The GoodRx Prescription Savings Blog

The latest updates on prescription drugs and ways to save from the GoodRx medical team

Here’s What To Do When You Can’t Take Viagra

by Katie Mui on February 16, 2018 at 3:29 pm

Last December, not one, but two generic versions of Viagra (sildenafil) became available in pharmacies. As a result, men can now purchase the erectile dysfunction (ED) treatment for as low as $17 with GoodRx, compared to $72 for the brand version. And although Viagra is an extremely popular medication, with more than 60 million men worldwide having used it since 1998, it’s not the answer for everyone.  

Below, Tim Aungst, PharmD and owner of The Digital Apothecary, shares his experience helping patients who are looking for ED treatment outside of Viagra and the class of drugs that work like it (PDE-5 inhibitors).


Consider the case of Mr. Jones, a patient I was helping in an outpatient cardiac clinic. Most of my patients are on multiple medications for their heart conditions and other complicated issues, so I often review their medications to make sure everything is all right. This includes screening labs, checking vitals, reviewing past reports, and conducting drug interaction checks related to therapy. If there are any concerns, I’ll meet with the patient and make recommendations to the healthcare team.

At his last visit, Mr. Jones was prescribed Imdur (isosorbide mononitrate) to help with his heart condition. Reading through the notes, it looked like the Imdur worked. He was feeling better – so much better that he wanted to start having sex with his wife again. And here was the problem: Mr. Jone’s doctor had renewed his Cialis (tadalafil) prescription.

The issue? Well, if you really listen to the advertisements on television for erectile dysfunction (ED) medications, ignoring the jazz from Viagra or the sunsets from Cialis, you may hear the line “Do not take if you take nitrates for chest pain, as it may cause an unsafe drop in blood pressure.” Viagra, Cialis, and Levitra belong to the same drug class called Phosphodiesterase 5 Inhibitors (abbreviated as PDE-5 inhibitors), and they all share the same interaction with nitrates. Many patients wonder how bad can a ‘drop in blood pressure’ be. The answer, as we learned after Viagra came out, is this reaction can lead to heart attack in patients and potentially cause death, leading to a black box warning for the whole class of drugs like Viagra.

Mr. Jones is on a nitrate, specifically Imdur. Fortunately for him, he had not yet used the Cialis. I advised him to avoid the combination, based on his significant cardiac history. But what can patients with ED and taking nitrates do to engage in an active sex life?

There is another drug that came out before Viagra, called alprostadil, available under two brand names: Caverject and Muse. It works by relaxing the penile tissue allowing for easier blood flow leading to an erection. The plus side is it works relatively quickly; the downside is that is not available as a pill.

And there’s the rub. Caverject must be directly injected into the base of the penis to work. Muse is an intraurethral (a fancy way of saying ‘insert via urethra’) version of alprostadil that comes as small pellets that have to be inserted into the urethra by the patient.

For many patients, when I mention there is another option to Viagra and other PDE-5 Inhibitors, their eyes light up, quickly followed by a nervous look as they find that it requires an injection to their penis or inserting something directly into their urethra. At this point, to not completely turn off the patient, I do try to get some information in to help them make a decision.

While both Caverject and Muse share the same active ingredient, there are some pros and cons of each. Caverject tends to work much faster (<10 mins) as it enters the bloodstream quicker, and has been found to work better. The drawback though is that it is an injection that needs to be applied to the base of the penis, and can cause irritation to the surrounding tissue. And let’s be honest, most men don’t want to engage in sex with a bruised member. It has a higher risk of causing priapism (basically an erection lasting for more than 4 hours, which incidentally is named after Greek god Priapus).

Muse, on the other hand, can cause a burning sensation to the penis along the urethra (this happens around 20% of the time) and it takes a little longer to work than the injectable formulation. But for men that don’t want a needle in their penis, it is an alternative. For this reason, I generally recommend starting with Muse prior to moving onto Caverject.

You’re probably wondering why alprostadil can’t just be applied directly to the penis as a topical agent instead of directly injecting or inserting it. A study conducted in 2006 in 1732 patients using a topical formulation did demonstrate some efficacy (though less than Caverject or Muse). Common side effects were burning sensation (for both men and women) though this was relatively low, with only 2.7% of subjects stopping its use. Currently, drug manufacturer Apricus Biosciences is looking to bring this formulation, named Vitaros, to market in the US (it’s currently available in Europe) but FDA approval has been slow. When and if this formulation makes it to the US market, it may be preferred by men who cannot take PDE-5 inhibitors.

Talking to Mr. Jones and those like him about these options takes some time and often requires some trial and error to find what works. At this point, I usually recommend most men to start with Muse and see if they have success with it, and if not they can move on to Caverject (they both run at about $75-$105 a dose). Some men are fine starting with Caverject right away and don’t mind the administration, but I would say it comes down to personal preference on what side effects are manageable for the patient.


Here’s How to Get Birth Control Without a Doctor’s Prescription

by Katie Mui on February 13, 2018 at 5:06 pm

More and more women across the U.S. can now use hormonal birth control without going through the hassle of having a doctor prescribe it.

7 states – Oregon, California, Colorado, Washington, New Mexico, Hawaii, Tennessee, and Maryland – and Washington, D.C. now allow pharmacists to prescribe birth control, saving women a trip to the doctor’s office. California, Maryland, and D.C. ensure residents get full access to contraception by also providing a 12-month supply at a time and requiring insurers to cover the entire cost. (Women in Illinois and Vermont also can get a 12-month supply paid by insurers, but only with a doctor’s prescription).   

How does it work? What do I do to get a prescription?

  1. Call your pharmacy to see if they offer the birth control prescription service. If not, you may have to call around to find one that does.
  2. When you get to the pharmacy, you’ll be given a short screening questionnaire and have your blood pressure taken to make sure hormonal contraception is appropriate for you. Trained pharmacists will know the pharmacology and screening procedures, and will know how to assess which method is best for each individual, so you’ll be in good hands.
  3. Your pharmacist will work with you to find a brand you can afford, with or without insurance. Refer to our explainer on birth control pills to understand all your options. In some cases, GoodRx can beat your insurance, and you can always use a GoodRx discount instead of your prescription insurance if the cost is lower.

What does this mean for me, specifically?

If you live in Oregon, California, Colorado, Washington, New Mexico or Hawaii, your state law is already in effect. Check the map below (thanks to the Kaiser Family Foundation) to see what type of birth control pharmacist in your state can prescribe. At the minimum, they can recommend and prescribe birth control pills, which have a 9% failure rate with typical use (compared to the 18% failure rate of condoms). California is currently the only state where women can receive a whole year’s supply in one visit.

If you live in D.C., Tennessee or Maryland, expect pharmacy programs to start rolling out as early as January 2019. We’ll report here on the GoodRx blog as we get more information.

What’s the catch?

Making birth control easier to access should encourage more women to get protection. In a 2013 study, 28.0% of participants not using any birth control and 32.7% of participants using a less effective method said they would use oral contraceptives pills if they were available over-the-counter. While the current laws don’t quite make birth control over-the-counter, they do mean women who would otherwise be restricted by work hours, child care, transportation, and money will have more options.

But even though these laws are in place, the service is not mandatory for pharmacies. Researchers found that only 11% of California retail pharmacies offer the service, one year after the law was put into effect. Requirements vary by state but they all require at least some training, so not every pharmacy can automatically offer the service. To see the larger impact legislatures and supporters hope for, more pharmacies would have to get on board. For example, Safeway is the first major retailer in Colorado dedicated to training their pharmacy staff.

One last thing: It’s not free. Pharmacies that do offer the prescription service typically charge between $25-$50. Because the Affordable Care Act only requires insurers to cover family planning services from healthcare providers, women would have to bear the full cost of the pharmacy consultation themselves; some may not be able to. Some states are making moves to change this: Oregon requires Medicaid to pay for the service, while California is hoping to do the same by 2021.


Here’s What You Need To Know About Your Meds If You’re 65 Or Older

by Katie Mui on February 6, 2018 at 3:35 pm

As we get older, our bodies start turning on us. Our blood pressure begins to rise, joints develop arthritis, and arteries start clogging up. We end up taking more and more medications. Some 90% of people over the age of 65 take at least one medication per week, and 40% take five or more. 1 in 6 people in this age group will inevitably experience a harmful side effect of a drug they are taking regularly.   

To prevent these sorts of adverse events, the American Geriatrics Society (AGS) developed a database called the Beers List to flag drugs inappropriate for people 65 years of age or older.

Why are some drugs dangerous for older people?

People in the geriatric group are twice as likely to experience medication side effects than younger people. That’s primarily due to three things:

  1. Our body composition changes as we age. We lose water and gain fat, so water-soluble drugs don’t dilute as well while lipid-soluble drugs nestle into our fat layers and are absorbed faster. In both cases, the concentration of the drug inside the body increases, which boosts the chances of side effects. With more of a drug circulating within the body, interactions with things like other drugs, supplements, certain foods, and alcohol are also more likely.
  1. Our liver and kidneys, two of the organs responsible for breaking down drugs, stop working as efficiently. When our metabolism decreases, drugs stay in our system longer, which can also lead to increased side effects.
  1. Older people tend to take more medications than younger people – and more drugs in the system mean higher risk of complications.

The Beers Criteria List

The Beers List, named after Dr. Mark Beers, was first released in 1991, with the most updated version being 2015. The list is meant for physicians prescribing drugs to older patients, but it’s also a good reference for patient education.

If you are 65 years old or above, or you’re looking after someone who is, it’s important to get a sense of what medications to avoid. You can look at the full list, which covers dozens of conditions and hundreds of medications, here. There is a surprising number of common medications on that list – including many that are available over-the-counter (OTC), which people generally assume are safer than prescription drugs.

Let’s take a closer look at some drug categories that are included in the Beers List 2015:

Cardiovascular drugs

Chronic high blood pressure (hypertension) is a common condition for older folks, with an estimated 64–79% of people over the age of 65 diagnosed with it. Doctors should check the Beers List when prescribing hypertension medications, though, because the drugs’ effects can go too far the other way, causing blood pressure to drop too low or slowing the heart down too much.
Included on the list:

Pain relief drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin and ibuprofen are some of the most commonly used OTC meds. But older people should be cautious and use them sparingly as they can have bad side effects, like gastrointestinal bleeding. It’s well-documented that long-term use of NSAIDs can take a toll on the liver and kidneys of older patients, increase their blood pressure, and cause headaches or dizziness.
Included on the list:

Antihistamines

In an older post about OTC antihistamines, we mentioned that first-generation allergy relief drugs can have many side effects, including sedation, drowsiness, or dizziness – all of which can lead to falls. Anyone 65 years of age or older should be careful when taking these meds due to the increased risk of falls.
Included on the list:

Anti-anxiety drugs
Benzodiazepines (“benzos”) are commonly used to treat anxiety. Beers recommends older patients avoid this class of meds due to exacerbated side effects, including cognitive impairment, feeling tired or having delayed reaction time. If prescribed to older adults, clinicians will want to use the lowest therapeutic dose so there’s less of the drug in the system.
Included on the list:


4 Tips If You Have A Kid With The Flu

by Katie Mui on January 25, 2018 at 12:49 pm

Thirty children have died so far this flu season, according to the latest CDC report released last week. It bears repeating: the best way to protect your kids from the flu is to have everyone 6 months or older in your household vaccinated. It can be scary if your child starts showing signs of the flu (fever, chills, muscle aches, ear pain, and respiratory issues), so here are some tips for getting them the appropriate care right away.   

1. Go see a doctor 

Children younger than 5 years old, and especially those younger than 2, are considered to be at high risk of developing flu-related complications – but given that some recent cases in the news have involved children well over the age of 5, it’s better to play it safe.

Most doctors will prescribe an influenza antiviral, like Tamiflu and Relenza (both approved for children), to a child presenting flu symptoms. These medications are most effective when taken within 1 or 2 days after symptoms start, so it’s best to get your child to a doctor right away.

It’s doubly important to seek medical attention if your child has another risk factor, such as asthma, diabetes, heart disease, kidney or liver disorder, among other conditions.

2. Not so fast with the over-the-counter meds

If you aren’t able to get to a doctor right away, or if you want to help relieve some your child’s symptoms with over-the-counter medicine, it’s important to know what’s actually safe to give them. The average drugstore carries over 300 cold and flu products – all generally suitable for adults, but perhaps not so much for children.

First, children under the age of 2 should not be given any cold and flu medicines at all – take them to a doctor. That’s been the recommendation since a voluntary proactive withdrawal in 2007 took most infant cough-and-cold medications off shelves. Follow-up studies showed that ER visits due to potentially life-threatening side effects were cut in half after parents were no longer advised to treat children in that age group.

All cold and flu medications, branded for children or not, will have dosage directions for different age groups on the back of the box. Pay attention to these guidelines, especially when they say “do not use” for children under a certain age (usually 2 or 4 years old).

3. You probably don’t need to double up  

One of the major problems with OTC cold and flu meds is that they are combination drugs with more than one medicine in them. For instance, Alka-Seltzer Plus Day Cold and Flu contains 3 active ingredients: acetaminophen (painkiller & fever reducer), dextromethorphan (cough suppressant), and phenylephrine (decongestant). For the average person, it can be almost impossible to understand all the ingredients listed on the box. It’s also easy to assume that, for example, if you’re suffering from body aches, taking a Tylenol or Advil on top of the cold medicine will help you feel better faster. But the Alka Seltzer already contains the painkiller acetaminophen, so you’re taking more than you need to.

Double dosing on these medicines can lead to dangerous unwanted side effects and complications. (We’ve already written about the dangers of unwittingly overdosing on acetaminophen/Tylenol.)

4. Look for medications with fewer ingredients

The drugs in cold and flu medicines fall into one of four buckets: painkillers, decongestants, antihistamines, and cough suppressants. Combo products often have more ingredients than you really need to treat the symptoms you actually have, which puts you at greater risk for side effects, drug interactions, and overdose. For children, it may be better to pick a single-ingredient OTC medication to lower these chances.

The recommended age for cold and flu meds varies depending on the ingredients, and drug manufacturers often make pediatric versions for kids under the age of 12. These versions will contain a lower dose of the medicine, and recommended dosage is calculated by age and weight.

Here’s a rundown of single-ingredient OTC meds you can find at your local drug store to treat mild cold and flu symptoms, along with the minimum age of use, as stated on the packaging.

Painkillers & Fever Reducers
Used to treat: Aches, pains, sore throat
Ingredient Brand Name Minimum Age of Use
(Children’s Version)
Minimum Age of Use
(Regular Version)
Ibuprofen Advil, Motrin 6 months 12 years
Acetaminophen Tylenol 2 years 6 years
Aspirin Aspirin No children’s version 12 years
Naproxen Aleve No children’s version 12 years old

 

Decongestants
Used to treat: Stuffy nose, chest congestion
Ingredient Brand Name Minimum Age of Use
(Children’s Version)
Minimum Age of Use
(Regular Version)
Phenylephrine Sudafed PE 4 years 12 years
Pseudoephedrine Sudafed 4 years 6 years
Guaifenesin Mucinex 4 years 12 years
Oxymetazoline Afrin No children’s version 6 years old

 

Antihistamines
Used to treat: Runny nose, watery eyes, trouble falling asleep
Ingredient Brand Name Minimum Age of Use
(Children’s Version)
Minimum Age of Use
(Regular Version)
Diphenhydramine Benadryl 2 years 6 years
Chlorpheniramine Chlor-Trimeton 6 years 6 years
Cetirizine Zyrtec 2 years 6 years
Doxylamine Unisom No children’s version 12 years old

Fun fact: CVS makes their own grape flavored allergy relief lollipop with 2mg of chlorpheniramine!

Cough Suppressant
Used to treat: Uncontrollable cough
Ingredient Brand Name Minimum Age of Use
(Children’s Version)
Minimum Age of Use
(Regular Version)
Dextromethorphan  Robitussin 4 years 4 years

3 Things You Probably Didn’t Know About Cold and Flu Meds

by Katie Mui on January 19, 2018 at 1:42 pm

By now, you’ve probably heard that this year’s flu season is getting pretty bad (or “moderately severe”, as the CDC puts it), with widespread flu activity all across the U.S. We believe prevention is the best medicine, but certain strains, like this year’s H3N2 virus, are more resistant to the flu shot.   

So if you find yourself feeling feverish and with chills, congestion, runny nose, or body aches (among other common cold and flu symptoms), you might be tempted to head to your local drugstore. But with over 300 products on the shelf in the typical cold and flu aisle (we counted), it’s easy to feel pretty overwhelmed – especially if you’re not feeling quite like yourself. Luckily, we’re here to help you sort through the confusion and pick the best over-the-counter cold and flu meds for you.

1. You’re getting duped by marketing

There are over 300 cold and flu products in the average drugstore, but what you probably don’t know is that they’re really just a handful of combinations of four basic types of ingredients: decongestants, pain and fever reducers, cough suppressants, and expectorants (mucus thinners). There are so many options because each brand (like Robitussin or Vicks) has its own version of almost every combination, plus many combinations come in more than one form (like liquid, dissolving tablets, and ‘liquicaps’). Some of this is good – for example, it’s nice to have a liquid option if you don’t like taking pills – but a lot of it is simply driven by marketing.

2. You’re spending too much on brand names

According to a 2014 study published by the National Bureau of Economic Research, drugstore shoppers spend an extra $44 billion a year on brand-name products, including over-the-counter medications and other health items. Pharmacists, on the other hand, are 90% more likely to buy generics, probably because they know how to hunt them down on store shelves and know that they’re just as effective. But it’s hard for most people to distinguish between pseudoephedrine and phenylephrine or dextromethorphan and doxylamine in order to pick a generic or store brand with the active ingredients they need.

3. You’re probably taking more medicine than necessary

People often take combination-ingredient cold and flu medicines like NyQuil or Tylenol Cold Multi-Symptom. You’ve probably seen TV commercials for these brands so they’re easy to recognize on the shelf, and you know they’ll probably cover whatever your symptoms are. But these combo products often have more ingredients than you need to treat the symptoms you actually have, which puts you at greater risk for side effects, drug interactions, and overdose. Overdose is especially risky with products that contain acetaminophen because going even just a little bit over the daily limit of acetaminophen can put your liver at risk and even cause death. Read our previous post on how to avoid taking too much acetaminophen or Tylenol.

So how do I find what’s right for me?

If you’re looking to treat the symptoms of a developing cold and flu early without having to visit the doctor’s office, our friends at Iodine have just the thing. Their cold & flu tool can help you save time, money, and extra stress on your body. Just select your symptoms, and it’ll narrow down all the options to products that treat the symptoms you actually have. You can compare them side by side and take the list with you to the pharmacy. Get in, get out, go home and rest.


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