Thursday, July 24, 2008

The Demon GERD

Is it possible to feel defeated by an acid reflux medication?  Even if it is a very special prescription medication, and even if I do not take it myself?  The answer is, yes.  

Prevacid SoluTabs is one of Robert's prescriptions.  We are now down to two prescription medications (from six): the aforementioned version of Prevacid (version 4.3, probably) and Sinemet 25/100.  And the dietary supplement biotin.  This would make for a much simpler life if only Prevacid (and its cousin Prilosec) would finally be required to relinquish their exclusive patents by the FDA.  But they keep finding ways to come up with new formulations of their products, some of which have been, really, life-saving applications for Robert.  For example, so many people who take this are tube-fed or have difficulty swallowing that the labs have developed versions of this complicated medication (time release capsules that had to be swallowed whole) that can be dissolved, sucked up into a syringe, and administered through a g-tube.  This is a small miracle.  Prior to this, we relied on faulty swallowing, imperfect and effective dissolution, a solvent available only through a university research lab, and prayer.

Do not misunderstand: I am glad of the pharmaceutical industry in many respects.  Robert would not be alive today and healthy if it were not for this small army of dedicated professionals in white lab coats and safety glasses, bent over titration vials and other beakers and assorted machinery.  I don't necessarily begrudge them their profits.  I'm just tired of their sturm und drang with the FDA.  

All of you out there at home, watching your TV sets may be quite tired of Prilosec and Prevacid hawking their wares and their endless discussions of esophageal erosions and so on.  I am, too.  But the development of these drugs is nothing short of a miracle for children with certain types of disabilities. These two drugs are proton pump inhibitors, and they work by reducing the amount of acid that the stomach produces altogether.  Previous drugs for acid reflux only reduced the amount of existing acid in the stomach.  What seems to be a minor difference here is actually a matter of restoring significant quality of life to a chronically ill person.

Children, with their shorter esophagi and lower muscle tone (especially if exacerbated by certain neuromuscular disorders) can actually die of acid reflux disease.  The refluxing can become so exaggerated and constant that it is impossible to hold down fluids or take in solids.  Electrolyte imbalances can occur.  Patients can aspirate their stomach contents (breathe them into their lungs) and develop serious pneumonias or die of the aspiration episode itself.  That is to say, nothing makes me more anxious than maintaining affordable access to this drug.

But here's the rub.  Because proton pump inhibitors work so much better than other acid reflux medications, doctors have tended to prescribe them to people who have mild heartburn on even an irregular basis.  To provide some perspective on this, a month's supply of Robert thrice daily dose (in med speak, t.i.d.) costs about $900-1,000 (per the contract rate my insurer negotiates with the drug manufacturer).  

Insurance companies have responded (as they have not to Viagara and Cialis, curiously) by greatly restricting the number of tablets they will dispense on a yearly basis with a regular prescription.  With our insurance plan, that would be 90 tablets for the year.  Robert takes that many every month.  So people who actually have GERD (gastroesophageal reflux disease, which can be a very serious medical condition) have to jump through multiple hoops on a regular basis.  You must have an authorization on file from your physician explaining your need for the drug.  That authorization may not overlap exactly with the term of your yearly prescription.  

So you can, as I just experienced, have a refill available on a prescription, but be unable to refill it because your authorization has expired.  This often requires multiple calls to the nurse at your doctor's office asking them to do things that may or may not be routine or easy for them.  The vendor who handles prescriptions (mail order in this case, which makes the drug affordable--cannot afford to have it filled at the local pharmacy as then I will be charged 25% of the insurer's contract price for the drug, in this case, $250/month--by mail order, it's $35 for a three-month prescription) may then screw up handling the processing of this authorization.

I've just spent 10 days interacting with various parties involved in this process, exchanged two emails, left three voicemail messages, had four live phone calls, and had one conference call.  I should get Robert's medication in 5-7 days, with express shipping provided at no cost to me.  Is that business days or calendar days?

Is is possible to be defeated by a g/i reflux medication?  Pretty close.  I live for the day the solutabs go generic--two years, three?  It will be something like being raptured up into some medical heaven in which Robert's health is finally liberated from the pitched, vicious battles of the stakeholders in the American healthcare system.

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