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by Cindy Cho, PharmD Candidate Class of 2019,
The University of Arizona College of Pharmacy

Are You Doing This Important Step After Using Your Inhaler?

If you use an inhaler for a breathing condition, like asthma, you may have been told by your doctor that you will need to rinse your mouth with water and spit after you use your inhaler. It may seem like a cumbersome additional step, especially since it already takes time out of your day to use your inhaler, so why is it important to spend time to rinse and spit after using your inhaler?

Not All Inhalers Require You to Rinse and Spit

Just to clarify, you don’t need to rinse and spit with every inhaler. There are numerous inhalers on the market with different active ingredients and different purposes (For more on this, refer to this post on the difference between rescue and controller inhalers: (https://news.wellrx.com/2016/08/18/breathing-condition-meet-lifesaver/).

However, a common type of inhaler that does require you to rinse your mouth after each use is called an inhaled corticosteroid (ICS) inhaler. ICS inhalers contain small amounts of steroids to help people breathe easier. Other types of inhalers have different active ingredients (e.g., albuterol, formoterol, tiotropium), so it is not necessary to rinse your mouth after using those.

Common ICS Inhalers

Examples of common ICS inhalers, or combination inhalers that contain a corticosteroid, are:

  • Advair Diskus & Advair HFA (fluticasone/salmeterol)
  • Aerobid (flunisolide)
  • Alvesco, Omnaris, Zetonna (ciclesonide)
  • Arnuity Ellipta (fluticasone furoate)
  • Asmanex (mometasone)
  • Azmacort (triamcinolone)
  • Dulera (mometasone/formoterol)
  • Flovent, Flovent HFA (fluticasone)
  • Pulmicort, Rhinocort (budesonide)
  • Qnasl, Qvar (beclomethasone)
  • Symbicort (budesonide/formoterol)

If you are using one of these inhalers or have been told that your inhaler contains a steroid in it, you will need to rinse your mouth with water and spit after each use.

Why do I Have to Rinse and Spit with ICS Inhalers?

ICS inhalers have a small amount of corticosteroid medication that reduces inflammation in your bronchial tubes and ultimately open your airways to help you breathe easier.1 These medications can be delivered through metered dose inhalers, dry powder inhalers, or through a nebulizer. When you breathe in your steroid inhaler medication, a small amount of steroid can stick to your mouth and throat as it makes its way into your lungs to help you breathe. If this small amount of steroid is not rinsed out from the inside of your mouth or throat, it can cause a fungal infection known as thrush.2

What You Need to Know About Thrush3

Oral thrush in adults generally looks like thick, white or cream-colored spots inside the mouth. The inside lining of your mouth may appear swollen and slightly red and may feel uncomfortable or a burning sensation. The good thing is that thrush is a treatable infection. Your doctor will prescribe an antifungal medicine in the form of a tablet, gel, lozenge, or mouthwash to help treat it. The better news is that this condition is preventable with proper rinsing and spitting.  

What You Can Do

Make sure to rinse your mouth with water and spit after using your ICS inhaler to prevent thrush. Another way to make it easier for you to incorporate rinsing your mouth after using your ICS inhaler is to brush your teeth after using your inhaler. As a friendly reminder, your ICS inhaler should be used on a routine basis, unless your doctor tells you otherwise, even when your breathing seems better. These inhalers will help maintain your breathing over time to prevent breathing-related complications and keep you out of the hospital.

References:

  1. Barnes PJ. Inhaled Corticosteroids. Pharmaceuticals (Basel). 2010;3(3):514-540. Published 2010 Mar 8. doi:10.3390/ph3030514
  2. Shuto H, Nagata M, Terashi Y, Yamaguchi M, Takizawa T, Shuto C, Watanabe K, Tosaka K, Okano M, Noguchi H. Esophageal candidiasis as complication of inhaled steroid therapy. Arerugi 2003; 52(11)1053–1064
  3. Oral thrush – Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/oral-thrush/symptoms-causes/syc-20353533. Published March 8, 2018. Retrieved February 22, 2019.

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$10 billion in prescription savings - scriptsave wellrx blog image

ScriptSave WellRx Marks Silver Anniversary –
25 Years of Prescription Savings, Totaling $10 Billion, and a Brand New Innovation to Help Patients Who View Food as Medicine

A new analysis from the prescription discount program, ScriptSave WellRx, has revealed the savings from the company’s pioneering efforts to lower out-of-pocket costs for millions of patients paying cash for their prescriptions. The results: more than $10 billion dollars of savings, as the company marks its Silver Anniversary with the release of a brand new module that can assist patients with their grocery choices.

Founded in 1994, ScriptSave has been a pioneer and innovator, leading the way in terms of creating tools and programs designed to help un- and under-insured patients better afford their medications. Working in close collaboration with many of the nation’s pharmacy and grocery chains, ScriptSave has created incredible savings opportunities for patients.

With the latest update to the ScriptSave WellRx mobile app, ScriptSave has announced a new wellness-focused tool that provides grocery guidance. Using the new tool, consumers can check:

  • ensure the foods they are eating are consistent with their goals for general wellness
  • choose foods better aligned for pregnancy
  • select appropriate foods for other health conditions, including heart health and diabetes.

Users of the app can even find similar food options that are better aligned with their needs. As with most other programs and offerings from ScriptSave, the ScriptSave WellRx app (and the new grocery guidance toolset) is available to users at no cost.

Prescription Savings - ScriptSave WellRx

ScriptSave Never Stops Innovating

scriptsave wellrx food index imageOther pioneering innovations that are also available (free) in the latest app release include:

  • geo-targeted price-drop alerts for prescriptions medications, allowing users to see when the prices for their own medications come down at nearby pharmacies;
  • medication refill and ‘take your pill NOW’ reminders, helping to ensure prescribed medication adherence, and;
  • medication interaction alerts, to flag possible life-threatening drug or lifestyle interactions.

The newest release of the ScriptSave WellRx app, can help guide shoppers while they browse the aisles at the grocery store or as they take stock of their pantry. It’s a clear expansion outside of ScriptSave’s traditional domain. Moving beyond just pharmacy and prescription medications, the grocery guidance module can guide users towards more health-conscious food selections. It’s designed to help users concerned with chronic conditions like diabetes or heart health, and can help identify appropriate food selections for pregnant women.

These latest innovations to the app’s features are the result of more than two years of ongoing product development. Along the way, the team even managed to pick up a few awards for prototype versions of the app (including as a category winner at the 2017 National Association of Chain Drug Stores’ Product Showcase). ScriptSave’s Vice President of Product & Technology, Shawn Ohri, noted that the timing of this release to coincide with ScriptSave’s Silver Anniversary could hardly seem more fitting or rewarding to the team.

$10 Billion Saved

Meanwhile, an in-depth analysis of the traditional prescription savings programs that ScriptSave has been evolving throughout the course of its 25 years of innovation, shows how the business has helped an estimated 85 million patients in the US save a total of $10 billion on their prescription medication costs. In 2018 alone, the prescription discount program saved consumers $450 million on medications.

ScriptSave WellRx’s free savings cards and prescription coupons—which can be found online or in the mobile app—can help save patients up to 80% on their medications, with average savings of around 60%. In terms of dollars and cents, the average cash saved by patients using ScriptSave WellRx in 2018 was $30.85 per prescription.

Ohri noted that with the ever-increasing prices of medication in the US, ScriptSave WellRx is helping patients pay for the medications they need to not only get over a cold or fever but, in some cases, survive.

“This is our 25th anniversary, and during those years we’ve helped patients save $10 billion on prescriptions they need to get and stay healthy,” said Ohri. “Our prescription discount programs help consumers save money they can use on other critical expenses, like keeping the roof over their heads, putting food on the table for the family and buying school supplies for their kids. We continue to operate with a start-up mentality, bringing new and innovative solutions to help people manage their health and wellness.”

WellRx Mobile App Helps Consumers Find Lowest Prices at the Pharmacysrciptsave wellrx price drop alerts - image

At its core, ScriptSave WellRx negotiates drug prices in bulk with pharmacies across the nation, giving it access to pricing information for most prescription drugs being sold at independent and chain pharmacies. Consumers can access this data at no cost with the free ScriptSave WellRx mobile app and website.

This provides a fast, easy, free way for patients (and physicians) to get a second opinion on what an out-of-pocket cost might be. Patients can price-check all their family’s medications at most pharmacies in any zip code with just one click.

The price-check tool is available for free—no sign-up necessary—and features savings on medications at over 65,000 retail pharmacies across the U.S. In 2018, the program delivered average savings of 60%, with potential savings of 80% or more (relative to the cash price of those prescriptions being filled).

Patients can download the free ScriptSave WellRx mobile app (for iPhone and Android) or visit the website for more information.


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too many drugs - scriptsave wellrx blog image

by Ryan Lowe, PharmD Candidate,
University of Arizona

The More Medications, The Merrier?

Have you ever heard of the term “polypharmacy” before? When you break that word down you get “poly”, which means multiple, and “pharmacy”, which means medications. Polypharmacy is defined as the use of multiple drugs, or more than are medically necessary.1 Depending on who you’re talking to will determine where their cut off is for ‘multiple drugs’, with some thinking as few as three is considered polypharmacy, while others say you need as many as five.

An example of using more drugs than are medically necessary would be having two blood pressure medications when your blood pressure has been running low. There are a lot of concerns about polypharmacy, especially in the elderly population.

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Polypharmacy in the Elderly

A study published in 2004 wanted to find out how prevalent polypharmacy was in the nursing home setting. With over 13,000 patients in the study, they found that approximately 40% of them were taking 9 or more medications.2 While 9 medications may seem absurd, as this study shows it’s not that unheard of.

As you can well imagine, taking multiple medications can lead to a variety of potential concerns. First off, the more medications you take means the more money it will cost to pay for those medications. Added hospital or clinic visits to manage those medications also contribute to the rise in costs. Another major concern is that of drug side effects, commonly referred to as Adverse Drug Events (ADEs).

Some patients report a side effect to one medication which then gets an entirely new medication to replace it. This can lead to a cycle of adding new medications which leads to polypharmacy. The more medications you must take also makes it harder to remember when to take them. Some patients struggle to take only one or two medications every day, so having upwards of nine becomes a very daunting task. Despite all these risks, there is still one concern that is at the forefront of any pharmacist’s mind: drug interactions.

The Major Risk of Drug Interactions in Polypharmacy

Drug-drug interactions, or DDIs, happen when one medication interferes with the way another medication works in your body. If you are taking nine medications at the same time, there is a much greater risk that at least two of those drugs will interact with one another. These interactions can range from the benign to the severe, sometimes increasing the effect of one drug or preventing it from doing its job.

Here is a list of some (but not all) of the most common drug interactions:

  • Warfarin: If you take warfarin to help thin your blood to prevent a stroke or DVT, you should know that warfarin has numerous DDIs. Ibuprofen or Aleve should be avoided when taking warfarin, and many antibiotics can also affect the level of warfarin in your body.
  • Grapefruit: You may have heard about some drugs interacting with grapefruit (including juice), but what drugs and why? Grapefruit can block an enzyme in your body that many drugs use as their metabolizing agent. When this happens, the amount of drug rises in your body to sometimes dangerous levels. If you’re taking any of these drugs then you should avoid eating grapefruit: some statin medications (like simvastatin and atorvastatin), nifedipine, cyclosporine, buspirone, amiodarone, and fexofenadine (generic Allegra).3
  • Levothyroxine: When you take levothyroxine, you’re supposed to take it one hour before you eat breakfast in the morning. This is because levothyroxine interacts with almost every food you can think of. If you take the drug with breakfast, lunch, or dinner then it will not be able to absorb fully, and it won’t reach its desired effect.

There are several tools available to check for drug interactions. The free ScriptSave WellRx app has a feature that allows you to check the medications you are taking for any harmful interactions. The app also has a lot of other useful features. For example, you can set reminders for taking your medications in case you have a hard time keeping track of them all, or when to refill them. You can also look up information about your medications including what it should like and possible side effects. The app is available for both Apple and Android, and can also be used in Spanish! If you still have questions, you can call the Ask a Pharmacist line at 1-866-268-2611 to speak to a pharmacist directly.

References:

  1. Maher, Robert L, et al. “Clinical Consequences of Polypharmacy in Elderly.” Expert Opinion on Drug Safety, vol. 13, no. 1, 2013, pp. 57–65., doi:10.1517/14740338.2013.827660
  2. Dwyer, Lisa L., et al. “Polypharmacy in Nursing Home Residents in the United States: Results of the 2004 National Nursing Home Survey.” The American Journal of Geriatric Pharmacotherapy, vol. 8, no. 1, 8 Feb. 2010, pp. 63–72., doi:10.1016/j.amjopharm.2010.01.001.
  3. “Consumer Updates – Grapefruit Juice and Some Drugs Don’t Mix.” U S Food and Drug Administration Home Page, Office of the Commissioner, 18 July 2017, www.fda.gov/ForConsumers/ConsumerUpdates/ucm292276.htm.

If you’re struggling to afford your medications,
visit www.WellRx.com to compare the cash price at pharmacies near you.
You may find prices lower than your insurance co-pay!

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marijuana interactions with prescription drugs - scriptsave wellrx

With the growing legalization of marijuana, which has been approved for recreational use in 10 states and for medical use in 33 states1, there’s naturally a lot of buzz around the medical benefits. Emerging research suggests it may be a safer substitute for opioids to treat pain. But what about potential drug interactions?

Limited Research

But as research continues into possible benefits of using marijuana for treatment, questions remain about how cannabis might interact with prescribed or over-the-counter (OTC) medications a person may also be taking.

Some states have legalized the use of marijuana for medical purposes, as well as for recreation to varying degrees, however, the federal government has not. The tight federal restrictions create a challenge in researching how marijuana interacts with other products, either OTC or prescribed.

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Interactions With Medications or Lifestyles

Some examples of medication types and common interactions include:

Drug Type Lifestyle Interaction
Tricyclic antidepressants May result in adverse cardiovascular effects, such as tachycardia and cardiac arrhythmias.
Nonsteroidal antiinflammatory drugs (NSAIDs) Administering nonsteroidal antiinflammatory drugs (NSAIDs) concurrently with marijuana may limit some of marijuana’s pharmacologic activities.
Benzodiazepines Using marijuana with benzodiazepines may result in an exaggerated sedative effect.
Amphetamines Using marijuana and amphetamines together may cause adverse cardiovascular effects, such as tachycardia and cardiac arrhythmias.
Beta-blockers Concurrent use may result in decreased beta-blocker efficacy, significantly increased heart rate and cardiac output lasting for 2-3 hours, myocardial infarction and cardiac arrhythmias.

Visit www.wellrx.com for more information on drug and lifestyle interactions.

Synthetic Marijuana (Marinol)

In addition to tetrahydrocannabinol (THC), cannabidiol (CBD) is found in high concentrations in marijuana. CBD does not produce any of the psychoactive responses and appears to block some of the effects of THC by acting as an antagonist at the cannabinoid receptors. Cannabinol is weakly psychoactive and appears to be primarily formed from the metabolism of THC. Another metabolite of THC is thought to contribute to the tachycardia and appetite-stimulating effects of cannabis.2,3

An FDA-approved synthetic form of marijuana uses a chemical compound similar to those found in cannabis. Marinol (drobinol) is approved to help with nausea induced by chemotherapy as well as anorexia caused by AIDS.

The Takeaway

For most patients, cannabis:

  • Is relatively safe
  • Well-tolerated, and;
  • Carries fewer risks of adverse drug interactions than many commonly prescribed drugs.

Given its therapeutic versatility, one of the best arguments for cannabis is that it can actually reduce the need to combine multiple medications, therefore lowering the potential risk of adverse interactions.4

References:

  1. https://www.businessinsider.com/legal-marijuana-states-2018-1
  2. https://health.usnews.com/health-care/patient-advice/articles/2018-03-08/how-does-marijuana-interact-with-medications
  3. https://www.pharmacytimes.com/publications/issue/2014/december2014/drug-interactions-with-marijuana
  4. https://www.leafly.com/news/health/cannabis-cannabinoids-drug-interactions

If you’re struggling to afford your medications,
visit www.WellRx.com to compare the cash price at pharmacies near you.
You may find prices lower than your insurance co-pay!

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by Ryan Lowe, PharmD Candidate,
The University of Arizona College of Pharmacy

For many patients with diabetes, insulin has become a mainstay of their therapy. Despite the addition of newer drugs on the market (like the exciting GLP-1 agonists such as Victoza (liraglutide), insulin remains a popular choice among physicians for its numerous benefits. The dose of insulin can be easily adjusted; if your blood sugars are running high then simply try taking two more units and reevaluate in a couple of days. Insulin is also a great drug when used in combination with other medications such as metformin; these combinations allow for greater control of a patient’s diabetes. According to a study from the CDC, the percent of patients taking both insulin and an oral medication increased between 1997 and 2011. This suggests the importance of both types of medication in diabetes management. 1

What are the different types of Insulin available?

Insulin can be divided up into two categories: long acting and short acting. Most patients start out with a long acting insulin before a short acting insulin is added. The most common long acting insulin is Insulin Glargine, or Lantus. Another long acting insulin you may see is Insulin Detemir, or Levemir. These insulins are normally dosed once a day, and they work to keep your fasting sugars (your blood sugar when you’re not eating any food) within normal limits.  The most common side effect of long acting insulin is hypoglycemia, or low blood sugar. When you take too much insulin your body eats up too much glucose, resulting in low blood sugar levels. If you are hypoglycemic then you may start shaking, feeling dizzy or faint, and feel confused or anxious. The quickest remedy for this is eating a high sugar snack or drink, such as a glass of orange juice. As noted earlier, one of the main benefits of long acting insulin is being able to adjust the dose more frequently to find the perfect dose for you. With a tablet medication it is harder to find the perfect middle ground; you either take one tablet or you take two. Insulin doesn’t work that way; since insulin is a liquid injection you can easily take a little more or a little less than you were previously to account for your blood sugar levels.

Short acting insulin works much quicker than the long acting insulins, hence the name. There are two common short acting insulins: Insulin Lispro, or Humalog and Insulin Aspart, or Novolog. These insulins are commonly taken after a meal. The idea behind this is that the insulin will counteract a large spike in blood sugar gained by eating a large meal. However, these insulins are rarely taken alone; rather they are normally used in combination with long acting insulin to combat both types of sugars: fasting and post-prandial, or post-eating sugars. Hypoglycemia is still a risk with these short acting insulins, but it isn’t as great a risk as with the long acting insulins. One consideration that has been on many patient’s mind, however, is the rising cost of insulin – and Humalog specifically has been in the news lately.

Why is Humalog making headlines?

Humalog is a short acting insulin manufactured by Eli Lilly, a drug company responsible for numerous popular medications. Eli Lilly released some pricing information about Humalog, and the numbers are raising some eyebrows among patients, healthcare providers, and even politicians. An insured patient will typically pay around $135 a month for Humalog (which is a decrease of 8.1% from 2014). When you don’t factor in the rebates typically covered by an insurance company, the monthly price of Humalog rises to $549.2 These differences have gotten a lot of people talking. Eli Lilly hopes that the information they released will help shed some light on the often-muddled issue of rising drug costs. Politicians on both sides seem to agree that drug costs need to come down in America, but the solution to this issue is not an easy one. Eli Lilly themselves hope to improve the situation by releasing a “half-price” Humalog under the generic name Insulin Lispro. The cost will be $137.35 per vial, which should significantly improve the annual cost for those uninsured patients with diabetes.3

In response to the Eli Lilly price drop for Humalog, Sanofi recently announced a program that they hope will make a difference in the cost of insulin.4 They unveiled a Netflix-like program that takes that model directly to patients, supplying insulin products for a flat monthly rate instead of the usual cost per prescription or refill. The drugmaker will use its Insulin Valyou Savings Program to deliver insulin products for $99 per month. For that monthly fixed price, Sanofi will offer up to 10 boxes of insulin pens and 10 mL vials per month, regardless of a patient’s income. The new $99-per-month price could be as little as one-tenth of the amount patients would have paid previously.

References:

  1. “Age-Adjusted Percentage of Adults with Diabetes Using Diabetes Medication, by Type of Medication, United States, 1997–2011.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 20 Nov. 2012, www.cdc.gov/diabetes/statistics/meduse/fig2.htm.
  2. Lovelace Jr., Berkeley. “Eli Lilly Sheds Light on Confidential Pricing, Discloses Charges for Popular Diabetes Drug Humalog.” CNBC, CNBC, 25 Mar. 2019, cnbc.com/2019/03/25/eli-lilly-discloses-pricing-data-for-its-popular-insulin-humalog.html.
  3. “Lilly to Launch a Half-Price Version of Insulin.” CNBC, CNBC, 4 Mar. 2019, www.cnbc.com/2019/03/04/lilly-to-launch-a-half-price-version-of-insulin.html.
  4. “Sanofi provides unprecedented access to its insulins for one set monthly price” Sanofi, 10 Apr. 2019   http://www.news.sanofi.us/2019-04-10-Sanofi-provides-unprecedented-access-to-its-insulins-for-one-set-monthly-price 

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2019 generics - scriptsave wellrx blog image

by Haley Stenquist, PharmD Candidate Class of 2019
The University of Arizona College of Pharmacy

A new group of generic medications are hitting the prescription drug market in 2019. At ScriptSave, we get a lot of questions about generic medications vs. brand name prescription drugs. “A” rated generics meet the same quality standards as brand name prescription drugs and so they provide the same medical benefits. A drug that is “A” rated by the FDA as a generic equivalent contains identical active ingredients as the brand name drug, the same dosage as the brand name drug, and delivers the same concentrations of drug to the bloodstream within the same amount of time. So what are the differences and what’s coming to a pharmacy near you?

Are Generic Drugs the Same as Brand Name?

Yes, generic drugs are “copies” of the brand name medication that was developed by a company other than the one that originally brought the branded medication to market. Generic drugs are available for a fraction of the price of brand name medications, so consumers are naturally eager for the generics to hit the market. Per the FDA guidelines, a generic drug application must first display the following parameters:

  • The generic drug is “pharmaceutically equivalent” to the brand
  • The manufacturer is capable of making the drug correctly
  • The manufacturer is capable of making the drug consistently
  • The “active ingredient” is the same as that of the brand
  • The right amount of the active ingredient gets to the place in the body where it has effect
  • The “inactive” ingredients of the drug are safe
  • The drug does not break down over time
  • The container in which the drug will be shipped and sold is appropriate
  • The label is the same as the brand-name drug’s label
  • Relevant patents or legal exclusivities are expired2

How Long Does It Take for a Drug to Become Generic?

After an application for a patent of a new drug is filed with the United States, it is granted patent exclusivity for 20 years.  The path to generic drugs coming to market was made cheaper, easier, and faster after the introduction of the Drug Price Competition and Patent-Term Restoration Act of 1984 or known as the Hatch-Waxman Act. This allowed companies to submit an abbreviated new drug application (ANDA). About one year before the expiration of the patent drug, companies that are wanting to manufacture the generic drug will submit the ANDA to the FDA. Generally, after that patent has expired and the ANDA is approved, a generic counterpart can be introduced into the market.1

First Generic Drug Approvals for 2019

Currently, the FDA has approved 16 first-time generics in 2019 between different manufacturers (each manufacturer must submit their own ANDA). These include:

  • pyridostigmine bromide syrup—Mestinon Syrup
    • Improves muscle strengths in patients with myasthenia gravis
    • Novitium Pharma LLC—03/08/2019
  • levofloxacin ophthalmic solution, 1.5%—Iquix Ophthalmic Solution
    • Treatment of corneal ulcer caused by certain bacteria
    • Micro Labs Limited, India—02/27/2019
  • deferiprone tablets, 500mg—Ferriprox Tablets
    • Treatment of transfusional iron overload due to thalassemia syndromes
    • Taro Pharmaceuticals Industries Limited—02/08/2019
  • sevelamer hydrochloride tablets, 400mg, 800mg—Renagel Tablets
    • Control of serum phosphorus in patient with chronic kidney disease
    • Glenmark Pharmaceuticals Limited—02/08/2019
  • levomilnacipran extended-release capsules, 20mg, 40mg, 80mg, 120mg—Fetzima
    • Treatment of major depressive disorder (MDD)
    • Amneal Pharmaceuticals Company GmbH—02/04/2019
  • acyclovir cream, 5%—Zovirax Cream
    • Treatment of recurrent cold sores in immunocompetent patients over 12 years of age
    • Perrigo UK FINCO Limited Partnership—02/04/2019
  • Wixela Inhub (fluticasone propionate and salmeterol inhalation powder, USP) 100mcg/50mcg, 250mcg/50mcg, 500mcg/50mcg—Advair Diskus
    • Treatment of asthma in patient over 4 years of age and COPD maintenance (250mcg/50mcg)
    • Mylan Pharmaceuticals Inc.—01/30/2019
  • sirolimus oral solution, 1 mg/mL—Rapamune
    • Prophylaxis of kidney organ rejection in patient over 13 years of age
    • Novitium Pharma LLC—01/28/2019
  • vigabatrin tablets USP, 500mg—Sabril Tablets
    • Treatment of refractory complex partial seizures (CPS) in patients over 10 years of age that have failed multiple alternative treatments
    • Teva Pharmaceuticals USA, Inc.—01/14/2019
  • ingenol mebutate gel, 0.05%, 0.015%—Picato Gel
    • Treatment of topical acne
    • Perrigo UK PINCO Limited Partnership—01/07/2019 (0.015%) and 01/09/2019 (0.05%)
  • lurasidone hydrochloride tablets, 20mg, 40mg, 60mg, 80mg, 120mg—Latuda Tablets
    • Treatment of schizophrenia and depressive episodes associated with bipolar disorder in adults
    • Torrent Pharmaceuticals Limited, Accord Healthcare Inc., Lupin Limited, InvaGen Pharmaceuticals, Inc., Amneal Pharmaceuticals Company GmbH—01/03/20193

Newest Generics of 2019

  • As of 03/12/2019, the FDA approved a new generic of Diovan (valsartan) among the vast recalls from multiple manufacturers, this was granted to Alkem Laboratories Limited.4
  • Lannett announced FDA approval for aspirin and extended-release dipyridamole capsules, 25mg/200mg—Aggrenox Capsules for secondary prevention of stroke and transient ischemic attacks (TIA) on 03/27/2019.5

Forecasted Generics for the Remainder of 2019

The Impact of Generics

It is a long, grueling process for a brand name medication to finally be released to the market as a generic, taking in excess of 20 years. Generic medications are instrumental in helping alleviate the financial burden of prescription medication costs in patients. Each year, the effect continues to grow. In the first quarter 2019, there is already a large impact with new generic medications coming to market. This impact is forecast to continue throughout the year, especially with the possibility of heavy hitters such as Lyrica and Restasis.

References:

  1. “S.1538 – 98th Congress (1983-1984): An Act to Amend the Federal Food, Drug, and Cosmetic Act to Revise the Procedures for New Drug Applications, to Amend Title 35, United States Code, to Authorize the Extension of the Patents for Certain Regulated Products, and for Other Purposes.” gov, 24 Sept. 1984, www.congress.gov/bill/98th-congress/senate-bill/01538.
  2. Center for Drug Evaluation and Research. “Generic Drugs – What Is the Approval Process for Generic Drugs?” U S Food and Drug Administration Home Page, Center for Drug Evaluation and Research, www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/genericdrugs/ucm506040.htm .
  3. Center for Drug Evaluation and Research. “First Generic Drug Approvals.” U S Food and Drug Administration Home Page, Center for Drug Evaluation and Research, fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/DrugandBiologicApprovalReports/
    ANDAGenericDrugApprovals/default.htm
    .
  4. Office of the Commissioner. “Press Announcements – FDA Provides Update on Its Ongoing Investigation into ARB Drug Products; Reports on Finding of a New Nitrosamine Impurity in Certain Lots of Losartan and Product Recall.” U S Food and Drug Administration Home Page, Office of the Commissioner, fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm632425.htm.
  5. “Generic Drug for Stroke Prevention Granted FDA Approval.” Pharmacy Times, pharmacytimes.com/news/genericdrug-granted-fda-approval.
  6. “Pipeline Report Generic Drugs .” Welldynerx. welldynerx.com/content/uploads/2019/02/Generic-Drugs-Feb-2019-2-12-19.pdf.
  7. “Upcoming Generic Drugs.” Corporate Pharmacy Services, corporatepharmacy.com/page/upcoming_generic_drugs.

 

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hepatitis c medications image - scriptsave wellrx blog

by Jamie L. Voigtmann, PharmD Candidate 2019
Saint Louis College of Pharmacy

In 2014, approximately 4 million people in the United States were infected with hepatitis C virus (HCV).1 According to the Centers for Disease Control and Prevention (CDC), acute HCV infections reported in the United States increased approximately 3.5 times from 2010-2016 (from 850 to 2,967 cases).2 The speculated reasons for this massive increase have been due to increased intravenous drug use (IVDU) as well as more specific & sensitive testing.

There are six genotypes of HCV that have been identified; but of these six, only three make up 97% of HCV infections in the United States.1 These three genotypes include Type 1 (both subtypes a & b), Type 2, and Type 3. HCV was initially discovered in 1989 and since then, a search for a cure has become imminent as HCV plays a major role in the development of chronic liver disease, cirrhosis, hepatocellular carcinoma, and commonly ends in the need for liver transplantation.3

Hepatitis Medications Today

Multiple medications have been proven to treat and/or cure of HCV. A cure is defined as a sustained virologic response (SVR) resulting in an undetectable HCV RNA, 12-24 weeks after treatment is completed.1 In the past, a medication called interferons were used to boost the immune system and attack HCV to defend the body; but in the 2017 AASLD/IDSA Guidelines, interferons are no longer recommended in the treatment of HCV.4 Ribavirin has also been used for acute HCV in the past, but now is only indicated for chronic cases of HCV.7 With both interferon and ribavirin, virological response did not often exceed 50%. Since 2014, four once daily HCV medications have been FDA approved for the treatment of acute HCV in naïve patients that exceed a virological response of 90% after 12 weeks of therapy.4

These more novel hepatitis medications consist of multiple drugs with differing modes of action. There are three classes of drugs that are used to treat HCV and they are called direct acting antivirals (DAA) because they directly attack the HCV genome and replication process.4 These three DAA classes include: NS3/4A Protease Inhibitors, NS5A Inhibitors, and NS5B Polymerase Inhibitors (Nucleoside & Non-Nucleoside).4 All of these medications inhibit replication of HCV in the host cell, stopping the life cycle and preventing its transmission to other host cells. Below is a picture that further explains the mechanism of action of each DAA along with each HCV drug and its corresponding DAA class.5

hepatitis c vaccinations - scriptsave wellrx blog imageDirect Acting Antiviral Classes5

  • NS3/4A Protease Inhibitors
    • Boceprevir
    • Telaprevir
    • Simeprevir
    • Asunaprevir
    • Paritaprevir
    • Grazoprevir
    • Glecaprevir
  • NS5A Inhibitors
    • Daclatasvir
    • Ledipasvir
    • Ombitasvir
    • Elbasvir
    • Velpatasvir
    • Pibrentasvir
  • NS5B Polymerase Inhibitors
    • Sofosbuvir
    • Dasabuvir

Comparing Four Novel HCV Medications6

As mentioned previously, there are four HCV medications approved by the FDA that are one pill taken once daily and can result in cure. These medications include Harvoni (ledipasvir/sofosbuvir), Zepatier (elbasvir/grazoprevir), Epclusa (velpatasvir/sofosbuvir), and Mavyret (glecaprevir/pibrentasvir). Harvoni was approved by the FDA in 2014, Zepatier and Epclusa in 2016, and finally Mavyret in 2017. This is relevant because the two more recent drugs, Epclusa and Mavyret, treat all 6 genotypes of HCV while Harvoni and Zepatier are both first line therapy for genotypes 1 and 4.7

Unlike their differing genotype coverage, side effects for all four of these medications are quite similar. The most common side effects include headache, fatigue, and nausea and the instances for these side effects are approximately 16%, 13%, and 9%, respectively. Other more severe side effects (anemia, diarrhea, insomnia, and irritability) have been reported with these medications but only in combination with interferon or ribavirin as well as with prolonged therapy between 16-24 weeks.5

Cost of Therapy

According to current HCV Guidelines, Harvoni, Zepatier, and Epclusa require 12 weeks (84 days) of therapy.7 Mavyret can be either 8 weeks (56 days) or 12 weeks of therapy depending on the patient’s baseline liver disease.7 Unfortunately, considering both the high cost of medication as well as the long duration of therapy does not allow all patient’s to receive treatment. Harvoni and Epclusa have generics available for patients, and the Brand Name options of Zepatier and Mavyret are thankfully in the same price range as the other generic options. The cost of one tablet for these medications is as follows:6

  • Harvoni:
    • Brand Name: $1,350
    • Generic: $500
  • Epclusa:
    • Brand Name: $1,050
    • Generic: $350
  • Zepatier:
    • Brand Name: $300
  • Mavyret:
    • Brand Name: $200

Because these medications are very costly, a 12-week drug treatment regimen of therapy ranges from $16,800 to $113,400. This is a problem. Many patient’s simply do not have this amount of money to spend on one prescription. This further leads to controversial discussions because as mentioned earlier, HCV plays a major role in the development of chronic liver disease, cirrhosis, hepatocellular carcinoma, and commonly ends in the need for liver transplantation.3

Fortunately, there are patient assistance programs and copay cards offered by the manufacturers of these medications which allow a minimum cost of $0 with patient assistance programs and a minimum cost of $5 for copay cards per 4-week supply. Harvoni and Epclusa are manufactured by Gilead Sciences, Zepatier is manufactured by Merck, and Mavyret is manufactured by AbbVie.

Patient assistance programs require paperwork completed by the patient as well as the prescribing physician. Copay cards only work for Brand Name medications and most commonly require private insurance as a primary payor (not government funded insurances such as Tricare, Medicare, or Medicaid). For more information, check out these websites:

If you need help affording other prescription medications, visit www.WellRx.com. Many prices are lower than insurance copay costs!

References

  1. Kohli A, Shaffer A, Sherman A, Kottilil S. Treatment of hepatitis C: a systematic review. JAMA. 2014;312(6):631-640.
  2. Centers for Disease Control and Prevention. Surveillance for viral hepatitis – united states, 2016. https://www.cdc.gov/hepatitis/statistics/2016surveillance/commentary.htm. Accessed on February 13, 2019.
  3. Chen SL, Morgan TR. The natural history of hepatitis c virus (hcv) infection. Int J Med Sci. 2006;3(2):47-52.
  4. Geddawy A, Ibrahim YF, Elbahie NM, Ibrahim MA. Direct acting anti-hepatitis c virus drugs: clinical pharmacology and future direction. J Transl Int Med. 2017;5(1): 8–17.
  5. Dugum M, O’Shea R. Hepatitis c virus: here comes all-oral treatment. Clev Clin J Med. 2014;81(3):159-172.
  6. HCV Treatments: Harvoni, Zepatier, Epclusa, & Mavyret. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. February 13, 2019.
  7. Recommendations for testing, managing, and treating hepatitis c. Joint panel from the American Association of the Study of Liver Disease and the Infectious Diseases Society of America. https://www.hcvguidelines.org. Accessed February 13, 2019.

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by Cindy Cho, PharmD Candidate Class of 2019,
The University of Arizona College of Pharmacy

When most people think of a diet that leads to poor diabetes control, they may think of a diet high in carbs and sugar. While those types of food do impact your blood sugars, consuming too many saturated fats can be an enemy against diabetes control,too. This is because a hallmark of pre-diabetes, type 2 diabetes, and worsening type 2 diabetes is insulin resistance.

Saturated Fat and Insulin Resistance

First, what is insulin? Insulin is a hormone produced by your pancreas to control your blood sugar levels. Insulin helps move the sugar from the blood into your cells for storage and energy. In other words, insulin is the key that unlocks the door of our muscle cells to let sugars in. Insulin resistance in the state of your body where insulin is not responding properly to move the sugar into the cells, which causes a rise in blood sugars as a result. The pathophysiology of insulin resistance is somewhat convoluted, but what is known is that saturated fat plays a role. It has been known since 1927 that increased consumption of fat delays the process of blood sugars going into the cells, which means that sugars hang around longer in the bloodstream.1 The results of both animal and human studies also show that a high intake of saturated fat is associated with insulin resistance and development of type 2 diabetes.2 This is because an uncontrolled state of insulin resistance leads to a higher risk of getting type 2 diabetes. People are also at higher risk of insulin resistance if they are overweight or obese.

Not All Fats are Bad

Contrary to the connotation of the word, not all fats are unhealthy. Two main sources of fat that we will focus on are saturated and unsaturated fats. Saturated fats are found commonly in animal products, such as red meats and dairy products. On the other hand, unsaturated fats come from mainly plant based sources and consists of foods like olive oil, nuts, and avocados. Studies have shown that in people with diabetes, saturated fats cause insulin resistance whereas unsaturated fats can improve insulin sensitivity.3 Because of this, the consumption of vegetables fats is favored in place of animal fats and processed grains.3 Not only are plant based foods lower in saturated fats, they are generally lower in calories and jam-packed with nutrients and fiber to nourish the body.

Ways to Improve Insulin Resistance

Lifestyle changes, particularly diet, address ones of the root causes of type 2 diabetes: insulin resistance. Following a plant-based diet can be a solution since animal products can contain a high amount of saturated fat. A plant-based diet generally includes legumes, whole grain, fruits, vegetables, and nuts, and discourages most animal products and refined foods.4 The Adventist 2 study, which included about 89,000 people extended across 50 years, demonstrated a substantial decrease in diabetes incidence in those who ate a vegetarian diet. The study also suggested that those who eat meat once or more days a week have significantly higher rates of diabetes.5 Plant-based diets also have been shown to work better in reducing blood sugars, body weight, and cardiovascular risk compared to diets that include animal-based products.6

Plant-based eating patterns, such as the DASH diet, healthy Mediterranean, and healthy vegetarian diets, have been shown to be associated with better health and lower risk for disease according to nutritional epidemiology, randomized controlled intervention trials, and most literature.7 These diets are also appropriate for the vast majority of people. Furthermore, exercise, with or without weight loss, helps improve insulin sensitivity so your body can use the insulin it naturally produces better.8 That in turn can mean lower doses of your diabetes medications, or even coming off the diabetes medications altogether, which can lower your costs on how much you spend on diabetes care. It is shown that after adjusting for population age and sex differences, the average medical expenses for people living with diabetes were about 2.3 times high than people who do not have diabetes.9

Dangers of Uncontrolled Blood Sugars

Controlling blood sugars is important because the longer a high amount of glucose is in the bloodstream, the more damage it can cause to your blood vessels, nerves, and tissues. Therefore, it is very important to have your doctors check your feet, eyes, and kidneys at least yearly if you have diabetes. People with uncontrolled blood sugars are also at higher risk for cardiovascular complications like heart attacks and strokes and are more prone to infections.10 Plant-based diets have demonstrated improvements in blood sugar control, which can possibly reduce or prevent the incidence of long-term complications of type 2 diabetes.

What You Can Do

Talk to your doctor or dietitian about eating more plant-based foods. It may also be easier to think of changes to what you eat as a lifestyle choice instead of as a diet. Small changes to the foods you consume can make a big impact on your health in the long run. Eating healthier doesn’t mean it has to be more expensive either. Shopping for produce in season, or even visiting your local 99 cent store that carries groceries can be helpful methods to save you money and keep you healthy too. You don’t have to be vegan to experience the benefits of a plant-based diet either. Any steps you take to adding more plant-based foods onto your plate can improve your blood sugars.5

Key Takeaways

To summarize, striving to increase the amount of plant-based foods you eat, minimize consumption of animal-based foods, increase your physical activity, along with taking your diabetes medications regularly, can make a positive impact on your blood sugars and overall health!

References:

  1. Dietary Factors That Influence The Dextrose Tolerance Test, J. Shirley Sweeney MD, Archives of Internal Medicine, December 1927
  2. ARIC Study Investigators; Plasma fatty acid composition and incidence of diabetes in middle-aged adults: the Atherosclerosis Risk in Communities (ARIC) Study, The American Journal of Clinical Nutrition, Volume 78, Issue 1, 1 July 2003, Pages 91–98, https://doi.org/10.1093/ajcn/78.1.91
  3. Rachek, L. (2014). Progress in Molecular Biology and Translational Science (pp. 267-292). Elsevier.
  4. McMacken M, Shah S. A plant-based diet for the prevention and treatment of type 2 diabetes. J Geriatr Cardiol. 2017;14(5):342-354.
  5. Tonstad, S., Stewart, K., Oda, K., Batech, M., Herring, R., & Fraser, G. (2013). Vegetarian diets and incidence of diabetes in the Adventist Health Study-2. Nutrition, Metabolism and Cardiovascular Diseases,23(4), 292-299. doi:10.1016/j.numecd.2011.07.004
  6. Trapp, Caroline B., and Neal D. Barnard. “Usefulness of Vegetarian and Vegan Diets for Treating Type 2 Diabetes.” Current Diabetes Reports, vol. 10, no. 2, 2010, pp. 152–158., doi:10.1007/s11892-010-0093-7.
  7. Laddu, D., & Hauser, M. (2019). Addressing the Nutritional Phenotype Through Personalized Nutrition for Chronic Disease Prevention and Management. Progress In Cardiovascular Diseases, 62(1), 9-14. doi: 10.1016/j.pcad.2018.12.004
  8. Duncan GE, Perri MG, Theriaque DW, Hutson AD, Eckel RH, Stacpoole PW: Exercise training, without weight loss, increases insulin sensitivity and postheparin plasma lipase activity in previously sedentary adults. Diabetes Care 26:557–562, 2003
  9. Economic Costs of Diabetes in the U.S. in 2017. (2018). Diabetes Care, 41(5), 917-928. doi: 10.2337/dci18-0007
  10. American Diabetes Association. 2019 Standards of Medical Care in Diabetes. http://care.diabetesjournals.org/content/42/Supplement_1. Published December 17, 2018. Accessed December 17, 2018.

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by Cindy Cho, PharmD Candidate Class of 2019,
The University of Arizona College of Pharmacy

In short, no. You cannot get pneumonia from the pneumonia vaccine. With all of the news coverage about vaccines, it is important to equip yourself with the knowledge on what vaccines are, how they work, and why they don’t cause disease, so you can make an informed decision on your health.

What is a vaccine?

A vaccine is a substance that contains very small amounts of weakened or dead germs to stimulate your body to produce immunity against certain diseases. Before the invention of vaccinations, the only way a person’s body can gain immunity to certain diseases is to (hopefully) survive an infection from the germ that causes the disease. For example, if a person gets pneumonia, an infection of the lung, from a certain germ and survives, their body will remember that specific germ if it were to come across it again. By remembering the germ, the body can protect itself and fight off the infection more efficiently to prevent sickness in the future. Vaccines provide a similar immune system response to help the body create immune system cells to remember disease-causing germs to protect your body, but the best part is that vaccines don’t come with the risks of getting the actual disease or its associated complications. Some vaccines can provide protection against multiple types of germs that cause the same disease to better protect against epidemics.1

What are pneumonia vaccines?

Now that you understand how vaccines work, let’s talk about the pneumonia vaccines! There are two pneumonia vaccines intended for use in the United States by the Food and Drug Administration (FDA), which includes the pneumococcal conjugate vaccine (PCV13 or Prevnar 13) and the pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax 23).2 Both of these pneumonia vaccines contain inactivated, or dead, germs. Because these vaccines contain dead germs, they cannot replicate in the body or cause disease.1 The differences between the two pneumonia vaccines are shown below:

  • Prevnar 13: this is a conjugated vaccine, which means it contains a protein that is joined to a part of dead bacteria to improve the protection the vaccine provides. Doctors give this vaccine to children at 2, 4, 6, and 12 through 15 months old. Young children need multiple doses of this vaccine to boost their protection since their immune system is not yet mature. Adults who need this vaccine only get a single dose. The vaccine has 13 in its name because it helps protect against 13 types of pneumococcal bacteria that most commonly causes serious infections in children and adults.2
  • Pneumovax 23:  this is a polysaccharide vaccine, which means it is made to look like the surface of certain bacteria in order to help the body build protection against that germ. Doctors give a single dose of this vaccine to people who need it. CDC recommends one or two additional doses for people with certain chronic medical conditions. The vaccine has 23 in its name because it helps protect against serious infections caused by 23 types of pneumococcal bacteria.2

 So, who needs the pneumonia vaccines?

Great question! Pneumonia disproportionately affects the young, the elderly, and the immunocompromised, so the CDC recommends these vulnerable patient populations to receive the pneumonia vaccines.3 The CDC created an immunization schedule that outlines when the two pneumonia vaccines should be received.

CDC recommends vaccination with the pneumococcal conjugate vaccine (PCV13 or Prevnar 13®) for:2

  • All children younger than 2 years old
  • All adults 65 years or older
  • People 2 through 64 years old with certain medical conditions*

CDC recommends vaccination with the pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax23®) for:2

  • All adults 65 years or older
  • People 2 through 64 years old with certain medical conditions*
  • Adults 19 through 64 years old who smoke cigarettes

*Certain medical conditions such as: chronic heart disease, lung disease, liver disease, diabetes, HIV, or certain cancers warrant some adults to receive the pneumonia vaccines before the age of 65.4

What are the side effects of the pneumonia vaccines?

Reactions to the pneumonia vaccine can occur, such as cold-like symptoms, but it is important to realize that those are adverse reactions to the vaccine and not pneumonia itself. Talk to your doctor if you have allergies to any ingredients in vaccines. Below are common adverse reactions to the pneumonia vaccines:

Mild side effects reported with Prevnar 13 can include:2

  • Reactions where the shot was given
    • Redness
    • Swelling
    • Pain or tenderness
  • Fever
  • Loss of appetite
  • Fussiness (irritability)
  • Feeling tired
  • Headache
  • Chills

Mild side effects reported with Pneumovax23 can include:2

  • Reactions where the shot was given
    • Redness
    • Pain
  • Fever
  • Muscle aches

Why are the pneumonia vaccines important?

Vaccines, like the pneumonia vaccines, can prevent or decrease the severity of diseases. Unfortunately, around 50,000 people die from pneumonia in the United States each year.3 It is passed along through airborne droplets, such as from a cough or sneeze, so it is a highly contagious infection.2 It is crucial to receive the pneumococcal vaccine to not only protect yourself but to protect your loved ones around you. Especially if you have a breathing condition like asthma or COPD, it is important to have the pneumonia vaccines to prevent respiratory infections that can potentially make your breathing worse. Talk to your provider or local pharmacy if you are due for your pneumonia vaccine today.

References:

  1. Principles of Vaccination. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/pubs/pinkbook/prinvac.html. Published September 8, 2015. Accessed February 14, 2019.
  2. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/vpd/pneumo/public/index.html. Published December 6, 2017. Accessed February 14, 2019.
  3. Top 20 Pneumonia Facts (2018). American Thoracic Society.  https://www.thoracic.org/patients/patient-resources/resources/top-pneumonia-facts.pdf. Accessed February 14, 2019.
  4. Recommended Adult Immunization Schedule for ages 19 years or older, United States, 2019. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#note-pneumo. Published January 2019. Accessed February 14, 2019.

 


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by Jamie L. Voigtmann, PharmD Candidate 2019
Saint Louis College of Pharmacy

There are many aspects in life that can decrease prescription fill rates. This in turn causes medication non-adherence, where patients are unable to take their medications regularly as prescribed by a physician. It’s a common and costly problem across America.

What Prevents Patients from Filling Prescriptions?

Barriers to medication adherence include lifestyle preferences, fear or uncertainty about the effectiveness of new medications or adverse reactions, The complexity of instructions and or drug regimens, personal beliefs, and insufficient funds also come into play.1 Patients who have insufficient funds to pay for medications include, not only decreased socioeconomic status, but also all patients that qualify as low-income based on age, gender, race, location, and family size. Patients who have financial restrictions will commonly delay prescription refills, as well as subsequent copays, by splitting pills, taking pills every other day, or even discontinuing medications on their own. This is because many chronic conditions require multiple medications for treatment and many medications are expensive even with insurance.1

The Low-Income Populations Includes Elderly Patients

As mentioned previously, low-income patients not only include race, location, and family size, but also age. As patients become ≥ 65 years old they are most likely dependent on Medicare for health insurance coverage, since it is offered through the government. Elderly patients who experience decreased prescription fill rates have been associated with having increased out-of-pocket costs with prescription medication coverage, lower net worth, and lower household incomes.2 This is important to consider because as patients age their health often declines, indicating more need for medications. It is also imperative to think about this aspect as many Baby Boomers fall into this category, increasing the number of patients sharing Medicare benefits.

Which Types of Medications Do Low-Income Patients Struggle To Get?

A common misconception is that patients with low-income only have trouble affording newer novelty medications, such as HIV, Hepatitis C, and oncology medications. With these types of medications, many patients including the middle and upper economic classes struggle to pay for the medications due to the outstanding drug cost dictated by the manufacturers. Low-income patients also struggle with common health conditions such as asthma, diabetes, and high cholesterol. Patients who are in a lower socioeconomic class experience significantly less control over their asthma and commonly experience increased exacerbations compared to patients who belong to a higher economic class.3

When considering Type-2 Diabetes Mellitus, patients with high-incomes had increased compliance to treatment regimens including diet, exercise, and medications.4 The high-income patient’s also checked their A1c more often and were associated with higher self-care ability.4 Finally considering cholesterol medications, a recent study showed that low-income patients were willing to give up their cholesterol medications if a copay was present because the benefits are not commonly felt unlike insulin for diabetes or lisinopril for increased blood pressure.5

Low-Income vs. High-Income Prescriptions

It is interesting to realize what types of medications low-income patients are filling at the pharmacy, compared to high-income patients. According to The New York Times, high-income patients receive more cosmetic medications to treat baldness, erectile dysfunction, wrinkles, and eyelashes.6 These patients were also more likely to purchase medications to treat mental health.6 They also had more prescriptions for birth control pills due to a consistent prescription from a regular doctor.6 Medications that are more commonly received by low-income patients include HIV and Hepatitis C, most likely due to lack of education in transmission and poor access to healthcare.6

Lowering Overall Drug Costs

Overall, the relationship between income and prescription fill rates at the pharmacy is much more complicated than low-income patients having decreased prescription adherence.6 Different patients are more likely to develop certain diseases or illnesses that would increase healthcare costs. Patients also differ on when they seek medical attention, resulting in a significant cost even before a physician writes a prescription.6 Regardless of income, it’s important to treat patients with as few medications as possible while still treating chronic conditions to help lower overall drug costs for all patients.

References:

  1. Mishra SI, Gioia D, Childress S, Barnet B, Webster RL. Adherence to medication regimens among low-income patients with multiple comorbid chronic conditions. Health Soc Work. 2011; 36(4): 249–258.
  2. Zivin K, Ratliff S, Heisler MM, Langa KM, Piette JD. Factors influencing cost-related nonadherence to medication in older adults: a conceptually based approach. Value Health. 2010; 13(4): 338-45.
  3. Bacon SL, Bouchard A, Loucks EB, Lavoie KL. Individual-level socioeconomic status is associated with worse asthma morbidity in patients with asthma. Respir Res. 2009; 10: 125.
  4. Habib F, Durrany AM. Effect of age and socio-economic status on compliance among type 2 diabetic patients. Curre Res Diabetes & Obes J. 2018; 7(3): 555714.
  5. Watanabe JH, Kazerooni R, Bounthavong M. Association of copayment with likelihood and level of adherence in new users of statins: a retrospective cohort study. J Manag Care Pharm. 2014; 20(1): 43–50.
  6. Quealy K, Sanger-Katz M. The prescription drugs that rich people buy. The New York Times. February 7, 2019. https://www.nytimes.com/2019/02/07/upshot/income-strong-predictor-drug-purchases-serious-diseases.html. Accessed March 9, 2019.

 


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by Jamie Voigtmann, PharmD Candidate

Your body has a number of glands, but the thyroid gland is the small gland at the base of your neck that makes hormones to regulate your metabolism. This impacts your body’s metabolic rate (how you burn calories) as well as heart and digestive function, mood, and more. But what happens if something impacts the thyroid?

How Does the Thyroid Work?

First, the hypothalamus releases TRH which activates the pituitary to release TSH.1 This in turns activates the thyroid to produce and release T4 and T3 into the body but at an approximately 14:1 ratio, with T4 being 14 and T3 being 1.2 Then T4 and T3 bind to proteins and travel to other tissues in the body. There, the T4 will be changed to T3 by removing one molecule iodine.1 This is important because T3 is the active thyroid hormone unlike T4, which is inactive; T3 allows the body to control metabolism, temperature, and heart rate.1 Finally, the T4 and T3 in the body cause a negative feedback loop to the hypothalamus and pituitary. This can make the hypothalamus and the pituitary produce more hormones when T4 and T3 are low or produce less hormones when T4 and T3 are high.1

thyroid process - diagram - scriptsave wellrx blog image

What are the Causes and Symptoms of Hypothyroidism?

Hypothyroidism is most commonly caused by an autoimmune disorder which is when the body’s immune system attacks its own tissues rather than infections. Because of this, the autoimmune disorder causes a decreased amount of T4 and T3 being made.3 Other causes, although unlikely, include a low amount of iodine through diet, removal of the thyroid, radiation therapy for cancer treatment, and certain drugs (amiodarone, lithium, iodine, and rifampicin). Signs and symptoms of hypothyroidism are commonly dry skin, sensitivity to the cold, constipation, poor memory, fatigue, weight gain, puffiness around the eyes, and a slowed heart rate. These signs and symptoms are highly suggestive of hypothyroidism, but alone cannot diagnose this condition. Diagnostic measures most commonly include high TSH levels and low T4 levels.

What are the Treatment Options?

Synthetic T4 Replacement

The most common T4 replacement medication is levothyroxine, and it is recommended as the first treatment option for hypothyroidism.2 Although it is not the active form (T3), it can be made into T3 in the body’s tissues and is generally well-tolerated by many patients. Benefits of levothyroxine include normalizing thyroid function, once daily dosing, few side effects, low cost, and safety in pregnancy.2 But one thing that is very important and specific about levothyroxine is how it is taken. Levothyroxine must be taken on an empty stomach so that it can be appropriately absorbed by the body.3 This is easiest to accomplish in the morning right after waking up, at least 30 minutes before eating breakfast; but, it is possible to take levothyroxine before bedtime as long as it is 4 hours after eating.2 Levothyroxine must also be taken separately (approximately 4 hours before or after) from products such as calcium, iron, and antacids that contain aluminum or magnesium in order to optimize its absorption and efficacy.3 These products are commonly in the form of vitamins or supplements, as well as Tums, Mylanta, Milk of Magnesia, Alka-Seltzer, Maalox, and Rolaids.

Synthetic T3 Replacement

Hypothyroidism therapy also can consist of liothyronine, which is the active form of thyroid hormone: T3. Liothyronine has some disadvantages for the treatment of hypothyroidism when compared to levothyroxine. Currently it is only approved for once daily dosing, but this does not mimic the true release pattern of T3 from the thyroid.4 One small, randomized study showed an improvement in weight loss and decreased lipid profile compared to levothyroxine, but only if liothyronine was taken three times daily.4 Because of this, liothyronine is not currently recommended over levothyroxine because it’s once daily dosing does not provide better results.2 But, it is possible an extended-release formulation of liothyronine can prove to be clinically beneficial in the future.2 Overall, liothyronine has some disadvantages for the treatment of hypothyroidism when compared to levothyroxine such as unknown dosing schedule for best effect and increased cost.

Synthetic Combination Therapy

Some medications used to treat hypothyroidism have a mixture of T4 and T3. Unfortunately, there are many differing studies with different T4:T3 ratios and have unclear results.3 But, many of these clinical trials do not show benefit of T4 and T3 over T4 alone (levothyroxine).2 It has been reported that few patients taking levothyroxine alone still experienced signs and symptoms of hypothyroidism, although their TSH level was corrected to its normal value; and it has been discussed that these patients could potentially benefit from combination T4 and T3 therapy, but evidence is limited.2,3 Overall, levothyroxine remains the standard of care when treating hypothyroidism, with combination therapy of T4 and T3 only being considered after a patient tries levothyroxine and it does not work effectively.2

Natural Desiccated Therapy

This type of hypothyroid medication is also a combination of T4 and T3 but instead of being synthetic (made from chemicals), it is naturally obtained. This is because it is derived from thyroids of animals, particularly domesticated pigs.2,5 The common name of this type of medication is Armour Thyroid.5 The T4:T3 ratio is always 4:1, unlike the natural body’s ratio of 14:1.2 This can lead to an increased level of T3 at once and can result in adverse effects including increased heart rate and anxiety.2 But, there was one minor study completed that reported results of patients preferring desiccated therapy over levothyroxine due to decreased symptoms of hypothyroidism.5 Because this study was small, did not use appropriate questionnaires, and did not assess safety, it does not warrant its use over levothyroxine for hypothyroidism.2 Natural desiccated therapy falls into the same category of combination therapy . It should only be considered for patients who have tried levothyroxine and did not correct his/her thyroid function.2

References

  1. Yen PM. Physiological and molecular basis of thyroid hormone action. Physiol Rev. 2001; 81(3): 1097-1142.
  2. Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid. 2014; 24(12): 1670–1751.
  3. Chakera AJ, Pearce SHS, Vaidya B. Treatment for primary hypothyroidism: current approaches and future possibilities. Drug Des Devel Ther. 2012; 6: 1–11.
  4. Celi FS, Zemskova M, Linderman JD, et al. The pharmacodynamic equivalence of levothyroxine and liothyronine. a randomized, double blind, cross-over study in thyroidectomized patients. Clin Endocrinol (Oxf). 2010; 72(5): 709–715.
  5. Hoang TD, Olsen CH, Mai VQ, Clyde PW, Shakir MK. Desiccated thyroid extract compared with levothyroxine in the treatment of hypothyroidism: a randomized, double-blind, crossover study. J Clin Endocrinol Metab. 2013; 98(5): 1982-1990.
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ScriptSave WellRx app pill refill reminders - blog image

by Dan Johnson, RPh and PharmD,
Vice President of Network Strategy, ScriptSave

The risk for medication interactions dramatically increases as patients take multiple drugs. ScriptSave’s own Dr. Dan Johnson recently had an article published on the Living Better 50 website on steps you can take to protect yourself from dangerous drug interactions.

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More than 2 million patients are hospitalized every year after they inadvertently mix their prescription drugs, while another 100,000 die annually. And the statistics get worse with age. The chance of an adverse drug reaction for people over 50 jumps 33 percent versus younger people.

Even over-the-counter medications and supplements can incite dangerous health risks.For example, patients with high blood pressure should avoid taking cough medicines with decongestants and should consult their pharmacist on the best options to seek relief from cold and flu symptoms. Patients taking prescriptions for depression, chest pain, ADHD, gout, arthritis and other common ailments can frequently be at more risk for dangerous reactions if they don’t keep track of their prescription regimen.

How Can Patients Protect Themselves From Drug Interactions?

  1. Ideally, patients should go to the same pharmacist and discuss any other prescriptions they may be taking. This conversation should include over-the-counter and supplements – in addition to any medications.
  2. Be aware of how common household foods can impact medications. People who take Lipitor or Zocor with grapefruit juice may experience muscle pain and other side effects.
  3. As we age, our bodies metabolize drugs slower and at different rates. Because of this, patients should monitor any reactions to any new or existing drugs.
  4. There are many user friendly, free mobile apps that keep track of a patient’s regimen – alerting them to potential dangerous interactions. ScriptSave WellRx has a new “Virtual Medicine Cabinet” that warns patients of hazardous drug interactions. It also sends reminders when patients need to take their next pill, or need a refill.

Read the full story on living50better.com.

 

————–Addendum (13 Mar, 2019)————–

…and check out what Dr Max Gomez had to say on CBS News, including an interview with ScriptSave’s Dr Dan Johnson.

 

 


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