Shopping for Drugs: 2007

Policy Reports | Health

No. 293
Thursday, November 16, 2006
by Devon Herrick, Ph.D.

Therapeutic Drug Substitution

Special Opportunities for Seniors to Save%3A Comparing Medicare Drug Plans

"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.  The notion that the choice of medications should be left completely to physicians is outdated.  Patients should ask if there are cheaper alternatives to a prescribed medication - including generic substitutes, alternative drug therapies or over-the-counter (OTC) drugs.  Research on patients with chronic conditions revealed that 72 percent found discussing drug costs with their doctors helpful.  And after these discussions, they were switched to a lower-cost alternative more than two-thirds (69 percent) of the time.30 

"There are many therapies to treat most conditions."

By communicating with their doctors, patients may find a wealth of drug options.  For example, unless patients bring up the subject, physicians may not even be aware of the cost of medications they prescribe, the extent of their patients' insurance coverage, or the patients' ability to bear significant out-of-pocket costs.   

"The cost of drug therapies for many conditions varies widely."

There are many therapies to treat most conditions.  [See Table I.]  Some therapies cost more than others to treat the same conditions.  Also, newer therapies may only offer modest improvement better than older ones.  Take drugs to treat schizophrenia. Recent research has raised concerns that newer drugs cost many times more than older drugs that appear to work as well in most people.31 [See Figure I.] 

"Smart Shopping: Consider therapeutic substitutes."

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 two fairly common conditions: allergies and heartburn.  Treatment options for these conditions are discussed below.  Patients already taking prescribed drugs can explore alternatives using the internet resources noted previously prior to scheduling their next doctor's appointments. 

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.32  They are economical and available OTC.33  Although they can cause drowsiness, studies have shown that they are often just as effective as newer, nonsedating drugs.34

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.)35  How much can patients save by considering other treatments for their allergies?  As shown in detail in Appendices A-1 and A-2: 

  • For newer, prescription-only antihistamines, patients shopping at can expect to pay about $129.49 per 100 doses of Allegra compared to about $192.89 for Zyrtec and almost $268.17 for Clarinex.36
  • Allegra's generic equivalent, Fexofenadine, is available at at a cost of $76.63 for 100 tablets.37 
  • However, 100 doses of OTC Claritin costs only about $76.63 at Walgreens Web site, while its generic equivalent, Loratadine, is available from Sam's Club for $5.28.38   
  • Another substitute that may work for some patients is the first-generation antihistamine Benadryl and its generic equivalent, Diphenhydramine, which is available at for about $3.90 if purchased in quantities of 200 tablets.39 
  • Research has shown that the first-generation, OTC drug Chlor-Trimeton (Chlorpheniramine) is more effective at binding to the histamine receptor than other antihistamines.40  It can be purchased in bottle of 100 4mg tablets for $4.79 from various vendors on Yahoo Shopping for about a penny per three-tablet dose.41

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 physician or pharmacist.  However, side effects may not be an issue for some people.  For example, Benadryl can cause drowsiness compared to Loratadine, but those suffering from nighttime allergies may find it is the ideal drug.42  And at less than four cents per tablet, it is about 98 percent less than newer prescription drugs.43  Consumer Reports rates Loratadine a best buy among antihistamines.44

"Older, cheaper drugs may be just as effective as newer drugs."

Case Study: Heartburn Medications.  Some newer therapies are only slightly more effective (or tolerable, with respect to side effects) for most patients than older therapies - but at a much higher price.  Experts suggest this may be the case with the newest heartburn medications, known as proton pump inhibitors (PPIs).45   For those with severe heartburn (called gastroesophageal reflux disease or GERD), PPIs such 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.46  Prilosec was the leading prescription PPI until it was moved OTC in the fall of 2003.47  Critics content that Prilosec OTC is just as effective as Nexium, the prescription drug that replaced it, but at much less cost.  However, Nexium is often prescribed for garden-variety heartburn.  And drugs in an older class (called H2-receptor antagonists) that includes Zantac and Pepcid are also much cheaper. 

PPIs are not cheap: 

  • The cost for 100 doses of Nexium is more than $493.30 if purchased in small quantities from;48  Prevacid is similarly priced.49 
  • However, purchasing 100 doses of Protonix (Pantoprazole Sodium) from would save more than $140.50 
  • Prilosec OTC is a less expensive option, currently available from for $61.88 for 100 doses.51 

For patients with little more than occasional indigestion, Zantac or its generic equivalent, Ranitidine, may be sufficient.52  Although Ranitidine is now available over the counter in 75mg tablets, it is often prescribed in 150mg doses.53  Among patients' options:

  • Purchasing 100 (150mg doses) of Ranitidine from Sam's Club would cost slightly less than $5, or 5 cents a dose.54 
  • sells 400 mg generic Tagamet (Cimetidine) in quantities of 100 tablets for $28.32, or about 28 cents for a 400mg dose.55
  • 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 Sam's Club.56 

Figure I - Daily Cost for Anti-Psychotics

Caution: Advertised and Sampled Drugs.  Why is it so important to be an informed drug consumer?  One reason is that the few drug therapies advertised are generally the most expensive.  Free samples given to physicians are often expensive drug therapies.  Critics also charge drug advertising is often not backed up by facts.  A study of pharmaceutical advertising materials sent to German physicians revealed that about 94 percent of claims had no basis in scientific fact.57

"Drugs that are advertised and given out as free samples 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.58  However, the drugs advertised are also likely to be the most expensive.59  By 2005 drug advertising surpassed $4 billion - about four times the level of spending in 1998, the first year after the Food and Drug Administration began to allow direct-to-consumer advertising.60  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 the correct therapy 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, about half the marketing budgets of pharmaceutical companies are spent on distributing free samples.61   When offered samples by their doctors, however, consumers should also ask if there are nonsample medications that might have similar therapeutic benefits.  Although samples are free at the doctor's office, refills may be costly.  Trying both free samples and alternatives (usually generic medications that must be purchased) will allow patients to compare whether the benefits of the newer drug outweigh the cost.  Furthermore, many clinics and university teaching hospitals no longer use free samples.  They claim it is cheaper in the long run to prescribe and purchase generic medications than to offer patients free samples of medications that are expensive to refill.62

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