I need to have the formulary done by the open of business tomorrow morning, so I'm spending the night sitting in the ambition-sucking chair and agonizing over the minutiae of a 5,000 line Excel document and its multitude of appendices. *sigh*

At least I'm having a Strongbow with my massive drug consumption. ;p

***************************

EDIT: 2:18AM - Done! Now off to have a little crack (read: custard) and then bed.

After a week of a nasty, nasty cold, I am finally starting to be human again. However, in the misery of my illness, it occurred to me that we have not had a lecture from Drug Doctor Jean in awhile, so this is a great opportunity.

Some information and advice regarding colds and the flu in, I think, my longest post evar! Just to be utterly clear, the products I recommend appear in BOLD CAPS

( The influenza vaccine )( Alternative medicine prevention and cures )

 

 

( Prescription antibiotics and antivirals )

( General advice )

Good luck with the rest of the winter virus season!

Possibly the biggest, scariest part of my job is developing the formulary for the entire organization. Essentially, we need a Part D formulary to be part of our contracting bid to Medicare/Medicaid/The State of Wisconsin. No formulary, no contract, no jobs for nobody. Not good. One of my great accomplishments in this job is that over the past two years I have had an annual reduction in drug costs of approximately 1% each year! OK, that does not sound impressive, but consider that is not adjusted for inflation, represents an improvement in drug utilization, and compares to a national average of a 6-7% increase in drug expenditures! The Utilization Management Committee pretty nearly got up and danced when I made my annual presentation.

So every spring I sweat and slave over the stoopid thing, trying to get it just right - covering enough things to be practical and beneficent, not covering the meds that pose high risks, and placing appropriate controls on the meds that are expensive or prone to abuse. Even on a normal year, it is a big task, but next year it is complicated by the addition of the CLA population - we will have many more patients, younger patients, and patients with very different problems than our accustomed frail elderly population.

Anyway, after several weeks of work, I just finished the initial 2009 formulary submission last night. I am sure CMS will mess with it and make me add all sorts of awful drugs I have no interest in covering, but right now, it is tight. I mean, it truly is a thing of grace and beauty. If it were not 50 pages long, I would frame it. :)

However, I know that I am the only one who really appreciates its glory, in part because many people do not understand what a formulary is or how it works. Never fear, the Pharmageek is here! Following is a short primer on what formularies are, how they work, and how you can get them to work for you. For all of you who ever wondered why your evil HMO wouldn't cover your meds, here are some answers and some techniques that might help...

********************************************************************

********************************************************************

Thanks for indulging me - I hope that helps some of you at some point in your struggles against Big Pharma, since everyone seems to have them sooner or later...

OK - a little professional rant here about the evils of the drug companies. Stick with me - this is longish and delves into chemistry and molecular structures, but I promise it will make sense and be worth it in the end.

When drugs lose their patent and generics are about to hit the market, the Evil Drug Companies have several nasty little tricks to extend the patent. Once way is getting approval for new indications, another is bringing lawsuits against the generic manufacturers for technicalities, and another is by coming out with a "new" copy-cat drug that they market as being better than the original. It is this third case I would like to discuss today.

Because of the way that carbons work in molecular structures, sometimes there are "chiral carbons" - carbons where the other molecules that stick to them can be arranged in one of two specific ways. This makes it so that there are essentially two drugs with the same chemical structure, but that are put together just slightly differently. The molecules are non-superimposable mirror images of one another. A great visual analogy to this is your hands - they both have a thumb and four fingers, but you have a right and a left and no matter how you turn them, they will never be the same. In fact, sometimes these carbons are referred to as "right-handed" or "left-handed" because of some optical effects they have in solution.

Anyway, usually, they way the molecules (fingers) are stuck onto the carbon (hand) are random and often it turns out to be about a 50/50 mix when the drug is made in the lab (it is possible for there to be other ratios but how and why that happens is complicated and beyond the scope of this post). Sometimes, both forms of the drug work just fine, sometimes there is one or the other that is responsible for the activity and/or side effects of the original mixture. Think of the activity sites in the body as gloves - sometimes you have a stretchy knit mitten - anything vaguely hand-shaped will do - but sometimes you have a tailored leather right handed driving glove and only the right hand of the person the glove was designed for will fit it. It is the same way with drugs- sometimes that chiral carbon matters, sometimes it doesn't.

So... the Evil Drug Companies, seeing that their big earner is about to lose its patent, will sometimes try to figure out which of the molecules is the active or more active form. They can usually then either figure out how to manufacture just that type or how to separate the two molecules after they are made. This does two things - it usually makes the process more expensive and it means that they can patent this "new" drug as a brand name drug. With sufficient advertising, they can even make people believe that this "new" drug is better than the old one. That is usually a lie. Sometimes both of the molecules were active and one was just chosen for its patentability. Sometimes the inactive or less active one was just "junk" - essentially taking up space but not doing anything. Rarely is the side effect or efficacy rate significantly changed by these little tricks.

***********************************************************************************************

Some examples:

Claritin (loratadine) 10 mg and Clarinex (desloratadine) 5 mg
See? They are using the right-handed molecule (ergo the "des" prefix on the generic name) and only using half as much, because they have taken out the left-handed loratadine that presumably was inactive. Now they have a drug that can be prescription only and brand name! Yay! Money for the Evil Drug Company!

Celexa (citalopram) vs Lexapro (escitalopram)
This one is a little harder to do the direct comparison because it comes in multiple dosage strengths. (In this care, it is an antidepressant that can work at different strengths for different people.) However, in general, the Lexapro doses are half the Celexa doses. This time it is the left-handed molecule that is used (es = S = sinister = left).

Prilosec (omeprazole) 20 mg and Nexium (esomeprazole) 20 mg
Oooh! My favorite. Remember all those ads about the "Purple Pill"? Remember when they started talking about the "NEW Purple Pill" and the pill got these adorable gold stripes on it? They were trying to get people to stick with the brand name product when omeprazole went generic and the generics were shockingly no longer in a purple capsule. Horrors! It won't work if it is not in a purple capsule! They touted all this "evidence" that Nexium (oooh! even the name implies progress!) worked better than omeprazole, but if you look at this mathematically - if the left-handed molecule is the one that works and the dose of both the mixed drug omeprazole (active and inactive) and the "pure" drug esomeprazole (all active) is 20 mg, which would you expect to work better? Perhaps the one with twice as much active ingredient? Shocking. But they don't want you to take two of the cheap-o $0.60 pills when you could take their $6.00 per pill Purple Pills! Look! they are shiny! and Purple!

Thalidomide
Thalidomide is a chiral drug too and only one of its molecules is responsible for the terrible birth defects seen in children of women who took it during pregnancy. However, it (and many others) cannot be marketed as a single type of drug because the human body can interconvert the two types of molecule and change the beneficial form into the teratogenic form after the drug is consumed. Some other drugs have this conversion happen too, but it can be of little or no consequence if the other form is benign or beneficial.

***********************************************************************************************

So, the take home message - when your doctor prescribes something - especially something you have seen a lot of commercials about - it is worth asking the doctor and/or your pharmacist if there is something older, cheaper, and just as good. Often, there is. Keep your money, don't give it to the Evil Drug Companies!


For those of you dorks interested in details:
Chirality the basic background chemistry
Enantiomers includes a list of drugs where this technique has been used

Thanks to damej for tipping me off to this article, published two weeks ago in JAMA and exerpted below.



*************************************************************************

Commercial Features of Placebo and Therapeutic Efficacy

"It is possible that the therapeutic efficacy of medications is affected by commercial features such as lower prices... Each participant was informed by brochure about a (purported) new opioid analgesic approved by the Food and Drug Administration; it was described as similar to codeine with faster onset time, but it was actually a placebo pill. After randomization, half of the participants were informed that the drug had a regular price of $2.50 per pill and half that the price had been discounted to $0.10 per pill... In the regular-price group, 85.4% (95% confidence interval [CI], 74.6%-96.2%) of the participants experienced a mean pain reduction after taking the pill, vs 61.0% (95% CI, 46.1%-75.9%) in the low-price (discounted) group (P = .02)."(emphasis and colors added – jsh) JAMA. 2008;299(9):1016-1017.

*************************************************************************

*snerk* Would you like a regular or extra-strength placebo?

So, I know a disturbing number of people who are either pregnant or are otherwise having tummy issues. My usual recommendation for this sort of upset is ginger tea (ideally Traditional Medicinal's - it is particularly strong and helpful). However, it is not always practical to boil up some water and make a cuppa, so I've been looking for an alternate. Ginger Altoids are pretty good, but I have a new favorite recommendation - Chimes ginger chews. They are very strong and effective against even pretty bad nausea. As a bonus for my preg-o friends, there are no preservatives and they are sweetened by cane sugar.  Enjoy!



[Edit: Chimes are available at Cost Plus World Market and Whole Foods. In Madison, I bet you can also get them at Willy St Co-op and Community Pharmacy. They are "candy" not meds so other places may carry them as well...]

Friday night, teffan and jenakaekat picked me up on their way down from the TC. We were supposed to meet up with HRM
hrodir for dinner, but he and his ride "missed" Madison. :P We finally got to site after dark and got set up by headlight right next to verymelm and assorted other folk. I stayed up entirely too late (early!) discussing Scotch, SCA dynamics, peeling M&M's and past midnight heart-to-hearts. I saw dawn - the sharp smell of dew in the dawning was intoxicating but quickly replaced by a lull-a-bye of rain.

Saturday was OK, even if my view of the event was fractured and short. I rose late, watched some fightin' (both heavy and light), but I missed large chunks due to being narcoleptic. I'd picked out a nice little spot in the shade to curl up on my plaid, so I was at least neither sunburnt nor stepped upon. Evening brought court, dinner, a tiny whiff of hope, and some conversations I wish I'd cut shorter, since I missed talking to some people I really ought to have.I'll have to catch up with some of the missed people soon, ideally before WW. Again, the night ended far too late/early, with Scotch and laughter. I am blessed in my friends.

Sunday was a late start as well, then packing, and lunch, and driving back to Madison. hrodir called early in the morning to inform me that they found Madison and the Perkins on their ride North, so perhaps there is hope for the boys. Evening was General Meeting, then a spontaneous trip out to the Resort to listen to mateobard and to visit with assorted folk. I even did a little bit of embroidery of questionable quality. I had some questions for PJ, but even though I got answers, I suspect I should email/call him about those tomorrow... He was on a multi-beer challenge and suggestible enough to do a line of Emergen-C. I thought his eye was going to pop out when the carbonation hit. I don't know that such a use is a good thing for him, but the laughter was medicinal for me. I ended the night with some other "pharmaceutical advice" and then hit the road with devikat. I almost made it home, successfully dodging deer and a possum, but had to hand over the keys around Lodi. We're home safe now, but after several days up late - pretty much the week, really - I find myself tired, but not sleepy...

There is much to do in the coming days, here's hoping I can maintain my new-found (low but existant!) level of productivity.