It’s a blessing to have effective meds to control nausea and vomiting from chemotherapy. Now we have an even better choice and this may be one of the best new meds of the year. Is it possible to transform the awful experience of chemo into one that’s better tolerated? Let’s hope.
Hot off the press is the approval of Akynzeo, a capsule for the prevention of nausea and vomiting from chemotherapy. Akynzeo is the first drug that is a combination of two meds that work differently: netupitant, an NK1 receptor antagonist, and palonosetron, a 5-HT3 receptor antagonist. Compared to palonosetron (Aloxi) alone, Akynzeo was significantly more effective and was generally well tolerated, and Aloxi has been the previous bad-ss in this category.
During the rollout of Akynzeo, which will likely be expensive, what are other options?
- Emend (aprepitant). Given in the days pre-chemotherapy (from day 1 to 3), Emend is an oral or intravenous medication that is expensive but works well to control nausea and vomiting.
- Dexamethasone given days 1 to 3 is a corticosteroid option you can get orally or through an IV. It’s cheap, has been around forever, and works well.
- 5-HT3 serotonin receptor antagonists have completely transformed the treatment of nausea and vomiting so you need to know this class of medications. Ondansetron (Zofran) is available as a generic so it is the cheapest of these medications. It comes in a dissolvable tablet or a pill. Palonosetron (Aloxi) is very expensive but works extremely well for nausea and vomiting from chemotherapy (though not as well as the new Akynzeo), but it’s good to have this drug as an option. Granisetron (Sancuso) is available as a patch, so you can avoid taking pills or receiving injections, but it’s expensive—really expensive.
Potassium chloride and potassium citrate—they’re both potassium so they should be the same, right? The names of these medications look nearly identical and can be extremely confusing, but you should know that these different forms of potassium treat different conditions and can’t be substituted for each other.
What does potassium chloride treat?
Potassium chloride is indicated for the treatment of hypokalemia also known as low potassium levels.
Low potassium levels may be due to diet, a side effect of medications, diarrhea and vomiting, sweating, or certain diseases.
What is the brand name for potassium chloride?
What does potassium citrate treat?
Potassium citrate is indicated for the treatment of kidney stones.
Kidney stones are crystal-like structures that form in the body usually as a result of excess amounts of uric acid or calcium. Kidney stone formation can be due to diet, certain diseases, genetics, or a side effect of medications.
What is the brand name of potassium citrate?
Potassium Chloride is available in 8 mEq, 10 mEq, 15 mEq, 20 mEq, 25 mEq, 40 mEq, and 50 mEq strengths, and in the following forms: tablet, capsule, effervescent tablet, powder packet, and liquid.
Potassium citrate is only available as a tablet, in 540 mg, 1080 mg, and 1620 mg (equivalent to 5 mEq, 10 mEq, and 15 mEq) strengths.
Pain is complex, so there is no “one pill fits all” treatment. Hydrocodone is the most prescribed medication in the United States, also marketed in combination with acetaminophen (Tylenol) under the brand names Vicodin, Norco and Lortab.
As of October 6, 2014, all drugs containing hydrocodone are schedule II drugs, and that means they are now much harder to get. There is no question this is a hassle for some patients and physicians but we (doctors) are too quick to prescribe it and for most pain, you don’t really need hydrocodone.
- Is hydrocodone better than over the counter pain meds?
In many studies done on specific types of pain: acute or chronic, musculoskeletal or postoperative among others, non-opioid medications were just as good if not better.
You see, the classic line taught in medical school is that NSAIDS/non steroidal anti-inflammatory drugs (ibuprofen, Motrin, naproxen) work just as well for pain but hydrocodone makes you care less about the pain. That’s because you will be much more dopey on hydrocodone—oh, and more constipated.
- Explore other options for postoperative pain.
After an operation is a time when most doctors will prescribe you hydrocodone but for some simpler surgeries you may not need it. NSAIDS work just as well most of the time. The use of a single dose of Celebrex (celecoxib) in the treatment of acute postoperative pain found that 33% of patients receiving celecoxib 200 mg, and 44% of patients receiving 400 mg, experienced at least 50% pain relief.
Listen to this too: a single dose of ibuprofen was found to provide at least 50% pain relief in approximately half of patients with moderate to severe postoperative pain. An NSAID may be all you need.
- Low back pain.
In most cases, first-line treatment of low back pain (LBP) should consist of an NSAID or acetaminophen. Long term use of NSAIDS is associated with gastrointestinal and kidney risks, so a short course of a low dose NSAID, possibly along with a proton pump inhibitor (omeprazole, etc) to protect your stomach and you should be set.
When pain is severe and disabling, guidelines cautiously recommend opioid analgesics like hydrocodone although the risk of addiction or dependence is noted and continued long term use is a bad idea.
- Arthritis pain/knee and hip pain.
Several classes of drugs are recommended by the American College of Rheumatology for osteoarthritis (OA) pain in the hand, knee, and hip. For hip OA, first line therapy is acetaminophen, NSAIDs, tramadol, and steroid injections into the joint. Opioid treatment like hydrocodone is recommended only in cases of knee or hip pain that have not responded to the above listed medications or physical therapy.
NSAIDS like ibuprofen and naproxen have been found to be effective in the treatment of migraine. Approximately one fourth of people with migraine pain experienced a reduction from severe or moderate pain to no pain within 2 hours of taking a 400 mg dose of ibuprofen.
- When should you use hydrocodone?
Opioids are recommended only for severe pain (a score of at least 7 out of 10), as in a postsurgical setting or other situations in which NSAIDs, acetaminophen, or other treatments provide inadequate pain relief.
- Why is liberal use of hydrocodone a bad idea?
Opioids are associated with serious side effects, including respiratory depression, motor and cognitive impairment, sedation, and the development of tolerance. Long term use of opioids can also result in the development of an increased sensitivity to pain, known as opioid-induced hyperalgesia.
- Hydrocodone doesn’t work as well at NSAIDS for many types of noncancer pain.
This always surprises people because they think hydrocodone is “stronger” and thus better. Most of the time it’s not better.
A 2004 meta-analysis of 18 randomized clinical trials of opioids for the treatment of various types of noncancer pain found that the mean reduction in pain intensity was approximately 20% to 30% for arthritis pain, but was approximately 10% for musculoskeletal pain. That’s not great.
- Why are we using more hydrocodone in the U.S.?
No reason. There should be widespread concern that the use of opioids is increasing at an unwarranted and possibly hazardous rate. With the increased use of opioids, there has been an increase in opioid-related overdoses and deaths.
CDC data on poisoning deaths indicate that the number of deaths related to opioid use increased nearly 4-fold from 4030 in 1999 to 14,800 in 2008. In 2008, the number of overdose deaths involving the use of opioid pain relievers exceeded the number of deaths caused by heroin and cocaine combined.
The FDA recently approved Harvoni (ledipasvir/sofosbuvir), a new combination oral medication for the treatment of hepatitis C that stops the replication of the virus.
What is Harvoni?
Why is Harvoni different from other hepatitis C treatments?
Harvoni is unique because it is the first combination pill approved to treat chronic hepatitis C genotype 1 infection and it DOES NOT require combination treatment with pegylated interferon or ribavirin—medications that use to be first line therapy, but have serious side effects.
The pegylated interferon alpha injectable often contributes to patients not finishing their course of hepatitis C therapy, mainly due to the unfavorable side effects. Discontinuation of peginterferon alpha is primarily due to adverse reactions like flu-like symptoms and psychiatric or stomach problems.
Who is Harvoni for?
As mentioned above, Harvoni is approved for the treatment of hepatitis C genotype 1 patients. Genotype is the genetic makeup of a person or virus, and each genotype has unique characteristics. The differences are important when it comes to treating the hepatitis C virus.
In the past, patients with genotype 2 and 3 had a better response and shorter treatment duration with mainstay treatments like interferon and ribavirin than those with genotype 1. However, genotype 1 is more common, affecting around 75% of Americans infected with hepatitis C. Genotypes 2 and 3 account for 20 – 25% of those infected, while genotypes 4, 5, and 6 account for a much smaller number, even outside the US.
Harvoni, with its combination of ledipasvir and sofosbuvir, has a very good response rate in comparison to older treatment options, and a shorter treatment duration, which is great news for genotype 1 patients.
What about cost?
Here’s the bad news. The wholesale price for a 12-week course of treatment with Harvoni is estimated to be $94,500. Many patients may only need an 8-week course, but the cost will still be very high. The recommended length of treatment with Harvoni will depend on prior treatment history, cirrhosis status, and baseline viral load, but it can be given in courses of 8 weeks, 12 weeks, or 24 weeks.
Are there other new hepatitis C treatments available?
Sovaldi (sofosbuvir) 400 mg tablets are a once-daily treatment that can also be used without the injectable pegylated interferon. The active ingredient in Sovaldi, sofosbuvir, is also one of the active ingredients in Harvoni.
Like Harvoni, both Sovaldi and Olysio are also very expensive—the wholesale price for one month of Sovaldi is $28,000, and the wholesale price for 12-week course of Olysio is $66,360, according to the manufacturers.
We get lots of questions from folks who don’t understand how GoodRx works. Over the next few months, we’ll provide a few short examples from Americans who have used GoodRx to understand and control their healthcare costs.
Louie is a member of Steven’s family. But not a son or daughter—he’s a dog.
Specifically, he’s their 11-year-old black Lab. Steven and his wife brought Louie home when he was just a puppy. He’s 11 now, and as he’s aged, Louie’s healthcare costs have started to add up.
Steven and his family would do anything for Louie. However, Louie doesn’t have pet insurance and he’s not eligible now because his conditions are pre-existing. Recently, Louie needed a few surgeries, leaving Steven and his wife with over $13,000 in vet bills.
Today, Louie is doing all right, but he needs to take ursodiol daily for fibrosis of the liver.
Steven was buying Louie’s meds online at a fairly reasonable $60 for a three month supply. Louie’s last refill, however jumped from $60 to $600 for the same prescription—ten times the cost!
Louie needs the medication to keep his liver working, and Steven was worried. $600 every three months simply wasn’t affordable, but they had to find a way to keep Louie alive.
Steven worked with his vet and tried everything to bring the cost down. They looked at ordering from Canada, but it was more expensive. The vet even suggested giving Louie one dose every other day or every three days to offset the cost. Louie could come back in three months to see whether less medication would work.
Steven wasn’t ready to give up on getting Louie the medicine he needed. He kept searching online for ways to save on prescriptions, and finally found a GoodRx coupon. He called his local Walgreens to make sure they would accept the discount, and was relieved to find out that they knew GoodRx and would take it.
Steven filled a three month supply of ursodiol for Louie for $104 using a GoodRx coupon, compared to a cash price of $603.
Today, Louie has his daily medication, and Steven and his wife will not only save nearly $2,000 per year, but more importantly, they’ll get to have Louie around for a while longer.