Cost of medications!

[DrJeff]

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I had a bit of a sticker shock situation today that got me thinking in a different manner about what I'm prescribing to a patient with respect to costs. A new patient came in for an emergency exam this morning, he had root tips remaining on #14, with a 2 cm fluctuant swelling located palatally to #14, and approximately 0.5cm of edematous, erythematous tissue on the buccal. Radiographically he had an approximatley 1 cm radiolucent lesion on the palatal root tip, and a 1.5cm radiolucency encompassing botht he mesiobuccal and distobuccal root tips. Extra-orally he was erthyematous over his left infraorbital region, with ild swelling of his left cheek. Basically your standard fully blown out, hopeless tooth with an attached aggressive area of infection(the patient had stated that the extra-oral erythema/edema wasn't there last night. I administered anesthesia, removed the root tips, drained approximately 2 ml of yellow puss, irrigated with approximately 100ml of sterile saline, and got ready to write out some scripts for him. Based on past similar situation where I've placed the patient on either 500mg Penicillin or 500mg Amoxicillin QID for 7 days and had the patients return after 2 to 3 days with new areas of swelling requiring drainage again, I wrote the script for 300mg Clindamycin QID for 7 days, I also gave him 15 Vicodin ES. He gratefully thanked me and went on his way.

After lunch, this man's wife(an established patient of mine) was in for some restorative work, and remarked to me about what an expensive drug that I had given her husband this morning. When I asked about what it had cost, she told me that they didn;t have prescription coverage and that the antibiotic was $170😱 (the patient didn't get the Vicodin filled because he doesn't like the way pain medication makes him feel, and believe me, you'll hear alot of people say that). While I wouldn't have altered my drug choice in this instance based on my clinical findings/impressions/past experiences, it was really a bit of an eye opener.

 

[no2thdk999]

Dr Jeff,

Did you write for Cleocin 300 and specify no generic?

Drugstore.com has generic clindamycin 300, 30 tabs for about $80. Brand name Cleocin was about $140. Generic 150 Clindamycin, 30 tabs, was $25. At your dose he could have gotten the same med for ~$50

Was the pt. allergic to PCN? If not I usually start with PEN VK 500, 28, 2 stat, 1 q6h. If you removed the source of infection this probably would have done it. Whenever I Rx I'm not trying to kill everything in sight, I just want to tip the balance in the patient's favor.

Another alternative would have been the above PEN VK with Metronidazole 250, same sig. Also known as poor man's clindamycin, about $15, with the same basic coverage.

Not trying to correct you, just offer an alternative.

JMHO
Rob

take it easy on me it's my first post

 

[DrJeff]

My script pad has the notation written on the bottom "generic okay to substitute unless specifically noted". Additionally by specifically writing "clindamycin" instead of "cleocin" that gives the pharmacist some leeway also.

I've done many similar situations over the years wil either Pen VK or Amoxicillin and have seen flair ups requiring subsequent drainage a few days later. This was purely a judgement call of using Clindamycin in this case based on the greater degree of clinical success I've seen in these types of cases where visible extra-oral swelling arises "overnight" per the patient when compared to Pen/Amox.

I'll generally use the Pen VK/Metronidazole (a.k.a. Flagyl) as a last line of defense since my experience with Flagyl is that it tends to have very severe GI side-effects to the patient, and then they'll stop taking it and give me a call a day or to later not only complaining of the dental pain still, but also GI cramping, vomting and diarrhea. I have found that Clindamycin and Flagy seem to be equally effective in aggressive infections, the lesser degree of GI effects with thwe clindamycin makes that my lead choice. Granted both of these drugs tend to have a greater degree of GI effects than Pen/Amox, but Pen/Amox also seem to be a bit less effect(and quick acting) than Clinda/Flagyl in my experience.

 

[Frank Cavitation]

DrJeff,

from this thread it appears to me that giving "the pharmacist some leeway" was not enough to guarantee an affordable price for the patient... if a similar case were to occur again, would there be something you can do to provide them with the $50 medication mentioned by no2thdk999? Obviously the patient is in some hurry to get these drugs and can't do comparison shopping at different pharmacies...

 

[ItsGavinC]

Rob,

Welcome to the forums! Good to have you here. You mentioned drugstore.com, do you have patients who fill their scripts there, or did you mention it simply because it is easy to search prices for comparitive purposes?

 

[no2thdk999]

The majority of prescriptons a GP writes are either inexpensive, needed expeditiously, or both. The shipping costs and delay involved with an online pharmacy make them counterproductive.

I always tell the patient to ask for a generic if available. I can't think of a single medicine where the brand name is adventageous compared to an available generic.

JMHO
Rob

 

[snsethy]

Originally posted by DrJeff
My script pad has the notation written on the bottom "generic okay to substitute unless specifically noted". Additionally by specifically writing "clindamycin" instead of "cleocin" that gives the pharmacist some leeway also.

Actually, I used to work as a pharmacy tech, and unless you write out "DAW" the pharmacy will not fill it for brand (unless no generic is available) as it would be insurance fraud (legally)... most dentists didn't realize that when filling out the blanks (circling daw already printed isn't good enough.) Also, as a sidenote, it's cheaper to get Amoxil 400's than generic amoxicillin 400's... at least it is at CVS.

 

[snsethy]

Originally posted by snsethy
Actually, I used to work as a pharmacy tech, and unless you write out "DAW" the pharmacy will not fill it for brand (unless no generic is available) as it would be insurance fraud (legally)...

Oh, to clarify, that is unless the patient requests the brand themselves (at which point they usually accuse you of trying to rip them off due to the high costs)