I’m sure this is pretty trivial, but I honestly don’t know the answer. Or if it even matters.

Problem: Person presents with chest congestion and a productive cough. You prescribe clarithromycin 500mg bid for an upper respiratory infection, and now they’d like something for their chest symptoms.

I would typically recommend an expectorant — either plain Robitussin or Mucinex, depending on their financial situation — and instruct them to drink plenty of fluids. Is it better to keep them away from DXM-containing products? Will they get better more quickly if you don’t suppress the cough? It’s my experience that guaifenesin quiets a productive cough somewhat anyway, but not as much as with DXM. Are they better off doing some coughing? Assuming, of course, that they aren’t hacking their lungs out.

Does it matter one way or the other?

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]

I was conversing with Dr. Dino the other day, and we were discussing OTC products, and which ones I recommended. Now, pharmacists don’t diagnose. Most of them don’t want to, and many of them will tell you that. (This is one reason reading statements like “Pharmacists are just people who didn’t get into medical school” really gets my goat, but that’s a rant best explored another time.)

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]

What you say??

Medscape has an Ask Marilyn type of thing, and this one was a head-scratcher:

What is the relationship between NovoLog and Humalog? Molecular structure aside, can they be directly substituted for each other?

I don’t know who’s asking the question, but I think it’d almost have to be a prescriber, or someone who supervises prescribing physicians. Especially given the answer:

Any differences in pharmacokinetic parameters are unlikely to be clinically relevant, and as such, these 2 agents may be interchanged. However, it is important to keep in mind that the pharmacokinetics and clinical response to all insulin products can vary between individuals due to a variety of factors. Individual patients switched from 1 agent to the other should be especially cautious about monitoring their blood glucose initially after the change.

Emphasis mine.

I hope no pharmacists out in the real world think to themselves “Gee, I’m out of NovoLog, so I’ll just substitute Humalog.” In this context, a disclaimer would have been nice, don’t you think, Mario?

For the non-endocrine types, lispo and aspart swap a pair of amino acids to make insulin adhere to itself less, which results in a smoother pharmacokinetic profile. Patients tend to like it better than NPH. It is, unfortunately, much more expensive.

[tags]Medicine, pharmacy, insulin, diabetes[/tags]

In 2008, CFC inhalers are going away, a topic I’ve covered extensively here and here. That leaves Sepracor in a position to make themselves quite a lot of money if they’re willing to do one thing out of the ordinary: price the Xopenex HFA MDI at or below the same price as the other HFA albuterol products. This would set up the PBMs to be receptive to making the product a Tier 2 copay, like most of the racemic albuterol HFA formulations.*

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]

How many times have you heard this phrase?

No, my fabulous pharmacy friends, these items are often considerably MORE expensive than gold… we’re talking Americium expensive.

For comparison, the price of Ridaura — a gold salt in capsule form — is $295.79 for 60 caps.*

In no particular order:

1. Zyvox (linezolid): $1,546.78 for 20 tablets.
2. Cocaine HCl 135mg: $1,144.80 for 100 tablets
3. 1L of normal saline: $100**
4. Casodex (bicalutamide): $519.76 for 30 tablets.
5. Enbrel (etanercept): $7,500/ounce.
6. Lamisil (terbinafine): $435.84 for 30 tablets.
7. OxyContin 80mg: $662.31 for 90 tablets. (Street value is approximately $7,200 for these same 90 tabs).
8. Aldara (imiquimod) cream: $268.38 for 12×1 gram packets.
9. Vancocin: $651.85 for 20 pulvules
10. Iressa (gefitinib): $2,127.35 for 30 tablets
11. Gleevec (imatinib): $3,563.26 for 30 tablets.

Got anything to add?

* All prices are AWP.
** Except this one. ;)

As a followup to my post the other day…

The NEJM concludes — along with the rest of the world — that HFA albuterol formulations are more expensive than their CFC counterparts. The article (subscription required) delves into some of the differences between the various HFA formulations as well as the differences between CFC and HFA albuterol.

The article doesn’t talk much about ProAir HFA, which I find a bit strange, especially as it has captured 60% of the HFA albuterol market. Unrelatedly, it seems that concentrations of albuterol are slightly higher with HFA than the CFC versions, despite the smaller plume.

Here’re some semi-relevant differences between Ventolin HFA and Proventil HFA, emphasis mine:

The excipients added to the propellant formulation differ according to the brand of HFA inhaler. For instance, each puff of Proventil HFA releases 4 μl of ethanol. This small amount of ethanol will not have a discernible clinical effect, but it may be of concern for patients who for religious or other reasons abstain from alcohol. Breathalcohol levels of up to 35 μg per 100 ml may be detected for up to 5 minutes after two puffs of Proventil HFA. Unlike CFC propellants, HFA propellants may cause false positive readings in anesthetic gas–monitoring systems. The infrared spectrums of HFA overlap with commonly used anesthetic gases in the range of 8 to 12 μm. One albuterol product, Ventolin HFA, contains no excipients other than the propellant, a characteristic that may improve tolerability for some patients. However, Ventolin HFA comes packaged in a moisture-resistant protective pouch containing a dessicant and has a limited shelf life once it has been removed from the pouch. Ventolin HFAs have a greater affinity for moisture than do CFCs, which means that water vapor is more likely to enter the canister around the meteringvalve gaskets. The other approved HFA inhalers are less susceptible to moisture permeation and do not require a protective pouch.

Shelf life for Ventolin HFA is 2 months after opening, so it’s a mixed bag.

A breakdown:

[tags]Medicine, pharmacy, albuterol, HFA, CFC[/tags]

In August of 2004, I went to Costa Rica on vacation, and we made a day trip into Nicaragua. One the whole, Nicaragua was probably my most favorite place on the whole trip. While we were in the country, we stopped into a Nicaraguan pharmacy. I couldn’t resist taking pictures, which frightened the pharmacist after a while.

I must have spent 20 minutes in this place, examining everything. It’s set up a like a deli: everything in glass cases, and you simply pick out what you want. No prescription necessary. It turns out that the pharmacist thought we were from the government — though I don’t think we could have looked more tourist-y if we tried). Perhaps she couldn’t fathom foreigners being so interested in a pharmacy? I don’t know. I didn’t notice this, but my girlfriend did (also a pharmacy student), and I said “farmacia estudiante” and she got very excited.

She got very excited about this, and started asking me questions about pharmacy in the United States. Alas, I don’t speak Spanish, so I was unable to answer her. That made me a little sad — this probably would have been the highlight of my trip if I had.

I asked about a couple of CIIs: Percocet, Adderall, Ritalin, etc. She didn’t have any stimulants, but she did have Percocet, which you needed a prescription for. I don’t recall if you could buy Vicodin with a script or not. I do remember seeing Tylenol with codeine, though I don’t know what the formulation was.

I ended up buying 60 tablets of alprazolam 0.5mg made by Merck, just because I could. In the US, these tablets would be under the Greenstone moniker. AKA, The Real Thing — you pharmacists know exactly what I’m talking about. This was back in 2004, and I paid about $12. The pharmacist was so happy, she gave me a student discount. (LOL) The sticker price was 234.30 Nicaraguan Cordobas, but she sold it to me for 199.50 Cordobas — about $12USD at the time. (I still have the receipt.) I took a picture of that this morning, and it’s at the bottom of this entry.

Anyway, the pharmacy was situated next to an open-air market. It was dusty, and most of the light came from the sun outside the building, which made it shaded inside, and mostly unsuitable for good pictures, and since the items were encased in glass, a flash would have reflected. These are the images that turned out satisfactorily. I wish I’d had a better camera like I do now.

[tags]Pharmacy, Nicaragua, drugs[/tags]

Trolling through the medical press releases today, I was reminded of the only time I ever told someone that they would die if they didn’t do something. He was about 25 years old, and he’d been bitten by an animal earlier in the day. He didn’t want to get his rabies series, so he decided he’d ask in the pharmacy while he was picking up his prescriptions if it would be okay if he didn’t get the vaccine. He just didn’t want to make the effort, and he wanted someone to help him feel better about his decision.

My words were, “If you have been bitten by an animal, and it has rabies, and you do not get the rabies vaccine, and you become infected, you will die.”

(If you’ve been bitten by an animal, and it has rabies, then it follows that you’ve now got it, too. But I suppose there’s always the off chance that infection didn’t occur…)

It was very strange to hear those words come out of my mouth. Very strange. I remember turning the conversation over in my mind for a few hours afterward, examining it from every conceivable angle. Was I wrong? Had I been too emphatic? Perhaps over-dramatic? Is it possible to be over-dramatic when you’re trying to drive the gravity of a situation home? Perhaps it felt wrong because you can’t be emphatic about much of anything in medicine, so being emphatic feels out-of-place — even when it’s warranted — because the profession itself deals mostly in shades of gray?

People survive being shot in the head with bullets and other objects on a semi-regular basis. But so far, not rabies. (Then again, gunshot wounds are more common than rabies infections, so maybe if n for rabies were a little larger…)

In any event, he ended up getting the vaccine.

[tags]Medicine, pharmacy, rabies[/tags]