My eye doc has recommended that I swith from Timolol to Istalol for my glaucoma. Problem is that in my drug plan Timolol costs me $3 foe 90 day supply, and Istalol is $76!!! It's not in their "preferred list". Is it worth it? My pressure seems to be under control, consistently about 18 in both eyes.
<suenjim4.badaddr...@comcast.net> wrote: >My eye doc has recommended that I swith from Timolol to Istalol for my >glaucoma. >Problem is that in my drug plan Timolol costs me $3 foe 90 day supply, >and Istalol is $76!!! It's not in their "preferred list". >Is it worth it? My pressure seems to be under control, consistently >about 18 in both eyes.
My "answer?"
Does your drug plan allow you to lobby to have drugs *added* to the formulary??
Jim T. wrote: > My eye doc has recommended that I swith from Timolol to Istalol for my > glaucoma. > Problem is that in my drug plan Timolol costs me $3 foe 90 day supply, > and Istalol is $76!!! It's not in their "preferred list". > Is it worth it? My pressure seems to be under control, consistently > about 18 in both eyes.
This is a question only your doctor, who knows your history and eyes and the reason for switching, can answer. Call his office and explain the problem.
If essential to switch, there may be a provision in your plan for that drug if your doctor provides a compelling reason.
> Jim T. wrote: > > My eye doc has recommended that I swith from Timolol to Istalol for my > > glaucoma. > > Problem is that in my drug plan Timolol costs me $3 foe 90 day supply, > > and Istalol is $76!!! It's not in their "preferred list". > > Is it worth it? My pressure seems to be under control, consistently > > about 18 in both eyes.
> This is a question only your doctor, who knows your history and eyes > and the reason for switching, can answer. Call his office and explain > the problem.
> If essential to switch, there may be a provision in your plan for that > drug if your doctor provides a compelling reason.
> Jim T. wrote: > > My eye doc has recommended that I swith from Timolol to Istalol for my > > glaucoma. > > Problem is that in my drug plan Timolol costs me $3 foe 90 day supply, > > and Istalol is $76!!! It's not in their "preferred list". > > Is it worth it? My pressure seems to be under control, consistently > > about 18 in both eyes.
Timolol is the generic name for Istalol. My wife does not trust generics at all. Timolol is a beta blocker for the eye.
> This is a question only your doctor, who knows your history and eyes > and the reason for switching, can answer. Call his office and explain > the problem.
You could try it, but most doctors do not have time to do a search so as to find out what I just mentioned. Also, doctors sometimes get biased by the pretty ladies who visit them to promote certain brands and leave starter kits, and some of them, like my wife, do not trust generics.
<suenjim4.badaddr...@comcast.net> wrote: >My eye doc has recommended that I swith from Timolol to Istalol for my >glaucoma. Problem is that in my drug plan Timolol costs me $3 foe 90 >day supply, and Istalol is $76!!! It's not in their "preferred list". >Is it worth it?
Here is what I can generically say, rather than commenting directly on your case in particular:
ISTALOL contains the same medication as timolol. However, it is formulated in a unique way (as TIMOPTIC-XE is) to allow once a day dosing. That is, essentially, the only real difference between timolol and ISTALOL.
IOW, ISTALOL qd is promoted and marketed as providing *the same IOP lowering* as timolol bid provides. But in fact, timolol bid may provide a more steady lowering and blunting of the IOP curve than ISTALOL.
So, in general, timolol bid and ISTALOL qd are interchangable. The reason doctors prescribe ISTALOL (or TIMOPTIC-XE) over standard timolol generally is because a once a day dosage promotes compliance. Most (but not all) of the time, there is no reason why a person *must be* on ISTALOL versus regular timolol.
If cost is a major concern, then I would askl your eye doctor two questions:
1. Why did he switch you from timolol to ISTALOL?
and, depending on the answer here,
2. Tell him cost is a "big deal" and ask him if there is any way he could switch you back to timolol. If not, have him explain why.
>My pressure seems to be under control, consistently about 18 in both >eyes.
FYI, one cannot say without knowing your optic nerve status over time whether your glaucoma is/has been "under control" if the IOP is "consistently about 18 in both eyes." And there is no a priori way of knowing whether in the future your glaucoma will not progress at an unacceptable rate if your IOPs are consistently about 18.
It is important to understand that IOP is merely a risk factor for glaucoma, as is thinner CCTs, age, family history of glaucoma, race, etc. However, it is an extremely imporant risk factor, because it is the only one that eye doctors can (attempt to) control.
On 6/21/06 9:40 AM, in article 1150908024.122197.247...@p79g2000cwp.googlegroups.com, "Dr Judy"
<mpac...@rogers.com> wrote: > This is a question only your doctor, who knows your history and eyes > and the reason for switching, can answer. Call his office and explain > the problem.
> If essential to switch, there may be a provision in your plan for that > drug if your doctor provides a compelling reason.
I hear many stories claiming this, but is it really true? When I get an eye examination, the ophthalmologist has much to do without much time for contemplating my history. If some fact sticks out, I am sure that he would pick up on it. Otherwise, my guess is that the practice of medicine truly is "practice". If a drug gives trouble, it is not prescribed again. If it is not effective, a similar one is selected. In the absence of a good reason, why shouldn't a physician select drugs on the basis of cost, especially at the behest of the patient?
My point is that unless there is something obviously different in the safety between two drugs having the same effect, there must be something that triggers a physician to prefer one over another. That can be from experience or because of a recent visit by a detail man (woman). What is it?
>> Jim T. wrote: >>> My eye doc has recommended that I swith from Timolol to Istalol for my >>> glaucoma. >>> Problem is that in my drug plan Timolol costs me $3 foe 90 day supply, >>> and Istalol is $76!!! It's not in their "preferred list". >>> Is it worth it? My pressure seems to be under control, consistently >>> about 18 in both eyes.
> Timolol is the generic name for Istalol. My wife does not trust generics > at all. Timolol is a beta blocker for the eye.
>> This is a question only your doctor, who knows your history and eyes >> and the reason for switching, can answer. Call his office and explain >> the problem.
> You could try it, but most doctors do not have time to do a search so as > to find out what I just mentioned. Also, doctors sometimes get biased by > the pretty ladies who visit them to promote certain brands and leave > starter kits, and some of them, like my wife, do not trust generics.
> -- > Dicky
I sent my post before reading this one. I cannot agree more. I did think that Timoptic was the only brand name until I read your post.
As I am a firm believer in atomic and molecular science, it would be against my religion to consider that the brand name of a molecule affects its effectiveness. Nevertheless, I know that people with limited scientific knowledge and experience still the the more expensive is better.
On Wed, 21 Jun 2006 18:15:57 GMT, Salmon Egg <salmon...@sbcglobal.net> spewed forth :
>why shouldn't a physician select drugs on the basis of cost, especially at >the behest of the patient?
Most physicians don't know how expensive (or cheap) any certain drug may be. One of my husband's drugs is a good example:
DH has chronic migraine. Last year his pain management doc gave me an Rx for 50mg Imitrex, twice daily. Copay $30
In January our plan change to a 30% copay for drugs with a resultant copay of about $1200 per month.
When my husband phoned his physician to discuss alternatives the doctor was shocked at the cost: retail cost per tablet is about $65.
+++++++++++++
Reply to the list as I do not publish an email address to USENET. This practice has cut my spam by more than 95%. Of course, I did have to abandon a perfectly good email account...
On Wed, 21 Jun 2006 20:16:43 GMT, Wooly <n...@body.nunya> spewed forth :
>On Wed, 21 J
>DH has chronic migraine. Last year his pain management doc gave me an
Gave DH the Rx. Duh :D
+++++++++++++
Reply to the list as I do not publish an email address to USENET. This practice has cut my spam by more than 95%. Of course, I did have to abandon a perfectly good email account...
>On Wed, 21 Jun 2006 10:15:19 -0400, Jim T. ><suenjim4.badaddr...@comcast.net> wrote:
>>My eye doc has recommended that I swith from Timolol to Istalol for my >>glaucoma. >>Problem is that in my drug plan Timolol costs me $3 foe 90 day supply, >>and Istalol is $76!!! It's not in their "preferred list". >>Is it worth it? My pressure seems to be under control, consistently >>about 18 in both eyes.
>My "answer?"
>Does your drug plan allow you to lobby to have drugs *added* to the >formulary??
>Many do.
>Best of luck!
>Neil
I thank all who responded. No one mentioned the ubiquitous (sp) drug salesmen who are in to the the doctor every time I'm there. I'll see what happens when I tell him (again) about the cost. This is a very well known and competent opthalmologist.
On 6/21/06 1:16 PM, in article 0l6j92l5varlhinpcpmn5tqpcasa9au...@4ax.com,
"Wooly" <n...@body.nunya> wrote: > When my husband phoned his physician to discuss alternatives the > doctor was shocked at the cost: retail cost per tablet is about $65.
I am shocked just reading about it! Bill -- Ferme le Bush
>I thank all who responded. No one mentioned the ubiquitous (sp) drug >salesmen who are in to the the doctor every time I'm there. I'll see >what happens when I tell him (again) about the cost.This is a very >well known and competent opthalmologist.
I want to make it clear I think there is absolutely nothing wrong with a doctor prescribing the very best medication among several potential ones. In fact, that's what I think doctors *should* do, it is what I would want my doctor to do, and it's what I do.
It is up to the patient do let the doctor know if they prefer, say, cost savings over a more convenient dosing schedule.
> On Wed, 21 Jun 2006 10:15:19 -0400, Jim T. > <suenjim4.badaddr...@comcast.net> wrote:
>> My eye doc has recommended that I swith from Timolol to Istalol for my >> glaucoma. Problem is that in my drug plan Timolol costs me $3 foe 90 >> day supply, and Istalol is $76!!! It's not in their "preferred list". >> Is it worth it?
> Here is what I can generically say, rather than commenting directly on > your case in particular:
> ISTALOL contains the same medication as timolol. However, it is > formulated in a unique way (as TIMOPTIC-XE is) to allow once a day > dosing. That is, essentially, the only real difference between > timolol and ISTALOL.
> IOW, ISTALOL qd is promoted and marketed as providing *the same IOP > lowering* as timolol bid provides. But in fact, timolol bid may > provide a more steady lowering and blunting of the IOP curve than > ISTALOL.
> So, in general, timolol bid and ISTALOL qd are interchangable. The > reason doctors prescribe ISTALOL (or TIMOPTIC-XE) over standard > timolol generally is because a once a day dosage promotes compliance. > Most (but not all) of the time, there is no reason why a person *must > be* on ISTALOL versus regular timolol.
> If cost is a major concern, then I would askl your eye doctor two > questions:
> 1. Why did he switch you from timolol to ISTALOL?
> and, depending on the answer here,
> 2. Tell him cost is a "big deal" and ask him if there is any way he > could switch you back to timolol. If not, have him explain why.
>> My pressure seems to be under control, consistently about 18 in both >> eyes.
> FYI, one cannot say without knowing your optic nerve status over time > whether your glaucoma is/has been "under control" if the IOP is > "consistently about 18 in both eyes." And there is no a priori way of > knowing whether in the future your glaucoma will not progress at an > unacceptable rate if your IOPs are consistently about 18.
> It is important to understand that IOP is merely a risk factor for > glaucoma, as is thinner CCTs, age, family history of glaucoma, race, > etc. However, it is an extremely imporant risk factor, because it is > the only one that eye doctors can (attempt to) control.
BTW, timolol can often be used once a day and do just fine. It depends on the individual case. Timolol does not "wear off" in 12 hours, it actually taks more than a few days. Full washout is up to 2 weeks, I am told. Yes, some cases do need twice a day dosing for maximal effect. In fact, many of us have a large number of patients taking regular timolol (not Timoptic-XE) just once a day. As mentioned above, this also leads to better compliance.
> On Wed, 21 Jun 2006 20:01:09 -0400, Jim T. > <suenjim4.badaddr...@comcast.net> wrote:
> [snip]
>> I thank all who responded. No one mentioned the ubiquitous (sp) drug >> salesmen who are in to the the doctor every time I'm there. I'll see >> what happens when I tell him (again) about the cost.This is a very >> well known and competent opthalmologist.
> I want to make it clear I think there is absolutely nothing wrong with > a doctor prescribing the very best medication among several potential > ones. In fact, that's what I think doctors *should* do, it is what I > would want my doctor to do, and it's what I do.
> It is up to the patient do let the doctor know if they prefer, say, > cost savings over a more convenient dosing schedule.
It is not clear to me that higher cost is an indication of better medication. To mention one medication I have taken various NSAIDS over the years. Daypro, Vioxx, and Celebrex are just three that were expensive and useless (for me). I guess I lucked out that Vioxx and Celebrex were no good. Not only did they not work for pain relief but they badly upset my gastric system, the main justification for their high price. The most recent one that was half way decent (for me) and reasonably expensive, is meloxicam. It is available as a generic from Canada. If price were a problem for me, naproxen is just about as good as meloxicam.
In my opinion, I am not medically trained, there is good reason for a physician to stick to prescribing old cheap and well tested drugs unless there is a reason not to! Best is not necessarily the latest.
>BTW, timolol can often be used once a day and do just fine. It depends on >the individual case. Timolol does not "wear off" in 12 hours, it actually >taks more than a few days. Full washout is up to 2 weeks, I am told. Yes, >some cases do need twice a day dosing for maximal effect. In fact, many of >us have a large number of patients taking regular timolol (not Timoptic-XE) >just once a day. As mentioned above, this also leads to better compliance.
The same is true of BETAGAN (levobunolol) which has an even longer half life than timolol. And I realize that a lot of other eye doctors are prescribing it on a qd basis. I am also aware this happens a lot in managed care situations such as HMOs where there is huge pressure to keep costs down because of the cost difference between generic timoptic and TIMOPTIC-XE.
I *personally* don't trust that once a day regular timoptic or levobunolol will keep the IOP down consistently over the full 24 hours. It may or it may not, and patients/myself don't like performing diurnal/serial IOP checks over a 24 hour period confirm/deny this.
So for the times when an once-a-day dosage of a topical beta blocker is prescribed by me for my glaucoma patients, it is always a drug that has FDA approval for qd dosage, such as TIMOPTIC-XE.
On Thu, 22 Jun 2006 05:16:15 GMT, Salmon Egg <salmon...@sbcglobal.net> wrote:
>It is not clear to me that higher cost is an indication of better >medication.
I never meant to imply that.
I do, however, in general, tend to prescribe newer medications because they have advantages over older medications. Likewise, I tend to use more modern lens designs/coatings, because they have advantages over older designs.
[snip]
>In my opinion, I am not medically trained, there is good reason for a >physician to stick to prescribing old cheap and well tested drugs unless >there is a reason not to!
Usually there are good reasons when I prescribe a newer drug versus an older one. It can be it more efficacious, requires less frequent dosing, less side effects, etc. That is usually the reason new drugs come out, because they have advantages over old drugs.
It is certainly also true that the newest drugs tend to cost the most.
> (newer drug) can bemore efficacious, requires less frequent > dosing, less side effects, etc. That is usually the reason new drugs > come out, because they have advantages over old drugs.
How about expiration of patents -- what do you think that is worth?
That could happen. It doesn't happen with me. I prescribe in the best interests of the patient.
>> (newer drug) can bemore efficacious, requires less frequent >> dosing, less side effects, etc. That is usually the reason new drugs >> come out, because they have advantages over old drugs.
>How about expiration of patents -- what do you think that is worth?
On 6/22/06 8:20 AM, in article ctcl92ldj9ent31i5b32t7qdnca4use...@4ax.com, "Anon E. Muss" <anonym...@example.org> wrote:
> On Thu, 22 Jun 2006 05:16:15 GMT, Salmon Egg <salmon...@sbcglobal.net> > wrote:
>> It is not clear to me that higher cost is an indication of better >> medication.
> I never meant to imply that.
> I do, however, in general, tend to prescribe newer medications because > they have advantages over older medications. Likewise, I tend to use > more modern lens designs/coatings, because they have advantages over > older designs.
Now you are talking about a field in which I do have some expertise. I see little new in ophthalmic corrective lens design that is a significant improvement over old ones except for cosmetic purposes. There may be much technology in cataract implants but it is in materials and mechanics rather than novel optics. I have not been able to get a simple quarter-wave hot AR coating applied to a glass lens that I would prefer over a plastic lens with coatings that flake in short order.
>> In my opinion, I am not medically trained, there is good reason for a >> physician to stick to prescribing old cheap and well tested drugs unless >> there is a reason not to!
> Usually there are good reasons when I prescribe a newer drug versus an > older one. It can be it more efficacious, requires less frequent > dosing, less side effects, etc. That is usually the reason new drugs > come out, because they have advantages over old drugs.
> It is certainly also true that the newest drugs tend to cost the most.
>> Best is not necessarily the latest.
> Correct.
I think new drugs come out primarily because old patents run out or to compete with someone else's blockbuster drug. Much of the improvement is that of marketing. If that were not the case how can brand names still compete with generics after the patents have expired?
Again, in my case, I am using the newer, improved, drug Xalatan. I can afford it. After this exchange, however, I might ask my ophthalmologist for a cheaper alternative. I do not mind using the drops twice a day.
On Thu, 22 Jun 2006 19:01:47 GMT, Salmon Egg <salmon...@sbcglobal.net> wrote:
[snip]
>>Likewise, I tend to usemore modern lens designs/coatings, because they >>have advantages over older designs.
>Now you are talking about a field in which I do have some expertise. I see >little new in ophthalmic corrective lens design that is a significant >improvement over old ones except for cosmetic purposes.
The newest generation of progressive lenses have been a welcome addition -- "substantial improvement" here is quite subjective, but...
I have patients who were unable to adapt in the past to older generations of progressive lenses (AO TruVision) able to adapt to newer designs (Varilux Panamic).
so to them it has been "substantial".
TRIVEX has been a welcome addition, supplanting polycarbonate in most cases. In a similar way, TRANSITIONS V is much better than older and other photochromic products (granted some of these are not available anymore).
>There may be much technology in cataract implants but it is in >materials and mechanics rather than novel optics. I have not been able >to get a simple quarter-wave hot AR coating applied to a glass lens >that I would prefer over a plastic lens with coatings that flake in >short order.
The newest plastic A/R coatings (e.g., Crizal Alize, Vivix Stainless) have been a welcome development over older ones. These coatings do not flake in short order with the vast majority of my patients. I cannot say that was the case with older coatings.
>I think new drugs come out primarily because old patents run out or to >compete with someone else's blockbuster drug.
On what do you base this belief?
There are certainly financial reasons why new drugs are produced. New drugs are typically where pharmaceutical companies make their largest profit margins.
However, there are some newer drugs that are truly breakthrough and of great benefits to our patients.
I remember what a breakthrough topical beta adrenergics were for glacoma when they came out. Before that, we basically had miotics, oral carbonic anydrase inhibitors and epipherine.
Another breaktrough were the prostaglandin analogs (e.g., XALATAN). These weren't just "new drugs" but were a great addition to the anti-glaucoma armenatrium.
Topical second-generations fluoroquinolones (e.g., CILOXAN) were another godsend for eye care. The fourth-generation (e.g., VIGAMOX and ZYMAR) were very welcome and benefical too. These drugs revolutionized the (monocare) therapy of corneal ulcers.
Before these came out, many cases of bacterial keratitis were managed using fortified antibiotics that had to be compounded at a pharmacy. These drugs were expensive, not available at the vast majority of pharmacies, couldn't be stored long at a doctor's office (hence the need to be compounded at a pharmacy) toxic and beat up the eye. More patients required hospitalization back then than now.
Other examples in systemic, internal medicine of great drugs that were truly needed are ZYVOX, imipenem/cilastatin, ACYCLOVIR, aztreonam, SYNERCID, daptomycin, CIPRO, etc. I could go on and on.
>Much of the improvement is that of marketing. If that were not the >case how can brand names still compete with generics after the patents >have expired?
One reason is some generic medications have a poor reputation. Many neurologist will not prescribe generic phenytoin because of inconsistent potency levels. Likewise, generic prednisolone acetate ophthalmic solution has a poor reputation for potency and many eye doctors only trust brandname PRED FORTE.
BTW, I am still a fan of a lot of older medications. I still prescribe bacitracin, POLYSPORIN and erythromycin ointments all the time.
>Again, in my case, I am using the newer, improved, drug Xalatan. I can >afford it. After this exchange, however, I might ask my ophthalmologist for >a cheaper alternative.
LUMIGAN and TRAVATAN are usually a little cheaper than XALATAN.
If you don't mind qid dosage, pilocarpine is real cheap. You could ask him about that. :^O
> Other examples in systemic, internal medicine of great drugs that were > truly needed are ZYVOX, imipenem/cilastatin, ACYCLOVIR, aztreonam, > SYNERCID, daptomycin, CIPRO, etc. I could go on and on.
>> Much of the improvement is that of marketing. If that were not the >> case how can brand names still compete with generics after the patents >> have expired?
> One reason is some generic medications have a poor reputation. Many > neurologist will not prescribe generic phenytoin because of > inconsistent potency levels. Likewise, generic prednisolone acetate > ophthalmic solution has a poor reputation for potency and many eye > doctors only trust brandname PRED FORTE.
> BTW, I am still a fan of a lot of older medications. I still > prescribe bacitracin, POLYSPORIN and erythromycin ointments all the > time.
>> Again, in my case, I am using the newer, improved, drug Xalatan. I can >> afford it. After this exchange, however, I might ask my ophthalmologist for >> a cheaper alternative.
> LUMIGAN and TRAVATAN are usually a little cheaper than XALATAN.
> If you don't mind qid dosage, pilocarpine is real cheap. You could > ask him about that. :^O
Again, I am not medically trained but I hope I can think logically.
Why not take the engineering attitude, and I think of medicine as an engineering like discipline, good enough is perfect! If an old and cheap medication does the job without doing harm--why not? New and expensive, think Vioxx although there are other examples, is no guaranty of of effectiveness and safety. Compare to naproxen.
On Sat, 24 Jun 2006 04:37:12 GMT, Salmon Egg <salmon...@sbcglobal.net> wrote:
>Again, I am not medically trained but I hope I can think logically.
>Why not take the engineering attitude, and I think of medicine as an >engineering like discipline, good enough is perfect! If an old and cheap >medication does the job without doing harm--why not?
Let me be clear: If new medications have no advantage, then certainly "old and cheap" (and proven track record) is preferable to me. OTOH, one will never know if a new medication is, in the real world, more effective/has advantages unless it gets prescribed.
However, most of the newer medications that (we as) eye doctors prescribe have clear real world (and theoretical) advantages to older medications.
>New and expensive, think Vioxx although there are other examples, is >no guaranty of of effectiveness and safety. Compare to naproxen.
Cox-2 selective inhibitors (C2SIs), like VIOXX and CELEBREX, had/have real world and theoretical advantages over, say, to use your example, naproxen Na.
C2SIs have about a 50% less chance of peptic ulceration (PUD) over other NSAIDs. Also, CS2SIs were less costly than NSAIDs when you factor into the cost the say, ZANTAC, that was needed to be prescribed along with the NSAID in order to prevent PUD.
> ... CS2SIs were less costly than NSAIDs when you factor into > the cost the say, ZANTAC, that was needed to be prescribed > along with the NSAID in order to prevent PUD.
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