Online Prescribing of Sildanefil (Viagra) on the World Wide Web

Introduction

The World Wide Web has become a medium to advertise and dispense medicines directly to consumers. Since little is known about the structure and "quality" of these "virtual pharmacies" in terms of how responsibly "online-prescriptions" are actually issued, we created a fictitious patient for whom the ordered drug (sildanefil, known by the brand name Viagra®) was clearly contraindicated and tried to purchase this drug on the Internet.

Methods

In March 1999, we searched for "cyberpharmacies" selling Viagra by entering the terms "+order +viagra" into a search engine (http://www.altavista.com). We reviewed the first 60 of the 60,000 pages found, and researched the company name and address behind the Internet addresses using InterNIC's "Whois" service [1]. Twenty-two distinct companies of three different types were identified: 2 required a written prescription by a "real" physician, 9 dispensed the drug without any prescription at all, and 11 issued an "online prescription" after an alleged physician reviewed the online order form containing medical questions answered by the patient. We tested 10 pharmacies of the latter type, among them 8 companies based in the USA, by posing as a 69-year-old woman giving a sexual history of having "no orgasm," with obesity (165cm/78kg), coronary artery disease, and hypertension, and taking captopril, pravachol, atenolol, and erythromycin. In this case, prescription of sildanefil would clearly not be indicated, as Viagra is not approved for females, and special caution has to be taken with patients having a history of cardiovascular disease [2]; besides, the fictitious patient was taking multiple medicines which could interact with sildanefil. We ordered a total of 66 pills among the 10 companies. The average price was US$ 17.00 per pill, ranging from US$ 8.33 to 50.00. Eight companies charged a consultation fee, ranging from US$ 65.00 to 89.00 (mean US$ 74. 88). In all cases, the consultation fee was only charged if the doctor determined that Viagra was "appropriate." Including shipping fees (US$ 34.00 on average), the total value of all orders was US$ 1,802.84.

Results

An overview of all cyberpharmacies contacted is given in Table 1.

All companies requested that customers waive the site's liability in the event that they experienced health problems. While all sites asked whether customers were currently taking nitrates, only 4 specifically asked about recent "myocardial infarction," and only 2 of those used the lay term "heart attack." Seven asked about hypertension, but only 3 used the lay term "high blood pressure." Only 3 asked about retinitis pigmentosa, another important contraindication of sildanefil.

One site offered to ship, together with Viagra, tablets of cimetidine (Tagamet®), as it causes "56% increase in plasma sildanefil concentrations when coadministered with Viagra. This would indicate that increased effectiveness would be noted with the same dose of Viagra taken with 800mg of Cimetidine."

Three companies, among them both European companies, delivered within 6, 10, and 34 days respectively. One company sent an email warning to discontinue all other 5 medications when taking Viagra. A photocopy of the original Pfizer package insert was enclosed in 1 case, in all other cases incomplete package information was provided.

Two companies declined to deliver because of import restrictions, 1 declined to deliver without giving specific reasons, 3 declined to deliver because the drug is not approved for women (2 of them however claimed that they "know of the benefits for women"), and 1 did not deliver "because the doctor was concerned about your heart conditions and the medication you are on." Two of the companies which did not deliver nevertheless charged the credit card. The name of the consulting doctor was revealed in only 2 cases.

Discussion

Although a surprisingly high number of Internet pharmacies declined delivery, the public should be alerted to the risks involved with prescription drug prescribing and dispensing via the Internet. In 30% of our cases, "prescriptions" were issued although clear contraindications existed, in 80% no complete history was taken, in 70% inappropriate medical terminology was used, and in only two cases was the order form reviewed by a physician who identified himself. Pharmacies claiming to "consult" consumers may be harmful, as the clients may rely on a non-existent "physician." However, even if doctors appear to be employed at the pharmacies, this is no guarantee for a safe drug-shopping experience for patients; in 2 out of the 3 cases where Viagra was delivered, physicians appeared to have approved the prescription, recalling the problem of the questionable credentials of "cyberdocs" [3]. Consumers should also be aware that Viagra on the Internet costs on average twice as much as in regular pharmacies, and that in our test 20% of the pharmacies charged the credit card without delivering a product. We estimate that at least 4,500-15,000 web pages offer online ordering of Viagra. Many dispensing companies run "affiliate" programs offering a commission to individuals who advertise and link customers to them [4], which is one explanation for the immense number of doorway pages, and another reason for incomplete and misleading drug information on the Internet. Future legislative action may target this lay-advertising practice. Consumer education and an international modus operandi for managing drug sales on the Internet are further steps that should be taken by the World Health Organization (WHO) [5] and other organizations.