Help! My Patient Doesn’t have Much Money:
Is there a Generic for that?A look at OTCs and Generics
Amelie Hollier, DNP, FNP-BC, FAANPPresident, APEA
Making the Most
1. Not all lists are the same• And the lists change periodically• Example: Benazepril/HCTZ available at
Walgreen’s but not Wal-mart
of the $4 generics
Making the Most
2. Not all generics are on the $4 list!
• Example: amolodipine, fluticasone nasal spray, losartan, many more!
of the $4 generics
Making the Most
3. Some doses of generics are NOT on the list
• Example: Pravastatin 10, 20, 40 mg
of the $4 generics
Making the Most
• Pravastatin 80 mg (30 tabs)• Price range: $18.99- $119.99 (without shipping)
of the $4 generics
Can you take (two) 40 mg tabs = (one) 80 mg tab? ($8)
4. Order 90 Day supply instead of 30 Days
• Larger quantities (90 day supply usually cheaper than 3-30 day supplies)
Annualized savings:• 1 script: $8 (12 months: $48 vs. $40)• 5 scripts: $40• 10 scripts: $80
Making the Most
7. Look for ways to combine meds
• Example: HCTZ 12.5 mg daily ($4/30 tabs)
• Lisinopril 10 mg daily ($4/30 tabs)
of the $4 generics
Rx Case 1: Patient takes lisinopril 10/HCTZ 12.5 • Lisinopril 10/HCTZ 12.5 mg tab• Lisinopril 20/HCTZ 25 mg tab
Can you split a Lisinopril 20/HCTZ 25 mg tab to get two doses?
Pill SplittingDon’t split if tablet contains more
than ONE active ingredient• Lisinopril/HCTZ• Combo antihypertensive medications
Pill Splitting CluesDon’t split if enteric coated,
sublingual, or buccal, some extended release tablets
Pill Splitting CluesDon’t split if medication is a narrow
therapeutic agent• Warfarin• Levothyroxine• Anti-seizure medications• Others
Warfarin
Digoxin
PhenytoinTheophylline
Levothyroxine
Lithium
(Toxic dose may be slightly above therapeutic dose)
Narrow Therapeutic Agents
Pill SplittingPrice comparable despite tablet strength
Medication Dose Double Dose Savings
Rosuvastatin 10 mg: $149 20 mg: $150 $74Atorvastatin 20 mg: $154 40 mg: $160 $74
Pill SplittingSome OTHER Considerations• Sharp tablet cutter• Good dexterity• Cognitive ability• Visual acuity
8. Member Discount PlansMany Businesses offer discounted
drugs if you are “a member”
• Membership: Free• Membership: Fee
Member Discount PlansLargest 8 Examples Nationwide:• Costco: Free for members ($50/yr)• CVS: $15/year• Kmart Prescription Savings Club: $10/yr• Kroger: Free• Rite-Aid Rx Savings Plan: Free• Target: Free• Walgreen’s Prescription Savings Club: $20
individual/$35 family• Wal-mart/Sam’s Club: Free
Combos are Cheaper, Right?• More than 75% of hypertensive
patients need two or more meds• Strategy: Use Combos???
Brand (Lotrel) Amlodipine 10/benazepril
40
$219.16
Generic Amlodipine 10/benazepril
40
$32.75
Savings with Generic: $186.41
Generics Save you Money, Right?
Watch out! Don’t get taken! At the same pharmacy…
Generic Amlodipine 10/benazepril
40
$32.75
Generic Amlodipine 10 $6.10Generic Benazepril 40 $5.90
Amlodipine 10 $5.09Benazepril 40 $4
Across the street…
$32.75 vs. $12.00
Amelie’s Favorite Site!• Free for iPhone, iPod Touch, and iPad• Online: www.goodrx.com• Finds lowest price drug in stores AND online• Taps into generic discount plans• Gives access to manuf coupons when there is
no generic• Finds prices of generic “equivalents”
AsthmaRESCUE MEDICATION!!!• Albuterol: generic product, but the
propellants changed in 2008• HFA more ozone friendly • Cost is about $45-$48
AsthmaMild persistent asthma:
Inhaled corticosteroids (ICS)
Moderate persistent asthma:
ICS plus LABA
AsthmaModerate persistent asthma:
ICS plus LABAFluiticasone/salmeterol (Advair) Budesonide/formoterol (Symbicort)Mometasone/formoterol (Dulera)
Cost: $185 - $285/30day supply (BID dosing)
Price Comparison Inhaled Combo Medications
• Advair Diskus: $285.46• Advair HFA: $285.46• Dulera: $242.69• Symbicort: $259.08
AsthmaModerate persistent asthma:
ICS plus LABAFluiticasone/salmeterol (GSK) Budesonide/formoterol (AZ)Mometasone/formoterol (Merck)
Cost: $185 - $285/30day supply (BID dosing)
AsthmaFluiticasone/salmeterol (866-518-HELP or
www.gsk-access.com) Budesonide/formoterol (800-292-6363 or
AZandMe.com)Mometasone/formoterol (800-727-5400 or
www.merck.com/ merckhelps/patientassistance/)
Web-based Resourceswww.needymeds.com• Brand and generic meds available through
patient assistance programs
www.rxassist.org• Patient can search medication by company,
brand or generic search; lists various options for patient assistance
Web-based Resourceswww.pparx.com• Pharmaceutical Research and Manufacturers
of America (PhRMA). Search by manufacturers; patient assistance programs available
Anti-Histamines
Cost1st gens cheaper/dose
2nd Gen Anti-Histamine Cost per Dose
Cetirizine .25/10 mg (generic)
Loratadine .25/10 mg (generic)
Fexofenadine $2/180 mg
Levocetirizine $3/5 mg
Desloratadine $4.06/5 mg
Lifestyle Modifications
• Maximize Non-pharm Management• Institute lifestyle modifications
(change in diet, increase physical activity, weight loss)
Hypertension
Life style Modifications
• DASH eating plan (8-14mm Hg)
• Weight loss (5-20 mm Hg/ 10kg)
• Exercise: 30 min most days (4-9mm Hg)
• Sodium restriction (2-8 mm Hg)
• EtOH in moderation (<2 drinks/d): (2-4mm Hg)
• Eliminate other CV risk factors
Anti-HypertensivesHow do I pick one?
Multiple $4 Generics Available• ACE inhibitors• Alpha blockers and BB• Thiazide diuretics• CCBs• Combos
Anti-Hypertensives
ARBs (not $4)
• Consider transitioning to an ACE inhibitor
• Losartan, irbesartan, valsartan, are generic (not $4)
• Candesartan generic 2012
Anti-Hypertensives
Generics• Takes at least 6 months as a
generic before price begins to decrease
• Occurs as multiple manufacturers produce drugs
Anti-Hypertensives
Alpha Blockers• Doxazosin (Cardura): once daily• Prazosin (Minipress): 2-3 times daily• Terazosin (Hytrin): once or twice daily
Anti-Hypertensives
Beta Blockers• Metoprolol tartrate (twice daily): $4 med
• Metoprolol succinate (once daily)
• Not for uncomplicated HTN
Anti-Hypertensives
Alpha/Beta Blocker• Selective alpha, non-selective beta• Carvedilol (Coreg): twice daily• Dose: 3.125 mg – 25 mg BID
Anti-Hypertensives
Think Combos• Most patients need more than one drug anyway
• ACE/HCTZ• Atenolol/chlorthalidone• Carvedilol• K+ sparing/HCTZ
Lifestyle Modifications
• Maximize Non-pharm Management• Institute lifestyle modifications
(change in diet, increase physical activity, weight loss)
Statin Efficacy
Atorvastatin Simvastatin Lovastatin Pitavastatin Pravastatin Rosuvastatin
LDL Decrease
38-54% 28-48% 29-48% 31-41% 19-40% 52-63%
Dose 10-80mg 10-80 mg 20-80 mg 1-4 mg 10-40 mg 10-40 mg
$4 Generic Medications
Generic sometimes $4
$17.99 - $35.99$15-16
Pill SplittingPrice comparable despite tablet strength
Medication Dose Double Dose Savings
Rosuvastatin 10 mg: $149 20 mg: $150 $74Atorvastatin 20 mg: $154 40 mg: $160 $74
CYP 450 EffectAtorvastatin Simvastatin Lovastatin Pitavastatin Pravastatin Rosuvastatin
LDL Decrease
38-54%10-80mg
28-48%10-80 mg
29-48%20-80 mg
31-41%1-4 mg
19-40%10-40 mg
52-63%10-40 mg
CYP 450 Effect
3A4 3A4, 3A5 3A4 No significant interactions
No significant interactions
No significant interactions
Basal Insulin• Sound familiar? Like the Inhaled combo
meds for asthma: there are no generics of basal insulin
• Insulin glargine (Lantus)• Insulin detemir (Levemir)
Basal Insulin• Vials are cheaper than pens• Pens are more convenient• Look for programs (basal insulins have
patient programs)
Web-based Resources
www.pparx.com• Pharmaceutical Research and Manufacturers
of America (PhRMA). Search by manufacturers; patient assistance programs available
Insulin Acquisition
Depression2010 American Psychiatric Association guidelines for major depressive disorder
American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (3rd Edition). October 2010. http://www.psych.org/guidelines/mdd2010. (Accessed February 18, 2011).
Depression• Most meds are similarly effective!• None more effective than another• Choose one based on side effects (or lack of
them!)
American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (3rd Edition). October 2010. http://www.psych.org/guidelines/mdd2010. (Accessed February 18, 2011).
DepressionDepression with insomnia• Consider paroxetine ($4 generic med)• Consider a sedating TCA ($4 generic med)• Mirtazapine (Remeron) generic; some $4 lists• Both associated with weight gain
DepressionDepression with fatigue, sleepiness• Consider bupropion SR (BID, not on all $4
lists)• Consider a less sedating SSRI: fluoxetine• Generic but not $4: Bupropion XR,
Venlafaxine***Less weight gain, fewer sexual side effects*** Hypertension with bupropion, venlafaxine
DepressionDepression with chronic pain, migraine
prophylaxis• Amitriptyline (10, 25, 50, 75, 100 mg
tabs)• Nortriptyline (10, 25 mg tabs)
***Migraine prophylaxis
DepressionSSRIs (if no response, try a different one)
• Citalopram• Fluoxetine• Paroxetine• Sertraline
McGrath PJ, Stewart JW, Fava M, et al. Tranylcypromine versus venlafaxine plus mirtazapine following three failed antidepressant medications trials for depression: a STAR*D report. Am J Psychiatry 2006;163:1531-41.
Proton Pump Inhibitors
7 Different ones on the Market• No clinically significant difference for
esophagitis healing, symptom relief, prevention of GERD relapse
• None clinically significant for treating ulcers, NSAID induced ulcers, duodenal ulcers or H. pylori
• No difference in side effects
Gastroenterology, 2008; 135:1392-1413
Proton Pump Inhibitors6 Different ones on the Market
Generic PPI Brand NameDexlansoprazole Dexilant (Kapidex)
Lansoprazole Prevacid, Prevacid OTC
Omeprazole Prilosec, Prilosec OTC
Esomeprazole Nexium
Omeprazole + Na bicarb Zegerid, Zegerid OTC
Pantaprazole Protonix
Rabeprazole Aciphex
Proton Pump InhibitorsDrug Interactions
PPI How MetabolizedDexlansoprazole 2C19, 3A4
Lansoprazole 2C19, 3A4, induces 1A2, inhibits 2C19
Omeprazole 2C19, 2C9, 3A4; inhibits 2C19, 2C9; induces or inhibits 1A2
Esomeprazole 2C19, 3A4, inhibits 2C19
Omeprazole + Na bicarb 2C19, 2C9, 3A4; inhibits 2C19, 2C9, induces or inhibits 1A2
Pantaprazole 2C19, 3A4; inhibits 2C19
Rabeprazole 2C19, 3A4; inhibits 2C19
H2 BlockersH2 Blocker Generic How Metabolized
Tagamet Cimetidine Multiple enzymes inhibited and used
for metabolism (3A4)
Pepcid Famotidine Min CYP 450 involvement
Axid Nizatadine Min CYP 450 involvement
Zantac Ranitidine Min CYP 450 involvement
Free Antibiotics• Amoxicillin• Ampicillin• Cephalexin• Ciprofloxacin• Doxycycline, Tetracycline• Erythromycin• Pen VK• SMZ/TMP DS
Watch out! Don’t get taken! At the same pharmacy…
Generic Amlodipine 10/benazepril
40
$32.75
Generic Amlodipine 10 $6.10Generic Benazepril 40 $5.90
Amlodipine 10 $5.09Benazepril 40 $4
Across the street…
$32.75 vs. $12.00
Thank you!For questions or to contact me:
Amelie [email protected]
Advanced Practice Education Associates
Lafayette, LA
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