Improve my pain and I’ll pay whatever it takes. That’s what many patients who struggle with pain in their feet from diabetic neuropathy, pain after a shingles outbreak or any other nerve pain say to their doctors. Gabapentin works, and it’s cheap and generic. But guess what, there are now two long-acting forms that aren’t so cheap. Are they better?
• Gabapentin was originally developed as a seizure medication, yet has shown to be effective in the treatment of painful neuropathies. Gabapentin (Neurontin) was approved by the FDA in December 1993 for the treatment of partial seizures and in May 2002 for the treatment of the pain after shingles, or post-herpetic neuralgia (PHN).
• Along came Gralise. A once-daily gabapentin tablet (Gralise) was approved in January 2011 for PHN. Gralise is much more expensive than gabapentin. Much.
• Wait wait don’t tell me. Another form of gabapentin, Horizant (gabapentin extended-release tablets) was approved by the FDA in April 2011 for the treatment of moderate to severe primary restless legs syndrome (RLS) in adults and in June 2012 for the treatment of PHN in adults. Also expensive.
• What’s different? The duration of action and when they reach their peak concentration is much different for these three medications. What this means for you is that Gralise and Horizant may provide longer steady coverage and are only taken once a day. Gabapentin is taken three times a day.The immediate release gabapentin can be taken with or without food, whereas Horizant and Gralise should be taken with food. Horizant and Gralise are absorbed better with a fatty meal—now you’re talking.
• Better? Whether or not one is better than the other for pain control is not known as there are no comparison studies.
Worth the cost? Those of you who have tried both, weigh in.
For 90 capsules of 100 mg, 300 mg, or 400 mg, you can find gabapentin at many pharmacies for under $20 per month, and it’s covered as a Tier 1 drug with a low copay by most insurance plans. In contrast, 30 tablets of Gralise comes in just under $100, and the same quantity of Horizant will run closer to $130. When covered by insurance, both Gralise and Horizant are often considered Tier 3, meaning you’ll pay your highest copay.
Two doses of progesterone-releasing IUDs are now available and are popular new options for birth control. Levonorgestrel (synthetic progesterone) IUDs are used for contraception and to control heavy menstrual bleeding. Women like these IUDs because you have little to no menstrual cycles and they are in place for years.
The benefits of Mirena:
• Has been around longer than Skyla.
• Mirena is approved for up to five years of use, but appears to be effective for up to seven years.
• It works. The probability of pregnancy is 0.1 percent
The benefits of Skyla:
• It is smaller in size than the Mirena and has a smaller diameter so there is less pain during insertion.
• It also works. The probability of pregnancy is 0.41
What do they have in common?
• With both, the progestin effect is primarily local meaning not much progesterone goes in to the system, unlike taking a pill.
• Spotting and irregular bleeding in the first months after insertion occur with both, and usually resolve.
Both are great, and it’s good to see new birth control options.
Like the brand, zolmitriptan tablets and orally disintegrating tablets are available in 5 mg and 2.5 mg doses, and sold in packages of 3 or 6. The nasal spray is still only available as brand name Zomig.
Another generic triptan for treating migraines is good news for anyone looking for lower prices and more options. Zolmitriptan joins sumatriptan (Imitrex), rizatriptan (Maxalt), and naratriptan (Amerge).
While zolmitriptan doesn’t offer huge savings over the brand just yet—the lower prices for a 5 mg pack of 3 tablets are around $70, while the same package of Zomig runs about $90 – $94—prices should continue to go down over time.
The generic is also good news for anyone with insurance; it will be more likely to be covered as a Tier 1 prescription under most plans, meaning you’ll pay only your lowest copay.
Insomnia is defined as “difficulty initiating or maintaining sleep” either over a short period of time or as a chronic problem. It is believed to affect 30 – 35% of adults and is common in the elderly. In some cases difficulty sleeping can be related to short-term stress (anxiety, worry, environment) that leads to sleep disturbances. In other cases, underlying medical conditions can cause chronic insomnia.
So, what should you try first to get a better night’s sleep?
1. Start by trying to establish a regular sleep pattern. This includes getting the recommended six to eight hours of sleep a day.
2. Try to avoid anything that can cause a feeling of wakefulness close to bedtime. This includes caffeine (coffee, energy drinks, tea, soda) and nicotine (cigarettes).
3. Set up a good sleep environment (no noise, light or other disturbances).
4. Don’t eat a large meal right before bedtime.
5. Avoid exercise 2 to 4 hours before bedtime.
6. Avoid watching TV or reading while in bed.
7. Review your medications with your doctor or pharmacist to make sure none of them may be affecting your sleep. Adjusting dose times for some medicines can help, so talk to your pharmacist if you have any further questions.
If you’re still having trouble sleeping, there are a few over-the-counter medication options as well:
8. Melatonin, a hormone in the body, is linked to good sleep health. Taking supplements can help in regulating sleep cycles, although the effect may be short-term and limited. It should be taken 1 hour before bedtime at only recommended doses.
9. Other herbal products such as Valerian, Kava and Chamomile have limited scientific data to support benefits and may not be helpful.
10. First generation antihistamines such as diphenhydramine and doxylamine cause drowsiness and are beneficial as short-term sleep aids. These are available under many names including Unisom, Benadryl, Sominex,and others. However, they should be avoided by some people and may have some adverse interactions, so ask your doctor or pharmacist first. You can also develop a tolerance, so do not use antihistamines for more than 14 consecutive nights.
If you are still having sleep disturbances after practicing good sleep habits and trying over-the-counter products, it may be time to discuss prescription options your health care provider. There are several prescription sleep aids available, including: Ambien (zolpidem), Lunesta (eszopiclone), Sonata (zaleplon) Restoril (temazepam), Rozerem (ramelteon), trazodone (Desyrel), and amitriptyline (Elavil).
These medications should only be used after a full medical assessment and under the direction of your doctor. Each prescription also has its own set of side effects to deal with. Most often this includes morning drowsiness, sleep walking, and difficulty operating vehicles or machines, although side effects are specific for each different drug. You should also not use alcohol with these drugs.
Sleep studies and treatment of underlying conditions are also options, so talk to your provider to find the treatment that best suits you.
Newsflash reminder: The FDA recently made a safety announcement regarding Ambien (zolpidem) and reduced the recommended dose for women from 10mg to 5mg for immediate release products and from to 6.25mg for extended release forms (Ambien CR).
Sleep well till next week!
The GoodRx Pharmacist
In the hunt for the female Viagra, there has been a small victory. Osphena has been approved for vaginal dryness and painful intercourse as a result of vaginal atrophy that occurs with menopause. What does this mean and will this help improve libido in women?
Libido in women takes a huge dive during menopause. One of the culprits for this is vaginal dryness that may result in uncomfortable sex.
Ospemifene (Osphena) has just been approved based on studies that showed it is effective and well-tolerated for the treatment of the symptoms of vaginal dryness and dyspareunia (painful intercourse) over and above the use of lubricants.
So, this is new. Postmenopausal women with vaginal dryness and pain during intercourse can try Osphena. Osphena is a pill that acts as an estrogen agonist/antagonist and it’s an alternative to vaginal or oral estrogens.
In early studies Osphena resulted in significant improvement of painful intercourse compared to women who received a placebo. Side effects were minor, with hot flashes being the most common followed by vaginal discharge.
Now for the warnings. The use of Osphena can stimulate the endometrium (lining of the uterus), which increases the risk of endometrial cancer because of the effects of unopposed estrogen. Adding a progestin to estrogen therapy can reduce this risk.
Women should use Osphena for short periods of time and must be evaluated for any unusual vaginal bleeding. From these studies we don’t know that it does anything to improve libido (interest in sex) so I ask you: will it be the female Viagra?