Shopping for Drugs: 2007

Policy Reports | Health

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

Weighing the Costs and Benefits of a Drug

"New drugs may have fewer side effects, but cost much more than older drugs."

To receive FDA approval, drug manufacturers must prove their drug is both safe and effective.  They don't have to prove the new drug works better than comparable therapies, only that the drug works better than a placebo.115  Some drugs are more effective in treating a condition than others, but some expensive drugs only work marginally better than cheaper alternatives.116  The idea of comparing the cost-effectiveness of drugs - that is, separating clinical evidence from economic considerations - is controversial when it comes to public programs, yet consumers do it every day when purchasing other goods and services.117 

Table III - Yearly Cost for Arthritis Pain Relievers

Consumers Union has created a Web site to help patients determine which drugs are a good buy versus those that may not be.118  They have also published reports on 12 drug classes, accounting for about 40 percent of drugs sold in the United States.119 

Another avenue for information available to patients is testimonials from Web sites and message boards.  One such Web site,, rates more than 2,500 medications based on average responses from thousands of patients.  Each report lists the total number of responses and the average rating.  Patients who want to delve deeper can examine the sex, age and comments of those who have provided feedback.120

Patients often begin taking a drug and never question its necessity later.  They should periodically ask their doctors if they still need to take a prescribed drug.121  Furthermore, not all prescriptions are appropriate for older patients.  According to studies published in the Archives of Internal Medicine, a senior receives one inappropriate medication for roughly every 12 doctor visits.122 Currently, some 20 percent of seniors are taking at least one medication that is not recommended for their age group, 15 percent are taking two inappropriate drugs and 4 percent have been prescribed three drugs deemed inappropriate.123  The likelihood of inappropriate medication is about double for women and increases when multiple drugs are prescribed.124 

"Some conditions can be treated with lifestyle changes."

There seems to be a pill for about every condition - real or imagined.125  However, patients are in the best position to decide if so-called "lifestyle" drugs are really worth the cost.  There are undoubtedly millions of people who would not agree that drugs such as Viagra for erectile dysfunction126 or Propecia127 for baldness have no medical necessity.

However, patients taking expensive medications often overlook nondrug alternatives.  For instance, statins (antihyperlipidemics) are one of the drugs most widely used by seniors.  Statins have been proven to extend life - but the greatest benefit is for seniors who have a serious heart condition.  They have only a marginal effect in healthy seniors,128 and many seniors would probably be healthier if they controlled cholesterol through diet.129  Physicians say losing weight and exercise are the best option for controlling high blood pressure.130  The first line of defense in preventing obesity and Type-II diabetes is prevention by changing diet and exercise.131  The same is true for GERD.  Gastroenterologists suggest most patients with GERD should first change their lifestyle before trying H2 receptor antagonists or before taking the more costly PPI drugs.132

Patients also often overlook cheaper drug options.  For example, research has found that a diuretic - a water pill - is more effective than newer, more expensive antihypertensive medications.133  In addition, a recent study in the Journal of the American Medical Association found that two aspirins daily were as effective in preventing recurrent strokes in African Americans as a daily 500mg dose of the drug Ticlopidine.134  This is a significant finding, given the fact that Ticlopidine can easily cost patients more than $100 per month.135

Treatment of migraine headaches provides another example.  A drug trial found that Acetaminophen combined with aspirin and caffeine (AAC) provided more sustained relief than the prescription drug Sumatriptan.136  Those taking Sumatriptan reported faster relief - 29 percent versus 19 percent of those on AAC - and had little or no pain after 30 minutes.  But at two hours, the AAC treatment group fared significantly better (84 percent versus 65 percent).137

"There are many drugs to relieve arthritis pain."

Choosing a Pain Reliever.  Some seniors may not be getting their money's worth from the new generation of "super-aspirins" called Cox-2 inhibitors.  They relieve pain and inflammation without the stomach irritation sometimes experienced by taking daily doses of aspirin, Ibuprofen or Naproxen.  But they may offer most seniors only modest benefits over cheaper drugs,138 and they may cause heart attacks.139

A recent study found that two-thirds of patients on Cox-2 inhibitors were not at risk for gastrointestinal conditions like ulcers or bleeding, but most of them had not tried cheaper alternatives.140  Another study, by the pharmacy benefits management company Express Scripts, found that more than three-fourths (76 percent) of these prescriptions are written for patients who are not at risk of gastrointestinal side effects.  On average, patients who receive new prescriptions of Cox-2 inhibitors use the drugs for less than 60 days.  This suggests that the drug is not necessarily prescribed for conditions that require long-term therapy, where the risk of serious gastrointestinal bleeding is a concern.141  Furthermore, a recent study found that many patients taking Cox-2 inhibitors also take aspirin daily to benefit their heart, which can negate the gastrointestinal benefits associated with the more expensive pain reliever.142

"The effectiveness of a drug may depend on the dose."

There are more than a dozen selective and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve pain from such diseases as arthritis.143  [See Table III.]  The price per dose ranges from $2.35 per capsule for Cox-2 inhibitors to mere pennies for aspirin.  Cox-2 inhibitors and other nonselective NSAID pain relievers are equally effective at controlling pain, but Cox-2 inhibitors cost more - up to $1,118.51 per year for someone taking 200mg per day of Celebrex, for example.144  Some experts question whether they are always worth the additional price.145  In fact, many patients taking the more expensive Cox-2 inhibitors may fare as well on NSAID pain relievers taken with proton pump inhibitors.146  For example, 20mg Prilosec OTC costing 63 cents per day, if taken with 12 tablets of 200mg Ibuprofen throughout the day, would cost only $343 annually compared with $900 or more for most COX-2 inhibitors.  

Choosing an Allergy Medication. Consumers also may not be getting their money's worth from expensive, prescription-only, second-generation antihistamines like Zyrtec, Clarinex and Allegra.  On the drug-rating Web site, patients tended to give antihistamines a rather low overall rating.147  Antihistamines received an average score of only 2.6 out of a possible 5 points.  By comparison, people rated Viagra 4.2 out of 5.  In addition, experts often claim Claritin (Loratadine) works only slightly better than a sugar pill.  For instance, in two clinical studies, Loratadine outperformed a placebo by a mere 11 percentage points.148  The older, first-generation antihistamines work just as well as the newer, second-generation nonsedating antihistamines.  In fact, research has shown that the first-generation antihistamine Chlor-Trimeton (Chlorpheniramine), which is now available over the counter, is more effective than other antihistamines at binding to the histamine molecules and reducing allergy symptoms.  But the molecules of first-generation antihistamines can pass through the blood-brain barrier into the central nervous system, causing sedation.  When it was developing Claritin, Schering-Plough knew that it only had a lucrative product if it did not cause drowsiness.  Thus, it only applied for approval of a 10mg dose since some patients experienced drowsiness at higher doses.149  Some critics within the FDA worried that the dose was too low to be effective.150 

Even though Loratadine's patent has ran out, generic manufacturers cannot increase the dosage they produce without going through an expensive FDA approval process.  Only the 10mg dose is FDA-approved, so that is the only dosage manufacturers are allowed to sell.151  People who have had little success with Claritin (Loratadine) may find that it is more effective if they take 20mg (2 pills) per day, if they can do so without feeling drowsy.152  Some conditions may warrant even higher doses.153  [Note: Patients should always consult a physician before taking more than the recommended dosage of any medication.] 

"Competition reduces prices for generic versions of namebrand drugs."

Those whose allergies are not controlled well with Loratadine or who cannot tolerate side effects such as sedation associated with Benadryl (Diphenhydramine) now have cheaper options.  For example, some of the patents for Allegra (Fexofenadine) recently expired,154 and the first generic version became available in 2006.155  Currently, 100 60mg generic Fexofenadine tablets are available at for $111.08 - $18.90 less than for Allegra.156  The price for Fexofenadine should drop even lower in the future.  The first company to apply for permission to produce a generic drug is granted a 180-day period of exclusive sales.  Once this six-month period has lapsed, many other companies will enter the market and drive prices down.  When that happens, the price for 100 60mg tablets of Fexofenadine will likely fall below $30, which could happen by late 2007.  Before this occurs, however, some experts expect Allegra's manufacturer, Aventis Pharmaceuticals, to introduce an OTC version of Allegra to counter the popularity of OTC Claritin.157  The patent on Zyrtex will also expire in 2007 so a generic (or an OTC) version should appear within the next year or two.158 

Experts also point out that inhaled corticosteroids tend to offer quicker symptomatic relief than antihistamines.159  Flonase (Fluticasone Propionate) is now approved in generic form and will probably be available shortly.160  Patients spending $50 to $80 per month on expensive prescription antihistamines (such as Allegra, Clarinex and Zyrtec) may find their symptoms of hay fever are better controlled with 1) low-cost OTC Chlorpheniramine, 2) an inhaled nasal corticosteroids such as generic Flonase, or 3) a higher dose of low-cost OTC Loratadine.

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