Authors of guidelines have strong links with drugs industry
by Alison Tonks, Bristol

Most guidelines on clinical practice are written by experts with undisclosed links to the pharmaceutical industry, researchers from Toronto, Canada, say in an article in the journal of the American Medical Association (JAMA 2002;287:612-7[Medline]).

In a survey of nearly 200 authors of 44 clinical guidelines, 87% of respondents admitted to financial links with one or more pharmaceutical companies. Over half of the authors had been paid to conduct research, over a third had been an employee or consultant, and two thirds had received fees for speaking.

On average each respondent had links with 10 companies, including companies whose products they recommended in guidelines. Only one of the 44 guidelines carried a declaration of the authors' competing interests.

"I'm not at all surprised by these findings," says Dr Bob Goodman, internist at Columbia University in New York and founder of No Free Lunch, the campaign for independent prescribing. "Other studies have already shown extensive links between physicians, researchers, and even policy makers and the pharmaceutical industry. It's particularly worrying, though, in the case of practice guidelines. These documents are widely distributed and intended to change physicians' practice.

"Any influence of a drug company on an individual author is multiplied thousands of times. Worse, there's a subjective element to the recommendations in clinical guidelines that makes them particularly vulnerable to bias."

Most (93%) of the study's respondents said their relationships with pharmaceutical companies did not affect their recommendations on treatment. But evidence cited by the researchers makes it clear that accepting money from drug companies alters prescribing, drives requests for additions to hospital formularies, and contributes to publication bias.

The researchers were unable to check whether authors' financial interests influenced the treatments recommended in guidelines, because there were too few independent guidelines in the sample to make a meaningful comparison. The study looked at guidelines on the management of 10 common diseases, including asthma, coronary artery disease, heart failure, depression, and peptic ulcer. All the guidelines were endorsed by professional societies in North America or Europe and were published between 1990 and 1999.

The researchers contacted 192 authors, but only 52% responded, despite a second mailing. They blame the low response rate on authors' reluctance to admit to links with drug companies and speculate that those who did not reply had even more to declare than those who did. If so, the links between authors of guidelines and the drugs industry are even more widespread than the study indicates, they conclude.

The researchers want a formal process built in to guideline development that forces authors to declare their financial interests. They also want written declarations of competing interests on every guideline.

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Sheri Nakken, R.N., MA 
Vaccination Information & Choice Network, Nevada City CA & Wales UK 
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