Patients who insist on DAW Nexium?

[NewYorkDoctors]

Have any GIs, PCPs, or other specialists who routinely prescribe PPIs come across the patients who insist on name brand Nexium only?

I have a fair number of patients who insist that none of the PPIs work but only Nexium brand name works
Generic esomeprazole does not.

I used to think there was secondary gain involved with selling these pills. But if that were the case, the person who uses the Nexium still would only insist on Nexium.

Is there some thing different pharmacologically about Nexium versus the other PPIs? Nothing about this seems to be the case?


The headache is that Nexium name brand is OTC and most insurances have removed it from their formularies. Before some insurances would allow a prior auth to get the DAW version but now in NY most formualries say "no means no."

The Medicare/medicaid population have an OTC Card that is worth $150 of money every month for this purpose. But patients and unscrupulous pharmacies just take the money out for themselves (i.e. pharmacy withdraws $150 of the OTC card and gives patinet $100 in cash or something) and then the patients come to begging for DAW and are mum on the OTC card situation. I usually shut them down on this point.

But some of these pains in the ***es patients keep insisting on Nexium

I have observed these patients have never employed a GERD dietary adjustment (I print out lists and go over it with them but nope patients gonna patient), slept elevated with a wedge pillow (which I can get as a DME through a local DME store) or automated bed, or abstained from alcohol.
But if that were the case, none of the PPIs should work really.

I thought about non-erosive reflux and tried to get them into academic GI for impedance manometry / 24 horu pH to prove "non-acid" reflux but none of the patients want to go in for it. Plus that would not explain why Nexium works


anyway, just wondering if anyone had any insights in this nuisance of an issue?

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[TexasMed22]

NYT has written a handful of great articles digging into the generic drug supply. TLDR, generic drugs aren't really equivalent to their name brand (and clinical trial proven) counterparts, even if they purport to contain the same active ingredient. So I'd say it's entirely possible that Nexium really is more effective.

Opinion | Americans Need Generic Drugs. But Can They Trust Them? (Published 2019)

The fake quality-control data, bird infestations and toxic impurities at the overseas plants that could be making your medication.

www.nytimes.com

A New Book Argues That Generic Drugs Are Poisoning Us (Published 2019)

In her stunning exposé “Bottle of Lies,” Katherine Eban describes a world of generic drug manufacturing rife with corruption and life-threatening misdeeds.

www.nytimes.com

 

[dozitgetchahi]

Have any GIs, PCPs, or other specialists who routinely prescribe PPIs come across the patients who insist on name brand Nexium only?

I have a fair number of patients who insist that none of the PPIs work but only Nexium brand name works
Generic esomeprazole does not.

I used to think there was secondary gain involved with selling these pills. But if that were the case, the person who uses the Nexium still would only insist on Nexium.

Is there some thing different pharmacologically about Nexium versus the other PPIs? Nothing about this seems to be the case?


The headache is that Nexium name brand is OTC and most insurances have removed it from their formularies. Before some insurances would allow a prior auth to get the DAW version but now in NY most formualries say "no means no."

The Medicare/medicaid population have an OTC Card that is worth $150 of money every month for this purpose. But patients and unscrupulous pharmacies just take the money out for themselves (i.e. pharmacy withdraws $150 of the OTC card and gives patinet $100 in cash or something) and then the patients come to begging for DAW and are mum on the OTC card situation. I usually shut them down on this point.

But some of these pains in the ***es patients keep insisting on Nexium

I have observed these patients have never employed a GERD dietary adjustment (I print out lists and go over it with them but nope patients gonna patient), slept elevated with a wedge pillow (which I can get as a DME through a local DME store) or automated bed, or abstained from alcohol.
But if that were the case, none of the PPIs should work really.

I thought about non-erosive reflux and tried to get them into academic GI for impedance manometry / 24 horu pH to prove "non-acid" reflux but none of the patients want to go in for it. Plus that would not explain why Nexium works


anyway, just wondering if anyone had any insights in this nuisance of an issue?

I have pretty significant GERD and take lansoprazole.

I can tell you that there is a pretty noticeable difference between name brand Prevacid and most generic lansoprazole out there. The generics generally do not work very well for me. (Interestingly, I tried Nexium in the beginning and found that it made me feel “weird” for some reason - I got switched to Prevacid and it didn’t make me feel that way. No idea why this is. I also felt Prevacid worked better than Nexium for me.)

I buy it OTC myself, which completely dodges the insurance problem.

 

[NewYorkDoctors]

Regarding PPIs, one issue I found is patients seldom take it 30 minutes before a meal. This is highlighting on how the proton pumps are only expressed at about 5% when fasting but are upregulated while eating. Hence it takes about 30 minutes for each pill to be swallowed and begin to take effect

They also seldom take it continuously for a period of time and opt for PRN use. It takes a few days to reach steady state.

I have zero idea if the PCP or GI told them these details or not. Maybe they did and the patient just did not pay attention. I usually have to deal with a lot of these little details.

Then I have to print out dietary list of GERD foods, discuss how to stay upright after last meal of the day for 4-5 hours idealy, use a wedge pillow, take a bite of a starch as the final food bolus after dinner to serve as a "sponge" of sorts, etc...)
(i.e. things the PCP or GI should be saying... assuming they did not already say this and the patient just forgot or did not pay attention)

Moreover, the term "acid reflux" is being thrown out a lot by patients and other providers when it's really Gastroesophageal reflux disease. It's not always acid.
I admit there is little reason to bother GI for 24 hour pH impedance test (which is the only way to prove non-acid reflux) as the management remains dietary, upright, lose weight etc... a fundoplication does not enter the equation unless there are the standard indications such as barrett's perhaps. I'll let GI and thoracic deal with that.
But patients are often disbelieving they they need PPIs and GERD lifestyle modifications because "I don't taste acid."


Anyway I would say 2/3 of my chronic cough referrals end up being GERD. It's usually that gigantic patulous dilated esophagus with intraluminal debris on the CTC images.

however, it is not typical GERD symptoms so I seldom bother to ask GI for input unless its for EGD to rule out gastritis/esophagitis (if they have some pain). I used to try to be "by the book" and get them to academic GI for Bravo and 24 horu pH impedance. .. but like i said this rarely changes the management

The only exception are for the NTM-LD patients who are not clearing the NTM with appropriate antibiotics, pulmonary hygiene, and GERD medical management (as NTM is ubiquitous in the environment, food, GI flora) and reflux is the prime route of respiratory tract inoculation) and CT shows that patulous esophagus with hiatal hernia. Then doing this full workup to prove reflux (again non-acid reflux by impedance perhaps) can justify thoracic to do some kind of fundoplication for these patients.



anyway, I was just wondering anecdotes (as no clinical trials of generic to brand will never be done so...) out there.

 

[dozitgetchahi]

Regarding PPIs, one issue I found is patients seldom take it 30 minutes before a meal. This is highlighting on how the proton pumps are only expressed at about 5% when fasting but are upregulated while eating. Hence it takes about 30 minutes for each pill to be swallowed and begin to take effect

They also seldom take it continuously for a period of time and opt for PRN use. It takes a few days to reach steady state.

I have zero idea if the PCP or GI told them these details or not. Maybe they did and the patient just did not pay attention. I usually have to deal with a lot of these little details.

Then I have to print out dietary list of GERD foods, discuss how to stay upright after last meal of the day for 4-5 hours idealy, use a wedge pillow, take a bite of a starch as the final food bolus after dinner to serve as a "sponge" of sorts, etc...)
(i.e. things the PCP or GI should be saying... assuming they did not already say this and the patient just forgot or did not pay attention)

Moreover, the term "acid reflux" is being thrown out a lot by patients and other providers when it's really Gastroesophageal reflux disease. It's not always acid.
I admit there is little reason to bother GI for 24 hour pH impedance test (which is the only way to prove non-acid reflux) as the management remains dietary, upright, lose weight etc... a fundoplication does not enter the equation unless there are the standard indications such as barrett's perhaps. I'll let GI and thoracic deal with that.
But patients are often disbelieving they they need PPIs and GERD lifestyle modifications because "I don't taste acid."


Anyway I would say 2/3 of my chronic cough referrals end up being GERD. It's usually that gigantic patulous dilated esophagus with intraluminal debris on the CTC images.

however, it is not typical GERD symptoms so I seldom bother to ask GI for input unless its for EGD to rule out gastritis/esophagitis (if they have some pain). I used to try to be "by the book" and get them to academic GI for Bravo and 24 horu pH impedance. .. but like i said this rarely changes the management

The only exception are for the NTM-LD patients who are not clearing the NTM with appropriate antibiotics, pulmonary hygiene, and GERD medical management (as NTM is ubiquitous in the environment, food, GI flora) and reflux is the prime route of respiratory tract inoculation) and CT shows that patulous esophagus with hiatal hernia. Then doing this full workup to prove reflux (again non-acid reflux by impedance perhaps) can justify thoracic to do some kind of fundoplication for these patients.



anyway, I was just wondering anecdotes (as no clinical trials of generic to brand will never be done so...) out there.

Another thing I usually stress to GERD patients (we see this in the context of scleroderma, sometimes with the patulous esophagus as well) is *smaller portion sizes*.

I can notice a pretty significant difference between eating a big meal and eating a small meal with GERD.

I’ve often wondered how much “GERD” (and hiatal hernias) in the US is just people repeatedly stuffing their stomachs until food backs up into their esophagus, leading to all sorts of other problems.

I’ve had patients tell me “if I eat a big meal, I can just feel the food sitting in my chest after that”. Well…cut yourself off earlier then. Eat less. (But you know telling that to most people in the US is pointless.)

 

[NewYorkDoctors]

Another thing I usually stress to GERD patients (we see this in the context of scleroderma, sometimes with the patulous esophagus as well) is *smaller portion sizes*.

I can notice a pretty significant difference between eating a big meal and eating a small meal with GERD.

I’ve often wondered how much “GERD” (and hiatal hernias) in the US is just people repeatedly stuffing their stomachs until food backs up into their esophagus, leading to all sorts of other problems.

I’ve had patients tell me “if I eat a big meal, I can just feel the food sitting in my chest after that”. Well…cut yourself off earlier then. Eat less. (But you know telling that to most people in the US is pointless.)

To be fair the ghrelin gremlins are hard to overcome

Wegovy is out of stock everywhere and Ozempic and mounjaro is in short supply .


The key is really become a part time athlete and just keep moving all day X . For working professionals it is standing desk and walk in place all day long . There are certain social and mental barriers there to overcome though

Pro athletes eat junk McDonald’s and Pizza Hut are are in great shape . “Genetics “ dictates how powerful their muscles are and speed

Once pro athlete retires but eats the same gets obese quite quickly

 

[Drrrrrr. Celty]

My mom fairs better with Dexillant and Nexium brand name than most alternatives. Even Omeprazole which is frankly a dirty and strong drug doesn't work for her as well as the other.

I will say that brand medication is predictable. Non-brand is not. My patients on levothyroxine can sometimes become hypothyroid just because the pill shape or color changed.

To be fair the ghrelin gremlins are hard to overcome

Wegovy is out of stock everywhere and Ozempic and mounjaro is in short supply .


The key is really become a part time athlete and just keep moving all day X . For working professionals it is standing desk and walk in place all day long . There are certain social and mental barriers there to overcome though

Pro athletes eat junk McDonald’s and Pizza Hut are are in great shape . “Genetics “ dictates how powerful their muscles are and speed

Once pro athlete retires but eats the same gets obese quite quickly

I don't think it's genetics as much as priming and macros. Pro-athletes eat Paleo levels of protein. And spend the whole day working and training.
Compared to that our 5-10 hours of higher heart rate or weight exercises are nothing.

We've opened a Pandoras box regarding GLP-1s. We need to figure out a way to make more of it.

 

[NewYorkDoctors]

My mom fairs better with Dexillant and Nexium brand name than most alternatives. Even Omeprazole which is frankly a dirty and strong drug doesn't work for her as well as the other.

I will say that brand medication is predictable. Non-brand is not. My patients on levothyroxine can sometimes become hypothyroid just because the pill shape or color changed.


I don't think it's genetics as much as priming and macros. Pro-athletes eat Paleo levels of protein. And spend the whole day working and training.
Compared to that our 5-10 hours of higher heart rate or weight exercises are nothing.

We've opened a Pandoras box regarding GLP-1s. We need to figure out a way to make more of it.

there is definitely truth in that

but I'd settle for our patients to get the bare basics and reduce BMI to under 30. The medical requirement is not to have everyone have six pack abs. That is a personal decision for each individual.

 

[Drrrrrr. Celty]

there is definitely truth in that

but I'd settle for our patients to get the bare basics and reduce BMI to under 30. The medical requirement is not to have everyone have six pack abs. That is a personal decision for each individual.

I believe honestly everyone with a BMI above 23 if white or black or 21 if asian should probably consider being on or can tolerate 0.5 of ozempic after 50. While no study is out, most suspect that mediating and reducing insulin resistance even in relatively normal for age sensitivity adults without diabetes likely will add years to life.

 

[NewYorkDoctors]

good point. for non-Caucasians, there is data that the waist circumference and BMI for overweight and obesity are actually lower due to varying racial differences in insulin resistance.

though I would also state that my general anti-establishment sentiment is I wish for patients to break the futile cycle of Big Food feeds Big Pharma and vice versa. For anyone able and willing to improve their metabolic syndrome through diet and exercise, the I usually pursue that route first. I am a fitness enthuasiast myself. But there is a fine line to walk in that I must never make any patients feel put down by the weight. That is just highly counterproductive and inefficient. (It is mean also. But I am no tree hugger lol. I just do not see the need to put down patients who likely already put themselves down)

But if someone is older, bad joints, sleep apnea, hormonal issues etc... and is unable to become a fitness enthusiast, then yes I would agree with your take that these meds can help increase life and quality of life (such as reduced MACE and ASCVD) down the line.

 

[Drrrrrr. Celty]

good point. for non-Caucasians, there is data that the waist circumference and BMI for overweight and obesity are actually lower due to varying racial differences in insulin resistance.

though I would also state that my general anti-establishment sentiment is I wish for patients to break the futile cycle of Big Food feeds Big Pharma and vice versa. For anyone able and willing to improve their metabolic syndrome through diet and exercise, the I usually pursue that route first. I am a fitness enthuasiast myself. But there is a fine line to walk in that I must never make any patients feel put down by the weight. That is just highly counterproductive and inefficient. (It is mean also. But I am no tree hugger lol. I just do not see the need to put down patients who likely already put themselves down)

But if someone is older, bad joints, sleep apnea, hormonal issues etc... and is unable to become a fitness enthusiast, then yes I would agree with your take that these meds can help increase life and quality of life (such as reduced MACE and ASCVD) down the line.

I agree. Honestly I can lose 10-15 pounds in 2-3 months reasonably. I accept that it will be inconvenient, non-linear project, and that it will make me feel like **** at least a few times a week.

A lot of my patients however are not willing to often engage with reality. They think they're eating 1200-1500 calories but are completely unaware that it likely is 2200-2500 half of the time. They also think that walking 6000 steps/ day is an achievement as opposed to the threshold for a normal person.

Also a lot of my female patients come in to my office in tears looking for a fix to their body dysmorphic disorder.

For a young person without PCOS with a BMI above 30 I will 100% tell them they're not going to have their GLP-1 approved and they need to make lifestyle changes.


That being said someone with DM Type 2, >50. A GLP-1 probably will prevent more diseases than statins or aspirins combined.

 

[NewYorkDoctors]

I agree. Honestly I can lose 10-15 pounds in 2-3 months reasonably. I accept that it will be inconvenient, non-linear project, and that it will make me feel like **** at least a few times a week.

A lot of my patients however are not willing to often engage with reality. They think they're eating 1200-1500 calories but are completely unaware that it likely is 2200-2500 half of the time. They also think that walking 6000 steps/ day is an achievement as opposed to the threshold for a normal person.

Also a lot of my female patients come in to my office in tears looking for a fix to their body dysmorphic disorder.

For a young person without PCOS with a BMI above 30 I will 100% tell them they're not going to have their GLP-1 approved and they need to make lifestyle changes.


That being said someone with DM Type 2, >50. A GLP-1 probably will prevent more diseases than statins or aspirins combined.

the key is standing desk and walking in place

i have a standing desk in my office room

i also purchase a "desk riser" to put onto existing desks (to minimize moving furniture around) at home.

just walking in a place everyday while typing (as I do now) really accumulates the step count. (i wear pedometers to keep track)

while the accuracy of how many steps counted and how many calories burned is questionable, the precision of doing this everyday and keep tracking is the easiest thing I have ever done.


the other thing I fill up on a non-workout day is psyllium husk fiber. metamucil stevia nonsugar or just plain old no flavor psyillium husk fiber plus a lot of water really bulks up the GI tract

I personally tried semaglutide in the past. I did not need it to lose weight but my mantra is "if I am going ot have a patient take something I Should try it out first..."

I will say loading up on psyllium husk fiber achieved that same feeling as semaglutide of "I feel hungry but I don't feel that hungry and I can ignore my hunger without affecting my mental performance now."

of course this is my n=1. moreover, a lot of prescription fiber products are loaded with sugar (no doubt to promote the osmotic laxative effect)

 

[Drrrrrr. Celty]

the key is standing desk and walking in place

i have a standing desk in my office room

i also purchase a "desk riser" to put onto existing desks (to minimize moving furniture around) at home.

just walking in a place everyday while typing (as I do now) really accumulates the step count. (i wear pedometers to keep track)

while the accuracy of how many steps counted and how many calories burned is questionable, the precision of doing this everyday and keep tracking is the easiest thing I have ever done.


the other thing I fill up on a non-workout day is psyllium husk fiber. metamucil stevia nonsugar or just plain old no flavor psyillium husk fiber plus a lot of water really bulks up the GI tract

I personally tried semaglutide in the past. I did not need it to lose weight but my mantra is "if I am going ot have a patient take something I Should try it out first..."

I will say loading up on psyllium husk fiber achieved that same feeling as semaglutide of "I feel hungry but I don't feel that hungry and I can ignore my hunger without affecting my mental performance now."

of course this is my n=1. moreover, a lot of prescription fiber products are loaded with sugar (no doubt to promote the osmotic laxative effect)

I think that certainly works.

I also agree that soluble fiber is a major cheat code. Similarly I think protein and fat work well too.

When I am losing weight I eat tons of fiber and I aim for 100-140 grams of protein in my diet/ daily.

But again. Most people are terrible cooks. Do not comprehend food science or flavor at all. And they end up feeling disgusted when their unmassaged kale salad tastes bland with just salt and pepper.