Asthma/COPD Inhalers: Why They Cost So Much

Some of my asthmatic friends constantly criticize pharmaceuticals as run by a bunch of evil rich people who are greedy and make money at the expense of the sick.  Their evidence is the fact that newer, non-patented, asthma medicine costs so much.  I would like to argue that pharmaceutical companies (or most of them) are run by people who simply want to make enough profit to stay in business.

It is true that asthma medicine costs too much. Consider that if your doctor prescribes Advair to control your asthma, it will cost you about $250 a month if you pay out of pocket.  If you have a copay the cost will be about $70 per month.  This copay is high, considering a typical copay for generic medicine is between $20 and $40 a month.

 Consider the following facts as reported by medicine.net, "Drugs: Why they cost so much?"

• The high price of Advair is not the result of greed, but of regulation. In fact, pharmaceuticals are constantly looking to find new medicines to help people.  They continue to do this even though they know that only one out of every 10,000 discovered compounds actually becomes approved by the FDA
• The early stages of development are not only expensive, but much of the expense incurred will not become approved drugs.
• It takes about 7 to 10 years and an average cost of 500 million dollars to develop each new drug. Keep in mind this money is spent before the FDA approves the drug. This means that if the drug is not approved, the company loses the money. 
• These expenses must be covered by the revenue from compounds that successfully become approved drugs (like Advair). 
• Moreover, only 3 out of every 20 approved drugs bring in sufficient revenue to cover their developmental costs, and only 1 out of every 3 approved drugs generates enough money to cover the development costs of previous failures. This means that for a drug company to survive, it needs to discover a blockbuster (billion-dollar drug -- like Advair) every few years. 
• After a drug is approved, millions of dollars are spent on marketing in educating healthcare providers and conducting post-marketing studies. Drug companies spend a lot of money on marketing because of the stiff competition they face from other drug companies for their drugs, and in order to develop each drug's highest revenue-generating potential. 
• Given the poor odds of discovering another successful drug, it is more efficient to maximize the returns on a drug that is already on the market through advertising. In this sense, drug companies are no different than any other type of company. They exist to make a profit by helping people.
• In addition to maximizing returns on their investment through advertising, drug companies also spend money to find new uses for drugs or better ways of using them. These efforts increase the use of the approved drugs and also benefit patients. 
• Additionally, drug companies donate millions of dollars to charities and provide free drugs to individuals or countries that cannot afford medications. In fact, it was through a program that I was able to get free Breo for a year (otherwise, I cannot afford it and I have insurance). 

Surely any person working for any company wants to become rich, but in order for this to happen the company they work for must develop, market, advertise, and sell a successful product. Due to the high risk of failure and the low risk of actually gaining FDA approval, the medicines that are approved will have a hefty cost.

Further reading:

• medicine.net, "Drugs: Why they cost so much?

Hospitals charging different prices for same treatment

Getting back to prices of healthcare, it seems that some hospitals are ripping patients off, charging more for services even than hospitals in the same city.  This is according to an AP article titled "High hospital bills go public."

The article ponders some interesting questions:

Why does a joint replacement cost 40 times as much at one hospital as at another across the country? It's a mystery, federal health officials say... The average charges for joint replacement range from about $5,300 at an Ada, Okla., hospital to $223,000 in Monterey Park, Calif., the Department of Health  and Human Services said.  That doesn't include doctor's fees... Hospitals within the same city also vary greatly.  At Beth Israel Medical Center in New York, the average charge to treat a blood clot in a lung is $51,580.  Down the street at NYU Hospitals Center, the charge for the same care would be $29,869. 

Interesting.  I wonder what the different costs for breathing treatments are?

Thoughts about Advair and alternatives

As I blogged about yesterday, many people have been asking about alternatives to Advair and Symbicort due to the high cost of these meds. I have listed some options here on this blog as they've come to me.

Today I have another option that has popped into my always thinking head. I'm a very curious person, and therefore sometimes I find myself thinking of things other people may never have considered. I'm not saying they'll work, I'm just thinking here.

It's something that's far out there, but actually it isn't. Since Advair** is an expensive mixure of a corticosteroid (Flovent) and long acting bronchodilator (Serevent) meant to treat both the chronic inflammation and prevent acute bronchospasm, why can't a mixture of less expensive meds be used as a replacement for Advair.

Of course Advair is the asthma wonder drug of choice not just because of what it prevents, but because it's easy to carry around, easy to use, and only needs to be taken twice a day. It's highly convenient, and makes asthmatics much more compliant than in years past. If cost were no obstacle, Advair is the medicine of choice.

The only problem with Advair (aside for some minor side effects), is that it costs an arm and a leg. And, since it costs so much, people who do not work, are poor, or have no health insurance have no way of gaining access to it. And it's these people we see in hospital emergency rooms.

So, as a replacement for an Advair discuss that costs $120 a month, why can't Asthmatics (and COPDers too), take Vanceril at $38 a month and Ventolin, which costs $42. That's still a chunk, but it's $40 less than Advair.
I can see a doctor switching a patient from Advair to Vanceril or some other generic corticosteroid (like Azmacort, Beclovent, Aerobid, etc). But instructing every asthmatic to take Ventolin every four hours is frowned upon. Why?

The asthma guidelines themselves say that any asthmatic who needs Ventolin more than 2-3 times in a two week period does not have control of his asthma. If that is true, then why are people who need Serevent in their systems all the time considered under control? Aren't they the same type of medicine, except one lasts for 12 hours and the other 4-6?

And yet, while the asthma guidelines recommends Advair and frown upon overuse of Ventolin (overuse would consist of using it more than the asthma guidelines recommend), it seems every single patient admitted to the hospital with Asthma or COPD is given Ventolin*** every 4-6 hours regardless of whether their disease is exacerbated. Ventolin lasts in the system about that long.

So a wise man asks: Why is it okay to order Ventolin every four hours as a preventative medicine in the hospital, but not okay to order it the same way for outpatient therapy?

A doctor recently gave me an answer when I questioned why she keeps ordering Ventolin Q4 on all her patients. She said, "Because they need it in their system to prevent shortness of breath."

Okay? So, if a patient needs it in his system while in the hospital to PREVENT shortness of breath, then why does this philosophy not apply outside the hospital? Either Ventolin is a preventative medicine or it is not?

It would seem to me if a patient does not respond well to Serevent, then Ventolin is a viable option. Of course you must consider what works for one patient does not work for all.

Personally, I don't think Ventolin prevents anything for most patients. The pre-use of Ventolin has never prevented me from having a bronchospasm. However, the pre-use of a corticosteroid has. However, I'm not saying Ventolin won't prevent for some patients.

I know Ventolin doesn't prevent for me because I had a pre and post PFT done to prove this. But doctors rarely order PFTs to determine if the Ventolin they are ordering on all their patients is working.

That would make too much sense. Better sense would be to use common sense and not order ventolin at all unless it is needed, or at least proven to be effected, which could be a subjective or objective measure.

But actually assessing to determine effectiveness would mean an actual assessment, which would be way to much work for some doctors to bother with. So they just order what feels right, not what is right (Kind of like Washington Politics, hey!).

I suppose you can create a third angle with this argument. If Ventolin should never be used unless a patient is having an exacerbation, then Serevent should never be used period. If the corticosteroid is doing its job, the patient should never get short of breath in the first place.

Yet that may not be a reasonable claim for many patients. Still, Serevent and Ventolin are the same medicine. And, while a patient is taking Serevent on a daily basis, it is still considered safe to use Ventolin with Serevent ( but never safe to use Serevent more than twice a days).

So, if you still need to use Ventolin every day regardless of being on Serevent, is the Serevent even doing it's job? Is it really preventing bronchospasm?

Or, is the reason Advair improves the lives of asthmatics so much more do do with the fact it's easy to use, convenient to carry around, and only needs to be taken twice a day, and not because it has both a corticosteroid and long acting bronchodilator. In other words, would a discus of Flovent alone work as well as Advair?

If the answer is yes, then any patient on Advair that costs $120 could easily be switched to a medicine like Vanceril which costs $38, and not lose any of the benefits. However, there would be one big if here: the patient would have to be as compliant with the Vanceril inhaler as he is with the Flovent discus.

Vanceril may be needed 4 times a day instead of the convenient two. Plus those patients who are now taking Vanceril will also have to lug around a bulky spacer. Obviously we're supposed to carry one around with our Ventolin too, but you and I both know most asthmatics (especially guys) don't carry spacers with them.

Ideally, Advair is better all the way around, except for cost. But, if you are strapped for money, perhaps an alternative generic corticosteroid may work just as well as the Advair, if proper technique is used. That means you have to use a spacer.

And perhaps, if you or your doctor thinks Serevent works so well for you, then why not take Ventolin every 4-6 hours round the clock too, regardless of what the guidelines say.

If I haven't lost you with my rambling here, tell me where you think I'm wrong (or right).

* costs listed are estimates.
**Advair and Symbicort are basically the same med, so when I refer to one, I'm also referring to the other.
***Xopenex may be ordered as well, and if it is the frequency is usually every 4-8 hours because that's how long the medicine lasts.

Asthma rule #1: Take your Singulair as ordered

I know (I know-I know) asthma experts like me preach you should never tinker with your medicine. And I know (I know-I know) we preach you should always take your medicine exactly as prescribed by your doctor.

But I did it anyway. I decided that Singulair is way too expensive at $30 per month, or $1 a pill. And that is with insurance. For those who don't have insurance you get 30 pills for $79, which comes to about $2.63 per pill.

Either way, that's a lot of money. And since there are no generic Singulair type medicines available, my insurance requires me to pay a certain percentage of the actual cost. Otherwise, for prescriptions that are reasonably priced I pay a $10 co-pay.

So, in order to try to spread out my prescription over two months, I decided that since I was feeling so well I'd take a pill every other day instead of every day. For the first month this seemed to be working quite well and I thought I was on to something.

But then over this past weekend it hit me. Thankfully I didn't have trouble with my asthma (thanks to Advair), but I did have a major case of the eye itches, sneezes, and runny nose.

Of course this could have been a coincidence, as it is true that many experts note that Singulair is not an antihystamine to stop the symptoms I describe, but a leukotriene blocker intended to block allergies from causing bronchospasm.

Yet I'm quick to attribute this to my Singulair trial, especially considering last spring I showed no symptoms of allergies for the first time in my entire life.

Some people who don't have as severe of allergies as me (I'm allergic to pretty much everything outdoors) may be able to get by taking a pill every other day, but that strategy won't work for me -- at least during the spring season.

I know (I know-I know) I shouldn't tinker with my medicine, but on occasion I find this is a good thing to do, for no other reason than to prove to yourself that the medicines you are on are working great, as opposed to just assuming (as some doctors do).

It's kind of a checks and balance system I like to use. So now I'm back to taking it every day, despite the high price.

I imagine some of you guideline followers might email me a "Smack!" or a "Kick" in the rump for doing something so stupid. Go ahead and do so, because I deserve it.

"Achoooooooo!"

Pharmaceutical companies need to make money

I have written the past 2 days about the high cost of Advair and what an asthmatic might do instead of choosing to not take this medicine at all. One of the ideas that was sent to me was this:
We could make it so pharmaceutical companies no longer make so much money at the expense of people who are sick. It's ridiculous that they make so much money anyway.

Another common question is this:

Why doesn't Obama put a cap on how much prescriptions can cost?

I had a reader email me the following, and I think it will make a fine answer to the above questions:

It is the capitalistic system that developed Advair--and other useful drugs. The drug companies have huge development costs, and huge costs getting through the FDA, and if the drug company can't recoup its expenses, and make a profit for its shareholders, there is no point in the company's ever developing a new drug. We won't ever get any new ones. You don't work for free; me neither. Neither do the shareholders, or the employees, of the companies that develop new drugs.

I agree with this answer completely. What makes America such a great country, and why our economy is the best in the world (despite the recession), is because of capitalism. And the key to making capitalism work is the risk/reward factor.

In the case of Advair, a pharmaceutical company sacrificed millions of dollars and many years of research developing a medicine that they had no idea of whether it would even be approved by the FDA for use.

If it were not for the reward factor (making a profit), there would be less risk taking. And, if there is less risk taking by pharmaceutical companies, that would be fewer new asthma meds, and less hope for even better meds for the future.

8 ideas for those who can't afford Advair

Yesterday I wrote about some ideas I had to help people cope with the high cost of Advair. This may perhaps be the greatest medicine ever invented for asthma patients, and yet it costs so darn much. Those with no health insurance may have to choose between Advair and nothing at all.

But that's not necessarily true. There are options. Here are some of the ideas people have emialed to me.

1. Talk to your doctor about free samples
2. Advair comes in two strengths--for example, if the doctor prescribes the 250, to be used twice a day, and the patient needs only the smaller 100, and uses the 250 once a day, maybe that is better than not using it at all.
3. Perhaps the doctor could prescribe one puff once a day to make the discuss last 2 months instead of one.
4. Talk to your doctor about taking alternative Corticosteroids, like Beclavent, Azmacort, Advair, Vanceril.
5. For those who need the added corticosteroid, they could take Advair in the morning and a substitute corticosteroid in the evening.
6. You could do a combination of the above to make the med last longer
7. Check this website out to find the cheapest asthma meds: http://www.needymeds.org/.
8. Pharmaceutical companies have programs for folks who can't afford drugs- call them!

These are just some ideas from me and some of my readers to help those of you who cannot afford these meds. You can discuss these with your doctor and see if they might work for you. You may have to experiment a little, and get creative.

But, please don't stop taking you preventative asthma meds just because you can't afford them. And please don't stop taking them just because you feel good after not taking them for a week. Asthma can pretend to not be there at times and then can show its ugly head on a dime.

Advair may be too expensive for many asthmatics

Being that we are in a recession and many of us are scrapping for money, some Gallant Asthmatics are finding it quite hard to afford their asthma medicines. This is especially true of Advair, which costs about $120 without health insurance.

Personally, even with health insurance I pay $80 a month for my asthma medicines. Thankfully I have a good job, and (fingers crossed) a recession proof job too. But others aren't as fortunate as me.

That in mind, in this edition of My Answer to Your Rt Queries I tackle the following tough question that was asked over at MyAsthmaCentral.com:

QUESTION:

I can no longer afford Advair. Are there different (and cheaper) meds to take?

ANSWER:

Advair is a medicine that has benefited many asthmatics, unfortunately it is a very expensive medicine. The cost of a medicine usually does not decrease in value until the patent runs out and generic meds are produced. A patent usually lasts about about 25 years.

This is something you should definitely talk to your doctor about, because while Advair may be the best medicine for you because it contains both Flovent and Serevent and is relatively easy to use, there are alternative corticosteroids on the market that are less expensive, such as Vanceril, Beclovent, Azmacort, Aerobid (although Aerobid tastes nasty, like rotten mints), etc.

Even though these may or may not be ideal for you, I think your doctor would rather have you on a med you can afford than to take nothing at all.

As for the Serevent component of Advair, I do not believe there are alternatives to this on the market right now.

I bet another alternative would be to talk to your doctor about getting free samples, but because one discus lasts only a month, this would only be a temporary solution.

I think it is unfortunate that the worlds greatest asthma medicine (in my opinion and my doctors) has to cost so much. But that's the way it is in a capitalistic system.