Targeted drug maker NitroMed Inc. plans to sell its BiDil drug business to JHP Pharmaceuticals LLC for a possible $26.3 million. New Jersey-based JHP, a privately held specialty pharmaceutical company, will buy the assets related to BiDil for $24.5 million in cash, plus up to an additional $1.8 million for inventory at the closing date.

[...]

NitroMed also reported its financial results for the third quarter which ended Sept. 30. The company's total revenues climbed slightly to $4 million, compared to $3.8 million for the same period in 2007. All of that revenue came from sales of BiDil, officials said. NitroMed's net loss dropped to $400,000 for the quarter, compared to a net loss of $8.4 million last year.

Yeah, sounds like it's time to off-load that to a company that has other winners in its lineup and doesn't need to maintain the marketing and manufacturing overhead required to keep BiDil on the market. Of course, they should have done that in the first place. You can't really build an entire company around an uninteresting drug priced too high to be relevant when its components are already available in generic form for pennies per tablet. It's not a bad drug; it's just too expensive for what it is.

If JHP is smart, they'll cut the price to about a third of its current cost, and let volume take care of the rest. Not that BiDil will ever be a huge winner, but it could certainly be bigger than it currently is if priced and marketed appropriately. Monopoly pricing only works when you have something people want, and are willing to pay for.

So these are college bookstores inadvertently advertising prescription drugs to the entire college population. Well, more accurately, to the population that chooses to have their books shipped to their home, anyway. I don't know if the bundles that can be picked up have similar advertising info.

Merck's going about it in a strange way, though. They're sticking the prescribing information into these boxes. No fancy brochures, just the PI packet, which I find rather bizarre.

I can't say it doesn't make sense, or that it's a terrible idea — I think it's better than advertising Ambien on television — but it does make me wonder what's next… Cephalon advertising Provigil to high school and college kids? Med students? Pharmacy students?

Hey, why not?

(No discounts for having advertising in your box of books, either. )

This is going to be quick and dirty because I've got some other things to do, but I've been putting it off far longer than I've meant to. (No time like the present, right?) In the January 2008 issue, CR ran a feature on how people could save money on prescriptions meds. Generally speaking, I am in favor of this kind of thing. I like people to know the alternatives, and how they can save money.

Generally-speaking, it's not a good idea to have word-choice errors in a piece that's supposed to be professional. (See image.) Maybe they should get a medically-trained copy editor and add them to the list of peer-reviewers. Ridiculous.

I've re-created the table they have:

I'll go through it quickly:

Zyrtec is now available OTC, and is comparable to the cost of Claritin. Claritin doesn't work for a goodly number of folks, so Zyrtec is a better option. Zyrtec went OTC the month after this was published — and it wasn't a big secret that it was going to happen.

For ADHD, Strattera is not a popular option. It doesn't work for many people, and ADHD people have a hard time remembering to take their meds consistently, which makes this option less desirable, particularly where it takes a little while for Strattera to begin working. I'm surprised this drug was listed at all, as it's rarely a first-line choice for ADHD spectrum disorders. Even comparing atomoxetine (an NRI) to methylphenidate (a stimulant) is a bit… off, and IMO, does the consumer no favors. Strattera is usually used where someone is at risk for drug abuse or has comorbidities like hypertension or anxiety (iatrogenic or otherwise) and so cannot tolerate stimulants.

Depression… don't have much to say there. Fluoxetine tends to be more stimulating than Lexapro, and there are other subtle differences (half-life, solubility, etc.), but for most people, switching from one to the other is probably not impossible.

As for Diabetes… well. Using a biguanide is usually the first step in treating metabolic syndrome, and then you add other meds on top of that. I'd be skeptical of any doctor who used Actos before using metformin without a given reason. Diabetes treatment tends to go in stepwise fashion like most other chronic illnesses. Removing a TZD from a pre-existing diabetic regimen can be done, but it's not as simple (or desirable) as this little blurb makes it seem. And a TZD isn't normally used as monotherapy. Frankly, I think suggesting Glucotrol rather than metformin would have made more therapeutic sense. And in terms of good use of space, I think think they would have been better going after the ARBs and hypertension in general here.

Heartburn and GERD? Nexium 20mg? Who even uses the 20mg strength Nexium? I see it maybe 3 times a year. They should have done 40mg Nexium and suggested 40mg of Prilosec. (Hilarious sidenote: 40mg Prilosec caps (the one without a generic) cost ~$60 more than 40mg Nexium caps.) Generally, though, this one wasn't too bad.

Insomnia: Eh, probably okay I guess. Insomnia is a poorly-treated condition in this country, and frankly, I'd rather see other methods explored before reaching for the BZRAs at all. But the BZRAs are the easiest, and they keep patients happy. Unfortunately, not enough time is spent diagnosing the underlying causes of insomnia, resulting in a poorly quality of life. There are differences in the polysomnograms of patients on eszopiclone and zolpidem, too, which are not talked about. I'd rather see ramelteon tried before any BZRA, and also see a psychologist about diagnosing an underlying cause for the insomnia in the first place, if a primary care provider cannot take the time (due to financial considerations) to do it themselves. And 5mg of Ambien might help with sleep induction, but the relatively short half-life will do next to nothing for those with sleep maintenance problems.

I'd rather have seen trazodone suggested, since insomnia is usually secondary to some kind of other psychiatric disturbance — a type of uni- or bipolar depression.

Not much to say about arthritis, but I hardly ever see Celebrex used anymore. Now that it stands alone as a COX-2 inhibitor, it's also the most expensive anti-inflammatory in the book and insurers are loathe to use it. I'd rather see diclofenac recommended over ibuprofen, and suggesting that 400mg of ibuprofen daily is anywhere near equivalent to 200mg of celecoxib is laughable.

Schizophrenia. SCHIZO-FREAKIN-PHRENIA? CR is going to tackle SCHIZOPHRENIA in an article about how to save money?!?! I am having difficulty wrapping my brain around that one.

But okay, here goes. Schizophreniform disorders should be managed by a psychiatrist or psychiatric NP, IMNSHO. Diagnosis is tricky, and management is always tricky. All that said… while first generation antipsychotics are often as effective as their second gen counterparts, I am extremely leery of merely saying that Y could be substituted for X. At least CR has the good grace to state "The antipsychotics have major side effects and response to them is highly variable" — AKA "Take our advice with a monster grain of salt." Not the least of the worries are akathisia, tardive dyskinesia, other extrapyramidal symptoms, weight gain, and about a bazillion other possible side effects. My mind is still boggled that they even went there.

Curiously, however, discontinuation rates of perphenazine in schizophrenic patients are lower than with any second gen antipsychotic save olanzapine (Zyprexa) — though people tended to d/c Zyprexa due to its metabolic effects and weight gain, and perphenazine for its extrapyramidal symptoms. Something to consider, I suppose.

–

All things considered, it's nice to see the mainstream media promoting saving money on drugs, but it bugs me that they did it in the way that they did.

Got a phonecall from an FP's office across the street from the pharmacy. Medicaid patient had brought in his Risperdal Consta injection for his bi-weekly shot. The nurse dropped the injection in the office, which broke it, resulting in some non-emergent, but non-trivial lacerations to herself in the process.

Could we get another one? Of course, it's 4pm on a Friday, and MassHealth doesn't do lost/damaged precription overrides — if they did, their budget would probably double (TAP doesn't make this shit up, you know) — but could we pleeeeeeease try. And they would, of course, call MassHealth themselves.

Risperdal Consta is about $650 per dose.

Of course the answer was no, but with both of us on the phone, MassHealth said they could do it tomorrow (that would be today, I guess) as a once-in-a-lifetime early-fill don't-ever-ask-again override.

I'm so glad it worked out, and I feel terrible for this nurse. She's probably wishing she had dropped some cyanocobalamin instead. We'd have just given it to them for nothing had it been something like that.

Based on Dino's examples on the oops meter, I'd give this a solid 8. Right next to breaking wind in front of your boss. On the elevator.

$594 per year.

I asked Jane if she'd ever taken anything before the Nexium, because it looked to me like she started it in early 2006, and she told me that she hadn't. The doctor had given her samples, and then a prescription, and she'd been taking it ever since.

Here's the thing: Nexium isn't better than Prilosec. Yes, we all know it's the isolated, active enantiomer of omeprazole, and its time to acid drop is a bit better, and "studies" (paid for by AstraZeneca) have shown that Nexium beats Prilosec in squashing acid production.

Except that it doesn't, because if you look at the fine print, you'll see that those glossy, purty brochures that the big-titted drug reps bring you compare 40mg Nexium to 20mg Prilosec. In fact, when AZ did studies comparing 40mg to 40mg, they discovered that the difference was inconsequential, so they didn't include those results in their marketing materials. (My source for this is a former sales manager for AZ who used to have Nexium as a drug, and then went on to be a regional drug rep manager. He's with Forest now.)

Pretty slick. And underhanded.

Oh, and time to acid drop isn't a particularly important metric, by the way, because PPIs are maintenance meds, not Tums. And Nexium was only something like 2% better than Prilosec for the 8% of the study participants that even showed a difference. Whoopty-do. Clinically significant? Not especially.

Back to saving money. By changing from Nexium to Prilosec, Jane is able to pick a different Part D plan that has a lower premium, not to mention that when she comes to the pharmacy, her copayment will be lower, too. So Jane will be switching. And she could probably eke out a few more dollars in savings if she tried just 20mg omeprazole daily, but I thought I'd be generous by allowing for a non-standard dose in my calculations so her doctor would feel better about switching.

There is a tiny, tiny percentage of people — less than 1 in 100 — that do not respond to omeprazole that do respond to esomeprazole. No one knows why this is, and simply changing from one to the other results in marked improvement. That is no excuse for reaching right for the Nexium over the omeprazole, because sometimes the reverse is true: omeprazole works when esomeprazole does not. Sometimes neither of them work and you need to pick a different drug altogether. This phenomenon is true across all drug classes, and is another reason that having an inflexible, national formulary is a BAD idea.

[tags]healthcare, inefficiency[/tags]

I can speak for pharmacists, technicians, and patients when I say that its really, really nice to see a doctor doing the research to find out how much drugs actually cost. I see so much healthcare inefficiency on a daily basis just as it relates to drug therapy, it makes me want to start knocking heads together. Prescribers going right for the Nexium or Prevacid without EVER trying omeprazole; Lipitor when simvastatin is just as effective and has never been tried; Lescol XL, when pravastatin has never been tried; Avodart when finasteride has never been tried. Right for the ARB when an ACEi has never been tried.

Look, I don't give a fuck what your pet drug is. I don't give a damn what the drug rep shoves under your nose on a weekly basis. I don't care that you're unaware of the top-of-mind marketing that's being used on you without your knowledge or consent.

If it's going to cost an elderly person on a fixed income an extra $594/year because you "like it better", you need an ass-kicking.

And so on. I'm all for moving from one drug to another if a less expensive drug has been tried and has failed. That makes sense. But the absolute waste of money because less expensive alternatives have never been tried boggles my mind. I can truly understand why prior authorizations were invented, even if I curse them daily for wasting minutes of my precious time.

Back to the topic at hand: this time of year, people make appointments to see me, where we sit down(!), chat, review medications, and then we talk about what can be done for 2008. Most people that see me are happy with their drug therapy, except for one thing: it costs too much. The goal of their visit is to reduce the cost of their drug therapy for 2008, every single time. Without fail.

I have seen 7 people across two days. (An average appointment lasts about 45 minutes.) In that time, I have saved patients $11,831. That's an average inefficiency of ~$1700 per person. And these are people with drug coverage. The single highest total for one person was ~$3600/year.

In the next couple of days, I'll try to share some scenarios so you can see how much just one simple switch can save an average person.

Keep up the good work, Jay. Seriously. Pharmacists, technicians, and patients everywhere applaud your good sense and efforts.

[tags]healthcare, inefficiency[/tags]

This guide does not apply if you have a hybrid medicaid-medicare plan through your state. Those folks know who they are, and if you have no idea what I'm talking about, you don't need to worry about it.

Before you begin you'll need three things:

1. A complete drug list of the person you're doing the research for. This means you'll need drug names, strengths, and quantities. Calculations are done for a 30-day supply, so if you take something 3 times a day, the quantity for 30 days will be 90.
2. About five minutes
3. An Internet connection (har har)

Here's a walk-through, so you'll want to open the link in a new window or tab…

Click on "Find & Compare Plans" which brings you to this:

Click "Begin Personalized Search" which will bring you to this next screen. You will want to click where it says "click here." Do NOT click the Continue button. This might trigger a browser prompt asking you if you want to continue sending this information over an unsecured connection. You're not actually sending any information about yourself, so click Continue.

That brings you to this page:

You'll want to mimic what I've done: put in the zip code of the person who you're doing the search for, ignore the age range and health status, and then select "No" for all three of the next questions. They have no bearing on choosing the Part D plan for the average person. Click "Continue" at the bottom.

That brings you to this. Click the "Continue" button. (Top or bottom doesn't matter.)

Get out that drug list that you put together. Click "Enter My Drugs" on this screen:

That brings you to this screen, where you can begin typing what drugs you take. I'll fill in a couple of examples that someone might take, and run you through a couple of screens that you might run into.

So here's my list for Bob Smith. Click "Continue" at the bottom when you are done filling in the drug names:

The next screen allows you to adjust the strength and monthly quantity. Go through the list of drugs on the left and change the strengths to reflect the drugs that you use before you start changing the quantities. Each time you select a strength other than the default, the page reloads, and you may lose any changes that you've made to the quantity. I learned this the hard way.

This next screenshot is the default, and the one after that reflects the changes I've made. Click Continue when you're finished.

The next step is optional. You can choose a Password Date that allows you to save your drug and location information and pharmacy preferences. That means that when 2009 rolls around, you can more quickly retrieve your drug list and make changes rather than having to enter all of the information from scratch. I recommend using the person's date of birth because it doesn't change. I will skip this step because I'm working with a dummy profile, but it is pretty self explanatory.

If you choose to save your drug information, be sure to write down the number that medicare.gov gives you, as well as the date that you chose.

Next you can choose a pharmacy based on zip code. This doesn't matter overmuch if you're going to use a chain or independent pharmacy. If you're working with a specialty pharmacy (for example, your doctor's office has its own dispensary, or you're a college student and use the university health office), then you may want to specify the pharmacy that you'll be going to. Again, I'm going to skip this step since it doesn't matter for most people.

At this point, all of the plans that cover the drugs you entered will show up. I like to display 10 on a page, but that would be a huge screenshot, so I'll stick with 5 for demo purposes.

You can compare up to 3 plans to see an in-depth breakdown of the plan information (monthly premium, what the copays will be on various drugs and so on. Tick the checkbox for the plans you're interested in and hit "Compare". (On every page thus far, there has been a "Printer Friendly" link in the upper left corner. This is particularly helpful if you want to print out the plan summaries and detailed breakdowns for offline viewing and annotating. I use it regularly.)

Plans I don't recommend

There's one company that I would avoid right now and that is WellCare. They are the cheapest (as you can see from my screenshots), but they have been in some substantial hot water lately, thanks to some VERY shady accounting practices. Their stock recently plummetted from $130 to $27 at its lowest thanks to being raided by the FBI. They also regularly screw over their customers. Please, stay away from the them.

Enrolling

Enrolling in a plan can be done online or on the phone. Some companies, like Humana, like to send a rep to your house to sign you up. Some people love this, and some people hate it. I find it a little weird, personally. I'd rather call a phone number and do the whole process from beginning to end without having someone come into my home.

[tags]Medicare Part D, How-To, prescription drugs[/tags]

I didn't bother to say anything about the antibiotic shenanigans.

The trouble with this is addressing something someone does without stepping on their toes. If I do something stupid, I'd like someone to smack me upside the head and tell me I'm wrong. Pussyfooting around the issue is for people with no self-confidence. I don't have that problem — after all, I write on the Intarweb, and think people actually care about what I have to say, don't I? — so just come right out and tell me I'm wrong.*

Not everyone is that resilient, however, and I'm sensitive to this.

Recently I've heard a pharmacist say she was going to take lots of Vitamin C and echinacea to get over a cold. I've seen pharmacists recommend Airborne for cold on more than one occasion. I've heard a pharmacist recommend a homeopathic remedy for migraine. I said nothing — these suggestions aren't harmful, but they certainly aren't helpful, either. In these cases, it's just not worth the effort. Besides, Father Time and the body's own defenses will clear these problems up on their own. (And in the case of the migraine, I suspect it was psychosomatic anyway.)

When someone says something boneheaded to a patient, how do you handle it? Especially if it's a pharmacist colleague? I would imagine doctors and nurses run into this problem from time to time as well, even if they practice alone now.

* I'm happy to say that this hasn't happened in a very long time, which can be viewed as either a good thing (I'm SMRT!) or a bad thing (I work with a bunch of idiots). Which one I lean towards is dependent on where and who I am working with, naturally.

Let's review, SAT-style:

Zyrtec:Xyzal::Claritin:Clarinex

Expect Zyrtec to go OTC as a means of ensuring continued profitability through marketing. (More people buy brand name Tylenol than the generic — same story for Claritin.)

Here's the bottom line: everything that Zyrtec works for, Xyzal will work for, and vice versa. Same side effects, too. And because this is so, you will never see a head-to-head study comparing Xyzal with Zyrtec, because the results will prove that it's just a waste of money. Like Clarinex. Oh sure, there will be a few isolated cases where Xyzal is 0.5% better for 0.1% of the study population, and these studies will be trumpeted, but remember that they're actually meaningless. You'll also see studies that show Xyzal is effective for some obscure condition that Zyrtec was never studied for. Just remember that this is done to make Xyzal seem like something more than a me-too drug, and that if someone bothered to spend the money, Zyrtec would work just as well.

So if you like to waste your time doing PAs or you feel an insane need to throw your patients' money away, prescribe Xyzal. Otherwise keep on using Zyrtec.

A couple of weeks ago, I was detailed by GSK. Unlike The Angry Pharmacist, I don't hate drug reps. The GSK guy isn't a busty blonde who brings us cannolies and only visits at lunchtime. He's actually a genuine human being, and he's probably old enough to be my dad.

But on his last visit, he did something that rubbed me the wrong way: he asked me to fill out these cute little forms and send them to the doctors to get them to switch to the controlled released versions of carvedilol:

Yeah okay, buddy. How about no? I like you well enough, but geeeeze. Your form is pretty, but a reversal of it would be more useful: seniors sure do like those generics that're covered even during the donut hole…

Needless to say, I threw the stack of forms in the trash without showing anyone else. As the person who makes the most therapy recommendations, no one but me would have a use for them anyway. Even if they weren't complete bullshit.

–

On a related note, I'm waiting for the day drug companies get a clue and make writing the original, IR version of a drug more troublesome to prescribe than the inevitable extended-release forms. Call it "Coreg IR" the first time around, and then call your extended-release, patent-protected, evergreened, overpriced bullshit version plain old "Coreg." As though it were Coreg As It Was Meant To Be — like that marketing crap Sanofi-Aventis tried with Ambien. (Zomg, we should never have made Ambien because Ambien CR is soooooo much better. Ugh.)

That'll work better than your fancy brochures, ridiculous therapy change forms, and formulary negotiations combined.

[tags]GSK, Coreg, carvedilol, marketing[/tags]

Heh heh…

This combo is not unlike their Vytorin arrangement, which is actually a pretty decent combination both therapeutically and financially: Vytorin is no more expensive than Zetia by itself, which makes it a good deal for consumers and insurers alike. (And there's also the more mundane fact that there's one less pill to take, and the fact that ezetimibe is of questionable value when prescribed alone.)

Because Claritin is now OTC, it is simultaneously more and less valuable to Schering-Plough. Less valuable because you can't charge as much for it as you could when it was Rx-only because no one would buy it — and more valuable because you've got a potential market limited only by the number of people in the United States. I know I recommend (generic) Claritin pretty regularly. It works well for most people, myself included.

If the pricing is done following in the footsteps of Vytorin — which I suspect it will be — it'll be a nice little niche drug for the two companies, and it'll save consumers money, if not insurers. I don't ever see it being a blockbuster like Vytorin, for obvious reasons.

The inobvious

One thing struck me about this deal after some thought, and it's the new reciprocity between the two companies: Vytorin is inherently more valuable to Schering-Plough because their drug ezetimibe (Zetia) is still protected by patent, whereas Merck's contribution — simvastatin — is not. With this new drug, the roles will be reversed. I don't know what this means in terms of dollars and cents, but Merck's got to be breathing a bit easier now that they're on more equal footing with their partner.

[tags]Merck, Schering-Plough, Claritin, Singulair[/tags]

In fact, I'm not arguing how efficacious it is. I'm sure it works. If it didn't, it wouldn't be approved. I'm merely questioning its place in current treatment paradigms. To explain what I mean, I'm going to use a crude analogy to compare angiotensin II receptor blockers (ARBs) and aliskiren, the only direct renin inhibitor (DRI).

Think of a sink. For whatever reason, you want to keep liquid from going down the drain. Does it make more sense to keep the sink turned off, or to plug the drain directly?

Well obviously if the goal is keeping the drain dry, you'd plug the drain. This is what ARBs do. They prevent specific and non-specific binding at the angiotensin II receptor sites. Tekturna just keeps the sink from turning on and does nothing to block the drain directly. This means there's still going to be non-specific binding at the angiotensin II receptor site. (Incidentally, this non-specific binding is not merely theoretical; if it were, ACEis would be more effective as a class than the ARBs, but instead they are merely comparable.)

Back to my point: Tekturna is more expensive than the ARBs, and it will be for a long time. I don't think having aliskiren as an option is a bad thing. I just question how valuable the drug truly is with less expensive ACE inhibitors and ARBs. Sitting here, it doesn't seem to have a real niche. Would I try Tekturna if nothing else worked? Of course I would. If I were targeting the RAAS, would I reach for it as first-line therapy? Hell no I wouldn't. I'd go for an ACE inhibitor in most cases.

I'm not going to delve into the heated debates about reactive renin production and other similar topics because I suspect that the reality lies somewhere in the middle ground, as it usually does.

In the meantime, I think don't think Tekturna has a meaningful place in current drug therapy. If ARBs do not work, it is unlikely that a DRI will, either. The only time I see it perhaps being useful is if a patient cannot tolerate ACEis or ARBs.

[tags]Medicine, pharmacy, Tekturna, aliskiren, hypertension[/tags]

I had an epiphany one day. It occurred to me that selling needles was the lesser of two evils.

Option 1: Withhold clean needles.
Outcome: Person still injects drug of choice, potentially using an unclean needle.

Option 2: Sell clean needles.
Outcome: Person still shoots up, but may avoid infecting or becoming infected with a blood-borne pathogen.

Option 2 is the better option, if for no other reason than it's more economical. By possibly reducing the spread of infectious disease, we're possibly saving taxpayer money. Drug abusers are typically uninsured, and wind up in the ER where tax money will pay for the cost of their care. It should go without saying that withholding clean needles isn't going to stop an addict from getting their fix. Of course drug abuse leads to other medical complications, so there's no guarantee that they won't end up there anyway…

Naturally, I play the "Gee I wonder if they're using it for insulin… or maybe their cat?" game all the time, even though I know it's unlikely. When they haven't showered in about a week, look as though they've been living in a box under a bridge somewhere, and complain that you're not snappy enough about selling them their $2.10 bag of syringes, it's probably a good sign that you're not using said needles for healthy reasons.

But it's a comfortable delusion nonetheless.

[tags]Medicine, pharmacy, needles, syringes, drug abuse[/tags]

It's not uncommon to hear people complain about the cost of Ambien (with apologies to Dr Dino ). Until recently, Ambien was one of the most expensive, yet most common medications. And also widely complained about. Patients don't like the fact that it's costing them $45/month to take some tablets to help them sleep.

But this anger is the result of a flawed perception. Instead of valuing the tablets as something that you hold in your hand and swallow, you should be valuing the quality of life that they afford you. Is it worth $1-1.50 per night to sleep well? If you asked a person with insomnia if they would pay $1.50 to enjoy a full night's sleep just before they're about to go to bed, most would pay without complaint.

It would be foolish NOT to.

It amuses me that people pay the high cost of Viagra without any problems. And that they'll throw down $10-15,000 on plastic surgery, or $75/month for Propecia, but they complain about a medication that is keeping them alive. Honestly, if having high cholesterol was a cosmetic issue, and relative attractiveness correlated with your LDL levels, there would be NO complaining about the cost of a given statin.

What a crock of shit.

Also of note is that generic zolpidem is less than half the price of it's name-brand counterpart — startling, given that new generic drugs typically run around 80% of the price of its brand competition for that first six months. I'm sure insurance companies are lovin' it.

What the hell is with that? You're going to make a guy with acid reflux, anxiety, depression, hypertension, hyperlipidemia, BPH, and T2DM split his fricken tablets?? Are you kidding me? This guy can barely remember all the medical conditions he has, nevermind what pills he takes at what time for which condition. (There's about 15 meds in all that he takes on a daily basis.)

I felt awful. I called UnitedHealth to no avail. I tried doing a prior auth — yeah, I do that sometimes when insurance companies let their little algorithms run wild without human supervision — nothing.

So now this guy has to remember to split his tablets as well when he's lucky he can get out of bed and tie his shoes in the morning. What assholes. This guy is NOT going to remember to do this right, and there's nothing I can do about it.

What about the money lost through patient non-compliance? I suppose that's not so easily measured when compared to a guaranteed savings of ~$5 per fill by instituting mandatory tablet splitting, so fuck it. We'll deal with the excessive cost of less-than-optimal therapeutic outcomes later.

(I'm conflicted about the idea behind splitting tablets for people since it destroys the tablet's integrity, and can confuse people when they open a bottle and see a bunch of little half tabs staring back at them. I would have asked anyway, but I was so pissed off at UnitedHealth when I got off the phone that it didn't occur to me.)

[tags]Medicine, pharmacy, HMOs, UnitedHealth, tablet splitting[/tags]

We got to talking about how I asked people about their symptoms, and we discussed how I asked nothing but close-ended questions. And this is quite true. Intentionally. In pharmacy school (like medical school, presumably) we are taught to ask open-ended questions. This is great in principle, but pharmacists can't stand and have a 15 minute conversation with someone about the etiology of their sore throat and chest congestion. Prescriptions need to be filled, phones are ringing, and goddammit Mrs. Smith is going to have a stroke if you don't get her triamcinolone cream out in the next 46 seconds.

So I very much have a flowchart mentality when dealing with minor complaints. My advice is usually ended with "If it doesn't get better in X number of days, you'll want to see your doctor." (Where X is adjusted anywhere between 3 and 7 days depending on the type of complaint.) After all, the first law states:

The Art of Medicine consists of amusing the patient while nature takes its course.

I like to think I do my small part in keeping the common colds and poison ivy and other trivial maladies of the ER/doctor's office/clinic while nature runs its course.

It's easy to have a flowchart mentality. I'll just have to remember later — when it's my job to diagnose — that I need to be more open-ended. In the pharmacy, however, the opposite is mostly true, though there are certainly times when it's better to be more involved. Good judgement always applies.

[tags]Medicine, pharmacy[/tags]

Then send out the drug reps.

In theory, levalbuterol almost sells itself. At least they won't have to resort to underhanded marketing tactics quite as much.

Will they do it? I don't know. Probably not. That would require doing things differently — like lowering the price right off the bat — and I think we all know how much Big Pharma likes to do things Their Way. Risk is, well, risky.

If I were captain of the ship, though, I'd roll the dice. The inhaler market is huge — and only going to get more lucrative once CFCs disappear — and right now, Sepracor is not positioned to be anything more than a niche player when they could easily have most of the pie.

* Cursory research indicates that some PBMs have the Xopenex HFA MDI at Tier 2 already, but most seem to require a Prior Authorization.

[tags]Medicine, pharmacy, Asthma, Sepracor, albuterol, Xopenex[/tags]