Thursday, February 17, 2011

Drug 'R Us

Pharmaceuticals are amazing stuff. You can bitch and moan about their costs, side effects, or the number of them you're taking, but what they've done to extend life and improve its quality is truly remarkable.

And for all the bad raps they get, I salute the pharmaceutical industry, and those who work anonymously in labs around the world, to bring us these miracles.

But drug companies also do absolutely weird crap. One thing that's recently driven me nuts is the trend away from drugs of real value toward what I call "drugs of convenience" (DoC).

What is a DoC? Let's take Fukitol. Fukitol is dosed twice-a-day. Taking a pill twice-a-day is something most of us can remember to do. Fukitol costs, say, $2 a pill. So a month of Fukitol is $120 (these numbers are just for example, obviously).

But, like all drugs, Fukitol's patent is going to expire. Then it will become a cheap generic (fukazolamide), and the price will drop to $0.20 per pill. So a month will now cost $12.

About 3 months before the generic comes out, the Fukitol rep shows up at my door. He now carries once-daily Fukitol-ER! Yes, now you only need to take Fukitol-ER once-a-day! And they trumpet this like it's a major freakin' medical breakthrough.

And they no longer carry plain old Fukitol samples. So if I want to start someone on Fukitol, I need to use Fukitol-ER, and when it goes generic in a few months, the patient ain't gonna want twice-daily fukazolamide.

Fukitol-ER is priced at $4 a pill, so a month is, again, $120.

When the generic comes out, the patient's insurance has a choice: pay $12/month for twice-daily fukazolamide, or $120/month for Fukitol-ER. That $108 difference becomes pretty significant if there are, say, 1 million people on the drug.

Now we get into numbers. The patient's insurance co-pay is $5/month for fukazolamide OR $40/month for Fukitol-ER. The insurance company is hoping that by putting more financial burden on Mr. Fukdeprived, he'll decide to go with the cheap generic.

But the drug companies have a counter to this- They've introduced coupons, also called "co-pay cards" or "patient loyalty cards" that give the patient $40 a month off the copay. So by using these things Mr. Fukdeprived gets Fukitol-ER free, while the insurance company is still getting dinged for the rest of the cost.

Now, given my never-ending battles with insurance companies, I don't often sympathize with them. But here I do: the patient is getting the gold mine, and the insurance is getting the shaft. And, of course, this situation increases health care costs for ALL of us, because the insurance has to raise my premiums to pay for the fact that somebody just can't bear the thought of having to take their pill twice-a-day instead of once.

My friends who are pharmacists also hate having to deal with the reimbursement issues on the co-pay cards, but that's another story. If they want to comment on it, they're welcome to.

But the fun doesn't end there. Let's take a real drug: Flexeril (generic name cyclobenzaprine). This muscle relaxant came to market quite a while back, and consequently has been available as a generic for many years. It's taken as a 10mg pill 3 times a day, and the generic is dirt cheap. Like a few pennies per pill.

So roughly 10 years ago, LONG after generic 10mg cyclobenzaprine was commonly available, some enterprising drug company actually was able to patent it AGAIN as a 5mg pill. They claimed it was less sedating at the lower dose, and therefore constituted a whole new drug.

And so it went to market as expensive Flexeril 5mg, because heaven forbid you should actually suggest a patient buy cheap generic 10mg cyclobenzaprine and break them in half!

Eventually the patent wore off on Flexeril 5mg, too, and it went generic, along with the 10mg. So what happened next? Another drug company actually re-patented it at a 7.5mg dose and renamed it Fexmid. I am not making this up.

Still another company has developed a once daily form of it called Amrix. So from 1 drug we now have 4 freakin' patents.

Here's another one: Doxepin is an ancient (by drug standards) antidepressant. It's been around since the 1960's. So it's dirt cheap, and comes in pills of 10mg and up. BUT some pharmaceutical company, after 40 years on the market, has re-patented it as a 3mg or 6mg sleep aid called Silenor. So you can buy 30 days worth of 10mg pills at Target for $4 OR you can pay the same amount per pill for Silenor in a smaller size. Step right up and buy this bridge!

But the fun goes on! One that REALLY chaps me is the bizarre trend of combining 2 old, cheap generics (some of which are even available over-the counter) to create a new, overpriced drug.

Other companies combine an existing generic with a soon-to-be generic as a desperate way of getting a few last bucks out of it. Because heaven knows it's SUCH a serious burden to have to take 2 pills at the same time instead of 1. This list includes Treximet (Imitrex + Naprosyn), Vimovo (Naprosyn + Nexium), Caduet (Norvasc + Lipitor), Vytorin (Zocor + Zetia), Symbyax (Prozax + Zyprexa), and many more.

No matter how much pharmaceutical companies try to portray these drugs as major medical breakthroughs, THEY AREN'T!

I just can't help but think that the money spent on creating them would be better spent on more novel drugs with greater long-term potential (and profit, since I admit that's the key) to help people.

84 comments:

JANpharmd said...

Lets add Beyaz to your hate it list.

An oral contraceptive with added folate to prevent neural tube defects to fetus. While pregrant. On a contraceptive pill? Who thought of THIS?!

Linda said...

Plus the pharm now has to stock all the meds, try to read the handwriting when there are now 30 with similar names and council the pts.

Lars said...

Still, I believe combination pills may aid in improving compliance, especially in patients who have been prescribed a huge amount of drugs to take at various times at the day. Most of the combinations make sense, too.

However, you are right: they are so damn expensive...

Anonymous said...

I love your blog Dr. Grumpy! Being a future pharmacist I had to comment on this one. Lipitor is also losing its patent soon. Can't wait for Lipitor-XR.

Not House said...

@Lars: Any pharmacy worth its salt can give someone a blister pack of all their meds, properly dosed, to take on their own. This is a money making move, nothing more.

The worst part is the psychologic effect on people who aren't familiar with the drug world; people assume that name brands MUST be superior (after all, they're told to ask their doctor about Celebrex, not Celecoxib).

Reuben said...

I kept waiting for the punch line, because Fukitol sounds a little like an expletive I like to exclaim when it's all become a bit too much.

But no punch line, and sadly, no surprise.

Anonymous said...

Obviously the system is broken. These situations should not be awarded new patents. Nothing new is being invented and there are no R&D costs that need to be recouped. It is a marketing scheme, plain and simple. The part I have a problem with is the US awarding patents for this crap. The system is perpetuating this gaming of the system. And until people stand up and fight back, it will continue.

Anonymous said...

Wow, and I thought Latisse ("a prescription treatment for hypotrichosis used to grow eyelashes, making them longer, thicker and darker") was a bullshit drug..

Anonymous said...

I don't know if Effexor is what you mean by 'Fukitol', but I have to say that I responded much better to the XR than the twice-daily dose, and the co-pay card is a godsend since the (supposedly) generic CR is actually more expensive than the name-brand.

Minerva said...

You forgot to mention the direct to consumer ads for the new Fukitol-XR. Because the patient now believes they NEED it because it is so much BETTER then regular old Fukitol that worked well for them for 10 years. Never mind the women in the white jacket with decades and 100 grand in eduction telling them otherwise. The magazine/TV/sign/pretty picture on the bottle told them otherwise!

Grumpy, M.D. said...

Anon @ 6:58- Fukitol doesn't refer to any drug in particular.

The RPh said...

Amen and hear, hear!!! I couldn't have said it better myself! The list of "me-too" drugs is so long that it would probably crash your server for me to list them! It is soooo irritating when trying to explain to a patient why they shouldn't pay for the Nexium when the GENERIC Prilosec OTC is the SAME drug! (Minus the useless metabolite) Thanks for the post!

Maria Stahl said...

This is wonderful. I'm sharing it all over the place.

Mike said...

With all due respect, I believe that there are R&D costs associated with formulating extended release medications. Are they lower than the costs associated with starting from scratch on a medication? Of course. But at the very least the cost of the clinical trials for the XR formulation is going to be a real and significant cost.

I'm less certain about this next bit, but I also believe that while there are several standard techniques for creating an extended release version of a medication, it's still going to require actual lab time to determine which specific technique will work with a given medication.

Again, this isn't to say that the costs associated with creating an extended release medication are comparable to those with creating a new drug ex nihilo. To say there are no R&D costs, however, is false.



As for the co-formulations and extended release formulations,it is my belief that they are a huge boon to many patients. My parents each are on anywhere from five to nine medications, with dosing times from once a day to three times daily. For my mother, in good health, this is no trouble. She keeps her pills on a card, and checks them off as she takes them daily. My father, however, is suffering cognitive difficulties, and had trouble remembering to dose himself, or which medications to use at which time. Even with a card available.

Those blister packs that Not House mentions are something I've only seen for inpatient or custodial care situations. If you don't have the freedom to choose your pharmacy, you're stuck with what they offer.

Anonymous said...

It always amazes me that docs aren't allowed to waive co-pays, but pharma (through coupons) is.

But, Dr. Grumpy, when you start a patient on Fukitol, if it's just 20 cents per pill, why not just write a script? What's this addiction to handing out samples?

The rule in our office is we only see reps who give us 80% generics when leaving samples. We don't see many reps.

Grumpy, M.D. said...

I'm talking about the 3 month time window when Fukitol-ER comes out, but Fukitol generic isn't available yet.

SeaSideRobin said...

An extension of the placebo effect? It costs more, so it must be better.

Sarah Glenn said...

Too bad they don't give coupons for orphan drugs like Tracleer. I honestly think the insurance company was dragging its feet in the hopes my father would die before they had to cover it.

SuFu said...

Same thing happened for albuterol. I went from a generic to over $100/inhaler.

Also the clinical trials on these drugs are CHEAP. All they have to do is a non-inferiority study. If it's just as effective, then that is fine. Smaller number of patients and less molecular work than attempting to show superiority. Also if they do show superiority then their other drug may lose its indication.

Anonymous said...

SuFu: the albuterol was a different story. The original propellant used CFCs or something like that, so they had to change the propellant. Fortunately, the people who patented HFA Proair were up to the task of collecting all of that money. In this case, I'm more interested in strangling the people who made the original propellant illegal--as if they couldn't just keep it legal until the patent expired on the new propellant. But albuterol is still definitely available in generic form, just the delivery methods are limited to oral or suppository or something equally as useless.

Anonymous said...

Leave it to Grumpy to get all serious on us on Thursday. You better be funny tomorrow.

I am lucky at age 60 I only have a low dose BP med, but this stuff would make me nuts.

Anonymous said...

@Anonymous 836:

Generic albuterol is available for nebulizers. More useful than a suppository. However it takes 20 minutes of ebulization for (roughly) the same treatment as a 30 second inhaler so not as useful for home treatment. Hard to carry around in your purse too.

Melissa ~ Mom to 5 + 1 on the way said...

As in Scrabble, the high value letters are "V", "Z" and "X". Any drug with those letters are high dollar and BONUS if you can use 2 or more in the same name!

Carry on drug namers...

Can't wait for the day when symbols become all the rage in drug names.

Anonymous said...

mike- if the intent was to create a more effective med, then i would agree with your grovelling on-message excuses for big pharma. but grumpy is right. these are not new or better drugs. the new med is for patent and profit, and the aggressive marketing is to interfere with use of cost effective generics.

Don said...

The RPH It is soooo irritating when trying to explain to a patient why they shouldn't pay for the Nexium when the GENERIC Prilosec OTC is the SAME drug! (Minus the useless metabolite) Thanks for the post!

I used to buy Prilosec OTC. I have a high deductible health insurance policy and a Health Savings Account through work. My employer was tossing $600 a year into my HSA on top of anything I was putting in. I would use my HSA money to purchase the OTC drugs and I was happy.

Obamacare changed that. As of January 1 of this year, I can no longer use my HSA money to purchase OTC meds. I have to go to a doctor and get a prescription if I want to use HSA money.

Because I have to involve a doctor, my HSA money doesn't go as far. I am not anti-doctor. I go whenever I need to. I don't have time to go to the doctor for little stuff.

I don't know who made that change, but I believe the Pharmaceutical industry was involved in that one.

Jeremy G. said...

I think my absolute favorite is Moxatag. Everybody loves "Designer Drugs" :) Even if it's just fancy Amoxicillin. Only much much more expensive!

Liz said...

As a pharmacist, I can think of so many examples - some of which have been mentioned above. One of my "favorites" is fenofibrate (brand name: Lofibra). It's currently available as generic in 5 or 6 different strengths. HOWEVER, it's also available as a Brand Name Only drug (Tricor or Trilipix) in 4 or so different strengths. When I got to my current pharmacy, we used Tricor like it was going out of style. I've since made it my personal mission to ask patients if they'd rather use a generic and (when they say yes) call the doctor to request a different dose. The highest and lowest strengths are all generic, so the need for the brand name is ridiculous.

Other examples:
+Celexa (citalopram) goes generic, Lexapro (escitalopram) is put on the market
+Flonase (fluticasone propionate) goes generic, Veramyst (fluticasone furoate) is put on the market
+Paxil (paroxetine hydrochloride CR and immediate release) goes generic, Pexeva (paroxetine mesylate) is put on the market
+Effexor (venlafaxine XR and immediate release) goes generic, Pristiq (desvenlafaxine) is put on the market

I could go on, but I think I've more than illustrated my point.

Bottom line? If you're spending a boatload on prescription drugs, talk to your pharmacist (and your doctor, if he's as smart as Dr. Grumpy!) to see if there's any cheaper alternatives you could use.

ERP said...

The proverbial carrot in front of the donkey is the potential for profit. It is a double edged sword if ever there was one. It drives people to innovate and invent new things but it also drives them to figure out ways to weasel. Take away the incentive for $$ and this crap would stop - but so would innovation. Sigh.

Anonymous said...

Name me a truly innovative drug that will be widely used (sorry orphan drugs) and actually treat something (sorry Latisse) that has been introduced in the last 10 years. Not a me too drug, not the CR/XR/SR crap. A truly new, innovative drug that no one has made before that will benefit millions, if not billions of people.

Let Watson answer that one on Jeopardy.

Hows about we spend the $$ to try to make something, oh, I don't know, NEW?

As for the combo drugs, Vimovo takes the cake by far! Let's combine two OTC drugs (I know, Nexium is not OTC, but you basically can get it OTC with omeprazole) and make it prescription! AWESOME!

Soooooo glad I am a compounding pharmacist...

Carol Reese said...

I agree with all of this, but there is something else you can do. Comparison shop. You would be amazed at how much difference there can be from one pharmacy to the next for the identical drug, both generic and name brand. For instance, I take Synthroid. Because Medicare won't pay for it, I shopped. I get it at a pharmacy where the cost is about 30% of the highest one I checked. (In no particular order, Kroger, WalMart, Walgreen, CVS, Rite-Aid, Publix.) My husband is prone to yeast infections when he is stressed - on his chest as well as the usual skin folds. A dermatologist gave him a cream that worked when none of the OTC stuff did. VA won't pay for it, but did write the prescription. We shopped. It was something like $80-120, generic, but one of the above pharmacies has it on their $4-6-8 generic list. I also take omeprazole 40 mg, which is prescription. Medicare will only pay for one a day, but I take it twice a day. I found a mail order pharmacy that charges about 25% of the general price range for this.

Anonymous said...

I don't know about everyone else but my doctor's (and I have several) are not into those mind games (it sounds like your not either). They want the cheapest, most practical, long term solution as possible. They would rather send me home with a $4 script than a few months of free samples that will cost me $40-$60 a month (in five months). They are very up front with this and I am not sure REALLY what the difference would be for a medication that is 5mg or 6mg? It does get a little complicated because I take a lot of liquid or compounded medications via J-tube so that changes things too. Your patients are lucky you pay attention to this stuff. Many MD's don't, and then, we, the patients get fuckitoled.

WV: FUNGL (what happens when you don't get your FUKITOL).

Anonymous said...

@Melissa Mom to 5............I can, I can (raises hand like a 5 year old).

Xopenex (2 X's)!

LOL

ndenunz said...

One of the other pharma tricks is to combine a drug that's about to go off patent with acetaminophen (ie. Ultram becomes Ultracet). Therefore you can expect Fukicet in the near future.

Special Sauce said...

I love Treximet. It's Imitrex and Naprosyn... of course both are dirt cheap on their own now. :) We MUST combine them, because people having a migraine are not swift enough to take two pills!

Anonymous said...

Don't feel too sorry for the insurance companies. They receive "rebates" (i.e. kickbacks) from the drug manufacturers for allowing the drug to be on their formulary.

Let say Fukitol cost $100 at XYZ Pharmacy. The patient pays a $40 copay leaving the insurance company $60 they pay the pharmacy. The insurance company is then rebated back $20 by the manufacturer. More often than not this savings is not passed on to the patient or plan sponsor (i.e. employer).

Marjorie said...

My husband's physician offered to write Treximet for him instead of his generic imitrex. My husband's response.."No, generic works great for me and if it ain't broke there is nothing to fix." So some MD's get sucked into the new drugs too.

Anonymous said...

The marketing games is one thing, but as a doctor, I find trying to figure out what the "new" drug efficacy to be one of the hardest. Or as illustrated above, all the newest branding of OTC drugs. My favorite is now the branding of generics - Ocella - generic of Yasmin. GREAT! By the way, we've had Yasmin, then yaz and the continous birthcontrol by yaz comming soon - YA!

Anonymous said...

First Dr. Grumpy Said:

"Anon @ 6:58- Fukitol doesn't refer to any drug in particular."

Then Dr. Grumpy Said:

"I'm talking about the 3 month time window when Fukitol-ER comes out, but Fukitol generic isn't available yet."

Damn it's hard speaking in the abstract sometimes isn't it? :)

Anonymous said...

I've been on all the triptans at one time or another. Imitrex was the first. I found Axert to be the best but it stopped helping me after a few years.

I tried Treximet even though I felt about it the same way as everyone else here. It worked really well for me.

I had my doctor prescribe generic Imitrex and I took Aleve with it (which is the OTC of the additional drug in Treximet). It didn't work as well.

My doctor gets migraines, too, and he said he's had the same experience. He doesn't know why the combo med works better.

I know this sounds like a placebo effect but I'm a very cynical patient. I was predisposed to balk at Treximet.

MDB said...

One cannot also forget all the blood pressure meds that get HCTZ added to them and suddenly that is the way to go regard that the first drug is going generic and HCTZ is dirt cheap.

I also have to make mention of the major screw up that is colchcine/Colcryst. When that came down the pipe there were alot of elderly patients at my pharmacy who were not happy to see their copays go from cheap to sky high if the insurance company covered it at all.

Also the Beyaz is one of those drugs that you have to wonder if the insurance is even going to cover, I've never dispensed it so far as people seem to prefer getting the generic of yaz and grabbing a bottle of folic acid from vitamin aisle, much cheaper too.

Lisa said...

I work in a pharmacy and agree 100% with what you say. My doc tried to write me a script for Treximet and I told him to write it for each med. When I filled the script I asked just out of curosity what the difference was. Treximet $120 or 2 scripts for $16 total. You know what I chose to stick with.

Hal Dall, MD said...

The FDA is complicit in some of this chaa. Generic colchicine (for gout) has been ordered off the market by the FDA. It has been used in one form or another for 2000 years. The drug is now only available as brand-name. As MDB noted, the price per 100 pills went from $25 to $538!

@Melissa Mom, here's an article about newfangled names of drugs
http://www.bmj.com/content/341/bmj.c6895.full

pharmacy chick said...

I need to add nothing more Grumpy, you wrote an excellent post with an excellent perspective from a pharmacist also. Have we run so much out of innovations that we have to resort to reinventing the wheel?

pharmacychick said...

to Melissa....ZYVOX...real drug.

triple word score please.

LOL

vicki said...

i'm on a bunch of meds for a bunch of ailments. and i am smart enough to take two generic effexor daily instead of one xr -- and it's so much cheaper.
more drugs need to go generic sooner so us patients can afford them. i just found out about the site for the "drug coupons" -- i was thrilled. thanks for sharing tips to us.

C. said...

the price of drugs baffles me. Yes, I know R&D, but how about all the effing commercials produced. We all survived before big pharma was putting on a commercial 15x an hour.

As a cheapskate, I prefer the generics and recently prescribed a flurry of meds to treat a relatively common condition. One of the generics was 500+ for a month supply! I cant even imagine how much the brand name would be.

txpharmguy said...

Let's not forget about quinine. It was available since the world was flat. Several years ago, Qualaquin was formulated (only indicated for malaria, NOT leg cramps). Some insurance companies won't cover it without a diagnosis.

@Melissa mom to five, Zyvox (chemical name linezolid), is a prescription antibiotic for vancomycin-resistant enterococcus. Do I get a double word score for that?!?

Another gem on the market Nuvigil. It is the r-isomer of Provigil (modafanil). The chemical name of Nuvigil: armodafanil?!?

Let's not forget about Clarinex and Xyzal (oooh, that's another high word value drug). These are two antihistamines with their parent compounds available OTC: Claritin and Zyrtec, respectively.

Grumpy, you don't deal with this, but their are two tetracycline type antibiotics on the market for acne: Dorxy and Solodyn (doxycycline exteneded release and minocycline extended release, respectively). They both retail for over $500 per month. I despise when people come from the dermatologist with no less than THREE coupon cards for grossly overpriced medications that have cheaper alternatives on the market.

w8ng2retirerph said...

it drives me up the wall when a customer hands me a script for the new "DoC", with or without coupon. i do not understand why some prescribers fall for this drug company nonsense! just because the friggin rep (who typically knows nothing but the annotations given to them on their journal/sales guide) gives you crap like coupons & useless formulary posters doesn't mean you have to use them! i hate it so much when i see a dr write for a DoC when there are countless other better, simpler, no-nonsense alternatives. it makes me as angry as i get when i'm given a script that says give "little punk" 11.38ml of amoxil bid, dispense 240.67ml ( & that's pretty angry!) give me a friggin break!!

wellillbe said...

Ok,I agree with 95% of what you said, except for the "most of us can remember to take a pill twice a day." Compliance really does increase with once daily formulations,at least from what I see as a pharmacist ie once dailys are renewed ontime more often than twice daily formulations in general that is. Id like to add another anoying as hell habit. Repatenting the active isomer only of a drug. Ie Nexium vs omeprazole or dexilant vs lansoprazole. Then they increae the dosing for the act ive isomer and of course they work better than the original drugm its 4 times as potent! Nexium 20 was never marketed only the 40. So people would compare teh original omeprazole 20 to the nexium 40 and say the omeprazole doesnt work. I say try 4 and they will. Dirty practices. However its the money of the metoo drugs that funds a lot of the research for drugs that can actually make animpact. Like new vaccines and new antiobiotics etc.

Anonymous said...

sometimes 2 doses is actually better for some people. For example, I need smaller doses of medications of the same amount of time as somebody wouldn't. For example, Levaquin is often prescribed 1 tablet daily at 500 mg (or 250mg); I do better with 250mg twice daily; as it's just too much on my system all at once. I have to do that with a lot of my medications but everyone is different.

101Md said...

i JUST had this same conversation with my sister during the Christmas holidays!! this issue is one that just drives me crazy!!

Anonymous said...

These drugs need more Vs through Zs in their names, maybe a Q for good measure. I've had a rep try to explain Keppra XR to me - patients weren't even taking fewer pills, just doing them all at once instead. Not convinced. I'm sure Lamictal XR will be a similar miracle.

Moose said...

I can think of two cases where the ER drug is actually a good thing:

Metformin [aka Glucophage] has been around to treat diabetes since 1/3 of forever. The regular form is taken 3x a day, typically with meals. But at least 30% of the people who start it have to stop from nearly non-stop gas and diarrhea [oh, this makes you SO popular at the office!]. The 1x/day ER version actually has less incidence of these side effects, closer to 10%.

Personally, the one for me is the Tramadol ER. Normal Tramadol is taking every 4-6 hours. If you sleep for more than 6 hours you're boned when you wake up in the morning, once again struggling to open a pill bottle with hands that do not work. The once a day ER version? Take it once, at night, wake up in the morning nearly pain free.

Speaking of diabetes and of goofy combinations, I'm not even going to start on my rant about how they keep coming out with insulin mixes, even though pre-mixed insulins is so very 1990s.

Anonymous said...

To the question of a truly new drug that is actually beneficial to a large population: Chantix is the only one I can think of in recent years. And Pradaxa will be if it pans out. But that is it.

JustADoc

Megan said...

One of these old drugs with a new patent is Zipsor (diclofenac). What pisses me off more is that Indiana Medicaid covers it!

Anonymous said...

I had breast cancer and can't get tested to discover if I have the gene because a drug company patented it. Not the test, the GENE. How can they claim they made a gene?

Anonymous said...

As a patient, I have a hard time buying the "combined pills increase compliance" argument. You may be right, but honestly, if a patient is invested in their own health and motivated to feel better, they'll find a way to increase their own compliance, regardless of how many pills they take. I've got multiple chronic illness, including RA, and I take over 20 medications when you include the ones that I take PRN or weekly/monthly. It took me a while to figure out a system, but I did. But then I also prefer to be able to open my car door and walk without a cane. Just sayin.

DixieLaurel said...

The 2 generic combined into one BRAND NEW DRUG!!! drives me NUTS. When I was working as an occupational health nurse I'd have patients come on with high blood pressure. When I'd ask why they didn't take their meds they would tell me they couldn't afford them. The med would usually be one of these combination drugs. So I'd tell them to call their doctor and have the prescription changed to the 2 generics that they could buy for $4 at WalMart.

Anonymous said...

2010 Financial Report for Novartis

Revenue: $50.624 BILLION dollars
Cost of Sales: $14.488 Billion
R&D: $9.070 Billion
Marketing & Sales: $13.316 Billion

Marketing & Sales make up over 32% of total expenses. R&D represents only 22% of total expenses.

Oh yeah, they turned almost a $10 BILLION profit in 2010. How's about we spend a little less in DTC and a little more into finding some NEW drugs?

For those of you counting at home, that's almost a 20% net profit margin. Pretty spiffy.

http://www.novartis.com/downloads/newsroom/corporate-publications/novartis-annual-report-2010-en.pdf

pg. 160

Shalom said...

You're lucky you're not a dermatologist. The dermatology drug companies come out with the stupidest, most expensive and most unnecessary drugs ever.

Let's bring up some hard numbers. TxPharmGuy mentioned the tetracyclines... they keep coming up with oddball strengths just to throw you off. Look, for example, at doxycycline. Wholesale cost for 50mg caps is $3.35 for 50 capsules. Of course this is a generic, so nobody makes any money on it (well, except me); therefore they came up with Oracea, which is 40mg of doxycycline. This one costs me, wholesale, $337.74 for 30 capsules. That's 146 times the cost, for 10 mg less. I mean, what the hell?

Minocycline is another one of these. The 50mg caps are $12.95/100; the 75mg *caps* (important) are $29.50, and the 100mg caps are $24.20.

Again, no patent, no profit. So they came up with Solodyn. This is available in no fewer than SEVEN strengths to take up room on your shelf, not to mention tying up your money in inventory: 45, 55, 65, 80, 90, 105 and 135mg. Each of these cost the same amount: $672.86 per 30 tablets. And this isn't even for something lifesaving like Zyvox, either: it's so you don't have zits on your face. Patients want to know how come they have to pay upwards of $800 a month for only one of several prescriptions the dermatologist wrote so they can have clear skin; I tell them it's because their dermatologist fell for some sales rep's spiel, and if you want I'm willing call him and get this changed to the one that'll cost you ten bux, as long as you're willing to take it twice a day. They usually are.

Even worse is Dynacin. This used to be just another generic of Minocin, and was priced accordingly, except for the 75mg caps, which were *over*priced accordingly (as there was no corresponding strength of Minocin; note above that the generic 75mg strength, once it came out, was still more expensive than the 100mg ones). Again, need to wring more money out of a drug that's already paid back its research costs, so they reformulated it as a tablet, so you can't substitute the capsule. My wholesaler is currently offering that one for $1,058.18 per 100, and that's with only four months dating to boot. They've just released a generic for this, but it's still $211.50 per 100 ('cos there's only one manufacturer, so they can still play the pricing games just like the brand name company does). What about this justifies charging so much more money for the tablet than the capsule? You know why do they do it? For the same reason the dog licks himself: because they can.

The most egregious offender in this case, though, is a particular prescription diaper rash ointment, which is a big hit with the pediatricians just now. Take 6.25 grams of 2% miconazole cream (equivalent to 125mg of miconazole), 7.5 grams of zinc oxide, and 41 grams of white petrolatum (a.k.a. petroleum jelly, or Vaseline). Note that all three of these ingredients are available OTC for a few dollars a tube. Now mix them together. Voila, you now have created Vusion, for which you can charge (wholesale price!) $232.80. Had a patient the other day whose insurance wouldn't cover it. She asked me why not, and I told her straight out, it's because they don't feel like paying over $250 for something that you can buy OTC and mix it yourself for less than $10. She left muttering about prior authorizations; good luck to her, is all I can say.

Shalom said...

WellIllBe brought up Nexium: it does in fact have a 20mg strength, but nobody prescribes it. (As a joke, I've lately been referring to omeprazole as "Previous-ium".)

(On the subject of imaginary drug names, I had one professor who came up with "Putyermycin". I leave you to guess what yer putting them into, probably some sort of homogenizer.)

Sorry this rant turned out so long; you can edit for length if you want to.

Baffled said...

As much as it annoys docs, pharmacy folk etc, I think that free samples and coupons do have their place when used with discression. I am very very sensitive to meds and no longer have drug insurance. When trying out a new class of drugs I never know if I am going to have side effects or not. I tend to have to cycle through several drugs before finding one that works. This recently happened with Nexium, Prilosec and the related drugs. Doc sent me home with various sample packs. I used some of each until I found one that worked for me and then he wrote a scrip for the generic form. This worked out great for both of us. We also did the coupon trick with Cymbalta which would have cost me a fortune out of pocket only to discover that I am allergic to the stuff. We are moving on to try other FM drugs so I'm off coupon hunting on the internet....

Pete said...

I'm surprised that in 53 comments, nobody's mentioned finasteride (Proscar/Propecia).

Proscar (finasteride 5mg, for enlarged prostate) is available in generic. It's not quite on the $4 value menu yet, but at around $10 a month is still pretty inexpensive.

Propecia (finasteride 1mg, for male pattern baldness) is brand-only. A month's supply costs somewhere in the neighborhood of $100... which means a cost of roughly 10x more per tablet (or 50x more per mg).

A couple of doctors around here kindly write scripts for generic Proscar, 1/4 tablet once daily. Close enough, I'm told, to make it worth not having to pay the Merck tax on brand Propecia.

Anonymous said...

Dermatologists - Need I say more? How many different ways can you reformulate tetracycline derivatives and benzoyl peroxide in order to gouge patients?

WV - larph: Laugh so hard you barf?

jmacc77 said...

so... if i combine two generics to get a NEW drug, does that count as an artisan drug? ;)

if you do that w/ dogs, take two purebreds and mix 'em, you get a "designer dog"... so this could be a designer pill! Eh... or a mutt.

Library-Gryffon said...

I do have to say that I find a massive difference between Claritin and Clarinex. Claritin knocks me out. As in, totally non-functional for hours. I can breath, but not much else. Clarinex lets me breath, but doesn't make me at all drowsy, and I only have to take it every other day since it has a much longer half life.

I do use generic prilosec which we get from the Navy Base pharmacy. It comes as capsules, 20mg. Once when I ran out, and we couldn't get a refill for almost a week, I tried the OTC tablet form. And it didn't work anywhere near as well.

But in general I have to agree with everyone here, but no one has mentioned my pet peeve on dosing, which is the osteoporosis drugs. I mean, really, by the time you need to take one of those you already have at least one daily maintenance drug, so how hard is it to remember to take the second? But first we have the weekly dosing (which would be much harder for me to remember), and then the monthly (harder to remember than the weekly), and now they've come up with an annual one, which I can sort of understand.

Anonymous said...

Kudos, Doc. Excellent. Those silly coupons/copay cards just drive up costs and are a pain in the posterior to process. This is a wonderful blog entry.

PharmacyJim

Mr Mobius said...

A great thing about the NHS in the UK. Because it is a financially limited system where money can be better used elsewhere in the system, all doctors have to prescribe generic drugs. It's really a good system for stopping abuse of resources by drug companies.

The drug companies still try to get away with it though so we still get regular drug lunches which is nice.

For example yesterday there was a drug rep in an anaesthetics lunchtime CME meet, advertising sub-lingual Fentanyl for chronic cancer break through pain. There are so many issues with this drug that even myself, a med student, could tear apart reasons for why it's less viable than currently available drugs.

was1 said...

My current favorite is Aricept 23mg. Why 23mg? Because 23 is a prime number and you can't get a 23mg dose using generic 10mg and 5mg tablets. The genius at pfizer who thunk that one up got a big bonus, I bet.

Anonymous said...

Me: "Oh, I see the doctor has given you a coupon for this new medication. Have you activated it yet?"
Patient: "Activated? Whaddya mean? Doc just told me to get my medicine with the coupon."
Me: "See the big sticker on the front of the card? It says "Must be activated before use." You'll have to call this 800 number on the card before it will work."

I *really* love it when a Medicare Part D patient comes in with a coupon card, and I have to tell them I can't use it because they are covered by Medicare. "But...but...my doctor gave it to me to use! You must use it!"
It's no fun telling them their doc didn't read the fine print on the card and is probably handing those cards out to everyone who comes in the office.

ThatLadyDruggist

wormpharmd said...

My favorite is BeYaz: let's add folic acid to our contraceptive, just in case you get pregnant while on it.

Anonymous said...

Robin Williams had a great routine based on Fukitol. I only wish it were a real drug, I could use some of that, since antidepressants either don't work or make me *more* depressed. (Been through damn near a dozen of 'em over the years. It gets old.)

Frantic Pharmacist said...

An excellent summary of the entire process! I get a kick out of submitting those Fukitol ER claims to insurance -- I can almost hear the insurance company computer laughing maniacally.
By the way, that "white pill with the line through it"? Its spironolactone, I'm SURE of it...

Smiley :) said...

I think jmacc77 had the BEST comment!! It actually made me laugh out loud!

lovinmyjob said...

Another big issue to consider is that most generics aren't really generics. They are what is refered to in the industry as CLONES. That is when the name brand company makes and distributes the so-called generic. That results in a very minor cost savings to the patient. Case in point: Omnicef vs Cefdinir. The capsules in the generic bottle actually say Omnicef on them. Who doesn't see that as just repackaging the same product and charging a different price. There are many insurance companies who are now recognizing this trend and only paying for the name brand product. Does this seem bass-ackwards to anyone but me?

Anonymous said...

Don't forget Soma 250 and the "new" tamsulosin/finasteride combo.

Old Rhp said...

This subject drives me crazy! A local derm prescribed time release Doryx 150 mg at $540 per 30. The patient was having trouble swallowing it, so this IDIOT doctor told her to just crush it - essentially turning it into $10 worth of doxycycline.

The Mother said...

Hey, the good news is that the drug companies don't spend very much money in R&D to extend the half-life of these drugs--the technology is well known.

Still...

PAS said...

Ahem. This might be quite extensive.

I'm the dark side here. The PBM. Prior Authorizations. And Dr. Grumpy has hit the nail head on here. This is a massive snarl of horror that makes victims out of the patients, the MDs, and even the insurance plan. My job would be far less necessary, and far more pleasant if this mess didn't exist to wrangle with. What goes on behind the scenes is a convoluted mess of fighting with rebates (both negotiated and federally mandated (Drug companies aren't so fond of those!), legal squabbles and regulatory messes.

I work principally on a state Medicaid. We are dirt poor, on a per patient basis. We have more than a million people, most of whom are dirty poor on a personal basis. A huge number of them are very sick, and more than half our children.

Yet how often do I get a PA request for Doryx (at it's lovely $500/month price), because that's what samples were on hand. Of course the patient's been started on the medication by those samples, and now the state's expected to pick up the rest of it. Advair is almost as bad an offender.

@Txtpharmguy, the reason for that on Quinine (the dx part) is the big fat blackbox on the drug:

"Quinine sulfate use for the treatment or prevention of nocturnal leg cramps may result in serious and life-threatening hematologic reactions, including thrombocytopenia and hemolytic uremic syndrome/thrombotic thrombocytopenic purpura (HUS/TTP). Chronic renal impairment associated with the development of TTP has been reported. The risk associated with quinine sulfate use in the absence of evidence of its effectiveness in the treatment or prevention of nocturnal leg cramps outweighs any potential benefit (Prod Info QUALAQUIN(R) oral capsules, 2010)."

You'd be surprised how many prescribers do not read black boxes. Horrified might be closer.

@Lovinmyjob, Oh yes. 'Branded' and 'licensed' generics. Some of the big brand name companies have 'pet' generic manufacturers that exist pretty much to sell licensed versions of generics. The effects of this are quite widespread, as the licensed generics are often priced only slightly lower than, or even higher than the brand name. This encourages insurance to show a preference to the brand, and retards generic competition. In one case, a brand owner licensed generics to over a half dozen companies, utterly FUBARing the pricing of the generic during a legal spat with a company that busted their patent.

Drug rebates are also calculated based on brand originator or generic status. By licensing their products as generics, under some circumstances a drug maker will pay less in rebates. In the case of Medicaid, these rebates are mandated and calculated by federal law, and the drug makers take a sadistic glee in gaming and abusing the system that makes it possible to afford drugs for people who have no resources at all.

Anonymous said...

hahahaha that last sentence made me laugh. Good one, Dr. Grumpy, that was one of the funniest punchlines I have ever read.

Parchment, CPhT said...

My favorite part of dealing with discount cards is when the patient 'forgets' to mention that they have one until I've rung their rx and the transaction is complete... even when I make a point of telling them the price beforehand.

Me: "Alright, your total is $50."

[complete sale]

Pt: "Hey, was that with my coupon? It's only supposed to be $20."

Me: ". . . manager to the pharmacy please, manager to the pharmacy."

Missy said...

That really pisses me off!! Drug companies rather make a few bucks and waste their time on drug combos and upping and lowering doseage and calling them flexmed (example whatever its called) they need to be out there finding a cure for AIDS, cancer and Childhood diseases, like a cure for VCD, ADHD and tracheal malasia (which my child has) man!!! That makes me so effin mad!!

Anonymous said...

Independent Coumpounding CPhT

Funny, no one mentioned Xopenex/albuterol.

Also, those co-pay rebate cards cost the pharmacy money to process, lowering our already pitiful profit margin.

It'sAllGoneToTheDogs said...

I have to say that as a veterinary assistant that deals with clients being picky about this very thing and having to, not only relay this to our doctors, but fill the scripts and explain that it's the SAME THING, I sympathize. I was also thinking the other day about this when I saw an add for a rosacea drug that is, "brand new!" and was labeled as plain old Doxy-freaking-cycline. Pharmaceutical companies can spend thousands to get rid of rosacea with a darn antibiotic that's been on the market for years, but can't come up with a more effective drug to treat my pituitary tumor? Sad.

 
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