Take for example, Lovaza, which is omega-3 acid esters. I know someone with borderline high cholesterol, ~220 mg/dl, good total/HDL ratio ~3.5, and with triglycerides less than 100 mg/dl who had Lovaza prescribed for her. Two 1 gram tablets twice a day. The cost for these from Medco is $370.18 for a 90 day supply, $4.11 per day. Lovaza’s main use is to reduce very high tryglycerides, >500 mg/dl.
Ignore the fact that in my opinion treating cholesterol that borderline without at least trying diet first is a little aggressive, “what about fish oil capsules?” I say. I take fish oil capsules purchased at Costco, getting 400 for $8.99, around $0.02 per capsule.
Well, she asks the doctor about these and he says you’d have to take 12 a day to give you the same benefit of 4 Lovaza tablets, and the insurance pays most of the cost of the prescription medicine. Which is true, the co-pay is only $35.00 for a 90 day supply, but still, it’s not like the money magically appears.
So we have a situation where the total cost to treat is either $4.11 on the prescription drug, or $0.27 a day on the over the counter (OTC) substitute. You do have to swallow an additional 8 capsules a day, but really, is the difference between 4 capsules and 12 worth $1400 per year?
So why would a doctor immediately prescribe a expensive drug for a condition that seems treatable by a cheap OTC?
According to my math, the prescription pills are costing your friend 39 cents a day, using $35 divided by 90 days.
Doctors generally prescribe based on their best judgement as to what is right for their individual patient. It is up to the patient to decide if he wants to comply or wants to try another remedy, do nothing, whatever.
In this particular case, I agree with the doctor. Had we been taking about one drug and it’s generic version, I think you would have a good point, but these two things are not the same. You have to factor in the cost the efficacy differences might cost long terms of worsening condition, and liability to the doctor, in addition to many other things.
I think it can be ethical for a doctor to consider compliance in what he decides to prescribe, at least to some extent. He may have experience that people do not stick with the fish oil regimen. I have trouble swallowing pills, especially large ones, and when I tried fish oil (not for cholesterol, I don’t even remember why, now) it gave me nasty, fish-flavored indigestion, and that was with one capsule. Although, looking at the Lovaza site, maybe it has those side effects, too. (Gak! Remind me to keep my triglycerides down)
In this particular example, I have more concerns about prescribing the drug for someone who apparently doesn’t have very high triglycerides. In that case, I wouldn’t have an ethical problem with the insurance company pushing back pretty hard on paying for it.
It’s hard to make a conclusion based on what is presented and what might be omitted or unknown. I once worked as a stockboy in a pharmacy and I remember a woman consulting with an RPh. She got the Rx from the doctor, looked it up in the PDR, and couldn’t figure out WHY she was taking it. She and the RPh managed to deduce that the doctor wanted to raise her low blood pressure and was using a drug for its side effect.
In that particular case, the doctor had chosen an inexpensive medication that wouldn’t interfere with anything else. But from what I see on TV these days in advertisements, I have to conclude that there’s money to be made and a lot of pharmaceutical companies would really YOU to do the prescribing.
After showing what the medication does, they go into the side effects. E.g. “Tell your doctor if you have advanced liver problems.” Whoa, wait! If he’s my DOCTOR, why wouldn’t he already know that? Etc.
IMO those ads are pretty inappropriate. In short, I don’t need to know what new medications are just coming on the market—my doctor needs to know. I think these companies would like me to go to the doctor and say, “I just saw this on TV and I want it,” and the doctor takes his orders from me, so he writes it. See, it’s up to me to listen to the ad to determine if the side effects would be a problem or not… :dubious:
These days, prescriptions are big business (and presumably big kickbacks for some doctors). I don’t think it’s unreasonable to question the doctor’s decision on this one.
I know it costs her $0.39 a day, but the total cost is $4.11. Increasing the cost to the insurance company by $1500 a year is not going to do anything towards keeping insurance costs contained. That money comes from somewhere. Every year my premiums go up, and a large part of it is from physicians who say “What do you care? The insurance company pays for it”. And in the meantime it drives up the cost of Lovaza for people who might really need it.
The doctor made no recommendations about diet or exercise, and in my opinion, a one time cholesterol reading of 220 mg/dl does not justify such an aggressive treatment. In such a borderline case I like a doctor to recommend the cheapest drug that would do the job. If that doesn’t work they can try the more expensive ones.
I take six generic fish oil capsules a day and my cholesterol was less than 165 mg/dl, and my total/HDL ratio around 2.5. There are some side effects, when I belch I sometimes think, “When did I eat salmon?” before I remember, but she has the same symptoms on the Lovaza.
Someone upthread mentioned the doctor may be prescribing “off label”, looking for a beneficial side effect. That could very well be true, but shouldn’t the responsibility be on the physician to carefully explain the reasoning before handing out a prescription?
IMHO, there’s too much prescribing of cholesterol meds for inconsequential cholesterol elevations.
A doc really does need to do a risk assessment regarding heart disease, to determine which interventions should be started. Such a risk assessment has many components, such as age, gender, family history, associated medical conditions, etc. Lipid levels are but one aspect.
Physicians who prescribe meds based solely on mildly elevated cholesterol readings are not practicing according to recommended standards, nor are they doing their patients any favors.
As to the OP, it’s ethical to prescribe the most suitable drug in the most appropriate dose.
Some people just assume that there’s nothing that the doctor can do for symptom X, so they don’t bring it up. Or they have trouble explaining what’s wrong until they hear the symptom described.
(I once almost put off complaining about a dental problem, but since the dentist asked directly I started trying to explain . . . and then she jumped in and said “so you’re having a packing problem?” Sure, if that’s it’s name. And if it has a name, it’s real and fixable.)
So I can see a value in the ads if it gets people to discuss symptoms with their doctor that they would otherwise not mention.
High triglycerides guy here.
I’ve had numbers in the 700 to 800 range like, forever. I have just completed 3 months on 2 Lovaza pills per day. My blood work came back today, and I’ve gone from 726 last March to 213 today.
I had been on a 2000 mg dose of over the counter Omega 3 for years. It was a waste of money. Hooray Lovaza!
My friend’s doctor prescribed 4 Lovaza pills per day with starting triglycerides lower than 100 mg/dl. And never suggested trying diet or OTC stuff first. But he did tell her that she would need 12000 mg per day of OTC stuff to equal the dosage in the 4 Lovaza capsules. I’m surprised he didn’t pull out a lot of bowls of capsules like the Total cereal commercial.
I’m sure it has value, especially in the target patient population. I just don’t think every man, woman, and child in North America needs to be on it.
I spend all day on the phone talking to folks about health-related issues and disease management, and cholesterol is a biggie, especially since the great majority of the people I talk to have cardiac histories and/or diabetes.
My observations…
Many, many doctors are recommending fish oil and many folks are taking it along with their other cholesterol medications.
Not seeing many Lovaza prescriptions (I see info from claims as well as knowing what our members self-report to us). Seeing a lot of Tricor prescribed lately. Many, many folks are still taking Vytorin despite some of the recent news there; there are a lot of docs who still believe in it and don’t regard the evidence as being all in.
Very very few people with elevated cholesterol levels are willing to go the diet/exercise route, even though it can be very effective for most folks. Yes, cholesterol problems can be partly hereditary but that doesn’t mean it isn’t worth it to do some lifestyle work. That’s one of the most frustrating things about my job.
I think that the doctor is obligated to prescribe for the patient what will, in the prescriber’s opinion, help the patient have the best possible outcome.
Think about a mentally ill patient, for example… The patient could perhaps get the same result from one extended release tablet taken daily, or 5 caps taken 5 times daily. Is this patient likely to be compliant with the second regimen? Not likely. Even if the first regimen is much more costly, it is more cost-effective if it is actually used correctly.
It’s a tough call.
Another issue is that patients want to take the “latest and greatest” meds. If you go to a doctor, and he suggests that you take Tums, you’re not going to believe that you got your “money’s worth” in seeking medical attention. Patients want validation from their physicians, and a lot of them believe it comes in the form of a prescription.
Or it could be that the patient has tried the diet/exercise routine and the cholesterol and triglycerides won’t budge any further, that there’s a history of heart problems in the patient’s own or family history that stamp “high risk” all over the diagnosis, that the patient has experienced side effects (or lack of effect at all) with other drugs or any of a half-dozen other reasons.