Since the FDA created the Priority Review Program, aimed at fast tracking the development of drugs used to treat serious conditions, new hepatitis C medications are being approved at a faster rate.
Recently, the FDA approved Mavyret, a new combination medication for hepatitis C.
What is Mavyret prescribed for?
Mavyret is a combination medication indicated for the treatment of all major genotypes for chronic hepatitis C.
Mavyret will be available as a combination tablet in the strength of 100mg/40mg, supplied in a 4-week (monthly) dose wallet. The recommended dose is 3 tablets once daily, for 8 weeks, with food. You may need to take Mavyret for longer than 8 weeks if you have been previously treated with other medications, or have mild liver disease.
What are the most common side effects associated with Mavyret?
The most common side effects include headache and fatigue. Be sure to speak with your doctor if you experience any of these side effects for a prolonged period of time.
Is there anything unique about Mavyret?
Yes. Mavyret is the only 8-week treatment for patients with hepatitis C, without liver disease, who have not been treated before.
How much will Mavyret cost?
Abbvie has priced Mavyret at $13,200 per month, or $26,400 per treatment course, before discounts. Although this is still expensive, Macyret is priced significantly lower than other hepatitis C treatments. For instance, popular medications Epclusa, Sovaldi and Harvoni are priced at $74,760, $84,000, and $94,500 respectively.
There is good news, though! Abbie offers a co-pay assistance program for commercially insured patients. If you are eligible, you may pay as little as $5 per co-pay using their Abbvie HCV Co-Pay Card. Visit the website here, and call 1-877-628-9738 to learn more and find out if you are eligible.
If you’ve got health insurance, now’s a good time to be paying attention. Each year, prescription coverage changes, and yours will likely be changing in 2018.
Express Scripts and Caremark, companies that handle pharmacy benefits for more than 200 million Americans, are removing more than 80 prescription medications from their formularies at the end of 2017. There is a silver lining for some of you though—almost 20 currently excluded drugs will be covered in 2018.
Find out below how your coverage may be changing next year.
What are Express Scripts and Caremark?
Express Scripts and Caremark are companies that administer prescription drug benefits for many health insurance companies and Tricare. While you may have health insurance from Anthem, Aetna or another insurer, your pharmacy benefits are usually handled by these companies or their competitors. They also set the formulary for everyone under their prescription drug benefit.
What do formulary changes mean for you?
Listed below are brand name drugs for which there may be a less expensive brand or generic alternative available. If your benefits are provided by Express Scripts or Caremark and you are filling one of these prescriptions, you’ll pay the full cash price at the pharmacy in 2018. (You can see estimated cash prices on GoodRx by clicking on a pharmacy name after you look up a drug.)
If your coverage is changing, talk to your doctor to see if a covered alternative might work for you. If you can’t switch, you may be able to use GoodRx or find patient assistance programs to help cover the cost.
Which drugs are affected?
⇒ Express Scripts: 64 new drugs have been added to the Express Scripts national formulary exclusion list.
The biggest change for many folks will be the exclusion of epinephrine pen Auvi-Q and epinephrine (generic Adrenaclick)—the main competitors to EpiPen. This isn’t great, but how it affects you will depend on which version you use, and how much you’re paying now. The Adrenaclick generic has less-expensive cash prices, starting at $110, but EpiPen (and its generic alternative) are still more popular overall.
If you use a long-acting powerful pain medication, you may want to check your coverage—Express Scripts will also be excluding Opana ER and generic oxycodone ER, along with Lazanda (fentanyl). Abstral and Fentora (also fentanyl pain medications) are already excluded. Your covered options will be mostly generics like hydromorphone ER, morphine sulfate ER, oxymorphone ER, and fentanyl citrate lozenges.
To be fair, 46 of 64 newly excluded drugs are simply brand-name drugs that now have a generic alternative—and several of the others are brand-only drugs with similar generics available in the same class.
⇒ Caremark: 19 new drugs have been added to the Caremark national formulary exclusion list. Similar to Express Scripts, 5 of these are brands with generic alternatives available, and several others have similar options in the same class.
On the other hand, Caremark is adding 19 drugs back to their covered formulary, some as preferred medications and other non-preferred (meaning you may need a prior authorization or step therapy to get coverage). This is great news, as there are some commonly used medications on this list that don’t have generics or close alternatives. These include asthma and COPD inhalers Symbicort, Dulera, and Incruse Ellipta; Levitra for erectile dysfunction; and Invokana and Invokamet for diabetes.
2018 Excluded Drugs
You can see all of the excluded medications below. For a full list of excluded drugs and covered alternatives, see the Express Scripts list here and the Caremark list here. If you’re not sure which company provides your pharmacy benefit, contact your plan administrator.
Aciphex (sprinkle) (Express Scripts)
Adderall (Express Scripts)
Androgel (1%) (Express Scripts)
Anusol HC (Express Scripts)
Atacand (Express Scripts)
Atacand HCT (Express Scripts)
Auvi-Q (Express Scripts)
Azor (Express Scripts)
Benicar HCT (both)
Bupap (Express Scripts)
Cymbalta (Express Scripts)
Cytomel (Express Scripts)
Effexor XR (both)
epinephrine (generic Adrenaclick) (Express Scripts)
Femring (Express Scripts)
Forteo (Express Scripts)
Fosrenol (Express Scripts)
Imitrex (Express Scripts)
Inderal LA (Express Scripts)
Intuniv (Express Scripts)
Lazanda (Express Scripts)
Lexapro (Express Scripts)
Librax (Express Scripts)
Lidoderm (Express Scripts)
Lovenox (Express Scripts)
Lunesta (Express Scripts)
Minastrin 24 Fe (Express Scripts)
Nasonex (Express Scripts)
Neupogen (Express Scripts)
Nevanac (Express Scripts)
oxycodone ER (Express Scripts)
Plaquenil (Express Scripts)
Plavix (Express Scripts)
Prevacid (Express Scripts)
Prilosec (suspension) (Express Scripts)
Pristiq (Express Scripts)
Protonix (Express Scripts)
Provigil (Express Scripts)
Prozac (Express Scripts)
Pulmicort Respules (Express Scripts)
Renagel (Express Scripts)
Sandostatin LAR Depot (Express Scripts)
Seroquel (Express Scripts)
Seroquel XR (both)
Signifor LAR (Express Scripts)
Singulair (Express Scripts)
Strattera (Express Scripts)
Sumavel Dosepro (Caremark)
Synjardy XR (Caremark)
Synvisc One (Caremark)
Tikosyn (Express Scripts)
Timoptic Ocudose (Express Scripts)
Tobi (solution) (Express Scripts)
Tribenzor (Express Scripts)
Trulance (Express Scripts)
Valium (Express Scripts)
Valtrex (Express Scripts)
Vytorin (Express Scripts)
Wellbutrin SR (Express Scripts)
Xanax (Express Scripts)
Xanax XR (Express Scripts)
Xenazine (Express Scripts)
Zegerid (Express Scripts)
Zoloft (Express Scripts)
Zyflo CR (Express Script
An important note about Medicare and individual plans:
These changes DO NOT apply to Medicare plans; if your Medicare benefit is managed by Express Scripts, you should check your coverage with your pharmacist or online through the Medicare.gov portal.
Some individual private insurance plans managed by Express Scripts or Caremark may also have different coverage. This means different drugs may be covered or excluded on your plan if you have coverage through work, for example. Please get in touch with your insurance provider if you have any questions about your coverage.
Low back pain is a part of life—common across sexes, age groups, and countries, it’s something that almost all people experience at some point. Treatment for low back pain often includes a combination of medication and non-medication options. What should you start with? What treatments have the best evidence? And more importantly . . . what’s coming our way for low back pain treatment?
To start #OldSchool—the best evidence exists for these three treatments:
- Non-steroidal anti-inflammatory drugs (NSAIDS). Which NSAID? Ibuprofen (Motrin, Advil), naproxen (Aleve), and celecoxib (Celebrex) are common examples. There does not appear to be a “best” NSAID for low back pain from the evidence. Start with low doses and go higher if needed, aiming for short term use. If you can’t take NSAIDS (stomach issues, kidney problems) take acetaminophen (Tylenol) instead.
- Muscle relaxants. Adding a muscle relaxant to an NSAID improves low back pain. Start with one that doesn’t make you tired like methocarbamol (Robaxin) or metaxalone (Skelaxin). See my previous blog here for full discussion on muscle relaxants for low back pain.
- Heat. Superficial heat for low back pain has been shown to help. There is moderate evidence from a small number of studies that heat wrap therapy provides short-term reduction in pain and disability in those with acute or sub-acute low-back pain (less than 12 weeks). When using heat wraps, use them only for 15-20 minutes at a time. Don’t fall asleep with them on.
Ok, then what’s next for back pain?
- Physical therapist or chiropractor. To sum up the evidence here: for low back pain, physical therapy and chiropractic manipulation have similar effects on symptoms, function, satisfaction with care, disability, recurrences of back pain, and subsequent visits for back pain. So think of them as being equally effective. I’d pick whichever one is more convenient and covered more by your insurance.
- Other exercise therapy. For example,yoga, tai chi or qigong. There is fair evidence that yoga and movement therapies will help for your back pain. Pursue them on your own and stick with one that interests you the most and is the most convenient.
- Other alternative therapies. Mindfulness stress reduction (meditation + yoga) and cognitive behavioral therapy outperformed NSAIDS in a recent study. Both are worth a try for sure if you are struggling with low back pain. Acupuncture, though—not so much. In the last two years a review of scientific evidence found the practice of acupuncture was no better than placebo in treating those living with low back pain and sciatica. Gua sha is another alternative therapy that may exhibit a more long-lasting anti-inflammatory effect relative to hot pack for pain relief and improved mobility in elderly patients with chronic low back pain.
What’s next for those with chronic, neuropathic (nerve-like) low back pain?
- Gabapentin (Neurontin) or duloxetine (Cymbalta) have the best evidence in addition to the above listed options for nerve-like pain in your low back that may radiate down your buttock or leg. Tramadol (Ultram) may also be added to your regimen at this point.
- The hot-button issue: Opioids for low back pain. Opioids are no more effective than NSAIDS for low back pain and have a high rate of adverse effects (the understatement of the year). Avoid opioids at all costs for low back pain.
Moving on—invasive procedures:
- Epidural steroid injections. Steroid injections in the lumbar spine are performed by pain management or interventional radiologists, and they do work. Epidural injections done with several approaches (interlaminar, caudal, or transforaminal) have been shown to reduce pain and disability short term (usually at 2 weeks) and help delay the need for surgical intervention. Epidural steroid injections may provide relief for a period of time and additional repeat injections are an option if pain recurs.
The future—and beyond:
- Radiofrequency denervation aka radiofrequency ablation (RFA) was the rising star, but a recent large study revealed disappointing results. RFA is a medical procedure where the nerve is ablated (the nerve endings are deadened) using high frequency alternating current. But does it work for chronic low back pain? Not so well. A recent study (JAMA July 4; 318(1):68-81) found radiofrequency denervation added to a standardized exercise program for chronic low back pain resulted in either no improvement or no clinically important improvement compared with a standardized exercise program alone. To sum it up: the findings do not support the use of radiofrequency denervation to treat chronic low back pain originating in the facet joints, sacroiliac joints, or intervertebral disks. Disappointing.
- Platelet rich plasma. Platelet rich plasma (PRP) has shown promising results when injected into the intervertebral disc and is currently being studied. PRP is high in growth factors, which is why it’s being studied, yet there are no active studies for low back pain being done. Will PRP help for low back pain? We don’t know yet, and won’t for a while.
- Stem cell therapy to regenerate cells and increase disc matrix production (the gel- like central part of the disc) is also currently being researched. This may be coming our way for low back pain, but no results yet.
- Cannabis. Studies on cannabis/medical marijuana are limited because it is still illegal under federal law, but several trials have evaluated the effectiveness of cannabis for patients with neuropathic pain. Patients with nerve pain from spinal stenosis or degenerative disc disease show a 30% improvement in chronic pain score following cannabis therapy. Pain relief provided by cannabis is dose-dependent, with higher THC content producing more pronounced pain relief. Know this: the strains of cannabis containing high levels of CBD (cannabidiol) generally make patients feel less high, since CBD acts as an antagonist to the psychoactive effect of THC. Consider starting with high-CBD, low-THC strains if you are concerned about feeling high.
What has helped for you?
If you’ve ever had prescription eye drops, you know that those tiny bottles can cost a pretty penny, and can be challenging to apply in the eyes. Eye drops can be used for many reasons like allergies, infections, inflammation, dryness or vision disorders.
Here are seven tips to help you get the very last squeeze out of your eye drops.
Don’t waste your drops.
Eye drops can be expensive, so it’s important to make sure you’re wasting as little as possible. If you have trouble applying eye drops, an eye drop guide may help. The AutoDrop Guide, the Magic Touch, and the Simply Touch are three popular guides that can help you easily apply your drops.
Make sure you know if your eye drops require any special instructions.
It’s important that eye drops are sterile when placing them into your eye. Therefore, it’s essential that you abide by any special instructions like:
- Storage requirements. Some drops, like Xalatan (latanoprost), should be stored in the refrigerator if unopened. However, once the bottle has been opened you can store the bottle at room temperature for 6 weeks.
- Expiration limitations. Some eye drops require that you throw it away after 14 days.
- Special directions. Some eye drops need to be mixed or require that you wait a certain amount of time before applying another drop of a different medication. Make sure you read the special instructions before using your eye drops.
Ask your doctor for samples.
The old saying “ask and you shall receive” can apply to prescription eye drops. Some doctors may be able to supply you with a sample bottle of an expensive prescription eye drop, and all you have to do is ask! Many doctor’s offices have a closet full of sample medications from pharmaceutical reps they can give out to you free of charge.
Some eye drops are now available over the counter.
The beauty of OTC medications is the convenience and ability to select a medication for your specific symptoms. Although a visit to your doctor’s office is typically not required, it is always recommended to check with your doctor or pharmacist before beginning to peruse the OTC aisles.
Make sure your eye drops don’t interact with anything else.
Regardless if you take a medication by mouth, apply it on your skin, inhale it into your lungs, or drop it into your eye it will still be absorbed into your blood stream and distributed throughout your body. Eye drops do have a more local effect meaning that they treat the problem you may be having in your eye; however, the medication can still get into your blood stream. This makes it important to disclose any other medications you may be taking to your doctor or pharmacist
Do the math.
Insurance companies won’t allow you to fill your medication if they think it’s too soon, based on the calculation the pharmacy provides them with. This means that it might be helpful to know the number of drops your bottle contains.
The most common conversion is 20 drops per 1 ml; however, some insurance companies may calculate it differently by using 15 drops per 1 ml or even lower at 12 drops per 1 ml. This means that a standard 1 ml bottle will contain 100 drops of medicine.
This calculation can give you an idea of how soon you can refill your medication.
Eye drops can be used in other places.
That’s right, eye drops are multi-purpose – they can be used in places other than just the eyes. Some eye drops are extremely versatile and can be used in places such as in the ears, on the tongue, or onto the nails.
Keep in mind that you shouldn’t use your eye drops in other places unless instructed by your doctor.
Female Pattern Hair Loss (FPHL) is the most common cause of hair loss in women. While the cause is unknown, FPHL is more common in women with obesity, high blood pressure, and insulin resistance (pre-diabetes).
FPHL mainly affects the mid and frontal regions of the scalp, while preserving the frontal hairline. Your part gets wider, and hair near your temples may recede, but you will not lose all of your hair. Noticing that your part is widening, or your ponytail is thinning, may bring you to your doctor. Help! What works?
Common myths about hair loss in women
- Genetics do not appear to play a role in female pattern hair loss. No definitive familial inheritance has been identified in women, unlike in men with androgenic alopecia (“male pattern baldness”) where genetics play an important role from both mom and dad’s side.
- The majority of female hair loss is NOT tied to high levels of androgens (male hormones). Only 39% of women with FPHL have high androgen levels whereas male balding is a genetically determined androgen-dependent trait.
- Taking oral estrogen (hormone replacement therapy) has no clear effect on hair growth and in some studies showed an inhibitory effect.
Medical causes for hair loss in women
Before you make the diagnosis of Female Pattern Hair Loss (FPHL) which has no known causes, look for these:
- An under or overactive thyroid. Hypo or hyperthyroidism may cause hair loss, and is easy to rule out with a blood test called TSH (thyroid stimulating hormone).
- Iron deficiency anemia. A common complaint in iron-deficient women is hair loss, with increased loss reported in women with ferritins less than 100ng/dL. That’s an easy blood test.
- Psychological and emotional stress. A major illness, severe psychological trauma, significant weight loss and childbirth may precipitate an episode of hair loss that begins a few months after the episode. This is called telogen effluvium, and hair loss occurs in all areas of the scalp.
- Polycystic Ovarian Syndrome (PCOS). Sometimes this condition causes your body to produce too many androgens, which can decrease the growth of hair on your scalp.
- Medications. Some common culprits include beta blockers, antidepressants, anticoagulants, and chemotherapy drugs. Read more about this in our blog here.
Options for treating hair loss
Once your hair loss has been determined to be FPHL, and not related to one of the above-listed conditions, here are your options:
- Topical solutions of 2% minoxidil (Rogaine). Minoxidil, applied as 1 ml twice daily, is the only drug approved by the FDA for the treatment of female pattern hair loss. What is interesting is that minoxidil 2% and 5% have basically the same result.
- Oral finasteride (Propecia). While finasteride 1 mg tablets have not been shown to be helpful, a few studies have shown improvement with finasteride 5 mg daily.
- Zinc sulfate + calcium pantothenate. These are over the counter supplements. For those using daily topical minoxidil adding zinc sulfate capsules 220 mg + calcium pantothenate tablets 100 mg twice a week was better than with minoxidil alone. Worth a try!
- Spironolactone (Aldactone). There is some evidence that using Aldactone (spironolactone) at a dose of 100-200 mg a day benefits women who haven’t responded to the use of topical Minoxidil.
- Platlet rich plasma (PRP) scalp injections. Very recent studies have shown that PRP injected into the scalp can improve both hair density and thickness. The basic idea behind PRP injection is to deliver high concentrations of growth factors to the scalp, which the hope of stimulating hair regrowth.
Hope this helps!