For women having trouble getting pregnant, the decision to try in-vitro fertilization (IVF) is a big deal. It requires 4 to 6 weeks of almost daily office visits, monitoring, and medication – and after everything’s said and done, the average cost of one IVF cycle is $23,000. Those who can afford it or whose insurance will cover it will often go through 2-3 IVF cycles to increase their chances of successful pregnancy.
Each year, about 1.5% of births in the U.S. are conceived through IVF. Fertility treatment is often recommended even after conception to help support and protect pregnancies. But now, progesterone in oil, an injectable medication that does just that, is facing a shortage.
Since the shortage began relatively recently in August, either the drug makers have not yet reported it to the FDA or the FDA has not yet updated their drug shortages database to reflect it. It is expected to be resolved late December at the earliest, which could affect many newly pregnant women in their first trimester.
What is progesterone in oil and why is it used?
Not to be confused with the two types of shots you have to take during the IVF cycle, progesterone in oil is only used after successful implantation through IVF. Progesterone in oil is an intramuscular injection, meaning you take the shot in the butt cheek. It helps thicken the uterine lining to secure the embryo and allow it to develop properly. A daily dose of 50mL is typically administered for the first 6-12 weeks (or first trimester) of pregnancy, but the dosage and length of treatment may be adjusted depending on how your body reacts to the initial doses.
While progesterone for fertility treatment is available in other forms, like oral capsules (generic progesterone, $23.76) and lozenges (not available retail), or vaginal suppositories (Endometrin, $235.34) and gel (Crinone, $422.50), many physicians consider the injection the first line therapy for women with infertility issues, either on its own or in conjunction with other forms. It’s also the cheapest option at $27.39 through GoodRx.
(In case you’re wondering, the other two shots are typically injected under the skin in the abdomen and thigh. Injections of gonadotropin hormones are taken throughout the IVF cycle to stimulate ovulation, while the human chorionic gonadotropin (hCG) injection is only needed 34-37 hours before the retrieval of the egg. The hCG hormone brings the egg to final maturation and assists in its release from the ovaries.)
What exactly is in shortage and why?
Surprisingly, the progesterone itself is not in short supply. Since the hormone comes as a powder that’s insoluble in water, it needs to be mixed with an oil to make it injectable. And it’s the oil that’s become hard to get – specifically sesame oil, which is the standard used by drug companies to produce the progesterone injection. Pharmaceutical grade sesame oil is considered different from food grade sesame oil (the stuff you find in grocery stores) because only certain production facilities following stricter FDA regulations are approved for drug production.
Since progesterone in oil is not officially reported as being in shortage, there is no way to know why there are limited supplies of sesame oil. But for any drug shortage, there are many factors to consider. Sometimes there’s a lack of raw material or a compliance issue during production. Or maybe the drug isn’t profitable enough for the drug company to prioritize manufacturing. The important thing is that the shortage is temporary, or that there are at least comparable alternatives for patients who rely on the treatment.
What if you need progesterone in oil – now?
Luckily, sesame oil isn’t the only oil used to make the progesterone injection. While leading drug manufacturers like Teva, West Ward, and Fresenius Kabi combine progesterone with sesame oil, some specialty or compounding pharmacies create made-to-order progesterone injections with ethyl oleate or olive oil (this is often done when a patient is allergic or has unwanted side effects with sesame oil). The key difference between the vehicles is the thickness of the oil – thicker oil requires a thicker needle, which may be more painful to use. Olive oil is the thickest of the three, while ethyl oleate is the thinnest.
One compounding pharmacy, MDR Fertility Pharmacy, has boosted their production of both progesterone in olive oil and progesterone in ethyl oleate during this shortage to help women in need of the progesterone injection. Robert Makhani, PharmD, MDR Executive Vice President, says MDR and other licensed sterile compounding pharmacies are working hard to ensure every patient who calls in can secure at least 2-3 vials of progesterone in oil (one vial lasts about 8-10 days). While Dr. Makhani is confident the shortage will end in January at the latest, he says MDR will fulfill orders well into the future, as needed.
Progesterone in sesame oil, brand name Progesterone Injection USP, will most likely be out of stock at your local retail pharmacy, like Walmart or CVS. It’s best to call and check to make sure it’s is available for pickup, even if it’s listed on the GoodRx page. If it’s not and you need it soon, call your fertility clinic to see if they work with any compounding pharmacies, or call MDR directly and mention “GoodRx” for competitive pricing.
Prices shown are average GoodRx discounted prices as of Nov 29, 2017. Local results may vary.
The next few months will mark the launch of generic alternatives for Viagra (sildenafil) and Cialis (tadalafil), the two most popular erectile dysfunction (ED) medications. Viagra, approved to treat Erectile dysfunction in men, could see a generic as soon as December 11th, 2017. Generic Cialis will arrive in pharmacies soon after, with an anticipated generic launch date of September 2018.
Here’s all you need to know about the upcoming generic launch of Viagra, and how to keep your costs down while you wait.
How popular is Viagra?
On GoodRx, Viagra is the third most popular PDE5 Inhibitor, a class of medications used for ED, hypertension, and enlarged prostate that also includes Cialis and Revatio. For ED in particular, Viagra is the second most popular drug after Cialis. Tens of million of American men have taken Viagra since it was introduced in 1998.
Popular, but not cheap: Since it has been available only from the brand manufacturer, cash prices for six tablets of Viagra have long been high and even increasing. Currently, the average cash price is around $73 for one tablet. What’s more, few insurance companies cover ED drugs like Viagra, forcing many people to pay out-of-pocket. The good news? A generic could hit pharmacies as soon as December 2017.
When will generic Viagra be available?
In March of 2016, Teva, a generic manufacturer, gained tentative approval for generic sildenafil from the FDA. So where is it? Unfortunately, in 2013, Teva reached a settlement agreement with Viagra manufacturer Pfizer that prohibited the generic from launching until December 2017. While this patent protection has postponed the savings, generic Viagra is close.
What will generic Viagra cost?
Generally, generic drugs first appear on the market at about a 50% discount to the brand. Unlike the brand, however, generic drug prices typically decrease very quickly as new manufacturers enter the market. Within a year of release, many generic versions of prescriptions can become very affordable, especially if multiple companies are making the generic.
One caveat for generic Viagra, though: Due to the settlement between Viagra and Teva, the generic sildenafil manufactured by Teva will be the only one on the market until April 2020. What does this mean? In short, it could mean higher prices for a good while. Fewer generic manufacturers decrease competition that drives prices down.
There is good news, though. As of 2016, at least nine other generic manufacturers have filed applications to manufacturing generic Viagra. So, as soon as Viagra’s patent expires in April 2020, more competitors will enter the space and likely drive costs down.
Can I take generic sildenafil instead of Viagra?
You might already know that generic sildenafil is already on the market, sold as a generic to Revatio, a popular pulmonary arterial hypertension drug. Generic sildenafil is much less expensive than brand name Viagra and is prescribed off-label by some doctors to treat ED. The bad news? This generic sildenafil is approved by the FDA for the treatment of pulmonary arterial hypertension, and is only available as a 20 mg tablet (Viagra is usually taken in 50 mg doses but is also available in 25 mg and 100 mg formulations). You will need to speak with your doctor to see if could be an option for you.
For more information about using sildenafil for ED, read here.
What about over the counter Viagra?
Over the counter Viagra is on the way, but not here in the US. The UK just recently became the first country where patients can buy Viagra over the counter (OTC), without a prescription. This decision by the Medicines and Healthcare Products Regulatory Agency (the UK’s FDA) is expected to reduce the use of unregulated, black market erectile dysfunction drugs. OTC Viagra, to be sold as Viagra Connect, will be available as a 50 mg tablet for £19.99, or $26.81 US dollars, for a 4-tablet pack. Pfizer, the drug’s maker, says it should be in UK stores by spring of 2018.
Are there any other ways to save on my ED medications?
- Remember to shop around. You may be surprised that prices for other alternatives could be less expensive. Compare prices for Viagra vs Levitra, Cialis or Stendra, three other common ED medications.
- Use a GoodRx Coupon. GoodRx offers discounts for Viagra, which can save you at least 15% off the full retail price.
- Save with a manufacturer coupon or patient assistance program. Viagra’s manufacturer, Pfizer, offers multiple ways to save. The Viagra manufacturer coupon can reduce your insurance co-pay by as much as 50%, while the patient assistant program can help you receive your medication at no cost, if you qualify. For more information on these programs, eligibility, and how to apply, be sure to read through our Viagra Savings Tips, or visit Viagra’s website.
- Fill a 90-day supply. Getting a 90 day supply instead of a 30 day supply can help shave a little more off of your out-of-pocket costs. Be aware that you will need a new prescription from your doctor, and approval from your insurance to fill for a higher quantity. Check in with your doctor, insurance, and/or pharmacist.
- If you have insurance, check your coverage. Many plans don’t cover ED drugs, but some will offer coverage for one or two preferred brands. You may be able to pay less at the pharmacy for Cialis or Levitra.
More than one in ten visits to a primary care doctor is for fatigue. Fatigue is composed of three major components: generalized weakness (difficulty in initiating activities), easy fatigability (difficulty in completing activities), and mental fatigue (difficulty with concentration and memory). While certainly not the only answer, medications may cause fatigue. Here are some of the common culprits.
Beta-blockers wear many hats. They are commonly prescribed to improve survivability after a heart attack, lower blood pressure, help prevent a migraine headache, and control heart rate in atrial fibrillation. But, there is a downside. They can make you sleepy.
Carvedilol (Coreg), atenolol and metoprolol are common offenders when it comes to fatigue, occurring in more than 10% of people taking them. In fact, a quarter to half of the folks taking beta blockers discontinue their use during the first year of taking them, often for fatigue.
Pro tip, starting at low doses and titrating up will help with the fatigue so lower doses of beta blocker, increasing over time, is the way to go.
These are medications used for allergies, hives, nasal congestion, and itchy rashes. Benadryl, Atarax and cyproheptadine are all very sedating, and most available over-the-counter. Over the counter meds ending in ‘pm’ like Tylenol PM contain Benadryl and of course will cause drowsiness.
Many folks taking muscle relaxants for back or neck pain have no idea these may make them feel like Gumby for a few days. Commonly prescribed muscle relaxants cyclobenzaprine, Soma (carisoprodol) and Zanaflex (tizanidine) are hugely sedating.
Amitriptyline and Nortriptyline are also used to treat depression, chronic pain, and migraine and cause drowsiness and fatigue. In some studies, up to 40% of folks taking these two reported fatigue. That’s high.
Another good option? Studies have shown that bupropion SR and XL (Wellbutrin XL) are just as effective as SSRIs for the remission of major depressive symptoms. Those taking bupropion are less likely to suffer symptoms of sleepiness and fatigue than those treated with SSRIs.
Topiramate causes drowsiness and fatigue in up to 15% of people using it. Commonly used for prevention of seizures, migraine headache and weight loss (Qsymia contains topiramate), Topamax carried the nickname Dopamax because those taking it may feel ‘dopey.’
And last but not least
- Narcotics like hydrocodone, oxycodone, and acetaminophen/codeine may make you sleepy.
- Benzodiazepines like Ativan (lorazepam), Valium (diazepam) and Xanax (alprazolam) often cause you to feel sleepy.
Pattern of Adverse Drug Reactions Reported with Cardiovascular Drugs in a Tertiary Care Teaching Hospital. J Clin Diagn Res. 2015 Nov;9(11)
Discontinuation of beta-blockers in cardiovascular disease: UK primary care cohort study. International Journal of Cardiology Vol 167 (6) 10 Sept 2012 pages 2695-2699.
New medications used to treat type 1 and type 2 diabetes are popping up left and right. From 2013-2016 there have been 15 new oral and injectable medications approved for the treatment of diabetes alone.
What’s noteworthy about this class? There’s a possibility that we might see some oral GLP-1 inhibitors soon! This could mean no more painful injections.
But first, what are GLP-1 agonists?
GLP-1 agonists are considered non-insulin injections that help to improve blood sugar control and control weight in patients with type 2 diabetes. Drugs in this class work by slowing the release of food from your stomach, reducing the amount of sugar your liver releases, and controlling the amount of insulin released into your pancreas.
GLP-1 agonists work strategically to control your blood sugar and can help lower your A1C by 0.8% to 2%. The downside? GLP-1 agonists are only available as injectables.
Will we see oral treatments in the foreseeable future?
Possibly! A leader in diabetes care, Novo Nordisk, has been working on an oral GLP-1 formulation that’s comparable to the current injectable formulations.
Before the possibility of an oral GLP-1 agonist, Novo Nordisk will most likely receive approval for their once-weekly injection, semaglutide.
But have no fear, Novo Nordisk has been testing the oral form of semaglutide in patients with type 2 diabetes. There are two current clinical trials that show a lot of promise for oral GLP-1 agonists, PIONEER 2 and PIONEER 8. In both of these trials, oral and injectable forms of semaglutide were related to an average drop in A1C by about 1.9%, and an approximate weight loss of at least 5% for most people.
At this point, the possibility of a once-daily oral GLP-1 agonist may soon become a reality for those with type 2 diabetes. Stay tuned!
Mealtime insulins, or fast-acting insulins, are injected before or after each meal to regulate the blood sugar. Type 1 diabetics require mealtime insulin injections as their pancreas does not produce insulin, whereas type 2 diabetics may only require mealtime insulin if they struggle with blood sugar control after meals or are not achieving their target A1C.
What is Fiasp indicated for?
Fiasp is a rapid-acting insulin indicated to improve blood sugar control in adults with type 1 or type 2 diabetes.
It will be available as a 10 ml multi-d0se vial, and a 3 ml single-use disposable FlexTouch Pen.
What dose of Fiasp will I need?
Your doctor will determine your exact dose based on your metabolic needs, blood sugar monitoring results, and your blood sugar control goal.
Dose adjustments may be needed if you experience changes in kidney or liver function, physical activity or meal patterns.
Is there anything unique about Fiasp?
Yes. Fiasp is a new formulation of NovoLog, in which the addition of niacinamide (vitamin B3) helps to increase the speed of the initial insulin absorption, resulting in an onset of appearance in the blood in approximately 2.5 minutes.
Is Fiasp approved for kids?
No. At this time Fiasp is not approved in pediatric patients.
For more information, see the press release from the manufacturer Novo Nordisk.