Friday, March 9, 2012

The Z-pak

Sexy names sell products. 

Ipod, Spanx, and Twinkle Toes are sexy names.  Their products sell. 

Prescription drugs are no different.

I don't know who comes up with the brand names for new drugs, but they must have a high-stress job.  The profitability of a drug seems to be directly proportional to the sexiness of its name.  Imagine your job depends on picking the right name for a new drug.  If you pick a good one, profit soars into the billion dollar per year range.  If you choose a dud, millions of dollars in research and development are flushed straight down the toilet.

I've noticed a trend in the brand names for new drugs.  Apparently the letters x,y, and z are finally getting the attention they deserve.  And apparently Americans think there is something sexy about them.  Take the following examples from recent years:


Ah yes, but I've intentionally left out the most popular of them all for dramatic effect.   Not only does it have an incredibly sexy name, but it comes in its very own package!  You guessed it - in fact you may have gotten one from your PCP recently.  It's the Z-pak.  

The generic name for the Z-pak is azithromycin.  Zithomax is the brand name, and it's packaged in a neat little box and marketed under the name Z-pak.  Azithromycin isn't too bad in and of itself, but nowhere near as sexy as Z-pak.  The popularity of the Z-pak is tied to nothing other than its name.  Whoever thought of that one is now probably living comfortably on a Carribean island.  They scored big time - hit the ball out of the park.  Would it have achieved the same level of popularity if was called a P-Pak?  Or how about an A-Pak?  No way!  The Z was genious. 

There aren't many prescription drugs that people ask for by name.  Z-pak is at the top of the list (with oxycontin following close behind).   Why don't people ask for clarithromycin or erythromycin?  These are both very similar drugs in the same class - for all intents they are chemically the same compound.  They would likely work equally effectively as well.  But Z-pak is just sooooo much cooler.

Now let me tell you a dirty little secret.  Ready?  This might sting a little - I hate the Z-pak.   

What?  You're kidding, right?  How can you say such a thing?  They work so well! 

No, I'm not kidding.  I really don't like the Z-pak at all.  I love azithromycin, but I despise the Z-pak.  Azithromycin - the generic name of the drug - is actually a wonderful drug.  I commonly use it for pneumonia and it works wonderfully for certain bacteria.  Regrettably, I also prescribe it commonly for sinus infections, which is why I hate the Z-pak.

Confused?  Let me explain.

Somewhere along the line, the Z-pak became the main go-to for treating patients complaining of acute sinusitis.  I'm not sure if this was excellent marketing or what, but somehow all of us just started using it years ago for upper respiratory symptoms.  And why not?  It is easy to take, has relatively few side effects, and is covered by insurance.  There are only 6 pills - two the first day, then 1 per day for the next 4 days.  Patients liked it.  In fact they liked it a little too much.

Let me tell you another dirty little secret.  Acute sinusitis, the condition that all of you have taken a Z-pak for at some point, is caused by a virus approximately 98-99.5% of the time.  And guess what?  The Z-pak is and anti-bacterial drug.  That means it has NO effect on viruses whatsoever.   So 98-99.5% of the time you've used one, you didn't even need it.

But what do you do when you get sinus pressure, greenish-yellow snot, and a fever?  You go to the doctor and secretly hope he recommends a Z-pak.  It's so innate to your thought process that it's like wanting water when you're thirsty of food when you're hungry.  And if the doctor doesn't give you one, you'll politely remind him that the amazing Z-pak has cleared up your symptoms every time you've taken one in the past.  And if he still doesn't give you one, you may even be so bold as to demand one.  After all, you paid money to see him and you feel like you have to get something out of this deal.  Chances are, he is so far behind in his schedule and tired of having the same conversation that he rolls his eyes and just gives you one.  That is why I hate the Z-pak.

The very name itself has empowered my patients to demand it by name.  It has imbued them with striking confidence - almost as if their medical knowledge is somehow better than mine.  No longer am I the physician who has spent my entire adult life learning when and how to use this drug - now I'm nothing more than a Z-pak dealer. 

Truth is, 98-99.5% of acute sinusitis will go away within a week without any treatment at all.  The official recommendation is to not even consider treating for bacterial sinusitis until you've had symptoms that are 1) persisting greater than 10 days; or 2) symptoms worsen after day 7.  And guess what the recommended drug for treating bacterial sinusitis is?  Not the Z-pak!  Good old fashioned amoxicillin is the recommendation.  Why?  Because bacteria, thanks to gross Z-pak overuse in the past 20 years, are becoming more and more resistant to azithromycin.  Don't believe me?  Look at this article and read the studies for yourself.  Resistance is as high as 30%!!!  Anecdotally, I was told recently that the rate is approaching 40% now - but I don't have a source for that (omg doctor you are soooo not evidenced-based).

But doctor, I swear the Z-pak helps! 

There's an old saying in medicine - you'll get better in 1 week if I prescribe medication, 7 days if I don't.  Fact is that you're getting better because you would have gotten better even without the Z-pak.  It's coincidence.  Still don't believe me?  This has been demonstrated over and over and over again in randomized, controlled trials.  Still don't believe me?  Then go get your Z-pak from someone else, because I'm done being your dealer.

So enjoy your life in the Caribbean, Mr. whoever created the Z-pak, because you've done your job and you've done it well. 

Next time you go to the doctor for sinusitis and he prescribes a Z-pak, surprise him and ask him if you really need it, or if you can just wait it out and see if it clears on its own.  I know you don't like taking all the other medications I prescribe for you, so why should the Z-pak be any different? 


  1. Your are the business my friend. Great to see some spot on, irreverent fun being poked at life in medicine. Looking forward to some more blogs from you. Keep it up.

  2. As a patient, I am glad to hear that you will not prescribe a drug that you have very good reason to think would be ineffective for a particular ailment.

    What I don't understand is why this policy is so difficult for other doctors to follow. Doctors hold all the power, so to speak, in this situation, don't they? The patient can't get the drug without a prescription, and unless a gun is literally held to the head of the physician, no one can force that physician to write the prescription. Let the patient leave your practice if they get upset. If all other doctors also decline to prescribe the Z-pak, the patient will ultimately figure out that his or her thinking on the topic was wrong (or they will never learn his or her lesson, in which case good riddance anyway). I am a professional in a field outside of medicine and I often have to tell my client "no." It is usually not a fun conversation. I am often yelled at. My clients frequently threaten to leave my practice. Some actually do. But my client's reactions do not change my position when I am reasonably confident that I am doing the right thing by saying "no."

    And why isn't it viewed as unethical for a physician to prescribe a useless drug that will ultimately hurt the patient in the long run by building up his/her resistance to that particular antibiotic? Or do doctors realize it is unethical and choose to prescribe anyway? Why don't doctors better police other doctors through disciplinary boards and the like?

    Am I oversimplifying? Why is this so hard for doctors to do? I just don't get it.

    1. Excellent point, anonymous. You are right on. We shouldn't be doing it, but we do. Why? I can only speak for myself, but I suspect the reason for prescribing unnecessary medications is the same for others as well. The sad truth is that it is sometimes easier to give in to a patient rather than stand your ground. It takes 2 minutes to write the rx and sometimes 10-15 to explain why they don't need it - and even after that they still want it! After a while you just throw int he towel and stop fighting the fight. The second reason is that I generally don't like patients being angry at me. Remember - it's angry patients that sue. That's a topic in and of itself that gets me worked up - more on that in a future post. Again, great points and I couldn't agree more.

    2. Very valid points, both of you. It's important to add that many patients feel that if they spend the time and money to go see their PCP (either by walking, bus/cab, or driving, which also usually requires taking time away from work) and are told that what ails them is simply viral in nature and that conservative symptomatic management is the evidence based-dictated method, many if not all patients feel that "nothing is being done." That in its totality, their trip to the doctor's office was fruitless and not a good "bang for the bank."

      Because in America, if I pay to see my doctor and am feeling lousy, I had better leave with something of more substance and exotic such as an antibiotic, rather than good old fashioned sleep, soup, and sex.

    3. "The patient can't get the drug without a prescription, and unless a gun is literally held to the head of the physician, no one can force that physician to write the prescription."

      Because one time, I told a patient that she had a virus and didn't need a Z-pack. And you know what she did?

      She looked me in the eye and said, "Do I need to call my lawyer." I kid you not.

      No, they don't hold a gun to my head....but they can hold a malpractice lawsuit instead.

      Great society we live in.

    4. The choice to prescribe or not prescribe might be harder when the patient has a serious illness. For example, you don't think chemo will help with his cancer, but he wants it anyway. In that case, the threat of legal action should give you greater pause if you are thinking about standing your ground. But in the case of a Z-Pack? Sorry, I don't buy the rationale that a threat of legal action warrants prescribing the medication, especially where you are sure that the patient has a viral illness. The practice of medicine, like all professions, is not completely risk free, and prescribing in this scenario is not appropriate.

    5. Another point as to why antibiotics are prescribed to patients that really don't need them is that the patients will complain to the hospital or office administrator and then the doctor gets chastised for upsetting the patient. Now a days it is all about patient satisfaction.

  3. Love the sexy name point. Oh so true.

  4. Here in India we doctors do not have this dilemma. The patients merely pop into one of the pharmacies on every block and buy their own anti-biotics at the drop of a sneeze!