to the editor: I was chagrined to recently find an unexpected piece of paper glued to the U.S. Food and Drug Administration (FDA) package insert inside a sample box of metformin (Glucophage). This advertisement and coupon for Choice dm, an over-the-counter “nutritional bar and beverage,” offered 25 cents off. It further asked the patient to complete demographic information on the coupon and a questionnaire to be mailed back to Bristol-Myers Squibb.

I'm sure that I have unknowingly given this advertisement to numerous indigent diabetic patients on continuous therapy. I only found the advertisement while initially starting a patient on metformin and giving her the enclosed FDA patient label that discusses lactic acidosis. The outside of the sample box gave no indication of the advertisement's inclusion inside. In this particular case, I certainly don't want to encourage my diabetic patients to consume products that look like candy bars and milkshakes. In the bigger picture, I do not ever want to be the involuntary dispenser of any consumer advertisement hidden inside a product sample box.

When I called my two local pharmaceutical representatives for an explanation of this outrageous hidden marketing, both of them were bewildered. They were embarrassed to admit that they were unaware of the advertisement, stating that Bristol-Myers Squibb had not alerted them to its inclusion in the sample product boxes that they deliver daily to physicians.

Most physicians bemoan the recent direct-to-consumer marketing of prescription drugs. This ugly new twist of hiding consumer ads inside pharmaceutical samples that physicians dispense cannot be tolerated. The patient receiving such an ad may incorrectly assume that the product is endorsed by the physician, who in fact has no knowledge of the advertisement inside. I urge all physicians to check for and refuse to accept such samples and further urge the FDA to disallow the practice.

in reply: Bristol-Myers Squibb is committed to extending and enhancing human life by providing the highest quality health and personal care products. One of the conditions that is of great concern to our company is type 2 diabetes (formerly known as non–insulin-dependent diabetes), a serious medical condition that affects approximately 15 million Americans. Our oral antidiabetic agent metformin (Glucophage) has helped more than 5 million Americans with type 2 diabetes to better manage their condition.

Proper management of type 2 diabetes also requires attention to diet and exercise. The Choice dm nutrition bars and beverages manufactured by Mead Johnson Nutritionals, a division of Bristol-Myers Squibb, have been clinically proven to result in a lower blood glucose response compared with other snack bars and standard nutritional beverages tested.¹ Our aim in providing information about Choice dm products in our sample box was to make type 2 diabetes patients aware of this option.

Bristol-Myers Squibb is constantly reassessing our materials to develop better packaging for patients and physicians who receive our product sample kits. We will certainly take Dr. Reynold's comment into consideration in the development of future samples.