches for amantadine spiked. Approved by FDA, but for use in influenza, amantadine ended up topping Google's Hot Trends.

Frosch believes FDA should start paying more attention, with an eye to new restrictions.

Liker, however, does not agree: "My sense is both the FDA and FCC are busy agencies, and they have a lot more important things to do with their time than focusing on product placement on fictional television shows."

As for other kinds of product placements on House, such as the clearly labeled Hill-Rom beds (see photo above), Liker says he can't comment on it. But he doesn't believe that it is the same as paying to mention a drug. "So if it's the KinAir bed, or the so-and-so bed that's in the room, it doesn't really matter," says Liker. "If it's a G.E. CAT scanner or a Siemens CAT scanner, it doesn't matter. But to say to a writer or producer, 'You must figure out a way to incorporate this drug into this show,' people kind of lose their focus."