Invokana (canagliflozin) is one of the new oral medications for adult onset diabetes. It’s expensive but has many upsides. Taken usually in combination with metformin it is a rising star in the treatment of diabetes. Here is what you need to know to help you decide: worth it or not?
- Invokana is taken as a 100 mg tablet once daily before breakfast, increasing to a 300 mg tablet once a day if you have normal kidney function. Invokana can be taken with or without food.
- Invokana is not yet recommended for use alone in the treatment of diabetes; it should be given as a second agent in addition to metformin or as a third-line treatment.
- Invokana works on the kidneys and tells the proximal tubule to resorb approximately 90 percent of the filtered glucose load. So, Invokana promotes dumping of glucose from the kidneys to the urine.
- Invokana used alone doesn’t lower blood sugars (measured by the A1C blood test) enough to make it effective as a single agent for diabetes. In studies it lowers A1C by 0.5 to 0.7 percentage points, making it a relatively weak glucose lowering agent.
- When should Invokana be added? It has been shown to be effective in lowering A1C when metformin alone is not achieving the goal A1C of < 7.0. Invokana 300 mg compared to Januvia 100 mg mixed with metformin was better at lowering blood sugar and helped with weight loss.
- Will I lose weight on Invokana? Yes, in most studies Invokana (used with metformin) resulted in a 6.5 pound weight loss at 12 weeks and an almost 10 pound weight loss at the end of a year. That’s quite a plus.
- The huge downside of Invokana is the frequency of genital fungal infections, which are almost sixfold higher. This means there is an increased risk of genital yeast infections: vulvovaginal candidiasis (vaginal yeast infections) in women but also male yeast infections, which carries a higher risk in uncircumcised males. There is also a small increased risk of urinary tract infections.
- Invokana can also raise potassium.
- Does Invokana cause low sugars/hypoglycemia? No, not really. Thats another benefit as hypoglycemia can get you into trouble with some of the older meds and insulin. The overall benefits of Invokana include a decrease in blood pressure and weight, and a low incidence of hypoglycemia when used alone or with metformin.
As 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 ear, nose, and throat (ENT) drugs for allergies and ear infections from their national preferred formulary and have 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 ENT coverage in 2015?
Caremark 2015: No changes from the 2014 formulary
Reminder: as of 2014, excluded nasal sprays included Veramyst, Beconase AQ, Omnaris, Qnasl, Rhinocort Aqua, and Zetonna. The suggested alternatives are flunisolide, fluticasone propionate, triamcinolone, and Nasonex.
I see a lot of patients using Veramyst, but the alternatives all seem to be good choices—in particular fluticasone propionate (generic Flonase). Veramyst is very similar to generic Flonase so you shouldn’t have issues converting. Nasonex also has a savings card available from the manufacturer.
I am not concerned here—I don’t think that the removal of Cetraxal from the 2015 formulary will cause many problems. Cetraxal is also available as generic ciprofloxacin 0.2% otic solution which is one of the suggested alternatives. Beyond that, however, both brand name Cetraxal and generic ciprofloxacin 0.2% are not often prescribed for ear infections due to their unpopular strength. Ciprodex, the other suggested alternative, is much more commonly used and prescribed. Ciprodex is a combination of the same antibiotic ciprofloxacin, and dexamethasone, a steroid, to help with inflammation.
Reminder: Express Scripts also doesn’t cover most brand name nasal sprays for allergies. Their suggested alternatives are also flunisolide, fluticasone propionate, triamcinolone, and Nasonex—the only real difference here is that Express Scripts offers coverage for Qnasl where Caremark doesn’t. Again, generic fluticasone propionate and Nasonex are good alternatives, and you shouldn’t have trouble switching if necessary.
Trulicity (dulaglutide) is a new once-weekly injection approved for the treatment of type 2 diabetes, in combination with diet and exercise. It was approved by the FDA on September 18, 2014.
When will Trulicity be available?
According to the manufacturer, Eli Lilly and Company, the anticipated availability date for Trulicity is later this year.
What are the available forms and recommended dosages for Trulicity?
Trulicity is available in 0.75 mg and 1.5 mg single-dose pens, which are each dispensed in a carton of 4 pens. Each pen has a pre-attached, hidden needle and does not require mixing.
Does Trulicity need to be injected with meals?
No. Trulicity can be injected at any time of day without regard to meals.
Can this medication be used in patients with type 1 diabetes?
No. It is only indicated for the treatment of type 2 diabetes.
How should I store Trulicity once it has left the pharmacy?
Trulicity should be kept in the refrigerator at 36ºF to 46ºF. If needed, you can keep pens at room temperature no higher than 86ºF for up to 14 days.
Can I use Trulicity with other diabetes treatments?
Yes. Trulicity can be used with your other diabetes medications including certain insulin(s).
What are some side effects of Trulicity?
The most common side effects of Trulicity include: nausea, vomiting, diarrhea, stomach pain, and decreased appetite.
Are there any other precautions associated with Trulicity?
Yes. Trulicity has a boxed warning regarding the possible risk of thyroid tumors as well as thyroid cancer.
Trulicity is also contraindicated in (meaning it shouldn’t be used by) patients with a personal or family history of medullary thyroid carcinoma or in patients with multiple endocrine neoplasia syndrome type 2.
Medullary thyroid carcinoma accounts for 3-4% of all thyroid cancer diagnoses. Multiple endocrine neoplasia type 2 is the hereditary condition associated with the tumors of medullary thyroid carcinoma.
GLP-1 medications help increase the release of insulin from your body in the presence of elevated blood sugar levels. These medications also delay gastric emptying which means that they help you feel full longer.
Are there other similar treatment options for type 2 diabetes?
Where can I find more information on Trulicity?
For more info, check out the manufacturer website here.
The most frequently performed eye surgery in the United States is cataract surgery. After your cataract procedure your doctor will prescribe you several eye drops with the goal of suppressing inflammation and improving pain. Well, those drops may also cost you an arm and a leg. Here is what you need to know.
You may be given at least three different eye drops after cataract surgery, all at a hefty price.
Antibiotic eye drops.
A few tips here: ask your doctor if he/she can prescribe one that has a generic option, like gatifloxacin, so it’s not prohibitively expensive.
The eye doctors like the newer antibiotic eye drops because they believe there is less antibiotic resistance. Ok, I get that, but find one with a generic option or ask for samples because you’ll get sticker shock if you don’t.
Steroid eye drops.
Pred Forte (aka Omnipred) has a generic option called prednisolone acetate 1% which is a much less expensive steroid eye drop than the others. Price these out. Vexol and Maxidex (dexamethasone) are also popular steroid eye drops that have a more reasonable price tag.
NSAID eye drops.
Adding non-steroidal anti-inflammatory (NSAID) eye drops to steroid eye drops improves outcome after cataract surgery with less swelling, pain and light sensitivity. So the two together are better than each alone.
If cost is an issue, ask about the generic options but they reportedly sting more and need to be used several times a day as opposed to once daily.
Shop around for better prices, generic options, coupons and ask your doctor for samples. Otherwise, these are going to cost you.
We get lots of questions from folks who don’t understand how GoodRx works or how it can help them. 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.
Marie, a woman who lives in Texas, experienced her first migraine at 18. Today’s migraine drugs hadn’t been invented yet, so she would lie in bed for days, sometimes needing a shot from the doctor for the pain. When she was prescribed her first migraine medication in her thirties, she considered it a gift.
Today, drugs like Maxalt (rizatriptan) or Imitrex (sumatriptan) can stop a migraine, or at least make it more bearable. However, they work best when they’re taken at the first sign of symptoms. It’s much harder to get rid of a full-blown headache than to catch one as it starts.
Maxalt was a life-saver for Marie, and when she started taking the drug, her insurance paid for 24 tablets per month at a very reasonable $20 co-pay.
A few years back though, her plan decreased her limit to 15 tablets for $20, and then to only four generic tablets for $9. While her co-pay was low, her insurance wasn’t covering enough medication. Frustrated, she asked the pharmacist how much the full 24-pill prescription would cost. The response: $900. Yes, $900, for the generic.
Marie and her doctor have both appealed to her insurance provider, but they haven’t budged—four tablets per month is all they’ll cover.
She’s been making do with only four Maxalt each month for nearly two years.
When seasonal temperature fluctuations brought on week-long headaches, she held on to her limited supply and suffered; there was always a chance the next day would be worse. She felt like she was back to the old days, where all she could do was lie down in a dark room.
Marie first heard about GoodRx through a friend whose husband was also having trouble with his insurance. She wasn’t sure if it would work for her, but she thought it was worth a try. She asked her doctor for a prescription for the 18 Maxalt tablets her insurance wouldn’t let her have, and took it to her pharmacy with a GoodRx coupon.
A few minutes later, the pharmacist returned to the counter, handed her the full prescription, and charged her $39—95% less than the cash price she had been quoted.
She took a minute outside the pharmacy window just holding the coupon and giving thanks.
At around $50 for 24 Maxalt tablets instead of almost $900, Marie saves over $10,000 per year. Now, she can afford her medicine and she has peace of mind knowing that she’ll have relief when she needs it.
Do you have a GoodRx In Action story you’d like to share? Email us at firstname.lastname@example.org.