Tuesday, December 31, 2019

Why combination pills?

Almost half of the drugs marketed today are fixed combinations of two (or rarely more) drugs that are also available separately. In a very few cases, the use of such fixed-dose combination products makes sense. Examples would be many birth control pills, the urinary infection drug trimethoprim-sulfa (sold as Bactrim or Septra) or the Parkinson’s drug carbidopa-levoda. Here the two drugs help each other and work better together than does either alone.

Many more combinations are no better than using the two products separately but offer some convenience and so improve compliance – it is always easier to take one pill than two. The medical problem with many combination pills is that the doses of the two ingredients cannot be adjusted separately, and it is only by coincidence that the amounts in the pill might be correct for any given person. In the World Health Organization’s list of 240 “essential” drugs, only seven are fixed-combination products.

A major societal problem with many combination pills is the absurd over-pricing attached to the product. One horrific example is Vivimo, marketed for pain (and really being pushed hard to doctors as an alternative to narcotics). What is Vivimo? It has the anti-inflammatory drug naproxen (Aleve and others) packaged with esomeprazole (Nexium and others). The logic is simple. Naproxen, like all “non-steroidal anti-inflammatories (NSAIDs)” (ibuprofen, aspirin and numerous prescription products), can irritate the stomach. For long-term users of these products, or for people with prior stomach bleeding who still might benefit from their use, doctors may prescribe an acid-suppressor along with the NSAID. You can buy 60 tablets of naproxen, a month’s supply, for about $35, and for about the same amount get a month’s worth of an acid suppressor like esomeprazole. So, $60-65/month for the same ingredients as are in Vivimo. Vivimo was first marketed by Astra Zeneca. Horizon Pharmaceutical bought rights to the product in 2013, when it cost $57 for a month’s supply and immediately raised the price to $400. Nine price hikes later, it now lists for $1241 for a month! Why, you may ask, would anyone use this? Since Horizon is very skilled at gouging, as are most pharmaceutical companies, they use coupons to lower the out-of-pocket cost to consumers – but not to their insurance companies, which then just jack up premiums to cover the cost.

Another similar example is Zegerid, which combines the acid-suppressor omeprazole (Prilosec and others) with sodium bicarbonate (yes, baking soda) and sells this frankly silly product at a list price of $14,213 for a 90-day supply! Again, coupons lower the out-of-pocket cost to the consumer, but the cost to society and indirectly to the consumer are very high.

A group of Harvard researchers looked at Medicare spending in 2016 and found that Medicare spent $925 million more for combination drugs than would have been spent on the products bought separately. While this is a small fraction of the enormous waste in our bloated healthcare system, it should be one of the easiest to fix. Just say no to fixed combinations in most situations.

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