Drug advice from Consumers' Reports
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.
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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.
Generic Famvir: Here today, gone tomorrow
That's my prediction, anyway. Teva has launched their generic Famvir amidst ongoing patent litigation, which is a pretty risky move. They risk damages if they lose their case, because there're no pesky clauses to cover their asses like Apotex had. So far as I know, anyway. As far as I can see, Teva's just using the ponderous judicial process to give them some time to sell a new drug. They'll block proceedings at every turn, that's guaranteed.
Quick review: Hatch-Waxman allows the first generic manufacturer to get its ANDA approved to have 180 days of market exclusivity, unless they sell the rights to this period of time back to the pharmaceutical company that developed the drug. This effectively results in 6 additional months being tacked onto the end of a patent. Apotex had done this with their generic Plavix, but slipped in a clause wherein they could start selling immediately if there was any question about the validity of the patent. Once BMS had inked the deal, Apotex turned around and contested the patent thereby allowing them to start selling immediately without fear of repercussion. Pretty shrewd on their part. (Apotex also has no annoying shareholders to please since they are a privately-held company, so they can get away with stuff like this.)
This was why generic Plavix was available for a while, and then disappeared.
Teva doesn't have anything like this, so they're really going out on a limb, here. I'm not sure how their move is legally defensible, and I'm 95% sure that they're going to lose. The only question will be whether the actuaries did their math right: will the revenue generated during this time will be greater than the damages awarded Novartis for stepping on their toes?
At least this won't be as bad as the Plavix debacle which really pissed a lot of people off on both sides of the counter, myself included. Famvir isn't really a maintenance drug in the same way as Plavix, and there're far fewer people taking it than Plavix. It's also not the only drug in its class, and Valtrex remains more popular. Thank God for small mercies.
Teva are a bunch of twats, though, as far as I can see.
[tags]Teva, Famvir, famciclovir[/tags]
You have failed as a parent. Give up.
Helicopter Mom: "Hi, I'd like to fill my son's prescription."
RJS: "OK, sure. [what's the number/process it/etc.] Hmm… looks like it's about two weeks too soon."
HM: "I know, but he's leaving for college in Florida tomorrow, and he needs it."
RJS: "Umm… okay. You might be able to get a vacation override or something, but they only allow that usually once per year."
HM: "Yeah, that won't help."
*RJS is totally baffled at this point* "You know there are other pharmacies in Florida, right? And that it's trivial to transfer it?"
HM: "Yes, I know. But my son is really ADD, and he'll never remember to fill it himself. Maybe it would be better to just wait until the insurance lets me fill it here and then mail it to him. I think I'll do that, so he doesn't forget."
RJS: "Er… okay?"
HM: "Thanks anyway! Bye!"
What does $5,256.08 look like?
It looks a little something like this:
I'm sure Pfizer *wishes* their profits were 60% of their revenue!
This article thing is popular today on del.icio.us. I tend to enjoy stuff like this so I opened it. The first link I clicked was the drug company one which displays the following graphic:
What a complete and utter crock of shit. Honestly, how did this BS make it past the content editors? The fact-checkers must be asleep at the wheel.
It's funny how quickly the cost of R&D is forgotten when ranting about the high cost of drugs. (Which isn't the driving force behind higher healthcare costs anyway.)
Saving money creatively
This here is the opposite of yesterday's post on mandatory tablet splitting. Every once in a while, you'll come across an instance where it's less expensive to use 2 pills with a strength of x strength rather than 1 pill of 2x strength.
This happened the other day with fluoxetine. 60 capsules of 20mg was half the price of 30 capsules of 40mg.
*scratches head*
Didn't make sense to me, either. I'm 80% sure it was the same manufacturer, too.
[tags]Medicine, pharmacy, drug prices[/tags]
Mandatory tablet splitting
I came across my first instance of an insurance company requiring a patient to split tablets about a month ago. One of our regulars has recently switched to a new doctor, and the doctor is adjusting doses on his various therapies. In any case, the doc prescribed citalopram 20mg qd #30, but the insurer (UnitedHealth for the win!) would only pay for citalopram 40 ½ tab qd #15.
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]