Vyvanse (lisdexamfetamine),a long-acting stimulant medication used in adults with ADHD, is one of the most commonly prescribed brand name drugs in the U.S. Given that 60% of adults who were children with ADHD have symptoms that persist to adulthood, long-term treatment may be necessary. If you’re taking Vyvanse long term, or thinking about starting it, what are some lesser known but important things you should know?
- In addition to being FDA approved in the U.S. for the treatment of ADHD, Vyvanse was the first medication ever approved for binge eating disorder.
- How is Vyvanse different from Ritalin, Adderall, or Concerta? There are two types of stimulants used to treat adult ADHD: methylphenidate and amphetamines. Concerta and Ritalin (either short or long-acting) are methylphenidate, while Adderall and Vyvanse are amphetamine stimulants.
- What made Vyvanse stand out was the long-term release. Taken once daily, Vyvanse is released at the same levels over time, which allows for a similar effect 90 minutes to 14 hours after taking it.
- Abuse potential. Vyvanse carries a smaller risk of abuse than shorter acting medications like Adderall, Ritalin, or Focalin, due to the longer duration of action. The longer effect of Vyvanse also leads to less rebound symptoms throughout the day compared to the shorter-acting ADHD meds.
- It doesn’t matter if you take Vyvanse with food or not.
- It does matter if you take Vyvanse with acidic meds or supplements. Some examples include vitamin C, aspirin, penicillin, or furosemide, which will all decrease the level of Vyvanse in your bloodstream. The opposite is true if you take Vyvanse with basic drugs like sodium bicarbonate (found in Zegerid or Alka Seltzer), Benadryl, codeine, or metoprolol, which may increase levels of d-amphetamine, the active metabolite of Vyvanse. Your pharmacist can help you with potential interactions.
- Most common side effects? The most commonly reported side effects in adults taking Vyvanse are decreased appetite, dry mouth, and insomnia, which occur in 1 in 5 folks taking it.
- Will it affect blood pressure and heart rate? Vyvanse leads to an increase in noradrenergic and dopaminergic neurotransmission—sympathetic nervous system effects, which means your “fight or flight response.” While increases in blood pressure and pulse may occur, changes in vital signs are usually small and changes in ECG (heart tracing) are not clinically relevant.
- What about driving when taking Vyvanse? In young adults with ADHD, treatment with Vyvanse had a positive effect on reaction time with significantly fewer accidents. Studies show Vyvanse was associated with significantly faster reaction times (91% faster) and lower rate of simulated driving collisions.
- Parenting. Interesting studies have been done looking at treatment with Vyvanse when both parent and child (age 5-12) have been diagnosed with ADHD. The parents with ADHD taking Vyvanse showed a significant reduction in “negative talk” and an increase in praise of their children. Results also showed reductions in the ratio of commands to verbalizations—less yelling, more talking.
What has your experience been?
Cialis, approved to treat both ED and benign prostatic hyperplasia (BPH), has about a year left on the countdown to its generic. Viagra will likely be available as a generic before Cialis.
Here’s all you need to know about the upcoming generic launch and how to keep your costs down while you wait.
When will generic Cialis be available?
After a patent dispute was resolved in the summer of 2017, Cialis is expected to be available as generic tadalafil as early as September of 2018. Previously, Cialis was expected to remain brand-only until 2020.
How popular is Cialis?
On GoodRx, Cialis is currently the second most popular PDE5 inhibitor, the class of medications that also includes Viagra and Levitra. It’s the most popular of the medications specifically used to treat ED (sildenafil / Revatio is the most popular in the class, but it is only approved for pulmonary arterial hypertension).
Have Cialis prices changed recently?
Cialis prices have moderately increased. Cialis is already expensive, and as a brand with no generic, there isn’t much competition. Like many brand-only drugs, Cialis prices have crept up slowly. Over the past 6 months, cash prices for Cialis have increased from about $370 to over $400—based on actual pharmacy claims for fills of thirty 5 mg tablets.
What will generic Cialis cost?
Generally, generic drugs first appear on the market at about a 15% discount to the brand. Unlike the brand, however, generic drug prices typically decrease very quickly. Within a year of release, many generics versions of prescriptions can become very affordable, especially if multiple companies are making the generic.
Cash prices for Cialis—thirty 5 mg tablets, the most common dosage—are currently about $400.
The latest GoodRx estimate is that generic Cialis will initially cost between $300 – 350. While this is still not affordable for most people, keep in mind:
- Discount prices will also decrease, probably by a similar amount. That could mean GoodRx prices at less than $275 for the same prescription, a savings of almost $100.
- Generics are more likely to be covered by insurance, so you may end up with a far lower out-of-pocket cost if you’re insured.
- Again, generic prices tend to go down quickly. Many generics drop to about 50% of the brand price after more than one manufacturer enters the market—increasing competition.
Are there any cheaper medications I can try for ED?
While Cialis doesn’t have a generic yet, there are other options to consider.
- First and possibly most important—Viagra will get a generic alternative before Cialis, by the end of 2017.
- Compare prices (whether you have insurance or not). Look at Cialis vs Viagra (sildenafil) or Levitra (vardenafil)—other common choices in the same class—along with Stendra (avanafil) and Staxyn (vardenafil). They may or may not be cheaper now—but both do offer manufacturer coupons and patient assistance programs, which Cialis does not. See manufacturer offers for Viagra here and Levitra here.
- 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 Viagra or Levitra.
- Generic sildenafil (Revatio) is much less expensive, and is used by some patients to treat erection problems. However, take note that it is only approved by the FDA for the treatment of pulmonary arterial hypertension. Your doctor will be able to give you advice on whether sildenafil could be an option for you.
- For more information on how Cialis, Cialis side effects, and how Cialis compares to other ED medications, check out Iodine’s comparisons with Viagra here and Levitra here. As always, you’ll want to discuss with your doctor if you think another medication might work better for you.
Cialis still works best for me—how can I save before the generic is released?
- Filling a 90-day supply at once can often help shave a little more off your out-of-pocket costs. You may also need a new prescription from your doctor, or approval from your insurance to fill a higher quantity, so check with your doctor, pharmacist, and/or insurance.
- Splitting a higher dosage pill can also help decrease costs, especially if two strengths are priced similarly. You’ll want to ask your doctor to make sure this is safe and a good option for you.
- Use a Cialis coupon. GoodRx does offer discounts for Cialis online. While this may not make it affordable for everyone, a coupon can still knock at least 15% off the full retail price.
- Try again to get it covered. If you have insurance and your plan doesn’t cover Cialis, ask your doctor about submitting an appeal. For conditions like ED this may not always work, but could still be worth a try.
Many women struggle with lack of interest in sex after menopause. Lower estrogen with menopause may result in vaginal dryness, painful intercourse and—because estrogen helps regulate the parts of the brain that control mood and desire—libido takes a hit as well. Many women come to primary care doctors for help when sexual desire is lacking and they want to get back to the days when they felt desire and satisfaction.
Pharmacologic therapies to improve libido in women are limited at best and while combination estrogen and progesterone therapy after menopause may help, it does matter how you take it.
This month in the Journal of the American Medical Association, results of a large study were released that showed the use of estrogen patches—but not pills—significantly improved libido.
Here’s what we know:
- Prior studies have shown that estrogens alone or combined estrogen and progesterone result in only a small improvement (related to pain during intercourse) when used within 5 years of menopause. Those studies didn’t classify how women were using the estrogen or progesterone though.
- Why an estrogen patch? This study separated out results from estrogen patches compared to pills. All women were also on progesterone, because women with a uterus need the progesterone to protect the lining of the uterus (endometrium). The estrogen patch may be more beneficial because the patch results in a ratio of estradiol to estrone (two types of estrogen hormone) that comes close to matching the ratio before menopause.
- Wait what? Yes—blood concentrations of free estradiol with a transdermal estradiol patch (used on your skin) is twice that seen with pills.
- Who was included in the study? 670 women, within 3 years after their last period, were treated for 4 years with either transdermal estradiol (patch) or oral estrogen pill. This study did not include women who had undergone hysterectomy or surgical menopause.
- What were the two groups prescribed? The women taking estrogen pills (0.45 mg estrogen + 200 mg progesterone for 12 days each month) were compared to the group using the estradiol patch (50 mcg + progesterone 200 mg). Sexual function was assessed by scores comparing desire, arousal, lubrication, pain, satisfaction, and orgasm.
- What did we learn? The group using estradiol patches had a 7.2% improvement in their scores while those taking estradiol pills did not have a significant increase. These changes in sexual desire were not immediate, and most were noticeable after 18 months of treatment. This effect was more significant for those who had low sexual function to start with.
- What are the estradiol patch options? Estradiol patches similar to those used in this study, in the 50 mcg dosage, are used either once or twice weekly. Estradiol, Climara, and Vivelle-Dot are all available as 50 mcg patches. See my previous blog on patch vs pill for cost discussion.
- Take home message: Treatment with estrogen patches showed modest benefit for sexual function, especially in those who had low sexual function to begin with—and patches were more effective than estrogen pills.
What has worked for you?
Effects of Oral vs Transdermal Estrogen Therapy on Sexual Function in Early Menopause. JAMA Internal Medicine published online August 28th 2017.
Remember way back in 2016 when we were outraged by the rising cost of EpiPen? How kids and schools couldn’t afford a simple, life-saving treatment? How the company’s CEO was grilled by the government and reporters and they pledged to do something about it?
Well, so much for public outrage. The cost of EpiPen has gone up yet again—by as much as 25%. No, we’re not kidding.
The EpiPen outrage of 2016
It’s been almost exactly year since news broke that EpiPen prices had increased by over 400% since 2007. At that time, Americans paying cash for their EpiPen would pay about $600 for a two-pack. While insurance often covers some of the cost, parents typically buy multiple two-packs to ensure that this life-saving treatment is available at home, school, in the car, or anywhere else they could be needed in an emergency. Those additional pens would not be covered, and the pens also have a limited shelf life, so they have to be repurchased every few years.
Thus, the typical American family would have to spend $1,000 or more to ensure that they had quick access to this life-saving medicine.
The outrage was swift and loud. It seemed like the American public had had enough with high drug prices, and finally something was going to be done. Or was it?
2017: Epipen prices increase by up to 25%
By August 2017, the price Americans are paying for brand-name EpiPen has increased yet again—this time by up to $150. That’s an increase of up to 25% since 2016. Yes, really.
Not all bad news
While all of the epinephrine pens out there are still expensive, there is some good news—you have more ways to save than ever.
- EpiPen and EpiPen Jr now have a less-expensive generic alternative, and a better manufacturer offer.
- CVS has introduced a lower cash price for the Adrenaclick generic.
- Auvi-Q, another epinephrine auto-injector, has been re-approved and is in pharmacies now.
- Another alternative, Symjepi, has also been approved and is expected to be available by the end of 2017.
Read on to find out how to save on each type of pen.
What are my options now?
First, know that all of the currently available epinephrine injectors come in two doses, 0.3 mg for adults and 0.15 mg for children, and come in a package containing two syringes or auto-injectors.
EpiPen and EpiPen Jr are still the most commonly used and prescribed epinephrine auto-injector pens. Mylan made an authorized generic available following the concerns over pricing, and made changes to the discounts they offer. However, we’re still seeing generic cash prices over $300 per two-pack, and brand-name EpiPen prices over $650 per two-pack—up to $750 at some pharmacies. Both generic and brand-name EpiPen have manufacturer discounts available, but they aren’t really going to cut it if you don’t have prescription insurance. The generic offer is for insured patients only. It’ll shave $25 off your insurance co-pay, but you’re still left with a $300+ cash price if you don’t have coverage (a GoodRx discount can drop this to around $150). The situation is about the same for brand-name EpiPen. Again, there’s a manufacturer offer that can drop your cost to $0—but only if you have prescription coverage. Bottom line: if you’re uninsured, or have high deductible prescription coverage, EpiPen (brand and generic) remains just about as costly as in 2016.
Adrenaclick and its generic have been the primary lower-cost alternative to EpiPen through the pricing concerns over the past year. The generic is available for just over $100 from CVS pharmacies, and has a manufacturer offer available that could reduce your co-pay to $0 if you have insurance. Like EpiPen, Adrenaclick is a pen-shaped auto-injector that’s designed to be easy to use.
Auvi-Q was pulled from the market in 2016, and re-released earlier this year. It’s very expensive, over $4500 even with a GoodRx discount, but the manufacturer has a mail order program that should reduce co-pays or out of pocket costs for many people to $0. Auvi-Q has a few unique features as well, like voice instructions to guide you through giving the injection, an auto-retractable needle, and a square shape that’s intended to be easy to carry.
Symjepi has been approved by the FDA, but isn’t in pharmacies yet. Expect to see it in pharmacies by the end of 2017. It’s intended to be a less-expensive alternative to EpiPen, and comes as a two-pack of regular pre-filled syringes, rather than auto-injectors. It won’t be quite as simple to use, and is the only option that will not have a lower 0.15 mg dose available—so this one may not be not a good alternative if your child carries an epinephrine pen. However, it could mean greater savings for some adults and medical professionals.
What can I do to save?
Your savings will depend on your insurance coverage, the pharmacy where you choose to fill, and which option you’ve been prescribed.
First—especially if you have prescription insurance—check for manufacturer discounts:
- The manufacturer offer for generic Adrenaclick can reduce your co-pay to as little as $0, and also offers up to a $300 discount per two-pack for cash-paying patients. Cash prices range from $110 to well over $500, but if you shop around, this can be a huge help whether you have insurance or not.
- EpiPen and EpiPen Jr have similar offers—if you have insurance, your co-pay can be reduced to $0, and cash-paying patients can save up to $300 per two-pack. Keep in mind though, this offer is for brand-name EpiPen, which still costs upwards of $650 if you’re paying out of pocket.
- The EpiPen generic also has a discount available . . . but it only offers $25 savings per fill, and is only available for insured patients. You can still use it if you have insurance that doesn’t cover the EpiPen generic—but without coverage, your cost per fill will likely still be over $300.
- Auvi-Q also offers a mail order program that can reduce your cost to $0. It’s available for all insured patients, and for uninsured patients with a household income below $100,000. If your annual income is higher, you can still receive it at $360 per fill. For comparison, Auvi-Q costs over $4500 per fill.
If you don’t have insurance, a low cash price or a GoodRx discount are the way to go.
CVS pharmacies (including locations inside Target stores) now offer the generic version of Adrenaclick at $109.99 for a two-pack. Walgreens also has a relatively low cash price, at $147.59. CVS and Walgreens are also your lowest-cost pharmacies for the EpiPen generic—discounts for a two-pack at both stores come in under $150.
Is there anything else I should know?
With generic alternatives now available for EpiPen and Adrenaclick, some insurance plans may not cover the brands, or may only cover one or the other. For example, starting in 2018, Express Scripts (which provides prescription benefits for millions of insured Americans) will only offer coverage for EpiPen and its generic. Adrenaclick, generic Adrenaclick, and Auvi-Q are being added to the exclusion list on their national preferred formulary.
If you’re having trouble with the cost of your epinephrine pen, talk to your doctor to see if any of the other options will work for you. Trying a generic alternative or switching to a different brand may save you hundreds per fill.
Antibiotic-associated diarrhea and colitis is affecting more of you, given the widespread use of antibiotics. Clostridium difficile (C. diff) is the organism that causes antibiotic-associated colitis; this happens because the bacteria is allowed to overgrow in the intestine when the normal intestinal flora is changed due to antibiotics. C. diff can release toxins that bind to receptors on intestinal epithelial cells causing inflammation (colitis) and diarrhea. This makes folks very sick.
Some antibiotics lead to C. diff much more often than others. When there are options for choice of antibiotic for your infection, err on the side of safety with less C. diff risk. Here’s what you need to know:
The Losers. These antibiotics are most frequently associated with C. diff diarrhea.
- Levofloxacin (Levaquin) is prescribed for bacterial sinusitis, urinary tract infection (UTI), prostatitis, and community-acquired pneumonia among other things. A convenient once-daily broad spectrum antibiotic is appealing, but it is more likely to cause C. diff than other antibiotics.
- Ciprofloxacin (Cipro) is very similar to levofloxacin, though it’s taken twice daily and is most often used for UTI and diabetic foot or bone infections.
- Moxifloxacin (Avelox) is another from the same class of antibiotics as Cipro and Levaquin. It’s prescribed for sinusitis and community-acquired pneumonia.
- Clindamycin (Cleocin) is prescribed for skin and soft tissue infections due to Methicillin-resistant Staph Aureus (MRSA), bite wounds, impetigo, and dental prophylaxis in those allergic to penicillin. It’s cheap and has been around forever, but it’s a known culprit in C. diff diarrhea.
- Cephalosporins like Omnicef (cefdinir), Ceftin (cefuroxime), and Suprax (cefixime) are broad spectrum antibiotics used for pharyngitis (sore throat), sinusitis, and ear infections. They also make the list for the antibiotics most frequently implicated in C. diff infections.
The Winners. These antibiotics are rarely associated with C. diff diarrhea.
- Doxycycline (brand names Oracea, Vibramycin) is an antibiotic prescribed for a wide variety of medical conditions including Lyme disease, bacterial sinusitis, chlamydia infection, rosacea, acne, or skin and soft tissue infections. It’s shown to cause nausea and upset stomach in only 8% of folks taking it. Pro tip: doxycycline monohydrate is easier on the stomach than doxycycline hyclate, and it’s essentially the same antibiotic. The difference is just the “salt” attached to it (monohydrate vs hyclate).
- Metronidazole (Flagyl) is an antibiotic that is actually used to TREAT C. diff infections. Pro tip: Think of metronidazole as an antibiotic primarily for infections from the waist down: sexually transmitted infections like trichomoniasis, pelvic inflammatory disease, C. diff diarrhea, diverticulitis, and bacterial vaginosis.
- Minocycline (brand names Solodyn, Minocin) is a tetracycline antibiotic similar to doxycycline that has limited use. It’s prescribed primarily for acne and treatment of STD infections.
Second Place. These are better than the worst, but not as good as the winners.
- Azithromycin (Zithromax, the “Z-Pack”) has many uses including sinusitis, strep throat, chlamydia and other STD infections, community-acquired pneumonia, and H. pylori, among others. It’s the jack-of-all-trades antibiotic, and there is very little bacterial resistance to azithromycin, making it a popular choice.
- Clarithromycin (Biaxin), like Zithromax, is also used for a number of illnesses including bacterial bronchitis, sinusitis, and skin infections. Pro tip: Almost 10% of you taking it may notice alteration in taste (dysgeusia), especially a metallic taste.
- Sulfamethoxazole/trimethoprim (Bactrim) is most often prescribed for urinary tract infections (UTI or cystitis), skin and soft tissue infections from MRSA, and travelers diarrhea. Pro tip: Don’t count on Bactrim for UTI treatment in areas of the country where there is greater than 20% resistance of E. coli (Los Angeles, for example), and if you’ve used it in the previous 3 months for UTI make another choice.
Honorable Mention. These antibiotics are not frequently associated with C. diff, but are primarily IV (not oral) medications.
- Vancomycin. While Vancomycin does come in a pill form, it is poorly absorbed from the gut so is ONLY indicated as a pill for the treatment of C. diff infection. So yes, oral vancomycin is prescribed for C. diff when metronidazole hasn’t worked. Vancomycin IV is used for treatment of many serious infections though, including sepsis, meningitis, bone infections (osteomyelitis), joint infections, and pneumonias.
- Gentamicin. If you are hospitalized with pneumonia, endocarditis, or a severe kidney infection you may be given Gentamicin IV, but its use is limited due to risk of kidney and ear (ototoxicity) damage.
- Tobramycin is prescribed as an inhaled solution or in IV form for patients with cystic fibrosis, as it is also poorly absorbed by the GI tract. Not all that helpful as on option if you are sick, unless you are hospitalized.
- Amikacin is used for hospital-acquired pneumonias, meningitis, and infections in cystic fibrosis patients so you will not see infections in the community treated with this antibiotic.
Hope this helps.