Best medicines for less

GlaxoSmithKline spent $52 million between 2005 and 2006 advertising the diabetes drug Avandia and increased sales by 20 percent. But older diabetes drugs that cost much less are equally effective and probably safer.

Alzheimer's drugs that cost $150 to $200 a month are heavily promoted to doctors and are routinely prescribed, yet studies show they may help only 10 to 20 percent of patients.

The four prescription drugs that treat heartburn or GERD (gastroesophageal reflux disease) produce about the same benefit. But there's a nonprescription drug that works just as well and can save users hundreds of dollars a year.

Those are among the highlights from Consumer Reports Best Buy Drugs, a public education project that makes comparative drug information available free of charge at www.ConsumerReportsBestBuyDrugs.org. We have now evaluated drugs for 35 conditions, including attention deficit disorder, heart disease, high blood pressure, high cholesterol, insomnia, menopause, migraine, and overactive bladder.

With 45 percent of U.S. adults regularly taking at least one prescription drug and 18 percent taking three or more, consumers need to know how to get the best value for their health-care dollar.

Consider John and Susannah Dodson, ages 70 and 68, from Shorewood, Minn., who both have high cholesterol, high blood pressure, and type 2 diabetes. Between them, the Dodsons take 12 prescription drugs every day, and more when allergies, arthritis, back pain, or heartburn flares up. They have struggled for years to keep their drug costs under control. While the new Medicare Part D program helps pay for a good portion of their drug bill, they still face around $260 a month in out-of-pocket drug expenses and were buying some prescriptions by mail from Canada.

Learning from CR Best Buy Drugs how drugs in a class compare was "enormously helpful right away," Susannah Dodson says. For example, she and her husband had been taking the cholesterol-lowering drug Lipitor (atorvastatin). After reading the report on cholesterol drugs, they asked their doctors whether they could safely switch to a new generic, simvastatin. The doctors agreed. "Making the change cut our drugs costs for cholesterol control in half," Susannah Dodson says.

Our analysis of many classes of prescription drugs showed the following:

Older drugs often match newer ones. Skillful marketing by pharmaceutical companies aims to convince doctors and consumers who compare drugs that newer medicines are almost always better. But expert evaluations have concluded that in many cases older drugs available as less expensive generics are as good or even better than newer ones. And because most older drugs have been taken by millions of people for years, experts usually have a better idea of their long-term safety.

Diabetes drugs are a case in point. For most people with type 2 diabetes, the generic drug metformin and a group of older medicines called sulfonylureas--also available as low-cost generics--are just as effective and as safe as a batch of new, highly touted, and more expensive medicines, according to the CR Best Buy Drugs findings. Indeed, the diabetes report was released amid a scientific flap over the new diabetes drug Avandia (rosiglitazone), which research has now linked to a possible higher risk of heart attack.

Older, less expensive drugs won't always meet your needs, though. For example, a newer drug is better for overactive bladder, a condition characterized by the frequent need to urinate that affects some 15 to 20 million people in the U.S. Tolterodine (Detrol), a more expensive brand-name drug, was named a CR Best Buy Drug because it caused fewer side effects than oxybutynin, an older generic.

Drugs within a class aren't always that different. Drugmakers argue that every drug is unique and that people respond differently to each. Therefore, they contend, more drugs in each class gives doctors and consumers more choice and a better chance of successful treatment.

But this mantra is driven more by a business agenda than a scientific one. To be sure, every drug has a different chemical composition, and studies show that in some classes, such as heart medicines, the effects of individual drugs vary significantly. But in other classes the medicines yield very similar results. When we compared 20 drugs known as NSAIDs (nonsteroidal anti-inflammatory drugs), they all delivered the same amount of pain relief at equivalent doses.

Safety considerations were similar, too. With the possible exception of naproxen (Aleve and generic), all NSAIDs probably pose a small risk of heart attack, especially if taken at high doses for long periods. And they all pose a risk of stomach problems. Our report on this class recommends three low-cost generics: ibuprofen, naproxen, and salsalate, a chemical cousin of aspirin. And it warns people against overusing NSAIDs for everyday pain relief.

A similar finding grew out of our analysis of the main class of drugs used to treat children with attention deficit hyperactivity disorder (ADHD). The five drugs in this class yield comparable benefits. Here, too, CR Best Buy Drugs are low-cost generics that could save you hundreds of dollars a year.

By contrast, if you have angina or heart disease, or have suffered a heart attack, you'll want to pay particular attention to which medicines you are prescribed in the two classes known as beta blockers and ACE inhibitors. The effectiveness of the 14 beta blockers and 10 ACE inhibitors differ markedly depending on your medical circumstances. For example, studies support only the use of particular beta blockers in treating people who have both high blood pressure and angina.

Some drugs are less effective than you might think. While many drugs are highly effective, some widely used ones don't work as well as their advertising campaigns suggest.

Our review of the five Alzheimer's drugs, for instance, found that when compared with a placebo (a sugar pill) only 10 to 20 percent of people taking any of the drugs had sustained improvement in their memory or cognitive abilities, or delay in the worsening of those mental functions. The CR Best Buy Drugs Alzheimer's report notes that the drugs are expensive ($150 to $200 a month) and concludes that they might not be worth it if the patient has to take many other medicines, as do many people with Alzheimer's.

Despite those results, two of the five Alzheimer's drugs, Aricept and Namenda, were among the top 100 best-selling brand-name drugs in 2006. Promotions of both drugs to doctors have been extensive. And Aricept's maker spent almost $60 million in 2005 and 2006 advertising the drug to consumers.

Adverse effects are understudied. For some categories of drugs your choice might well be based more on the side-effect risks than on how well the drug works. But be prepared that your doctor might brush off your concerns. A study in the August 2007 issue of the journal Drug Safety found that physicians were more likely to deny than confirm a suspected adverse effect from a statin drug, even when the symptom was well reported in the literature.

CR Best Buy Drugs reports compare drugs on the side effects they can cause. The diabetes report, for example, notes that two subgroups of drugs can trigger substantial weight gain and thus should not be prescribed for people already significantly overweight. And we note in the drug comparison that if you have stomach problems, our CR Best Buy Drug metformin might not be for you because it carries a greater chance of nausea and diarrhea.

Other classes of drugs pose such a high risk of adverse effects that their benefit is often overshadowed for some people who might be candidates for treatment. The antipsychotic drugs used to treat people with schizophrenia are an example. Studies indicate that 80 to 90 percent of people who take an antipsychotic have at least one side effect, such as blurred vision, constipation, muscle weakness, sedation, slurred speech, or tremors.

Discussing the risks of adverse effects with your doctor can prepare you for what you might encounter and can improve the chances you'll stay on a drug you need. Most research focuses on a drug's benefits rather than on potential problems, so use caution when you are prescribed any new drug. And let your doctor know about any problems and symptoms even if they aren't listed on the drug's package insert or in the material from your pharmacist.

No, Consumer Reports doesn't test drugs on people in our labs to find out how well they work. We use research reports from the experts at the Drug Effectiveness Review Project (DERP), whose headquarters are at the Oregon Health & Science University in Portland. The program is funded by 13 states to help them wisely spend their Medicaid dollars.

DERP assigns teams of physicians at university-based research centers to examine hundreds, and sometimes thousands, of studies of classes of highly prescribed medicines. When a final DERP report, often hundreds of pages long, is issued, Consumer Reports Best Buy Drugs translates the findings into easy-to-understand language, adds cost data, and chooses Best Buys for the category.

To be named a CR Best Buy Drug, a drug must be as effective and safe as others in its class and be available at a lower cost. Often generic rather than brand-name drugs are the CR Best Buy Drugs. But if the evidence shows a brand-name drug is superior to lower-cost drugs in effectiveness or safety, it will be deemed the CR Best Buy Drug regardless of price.

Reports covering 35 medical conditions, along with two-page summaries in English and in Spanish, are available free of charge at www.ConsumerReportsBestBuyDrugs.org. CR Best Buy Drugs is supported by Consumers Union, the nonprofit publisher of Consumer Reports, with substantial grant funding from the Engelberg Foundation and the National Library of Medicine of the National Institutes of Health.

You can save hundreds or even thousands of dollars if you and your doctor choose a CR Best Buy Drug over a newer, highly advertised alternative. Prices are the national retail averages for commonly prescribed doses, from data collected by Wolters Kluwer Health, Pharmaceutical Audit Suite. Annual savings are presented only for drugs that are usually taken daily for extended periods.

Studies show that doctors and patients often don't communicate well about prescriptions. Here's how to improve the conversation:

• List your drugs. Itemize what you are taking, or have taken over the past year, and mention any adverse reactions.
• Ask about options. Don't be shy about asking why your doctor is prescribing a particular drug over others. There should be a clear reason. And find out whether the recommended drug is approved for use for your condition or is being prescribed "off-label." Off-label uses are often beneficial but also might pose a higher risk of problems.
• Be wary of free samples. They come from drug companies and are usually widely available for only newer brand-name drugs, which might not be the best choices for you.
• Raise cost concerns. Studies show that doctors are often unaware of drug costs and don't ask patients whether cost is an issue. Ask whether a less expensive generic drug would do just as well. Lowering costs by splitting pills or getting them by mail order might also be an option. And many brand-name drugs are available free of cost to low-income people without insurance. Your doctor or the office staff can help you find out whether you are eligible for a drug-assistance program.
• Double-check dosing. Be sure you know how often you should take the drug, whether you should take it with food, and what to do if you miss a dose. Ask whether a lower dose is an option.
• Don't ignore side effects. With any new prescription, ask about common side effects. Be assertive if you are having uncomfortable symptoms; studies show many doctors dismiss such complaints. Ask whether there's another drug for the condition that you might be able to tolerate better.