Tuesday, July 23, 2019

Shop 'til the prices drop

It has been said, only partly in jest, that only five people in the world understand U.S. drug pricing, and that they all work for pharmacy benefit managers (PBMs). Readers of Prescription for Bankruptcy or of these postings know that I feel that the entire pharmaceutical enterprise in this country is dedicated to maximizing profit, patients be damned. Recent studies have only reinforced this belief. Earlier this month, drug pricing research firm 46brooklyn analyzed pricing of generic drugs and found unbelievable variation. As an example, Medicare Part D sponsors priced a generic antipsychotic drug aripiprazole (brand name Abilify) from less than 30 cents a pill to over $22 a pill. Generic drugs have a true market-based cost. This is the ingredient cost plus a reasonable margin to keep the PBMs and pharmacies in business. This cost is easily found in pricing benchmarks such as the National Average Drug Acquisition Cost, which is published on-line. This price can then be compared to the better-known Average Wholesale Price (AWP). Most insurers pay some discount to the AWP, and if they are getting a sizable discount, assume this is a good deal. The disconnect between these two prices can be enormous. 46brooklyn Research gave an illustrative example. The median NADAC price for extended release duloxetine (generic Cymbalta) has fallen from $6/pill to pennies. The AWP has stayed rock-steady at $8/pill. So much for generics automatically saving money!
Earlier this summer, MASSPIRG looked at prescription drug pricing at over 250 retail pharmacies across 11 states. They compared the cost to a patient for 12 commonly-used medications, including thyroid, branded and generic Lipitor, Lantus insulin and others. The MASSPIRG staff and volunteers called the pharmacies and asked for the cash price for a typical 30-day supply. The range of prices was, to say the least, broad. 30 tablets of 10 mg lisinopril, used for blood pressure, could cost you from $3.99 to $59.02. 30 tablets of 40 mg atorvastatin, used to lower cholesterol, ranged from $6.99 to $393. 30 tablets of branded Nexium ranged from $54.94 to $950.45; the generic version, esomeprazole, from $10 to $338.40. We have all heard the horror stories of diabetics getting sick and even dying because they could not afford their insulin. Five pens of Lantus insulin ranged from $96 to a chilling $1,759.19!
What is the take-home? First, we must hold our legislators’ feet to the fire and get the industry to start putting patients at least on a par with profits. There is no reason pharmaceutical companies cannot earn a profit, nor are pharmacies charitable organizations, but some limits must be set. As individuals, do what I have always advised my patients – let your fingers do the walking. If you are paying more than $20/month for a prescription, call around. The MASSPIRG staff found that independent pharmacies often had lower prices than did the big chains, so be sure to include some of them in your search. Your wallet will be happier.

Prescription for Bankruptcy. Buy the book on Amazon

Thursday, July 18, 2019

How to prep

You know you should have a colonoscopy, right? Katie Couric says so. Your doctor says so. The US Public Health Service says so. Why haven’t you? The procedure itself is usually a piece of cake – you are sedated and the procedure is over before you know it. Colonoscopy is one of the few screening tests about which there is very little disagreement of its value.
One problem, unfortunately, in our crazy quilt “system” is cost. If your insurance does not cover it, the procedure will cost you thousands of dollars. If you have a high-deductible plan, the cost may run up to your deductible.
For everyone, regardless of insurance, however, the major factor that leads many to refuse the test is the dreaded “prep.” For the gastroenterologist to perform the test properly, you must have a clean colon. If there is a lot of fecal material still in the bowel, they may not be able to do the test at all, or they may do it but not be confident they have seen what they need to see. The standard way of achieving a clean colon has been to require you to drink a gallon of a foul-tasting liquid called GoLytely the day ahead. Most of my patients who did this once said they did not mind the colonoscopy itself, but that there must be a better way to a clean colon.
It turns out that there is. Many colonoscopists have begun using MiraLAX in Gatorade along with bisacodyl tablets in place of GoLytely. The taste is much better – you really only taste the Gatorade – and the volume to be drunk less. Instead of a gallon, the volume is halved – two quarts. This prep was tested in a trial in Boston and found to be as effective as the old standard and tested again at a community hospital in Michigan. In the latter study, about 400 patients who took MiraLAX/Gatorade were compared to a similar number using GoLytely. In both groups, about 90% had an excellent or good bowel cleansing. There is no getting around having diarrhea – no diarrhea, no cleansing – but with the new prep, the taste is clearly better.
So, as the commercials say: ask your doctor if is this right for you.

Prescription for Bankruptcy. Buy the book on Amazon

Wednesday, July 10, 2019

Do I really need those vitamins?

Americans love their vitamins and “nutritional supplements.” Surveys have shown that over half of us take at least one and 10% use at least 4 dietary supplements daily. Among those 60 or older, use is even higher; 70% take at least one and 29% take four or more supplements. The market is huge, in the billions of dollars, and “brand extension” is common. You can buy multivitamins, multivitamins for women and multivitamins for seniors. Vitamin D capsules crowd the shelves with sizes from 1000 units to 4000 units and more. Ever since chemist Linus Pauling pronounced it a miracle, millions of us use Vitamin C to prevent or cure a cold.
Besides making money for the manufacturers, pharmacies and GNC, do vitamins and supplements do any good? Clearly it is important to replace any deficiencies. If you have pernicious anemia, (https://www.whatswrongwithhealthcareinamerica.com/2019/06/b12-deficiency-great-imitator.html ) you need Vitamin B12, either by injection or in very large doses by mouth. If you do not drink milk and avoid the sun, you may well need to take Vitamin D. If you are a woman with very heavy periods, a daily iron supplement may be needed. Certain vitamins have been shown helpful in slowing the advance of macular degeneration.
What about the vast majority of supplement users? Most people who take these products take a multivitamin, but rarely is that the only product used. Other commonly used supplements are omega-3 or fish oil, calcium, Vitamin D, Vitamin C and botanical products. Ironically, but not surprisingly, supplement users are much more likely than non-users to say that they try to eat a balanced diet, see their doctor regularly, get a good night’s sleep, exercise regularly and maintain a healthy weight. Many studies over the years have looked at the benefits of taking various forms, particularly at their effect on cardiovascular disease, still the number one killer in western countries.
A recent study published in the Annals of Internal Medicine looked at 277 trials involving 24 supplements or combinations of supplements and almost 1 million subjects. These studies found that reduced salt intake lowered the death rate in all and cardiovascular death in subjects with hypertension. Omega-3 long-chain polyunsaturated fatty acid (LC-PUFA) reduced the risk of coronary disease and heart attacks by a modest amount (7-8%). Use of folic acid was associated with a 20% decreased rate of stroke. Somewhat alarmingly, use of calcium plus Vitamin D was associated with a 17% increased risk of stroke. All the other supplements, including Vitamins B6 and A, multivitamins, “antioxidants” and iron had no measurable benefit. Some 25% of us over 50 take a supplement touted as good for "brain health," but the AARP Global Council on Brain Health has come down strongly against this practice, calling it a "massive waste of money."
Bottom line? Don’t waste your money. If you eat a balanced diet, the odds are you are getting all the nutrition you need. If you feel better taking a multivitamin, there is no evidence it does you any harm, but you are better off choosing the house brand and saving money. If you are shoveling down 8 or 10 “supplements” daily, you are probably wasting your time and money.

Prescription for Bankruptcy. Buy the book on Amazon

Wednesday, July 3, 2019

Is dementia the price to pay to be dry?

First, a little background and terminology. Our brain cells talk to each other via “neurotransmitters.” One of these is a compound called acetylcholine. There are two relevant classes of medication that act on acetylcholine. One group are anticholinergic drugs, which block the effect of acetylcholine. These are used in many ways, and there are many subgroups. They are used to treat vertigo and nausea; they are used to prevent seizures; they include many of the older antidepressants, antipsychotics and antihistamines; they are antispasmodics for the intestine, and notably, they are used to treat urinary incontinence. The other class of drugs are cholinesterase inhibitors. The chemists among you will figure out that these block the breakdown of acetylcholine and so increase its effect. The best-known of this class are the drugs used to slow the progression of Alzheimer’s Disease.
It has been long-known that use of anticholinergics can cause confusion in elderly patients, and doctors have been taught to use these cautiously. What has not been known is if they have any long-term effect in patients who seem to tolerate their use. A study published online in JAMA Internal Medicine in June looked at this by studying a very large (30 million patients) British research database. They compared patients diagnosed with dementia with those who were not, matched by age and gender. They then looked at use of any of over 50 drugs with anticholinergic properties by type and by duration of use. They found that patients with dementia were much more likely to have been prescribed an anticholinergic drug over extended periods than were controls. The drugs that most clearly showed this effect were from the group that were expected to be used daily for a long time.
I would like to call your attention in particular to the group of drugs used to treat urinary incontinence. I do this because they are very widely advertised and widely-used by middle-aged and older women. They tend to be used for indefinite periods. They are also of marginal benefit at best. Many of the other drugs in this class are of less current concern because they are used only infrequently (anti-nausea, muscle relaxants) or because they have been largely replaced by newer drugs (tricyclic anti-depressants). Bladder problems are very common and while not life-threatening can be annoying and embarrassing. Oxybutinin (Detrol and other brands) is probably the most widely-used drug to treat overactive bladder. It universally causes a dry mouth, such that the increased thirst works against the desire to void less often.
While this was an “observational study,” and not a randomized trial, it has some inherent validity. We know that anticholinergics can cause confusion in some users. We know that acetylcholine is important in brain function. We know that drugs that increase acetylcholine have some benefit in dementia. My advice is to use these drugs only if other remedies have failed and only if the benefit is very strong. If your reaction is “well, it seems better than nothing,” I’d think twice. Maybe a pantie-liner would do as well and be safer.

Prescription for Bankruptcy. Buy the book on Amazon