Last December, not one, but two generic versions of Viagra (sildenafil) became available in pharmacies. As a result, men can now purchase the erectile dysfunction (ED) treatment for as low as $17 with GoodRx, compared to $72 for the brand version. And although Viagra is an extremely popular medication, with more than 60 million men worldwide having used it since 1998, it’s not the answer for everyone.
Below, Tim Aungst, PharmD and owner of The Digital Apothecary, shares his experience helping patients who are looking for ED treatment outside of Viagra and the class of drugs that work like it (PDE-5 inhibitors).
Consider the case of Mr. Jones, a patient I was helping in an outpatient cardiac clinic. Most of my patients are on multiple medications for their heart conditions and other complicated issues, so I often review their medications to make sure everything is all right. This includes screening labs, checking vitals, reviewing past reports, and conducting drug interaction checks related to therapy. If there are any concerns, I’ll meet with the patient and make recommendations to the healthcare team.
At his last visit, Mr. Jones was prescribed Imdur (isosorbide mononitrate) to help with his heart condition. Reading through the notes, it looked like the Imdur worked. He was feeling better – so much better that he wanted to start having sex with his wife again. And here was the problem: Mr. Jone’s doctor had renewed his Cialis (tadalafil) prescription.
The issue? Well, if you really listen to the advertisements on television for erectile dysfunction (ED) medications, ignoring the jazz from Viagra or the sunsets from Cialis, you may hear the line “Do not take if you take nitrates for chest pain, as it may cause an unsafe drop in blood pressure.” Viagra, Cialis, and Levitra belong to the same drug class called Phosphodiesterase 5 Inhibitors (abbreviated as PDE-5 inhibitors), and they all share the same interaction with nitrates. Many patients wonder how bad can a ‘drop in blood pressure’ be. The answer, as we learned after Viagra came out, is this reaction can lead to heart attack in patients and potentially cause death, leading to a black box warning for the whole class of drugs like Viagra.
Mr. Jones is on a nitrate, specifically Imdur. Fortunately for him, he had not yet used the Cialis. I advised him to avoid the combination, based on his significant cardiac history. But what can patients with ED and taking nitrates do to engage in an active sex life?
There is another drug that came out before Viagra, called alprostadil, available under two brand names: Caverject and Muse. It works by relaxing the penile tissue allowing for easier blood flow leading to an erection. The plus side is it works relatively quickly; the downside is that is not available as a pill.
And there’s the rub. Caverject must be directly injected into the base of the penis to work. Muse is an intraurethral (a fancy way of saying ‘insert via urethra’) version of alprostadil that comes as small pellets that have to be inserted into the urethra by the patient.
For many patients, when I mention there is another option to Viagra and other PDE-5 Inhibitors, their eyes light up, quickly followed by a nervous look as they find that it requires an injection to their penis or inserting something directly into their urethra. At this point, to not completely turn off the patient, I do try to get some information in to help them make a decision.
While both Caverject and Muse share the same active ingredient, there are some pros and cons of each. Caverject tends to work much faster (<10 mins) as it enters the bloodstream quicker, and has been found to work better. The drawback though is that it is an injection that needs to be applied to the base of the penis, and can cause irritation to the surrounding tissue. And let’s be honest, most men don’t want to engage in sex with a bruised member. It has a higher risk of causing priapism (basically an erection lasting for more than 4 hours, which incidentally is named after Greek god Priapus).
Muse, on the other hand, can cause a burning sensation to the penis along the urethra (this happens around 20% of the time) and it takes a little longer to work than the injectable formulation. But for men that don’t want a needle in their penis, it is an alternative. For this reason, I generally recommend starting with Muse prior to moving onto Caverject.
You’re probably wondering why alprostadil can’t just be applied directly to the penis as a topical agent instead of directly injecting or inserting it. A study conducted in 2006 in 1732 patients using a topical formulation did demonstrate some efficacy (though less than Caverject or Muse). Common side effects were burning sensation (for both men and women) though this was relatively low, with only 2.7% of subjects stopping its use. Currently, drug manufacturer Apricus Biosciences is looking to bring this formulation, named Vitaros, to market in the US (it’s currently available in Europe) but FDA approval has been slow. When and if this formulation makes it to the US market, it may be preferred by men who cannot take PDE-5 inhibitors.
Talking to Mr. Jones and those like him about these options takes some time and often requires some trial and error to find what works. At this point, I usually recommend most men to start with Muse and see if they have success with it, and if not they can move on to Caverject (they both run at about $75-$105 a dose). Some men are fine starting with Caverject right away and don’t mind the administration, but I would say it comes down to personal preference on what side effects are manageable for the patient.
Manufacturer Unichem Pharmaceuticals has issued a voluntary recall of divalproex, used to treat certain types of seizures, bipolar disorder, and migraine headaches.
This is a class II recall, the most common type of recall, which means that there is a situation where the use of the recalled medication may cause temporary or medically reversible adverse health consequences, but the likelihood of serious adverse effects is small. For more information on the different types of recalls, see our overview here.
Why was Divalproex recalled?
The manufacturer, Unichem Pharmaceuticals, has issued a nationwide voluntary recall of divalproex, with the knowledge of the FDA, due to possible contamination with another medication, metronidazole.
Metronidazole is an anti-fungal medication. Taking a contaminated medication can cause severe adverse effects.
What is affected by this recall?
The recall will affect the following:
- Drug: Divalproex delayed-release 500 mg tablets
- Manufacturer: Unichem Pharmaceuticals
- Bottle size: 100 count bottle
- National Drug Code (NDC) and Lot(s): NDC: 29300-140-01, Lot: ZDPH17040
Unichem Pharmaceuticals is notifying distributors and customers by letter and is arranging for return of all recalled products.
What should I do if I think I may have the affected product?
You should contact your physician or healthcare provider if you have experienced any problems that you think may be related to taking this medication.
You should not stop taking divalproex without talking to your prescribing physician.
If you’ve watched the news or heard anything about the flu this season than you’ve probably heard that it hasn’t been going so well. According to the Journal of Family Practice, the 2017-2018 flu vaccine has been reported to only be about 34% effective against influenza A and 56% for influenza B.
Because the flu virus is constantly changing, scientists are challenged with reviewing the vaccine each year. The flu vaccines are then updated as needed based on which influenza viruses are making people sick, the extent to which those viruses are spreading, and how well the previous season’s vaccine protects against those viruses.
We have some exciting news, though. Although we’re aren’t quite there yet, a universal flu vaccine is in the works. A company in the UK, Vaccitech, is currently conducting a clinical trial of what could become the first universal flu vaccine in the world. In the United States, Inovio Pharmaceuticals is conducting their own research for a universal vaccine.
The launch of a universal flu vaccine would be extremely beneficial for global public health and eliminate the need for annual injections. Additional benefits of a universal flu vaccine may include the following:
- Targets flu viruses in a different way.
- Reduce flu transmission more effectively than conventional flu vaccines.
- Slow the development of new strains of flu virus.
- Strengthen the immunity of a population, allowing protection against the emergence of dangerous pandemic strains.
More and more women across the U.S. can now use hormonal birth control without going through the hassle of having a doctor prescribe it.
7 states – Oregon, California, Colorado, Washington, New Mexico, Hawaii, Tennessee, and Maryland – and Washington, D.C. now allow pharmacists to prescribe birth control, saving women a trip to the doctor’s office. California, Maryland, and D.C. ensure residents get full access to contraception by also providing a 12-month supply at a time and requiring insurers to cover the entire cost. (Women in Illinois and Vermont also can get a 12-month supply paid by insurers, but only with a doctor’s prescription).
How does it work? What do I do to get a prescription?
- Call your pharmacy to see if they offer the birth control prescription service. If not, you may have to call around to find one that does.
- When you get to the pharmacy, you’ll be given a short screening questionnaire and have your blood pressure taken to make sure hormonal contraception is appropriate for you. Trained pharmacists will know the pharmacology and screening procedures, and will know how to assess which method is best for each individual, so you’ll be in good hands.
- Your pharmacist will work with you to find a brand you can afford, with or without insurance. Refer to our explainer on birth control pills to understand all your options. In some cases, GoodRx can beat your insurance, and you can always use a GoodRx discount instead of your prescription insurance if the cost is lower.
What does this mean for me, specifically?
If you live in Oregon, California, Colorado, Washington, New Mexico or Hawaii, your state law is already in effect. Check the map below (thanks to the Kaiser Family Foundation) to see what type of birth control pharmacist in your state can prescribe. At the minimum, they can recommend and prescribe birth control pills, which have a 9% failure rate with typical use (compared to the 18% failure rate of condoms). California is currently the only state where women can receive a whole year’s supply in one visit.
If you live in D.C., Tennessee or Maryland, expect pharmacy programs to start rolling out as early as January 2019. We’ll report here on the GoodRx blog as we get more information.
What’s the catch?
Making birth control easier to access should encourage more women to get protection. In a 2013 study, 28.0% of participants not using any birth control and 32.7% of participants using a less effective method said they would use oral contraceptives pills if they were available over-the-counter. While the current laws don’t quite make birth control over-the-counter, they do mean women who would otherwise be restricted by work hours, child care, transportation, and money will have more options.
But even though these laws are in place, the service is not mandatory for pharmacies. Researchers found that only 11% of California retail pharmacies offer the service, one year after the law was put into effect. Requirements vary by state but they all require at least some training, so not every pharmacy can automatically offer the service. To see the larger impact legislatures and supporters hope for, more pharmacies would have to get on board. For example, Safeway is the first major retailer in Colorado dedicated to training their pharmacy staff.
One last thing: It’s not free. Pharmacies that do offer the prescription service typically charge between $25-$50. Because the Affordable Care Act only requires insurers to cover family planning services from healthcare providers, women would have to bear the full cost of the pharmacy consultation themselves; some may not be able to. Some states are making moves to change this: Oregon requires Medicaid to pay for the service, while California is hoping to do the same by 2021.
It’s Valentine’s Day, the day of romance, which means an abundance of chocolates, flowers, and…Viagra?
We were wondering whether prescriptions for erectile dysfunction (ED) drugs like Viagra and Cialis take a leap before Valentine’s Day, and since we happen to have a little extra time, we ran the numbers. It turns out we were right: Valentine’s is a popular time to pop a Viagra.
But it turns out it’s not the most popular time.
Here are the most (and least) romantic times of the year, based on a representative sample of erectile dysfunction prescription claims across the U.S.
1. New Year’s Eve (52% higher than annual average)
The largest amount of ED drug fills are in the days leading up to New Year’s Eve – with fully 52% more prescriptions than the annual average fill rate. Our scientific hypothesis: people are planning for their New Year’s kiss.
2. 4th of July (50% higher than annual average)
Apparently, the week before Independence Day is an exciting time of the year, as well. The long weekend brings BBQs, parades, and plenty of fireworks. Ahem.
3. March 4th (46% higher than annual average)
A weird one, but this day has seen an especially high amount of prescription fills for erectile dysfunction drugs for the past two years. Maybe people are actually ‘marching forth?’
4. April Fools Day (44% higher than annual average)
We have no idea what’s going on here, but April 1st has been a very popular day for ED fills for the past two years. Interestingly, ED prescription fills are very low for the rest of April. We’re not sure why.
5. Valentine’s Day (40% higher than annual average)
The week before the supposed “most romantic day of the year” comes in at fifth in terms of prescription fills for ED medications, exceeding the annual fill rate by 40%. Perhaps it’s so romantic that people don’t need help?
And the least romantic time of year?
Christmas Day (9x lower than national average)
While the days leading up to Christmas see more ED fills, only a handful of people are filling on Christmas Day. It makes sense though – too much food and family (and few people are going to the pharmacy). Is mommy kissing Santa Claus?
And the most popular day of the week?
This one was no surprise. The most popular day to fill a prescription for Viagra or Cialis is… Friday. This makes sense; after all, Viagra has been dubbed ‘the weekend pill.’ And by Sunday or Monday, very few people are filling their ED prescription.