Drugs (Not) On The Market

One day last October I was sitting at a computer screen at my office’s reception desk scrolling through the images of a patient’s CAT scan – my own computer wouldn’t do because I’m an Mac girl and all radiology CDs in Italy are Windows-only – struggling to keep my concentration on the patient’s insides and ignore the chaos around me.

My secretary Mariateresa was speaking into a phone and her voice succeeded in penetrating my defenses. “Robertino needs his hepatitis B vaccine? No, I’m sorry, there’s no point in taking an appointment with the pediatrician, because that vaccine is unavailable at the moment. The Haemophilus influenzae shot? Same story, I’m afraid.” This was so startling that I abandoned the CAT scan images and indulged my curiosity: “Not available? How can that be? Those are obligatory vaccines. Kids can’t start school without them.” Mariateresa shrugged dismissively, “Of course, that’s exactly the point. Every fall parents scramble to get their kids vaccinated, and every fall there aren’t enough vaccines to go around. This year the missing ones are hepatitis and Haemophilus, last year it was meningitis and measles-mumps-rubella.” If you think about it this kind of shortfall is inexcusable. Italy has universal population registries, so it could easily calculate the number of necessary doses ahead of time, but hey that’s our beloved Bel Paese.

The Italians have a saying about the marvels of Rome, “Non basta una vita,” a lifetime is not enough to see them all. Well, the same goes for its foibles – after 39 years here I’m still encountering new ones.

Generally speaking Italy is a great country to buy medications: list prices trend low, and anyone with a National Health Service prescription pays zero or close to. The authorities are able to swing this by bargaining ruthlessly with the drug companies over prices. Just a couple of months ago California-based Gilead Pharmaceuticals agreed to accept $11,000 for each course of hepatitis C treatment with their new pill Epclusa. That may sound like a lot but it’s far lower than the $75,000 they get in the States. If Gilead hadn’t agreed to cut the price of Epclusa, it wouldn’t have been included on the National Health Service formulary and no doctors in Italy would prescribe it.

The ins and outs of the system keep us docs on our toes. The yearly vaccine debacle may have been new to me, but I’ve always known the pharmaceutical supply chain to be iffy. Things change fast. Yesterday you could buy the equivalent of the tranquilizer Ativan only as generic lorazepam, today there’s only brand-name Tavor. This week the antibiotic metronidazole is on pharmacy shelves only as Flagyl, next week only as a generic, the week after only as Deflamon, then for six months it’s unavailable under any name. During the entire 2013-14 flu season neither of the two approved anti-influenza drugs, Tamiflu and Relenza, could be found anywhere in Rome. Premarin, the classic hormone pill and vaginal cream, disappeared mysteriously from Italian pharmacies in 2009 and has never shown up again. Yes, I know the US runs low on a drug now and then, but here shortages are too commonplace to warrant a mention in the paper much less headlines.

Then there’s the way brand names keep biting the dust. The Italian companies that make the meningitis vaccine and the one against measles-mumps-rubella change every few years. For a decade I prescribed menopausal women a rub-it-in estrogen skin gel called Gelestra (Estrogel in the States), but at the end of 2014 it became Ginaikos – same gel, same pharmaceutical company, same dose, same formulation, same color box, but pharmacies won’t dispense it unless my prescription bears the new name.

Almost all medications found in the US or the UK are on the market here, plus some that either are new and got approved here first or are left over from the Jurassic era. But like so much else in Italy, getting hold of a specific drug can sometimes be a crap shoot. Don’t even consider having your supply shipped from home – it’s close to impossible to extricate prescription drugs from Italian customs, which is on the lookout for them.

Moral of the story: if you’re coming to Italy and there’s a medication you really really need, bring along enough to last you for the duration.

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Sorry for the long gap between posts – vacation intervened! A version of this one has been published as "Musical Drugs" in my The American In Italia column, Bedside Manners.