Do we have better meds for weight loss now? September brought news of two new weight loss medications, Contrave and Saxenda. Funny thing is both of them are drugs used for other indications, now approved for weight loss. So these meds have been around, in one form or another. These two will join Belviq, Qsymia, and orlistat (available over the counter as Alli).
The newest drug available for weight loss is Contrave which is a combination of two older drugs: bupropion and naltrexone. Contrave was first rejected in 2011 but the company did more safety studies to solidify cardiac safety and now the FDA has approved it.
What’s the story with Contrave?
- Half of it is a drug we know well: bupropion is the generic version of Wellbutrin. Bupropion is used for the treatment of anxiety and depression, and tobacco cessation.
- The other half of Contrave is naltrexone, which has been used to treat people with alcohol or opioid dependence and has been found to suppress appetite as a “positive” side effect.
- Contrave is indicated for adults with a body mass index (BMI) of 30 or higher and adults with a BMI of 27 or higher with one or more weight-related conditions, including hypertension, type 2 diabetes, or high cholesterol.
What about Saxenda?
- This is interesting. Saxenda is the injectable diabetes drug Victoza, just at a higher dose.
- An FDA advisory panel has just voted 14 to 1 in favor of this injectable diabetes drug (liraglutide) for the treatment of obesity.
- Victoza has been available in the US since 2010 for the treatment of type 2 diabetes and in previous blogs I’ve explained how it works. Saxenda is the brand name for the obesity treatment, which is basically Victoza at a higher dose—3.0 mg, in contrast to 1.2 or 1.8 mg for diabetes.
- This would be a no brainer for someone with both diabetes and obesity.
It has been slim pickings with respect to medications for weight loss, so here are two more to think about.
A 2014 comes to a close, we should be thinking about what to expect for 2015. The start of a new year is a time for new challenges, new goals, and inevitably, a new prescription formulary.
What does this mean for you?
Express Scripts and Caremark have decided to remove certain diabetes medications from their national preferred formulary and provided a list of covered alternatives. For more information and the full list of excluded drugs, see our post on the 2015 formulary changes.
What if my prescription is on the exclusion list?
- First, confirm whether Express Scripts, Caremark, or another PBM manages your pharmacy benefits. Many drugs that aren’t covered by one company are covered by the other.
- Next, check with your plan to be sure that your prescription won’t be covered. Not all plans use the national formulary, and yours may vary.
- If your prescription won’t be covered, it doesn’t hurt to try appealing. Ask your doctor to write a note, and ask your plan for information on how to appeal for coverage. This is more likely to work in cases where you’ve tried the other options and they don’t work for you, or there’s a medical reason why you aren’t able to take the covered alternative.
- Finally, get in touch with your doctor and explain that your current prescription will no longer be covered by your insurance in 2015. Show thm the list of preferred alternatives. You and your doctor can decide which alternative to try, or whether to explore other options for coverage.
So what are the changes for diabetes coverage in 2015?
Caremark 2015 Formulary Change
Good news here—the suggested alternative OneTouch is the main brand of glucometer kit and test strips I see dispensed and preferred by a lot of pharmacies. OneTouch is often dispensed your doctor doesn’t specify and just writes a prescription for “glucometer and strips” due to the reliability and familiarity of pharmacists with Lifescan’s OneTouch products.
The problem with removing Accu-Chek from the 2015 formulary? A lot of patients have a hard time embracing change. The One Touch glucometer and strips are basic and easy to learn though, which is an advantage. If you need help or just a refresher on how to use OneTouch meters and strips, Lifescan offers support that can be accessed here.
Reminder: in 2014, Caremark also removed ALL Humalog and Humlin insulins from their national formulary (with the exception of Humulin U-500). The suggested alternatives are Apidra, Novolog, and Novolin insulins. I see more patients on Humalog rather than Novolog, though both work the same way in the body. Questions about conversions between the different types of insulin? Check out these links for help: part one and part two.
Express Scripts 2015 Formulary Change
The only difference this year is that the recently approved Tanzeum injection is excluded. Tanzeum was approved by the FDA on April 15, 2014 as a once-weekly injection similar to Bydureon. I do not think the exclusion of Tanzeum will affect many patients, especially since it is newly approved and Bydureon, a suggested alternative, is a comparable once-weekly option.
Reminder: in 2014, Express Scripts also removed Victoza from their national formulary. Victoza has been gaining a lot of popularity in the diabetic community and among prescribers. More patients are using Victoza injections than the covered alternatives Byetta or Bydureon. Victoza is unique because it is a once daily injection rather than twice daily like Byetta. One positive though—Bydureon, the other alternative, is only injected once weekly.
One million Americans get shingles, aka herpes zoster, each year. Early treatment is key. In addition to antiviral medications to shorten the duration of your shingles outbreak, you need to know about the dreaded—and most common—complication of shingles, which will occur in 20% of cases . . . post-herpetic neuralgia.
Shingles is a viral disease caused by the reactivation of varicella zoster virus that had remained quiet in the sensory ganglia since you were first exposed to chickenpox. A vaccine against herpes zoster exists for everyone over 50; it’s called Zostavax. That’s your best way to keep from getting shingles.
I have shingles, now what?
- Repeat after me: call your doctor right away, within 72 hours. The earlier the better.
- Antiviral agents, preferably valacyclovir or famciclovir, should be started within 72 hours of onset to reduce the severity of the infection, the duration of the skin lesions, and the intensity of acute pain.
- Valacyclovir 1000 mg three times a day for 7 days works better than acyclovir in head to head studies. Valacyclovir also has better bioavailability so you only take it three times daily instead of five times a day like acyclovir.
- Famciclovir (500 mg three times daily) for 7 days is equivalent to valacyclovir for healing of shingles lesions and reducing pain from the lesions.
- Acyclovir 800 mg five times a day for 7 days will help your lesions crust over faster and help reduce pain but not as well as valacyclovir.
- Know that topical antivirals (Zovirax ointment for example) will do nothing for the rash from shingles.
I have pain from my shingles rash, what helps?
- Your next step is an opioid medication like oxycodone or hydrocodone/acetaminophen for short term treatment of your painful rash.
- What is interesting is that adding a steroid, prednisone, to an antiviral does help for acute pain but does not help lesions heal faster and does not help prevent post-herpetic neuralgia which we talk about next.
My rash is gone, but I still have pain: treatment of post-herpetic neuralgia.
- Post-herpetic neuralgia is the most common complication of shingles and occurs in 1/5th of people who get shingles. It is from damage to the nerve fibers.
- FDA approved first line therapies for treatment of post-herpetic neuralgia are: gabapentin (Neurontin), Horizant (an extended-release form of gabapentin which is brand name only and expensive), Lyrica and a lidocaine 5% patch.
What worked for you?
Kids are back in school, the weather is cooling down—fall is here. Unfortunately, along with the great parts of the season (like pumpkin-flavored everything and football) comes everyone’s least favorite part: germs.
There is no better time than right now to protect yourself and your loved ones from this season’s flu virus. Many local pharmacies already have this year’s flu vaccinations in stock, so keep an eye out!
Isn’t it too early for a flu shot?
NO! Flu season usually peaks in the US in the colder months of December or January, but it can begin as early as October.
How long does it take for the flu shot to start to work?
It take up to 2 weeks for the vaccination to fully protect you against the flu. That’s why the Centers for Disease Control and Prevention (CDC) recommends getting the vaccinated as soon as it becomes available, or at least by the month of October.
How long will my flu shot last?
In most healthy individuals the flu shot should last you the entire flu season.
However, this can be different from person to person due to the variation in the amount of flu antibodies we each produce from the vaccination.
Do I have choices for how to get the flu vaccine?
Yes! The flu vaccine is available in the following forms:
- Intramuscular injection. This is the most common, the typical flu shot.
- Nasal spray. This may be easier to take, especially if you or your child have an aversion to shots. Be aware that there may be more flu-like side effects and more restrictions on who can use this form of the vaccine.
- Intradermal injection. Another possibility for those who don’t like needles, this vaccine has a much smaller needle that injects the vaccine into the skin instead of the muscle. This one is only available for adults ages 18 – 64.
Most pharmacies stock the intramuscular injection, which also comes in a few variations:
- Trivalent: Most typical flu shots are trivalent. These protect against three major flu strains.
- Quadrivalent: These protect against four major flu strains. This year, the nasal spray will also be quadrivalent.
- High Dose (HD): High dose shots are the first choice for anyone over the age of 65. These also protect against three major flu strains, but have a higher dose for a better immune response in older patients. They are also covered by Medicare Plan B.
Where can I get a flu shot?
First, most local pharmacies have convenient, no appointment needed, walk-up service for the flu shot. They aren’t your only option though—some other places that may offer flu vaccinations for the 2014-2015 season include:
- Your doctor’s office
- Health Department
- Your place of employment
- Flu clinics
- Urgent care clinics
- College health centers
Need help locating where to get your flu vaccination this year?
Check out HealthMap Vaccine Finder! If you need a special vaccine (high dose, nasal spray, etc), you can search to see which pharmacies or other locations in your area can help.
Where can I find more information about the 2014 – 2015 flu vaccine?
When you’re vaccinated, you should receive a Vaccine Information Statement (VIS) from the CDC. In case you’d like to take a look beforehand, you can also find this year’s VIS here.
How much will the flu shot cost?
The typical out-of-pocket cost for an intramuscular flu shot can range from around $25 to $75 depending which strength is selected.
What can I do to save on a flu shot?
- Look in your area for a clinic, organization, or pharmacy offering a free flu shot program. There are some available every year, though you may need to go on a particular day or time to be able to get the shot for free.
- Check GoodRx for a discount—yes, you can use a coupon on flu shots too! Find the full list here.
- Ask your pharmacy if they can price match if you find another pharmacy in your area offering the flu shot for less.
- Many pharmacies have store savings programs, where the cost of the flu shot will count just like groceries or other items purchased in the store—this won’t be a direct savings but might help get you a discount at the store later.
- Some employers will provide flu shot vouchers that will cover the cost of the vaccination if you go to a participating pharmacy.
- Medicare B will cover the cost for the HD flu shot.
Arnuity Ellipta (fluticasone furoate) is the newest corticosteroid inhaler approved for the long-term maintenance treatment of airflow obstruction in patients with asthma. It was approved by the FDA on August 20, 2014.
When will Arnuity Ellipta be available?
At this time the manufacturer, GlaxoSmithKline, has not set a release date.
How is this medication to be taken?
Arnuity Ellipta is an inhalation powder that is used once-daily. It is indicated for patients 12 years of age and older for the preventative treatment of asthma.
Who should not use this medication?
What are some side effects of Arnuity Ellipta?
The most commonly reported side effects include nasopharyngitis (AKA the common cold), upper respiratory tract infection, headache, and bronchitis.
In what strengths and forms will Arnuity Ellipta be available?
Arnuity Ellipta will be available as a 100mcg or 200mcg dry-powder inhaler (DPI).
Arnuity Ellipta a dry-powder inhaler (DPI)–what does that mean?
Unlike classic metered dose inhalers (like Proventil HFA or Proair HFA), the medication in the Arnuity Ellipta is a powder for inhalation and the inhaler does not use a propellant to get the medication into the lungs. The Ellipta inhaler relies your ability to inhale the powder in order for it to be dispersed properly.
For more information on DPIs, check out this post.
What type of medication is Arnuity Ellipta?
Arnuity Ellipta is a corticosteroid. Corticosteroids decrease inflammation and swelling in the airways when inhaled.
Is Arnuity Ellipta considered a rescue or maintenance inhaler?
Arnuity Ellipta is a maintenance inhaler. Maintenance inhalers are important because they help to control your asthma symptoms before they even start–they maintain your airways so that there is less inflammation and swelling.
Can I skip my maintenance inhaler dose if my breathing is okay?
NO. Maintenance inhalers need to be used as prescribed on a daily basis even if you do not have trouble breathing that day.
Maintenance inhalers may NOT be used on an as-needed-basis whenever you feel you are having trouble breathing, and are NOT to be used during an asthma attack.
In contrast, fast-acting or rescue inhalers should be used instead during an actual asthma attack. They work by quickly opening the airways in the lungs so that you can breathe more easily.