The first thing to understand about testosterone replacement is that oral testosterone (pills taken by mouth) doesn’t really work because it is broken down so quickly by the liver. The solution to this problem involves patches, gels and shots. Here are your options, with some new players in the game:
1. Testosterone patches: Androderm patches are meant to be worn on the arm or torso. Androderm patches deliver approximately 5 mg of testosterone per 24 hours and results in normal testosterone levels in the majority of hypogonadal men. These have been around for a while.
Axiron (2 percent testosterone solution) is a solution of testosterone that comes in a metered-dose pump with applicator. This is a gel applied to the underarm and it is quite expensive so be prepared.
Are testosterone shots the way to go? The option of intramuscular injections is a good one, though it requires office visits. Injections are usually given one shot of 100 mg, once a week for 12 weeks. Regimens of 300 mg every three weeks and 400 mg every four weeks can also be used. An advantage of the shots for men is the freedom from daily administration of a gel or patch, while the disadvantages are the need for a shot of an oily solution every one to three weeks.
Most options for testosterone replacement are considered Tier 2 drugs by many insurance plans, though they may fall under higher copays or may not be covered with some plans. Androderm patches and all gel options run about $300 – $350 per month or per prescription (for 30 patches or one container of gel). Testosterone shots are significantly less expensive, with generic versions sometimes available for as little as $20 per dose.
Update March 2013:
The FDA has just approved a new option for AndroGel 1.62%. Now in addition to the metered-dose pump packaging, AndroGel 1.62% will also be available in two separate strength packets. Each packet will contain either 20.25mg of testosterone in 1.25 g of gel or 40.5mg of testosterone in 2.5 g of gel (note that the starting dose of AndroGel 1.62% is 40.5mg of testosterone). Separate packets should make dosing a little easier than a metered-dose pump.
Medications that increase health care costs without improving care are silly, and doctors love to hate ‘em. “PharManure” is the brilliant term used to describe these medications. Here is a list my colleagues and I love to hate:
1. Intravenous acetaminophen (Ofermiv). This intravenous Tylenol (acetaminophen) was just approved. Acetaminophen is already available as a suppository in the event you can’t swallow a pill. Acetaminophen through the IV is really expensive . . . and silly.
2. The new spray form of the sleep medication zolpidem (the generic for Ambien) is Zolpimist and it’s expensive and silly. They have also come out with a dissolvable zolpidem tablet called Intermezzo which is also silly.
3. Brand name minocycline (Dynacin or Minocin). Minocycline has been around forever as a generic yet drug companies are now making brand name minocycline variations for the treatment of acne. Don’t get tricked in to paying for them.
4. New combinations of older drugs: examples are ibuprofen/famotidine (Duexis) and naproxen/esomeprazole (Vimovo). So these are anti-inflammatories mixed with generic stomach medications in to a new pill. They are so cheap on their own it makes no sense to pay for the combo.
5. Irritable bowel syndrome (IBS) medications that cost hundreds of dollars a month and don’t tend to do any better than placebo for symptoms. Amitiza is the latest example for IBS where very few patients respond to it and it’s pricey. Studies show most IBS drugs don’t work much better than placebo for IBS symptoms.
6. It’s a love-hate relationship for doctors with the erectile dysfunction meds but there is new reason for pure love. The hate comes from how expensive they are for our patients. The bright spot here is there a new indication for tadalafil (Cialis). Cialis is now FDA-approved to treat benign prostate hyperplasia (BPH). This new indication may ease the pre-authorization process for the drug so you can actually get it covered.
7. Petadolex: While I am a believer in butterbur supplements for migraine prevention this prescription form is too expensive for something available over the counter.
8. Ella (ulipristal acetate) is uber expensive at 44 dollars a pill. Ella is used as an emergency contraceptive where you have other cheaper options like Plan B. What is promising, though I can’t even imagine the cost, is that Ella will soon be tested and marketed as Esmya to control bleeding in women with fibroids.
For an example in the potential difference in cost: generic minocycline will likely be covered by most insurance plans as a Tier 1 medication, meaning you’ll pay only your lowest copay, and can cost as little as around $75 for thirty tablets. Dynacin, in contrast, is considered Tier 3 by most plans, meaning you’ll pay your highest copay, and can cost upwards of $400 for the same thirty tablets.
‘Tis the season for allergy eyes, so what medications really work?
Allergic conjunctivitis is the name for the red itchy eyes you get from allergies. It’s an annoying problem that brings people to the doctor, with at least 20 percent of people affected at some point during the year. You need to know what medications work for red itchy eyes.
First, here are some weird facts. Allergic conjunctivitis is a disease of young adults, with an average age of onset of 20 years of age. Symptoms, for some reason, tend to decrease with age. Half of patients have a personal or family history of other allergic symptoms.
What you feel is itching, tearing, red and puffy lids, watery discharge, burning, and light may bother your eyes. It’s usually in both eyes but sometimes one will bug you more than the other.
Before you decide on a treatment you will want your doctor to make sure your red eye is NOT infectious “pink eye,” dry eye, or blepharitis. If your eyes itch, that’s a strong sign it is allergic and not infection. Also, start with some basic “treatment” before you get your prescription medications: don’t rub your eyes as that will cause worsening of symptoms, you can use artificial tears to help dilute and remove allergens, and cool compresses help too.
Ok, you did that, but you are still suffering. So, some medications for red, itchy eyes that really work:
The prescription eye drops that are your best choice are eye drops with both antihistamine and mast cell stabilizing properties. Olopatadine (only available as brand names Pataday and Patanol) was the first drug in this class to be approved.
Other popular brands in this class that work well for red itchy eyes include Optivar (available as generic azelastine), Alocril (nedocromil),and Alamast (pemirolast potassium). The only generic in this class also available over the counter is ketotifen fumarate (known as Claritin Eye, Itchy Eye, Alaway, or Zaditor).
Over-the-counter choices that don’t work as well are naphazoline/pheniramine maleate (available as Naphcon-A, Opcon-A, and Visine-A). These products are intended for short-term use only!
If you hate eye drops you can also try over-the-counter or prescription antihistamines, but eye drops are faster-acting and less likely to cause systemic side effects, so are usually preferred. Fexofenadine (generic for Allegra), loratadine (generic for Claritin), desloratadine (Clarinex), cetirizine (Zyrtec), and levocetirizine (Xyzal) are examples.
Prescription brand name medications with no generic equivalent, like Xyzal, Clarinex, Optivar, Alocril, and Alamast, will likely be considered Tier 2 or 3 medications by insurance companies, meaning you will have a moderate to high co-pay. Many of these medications can cost $100 per month or per bottle of drops. Generic versions are more likely to be covered under your lowest co-pay as Tier 1 medications, and range from about $20 – $80 per month or per bottle. The over-the-counter eye drops tend to range in price from $5 – $15 per bottle.
Nocturnal leg cramps are a common cause of pain in the legs that can disrupt sleep. They are present in nearly 50 percent of those over the age of 50. Leg cramps are characterized by sudden muscle tightness, most commonly in the foot, thigh, or calf, that may last from seconds to minutes. Forceful stretching of the affected muscles usually relieves these leg cramps. For some reason, the vast majority of people have these cramps only at night.
What is unhelpful to hear is that for most cramps, we have no idea why they happen. Patients sometimes wonder if their medication is leading to their nighttime leg cramps and well, yes, some medications can.
Here are the players that may contribute to nocturnal leg cramps:
There are of course other causes of nocturnal leg cramps. Two major culprits are prolonged sitting and volume depletion (due to diuretics or excessive sweating without sufficient salt replacement). Leg cramps at night are more common with diabetes, hypoglycemia, alcoholism and hypothyroidism.
So, what medications HELP for nighttime leg cramps?
2) Calcium channel blockers, including diltiazem (30 mg per day), which has also been used in a dose of at bedtime.
5) Quinine is the best-studied drug for nocturnal leg cramps and has been found effective in some studies. Yet quinine is no longer routinely recommended for treatment due to the potential for serious and/or life-threatening side effects.
Lastly, there are some non-pharmacologic solutions to nighttime leg cramps:
1) Walking or leg jiggling followed by leg elevation.
2) A hot shower with the stream directed at the cramp area of the body, usually for five minutes, or a warm tub bath.
3) Ice massage.
3) If you are sedentary, riding a stationary bicycle for a few minutes before going to bed HELPS.
4) Keeping the bed covers at the foot of the bed loose and not tucked in.
5) Maintaining adequate hydration, particularly if you are on diuretics.
Hope this helps!