Small Doses

Over the past few years, pharmacy services in many places have been expanded to cover Medication Therapy Management (MTM). MTM is a service provided by a pharmacist aimed at improving your health through better drug-related care.

So what is MTM exactly?

The American Pharmacists Association (APhA) describes MTM as a broad range of health care services provided by pharmacists in a patient-centered approach that includes drug consulting, disease state management & coaching, immunizations and other health management services. Basically, your pharmacist will work with you based on your individual medications and diagnosis to help you achieve your health goals and improve your quality of life.

How does it apply to you?

MTM is currently available in a variety of pharmacy settings, and may be available at your local pharmacy. It is also offered through specialized MTM organizations, long term care service providers, and insurance providers. Currently, most Medicare Part D plans cover MTM services at no additional cost. The service includes face-to-face or phone appointments with your pharmacist involving review of your prescriptions and usage, and safety evaluations. If you receive state or federal health benefits you may also be covered, especially if you have a complex medication regimen. Some typical insurance plans also cover MTM services, and you can seek consultation on your own, although fees or other charges may apply.

What’s the benefit?

A more well-rounded approach to your healthcare. MTM allows you to have a medication-centered voice in your care provided by a pharmacist. The service is aimed at improving your care by decreasing medication-related problems. It also benefits public health, and can help you save personally in the long run.

How can it help you save?

By doing a detailed evaluation your pharmacist can point out unneeded treatments, recommend cost-saving alternatives to your doctor, suggest helpful changes to your prescription regimen, and provide drug and disease education. The APhA estimates that there are up to 1.5 billion drug-related adverse events each year resulting in $177 billion in healthcare costs. Having help tracking your prescriptions and your care can help keep you healthy and lower your future healthcare costs.

Talk to your pharmacist to see if MTM is an option for you.

The GoodRx Pharmacist

Finasteride (generic Propecia) has also been available for some time now as a generic alternative to Proscar, the benign prostatic hyperplasia (BPH) med. Since the two are different strengths—1 mg for Propecia and 5 mg for Proscar—a generic specifically for Propecia should have been great news for anyone looking to save.

The 5 mg finasteride is still significantly cheaper though, as low as $10 at some pharmacies for 30 tablets, where the 1 mg tablet is often priced at $70+ for the same quantity. There are probably a couple of reasons why.

First, the 5 mg strength has been around longer, and the price has decreased over time. However, finasteride for hair loss isn’t covered by as many insurance plans, and with more people willing to pay out of pocket, the 1 mg price may take longer to catch up if it does at all—even though you’re getting less active ingredient per pill.

So, how do you find the best price for your generic Propecia? Shop around. In this case, you can find a coupon that will bring your price at Walgreens to around $36 for 30 tablets, cutting that sky-high $70 in half, and coming in a good $10 – $20 less than the next lowest price in most areas.

If you prefer not to go with Walgreens, the next coupons in line are for Rite Aid at around $45 and some grocery store chains (Kroger stores, Winn-Dixie, and Publix, for example) in the $55 – $65 range. Cash prices at warehouse clubs like Costco and Sam’s Club may also be about $45 – $60.

The cost of finasteride 1 mg tablets will hopefully continue to drop over time, and until then you can check for coupons in your area here.

If you are taking a statin like Lipitor (atorvastatin) or Zocor (simvastatin) you probably have been told to avoid grapefruit and grapefruit juice. You might have asked yourself—why? If so, here is your answer.

Statins are metabolized in the liver by a select group of enzymes. Grapefruit can also attach to these enzymes, which can lead to decreased statin metabolism—meaning your body won’t process the medication the way it’s supposed to. So, grapefruit and statins together can lead to increased levels of the statin in your body. This can cause a five-fold increased risk of adverse events, most commonly muscle pain (myopathy). This interaction only applies to grapefruit, and will not occur with any other fruits or vegetables.

There is hope, however, if you really enjoy grapefruit. Not all the statins have the same negative interaction. The effect is only seen with Lipitor, Zocor, and Mevacor (lovastatin). Lipitor and Zocor are the most widely used statins in the country, so many people taking a statin are aware of the restriction, but the ban on grapefruit is for those three in particular.

The grapefruit effect isn’t seen with Pravachol (pravastatin), Crestor (rosuvastatin), Lescol (fluvastatin), or the newest statin, Livalo (pitavastatin). However, Crestor and Livalo are brand-name-only and the cost is generally higher, even with insurance. Pravachol and Lescol are both low-potency statins, so keep in mind that you may end up needing a stronger option.

If you must take Lipitor, Zocor, or Mevacor, you will need to avoid grapefruit and find an alternative fruit to enjoy. If you love grapefruit or grapefruit juice, one of the alternatives may be for you.

The GoodRx Pharmacist

One of the most glaring examples of random pricing of medications is the varying price of capsules vs tablets. Most physicians and pharmacists know that the same medication will work just as well in a capsule or tablet form, but many don’t know there is such a huge price difference. Listen up.

Aside from some obvious differences (capsules can’t be crushed or split while tablets often can) here are some surprises in the capsule vs tablet discussion. Know this, and know you can check on the price of your medication to see if it varies based on what form it comes in: capsule vs tablet. Price differences between $10 and $100 a month are common, so let me give you some examples.

• Doxycycline is commonly used for acne, rosacea and infections. Doxycycline monohydrate and doxycycline hyclate both come in capsule and tablet form. Guess what, it doesn’t matter which one you take, so pick the cheaper one. In some doses the tablet is cheaper while in others the capsule is cheaper. The way the drug works and its absorption are exactly the same, so track this on Goodrx to see if you can save some money.

• Minocycline is also used for acne, and has the reverse problem of doxycycline. See how random this is? The 50 mg and 100 mg tablets of minocycline are way more expensive than the capsules.

• Now, to antidepressants. There is a 70-dollar difference here: venlafaxine XR (the generic Effexor XR) is more expensive in tablet form than capsule form at all doses. There is no reason not to take the capsule other than that the tablet will allow you to split your pill (which is not always recommended for extended release formulations anyway).

• The blood pressure medication diltiazem ER (Cardizem CD and Cardizem LA generic) comes in a capsule and tablet at all doses, and the capsule is much cheaper than the tablet. Again, there is no benefit of one over the other.

• There are rare examples where the tablet and capsule are slightly different. Tizanidine (Zanaflex) is a muscle relaxant, and the tablet form is much more expensive than capsules. The two forms of this medication ARE bioequivalent under fasting conditions (when taken on an empty stomach) but not under non-fasting conditions (when taken with food).

If you are taking a medication that is cheaper in a tablet or capsule form, ask your doctor about switching. My bet is your doctor won’t care which form of the medication you are on and would like you to save some money. Lesson learned.

Dr O.

Recently the FDA announced new changes to current rules regarding emergency contraception. The medication in question, Plan B One-Step, is a single high-dose hormone (levonorgestrel) treatment that can prevent pregnancy if used correctly within 72 hours of contraceptive failure. It does not prevent sexually transmitted diseases.

Previously, Plan B One-Step was available over the counter to patients above the age of seventeen. For patients under the age of seventeen, a prescription was required.

Earlier this month, the FDA passed a new ruling that will make Plan B available without a prescription to females age 15 and older. The change is intended to increase access to the medication and help prevent unintended pregnancies. All studies have indicated that the medication is safe to use in young women, and therefore would not pose an increased risk by being made widely available. This ruling only applies to the Plan B One-Step and not to other similar “morning-after” pills. As per the FDA, the ruling was to take effect immediately. The Justice Department has also appealed a broader ruling that would not allow the FDA to put any age restrictions on the over-the-counter sale of Plan B One-Step.

With the debate still ongoing, Plan B One-Step will continue to be available at pharmacies, but it may take some time before the changes will occur. You may still require your ID or a prescription, as most pharmacies are currently still operating according to the previous standards. The ruling also applies only to Plan B One-Step, and other emergency contraceptives (such as the two-dose Plan B or Next Choice) will not be available under the new rules.

Stay tuned for updates.

The GoodRx Pharmacist

Those of you on the blood thinner Coumadin (warfarin) know the dangers of your blood being too thin, which can lead to serious bleeding complications. For this reason, Coumadin is the medication responsible for the most hospitalizations due to complications. What happens is the levels of blood thinner get too high because your dose hasn’t been properly adjusted and this can lead to bleeding in the gut, the brain and the joints among other places. I’ve seen it quite a bit.

In the past we have given Vitamin K and fresh frozen plasma (which contains clotting factors) to reverse the effects of your Coumadin but now we have something easier and faster!

The FDA just announced the approval of Kcentra for the urgent reversal of coumadin in adults with acute major bleeding. Kcentra is made from the pooled plasma of healthy donors, and is processed in a way to minimize the risk of viral and disease transmission.

Kcentra is used with the administration of vitamin K to reverse the effect of your blood thinner. The benefit, unlike plasma, is that Kcentra doesn’t require blood group typing or thawing, so it can be administered more quickly than frozen plasma. Kcentra is given by single injection.

Good deal.

Dr O.

Memory loss, dementia, and cardiovascular disease prevention are the main reasons many of you wonder if you should be taking gingko (Gingko biloba).

There was hope for years in gingko. It works to improve blood flow through increased release of nitric oxide, and it works as an anti-inflammatory so it was believed to be neuroprotective.

Well, it doesn’t really do what we’d hoped. The National Center for Complementary and Alternative Medicine funded the Gingko Evaluation of Memory (GEM) study, the largest and longest trial done. The study found no scientific evidence that ginkgo decreases the incidence of dementia or Alzheimer’s disease in elderly adults and sadly, that it was ineffective in slowing cognitive decline. In that same study, ginkgo did not reduce incidence of or mortality from cardiovascular disease.

Gingko may cause side effects and interact with your meds. The main complaints in those taking gingko are GI complaints (nausea) and it can prolong bleeding so anyone having a surgical procedure needs to make their doc aware they are taking this.

Gingko interacts with many medications: alprazolam (Xanax), omeprazole, ritonavir (Norvir), antiepileptics, thiazide diuretics, ibuprofen, risperidone (Risperdal), trazodone and warfarin among others.

Worth it?

I think not.

Dr O.

Recent product recalls from compounding pharmacies have been getting a lot of attention. Here are five things you need to know about compounding and why the recalls have been happening:

1. Compounding pharmacies are pharmacies that are able to make specific drugs for patients. This includes compounding of discontinued or unavailable medications, special formulations (suppositories, liquids, injections) of drugs that might not be sold that way commercially, specialty medications (hormonal treatments, some IV infusions) and other products that are not commercially available. All compounding is done by or under the supervision of a pharmacist, in community and hospital pharmacies.

2. The controversy: Late last year a number of doctor’s offices received spinal injections made by a compounding pharmacy that were contaminated by a fungus. This lead to numerous cases of fungal meningitis in patients that had received the injections, with several deaths reported. The pharmacy in question was closed down and the FDA initiated an investigation. There have been several other voluntary compounding pharmacy recalls in the months following.

3. What does this mean for you? For compounded medications that are used topically (creams, suppositories, ointments) or orally (liquid, capsules) the risk of contamination is generally low. The majority of compounding at your local pharmacy will be of these low risk medications. If you are receiving specialty drugs from a compounding pharmacy though, this may not be the case. The risk of contamination is higher for sterile products such as injections.

4. Check with your pharmacy or health care professional. If you are concerned about a compounded product, contact your pharmacy or your doctor with any questions you may have. Compounding pharmacies are expected to adhere to strict standards for preparing medications. Patients should be able to check on whether equipment, testing and other related procedures are up to date. You can also check the FDA Recalls page for listings of pharmacies and products that are involved in recalls or withdrawals.

5. The latest news: The outbreak of fungal meningitis has since been contained, and all patients that received a contaminated dose were informed and checked. Since then, increased regulation of compounding pharmacies has been proposed. Currently, a bill is being reviewed in the Senate to increase the FDA’s jurisdiction over compounding pharmacies. In addition, the FDA has increased audits and harsher penalties are being imposed on pharmacies that do not meet standards.

The GoodRx Pharmacist

APP Pharmaceuticals has announced a shortage of both forms of their fluphenazine injection, used for the long-term management of conditions such as schizophrenia.

The fluphenazine decanoate 25mg/ml 5 ml vial is currently backordered, with an estimated rerelease in the third quarter of 2013. The fluphenazine hydrochloride 2.5mg/ml 20 ml vial is also backordered, with a new shipment due in late May 2013—although some vials expiring in the next seven months (through 11/30/2013) may be available now.

Fluphenazine is a generic drug without a current brand equivalent. APP Pharmaceuticals’ fluphenazine hydrochloride is the only FDA-approved version, though you may be able to find the more concentrated fluphenazine decanoate vial from another manufacturer. However, the backorder in both cases is due to a shortage of the active ingredient, so other manufacturers could be having the same issue.

If you’re having trouble getting the medication you need, talk to your doctor about other options in the meantime; you may be able to substitue an oral version of fluphenazine or try another injection in the same class of drugs.

For more information, contact APP customer service at: 1-888-386-1300

Recently Pfizer, the manufacturer of Levoxyl, has issued a national recall of all Levoxyl products from retail pharmacies. As of April 2013, pharmacies will no longer have any strengths of Levoxyl available. Here’s what you need to know:

What is Levoxyl?

 Levoxyl (levothyroxine) is used to treat low thyroid levels and to prevent certain types of goiters (an enlargement of the thyroid gland). Levoxyl is also available in its generic form, levothyroxine, or as other brands, such as Synthroid, Levothroid, and Unithroid.

With so many options, why does the recall matter?

Thyroid medications have a narrow therapeutic index (NTI), which means that any change in dose or formulation—including from one brand or generic to another—can lead to significant differences in how your body responds. Once you start one, you typically have to continue using the same prescription. Switching between brands should be done under your doctor’s supervision.

Why was the recall initiated?

The manufacturer ordered a voluntary recall after some patients and pharmacists complained about a “plastic-like” smell in some bottles. According to Pfizer’s official statement, the odor came from oxygen-absorbing canisters in the packaging and it was “not likely to cause any adverse health consequences.”

What should you do if you are taking Levoxyl?

If you currently are taking Levoxyl there is no need to discard or discontinue the medication. You should continue taking it as prescribed.

What if you need to fill your Levoxyl prescription?

Since Levoxyl isn’t currently available, you will need to switch to an alternative: the generic levothyroxine or another brand. You can ask your pharmacist to let your doctor know, or contact them directly. You may need a thyroid level test, or may be asked to follow up after changing medications. Any of the alternatives will still continue to act as a replacement for low thyroid levels, but you may also need dose adjustments and further assessment.

Will it cost you more?

Depending on which brand or generic you switch to, you could pay more or less.  Copays and prices will be different, especially if you move to generic levothyroxine. The price difference isn’t huge, but the generic is generally less expensive and part of many pharmacies’ generic discount programs. Ask your pharmacist to check what the difference might be for you.

When will it be available again?

Currently there is no date set for the return of Levoxyl to the market. Pfizer anticipates that it may not be available again until 2014.

More questions?

If you are taking Levoxyl and have more questions do not hesitate to ask your doctor or pharmacist; they can help you find a treatment that will work for you.

The GoodRx Pharmacist