Best Drugs for Less - Consumer Health Choices

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Dec 17, 2013 - What's safe, what isn't, and how to get a good night's ...... prices can be even cheaper than what you mi
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2015-2016

Top choices for: Allergies,

Depression, Diabetes, Heartburn, Headache, High Blood Pressure, High Cholesterol, Insomnia, Joint Pain, and more

PLUS: 8 Ways to Save Big On Your Rx Meds

About Consumer Reports Best Buy Drugs Whether you’re suffering from a common headache or a chronic condition like Type 2 Diabetes, Hypertension, or Depression, Consumer Reports Best Buy Drugs can help you get the best drug at a price you can afford. We rely on an expert panel of doctors to provide information and advice about nearly 650 medicines in both English and Spanish. Because our grant-funded program is a public education project, we make all our recommendations free. Our mission is simple: To help you make smart drug choices based on expert medical advice. Go to CRBestBuyDrugs.org to access our free, consumer-friendly reports for your condition. Get social with us: facebook.com/ConsumerReportsBestBuyDrugs instagram.com/CRBestBuyDrugs twitter.com/CRBestBuyDrugs En Español:

facebook.com/CRenespanol twitter.com/CRenespanol  Subscribe to our e-newsletter: Stay up to date on all the latest content we publish. Visit ConsumerReports.org, enter your email address and select “Best Buy Drugs” from the menu. Send your questions to: [email protected] and include “PHARMACY QUESTION” in the subject line.

CONTENTS 2 Get the best medication for what ails you Which generics beat brandname drugs? 13 The dangers of painkillers America is in pain—and being killed by its painkillers 21 8 ways to save big on your medication Hundreds of common generics can be purchased for pennies per pill 25 The truth about sleeping pills What’s safe, what isn’t, and how to get a good night’s sleep 30 Spotlight: Treating high blood pressure 4 steps to keeping it low

41 Generics Medicine you need at a price you can afford 46 10 surprising new drugstore perks Services that save you time and money 54 Pill splitting Cut your prescription drugs (and costs) in half 60 Stay safe, be smart 12 Rx drug tips you must know 62 Starting a new drug? Questions to ask your doctor 64 About this guide

36 What over-the-counter drug labels really mean How to get the relief you need in spite of confusing claims

Find important info on these drugs—and more: Acetaminophen (Tylenol).................. 18

Glipizide (Glucotrol)............................ 6

Pioglitazone (Actos)............................ 6

Atorvastatin (Lipitor)............... 8, 56, 58

Guaifenesin (Mucinex)...................... 37

Ramelteon (Rozerem)....................... 26

Azelastine (Astepro)............................ 4

Hydrocodone ER (Zohydro)............... 18

Ranitidine (Zantac).............................. 7

Celecoxib (Celebrex)......................... 12

Rizatriptan (Maxalt).................... 10, 29

Citalopram (Celexa).................. 5,23,56

Hydrocodone + Acetaminophen (Vicodin)............................................ 14

Desloratadine (Clarinex)..................... 4

Ibuprofen (Advil, Motrin).............. 9, 12

Diphenhydramine (Benadryl, Sominex)................ 9, 26, 28

Loratadine (Alavert, Claritin)......... 4, 26

Duloxetine (Cymbalta)........................ 5

Naproxen (Aleve).............................. 12

Escitalopram (Lexapro)..................... 58

Omeprazole (Prilosec)......................... 7

Eszopiclone (Lunesta).................... 9,26

Oxycodone (Oxycontin)..................... 14

Famotidine (Pepcid)............................ 7

Oxycodone + Acetaminophen (Percocet).......................................... 15

Fluoxetine (Prozac)....................... 5, 23

Metformin (Glucophage)............... 6, 23

Rosuvastatin (Crestor)................... 8, 58 Simvastatin (Zocor)....................... 8, 56 Sumatriptan (Imitrex)........................ 10 Suvorexant (Belsomra)...................... 26 Tolterodine (Detrol)........................... 11 Trazodone......................................... 28 Valsartan (Diovan)............................ 58 Zolpidem (Ambien)....................... 9, 25

BEST BUYS

Get the best medication for what ails you Find Best Buys that are less expensive, as effective, and as safe as some pricey, brand-name drugs

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ou’ve probably seen them dozens of times: Ads for drugs that promise new solutions to your health-related problems. But are those drugs really the best choice for your condition? Pharmaceutical companies spend billions to convince us they do—$4 billion in 2014 alone to reach consumers—on top of an estimated $22 billion the same year to promote medications to doctors, according to figures from Cegidem Strategic Data, a global marketing research company. And the promotions work. Our research shows that nearly one of every five people who take a prescription medication said they’ve asked their doctors to prescribe a drug they’ve seen advertised. And two-thirds said their doctor complied with the request, according to a recent survey by Consumer Reports Best Buy Drugs. The problem is that it’s hard for consumers to know if an advertised drug works better than a less expensive generic. That’s where Consumer Reports Best Buy Drugs can help. Our “Best Buy” recommendations are drugs that are as safe and effective as other medications in their respective classes, and are typically less expensive. Conversely, if research shows that a brand-name drug is notably safer or works better than a lower-cost medicine, it is deemed a CR Best Buy, regardless of its price. We base our conclusions on systematic reviews from credible sources such as the Agency for Healthcare Research and Quality (AHRQ) Evidencebased Practice Centers and the Cochrane Library. Prices of drugs come from Symphony Health Solutions, which is not involved in our analyses or recommendations.

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BEST BUYS

Many newer drugs are often no safer or more effective than older medications that cost a fraction of the price.

Most of the CR Best Buy picks are generics. Surprised? If so, you’re not alone. Our own survey recently found that 43 percent of people said they had some type of concern about generic drugs—including that generics weren’t as safe or effective as brand-name medications, had different side effects, or were regulated differently by the U.S. Food and Drug Administration (FDA). But there’s no reason to be suspicious of generics. To get approval from the FDA, a generic-drug maker must prove that its product contains the identical active ingredient as its brand-name counterpart and that the drug is “bioequivalent,” meaning that levels of the active ingredient in the bloodstream are the same as its brand-name counterpart. Generics that meet those criteria are expected to have the same therapeutic effect as brand-name drugs. Also, the FDA regulates generics just as it does brand-name drugs and monitors them once they’re on the market. (See page 41 for more details on what to know about generic drugs.) Smart money-saving swaps

Here are a few examples that show how choosing a generic can meet your health needs while reducing your cost. >> 2015–2016 Consumer Reports Best Buy Drugs 3

BEST BUYS

ALLERGIES Newer antihistamines are less likely to cause drowsiness, and inexpensive generics are the best option. Brand-name or top-selling drug Clarinex One 5-mg pill per day $235/month

CR Best Buy Recommendation

vs.

Loratadine (generic) One 10-mg pill per day $4/month $

If you suffer from hay fever or other allergy symptoms, such as congestion, sneezing, and watery eyes, you’ve got a variety of choices for relief. Pharmacy shelves are packed with older antihistamines, such as Benadryl, and newer formulations, such as Claritin. But which ones are best? Newer antihistamines aren’t any more effective at relieving allergy symptoms than older ones, but they are less likely to cause drowsiness. They also offer the convenience of one pill daily. But those advantages come with a higher price. Newer medicines, which include loratadine (Claritin and generic) and cetirizine (Zyrtec and generic), run from about $4 to more than $200 per month for prescription strength. Although drowsiness is less of a problem if you opt for one of the newer antihistamines, you’ll still have to watch out for it and other side effects, particularly with high doses. And don’t ignore a rapid heartbeat or heart palpitations. These are rare side effects, but if they occur, see your doctor. If you take allergy medications regularly, talk with your doctor to make sure your problems stem from allergies. Up to one-third of people with allergy symptoms don’t actually have allergies; other conditions, such as a cold or even reactions to certain drugs, can cause the sneezing, congestion, or runny nose typical of allergies.

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Estimated monthly savings

$231

CR Best Buy • Generic loratadine This inexpensive medication is available without a prescription.

Less impressive • Azelastine (Astelin, Astepro, and generic) • Olopatadine (Patanase) These nasal sprays are linked to smell and taste problems, and the possibility of birth defects. Women who are pregnant or breast-feeding should avoid them. Note: The $ icon indicates that a CR Best Buy in the dosage above is likely available for a low monthly cost through discount generic drug programs offered by most chain stores.

BEST BUYS

DEPRESSION Antidepressants can help some people with severe depression. If you need one, the five generics we recommend are good first options to try. Brand-name or top-selling drug Cymbalta One 60-mg pill per day $271/month*

CR Best Buy Recommendation

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Estimated monthly savings

Fluoxetine (generic) One 20-mg pill per day $4/month $

$267

*it’s now available as a generic but still expensive at $173 per month.

Each year, nearly 7 percent of U.S. adults—some 14.8 million people— suffer from a depressive illness that warrants treatment, according to the National Institute of Mental Health. Contrary to ads from pharmaceutical companies that suggest medication is the only answer, the first step is to see your doctor and then possibly a therapist. Talk therapy might be all you need to feel better. It worked for our readers: According to our 2009 Annual Questionnaire, those who had at least seven counseling sessions reported just as much relief as those who only took medication. Those who did both fared even better.

And even then, up to 45 percent of people who try antidepressants still have feelings of depression. If you already take an antidepressant that is working well for you, we do not recommend switching to another one.

If your doctor recommends an antidepressant, our Best Buy Drugs analysis finds that all are equally effective at relieving depression, so your choice might come down to safety, cost, and whether you have other medical conditions. People respond differently to antidepressants, so you might have to try several before you find one that works.

These medicines are less expensive than brand-name antidepressants and are equally effective. They are good options to try if cost is an issue.

Our five CR Best Buy picks are inexpensive generic drugs with well-established safety profiles that will save you money over brand-name drugs. Some are more likely to cause certain side effects than others, so make sure your doctor is aware of any you especially want to avoid. For example, paroxetine is associated with a higher risk of sexual problems, and sertraline is associated with a higher rate of diarrhea.

CR Best Buys • Generic bupropion • Generic citalopram • Generic fluoxetine • Generic sertraline • Generic escitalopram

Less impressive • Desvenlafaxine (Pristiq). Available only since 2008, it does not have the long track record of other antidepressants, some of which have been around for more than two decades. • Duloxetine (Cymbalta) These are expensive, brand-name drugs that are no more effective than the generic Best Buys. >> Note: The $ icon indicates that a CR Best Buy in the dosage above is likely available for a low monthly cost through discount generic drug programs offered by most chain stores.

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BEST BUYS

DIABETES Older drugs work just as well as newer drugs and may be safer in some cases. They could also save you a lot of money. Brand-name or top-selling drug Generic Actos One 30-mg pill per day $242/month

vs.

CR Best Buy Recommendation

Estimated monthly savings

Metformin (generic) One 500-mg pill three times per day $4/month $

$238

If you’re one of the nearly 26 million people in the U.S. with type 2 diabetes, exercise, a healthful diet, and weight loss if needed, are essential to help keep your blood-sugar levels in check. For some people, these might alleviate the need for medication all together. If you need medication, three older, inexpensive drugs are your best first options. They’re just as effective as newer medications, and, in some cases, are better and safer.

CR Best Buys • Metformin and Metformin Sustained-Release • Glimepiride • Glipizide and Glipizide Sustained-Release All available as low-cost generics.

Less impressive

The best first option for many people is generic metformin. If that doesn’t drop your blood-sugar levels enough, you might need to add one or both of these medications: glimepiride or glipizide.

• Pioglitazone (Actos and generic). Linked to higher risk of heart failure, and also a small but increased risk of bladder cancer for those who take it for a year or longer. Only consider as a last resort, and if other treatments have not worked.

If you also have heart failure or kidney disease, your doctor might start with one of those drugs instead.

• Sitagliptin (Januvia). Expensive brandname drug that’s no more effective than metformin. Note: The $ icon indicates that a CR Best Buy in the dosage above is likely available for a low monthly cost through discount generic drug programs offered by most chain stores.

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BEST BUYS

HEARTBURN Make sure you really need a prescription. If you do, consider the least expensive option because no one drug is clearly better than another. Brand-name or top-selling drug Dexilant One 30-mg pill per day $250/month

CR Best Buy Recommendation

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Estimated monthly savings

Omeprazole (generic) One 20-mg pill per day $17/month

When heartburn flares up, many people turn too quickly to powerful drugs called proton pump inhibitors (PPIs). Instead, try lifestyle changes or antacids to get relief. Studies show that up to 69 percent of people who are prescribed a PPI don’t actually need it. Not only can that be a waste of money, but it can also expose you to potentially serious side effects, including an increased risk of pneumonia and fractures of the hip and other bones. For relief of mild or infrequent heartburn, cut back on alcohol and caffeine, quit smoking, eat smaller meals, don’t lie down for two hours after eating, and lose weight if needed. If those changes don’t bring relief, try an inexpensive over-the-counter antacid, such as Maalox, Mylanta, Rolaids, Tums, or their generic equivalents, or other drugs called H2 blockers, such as Pepcid AC, Zantac 150, or their generic equivalents.

$233

CR Best Buys • Generic omeprazole • Generic lansoprazole Those are available over-the-counter and cost an average $17 or less for a month’s supply and work as well as the more expensive prescription medications.

Less impressive • Dexilant (dexlansoprazole), AcipHex (rabeprazole). These branded prescription medications are much more expensive and not much more effective than generics in this class. Dexilant is not available as a generic. >>

If heartburn strikes twice a week or more for several weeks, see a physician. You might have a more serious condition called GERD (gastroesophageal reflux disease), and you might need a PPI.

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BEST BUYS

HIGH CHOLESTEROL You might be able to lower your cholesterol enough with diet and exercise. If not, an inexpensive generic is your best bet. Brand-name or top-selling drug Crestor One 10-mg pill per day $228/month

CR Best Buy Recommendation

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Estimated monthly savings

Atorvastatin (generic) One 40-mg pill per day $100/month

$128

*For people who need to reduce LDL by more than 30 percent.

If you have high cholesterol, a healthful diet and exercise can help lower it. Doing so could mean you no longer need medication. But if lifestyle changes don't lower it enough, you may need a medication called a statin. All these drugs can lower cholesterol, and some reduce it more than others. If you haven’t had a heart attack, the first thing to do is determine with your doctor your overall risk of heart attack or stroke in the next 10 years. If your 10-year risk is more than 10 percent, and you need to lower your cholesterol to help reduce that risk, determine whether you need a "high" or "moderate" intensity statin. Consider a moderate-intensity statin if you need to reduce your LDL cholesterol by 50 percent or less. Or if you are: • Older than 75 with a history of heart disease or heart problems. • You have an increased risk of side effects from a high-intensity statin—this includes those older than 75, those with multiple and/or serious medical conditions, such as impaired kidney or liver function, those with a history of stroke or muscle disorders, those who currently use medications that could interact with statins, and those of Asian heritage. Consider a high-intentsity statin if you need to reduce your cholesterol by 50 percent or more. Or if you:

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• Have a very high LDL cholesterol level—190 mg/dL or greater. • Are between the age of 40 and 75, you have diabetes, and your risk of heart attack and stroke is greater than 7.5 percent over the next 10 years. • Are under the age of 75 with a history of heart disease or heart problems. If you are between 40 and 75 years old and your risk of heart attack or stroke over the next 10 years is between 7.5 and 10 percent, our medical advisers say diet and lifestyle changes could be the first step instead of a drug. Those changes could lower your risk enough that you no longer need a statin.

CR Best Buys For people who need a moderateintensity statin: • Generic atorvastatin 10 mg or 20 mg • Generic lovastatin 40 mg • Generic pravastatin 40 mg • Generic simvastatin 20 mg or 40 mg For people who need a high-intensity statin: • Generic atorvastatin 40 mg or 80 mg

Less impressive • Rosuvastatin (Crestor). It’s available only as an expensive brand-name drug and does not offer advantages over the Best Buys.

BEST BUYS

INSOMNIA For chronic insomnia, working with a sleep therapist, instead of using sleeping pills, is a safer bet. Brand-name or top-selling drug Lunesta 1 mg per day $106/7-day supply

CR Best Buy Recommendation

vs.

Try lifestyle changes and sleep therapy first.

If you can’t sleep once in a while, we suggest trying an over-the-counter drug that contains diphenhydramine, like Benadryl or Unisom. But use those drugs carefully because they can cause nextday drowsiness. If the problem continues over several months, consider with your doctor getting cognitive behavioral therapy, a form of talk therapy. It helps 70 to 80 percent of people with chronic insomnia. And it appears to be at least as effective as sleeping pills.

Estimated 7-day savings

$106

CR Best Buy • Generic zolpidem Seven pills costs $16.

Less impressive • Lunesta. Along with a cost of more than $100 for seven 1-mg pills, evidence has shown that Lunesta has a higher rate of next-day drowsiness than nearly all of the other drugs. >>

Research has found that people with mild insomnia sometimes unnecessarily take insomnia medications like zolpidem (Ambien and generic) or eszopiclone (Lunesta) when they might be able to resolve their sleep issues another way, like cutting back on caffeine and alcohol before bedtime. All insomnia medicines can cause side effects and dependency, and even worsen your sleeping problems when abused, misused, or taken too often. Possible side effects include daytime sleepiness, dizziness, unsteadiness, and rebound insomnia. Sleep-walking, sleep-driving, sleep-eating, memory lapses, and hallucinations have also been reported. If your doctor is ready to prescribe a sedative, we suggest asking for the generic version of Ambien, called zolpidem. Our analysis finds that by some measures, it’s more effective than the others.

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BEST BUYS

MIGRAINES For mild migraines, an over-the-counter pain reliever may be a good first choice. Brand-name or top-selling drug Maxalt 5-mg tablet per headache $38/headache

CR Best Buy Recommendation

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Sumatriptan (generic) 50-mg tablet per headache $2/headache

Almost everybody suffers from a headache once in a while, but if the pain is excruciating, you could have a migraine. Over-the-counter pain relievers like ibuprofen (Advil and generic) or combination products that contain acetaminophen, aspirin, and caffeine (Excedrin and generics) are a good first option for treating mild and occasional migraines. But if those don’t work, it may be time to reach for a stronger type of medicine called triptans. Triptans are effective medicines. They can reduce migraine pain within two hours for most people. Complete relief is less common—however, if you take a triptan early during a migraine attack you may have a better outcome. We recommend generic sumatriptan as our Best Buy. Our analysis shows that sumatriptan (Imitrex and generic) works as well as, or even better than, the other drugs in its class. All of these medications can cause side effects. The most common include dizziness, numbness, tingling, flushing, sleepiness, and fatigue. If you experience more serious effects like chest pain or tightness, contact your doctor immediately.

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Estimated monthly savings

$36

CR Best Buys • Generic sumatriptan tablets, nasal spray, and injectable forms Sumatriptan is available as a less expensive generic, and studies have found that it is as effective as or better than most of the other triptans when it comes to pain relief.

Less impressive • Relpax. It’s no more effective than other triptans, and it’s only available as an expensive, brand name drug.

BEST BUYS

OVERACTIVE BLADDER Before taking a drug to relieve your symptoms, first try certain exercises to strengthen your bladder and cut back on caffeine. Brand-name or top-selling drug Toviaz 4-mg once daily $284/month

CR Best Buy Recommendation

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Try lifestyle changes first

If you’re going to the bathroom frequently, it doesn’t necessarily mean you need a medication. Lifestyle changes, such as cutting back on caffeinated beverages and bladder training exercises can often provide relief without the need for a drug, so you should try those first. Also, ask your doctor to show you how to strengthen your pelvic muscles by doing Kegel exercises. Doing so could relieve symptoms enough so that a drug isn’t necessary. Other medications you take, such as those used to treat high blood pressure, could also cause you to urinate frequently. They could even trigger incontinence or an urgent sense of needing to go to the bathroom. So can having diabetes, heart disease, urinary-tract infections, kidney stones, and strokes. See your doctor to rule out any of these causes before you turn to medication. However, if you and your doctor decide you need a drug because symptoms are severe enough, we recommend tolterodine, the generic version of Detrol. It works as well as others in its class and has fewer side effects. Common ones include dry mouth, constipation, blurred vision, and dizziness. Many people stop taking these drugs within six months, often because they find that fewer trips to the bathroom aren’t worth experiencing the side effects.

Estimated monthly savings

$284

CR Best Buy • Generic tolterodine This costs more than another generic medication, oxybutynin, but we chose it as a Best Buy because it offers the advantages of fewer side effects and a lower rate of people who stop using it due to adverse events.

Less impressive • All overactive bladder drugs. There are six different medications that have been turned into at least a dozen separate products—darifenacin (Enablex), fesoterodine (Toviaz), oxybutynin (generic, Ditropan, Ditropan XL, a skin patch called Oxytrol, and a topical gel called Gelnique), solifenacin (Vesicare), tolterodine (Detrol, Detrol LA), and trospium (Sanctura, Sanctura XR). They are only moderately effective and can cause serious side effects, including blurred vision, confusion, constipation, dizziness, and dry mouth. In addition to the side effects, these drugs are expensive, with some costing nearly $300 per month. Oxytrol is available without a prescription, but see a doctor to make sure you have overactive bladder before you take it. Many conditions cause similar symptoms. If those other medications don’t help, Botox injections might work, but our medical advisors note they have a high risk of urinary tract infections and are expensive. >>

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BEST BUYS

PAIN For moderate joint pain, generic drugs such as ibuprofen and naproxen are a good bet. They could save you a bundle over brand-name prescription options. Brand-name or top-selling drug Celebrex One 200-mg pill per day $272/month

vs.

CR Best Buy Recommendation

Estimated monthly savings

Ibuprofen (generic) Two 200-mg pills four times per day $19/month

$253

*It’s now available as a generic for $176 per month.

When muscle aches, headaches, or joint pain strikes, the best remedy might already be in your medicine cabinet. Common over-the-counter painkillers, such as ibuprofen (Advil, Motrin IB, and generic) and naproxen (Aleve and generic), are just as effective as prescription drugs in this class but cost much less. But those medications—known as nonsteroidal anti-inflammatory drugs (NSAIDs)—can carry serious risks and aren’t for everyone. Prolonged use, especially at high doses, can lead to a heart attack or stroke. NSAIDs can also be tough on your gut—they can cause stomach ulcers and gastrointestinal bleeding. If you have had an ulcer or intestinal bleeding, acetaminophen (Tylenol and generic) is a good first choice for pain relief. Acetaminophen is not an NSAID. It is less likely to cause bleeding, but be careful: High doses can damage the liver and lead to liver failure. Even taking just a little more than the recommended daily dosage can be toxic. Acetaminophen or aspirin are also good options to consider for those who have had a heart attack or stroke, or who suffer from heart disease or uncontrolled high blood pressure. For chronic pain sufferers whose only relief is routine use of an over-thecounter NSAID, it’s time to see your

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doctor. They can suggest other strategies to help manage your pain. In some cases, such as for people with osteoarthritis, a prescription-strength NSAID might be necessary. Finally, you might consider nondrug alternatives such as heat and ice, acupuncture, massage, or dietary changes.

CR Best Buys For joint pain (osteoarthritis): • Ibuprofen • Naproxen These inexpensive generics are available over-the-counter or by prescription.

Less impressive • Celebrex (celecoxib) Evidence indicates that Celebrex poses a lower bleeding risk than other NSAIDs. However, it is no more effective. And it is much more expensive, so unless you are at higher risk for bleeding, the extra cost is unnecessary for most people.

i

To learn more, log on to CRBestBuyDrugs.org.

PAINKILLERS

The Dangers of Painkillers

America is in pain—and being killed by its painkillers.

>>

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PAINKILLERS

I

t starts with drugs such as OxyContin, Percocet, and Vicodin—prescription narcotics that can make days bearable if you are recovering from surgery or suffering from cancer. But they can be as addictive as heroin and are rife with deadly side effects. Use of those and other opioids has skyrocketed in recent years. Prescriptions have climbed 300 percent in the past decade, and Vicodin and other drugs containing the narcotic hydrocodone are now the most commonly prescribed medications in the U.S. With that increased use have come increased deaths: 46 people per day, or almost 17,000 people per year, die from overdoses of the drugs. That’s up more than 400 percent from 1999. And, more than 500,000 people are admitted to the emergency room each year because of opioid complications. “All of this doesn’t mean that everyone should avoid opioids and acetaminophen altogether,” says Marvin M. Lipman, M.D., chief medical adviser for Consumer Reports. “But people do need to be aware of the risks.”

Opioids: Deadly misconceptions One of the biggest misconceptions people have about opioids is that

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the risks apply to other people, not themselves. But the “typical” victim of overdose might not be who you think. About 60 percent of overdoses occur in people prescribed the drugs by a single physician, not in those who “doctor shopped” or got them on the black market. And a third of those were taking a low dose. Used properly, opioids can ease short-term pain from, say, surgery or a broken bone, and manage chronic pain from an illness such as cancer. But people run into trouble when they inadvertently misuse the drugs— combining them with alcohol or other drugs (such as sleeping pills), taking them in doses that are too high, taking them for too long, or using them while driving, or in other situations when they need to be alert. Ideally, health care professionals should act as gatekeepers, prescribing painkillers only when they’re appropriate and monitoring patients for side effects. But that’s not always done, says Richard Blondell, M.D., director of the National Center for Addiction Training at the State University of New York in Buffalo, N.Y. “No doubt, the public needs to be better educated about the risks,” Blondell says. “But ultimately this epidemic starts with the doctor’s prescription pad.” The general public and health care providers harbor outdated and >>

PAINKILLERS

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PAINKILLERS

dangerous notions about opioids. Below are three of the biggest misconceptions and the facts you need to know to stay safe: Misconception #1: Opioids work well for chronic pain. An estimated 90 percent of

people suffering long-term pain wind up being prescribed an opioid despite little evidence that the drugs help much or are safe when used long term. “But we do know that the higher the dose and the longer you take it, the greater your risk,” says Gary Franklin, M.D., Research Professor of Environmental and Occupational Health Sciences at the University of Washington in Seattle. People who take opioids for more than a few weeks often develop tolerance, so they require higher doses, which in turn breeds dependence. And although higher doses can ease pain, they commonly cause nausea and constipation, disrupt your immune system and sex life, and leave you feeling too fuzzy-headed to participate in things such as physical activity that can speed your recovery. And in a cruel twist, the drugs can make some people more sensitive to pain. The safer approach: For certain types of pain—including nerve pain, migraines, and fibromyalgia—other prescription medications usually

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work better than opioids. For other types of chronic pain, ask your doctor about trying OTC drugs such as acetaminophen, ibuprofen, and naproxen before prescription drugs. Nondrug measures such as exercise, massage, behavioral therapy, spinal manipulation, and acupuncture might also help. If you have chronic pain that hasn’t responded to other treatment, opioids may be an option. But your doctor should prescribe the lowest effective dose for the shortest possible time and monitor you for side effects. Misconception #2: Opioids are not addictive when used to treat pain. “That’s what

I and a lot of other doctors learned in medical school,” Blondell says. “But we now know that’s just not true.” Somewhere between 5 and 25 percent of people who use prescription pain pills long term get addicted. Fewer women are dependent on prescription painkillers than men, but they may become dependent more quickly and are more likely to doctor shop. The safer approach: Chronic pain often waxes and wanes. If you and your doctor feel you need an opioid, reserve it for flare-ups. If you take it for more than a few weeks, your doctor should advise you about early signs of addiction, including unusual >>

PAINKILLERS

Guide to safe opioid use WHAT ARE OPIOIDS? They’re the strongest pain medications, available only with a prescription. Common brand names include OxyContin, Percocet, and Vicodin. Generics include fentanyl, hydrocodone, morphine, and oxycodone. READ THE LABEL

DON’T DRIVE

Never take more than advised, don’t take with alcohol, and don’t combine with any other drug without your doctor’s OK. Most opioid deaths involve alcohol or sleeping pills.

or do anything that requires you to be fully alert, especially when you start taking an opioid or whenever you change the type or dosage.

GET TESTED

“Keeping opioids around is like keeping a loaded gun in your medicine cabinet,” says Richard Blondell, M.D., whose research shows that most teens hooked on prescription painkillers started with medication they got from their own house or from a friend.

for sleep apnea. If you snore loudly, get checked for the condition, because opioids can make it worse or even fatal. TELL YOUR DOCTOR

if you have a cold, an asthma flare-up, or bronchitis because opioids can interfere with breathing. You may need a lower dose until you recover.

LOCK UP OPIOIDS

EXPECT REGULAR MONITORING

If pain and function do not improve at least 30 percent after starting the drugs, then they probably are not working well enough to justify the risks,” says Gary Franklin, M.D. Your doctor should also make sure that you take the drugs as prescribed by, for example, counting your pills. DISCARD UNUSED PILLS

You may be able to give them back to your pharmacy. If you can’t, the FDA says, unlike other drugs, opioids are so risky that excess pills should be flushed down the toilet.

If you are taking the drugs for chronic pain, “your doctor should assess you at regular visits.

2015–2016 Consumer Reports Best Buy Drugs 17

PAINKILLERS

moodiness, cravings, temper flareups, and taking unnecessary risks.

Acetaminophen: Dangerous doses

Misconception #3: Extended-release versions are safer. Extended-release, or long-

Opioids aren’t the only painkillers that pose serious risks. Almost as dangerous is a medication renowned for its safety: acetaminophen (Tylenol and generic). Almost 80,000 people yearly are treated in emergency rooms because they have taken too much of it, and the drug is now the most common cause of liver failure in this country. Though some of those tragedies stem from abuse, many are accidental. It’s not just that people are careless. For example, we found that drug labels on over-the-counter products provide confusing and conflicting advice on how much acetaminophen people can take: Some labels advise taking no more than 1,000 milligrams daily; others set the limit almost four times as high. And with acetaminophen, taking too much is all too easy. That’s because it’s the most common drug in the U.S., found as an ingredient in more than 600 OTC and prescription medications, including allergy aids, cough and cold remedies, fever reducers, pain relievers, and sleep aids. When taken at recommended doses, acetaminophen is safe for most people, even when used long term. But there’s little margin for error. Exceeding the maximum recommended dose—by even a little

acting, versions of opioids such as hydrocodone (Zohydro ER), hydromorphone (Exalgo), oxycodone (OxyContin and generic), and morphine (Avinza, MS Contin, and generic) stay in the body longer and are usually stronger than shortacting forms. They should be reserved for patients who need round-theclock relief. But doctors sometimes prescribe them for convenience— patients need to take fewer pills—and because they believe that long-acting drugs are less likely to cause a drug “high” and lead to addiction. But there’s no evidence those drugs work better than short-acting ones and they may be riskier. People who took extended-release opioids were much more likely to accidently overdose than those taking short-acting versions according to a recent study of patients treated in the Veterans Administration Healthcare System. The safer approach: It’s usually best to start with a short-acting opioid. Because long-acting drugs are more likely to be stolen, misused, and abused, if your doctor prescribes one, expect careful monitoring.

18 2015–2016 Consumer Reports Best Buy Drugs

PAINKILLERS

IT’S EASY TO OVERDOSE ON ACETAMINOPHEN Acetaminophen is in many products, making it easy to get more than the 4,000 milligrams per day linked to liver damage and the 3,250 milligram daily maximum we recommend.

TOTAL

Tylenol Extra Strength

NyQuil Cold & Flu

Walgreens Pain Reliever PM

CONTAINS

CONTAINS

CONTAINS

500 milligrams of acetaminophen per pill.

325 milligrams of acetaminophen per pill (plus dextromethorphan and doxylamine for cold and flu symptoms­).

500 milligrams of acetaminophen per pill (plus diphenhydramine as a sleep aid).

DIRECTIONS

Take no more than six pills in 24 hours. MAXIMUM DAILY DOSE

3,000 milligrams

DIRECTIONS

Take no more than eight pills in 24 hours. MAXIMUM DAILY DOSE

acetaminophen within a 24-hour period:

6,600 mg

DIRECTIONS

Take two pills at bedtime. MAXIMUM DAILY DOSE

1,000 milligrams

2,600 milligrams

bit—can prove toxic, especially to the liver. And that’s relatively easy to do. For example, take the maximum recommended doses for Tylenol Extra Strength for your joint pain, Nyquil Cold & Flu, and a nighttime sleep aid like Walgreens PM, and you will

get 6,600 milligrams—well above the 4,000 milligrams a day that’s linked to liver damage (see chart, above). It has long been known that large doses of acetaminophen taken at once can be fatal. But cumulative smaller doses totaling more than 4,000 >>

2015–2016 Consumer Reports Best Buy Drugs 19

PAINKILLERS

milligrams (eight 500-milligram, or “extra strength,” pills) can be just as dangerous, if not more so. People who took repeat doses of the medication—for complaints such as headaches, muscle pain, and toothaches—that put them over the maximum daily amount were more likely to have brain, kidney, and liver problems, and faced a greater risk of dying or needing a liver transplant than people who had taken a single, large overdose. That’s according to a 16-year Scottish study of people treated in the emergency room published in 2011. Because acetaminophen shows up in so many products, you need 20 2015–2016 Consumer Reports Best Buy Drugs

to check all drug labels for the painkiller. Then make sure you stay below the safe upper limit (we recommend no more than 3,250 milligrams within a 24-hour period) when you combine the pills. And you should avoid acetaminophen altogether if you are at risk for liver disease or drink alcohol heavily, because that multiplies the dangers. If you regularly take the drug, watch for signs of liver damage, including dark urine, pale stools, upper-right abdominal pain, and a yellowish tinge to the whites of the eyes.

8 WAYS TO SAVE

ways to save big on your medication Costco, Target, and Walmart offer discount drug programs that can be cheaper than using your insurance

C

hances are you’re paying more than you need to for prescription drugs. But thanks to discounts offered at Costco, CVS, Target, Walgreens, Walmart, and others, hundreds of common generic drugs can be purchased for pennies per pill. Retailers offer the discounts to draw in customers. The lower-priced pills aren’t part of any health insurance, and using them usually won’t count toward your deductible. But they can be a big help in terms of savings, especially if you don’t have insurance or good drug coverage. And sometimes prices can be even cheaper than what you might pay with your health insurance. Program details vary, so you may need to shop around and call different pharmacies to get the best savings. When checking them out, ask the pharmacist on duty if medications you take are included, and if you qualify for additional discounts. Here are eight more ways to save on these programs. >> 2015–2016 Consumer Reports Best Buy Drugs 21

8 WAYS TO SAVE

1

Ask for a 90-day Rx To offer such low prices, retailers often buy the medications in bulk. You should, too. A threemonth supply could cost just $10, compared with $4 for a one-month supply.

2

Factor in membership fees Though Costco, Target, and Walmart offer savings without enrollment or fees, (yes, you can use the pharmacy at any Costco without being a member), others don’t: CVS charges $15 per person; Kmart, $10 per household; and Walgreens, $20 for individuals or $35 for a family.

3

Consider your privacy To take advantage of savings, you may be required to sign a form or check a box giving the pharmacy or third parties such as drug manufacturers or insurance companies permission to contact you with other offers and promotions. Ask whether you can get the discounted price if you don’t 22 2015–2016 Consumer Reports Best Buy Drugs

check that box, says Stephen W. Schondelmeyer, Ph.D., a pharmaceutical economics professor at the University of Minnesota.

4

Ask for the lowest price That’s what helped our secret shoppers get the best deals when they called more than 200 pharmacies across the U.S. “Also, ask your pharmacist, ‘What would this cost if I didn’t use my insurance?’” Schondelmeyer says. For an independent pharmacy, see whether it will match or beat competitor prices.You might be surprised. Independents might be more willing to negotiate prices because they have more discretion over costs than do larger chains. Earlier studies by Consumer Reports suggest that prices at independent pharmacies may be much higher or much lower than those at chains or big-box stores. To find out, make a few phone calls. In many cases the independents will try, and they may even offer a discount generic drug program of their own. >>

8 WAYS TO SAVE

Save big on common generic drugs It pays to shop around—you could save hundreds of dollars a year.

Average retail price

30 daysupply CVS

90 days

Kmart

30/90 days

Rite Aid

30/90 days

Target

30/90 days

Walgreens

30/90 days

Walmart

30/90 days

Citalopram (Celexa)

Fluoxetine (Prozac)

Lovastatin (Mevacor)

Metformin (Glucophage)

20 mg, 1 pill daily, treats depression

20 mg, 1 pill daily, treats depression

20 mg, 1 pill daily, treats high cholesterol

500 mg, 1 pill twice daily, treats type 2 diabetes

$29

$32

$19

$17

$11.99

$11.99

$11.99

$11.99

$5/$10

$5/$10

$5/$10

$5/$10

$9.99/ $15.99

$9.99/ $15.99

$9.99/ $15.99

$9.99/ $15.99

$4/$10

$4/$10

$4/$10

$4/$10

$10/$20

$5/$10

$5/$10

$5/$10

$4/$10

$4/$10

$4/$10

$4/$10

2015–2016 Consumer Reports Best Buy Drugs 23

8 WAYS TO SAVE

5

Check back often Which drugs are discounted, as well as the doses and prices, are subject to change. So be sure to check in periodically to make sure your medications are still offered at a discounted price. If your drug falls off the list, discuss savings options with your doctor or pharmacist, including possibly switching to a lower-priced alternative drug.

6

Look for other extras CVS, Kmart, and Walgreens offer discounts of between 5 and 20 percent on flu shots and other immunizations, health screenings, and similar services. At Target, membership in the Pharmacy Rewards program gets you a 5 percent discount on a day of shopping after the first prescription fill. Every five fills after that earns you an additional 5 percent discount on store purchases. Walmart offers free shipping on many $10, 90-day prescriptions.

24 2015–2016 Consumer Reports Best Buy Drugs

7

Know the restrictions Program discounts usually cannot be combined with other promotions or even insurance. For example, people who use Medicaid and Medicare aren’t eligible for discounts at Costco. Certain discounts are offered only to those who don’t have drug insurance or are for drugs not covered by insurance. And some drugs may be priced higher in certain states.

8

Practice Rx safety Getting a good deal is important, but be sure to have all of your prescriptions filled at a single pharmacy. That keeps all of the drugs you take in one system so your pharmacist can flag any potentially dangerous drug interactions or allergies.

i

To learn more, log on to CRBestBuyDrugs.org.

INSOMNIA

The truth about sleeping pills What’s safe, what isn’t, and how to get a good night’s sleep

H

eavily advertised prescription sleep drugs such as Ambien and Lunesta are sold with the promise of a good night’s rest. For the estimated 25 percent of Americans who occasionally struggle with sleep or the 10 percent with chronic insomnia (trouble falling or staying asleep at least three nights per week for a month or more), the drugs may seem like a quick route to relief. >>

2015–2016 Consumer Reports Best Buy Drugs 25

INSOMNIA

But new evidence suggests that they aren’t as useful as once thought. They can pose significant risks, especially for older adults. And new drugs keep coming; the latest is suvorexant (Belsomra). Here’s what you need to know about sleep drugs: Newer sleep drugs aren’t very effective

Recent analysis by Consumer Reports Best Buy Drugs found that people who take newer prescription sleeping pills fall asleep only 8 to 20 minutes faster than with a placebo. That category of sedatives includes eszopiclone (Lunesta and generic); ramelteon (Rozerem and generic); zaleplon (Sonata and generic); and zolpidem (Ambien, Ambien CR, Edluar, Zolpimist, and generic). Ambien and Lunesta, for example, help people fall asleep only about 20 minutes and 19 minutes faster, respectively, than a placebo, on average. In addition, Best Buy Drugs found that the drugs add just 3 to 34 minutes to total sleep time. Their effectiveness is so limited that as of late

26 2015–2016 Consumer Reports Best Buy Drugs

2014 they were no longer considered a first-choice treatment for chronic insomnia by the American Academy of Sleep Medicine (AASM). SAFER STRATEGY: Try

sleep therapy (see below). Our analysis found that it might be as effective, if not more so, as drugs. They can have side effects, too

These sleep drugs can cause dependency, daytime drowsiness, and dizziness, and may worsen sleep problems if you stop taking them after regular use. And in rare cases, people have reported sleep driving, sleep eating, amnesia, and hallucinations. In addition, the older you are, the more intense the sleep-inducing effects and side effects may be. Taking any of those drugs (or a benzodiazepine, an older type of prescription sedative) can impair your driving ability and increase your risk of falls and hip fractures. And a 2013 government report noted a 220 percent jump in emergency room visits for adverse reactions

INSOMNIA

If you do take a sleeping pill, here's how to stay safe ✓ Take sleeping pills only if you have time for at least 7 to 8 hours of sleep, so the effect has time to wear off.

✓ Never mix a sleep drug with alcohol or sedatives.

✓ Don’t rely on them every night (or almost nightly) for months or more. That boosts the likelihood of adverse effects.

to zolpidem between 2005 and 2010. A study published in JAMA Psychiatry in 2014 found that about 21 percent of psychiatric drugrelated ER visits were by people 65 and older taking zolpidem. SAFER STRATEGY: It’s

best to take the lowest dose possible for no longer than a few days. Older drugs are risky

Older prescription sedatives called benzodiazepines are used primarily for anxiety. But several are FDAapproved for insomnia: estazolam (generic), flurazepam (Dalmane and generic), quazepam (Doral), and temazepam (Restoril and

✓ Take the lowest effective dose. ✓ If you’re offered a sleep drug in the hospital, think twice. A 2014 study found that 26 percent of subjects received sleep drugs while hospitalized. And 34 percent of those who hadn’t used a sleep aid before admission left with a prescription for one.

generic). Our analysis found them to be generally no more effective than the newer sleeping pills. Studies suggest that they have a higher risk of day-after sleepiness and grogginess, dependency, and rebound insomnia. Despite years of concern, those drugs are prescribed to older adults at a disproportionate rate. And a new study in JAMA Psychiatry found that older adults are more likely to take them for far longer than recommended. SAFER STRATEGY: Consider

a benzodiazepine only if you have a diagnosed anxiety disorder that disrupts sleep, and use it only intermittently. >>

2015–2016 Consumer Reports Best Buy Drugs 27

INSOMNIA

OTCs can pose problems

Trazodone: Not for sleep

Older over-the-counter antihistamines such as diphenhydramine (Benadryl Allergy, Nytol, Sominex, Tylenol PM, and generic versions), and doxylamine (Unisom and generic) may be useful for very short-term insomnia. But rebound insomnia is a concern, as is daytime drowsiness, confusion, constipation, dry mouth, and problems urinating. And a 2015 study published in JAMA Internal Medicine reported a higher risk of dementia in people who regularly used those type of drugs, which are known as anticholinergics.

Trazodone, an older antidepressant, is commonly prescribed off-label for insomnia. But in the one study that tested it against a placebo and Ambien, it was only slightly more effective than the placebo and less effective than Ambien. The drug can cause next-day drowsiness and very low blood pressure, which can lead to fainting.

OTCs for no more than one or two nights at a time. If your insomnia lasts longer than a few days, check in with your doctor.

SAFER STRATEGY: Unless

your doctor has diagnosed depression, or until other studies show it effective for use in those without depression, skip trazodone for sleeplessness.

SAFER STRATEGY: Use

28 2015–2016 Consumer Reports Best Buy Drugs

i

Want to read more details about drugs to treat insomnia? See our Best Buy Drugs report online at CRBestBuyDrugs.org.

INSOMNIA

Tips for better sleep Try one or more of the following approaches before you take a sleep aid. STAY ON SCHEDULE.

Go to bed and get up at the same time every day. Can’t sleep? Leave the bedroom and do something restful, such as reading, until you feel sleepy. If you nap, do so before 3 p.m. for no more than 30 minutes. MAKE CHANGES IN YOUR BEDROOM.

Block out noise and outside light. Make sure that your mattress and room temperature are comfortable. Remove the TV. EAT AND DRINK WISELY.

Avoid or minimize alcohol, caffeine, and nicotine; they can affect sleep. Don’t eat heavily within several hours of bedtime. EXERCISE REGULARLY.

It promotes healthy sleep (but not shortly before bedtime). GET NATURAL LIGHT.

TURN OFF E-READERS AND OTHER DEVICES 2 HOURS BEFORE BED.

They can emit blue light, which suppresses levels of melatonin, the hormone that regulates sleep. If you can’t unplug, dim the device and hold it at least 14 inches from your eyes. REDUCE STRESS.

Meditation, yoga, and tai chi can help. For example, a study published in the Journal of the American Geriatrics Society found that six months of tai chi three times per week helped older adults fall asleep faster and sleep longer.

TRY SLEEP THERAPY.

Research has found that cognitive behavioral therapy for insomnia (CBT-I) is quite effective at helping people with sleep problems fall asleep and stay asleep. “CBT-I rebuilds people’s confidence in their ability to sleep,” says Ryan G. Wetzler, Psy.D., Director of Behavioral Sleep Medicine at Sleep Medicine Specialists in Louisville, KY. CBT-I is often covered by insurance and doesn’t require a significant time commitment. Wetzler says that his patients usually see improvements after only six visits.

GET A CHECKUP.

Some medications and health problems can disrupt sleep, so see your doctor if lifestyle strategies haven’t helped after a month.

A study at the University of Illinois at UrbanaChampaign found that people exposed to natural light at work slept better and longer.

2015–2016 Consumer Reports Best Buy Drugs 29

HIGH BLOOD PRESSURE

Spotlight:

Treating high blood pressure 4 steps to keeping it low

H

igh blood pressure triggers more heart attacks and strokes in the U.S. than any other cause, killing more people worldwide than smoking, diabetes, or obesity. And yet, almost 20 million Americans with high blood pressure don’t know they have it. Here’s why: High blood pressure rarely causes obvious symptoms, and doctors don’t always test patients who might be at risk. So it’s important that you ask your health care provider to check your blood pressure at every appointment. If your doctor diagnoses you with high blood pressure (hypertension), learn how to get it under control. Simple lifestyle changes, such as a healthful diet and regular exercise, often help. If your blood pressure is still high, drugs can usually help. Ask your 30 2015–2016 Consumer Reports Best Buy Drugs

doctor about diuretics—a class of lowcost medication that is at least as safe and effective as newer, pricier drugs. Step 1: Get screened.

Over time, high blood pressure can damage blood vessels in the body, increasing the risk not only of heart attacks, but also strokes, kidney damage, vision loss, arterial blockages in the legs, and sexual impotency. Blood pressure increases for many reasons: advancing age, a genetic predisposition, certain medications, and risk factors such as inactivity, obesity, and smoking, for example. It’s important to detect high blood pressure early, before too much damage is done. Have your blood pressure checked at least once every two years, and more often if you’re 50 or older or have other risk factors. In fact, it’s

HIGH BLOOD PRESSURE

a good idea to have it done during every visit to a health care provider. If your initial reading is high, don’t panic. A number of factors, including pain and emotional stress, can temporarily boost blood pressure. To improve accuracy: • Don’t smoke, exercise, or consume anything caffeinated for at least half an hour before your appointment. • Go to the bathroom first, since a full bladder can affect the reading. • Sit with your feet flat on the floor for five minutes before the reading. Rest your arm on a table so it’s at heart level. Remain quiet during the test.

You’re not considered to have high blood pressure until your systolic pressure tops 140 mm Hg or your diastolic pressure exceeds 90 mm Hg. But even below those levels, the risk of a heart attack or stroke increases as pressure rises. If your systolic (upper) level is 140 millimeters of mercury (mm Hg) or higher, or your diastolic (lower level) is 90 mm Hg or higher, your doctor should retest at least twice over the next several weeks to confirm the results. >> 2015–2016 Consumer Reports Best Buy Drugs 31

HIGH BLOOD PRESSURE

Step 2: Know what your blood pressure numbers mean.

Blood pressure is measured as two numbers, one over the other—for example, 120 over 80 mm Hg (millimeters of mercury). The systolic, or upper, number reflects the pressure in the arteries when the heart contracts; the diastolic, or lower, number reflects the pressure between heartbeats, when the heart rests. An elevation in either or both of those numbers constitutes hypertension, as shown here. Systolic measure (mm Hg)

Normal

Below 120

Diastolic measure (mm Hg)

What to do

Below 80

Maintain a healthy lifestyle to avoid increases in levels, which are common as people age.

High-normal (prehypertension)

120 to 139

80 to 89

Make lifestyle changes: stop smoking, cut back on sodium, lose excess weight, exercise regularly, and drink moderately, if at all.

High for people under age 60 and people 60 or over with diabetes or kidney disease

140 or above

90 or above

Make lifestyle changes. If pressure is not lowered to normal within a few month, start medication treatment.

High for people aged 60 and older who don’t have diabetes or kidney disease

150 or above

90 or above

Make lifestyle changes. If pressure is not lowered to normal within a few months, start medication treatment.

Very elevated, all ages (sometimes referred to as stage 2 hypertension)

160 or above

100 or above

Your doctor will prescribe medication in addition to recommending lifestyle changes.

Source: Adapted from (1) “The 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults,” a report from the panel members appointed to the eighth Joint National Committee (JNC8); Journal of the American Medical Association; Feb. 5, 2014; Vol. 311: 507-520. (2) “Clinical Practice Guidelines for the Management of Hypertension in the Community, A Statement by the American Society of Hypertension and the International Society of Hypertension;” Journal of Clinical Hypertension; Dec. 17, 2013.

32 2015–2016 Consumer Reports Best Buy Drugs

HIGH BLOOD PRESSURE

Step 3: Change your lifestyle, lower your blood pressure.

The table below shows how much you can lower your systolic (upper) blood pressure level by making these recommended changes. People who make multiple changes and stick with them can expect even greater reductions. >>

Lifestyle change

Estimated reduction in systolic blood pressure

Adopt a healthy diet

Consume a diet rich in fruits, grains, vegetables, and low-fat dairy products and low in saturated and total fat.

8 to 14 mm Hg

Be active

Engage in regular aerobic physical activity, such as brisk walking (at least 30 minutes a day, most days of the week).

4 to 9 mm Hg

Cut back on salt

Reduce dietary sodium intake to no more than 2,400 milligrams a day, the amount in a teaspoon of salt.

2 to 8 mm Hg

Drink moderately, if at all

Limit consumption to no more than two drinks (e.g., 24 oz. of regular beer, 10 oz. wine, or 3 oz. of 80-proof whiskey) a day for most men, and no more than one drink a day for women and lighter-weight men. Lose excess weight

Aim for a body mass index under 25.

2 to 4 mm Hg

2.5 to 10 mm Hg for about every 11 pounds

2015–2016 Consumer Reports Best Buy Drugs 33

HIGH BLOOD PRESSURE

Which blood pressure drug is right for you? Drug Thiazide diuretics

Chlorthalidone, hydrochlorothiazide, and others

ACE inhibitors

Benazepril, (Lotensin and generic) enalapril (Vasotec and generic), lisinopril (Prinivil, Zestril, and generic), and others

Angiotensin II receptor blockers (ARBs)

Losartan (Cozaar and generic), candesartan (Atacand), and others Calcium-channel blockers

Amlodipine (Norvasc and generic), diltiazem (Cardizem and generic), and others

Good candidates

Common side effects

Often the first choice, alone or with other drugs, for most otherwise healthy people.

Frequent urination, low potassium levels, and erectile dysfunction.

Especially for people with diabetes, heart failure, kidney disease, or a history of heart attack or stroke.

Persistent dry cough, high potassium levels, reduced kidney function, and an uncommon but potentially fatal allergic reaction, angioedema, especially in African-Americans. Not to be taken together with an angiotensin receptor blocker (ARB).

People who would otherwise be candidates for ACE inhibitors but can’t take them because of excessive coughing.

Similar to ACE inhibitors but less likely to cause coughing. Not to be taken together with an ACE inhibitor.

African-Americans and people who also have angina (chest pain), certain heart-rhythm abnormalities, and possibly migraines.

Dizziness, fast or slow heartbeat, flushing, headaches, swollen gums, and, less often, breathing problems.

34 2015–2016 Consumer Reports Best Buy Drugs

HIGH BLOOD PRESSURE

Step 4: Get the right drugs.

If healthy lifestyle changes alone are not enough to lower your blood pressure, or if your levels are very high, consider medication. Until recently, guidelines recommended a “water pill,” or a thiazide diruetic, as the best first choice for most people. Those are still a good option, but several other classes of drugs work just as well. And, like diuretics, they are available as generics, costing less than a dollar a day. In some cases, those other drugs are actually better choices. Whether you take a diuretic or other drugs, use these tips to reduce the chance of side effects—and increase the likelihood that you’ll stick with the therapy:

• Get your blood levels of magnesium and potassium checked periodically, since diuretics can deplete those minerals. Call your doctor if you have cramps, begin vomiting, or your heart rate or pulse increases, which can indicate low potassium levels. • Watch for signs of gout—for example, an acutely inflamed big toe or knee. • If you also have diabetes, monitor your insulin level extra carefully because drugs for high blood pressure can cause it to fluctuate. • Follow dosing instructions carefully and read the product label for possible side effects.

2015–2016 Consumer Reports Best Buy Drugs 35

OVER-THE-COUNTER DRUG LABELS

What overthe-counter drug labels really mean Claims like ‘All Day,’ ‘Non-Drowsy,’ and ‘Maximum’ might not be what they seem

N

avigating the sea of labels on drugstore shelves can leave you feeling sick and confused. Words and phrases like “extra strength,” “PM,” or even “cold and flu” seem to spell relief, but what exactly they’re selling may be less clear. The confusion exists because there’s limited government regulation of over-the-counter drug-label terms; companies don’t have to stick to standard definitions. “The variation in the labeling terms is primarily due to marketing by OTC drugmakers and not the science behind how that drug works,” says Carmen Catizone, executive director of the National Association of Boards of Pharmacy, which works with state regulatory boards. Terms like “extra,” “maximum,” and “ultra strength,” for example, essentially mean the same thing: that the formula has more of its active ingredients than the regular version. It’s up to the consumer to figure out exactly how much more—and how much of the product to safely take. >> 36 2015–2016 Consumer Reports Best Buy Drugs

OVER-THE-COUNTER DRUG LABELS

1

4

2

3

5

1. Taken as directed, you’re near the daily limit for acetaminophen (4,000 milligrams). If you take other drugs with this ingredient, you risk overdose. 2. Decongestant, pain reliever, cough suppressant, expectorant, and antihistamine—a lot of medicine, all in one box. 3. Pills are different colors, but ‘day’ and ‘night’ tablets aren’t labeled. That could increase your risk of taking the wrong drug, potentially leading to problems such as driving while drowsy. 4. ‘Fast-Max’ could mean that the medicine will act more quickly than others, but it’s unclear. 5. Our medical advisers recommend using one drug at a time for each symptom so that you don’t accidentally take too much. 2015–2016 Consumer Reports Best Buy Drugs 37

OVER-THE-COUNTER DRUG LABELS

To get a sense of what consumers are seeing, we took a close look at the labels of the more than three-dozen products our secret shoppers bought. We didn’t just find inconsistencies: Some product claims were basically meaningless, and some products were simply spin-offs of the original versions. Below you’ll find the facts behind some common over-the-counter label claims, along with our advice on how to stay safe. Non-drowsy

Non-Drowsy Vicks QlearQuil Daytime Sinus & Congestion, Non-Drowsy Walgreens Wal-Fex 12 Hour Allergy EXAMPLES:

WHAT IT MEANS: “Non-drowsy”

usually indicates an absence of active ingredients that cause drowsiness, like diphenhydramine or dextromethorphan. Don’t assume that “non-drowsy” medicine will help you stay alert, even though some products contain ingredients that act as stimulants (such as the decongestant pseudoephedrine, found in Sudafed). Read the Drug Facts label on the medication so that you know what you’re getting. If it contains stimulants, avoid caffeine. Otherwise, you risk increased restlessness and difficulty falling asleep. OUR ADVICE:

38 2015–2016 Consumer Reports Best Buy Drugs

PM EXAMPLES: Aleve

PM, Motrin PM, Tylenol PM Drugs with “PM” in the name usually contain an old-school antihistamine such as diphenhydramine (found in Benadryl Allergy) or doxylamine, which can make you sleepy as a side effect. WHAT IT MEANS:

Don’t rely on a PM drug longer than a few days. If taken too often, they can worsen your sleeping problems. They can also cause daytime sleepiness, confusion, constipation, and dry mouth, especially for older people. Steer clear of PM drugs if you take blood pressure meds because in combination they may cause excessively low blood pressure. Also, don’t drink alcohol when taking PM formulas; the combo may increase the risk of side effects. And use caution if you drive the next day; you might still be drowsy. OUR ADVICE:

Daytime and nighttime EXAMPLES: Walgreens

Maximum Strength Daytime/Nighttime Mucus Relief Sinus Congestion, QlearQuil Daytime/Nighttime Sinus & Congestion Newer on the shelves are day-and-night combination cold-and-flu products packaged and sold in one box. “Daytime” may mean WHAT IT MEANS:

OVER-THE-COUNTER DRUG LABELS

ALL DAY

MAX

FLU

LD

CO

there are no ingredients that make you sleepy; “Nighttime” can mean the product has a drug that causes drowsiness, such as diphenhydramine. The products might also contain a laundry list of active ingredients, which can put you at a higher risk for accidentally doubling medications, especially if you take other drugs, such as acetaminophen (found in hundreds of over-the-counter products). Maximum Strength Mucinex Fast-Max Daytime Severe Cold/Nighttime Cold & Flu, for example, contains a decongestant (phenylephrine), a pain reliever/fever reducer (acetaminophen), a cough suppressant (dextromethorphan), an expectorant (guaifenesin), and an antihistamine (diphenhydramine) that can cause next-day drowsiness. Skip the multisymptom combo packs, especially if you take OUR ADVICE:

TR UL

A

ALL NIGHT

a.m.

p.m.

other over-the-counter drugs. Use single-ingredient drugs whenever you can. Treat a headache with acetaminophen, for example, rather than taking a pill for a headache plus congestion, fever, and other symptoms you don’t have. All day EXAMPLES: All

Day Strong Aleve Liquid Gels, Up & Up All-Day Allergy Relief WHAT IT MEANS: These

are extendedrelease versions of drugs that work over many hours. They may last 12 hours or 24 hours, so for some meds, one daily dose might be all you need; for others, it could be two doses. >> Read labels to determine how often to take the drug. For example, All Day Strong Aleve is taken every 8 to 12 hours for pain relief, and Up OUR ADVICE:

2015–2016 Consumer Reports Best Buy Drugs 39

OVER-THE-COUNTER DRUG LABELS

If you want the facts, flip over the package The Food and Drug Administration does review terms and packaging for newly approved OTC drugs, but it doesn’t check label claims like “Max” and “All Day” for drugs the agency already considers safe—such as acetaminophen. When we contacted the agency to ask whether the lack of standard definitions could be confusing or even dangerous for consumers, a spokesperson referred us to the Drug Facts label (usually on the back of a container) and said that safety concerns and other issues could be reported at fda.gov/safety/medwatch.

The surest way to know exactly what you’re getting is to “skip the hype or the promotional wording on the package,” says Marvin M. Lipman, M.D., Consumer Reports’ chief medical adviser. “Pay attention only to the list of active ingredients and the directions for use on the drug container itself.”

& Up is taken once every 24 hours for allergy symptoms. Migraine

Excedrin Migraine, Advil Migraine EXAMPLES:

WHAT IT MEANS: You

might think you’ll get a stronger medicine because migraines are often more severe headaches. But some products contain the same-strength active ingredients as the original versions with different dosage instructions. Studies suggest that OTC medicines can help some OUR ADVICE:

40 2015–2016 Consumer Reports Best Buy Drugs

migraine sufferers with mild or infrequent pain. But read labels to make sure that you’re getting the right medicine. Excedrin Migraine and Excedrin Extra Strength contain the same strength of acetaminophen, aspirin, and caffeine, but the maximum daily dose for the migraine version is no more than two pills per day; for Extra Strength, it’s no more than eight. One reason: Overuse of OTC pain meds for migraines can cause rebound headaches. When in doubt, consult a doctor or pharmacist.

GENERICS

Generics: Medicine you need at a price you can afford What you should know

Even though about 80 percent of prescriptions today are written for generic drugs, many consumers still worry about their safety and effectiveness, according to a recent survey by Consumer Reports Best Buy Drugs. “When people hear the word ‘generic,’ they think of generic plastic wrap or generic pasta, and associate that with inferior quality,” says Aaron S. Kesselheim, M.D., an assistant professor of medicine at Brigham and Women’s Hospital in Boston. “But for the vast majority of people, generic drugs are as safe and effective as brand-name drugs.” >>

2015–2016 Consumer Reports Best Buy Drugs 41

GENERICS

In fact, the active ingredients in generic drugs work the same as their brand-name counterparts—and offer significant savings to you. Still not sure? Get to know the truth about generics with the answers to these common questions. What, exactly, are generic drugs?

Generics use the exact same active ingredients as their brand-name counterparts. By law, generic drug companies can legally manufacture the branded drug once the patent has expired—usually 12 to 15 years from the drug’s initial release. And because brand-name drugs are prescribed for many years before they can be copied,

To find information about recalls and other medical safety alerts for all drugs, go to the FDA’s website, FDA.gov. If you’re concerned about a drug you are taking or if you’re experiencing problems that might be related to your medications, speak to your physician, pharmacist, or other health care provider.

42 2015–2016 Consumer Reports Best Buy Drugs

their generic clones are considered, by extension, “tried and true.” The Food and Drug Administration requires that overthe-counter and prescription generic drugs have exactly the same active ingredients in the same strength as the brands they copy. It also requires that they have the same purity and stability, come in the same form—for example, tablet, patch, or liquid—and be administered the same way (for example, swallowed as a pill or given as an injection). In addition, manufacturers of a generic must demonstrate that the drug is “bioequivalent” to its corresponding brand by showing that it delivers the same amount of active ingredients into a person’s bloodstream in the same time as the original brand. A 2009 analysis of 2,070 bioequivalence studies found that the average difference in absorption—using two measures—between a generic and its branded prototype was about 4 percent, the same variation that is found between two batches of the same brand-name drug. That means that generic drugs maintain the same therapeutic effect— and therefore the same benefits and risks—as their brand-name counterparts, all while saving you as much as 95 percent of the price.

GENERICS

How many generics are available on the market?

If you don’t have insurance coverage for drugs, talk to your doctor, as switching to a generic may mean substantial cost savings.

Generics are available for nearly 80 percent of all prescription medicines. And when an exact generic is not available for a certain drug, as is the case with many newer brand-name drugs, doctors or pharmacists can often substitute a generic version of an older drug in the same class of drugs that has equivalent effectiveness (and often a longer safety record).

as their branded version due to patent issues. The shape, color, and taste of a pill make no biological or medical difference, except in rare instances when someone might be allergic to an inactive ingredient.

So what about over-thecounter generics?

But I recognize the brand names.

They’re required by law to meet the same manufacturing standards as the name brands with which they compete. They have the same benefits and risks as their brand-name counterparts, but at a lower cost to you.

Yes, because drug companies do a good job of advertising. But don’t pay for brand names simply because you recognize them. Most drugs have a brand name and a generic name. For example, the generic name for Lipitor is atorvastatin, which is the main ingredient in Lipitor. Get to know the generic names of drugs you take.You’ll have an easier time getting information on the drug from reference books or on the Internet.

What’s the difference between generics and brand-name drugs?

Aside from the contrast in cost, the biggest differences are simply cosmetic and bear no influence on the quality of the drug. Brand-name pills may have a colored outer shell that contains a sweetener. Generics, on the other hand, are often plain white pills that don’t appear to be as high quality. However, generic pills, by law, cannot look the same

So why hasn’t my doctor prescribed a generic to me?

In many cases, doctors will write a prescription for a brand-name medicine and leave it to the pharmacist to substitute a generic when applicable. Pharmacists in >> 2015–2016 Consumer Reports Best Buy Drugs 43

GENERICS

every state can legally switch you to an approved generic version of the branded drug prescribed to you without your doctor’s permission. Talk with your doctor about your prescription as it is being written. Ask whether the prescription is for a brand-name or generic drug and why the doctor has prescribed one or the other. And if cost is a concern, let the doctor know that you would prefer the less-expensive choice as long as safety and effectiveness are the same.

Even if you have insurance, the co-pay for a generic drug is often less than for the branded version. For example, you may only have to pay $4 to $10 for a generic versus $15 to $35 for a brand-name. When you are taking several medicines, these savings can add up.

Can I really save that much by switching?

Generics can cost up to 95 percent less than their brand-name versions and save consumers an estimated $8 to $10 billion a year. They’re less

44 2015–2016 Consumer Reports Best Buy Drugs

expensive because manufacturers don’t have the expense of developing them from scratch and rarely spend money on advertising. The lower price not only helps your wallet but might also help your health. Research suggests that people who use generics are more likely to keep taking their drugs as directed, compared with those who use costlier brand-name drugs. Are generic drugs made overseas safe?

Yes, or at least as safe as brand-name drugs made overseas. Eighty percent of the active ingredients in all U.S. drugs—generic and branded—are now made in foreign countries. In fact, many brand-name drugs are produced in the same countries and often at the same factories as their generic counterparts. How do I switch?

When your doctor prescribes a drug, ask if there is a generic version that would be just as safe and effective but less expensive. If one isn’t available, as is the case with many newer brand-name drugs, ask if a generic version of an older drug in the same class would work as well.

GENERICS

Is there a time when generics aren’t a good choice?

Some experts think so, though that’s controversial. The debate over the safety of using generics in place of brand-name drugs that have a “narrow therapeutic index” (NTI) because they work and are safe only within a small dosing range. In other words, too little active ingredient and the drug doesn’t work; too much and it becomes toxic. NTI drugs include antiseizure medications for treating epilepsy, blood-thinning drugs like warfarin, antiarrhythmics for controlling irregular heartbeats, and drugs that help prevent the rejection of a transplanted organ. For NTI drugs, particularly those to treat epilepsy, our medical consultants recommend staying on a generic made by one manufacturer to avoid slight variations that may occur with different manufacturers.

Talk with your pharmacist to ensure that he or she can provide that consistency month-to-month, or at least tell you if the pharmacy switches its generic supplier. If you do switch to a different generic or from a brand to a generic, your doctor may want to monitor your response more closely during the transition period. Where can I learn more?

Check out our free Best Buy Drug reports on more than 25 classes of drugs to treat dozens of conditions and find out whether a low-cost generic is available. See the back cover of this publication for a list of available reports at CRBestBuyDrugs.org. For more on generic drugs go to FDA.gov.

2015–2016 Consumer Reports Best Buy Drugs 45

DRUGSTORE PERKS

46 2015–2016 Consumer Reports Best Buy Drugs

DRUGSTORE PERKS

surprising new drugstore perks Services that save you time and money

P

harmacies are rolling out all kinds of new in-store, online, and mobile services to make it more convenient to stay healthy. They might even save you a trip to the doctor. Here’s our top 10 list of new services worth checking out. >>

2015–2016 Consumer Reports Best Buy Drugs 47

DRUGSTORE PERKS

1

Private consultations with a pharmacist It can be difficult in large stores to talk with pharmacists. In a recent national Consumer Reports survey, onethird of shoppers at chain pharmacies and big-box stores said they weren’t comfortable discussing personal medical concerns at the drugstore. Plus, they thought the pharmacist seemed too busy anyway. To help you get more up close and personal, Walgreens has moved them to desks up front in some of its stores. Many drugstores also have a consultation area. Don’t be shy about asking to talk there rather than at the pick-up counter.

48 2015–2016 Consumer Reports Best Buy Drugs

DRUGSTORE PERKS

2

Enhanced wellness programs Sometimes it can be more convenient to visit a neighborhood pharmacy than to make a trip to the doctor. New health and wellness programs help keep tabs on blood pressure, blood sugar, and cholesterol. Walgreens, for example, expanded its wellness services to monitoring and management programs for asthma, emphysema, osteoporosis, thyroid diseases, and more. Kroger and others offer smokingcessation programs and consultations to help people manage their meds. At certain times of the year, pharmacies may also offer diagnostic tests such as bone-density and skin-cancer screenings at special store events. If you try one of those wellness programs, be sure the pharmacist is certified and trained to provide that kind of counseling, and let your doctor know what you’re up to. “Make sure your pharmacist forwards any test results to your doctor’s office so that they can be included in your medical chart,” Marvin M. Lipman, M.D., Consumer Reports’ chief medical adviser, said. “And always follow up with your physician to verify the diagnosis and discuss possible treatments.”

3

Personalized packaging Do you ever forget to take your prescribed medications? Sam’s Club, Walmart, and some independent drugstores will put your pills in individualized, daily packets instead of the usual bottles so that you can tell at a glance if a dose has been taken. >>

2015–2016 Consumer Reports Best Buy Drugs 49

DRUGSTORE PERKS

4

24-hour live chats Rite Aid and Walgreens offer a 24-hour live chat feature for registered users. The free and confidential chats allow you to contact a pharmacist with questions or concerns about prescriptions, over-the-counter medicines, potential drug interactions and side effects, or anything else about your drugs.

5

More shots You know that you can get a flu shot at the pharmacy, but you might not know that you can get other vaccines, too. Though rules vary by state, CVS, Rite Aid, and other chains offer vaccinations for chicken pox, diphtheria, hepatitis A and B, human papillomavirus (HPV), measles, pertussis (whooping cough), pneumonia, polio, shingles, and tetanus. And Walgreens covers shots you may need for an overseas trip, such as those for meningitis, typhoid, or other diseases. Insurance covers some vaccines with no copay, so you might not even be charged.

50 2015–2016 Consumer Reports Best Buy Drugs

DRUGSTORE PERKS

6

Extended-hour clinics Some chain pharmacies, including CVS, Walgreens, and Walmart, offer in-store walk-in clinics staffed by nurse practitioners or physician assistants. Rite Aid has also opened new RediClinics inside pharmacies in Baltimore, Philadelphia, and Washington D.C. No appointments are necessary, and many are open seven days per week, with extended evening and weekend hours. The clinics are good options for non-emergencies such as bronchitis, burns, head lice, pink eye, rashes, strep throat, and even migraines or minor back pain. Most appointments are covered by insurance or are offered at low cost.

7

Faster refills Walgreens lets you skip the line altogether by picking up refills at one of the store’s self-service kiosks. Most chain drugstores offer re-fill ordering online or via their mobile apps and will send a text message when it’s ready. Kroger, Rite Aid, Walgreens, and other pharmacies will put your refills on autopilot, replenishing and readying them for pickup automatically a few days before they run out. And a number of pharmacies now also offer a service called refill synchronization. Pharmacists will coordinate all of your refills so that they happen at the same time, which is more convenient than picking up your various prescriptions at different times throughout the month. If you prefer in-person refill orders but can’t deal with a long wait, consider switching to an independent pharmacy. Our recent survey found that only 4 percent of customers at independents complained of long waits during the previous 12 months compared with 21 percent at chains. >>

2015–2016 Consumer Reports Best Buy Drugs 51

DRUGSTORE PERKS

8

New ‘get healthy’ rewards programs With the Walgreens Balance Rewards for Healthy Choices program, you’ll get 20 points for each mile you walk, run, or cycle, 20 points per logged weigh-in or blood glucose or blood pressure reading, and 20 points for logging other healthy activities, such as quitting smoking. For every 5,000 points, you’ll get $5 to spend in the store.You can even sync it to your FitBit, iHealth, or Jawbone fitness-tracking device, or connect it to smart-phone apps such as MapMyFitness, MyFitnessPal, and RunKeeper. The Rite Aid chain also offers several wellness rewards programs. Sign up for Wellness65+ and get 20 percent off your purchases on the first Wednesday of each month and a free pharmacist consultation.

52 2015–2016 Consumer Reports Best Buy Drugs

DRUGSTORE PERKS

9

Safe drug disposal Many independent and chain pharmacies accept and dispose of unused and expired medications for you—or provide return envelopes for mailing them directly to a location for safe disposal. These programs keep medications from ending up in the wrong hands or being disposed of in ways that can pollute waterways. New rules from the Drug Enforcement Administration now allow you to drop-off leftover opioids—powerful pain relievers—including codeine, fentanyl (Duragesic and generic), hydrocodone(Vicodin and generic), meperidine (Demerol and generic), morphine, and oxycodone (Oxycontin, Percocet, and generic)—at some pharmacies or mail them to authorized collection centers. But you must use approved packaging, which you can get from pharmacies and other designated locations. Two online resources, DisposeMyMeds.org and Sharps Compliance’s Pharmacy Locator, available at Sharpsinc.com/locations/ can help you find pharmacies near you that accept leftover medications.

10

Meds for Fido Some pharmacies will fill prescriptions for your pets, too, as long as that same drug is also prescribed to humans—and might charge less than the vet charges. Prices can be as low as $4 for a month’s supply. At Costco, Giant/ Eagle, Kmart, Kroger, Rite Aid, Target, and Walgreens, pets can be enrolled in their discount programs. And pharmacists can turn many pills into a flavored liquid.Yes, a spoonful of chicken flavor can make the medicine go down! 2015–2016 Consumer Reports Best Buy Drugs 53

PILL SPLITTING

Pill splitting:

Cut your prescription drugs (and costs) in half

P

ill splitting can be an easy way to save money. For certain medications, at certain strengths, you may be able to essentially buy two doses of medicine for the price of one. Research shows that a wide variety of drugs can be split safely, as long as it’s done carefully. The following are some tips and best practices you should use if you’re considering splitting your pills. Ask your doctor or pharmacist whether your medication can be safely split. The Food and

Drug Administration has called pill splitting a “risky practice” and does not encourage it unless the package insert specifically states it has been approved for splitting. However, our medical advisers say pills can be split safely as long as your doctor agrees that it’s appropriate for your health situation, you learn how to do it properly, and you only split pills that can actually be split. As 54 2015–2016 Consumer Reports Best Buy Drugs

long as you follow those guidelines, many common drugs—including aspirin, cholesterol-lowering drugs, and many high blood pressure and depression drugs—can be split safely. Review reasons why you shouldn’t split your pills.

If you have trouble physically splitting pills due to poor eyesight, tremors, arthritis, or dementia, or if your doctor says pill splitting is bad for your condition, you should never attempt it.

PILL SPLITTING

Always use a pill splitter to ensure you’ve split the medication into equal halves.

Pill splitters are widely available from pharmacies for as little as $3. Check with your insurance company, they might provide one for free.

the prescription or a refill, ask if the pills have been split so you don’t inadvertently halve them again. Also be aware that the prescription label may refer to “one tablet” even though your doctor has told you to split the pills. If you’re not

Don’t use a knife or scissors.

Doing so can lead to unequal halves—a dangerous outcome. Pills should only be split in half, not into smaller portions, such as thirds or quarters. Ask your doctor or pharmacist to show you how to split your pills. Research has shown that

patients who receive instructions from medical professionals divide their pills more evenly. Do not split your pills in advance.

Some pills may deteriorate when exposed to air and moisture for long periods after being split. So for medications taken on a regular basis, only split your pill on the day you take the first half, and then take the other half whenever you are scheduled to take your next dose. If your doctor has prescribed half tablets, your pharmacy may split the pills for you. So when you pick up

The biggest savings come from splitting brand-name drugs that you take regularly for a chronic condition. You might be able to save more money by switching to a generic version of your prescription, if one is available. Talk to your doctor to see if this is an option for you. sure about the label instructions or your doctor’s instructions, ask for clarification before splitting or taking your medication. Although there is no official or complete list of medicines that can be split, the following lists can inform your conversation with your doctor. >>

2015–2016 Consumer Reports Best Buy Drugs 55

PILL SPLITTING

Which pills CAN be split? These medications can be split but always check with your doctor or pharmacist beforehand:

Common use

amlodipine (Norvasc)

High blood pressure; heart disease

atorvastatin (Lipitor)

High cholesterol

citalopram (Celexa)

Depression

doxazosin (Cardura)

Enlarged prostate

finasteride (Proscar) NOTE: Women should NOT handle crushed or broken tablets if pregnant or possibly pregnant. Broken tablets lose some of the protective outer coating, thus allowing absorption of finasteride through the skin. The drug may cause a male fetus to be born with abnormalities of his sex organs.

Enlarged prostate

levothyroxine (Synthroid)

Under-active thyroid

lisinopril (Zestril)

High blood pressure

lovastatin (Mevacor)

High cholesterol

paroxetine (Paxil)

Depression

quinapril (Accupril)

High blood pressure

sertraline (Zoloft)

Depression

simvastatin (Zocor)

High cholesterol

tadalafil (Cialis)

Erectile dysfunction

vardenafil (Levitra)

Erectile dysfunction

56 2015–2016 Consumer Reports Best Buy Drugs

PILL SPLITTING

Which pills CANNOT be split? It can be dangerous to split some drugs. Generally, the following kinds of pills should not be split: Chemotherapy drugs Anti-seizure medicines Birth control pills Blood thinners (Coumadin, warfarin) Capsules of any kind that contain powders or gels Pills with a hard outside coating Pills designed to release medication over time in your body (i.e. long-acting, extended-release, etc.) Pills that are coated to protect your stomach (enteric coating) Pills that crumble easily, irritate your mouth, taste bitter, or contain strong dyes that could stain your teeth and your mouth. Combination tablets that contain two or more medicines. Here are some examples:

• amlodipine/atorvastatin (Caduet) • amlodipine/olmesartan (Azor) • amoxicillin/clavulanic acid (Augmentin and others) • ezetemibe/simvastatin (Vytorin) • irbesartan/hydrochlorothiazide (Avalide) • oxycodone/acetaminophen (Percocet and others) • sitagliptin/metformin (Janumet) >>

2015–2016 Consumer Reports Best Buy Drugs 57

PILL SPLITTING

How much could you save by Drug

What is it?

Generic Lipitor (atorvastatin)

A statin prescribed along with lifestyle changes to reduce LDL-cholesterol in the blood and the related risk of heart attack and stroke.

Escitalopram (Lexapro)

An antidepressant prescribed to treat generalized anxiety disorder (excessive worry and tension that disrupts daily life and lasts for 6 months or longer) and depression.

Irbesartan (Avapro)

A medication to control high blood pressure. It is also used to treat kidney disease caused by diabetes in patients with type 2 diabetes and high blood pressure.

Rosuvastatin (Crestor)

A statin prescribed along with lifestyle changes to reduce LDL-cholesterol in the blood and the related risk of heart attack and stroke.

Valsartan (Diovan)

A medication to control high blood pressure. It is also sometimes used to treat heart failure in people who cannot take angiotensinconverting enzyme (ACE) inhibitors.

Monthly cost reflects national average retail prices for January 2015, rounded to the nearest dollar. Data provided by Symphony Health Solutions, which was not involved in our analysis or recommendations.

58 2015–2016 Consumer Reports Best Buy Drugs

PILL SPLITTING

splitting your pills? Resulting average monthly cost with split pills

Monthly savings

Average monthly cost

Cost of doubled dose

20 mg: $102

40 mg: $100

$50

$52

10 mg: $242

20 mg: $254

$127

$115

150 mg: $147

300 mg: $175

$88

$59

10 mg: $228

20 mg: $234

$117

$111

80 mg: $168

160 mg: $181

$91

$77

Your insurance plan might also provide a list of drugs that can be split. If so, review the list with your doctor or pharmacist before ever splitting your pills.

2015–2016 Consumer Reports Best Buy Drugs 59

12 RX DRUG TIPS

Stay safe, be smart:

Rx drug tips you must know

1

Ignore drug ads. Sure, they can let you know when a new drug is on the market, but an impressive ad doesn’t mean the drug is better than older drugs. Often, it’s just more expensive.

2

Talk to your doctor about cost. Unless you bring it up, your doctor might assume that prescription cost isn’t a factor for you.

3

Ask why. Find out why your doctor is prescribing a drug, and ask if it’s approved by the U.S. Food and Drug Administration (FDA) for your condition. If not, it’s being prescribed “off-label.” In other words, to treat a condition other than those for which the FDA has approved it. Ask your doctor about the scientific evidence that shows it will work in your case. 60 2015–2016 Consumer Reports Best Buy Drugs

4

Don’t fall for free samples. Free samples, like drug coupons and vouchers, might seem like sweet deals but they probably won’t lead to long-term savings because they tend to hook you on newer, pricier brand name drugs.

5

Keep track of your medicines. According to a recent survey conducted by Consumer Reports Best Buy Drugs, about half of the United States adult population currently takes an average of four medications, and 16 percent take seven or more. Because drugs can interact in dangerous ways, schedule a “medicine review” with your doctor. And each time you fill a new prescription, ask your doc and the pharmacist how it will interact with your current medicines.

12 RX DRUG TIPS

6

Watch out for supplements, too. They can interact with drugs as well, so keep a single list of all drugs and supplements you take and ask your doctor about dangerous interactions.

7

Ask about splitting pills. Often, you may be able to save money if you fill a prescription for pills that are twice the dose you need and then cut them in half with a pill splitter. (See page 54.)

8

Don’t dismiss older drugs. In many cases, and for many conditions, older drugs available as low-cost generics are just as good as—or even better than—newer, pricier drugs.

9

Shop carefully online. Brandname drugs appear less expensive from websites that claim to be based in Canada or Europe, but don’t be fooled: The majority of those foreign websites are illegitimate. You may expose yourself to the risk of counterfeit medications.

10

Stick to one pharmacy. To lower your risk of potentially dangerous drug interactions, fill all of your prescriptions at one store.

11

Consider a generic ‘therapeutic substitution.’ If a generic drug is not available for the brand-name drug you’ve been prescribed, consider asking your doctor for another generic in the same “class” of drugs instead. Drugs within a class or group aren’t always that different. Drug makers claim that each drug is unique, but in some classes of medicines there are several drugs that achieve similar results for most people.

12

Report harmful side effects immediately. If you have an adverse reaction that you think is related to a medication, tell your doctor right away.You can also notify the FDA’s MedWatch Adverse Event Reporting System (fda.gov/ medwatch). If you have a negative reaction to a vaccine, notify the FDA at fda.gov/cber/vaers/vaers.htm.

2015–2016 Consumer Reports Best Buy Drugs 61

3 QUESTIONS TO ASK

Starting a new drug?

questions to ask your doctor

W

hen it comes to starting a new drug, it’s normal to have questions— and your doctor expects it. “Patients worry their questions might be interpreted as second-guessing,” says Orly Avitzur, M.D., Consumer Reports’ medical adviser. “But we want our patients to be informed so they can make sure they can follow their medication instructions as well as understand the risks and benefits of taking the drug.” To address this, we encourage you to make it a habit to ask three questions each time your doctor writes you a new prescription:

1

Why should I take this drug? Drugs to treat many common conditions—such as diabetes and high blood pressure—are often prescribed long term, and maybe for the rest of your life. So it’s critical you understand what the medication is for and how long you should take it. If you are not sure you want to take the drug, ask if there are nondrug options to help your condition, such as improving your diet, exercising more often, stopping smoking, or even counseling.

2

Are there any side effects? All medications have side effects, such as drowsiness, dry mouth, headaches, or nausea. Ask about any common side effects that the drug could cause, as well as more serious ones. If a side effect is a problem for you, your doctor may suggest ways to manage or reduce it. For example, diuretics used to treat high blood pressure may send you to the bathroom more often. So your doctor may suggest you take the pill in the morning so that you don’t go to the bathroom as much during the night.

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3 QUESTIONS TO ASK

Don't hesitate to ask your doctor about your medications. It's important for your health and safety to understand the risks and benefits of your treatment.

3

Is there a generic form of this drug? If your doctor prescribes a brand-name drug, always ask if there’s a generic version. Many people—including physicians—assume that newer drugs are better, but that’s not necessarily true. More than 80 percent of all medications in the U.S. are available as a generic and studies consistently find that older medications are as good, or even better, than newer ones. If your doctor tells you a generic isn’t available, as is the case with many newer brand-name drugs, ask if a generic version of an older drug in the same class would work as well.

i

To learn more, log on to CRBestBuyDrugs.org.

2015–2016 Consumer Reports Best Buy Drugs 63

ABOUT THIS GUIDE

About this guide Best Drugs for Less is a Consumer Reports public education project. Because our grant-funded program is intended to educate consumers, we make all our Ratings and reports free. If you’re interested in learning more about the project, visit us online at CRBestBuyDrugs.org. At our web site, you can also find a digital version of this publication. Updated in 2015, this guide is made possible by a grant from the states Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multistate settlement of consumer fraud claims regarding the marketing of the prescription drug Neurontin. The Engelberg Foundation provided a major grant to fund the creation of the project from 2004 to 2007. Additional initial funding came from the National Library of Medicine, part of the National Institutes of Health. We followed a rigorous editorial process to ensure that the information contained herein and on the Consumer Reports Best Buy Drugs Web site is accurate and describes generally accepted clinical practices. If we find, or are alerted to, an error, we will correct it as quickly as possible. But Consumer Reports and its authors, editors, publishers, licensers, and any suppliers cannot be responsible for medical errors or omissions, or any consequences from the use of the information here or on the site. Please refer to our user agreement at CRBestBuyDrugs.org for further information. Consumer Reports Best Buy Drugs should not be viewed as a substitute for a consultation with a medical or health professional. The information contained herein and the information on CRBestBuyDrugs.org is provided to enhance your communication with your doctor rather than to replace it.

64 2015–2016 Consumer Reports Best Buy Drugs

You may have noticed this publication is an ad-free zone. That's because at Consumer Reports, we don’t accept advertising. Period. We are supported entirely by individual subscribers, donations, and grants. This keeps us independent, and allows us to work entirely for you, the consumer. In the area of medication, we review large-scale scientific analyses of groups of drugs to understand how well they work, and how safe they are. This helps us make recommendations for the best value drugs to treat a condition. See the results, for free, at CRBestBuyDrugs.org

Consumers have trusted the independent and impartial advice of Consumer Reports for nearly 80 years to make smart choices about car-buying, home appliances, electronics, and much, much more. In this free publication, we help consumers get the best medicines based on a rigorous and scientific review of safety, effectiveness, and cost. Want to know more? Visit CRBestBuyDrugs.org for advice you can trust in both English and Spanish for the following conditions: • Allergies, Hay Fever, and Hives • Alzheimer’s Disease • Angina • Atrial Fibrillation • Asthma and Lung Disease • Attention Deficit Hyperactivity Disorder • Fibromyalgia • Chronic Pain • Constipation • Depression • Enlarged Prostate • Heart Disease, Heart Attack, and Stroke

• Heart Failure • Heartburn, Acid Reflux Disease • High Blood Pressure • High Cholesterol • Inflammatory Bowel Disease • Insomnia • Migraine Headaches • Muscle Spasms and Spasticity • Osteoarthritis, Pain • Osteoporosis • Overactive Bladder • Psoriasis • Rheumatoid Arthritis • Type 2 Diabetes