Prescription Drug Prices

Prescription drug prices are highly variable and out of control in the United States. Often times, we will find ourselves telling a patient they should see their PMD and take all their medications, or we’ll be prescribing a medication for a newly diagnosed chronic condition. Whether or not our patients follow our advice is dependent on dozens of socioeconomic factors, but one of those is the price of prescription medications.

I was curious about the prices our patients face for some of the common medications we often send them home with or expect them sometimes for the rest of their lives. Of course, insurance is a whole other issue, but these are just some of the upfront costs that particularly our most vulnerable and socioeconomically destitute patients may face:

*prices listed are the lowest price at a pharmacy within 5 miles of the hospital

Albuterol HFA inhaler, $22.14

Amlodipine 5mg, 30 tabs, $5.20

Amoxicillin 400mg/5mL, 100mL bottle, $9.45

Atorvastatin 10, 30 tabs, $6.27

Azithromycin 250, Z pack with 6 tablets, $9.49

Cephalexin 500mg, 30 tabs, $10.86

Ciprofloxacin 500mg, 20 tabs, $17.42

Clopidogrel 75mg, 30 tabs, $6.60

Doxycycline 100mg, 30 tabs, $19.46

Divalproex 500mg, 30 tabs, $14.41

Furosemide 40mg, 30 tabs, $5.10

Gabapentin 300mg, 30 tabs, $6.07

HCTZ 12.5, 30 tabs, $5.58

Ibuprofen 400mg, 30 tabs, $6.65

Levothyroxine 50mcg, 30 tabs, $10.72

Lisinopril 20mg, 30 tabs, $4.99

Metformin 500mg 30 tabs, $4.99

Nitrofurantoin 100mg, 14 tabs, $18.64

Omeprazole 20mg, 30 tabs, $7.47

Prednisone 10mg, 21 tabs, $14.29

Tamsulosin 0.4mg, 30 tabs, $7.77

Drug prices are extremely hard to track down. For instance, the NYS DOH website for searching drug prices hasn’t updated their list of prices for our MMC Pharmacy since 2013.

Our wonderful ED pharmacist Ankit Gohel also pointed out to me that you can look up the average wholesale price of any medication on uptodate in the ‘price’ section.

The Epocrates app will also list average retail prices.

Hope this can be some food for thought.

Source: www.communitycaresrx.com

https://apps.health.ny.gov/pdpw/SearchDrugs/Home.action

https://www.goodrx.com/

Neuroleptic Malignant Syndrome/Serotonin Syndrome

Let's talk about hyperthemia today, the weird kind. NMS and SS - I often get confused between the two, so this is as much as I can remember:

NMS is SLOW, it happens slowly and takes forever to resolve. Fever + rigidity.

SS is FAST, hyper reflexive and agitated, quick on and relatively quick off. Fever + clonus.

Both have fever/elevated temp. Treat both with benzos. For NMS, add on bromocriptine (SLOW down BRO). For SS, just use the other weird-sounding drug (cyproheptadine).

I think it's also important to learn to recognize potential offending agents when you are doing med recs on patients.

Definitely not a comprehensive list but here are some our patients might be taking (or you are giving them):

NMS

typical antipsychotics > atypicals. Classically, haldol, droperidol, thorazine, pheneragan. Metoclopramide. Less rare but atypicals like clozapine, olanzapine, risperidone, quetiapine, ziprasidone.

SS

sertraline, fluoxetine, citalopram, paroxetine, trazadone, buspirone, venlafaxine, valproate, tramadol, fentanyl, meperidine, ondansetron, metoclopramide, sumatriptan, linezolid, dextromethorphan, MDMA, LSD, St. John’s wort, ginseng.

Check this out for more details and some of the more nitty gritty:

http://www.emdocs.net/toxcard-differentiating-serotonin-syndrome-neuroleptic-malignant-syndrome/

Euglycemic DKA

What is it? 

DKA without the elevated glucose that usually triggers us to think about DKA in the first place. Patients often have blood glucose levels less than 250 mg/dl. 

Why do we care? 

Because untreated DKA can lead to cerebral edema, ARDS, renal failure, shock and death.

Why does it happen?

Euglycemic DKA can occur in any diabetic, but there is a rising incidence in those taking SGLT2 inhibtors (-gliflozins) (listed below). The pathophysiology behind this isn't totally clear yet though there are some theories. 

US approved: Dapagliflozin (Farxiga), Canagliflozin (Invokana), Empagliflozin (Jardiance)

It can also occur in those who have underlying disease that depletes the liver's ability to make glucose (putting those who are pregnant or have long bouts of nausea and vomiting under increased risk).

And of course, think of the usual triggers for DKA (ie infection, alcohol use, etc)

When to suspect it?

In any patient with a history of diabetes, including but not limited to those taking SGLT2 inhibitors, who come in for vomiting, generalized weakness, or SOB. Also consider euglycemic DKA in those who have a metabolic acidosis without other clear cause. Draw serum ketones or obtain urine ketones in these patients. 

Sounds a lot like alcoholic ketoacidosis--how to tell the difference?

History: history of heavy alcohol use vs a diabetic on an SGLT2 inhibitor.

Signs: those with alcoholic ketoacidosis tend to have a very low glucose. 

And maintain a high level of suspicion. 

How do we treat it differently than hyperglycemic DKA?

Overall, we treat it pretty similarly. A key difference is that you will need to start fluids with dextrose initially or much earlier than you would with hyperglycemic DKA. 

Sources

https://rebelem.com/euglycemic-dka-not-myth/

https://emcrit.org/ibcc/dka/#euglycemic_DKA

https://emergencymedicinecases.com/euglycemic-dka/

http://www.emdocs.net/diabetic-ketoacidosis-sneaky-triggers-clinical-pearls/