Shopping for Drugs: 2004

Studies | Health

No. 270
Monday, October 11, 2004
by Devon Herrick, Ph.D.


Therapeutic Drug Substitution

“Patients should discuss drug therapy choices with their physicians.”

The doctor’s office is a good place for patients to start lowering their drug bills. It is an outdated notion to leave the choice of medications completely to physicians without question. Patients should ask if there are cheaper alternatives to a prescribed medication — including alternative drug therapies, generic substitutes or OTC drugs. Research on patients with chronic conditions found that when they discussed drug costs with their doctors, 72 percent found the conversation helpful. After such discussions, they were switched to a lower-cost alternative more than two-thirds (69 percent) of the time. 14 Unless patients bring up the subject, physicians may not even be aware of the cost of medications they prescribe, the extent of the patient’s insurance coverage, or their patient’s ability to bear significant out-of-pocket costs. By communicating with their doctors, patients may find a wealth of drug options.

Patients already taking prescribed drugs can explore alternatives prior to scheduling their next doctor’s appointments. Rxaminer.com, cofounded by cardiologist Joseph C. Rogers, is a Web-based service that helps patients find cheaper medications comparable to the ones they currently take. 15 Customers enter the names and dosages of medications, Rxaminer compares them, suggests substitutes (often several choices) and allows users to print reports detailing potential savings. Patient can discuss these reports with their physicians to see if the cheaper medications are appropriate.

In many cases, newer drugs are only “better” than older ones because they have fewer side effects. For example, numerous studies show that newer antidepressants, called selective serotonin reuptake inhibitors (SSRI), are similar in effectiveness to older tricyclic antidepressants. 16 But SSRIs are better tolerated — resulting in more patients adhering to their treatment protocols.

There are numerous therapies to treat most conditions. [See Table I.] In some cases, a drug class includes OTC medications, as well as brand-name prescription drugs and generics. Drugs within a therapeutic class may be similar, but their prices often vary substantially. For example, alternative therapies are readily available for three fairly common conditions: allergies, heartburn and gastro-esophageal reflux disease (GERD).

Case Study: Allergy Medications. Patients suffering from seasonal allergies have a myriad of choices, including prescription drugs, OTC drugs, decongestants, antihistamines and nasal inhalers. All of them offer symptomatic relief, but some have fewer or less severe side effects than others. The most popular sinus allergy medications are antihistamines, the cheapest of which are first-generation antihistamines. They are economical and available over the counter. 17 Although they can cause drowsiness, studies have shown that they are often just as effective as newer, nonsedating drugs. 18

The allergy medication Claritin and its generic equivalent (Loratadine) are now available over the counter. Although they still cost more than older OTC antihistamines, they are cheaper than prescription alternatives, such as Allegra, Zyrtec and Clarinex. (Clarinex is a new prescription variant of Claritin from the same manufacturer; some critics claim it is about the same as the older drug.) 19 How much can patients save by considering other treatments for their allergies? As shown in detail in Appendices A-1 and A-2:

  • For the newer (prescription-only) antihistamines, patients shopping at Drugstore.com’s Web site can expect to pay about $123 per 100 doses of Allegra compared to about $181 for Zyrtec and almost $210 for Clarinex. 20
  • However, 100 doses of OTC Claritin sells for less than $68 at Walgreen’s Web site, while its generic equivalent (Loratadine) is available from Costco.com for less than $9. 21
  • Another substitute that may work for some patients is the first-generation antihistamine Benadryl and its generic equivalent (Diphenhydramine), which is available at Drugstore.com for about $6.50 if purchased in quantities of 200 tablets. 22 

Table I - Therapeutic Substitutes

Although there are many medications to treat allergy symptoms, there are tradeoffs with respect to side effects. For example, antihistamines tend to raise blood pressure. Ideally, patients should confirm the safety of any drug taken regularly — including OTC medications —with a pharmacist or physician. However, side effects may not be an issue. For example, Benadryl can cause drowsiness, but those suffering from nighttime allergies may find it is the ideal drug. And at less than seven cents per tablet, it is 95 percent less than newer prescription drugs. 23

“Smart Shopping: Consider therapeutic substitutes.”

Case Study: Heartburn Medications. Some newer therapies may offer most patients only a slight advantage over older therapies — but at a much higher price. Experts suggest this may the case with the newest heartburn medications, known as proton pump inhibitors (PPI). For those with severe heartburn (called gastroesophageal reflux disease or GERD) such PPIs as Nexium, Prevacid, Protonix or similar drugs are the treatment of choice. PPIs were the second most popular class of drugs in 2003 with $13 billion in sales. 24 Prilosec was the leading prescription PPI until it was moved over the counter in the fall of 2003. 25 However, the PPI Nexium is often prescribed for garden variety heartburn even though there are cheaper OTC drugs. Critics content that Prilosec OTC is just as effective as Nexium, the drug that replaced it. And drugs in an older class (called H 2 receptor antagonists) that includes Zantac and Pepcid are much cheaper.

PPIs are not cheap. The cost for 100 doses of Nexium is almost $420 if purchased in small quantities from RxUSA.com Web site. 26 Prevacid is similarly priced. However, purchasing 100 doses of Protonix (pantoprazole sodium) from Drugstore.com would save $112. 27 Prilosec OTC is a less expensive option, currently available from Costco.com for $59.50 for 100 doses. 28 For patients with little more than occasional indigestion, Zantac or its generic equivalent Ranitidine may be sufficient. 29 Although Ranitidine is now available over the counter in 75mg tablets, it is often prescribed in 150mg doses. 30 Among patients’ options:

  • Purchasing 100 (150mg doses) of Ranitidine from Costco’s Web site would cost slightly less than $5, or 5 cents a dose. 31
  • Drugstore.com sells 200mg generic Tagamet (Cimetidine) in quantities of 70 tablets for $9.79, or about 28 cents for a 400mg dose. 32
  • Patients who do not do well on Zantac or Tagamet can choose the generic equivalent of Pepcid (Famotidine) for around 12 cents per 40mg dose at Costco.com. 33

Caution: Advertised and Sampled Drugs. Why is it so important to be an informed drug consumer? One reason is that the few drug therapies that are advertised are generally the most expensive. The free samples given to physicians are often the most expensive drugs.

“Drugs that are advertised and sampled are usually expensive.”

Direct-to-Consumer Advertising. Drug advertising is beneficial because it educates patients about new clinical treatments and often prompts them to seek care for previously untreated medical problems. 34 However, the drugs advertised are also likely to be the most expensive. 35 In 2000, drug manufacturers spent $2.5 billion on direct-to-consumer advertising; about $1.5 billion dollars was spent to promote a mere 20 drugs. 36 Advertising is by no means representative of all therapies available. The newest innovative therapies are the ones most likely to be advertised because these drugs are under patent protection and the manufacturer profits by informing potential consumers. Drugs that have lost patent protection are rarely promoted because doing so benefits competing generic drug manufacturers.

Newer drugs may offer considerable advantages over older products. A new drug advertised on television may indeed be right for some patients. But patients and their doctors should make the decision after considering all options — not just the ones seen on TV.

Free Samples. Drug company marketing also benefits patients by providing free samples to doctors. Drug samples allow patients to try new medications without cost. In fact, pharmaceutical companies spend about half of their marketing budgets promoting medications by distributing free samples. 37 When offered samples by their doctors, however, consumers should also ask if there are other, nonsampled medications that might also have therapeutic benefits. Although samples are free at the doctor’s office, refills may be costly. Many clinics and university teaching hospitals no longer use free samples. They claim that it is cheaper in the long run to prescribe (and purchase) generic medications than to offer patients free samples of expensive medications that often must be refilled at significant cost. 38


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