Prescription drugs and its copycats contribute to health waste

I’ve recently 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 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.

Roy Benaroch is a pediatrician who blogs at The Pediatric Insider. He is also the author of Solving Health and Behavioral Problems from Birth through Preschool: A Parent’s Guide and A Guide to Getting the Best Health Care for Your Child.

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  • Matthew Mintz

    Many of your points are well taken. While Nexium and Xyzal are patent extenders, there is some role for “copy cats”. Allegra is a much stronger drug than Claritin and doesn’t nearly have as much side effects as Claritin or Zyrtec. In addition, what the patient pays out of pocket is also a major factor. Though there is no evidence that Veramyst works better than generic Flonase (though I do like the vehicle better), with a coupon that the drug company offers (an in some cases with the deal the drug company makes with the insurance company) it is sometimes cheaper for my patients to get the branded drug instead of the generic.
    The easiest way to solve this problem is to require that any non first-in-class drug that is approved by the FDA be either more effective or have fewer side effects (safer) than a similar drug. This would have likely allowed Zyrtec (stronger) and Allegra (stronger, safer) to be approved by the FDA, but likely prevented Xyzal coming to market.

  • Devon Herrick, PhD National Center for Policy Analysis

    The main reason for high prescription drug prices is our over-reliance on third-party payment. Third parties pay 75% of prescription drug expenditures. This means patients only care one-forth as much, on average, about their prescription drug costs. If they paid more for the drug bills directly (as opposed to indirect payment through higher insurance premiums), patients would be wiser consumers of drug products. They would ask prices, discuss alternatives with their doctor or ask their pharmacist about other options.

    Nearly a decade ago my doctor handed me a one-month supply of Claritin (free samples). When I went to refill my prescription, I discovered that Claritin would all but drain my annual $1,000 medical savings account (MSA) contribution from my employer (cost $2.92 per tablet). I quickly found a substitute (OTC Sudafed and OTC Actifed taken several times throughout the day) that was one-tenth the cost. Within a couple years OTC Claritin came and then the generic version. A yearly supply of generic OTC Claritin (Loratadine) is now around $20. More recently I bought a year’s supply of OTC generic Zyrtec (Cetirizine) from Amazon for $35.

    Unfortunately, rather than expose patients to more cost-sharing for drug expenses, the Administration wants to shield us further from making these decisions.

  • KP Internist

    I agree. The best way to affect healthcare utilization is to induce some measure of cost sharing. The biggest bang for your buck is to shift it to the patient. But, it is rather hard for patients to evaluate the merits of every medication. So, I would go on to offer that the cost sharing extend to the providers also. Doctors who utilize high costs treatments relative to their counterparts should earn a low “bonus” payments for irresponsible practice pattern. It is not to say that they can’t continue to do so; but, it will make the practice negatively incentivized.

  • stargirl65

    Many patients did well on claritin for their allergies. Then claritin went over the counter and was no longer covered by their health insurance. Amazingly I was rushed with patients who said claritin no longer worked for them. This has happened with many other medicines as well. Patients do not want to actually pay cash for something. They paid for health insurance and want to use it.

    I have many patients on GERD for indigestion. They take these pills daily. They are not concerned about side effects or complications. They want it covered by their health insurance companies. They have been told that lifestyle changes, which are free, can often improve their symptoms. Few make the change. Some blatantly state that they want the medicine so they can eat and do what they want. They do not want to participate in their health care at all. They wanted it all handed to them.

    This has happend with other medical conditions as well. “Hey doc. Give me diabetes pills and cholesterol pills so I can eat what I want.”

    America needs to be involved in wanting to be healthy to actually improve their health. Healthy involved patients can help decrease health care costs in this country.

  • Max

    Personally I have found it refreshing to tell a patient “oh I’m sorry, your medicine has gone over the counter you may buy it there”. I’m enjoying that. No more free samples for freeloaders who take vacations and get their nails done. Nope. It’s over the counter now. No, you can’t have another prescription and besides, your copay has gone up so much, your OTC med at Costco is cheaper. See you next year. YOU fight for your Veramyst if you want it, they’re not paying and I’m not fighting for it for you.

  • Bob Goldberg

    Everyone is entitled to their own opinion but not to their own facts. And the facts are that generic prescriptions comprise 70 percent of all scrips written and that figure will increase over the next five years. The fact is those generics were once brand drugs. The fact is, for years companies tried to move their products OTC only to have a cautious FDA (and generic firms) object. The fact is generic companies are opposing competition from innovator companies who try to launch their own generic products. I am tired of gratuitous attacks on BIG PHARMA based on factoids. Meanwhile, the generics the author has a romance with were developed by BIG PHARMA. Deal with it.

    • BobBapaso

      Deal with it, Bob. Attacks and fighting is how we live. And who fights fair? How many drugs, patented by BIG PHARMA, do you take? Fortunately, I only take one.

  • William Nuesslein

    If one thinks of Big Pharma as an institution that comes up with helpful drugs and profits from patents as a mechanism to finance drug development, then generic drugs make little sense in a macro economic sense.

    Perhaps we should have some way of getting more money from general revenues to drug development instead of having sick Americans bear the entire burden. Taxing generics would also be a good idea.

  • DanaW

    I am one of the people in big, bad pharma. I’ve represented insulin and other injectible diabetes products once they were FDA approved. All truly innovative and life changing for the people who took them.

    If you only look at clinical data, there’d be no need to rapid acting insulin. Regular insulin is more natural, but its onset is delayed by aggregating in the subcutaneous tissue. So, Humalog, NovoLog, Apidra were all game-changers because they made the use of the medications and compliance safer. How many people know they have to wait 30 minutes after injecting to eat? Few.

    When my 26 year-old boyfriend (now husband) was diagnosed with a hiatl hernia, I was selling AcipHex and bought into it being the “best” on the market because of the data. The ER gave him Protonix, his FP gave him Prilosec, then he got AcipHex samples. Finally Nexium was the one that worked. Clinical laws of averages were wrong.

    My chemo treatment was all old medications, but NO medication, brand or generic, could control my side effects. My treatment was a bargain at just under $2000/treatment. Thank God someone put ABVD together when MOPP was too toxic (though effective).

    Go to the grocery store and purchase generic foods. Sometimes, you can’t tell a difference, sometimes you can. Generic medications are the same. Sometimes they’re a close (almost identical) replica of the brand. Many times, they’re not. Generics are not always the answer, and the patient should have the opportunity, not a physician trying to hit a bonus, or a pharmacist incentivized to dispense generics.

    I disagree that there are too many me-toos on the market. The fact is that by trying to create new medications for one disease, many new medications have been discovered for others. If we stifle innovation because we want to keep costs down, many patients such as my husband will face different outcomes.

    For the record, I take 2 medications, one brand, one generic. I would have paid ANYTHING to have control over my phebitis and nausea when going through chemo with a 2 year-old and infant at home and still working a full-time job in pharmaceutical sales. Additionally, my Oncologist could have prescribed Nupogen or Neulasta to raise my white cells and prevent me from literally having no immune system. Many oncologists do, but it’s contraindicated in Hodgkins patients receiving ABVD because of interactions. So, I mothered two young children knowing they could possibly bring home an infection that would kill me so I would have the chance at being their mother longer.

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