Health care costs: Prescription medications

The Pediatric Insider

© 2010 Roy Benaroch, MD

I’ve posted about the insane costs of health care, and about how defensive medicine is a big contributor. Prescription drugs are another huge cost, accounting for about 11% of the 2 trillion spent each year on health care in The United States. And it turns out that the marketplace for prescriptions is also rife with bizarre sources of waste and sneakery.

First, some good news: prescription medications are now available to treat a huge number of diseases. Got ulcers? No problem. Asthma? HIV? We can manage those. How about infertility, schizophrenia, seasonal allergies? Gotcha covered. There are a huge number of effective and reasonably safe medications out there, and a big part of our good health can be attributed to this growing armamentarium of really effective tools.

But those tools can sure be expensive, and you’re not always getting the value you might expect.

Take those seasonal allergies. Until about 10 years ago, the best medications were antihistamines like Benadryl. Effective, but they made people sleepy, and they had to be taken several times a day. Then came the newer gang of allergy meds, led I think first by Seldane (which has since been taken off the market for safety concerns). Within a short time, Claritin came out, and millions of allergy sufferers could breathe better and sneeze less. What has happened since in the world of oral antihistamines? Well, nothing, really. Two other manufacturers came out with copycats– Zyrtec and Allegra, which are really no better than Claritin, but earned their manufacturers piece of the pie. Then, as Zyrtec approached the date of losing its patent, it’s maker came out with a true weasel-drug: Xyzal, which is in every practical way the exact same thing as Zyrtec. Works the same, same side effects, same everything– in fact the molecule itself is basically the same, it just all faces one direction rather than being a mix of right-handed and left-handed versions. Of course, they tried as hard as possible to switch as many patients over to Xyzal before generic Zyrtec became available. Did this help anyone? Of course it did–the people who own shares in the company that makes Xyzal. A nearly-identical story occurred with the cleverly named “Nexium” (get it? next?), which has no possible advantage over the drug it replaced, Prilosec. Except of course it’s still protected by patent.

Copycats are drugs made by one manufacturer to cleave off some market share; though they don’t directly help patients any more than the originals, at least in theory they help keep prices low through competition. Drugs like Nexium and Xyzal aren’t copycats– they’re just patent-extenders, and by no stretch of the imagination are they helping health care in any way. They just drive up costs.

Another example: “Flonase” can be squirted up your nose to treat and prevent allergy symptoms. It’s a terrific medication– it works, and it’s safe for almost everyone. Just as the patent expired, the manufacterer came out with a nearly-identical medication, but put it in a bottle where the squirt-button is on the side, rather than the top. Got it? You hold the bottle differently to squirt it up your nose. They somehow got a patent extension for “Veramyst,” and for reasons I can’t possibly imagine physicians are actually writing prescriptions for it.

Wise doctor: “Ms. Johnson, this product is far more expensive because there’s no generic, but I’m sure you realize how crucial it is that you can squirt it with your hand sideways rather than upright.”

Besides coming up with copycats and patent-extending tweaks, drug companies have other tricks to fend off patents. In some cases, they just pay off generic manufacturers to delay their selling copies of the drug.

Doctors who prescribe these things without regards to costs share the blame. We’re too easily influenced by the ubiquitous drug reps, who bring gifts and goodies and wear low-cut blouses. Sometimes, doctors become even more enmeshed with the drug companies– I’ve been offered thousands of dollars to give talks in support of one antibiotic, as well as travel perks for myself and my family.

The drug companies behave like weasels, yes, but they can’t directly influence purchasing without going through a doctor, right?

Wrong. Direct-to-consumer ads are all over the place, and have helped create huge markets for drugs for Erectile Dysfunction (a term invented by drug marketers) and restless legs syndrome. Not only do direct ads push specific drugs– “Ask your doctor if Vyvtera is right for you”– but indirect ads create a market by publicizing the existence of a disease. Had you ever heard of Restless Legs Syndrome before there was a medication that could be sold to treat it?

(I don’t mean to pick on RLS. It’s a real disease, and it’s really debilitating. But drugs have been available for years to treat it. Only when one name-brand medication got an FDA-approved indication for RLS did anything about this condition appear in the press. I wonder how an administrative decision to approve a medication led to such widespread media attention. Spooky.)

And don’t even think about the bizarre ways that medicine prices are determined in the USA, or how the same medications, manufactured by the same companies, have vastly different prices in different countries. You want to make sense out of that?

Though they account for “only” 11% of health care expenditures, prescription medications are a good example of what’s both good and bad about American medicine. Many treatments are available, for many, many conditions– but the prices of the treatments are utterly nonsensical, and the prices have very little to do with how well the treatments are going to work, or how essential the medication really is. And the people who should be in control of deciding which medicine is “best” often don’t seem to care about which medicine is the most cost-effective. Recent health care legislation has rearranged the deck chairs, but the ship is still going down under the weight of huge costs that no one is willing to face.

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4 Comments on “Health care costs: Prescription medications”

  1. Shannon Says:

    I agree in many respects with this article. However, for whatever reason, Claritin and Allegra do not work on me but Zyrtec works like a dream. So they don’t all work on each person the same. Also, our Allergist prescribed Xyzal for my kids because I told her that Zyrtec changed my daughter’s personality. Other mothers I’ve spoken to have said the same thing about their children. The Allergist said that the newer formulation of Zyrtec in the form of Xyzal was supposed to eliminate behavioral change side affects. I haven’t tried it yet because their seasonal allergies haven’t seemed as bad this year so I cannot provide anecdotal evidence. Have you heard this?

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  2. Dr. Roy Says:

    Allegra and Zyrtec are (at least) not identical copies of the older antihistamine Claritin, so it’s at least feasible that some people would do better on one than the other.

    Zyrtec is 10 mg of “cetirizine”, which is a mix of 5 mg of “levocetrizine” and 5 mg of “right-cetirizine” (well, there really isn’t any such thing, but if there were it would be.) In other words, Zyrtec is equal parts of two mirror images of the same molecule. As often happens, only one mirror image has biologic activity, in this case the “levocetirizine”. Xyzal is 5 mg of “levocetirizine”, without any of the 5 mg of the inert mirror image. There is no evidence whatsoever that the inert mirror image causes behavioral side effects or any other problems. The manufacturer hasn’t done any studies to support that it has fewer side effects. That Xyzal is somehow superior to Zyrtec is very difficult to believe, given the chemistry of the molecules.

    Allergists prescribe it because general practitioners have already prescribed Zyrtec, and they have to do something different. It also seems more “powerful” because it’s newer, and because the allergists says its better.

    By the way, the Claritin people pulled a fast one with Clarinex, which is the first metabolite of Claritin. That is, your oven liver converts Claritin to Clarinex. There is no possible plausible reason that Clarinex would be superior, but it does have “nex” in it.

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  3. mkr Says:

    The reason people are not willing to face the issue is because if they say something then that would mean that they may possibly loose their drugs in the process. I see it as “as long as I get mine, that is all that matters.”

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  4. Dr. Roy Says:

    Holly forwarded me this article, more details about how pharmaceutical companies get docs to prescribe the latest, most expensive thing:
    http://www.npr.org/templates/story/story.php?storyId=130730104

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