Big Pharma Kicks Us In The Teeth (Again)

One day last week, the top five most-read stories in the New York Times were all about Mylan, the generic drug manufacturer and owner of the EpiPen, a pre-filled syringe of epinephrine used for severe allergic reactions. Mylan didn’t invent the EpiPen. It just bought the company that developed it.

For years, EpiPens were $100 for a two-pack, but last week Mylan increased that price tag to $600.

In response to what I’m sure was an expected firestorm, Mylan CEO Heather Bresch (who earned $19 million in 2015) said she’s not the villain in this matter. Haven’t you noticed that people who say “I am not a…” more often than not are precisely what they’re denying? Seems to be a popular phrase among presidential candidates, too: “I am not a liar,” “I am not a racist.” And Bresch, whose career was undoubtedly helped by her father being a US Senator, avers that she’s just doing her job.

She justifies her actions by saying Mylan is a for-profit company and her obligation is to shareholders, not to the public. Previously, she’d moved Mylan’s headquarters from the US to the Netherlands to reduce taxes and avoid all sorts of regulations and takeover possibilities.

You must appreciate Mylan/Bresch are not alone in this chicanery. In 2012, Questcor Pharmaceuticals bought the rights to an injectable med called ACTH, raising the price from $9.00 per vial to $28,000 per vial (which contains one teaspoonful).

Last year, Turing Pharmaceuticals raised the price of the anti-parasite medicine pyrimethamine from $13.50 to $750.00 per pill.

It’s the new Big Pharma trend

Memo to staff from Big Pharma CEO: Don’t waste valuable time researching and developing new drugs. Find something tested and true that’s an inexpensive generic, buy the company, rename the product, raise the price, and hire a bevy of former cheerleaders to invade physician waiting rooms and gouge the American public.

Specifically “American” public, because all these medications are far more regulated elsewhere. EpiPens still cost $50 each in Australia, a fact that probably causes Bresch to grind her teeth in her sleep

I promise you it wasn’t always this way.

Before greed became the watchword of Big Pharma, newly developed meds appeared regularly and were very fairly priced. In fewer than 20 years, Big Pharma introduced the first antidepressants (Prozac, et. al.), the first proton pump inhibitors (Tagamet, Nexium, et. al.), the first statins (Lipitor et.al.), the first non-steroidal anti-inflammatories (ibuprofen et. al.), the first triptans for migraine (Imitrex et. al.), and numerous blood pressure meds (Inderal et. al.) and antibiotics (Cipro et al).

These days, Big Pharma’s newly discovered jewels in the crown are the biologics (Humira, et. al) and some interesting cancer drugs, all insanely priced.

Scroll down in the very interesting (but depressing) series “The Price of Profits” on NPR’s Marketplace and listen to the segment on Big Pharma, including the interview with the 86-year-old, long-retired CEO of Merck. “We weren’t just in it for the money,” he says. Merck was truly proud of the drugs it developed and how they changed lives.

Repackaging is key

Today, Big Pharma simply repackages old pharmaceutical warhorses or pushes through a new condition to be treated by an old drug. Here are a couple of examples of Big Pharma kicking us in the teeth:

• Treximet, for migraine, combines generic imitrex ($2.00 a pill) and generic naproxen (66 cents a pill) into one tablet that sells for $83.00 a pill. Could you save $80.33 per pill with two separate prescriptions? Yes.
• Cambia, also for migraine, works extra fast because it’s in powder form. It’s made from generic diclofenac, a nonsteroidal anti-inflammatory drug. Cambia costs $50 a dose. As an alternative, you could get a prescription for 50-mg diclofenac tablets (about 10 cents a pill), buy a mortar and pestle on eBay, and grind your own. (Put the powder from the one-dose tablet into a little glassine envelope and carry it with you. Mix with a little water to help it go down.)
• Silenor, a sleep aid, is simply a repackaging of doxepin, an antidepressant. Instead of paying $10 each for Silenor tablets, get a prescription for doxepin (30 cents each), twist open the capsule, shake out half, and you’ll have Silenor.

Sometimes this strategy of buying an old drug and repackaging it backfires, and instead of kicking you in the teeth, Big Pharma gets bitten in the ass. This happened to Valeant, the Comcast of Big Pharma, which paid a cool billion (with a “B”) for rights to a failed antidepressant called flibanserin. Somebody told them it was great for female sex drive enhancement so they marketed it as Addyi (taken daily @ $27 a pill). Just one problem: it didn’t work. Apparently this and other bad decisions cost the CEO his job.

Multiple-use applications rising too

The other Big Pharma strategy is to increase the number of uses for a drug already owned.

Botox (yes, that Botox) started on the market for cervical dystonia (neck spasms) and now has more than 20 medical indications in addition to its use in the cosmetic surgery industry. A Big Pharma CEO dream is to own a drug that has made billions for one indication and then, just as the patent expires, to find another indication and get a patent extension and thus a new profit stream.

One final point (well, maybe not final). These companies always tell the news media they’ll help with the price increase by giving the patient a coupon that reduces the co-pay to a reasonable $10 or $20. The consumer thinks “how thoughtful.” Your health insurer knows better. A $500 prescription costing you only $20? Realize that your health insurance company pays the remainder, so when you get an eye-popping premium increase, Big Pharma’s draining of your insurer has contributed mightily to this.

EpiPen redux

Let me end with more on the EpiPen. The contents of the pen (epinephrine 0.3 mg) cost less than a penny to manufacture. You’re paying for the patented auto-injector system, which allows you to inject the drug without seeing the needle as you hold the pen to your flesh.

In a recent study, 84% of EpiPen users were using the pen incorrectly and didn’t get an adequate dose. That means just 16% of EpiPen users are actually getting the correct dose of epinephrine. If you have a few minutes, read this Wikipedia article on the EpiPen. By the end of it, you may think (as I did) that more lawyers have been involved in merger/acquisition agreements and patent infringement lawsuits than there are users of the EpiPen itself.

If you’re willing to work with a needle and syringe like insulin-dependent people with diabetes, you can ask your compounding pharmacy about pre-filled epinephrine syringes, which you keep in a refrigerator or a carrying case. If you can’t get the syringes pre-filled, it’s not difficult to make them yourself. The epinephrine comes in 1.0 ml. glass vials. You take a 1.0 ml needle/syringe combination, snap open the vial, draw up 0.3 ml and you have created your own Epi-Pen for about one dollar.

However, if you get the willies just thinking about this, know that a generic version of the EpiPen, after several delays, is finally available. Called Adrenaclick, it’s the same as an EpiPen. Best price is $140 for two pens, at Walmart, using this coupon. More companies want to get on this gravy train and I’m hopeful that further price drops will follow.

Be well,
David Edelberg, MD