When physicians say no to Cipro, some people turn to the Internet

Online pharmacies under fire for prescribing antibiotics for worried stockpilers.

By Tyler Chin, amednews staff. Nov. 5, 2001.

Capitalizing on the anthrax scare that has gripped the nation since last month, several Internet pharmacies have started selling Cipro on the basis of an online consultation.

Ciprofloxacin is the antibiotic most often cited as a treatment for anthrax, although regimens proposed by federal health agencies also suggest the use of doxycycline and ampicillin.

Prescribing peace of mind?
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"I've had several people calling up saying they wanted Cipro because they thought they had anthrax or wanted it just in case," said Paul Kechijian, MD, a dermatologist in Great Neck, N.Y., a suburb of New York City. "I said, 'Look. I'm not going to give you Cipro because you don't have [anthrax] and I guarantee that if you need it, [health officials] will be all over you like a tent, and you will have plenty of it.' "

Public health officials and medical experts wish all physicians would follow Dr. Kechijian's example. They are urging physicians not to cave in to patients who want to have Cipro on hand because they fear a bioterrorism attack.

And they are upset that Internet pharmacies make it easy for people whose doctors rejected their requests for Cipro to get it anyway. Most of those pharmacies sell prescriptions without seeing the buyers or first establishing a physician-patient relationship.

More than 30 online pharmacies are selling Cipro, according to the Federation of State Medical Boards, which investigates improper online prescribing by physicians and turns over information to its member boards for further investigation.

Inappropriate online -- and offline -- prescribing poses a serious health risk for patients, said Charles N. Aswad, MD, executive vice president of the Medical Society of the State of New York.

Those who go online to buy a 60-day supply of Cipro, which costs up to $500, also face the risk of receiving bogus medication. "There's always unscrupulous people who will take advantage of the situation. You can't even be sure you're getting Cipro and paying large amounts of money for it," Dr. Aswad said.

Touting sales

While many Internet pharmacies and their operators bend over backwards to avoid scrutiny from pharmacy and physician regulators, Morrisville, N.C. -based VirtualMedicalGroup.com on Oct. 10 issued a news release boasting that it "has become a central figure in the American public's quest for protection against the potential threat of bioterrorism" by selling Cipro online.

The North Carolina Dept. of Health and Human Services immediately accused the self-described Internet-based network of physicians of "preying on the public's fears."

By selling the antibiotic and publicly trumpeting it, VirtualMedicalGroup.com is "contributing to the hysteria" involving anthrax, said Kelly McKee, MD, the head of the general communicable disease branch and epidemiologist at the North Carolina Dept. of Health and Human Services.

Regardless of whether physicians practice online or offline, they should not prescribe Cipro "unless there is a special indication based on clinical evaluation that someone has signs and symptoms consistent with anthrax," Dr. McKee said. "This is clearly not in the best interest of the public and poses potential health risks."

Those risks include antibiotic resistance, allergic reactions or other serious side effects if patients take Cipro unnecessarily, he and other experts say. Another concern is that people might give the antibiotic to their children, posing a serious risk of adverse effects.

Further compounding the problem of inappropriate prescribing is that early symptoms of flu and anthrax are similar, Dr. Aswad said. People who have stockpiled Cipro and have the flu might take the medication on the mistaken belief they have contracted an anthrax infection. Or people might simply use Cipro in an ineffective attempt to treat the flu.

VirtualMedicalGroup.com responded that it is not doing anything wrong. "We went forward with this after weighing all the medical concerns and our patients' concerns," said Tania Malik, the firm's CEO. "We decided to move forward with precautionary measures and safeguards in place. We're not preying on people's fears. We're responding to public demand and satisfying their concerns."

People who want Cipro must fill out an online questionnaire covering medical history, Malik said. A physician in the company's network will review the answers and if there are any problems, the physician will discuss them with the patient by e-mail over a secure network.

"We establish a physician-patient relationship online because we have a secure and unlimited communication tool and patients can speak with their doctor in an unlimited manner and vice versa," she said. Also, when people fill out the questionnaire they are given information addressing the concerns the medical community has raised about stockpiling Cipro, she said.

Because she believes that VirtualMedicalGroup.com is acting responsibly, Malik said she resented that the company had been criticized. "We're not the only physician group that is prescribing Cipro. There are physicians who are giving prescriptions for Cipro in their offices, so to target us and say, 'You're doing it wrong and inappropriately,' is inappropriate."

The North Carolina Medical Board, however, said it is unprofessional for physicians to prescribe medications to people they have never met on the basis of an online or telephone consultation. If the board becomes aware of physicians it licenses doing that, it would investigate them, a spokesman said.

VirtualMedicalGroup.com has sold 100 prescriptions daily since it began offering the antibiotic on Oct. 8, Malik said. She would not disclose how those sales compared with other drugs, such as Viagra, another popular drug in online pharmacies, but said that the site sold only a "small number" of Cipro prescriptions before anthrax grabbed national headlines.

ADDITIONAL INFORMATION:

Prescribing peace of mind?

Number of new prescriptions for Cipro during the two-week period ended Oct. 12:

	2000	2001
Nationally	502,760	639,212
Florida	33,610	48,839
New York	22,001	46,405
Washington, D.C., Maryland, Virginia and West Virginia	9,645	13,335