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In the past year, news stories have featured multiple outsider challenges to “the Establishment.” Traditional authority faces threats of being upended. Moreover, the challengers seem to have emerged with tsunami-like force, seemingly out of nowhere. Technology makes it easier for like-minded individuals to find each other and collectively demand changes that may shake up the status quo. Since branding uses messaging to reinforce an organization’s or product’s “reason for being,” it is worth looking at what potential shake-ups could mean for the industry.

This is particularly important for advertising agencies serving healthcare and pharma, sectors that have recently faced their own heightened public scrutiny. Turing Pharmaceuticals' Martin Shkreli became the poster boy for corporate greed. Mylan’s EpiPen price increase owned the headlines this summer, and renewed focus on perception of co-pay programs across patients, payers, and physicians. The US Treasury Department blocked Pfizer’s plans to buy Allergan, an acquisition that would have drastically reduced Pfizer’s American tax exposure. And despite the fact that Bill Gates calls the US’s drug-pricing system “better than most,” there is a growing narrative that suggests companies are putting their money into communications to push profits over patient-saving innovations. But do these discussions truly challenge the $21 billion-plus advertising spend of America’s pharma industry?

The conversation may be intensifying due to societal changes, but there have been periodic calls to ban pharmaceutical advertising since Merck ran the first DTC ad in 1981. (A ban would likely be unconstitutional under the First Amendment.) Calls for increased regulations have been considered, as well. The Responsibility in Drug Advertising Act, introduced in February 2016 by Connecticut Congresswoman Rosa DeLauro and Comptroller Kevin Lembo, would place a three-year moratorium on any ads for newly approved prescription drugs. Minnesota Senator Al Franken introduced similar legislation, the Protecting Americans from Drug Marketing Act, which would lead the IRS to stop drug companies from deducting marketing costs of direct-to-consumer (DTC) advertising.

So what’s really going on? Reinhard Angelmar, emeritus professor at INSEAD and an expert on pharma marketing, says criticisms of pharmaceutical advertising are misplaced. “The call for a DTC advertising ban is a desperate attempt to slow down the erosion of organized medicine by tackling the pharmaceutical industry,” Professor Angelmar told Havas Tonic. “The timing is well chosen. It fits the current debate around high drug prices, while diverting attention away from the high price of healthcare.”

Angelmar sees multiple factors eroding the traditional sources of physician power. Web and mobile technologies have increased consumer access to medical information through online sites and digital apps. In addition, Angelmar points to ACA-related price pressures on both patients and doctors, which have led to consumers demanding a greater say in medical decisions. Finally, Angelmar focuses on the expanding sector of nontraditional healthcare providers, including pharmacy-based clinics and nurses, as well as “third-party payers who convert independent physician-entrepreneurs to contracted agents and salaried employees.”

Where does that leave Big Pharma? Or the advertising agencies that service it? Or the media that carry the communications? From Professor Angelmar’s perspective, pharma brands and their marketing partners need to be more proactive in reaching out to multiple constituents. Angelmar believes that doctors and payers, as well as patients, can (and should) be courted as natural allies of DTC: “Develop a plan to improve the perceived value of DTC among physicians,” he says. “What do third-party payers think about DTC? Ensure that they perceive the value of DTC.”

These are good points, and there is evidence that DTC has a real value. For instance, health economist Austin Frakt, in a March 2016 New York Times The Upshot Blog, pointed to multiple studies that demonstrate positive healthcare outcomes generated directly by DTC, ranging from better-informed consumers to better patient care. One study about DTC antidepressants showed that when patients “requested a specific drug, 90% received appropriate care, but not all of it involved drugs.”

Havas Tonic’s learning from a multi-month healthcare panel it ran in 2015 supports these points. Paul Klein, Managing Director of Havas Tonic, says, “Polling consumers about their attitudes toward DTC advertising, we found the most receptive audiences for such marketing were more – not less – informed about healthcare, media, and marketing. The study seems to negate the assertion that advertising exploits vulnerable consumers.”

In fact, the poll suggests that the most engaged audience for such messaging (i.e., “Requestors”) is a sophisticated group. And compared to those polled who feel negatively about DTC (i.e., “Non-Requestors”), this group expressed a sense of empowerment around their healthcare decisions. Take their relationships with doctors. Says Klein, “Compared to Non-Requestors, Requestors expressed feeling far more engaged with their physicians and were conscious about maintaining a patient-doctor dialogue.” This makes sense: The Requestor, after all, is bringing an informed request to their doctor. It is up to the doctor whether or not to grant it.

A compelling aspect of Requestors is their attention to societal values. Pharma brands should take note: Their most engaged customers prioritize companies with a social conscience. For Requestors, this means demonstrating a propensity for innovation. For instance, a company might stress the research as well as the innovation behind the treatments it brings to market. Pfizer’s “Before It Became a Medicine” is one such effort. Consumers care about a brand’s overall societal imprint, and will lean in to companies that work to establish that they are truly keeping the patient top of mind in their efforts. But pharma needs to be careful – if every pharma company comes out with a personal story about why they pursued innovation, the messages will quickly become duplicative and dissonant. We’re already seeing this in consumer perception of patient-assistance programs – if the drugs weren’t so expensive, then there wouldn’t need to be financial assistance.

There are challenges to DTC advertising that need to be taken seriously. Addressing them starts with recognizing that today’s DTC advertising audiences are not mindlessly consuming products. They are thinking carefully about what they purchase, and from which companies they purchase. The most powerful branding for them will acknowledge their hunger for innovation, as well as social consciousness. Equally important, pharma brands (and their marketing partners) have to be more imaginative in thinking about allies, from patients to doctors to payers.

Part 3: The Medications

A few months ago, I went for a blood test and found out my A1C was over 10%. This, combined with an unexplained weight loss of about 30 pounds, lead doctors to the obvious conclusion that I had joined the ranks of about 30 million Americans who had diabetes. At this point, the two major questions were which type of diabetes, and how can I treat it? Because it came on suddenly and quite severely, my doctors suspected type 1. I, knowing my diet and physical activity regime over the last 30 years, suspected type 2.

As diabetes is very complex, it's more than just taking medication every day to treat this disease. There is a great deal a patient has to know about diet, exercise, devices, drug interactions, dosing, and testing. As there was so much to take in, I decided to detail my experience as a newly diagnosed diabetic and the challenges I have faced, having spent so much of my time on the marketing side, to now be on the patient side. In this article, I detail my experience with diabetes medications and why I chose the ones I did. My final article in this series will deal with the overall consumer experience.

Upon getting my diagnosis, my doctor prescribed me two things, insulin shots 3 times a day, with meals, and Glimepiride (Amaryl). I was surprised not to receive Metformin, as I heard this was usually a first line treatment, but was told that Glimepiride was secondary to Metformin in history and lack of side effects. For my other prescription, I was given Humalog quick acting insulin, along with a very quick primer on how to use it and instructions on self-dosing.

For reference, my numbers at this meeting were awful. My A1C was around 12%, which equates to a blood sugar around 300 mg/dL. My cholesterol was also awful, with a total of 327 mg/dL. My LDL was 228 mg/dL and my triglycerides were 206 mg/dL. Other endocrine numbers were also terrible but those were the most alarming to me, especially since all of these readings were normal at a physical almost a year earlier.

My instructions were to take the Glimepiride twice a day and take the Humalog twice a day, with 1 unit of insulin for every 40 points of blood sugar over 140 I was getting. Early on, most of my readings were in the 240 range, which equated to 3 units of insulin 3 times per day. The Glimepiride was easy, just a small pill, twice a day, no side-effects. My endocrinologist told me I’d see results pretty quickly if it worked, but I saw almost nothing from the pill alone. A few days later, once I mustered up the nerve to do the injections, I added the insulin to my regimen.

This immediately started to bear fruit, not only reducing my average blood sugar to the low 200s over the next few weeks but controlling my spikes. After a high carb meal, I could hit over 300; but now my spike would usually stay down in the 250 or less range. While this was an improvement, it was still way too high for me.

As far as taking the insulin, the hardest part was doing the injection. My instructions weren’t great and sticking a needle in your own stomach goes against every instinct you have, so it was a hard mental barrier to overcome. The Humalog pen, however, made it much easier than this otherwise would have been. Choosing an insulin dose was incredibly simple, physically injecting and administering the medication was quite simple, and with the insulin not needing refrigeration, it was a matter of keeping it out of heat and direct light, as well as making sure I had the proper equipment.

The needles given to me were Becton Dickinson ultra-thin micro-needles. Supposedly, they are some of the smallest needles on the market and, as my nurse told me, were lubricated to make injection/removal simple and painless. For the most part, this was true. If I could muster up the nerve, the injections were pretty easy, removal was always quick, and there was only occasional some redness or marks at the injection site.

I never really noticed many side effects from either medication or the physical injections, except for an occasional sting when the medicine was being administered. There occasionally may be some small bleeding if I came in at the wrong angle or a sting like getting pricked at the wrong spot if I hit a nerve, but the mental part was much harder than the physical part. I attribute that a lot to the quality of the penlike injection device and the quality of the needles as I don’t know how I could make it through this if I needed individual needles, syringes, and vials as previous diabetics would.

Adding an additional treatment option

While this was starting to move my numbers, I still wasn’t happy with the progress I was making so I requested my doctor add Metformin to my treatment plan. I was told that it could cause stomach discomfort but discounted that as I rarely experience digestive side effects from medication that is prone to cause those, but I erred significantly here. Firstly, I was prescribed 4 XR 500mg pills, 2 each twice a day. The pills are massive horse pills, so they physically aren’t the easiest to take. But the side effects made the experience much worse. At two a day, I experienced mild and occasional discomfort, but three (taken two in the morning and one at night) made things much worse. Frequent diarrhea, stomach pains, and overall discomfort became fairly common. Once I increased to four, it became almost unbearable as it went from an inconvenience to a real impediment in living my daily life.

If I was seeing major results, it would have made the effects more palatable, but I only saw maybe a 20-30 point drop in my already high blood sugar range during this time, to the 180s to low 200s on average. Because the side effect risk with Metformin, other than the stomach issues, was very low, as was the cost, I elected to remain on the medication but wanted to find an additional treatment option to hopefully reduce or replace my reliance on these medications.

I examined many type 1 medications, which are few and far between, as I was told it was likely type 1 early in my journey. Upon finding out a few weeks later that it was type 2, that opened up my world of medication options. I was looking at several, including Actos, Januvia, and Invokana, as I was adamant that I did not want to take any more injections. However, the potential side effects I read on many of these medications was enough to frighten me off, as was the cost on several of them. After further research and seeing that by body did react to insulin, I decided to go with a long-term insulin. I felt it would be the most effective, have the least side effects, and possibly replace one of my other injections so it wouldn’t really be adding to my troubles.

After examining my options, I tried to decide between Toujeo and Tresiba, the two newest on the market. Toujeo had a long-history as a somewhat newer version of Lantus. However, you needed a fairly strict dosing schedule on this insulin. Secondly, the discount program was less than stellar (more on this in my next article). Lastly, the patient reviews I read on Drugs.com for it were really poor, with lots of adverse reactions. While I know that people who have bad experiences are much more likely to post than those with good, I found there to be enough ratings to be of significance and they rated poorly compared to similar products.

I found this not to be the case for Tresiba. The fact that it would work for almost two days gave me some comfort as I was still figuring out my dosing and medication needs so that flexibility was something I valued. I could get it at a very reasonable cost while I tried it out so the financial investment wasn’t terrible. Lastly, the user experiences and clinical trial results for it were very favorable. Therefore, I had no problem anxiously asking my doctor to try Tresiba.

Upon starting Tresiba, about a month after my initial diagnosis, the hardest thing I found about it was the actual purchase (more on this next article). Taking the medication was very similar to the Humalog, with a similar device. However, I found, for whatever reason, it was even easier to take. The injections were simpler and less painful, the needle went in more easily (despite it being the same needle), and the medication caused less of a reaction. The pens also kept a long time, for about 45 days rather than the 30 days as with other pens. For someone like myself, who was put on a very low dose (8 units, even lower than the recommended 10 unit start dose), this allowed me to use the entire pen before expiration, saving me both inconvenience and money.

I was told the Tresiba could take nearly a week to work but within 3 days, my numbers fell substantially. I was getting my first readings in the normal range at that point, well enough that I could both dial back on the Metformin and no longer needed the quick-acting Humalog. Instead of getting in the upper 180s as I was prior to this prescription, I was getting most of my pre-meal readings around 120, with my spikes only going up to around 170 or so. For medical purposes, within a week of Tresiba, I was getting readings akin to what a healthy person would get.

All that was left was to fine tune my medicinal treatment and diet plan. Shortly after starting Tresiba, I spent ten days in Germany on a long-planned vacation. With a diet heavy on beer and pretzels, I was quite nervous what would happen to me, yet I only spiked to over 200 if I was REALLY bad with my diet. I would also come down to normal readings by the next morning and almost never experienced low blood sugar.

Long-term planning

Once I returned home, I was able to normalize my schedule and found even better results. I switched to taking my Metformin to one pill in the morning and two in the evening, from two pills twice a day. Suddenly the unbearable stomach issues I had from taking four pills were nullified almost that day. Furthermore, my waking blood sugar was down from its prior readings of 120-140 to around 90-110. I was so pleased with these results that I quit the Glimepiride entirely without any adverse results about a month later.

Keeping myself only on the 8 units of Tresiba for about two months and 1500 mg of Metformin XR for about a month, I went in for a followup blood test. I figured my A1C would be way down, based on my blood sugar monitor readings and that my diet was better so my cholesterol would be down. However, I was shocked when my results came in. My A1C, which was measured in late July at around 12%, was down all the way to 6.6%, which was pretty much within normal range. I expected improvement, but not that much.

Even more shocking was what happened to my cholesterol. When I took my initial test, my doctor wanted to put me on a statin immediately but I wanted to see what treating the diabetes would do. He approved this line of treatment but said not to expect a significant improvement. Therefore, he was shocked to see most of my numbers were cut nearly in half. Total cholesterol down to 167 mg/dL. Triglycerides down to 113 mg/dL. LDL down to 88 mg/dL. All of these numbers were improvements beyond my best hopes, despite mediocre commitment to diet and exercise. Furthermore, the significant 30 pound weight loss I obtained from diabetes has been maintained.

For now, I am maintaining my treatment of 8 units of Tresiba every morning and 1500 mgs XR of Metformin. I am thrilled with the results and finding that, thanks to the medications I am on, just three months after a terrible diagnosis, I am able to live my life much as before while keeping my numbers in a normal range. Other than annoying side effects from the Metformin, I have very little issues from my treatments. I don’t workout nearly enough and I am not strict about my diet, although I try to avoid high carb sides and desserts, as well as eat smaller portions than before, yet I have still achieved and maintained successful numbers with very few troublesome spikes. I have kept my weight lower; my vitals and cardiovascular numbers have improved considerably. While injecting myself every day is an annoyance, it's not a major problem. I am still hoping for a longer-lasting insulin so I can cut my dosing, but I am comfortable that maintaining this treatment plan and nothing else can lead me to a long, healthy life – something I never thought I’d be able to write a few months back.