Removing the wool

well what about your patient’s that still want the hydrodiuril. i had one of them today. if she was asthmatic she’d be all over xopenex. the funny thing is that her prescription still says HCTZ, she just wants me to tell her it’s different.

you had a lot of problems with ranbaxy lately? i know the FDA shit, but now customers are asking for accutane which not only fucks up insurance, it guarantees a 30 minute reversal on ipledge
dm

You forgot about PEXEVA – the
newest, brightest in the paroxetine clan–paroxetine mesylate! So it would be the rep from Noven Therapeutics that the doc’s head is buried in……

This is another post all together.
Paroxetine HCl (Paxil) ====> Paroxetine Mesylate (Pexeva)
Zolpidem HCl (Ambien) ====> Zolpidem HCl (Ambien CR)
Venlafaxine (Effexor) 2-3/day ====> Venlafaxine (Effexor XR) 1/day
Metoprolol Tartrate (Lopressor) 2/day ====> Metoprolol Succinate (Toprol XL) 1/day

The latter two, I can understand. Less doses per day could increase compliance. But, going from once per day to once per day, especially in a long half-life drug like paroxetine just stumps me…

“Citalopram (Celexa) is a racemic mixture. Only the Dextro isomer is active….the inactive isomer has been removed. Escitalopram (Lexapro)…”

Don’t you mean only the Levo (S) isomer is active? If D is the only active enantiomer, then Lexapro would not have been called escitalopram (named for the inactive S isomer)…am I missing something?

R and S are different from D and L. R can be D or L. S can also be D or L.
Citalopram = 1-[3- (dimethylamino)propyl]-1-(4-fluorophenyl) -1,3-dihydro[3,4] benzofuran-5-carbonitrile
Escitalopram = S-(+)-1- [3-(dimethylamino)propyl]-1- (p-fluorophenyl)-5- phthalancarbonitrileoxalate

So, for this molecule, S is dextrorotatory and R is levorotatory.

today i had a sensible patient who was willing to listen. i told her to forget about the PA for Xyzal and to go to Costco and buy herself some shitload of citerizine for 20 bucks, i could have sold her my store brand, but i thought it was a rip off (30 tab/~$12).

“He’s too busy with his head buried in some drug rep’s tits….”

…you’re just jealous…. and so am I ;)

Had to argue with my MD to get a RX for Gabapentin instead of Lyrica.

All I want to say is AMEN.

Patients bitching about copays or insurance won’t pay for it, and all pharmacists have seemed to become (at times) is the complaint department for the insurance company!!

The docs don’t understand, we KNOW this. Even when I was working in hospital, you tell the doc we don’t have something on formulary (IE Desvenlafaxine) and what the formulary alternative is (Venlafaxine) and they have a fit or “BUT the patient is on THIS you can’t just SWITCH them”

Um, why not
you’re a doc, just write the damned order.

Hilarious insight but unfortunately true. I wonder if the drug companies are paying for the breast implants? LOL

What is a “fill-call”?

Fill it as if there is a refill or the change is okay and call the doctor the next business day….Rather than front a few tablets to a patient, I sometimes do that. If the doc says no or changes it, I’m out a few bucks. I’d never do it on a narc or drug that is relatively new or frequently titrated.

Also a necessary evil on drugs that cannot be ‘fronted’ like an albuterol inhaler.

Good points…in my small critical access hospital I had a rather new nurse ask me the other day why we didn’t carry such and such on the formulary, so I briefly touched on the whole rigamarole about containment of costs, availability of various drugs, i.e. formulary concept. She seemed to be nodding her head in the right places at the explanation, but then I wondered if she ‘got’ it when she said, ‘but the docs used to be able to get whatever they wanted when they ordered it, right?’ (Yea, and they used to be able to write ‘Do not label’ on scripts, and just how many drugs were available back then?) Generally, I’m under the impression that MDs graduating in last 20 yrs ‘get’ it, unless they learned their art under a toadstool.

So when the new laws go into place about the drug reps not being able to give shit out (pity, I got into Pharmacy was for the pens…)
Think that will stop the drug reps?

No. They’ll find a loophole…a way around…

Don’t forget about Veramyst (Flutiscasone) and generic Flonase (fluticasone). Veramyst is not on many pbm’s formulary’s and yet generic flonase is overlooked for the more common rhinocort, nasacort aq, veramyst, etc. Wake up people!!! Oh and who did nasacort aq have to sleep with to get on medicaids formulary?

Absolutey AMEN
I have never dispensed that Xyzal crap (amazing how the $50 copay make patients believe me when I point to the $6 store brand Zyrtec) I also have a whole little “patient friendly” speech, involving left and right hands and gloves, to explain to people why they are getting screwed. Tinker toys work too.
What I don’t get is why don’t the MD’s understand the concept. When I took Organic chemistry and learned about enantiomers, the rest of the class was almost exclusively pre-med. Why do I still have to pull out my gloves when I try to explain this to a prescriber! It should at least sound familiar when I use words like racemic and isomer.

Hey! I got a black message :) Try again….

“He’s too busy with his head buried in some drug rep’s tits “… you’re just jealous….

…and so am I ;)

I couldn’t agree more. I’m glad you picked Forest as your example; that company makes me angry. I had one of their reps come in one day and push Lexapro as being vastly superior to generic citalopram. He basically answered all my questions with “well, some studies have shown Lexapro is better. Also, the FDA approved it for generalized anxiety disorder.”

I’m sure they could get citalopram indicated for GAD, too, if there were any money in it.

The rep also decided to start talking about Namenda and the apparently overwhelming amount of evidence for giving every patient who might possibly be developing Alzheimer’s Namenda because “why take the risk?” I dunno, dropping another $200 a month to “maybe possibly slow down just a little bit” the development of Alzheimer’s may or may not be everyone’s cup of tea.

O Great One, I am but a pharmacy student to petition your wisdom on a similar matter. Does Trexima and Imitrex have the same situation as this?

Treximet = 85mg Sumatriptan, 500mg Naproxen (Aleve, essentially)
Imitrex = 25mg, 50mg, or 100mg Sumatriptan (Or equivalent Injection/Nasal Spray)

Yes, my dear, they are the same drug. Consider the costs. Aleve is a dirt cheap
drug, available over the counter. Should we really be charging buttloads of money to
add that to the Drug of Choice for migraines? More importantly, don’t most migraine
suffers try the OTC treatments like Aleve, Advil, and Excedrin before they seek help
from a physician and get prescribed Imitrex, Maxalt, etc? Of course they do.

If you knew the first thing about drug metabolism, you would know that in many racemic mixtures, the inactive enantiomer is converted to the active form by the liver. Several types of long acting medications, such a pain relievers, use such a system. The active enantiomer goes to work right away, while the liver more slowly converts the inactive to prolong the effect.

Ohh yes — If I knew anything. Why did you feel the need to use such a bitch fucking tone? I don’t get why people have such a wild hair to be pricks in their comments on the internet. You could have worded that SO much better — to not seem like an asshole.

Okay. Let’s go. Tramadol converted by the liver to the M metabolite which is a weak opioid. Now, you name the rest smartass.

Good article. I may also point out that Xyzal is backwards for “Lazy”X… the drug companies know what they are doing and are snotty enough to put it right into the product naming.

Never saw it…wow…

Excellent post!

[...] I got a note from The Ole Apothecary about a new drug he got wind of after reading my old post, Removing the Wool. [...]

My favorite is Sular 10/20/30/40mg (now discontinued) to Sular 8.5/17/25.5/34mg. They didn’t even try to change the drug.

What a righteous rant! My favorites are the docs who don’t think the trips to the bahamas with the big tit sales reps affect their prescribing. I’ve seen this work with a certain set of female docs too.
The latest I heard about was *** bringing in the hunky ex-college cheerleader guy to sell ***** to the local Ms Lonely Heart Doc.

Considering I don’t prescribe and I take every opportunity to change brand name junk to equivalent generic substitutes, I would agree that I am righteous in this instance.

While I agree that drug companies are out to make as much profit as possible on the backs of the consumers I do have to point out that sometimes a patient does respond better to the newer version of a medication.

For example, I took Lexapro for 3 yrs. Moved to a different state and didn’t have insurance. My new doctor prescribed me Celexa. Took it and developed more anxiety and depression symptoms. Got a new job with Group Health insurance and new doctor who listened to me when I explained the differences *I* felt between the 2 drugs and prescribed Lexapro. She called the pharmacy and discussed it with the pharmacist, 5 minutes later I had my Lexapro even though it wasn’t on the formulary because I needed it for a medical reason. There is a difference in some patients.

First off, I’m a student – and I really hope the one asking about Treximet and Imitrex was joking. Anyhow, I know that some people respond differently to brands and generics, I will not dispute that. BUT, most of the population does not. However, the dumbass who said “I’m allergic to all generics” needs to do some damn research into basic drug fillers.

Also, to Donna – I really really hope you realize that the pharmacist you are taking to does in fact “know the first thing about drug metabolism” So, using pain relievers as your example, do you not realize it might be desirable for a quick effect AND a later effect from the drug being slowly metabolized?

Also, a lot has to do with storage. If you look at profiles of something like carbamazepine when it’s stored incorrectly and water is incorporated, bioavailability is reduced by far. Comes out to PATIENT ERROR.

I had a doctor come into the pharmacy a while ago who noticed my nice pen and said something about the things drug reps giving him really affects his prescribing. I really really hope he was joking. Yikes, but he was probably serious.

Megan,
I hope you are in a PharmD program that actually talks about the influence of PhRMA trinkets on prescribing. It is sad, but there are plenty of research articles of the effects of trinkets on prescribing. I highly suggest that you investigate the website http://www.nofreelunch.org, or do a PubMed search on Pharmaceutical industy influence. And it doesn’t stop with physicians, ARNPs are the absolute worst when it comes to being influenced by a tote bag or lunch. And I’m very sorry to say it even happens with some clinical PharmDs and their recommendations for treatment to physicians and to their work on P&T committees.

you are all wrong i have had severe chronic hives for 2 years, been on everydrug including zyrtec 3 times a day plus more medrol than anyone needs to take. at one point had 10 different rx’s and still had hives until xyzal, 5mgs 2 x a day and no hives. i don’t care how much it costs and my insurance does cover it. thank god i don’t have to suffer anymore.

No, we are not wrong. You are either:
a) A Freak of nature
b) A brand-whore that is lying to try and prove a point
c) A drug rep in disguise
d) Some odd combo of the above

The science, facts, and data is on my side. You telling me that nothing else works except the active isomer of one drug that happened to have just gone generic is not going to rewrite the algorithms in Dipiro or Koda-Kimble….sorry!

I agree with Angriest.
Lisa, you were taking Xyzal when you took Zyrtec, and actually you are taking less with 5mg 2 times a day- you were getting 5mg 3 times a day before.
Besides, if 1 out of 100 people actually do better with the odd isomer, why does PhRMA think they have to have all 100 take it, wasting thousands of dollars.
I’m the high priest of step therapy- use the wierd crap if and only if the other 10 things available that are generic don’t work

WOW! what a bunch of idiots you are. i am one of many people who have only have relief with this drug, read the blogs on chronic hives! and also i can’t imagine who you morons are that can only come back with insulting remarks instead of actual feedback from people who have taken this drug. are you all in the 3rd grade ? LOSERS

Listen here, dike, by calling us morons and losers, you are being insulting. In essence, you have proven yourself to be profoundly retarded. I’m not sure how the sand got in your vagina, nor how you got the hives, this post was created for the shear purpose of pointing out the games drug manufacturers play when it comes to active isomers and racemic mixtures. For you to say that Xyzal works wonders (levocetirizine) while Zyrtec does nothing (Cetirizine) has absolutely no basis in what would be considered a rationale medical opinion. Do you understand why? If not, I underlined the reason why above — if it isn’t clear enough for you.

You were only made fun of for failing to realize that — and rightfully so. Don’t comment again.

how many times can they reinvent fenofibrate?

Just had this sent to me via StumbleUpon:

“You should be embarrassed if you prescribe Nexium because you’re screwing the patients and you’re screwing taxpayers.” – Thomas Scully

I am a retired physician and I served on our P + T committee at a federal facility so I am well aware of the abusive pricing and profittering of big pharma by renaming and repackaging the “old”, but cost effective medications for outlandish markups. A few years ago, a member of my family was given a name brand Rx (which I did not recognize) for her IBS. Before filling it, I checked a database and found the active ingredient was hyoscyamine and the average wholesale cost was $100.00 for a 30 day supply; while the average wholesale cost for a 30 day supply of generic Donnatal was 68 cents. That’s over a 14,000% markup. Needless to say, we went the generic route. I’m not anti-business, or anti-reasonable profit but that is ridiculous and cannot be justified. As another example, a friend’s daughter was prescribed a “once a day” form of minocycline at a cost of $400.00 for 30 tablets. Of course, the appropriate dose of generic minocycline in a “bid” format would have been just as effective. When my friend asked the prescriber about this, the PA refused to change the Rx. So, it cost an extra $300.00 per month to take the med once a day instead of twice a day. That is a ridiculous cost for once a day convienence. And, yes, I know about the Prilosec – Nexium ploy.