Introducing ‘Drug of the Month Blog’ – First up, Duexis®

by Alan Rook
PharmD, Clinical Pharmacist

The myMatrixx Clinical Team is launching a monthly blog that will focus on a drug. The primary purpose of these blogs is to educate claims professionals. We hope to educate claims professionals by providing information that will assist in the decision-making process of approving or denying pharmacy transactions. In each blog, we will discuss the drug’s place in workers’ compensation and the mechanism of action of the drug. Additionally, we will suggest medications that may be preferred due to safety or cost concerns.

April ‘Drug of the Month’ – Duexis®

For our debut of the “Drug of the Month Blog,” the drug being reviewed is Duexis®. Duexis® is a combination product—a single tablet containing 800 mg of ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), famotidine 26.6 mg, and a histamine H-2 antagonist. The recommended dose is one tablet three times daily. Duexis® is FDA-indicated for signs and symptoms of rheumatoid arthritis, osteoarthritis, and to decrease the risk of developing upper gastrointestinal ulcers due to the use of a NSAID. The Official Disability Guidelines (ODG) state that the use of NSAIDs for chronic low back pain is “recommended as an option for short-term symptomatic relief.” Additionally, the ODG says that NSAIDs “have fewer side-effects than muscle relaxants and narcotic analgesics,” which explains the widespread use of NSAIDs in workers’ compensation.

how-duexis-works

Image from: Duexis.com

Duexis® Side Effects

Like most drugs, there are side-effects associated with the use of NSAIDs. One major concern is an increased risk of gastrointestinal events. Based on clinical trials, gastrointestinal events occurred in approximately 1% of patients treated for 3-6 months and in 2%-4% of patients treated for one year. NSAIDs inhibit the production of prostaglandins—natural chemicals in the body that promote inflammation. When prostaglandin production is decreased, inflammation, pain, and the signs of inflammation also decrease.

Interestingly enough, prostaglandins are important in protecting the stomach lining from the corrosive effect of stomach acid. Unfortunately, the stomach lining is exposed to the potential harmful effects of acid with chronic NSAID use. It is important for the clinician to determine the patient’s risk for gastrointestinal side effects from NSAIDs. If a patient is determined to be at risk, it is recommended to add medication that protects the stomach.

The criteria for a clinician to determine whether or not a patient is at risk for gastrointestinal events includes:

  • – Age > 65 years of age
  • – History of peptic ulcer
  • – Concurrent use of aspirin, steroids, or a blood thinning agent; and
  • – High-dose or multiple NSAIDs

Duexis® Dosage

The 800 mg dose of Ibuprofen in Duexis® is prescription strength and considered to be high-dose. Therefore, it is therapeutically appropriate to prescribe a medication that protects against gastrointestinal events along with the high-dose of Ibuprofen.

Duexis® Benefits

The major benefit of taking Duexis® is that patients reduce the number of tablets they take per day by combining two medications into one tablet. Another benefit of Duexis® is that the patient is guaranteed to be taking both medications by taking the one tablet, which ensures compliance with the regimen.

Duexis® Price

When Horizon Pharma introduced Duexis® in 2011, the Average Wholesale Price (AWP) was $1.86 per tablet. The medication is dosed three times daily requiring 90 tablets per month, making the AWP for a 30-day supply $167.40. Since Duexis® was introduced to the market, the cost has increased exponentially. Now, the AWP for Duexis® is $18.65 per tablet or $1,678.32 per month. Both drugs in Duexis® are available separately as generics at a substantially lower price. Currently, the AWP for 800 mg of ibuprofen is approximately $0.43 per tablet, and 20 mg of famotidine is approximately $2.42 per tablet—making the cost per month for both medications approximately $254.70. Duexis® is $1,423.62 more expensive per month in comparison to the individual generic drugs. Using the individual ingredients instead of Duexis® results in an annual savings of $17,083.44 for one patient. This difference is staggering, especially considering that the primary benefit is reducing the number of tablets a patient takes to three per day.

Our experience indicates that the physician will almost always agree to change prescriptions to the alternative generic medications if the information is shared with the treating physician prospectively, or even prospectively.

Duexis information

Duexis® Bonus Information:

Why did the cost of Duexis® escalate in such a dramatic fashion? Part of the reason is that Horizon Pharma, the manufacturer of Duexis®, acquired the U.S. marketing rights to a similar combination drug known as Vimovo® (naproxen and esomeprazole) from AstraZeneca in November 2013. Since these are the only two combination products available in this therapeutic class, Horizon Pharma had a monopoly on the combination products, allowing them to maximize revenue from the sale of both of them.

Vimovo® is a combination of a NSAID (naproxen 500 mg) and a proton pump inhibitor (esomeprazole 20 mg—more commonly known by its brand name Nexium®). Esomeprazole’s mechanism of action is slightly different than the histamine H-2 antagonist, but they both inhibit gastric acid secretion, protecting the stomach from gastrointestinal events due to high-dose NSAID use. Vimovo’s® AWP has also been escalating since Horizon Pharma acquired the product. The recommended daily dose for Vimovo® is one tablet twice daily. The AWP per tablet is $27.97, making the AWP for a 30-day supply $1,678.20, which is virtually the same price as Duexis®. When comparing the cost of Vimovo® to the generic alternatives prescribed separately, the difference is significant. Thus, requesting that the prescribing physician switch to the generic alternatives is recommended.

Stay tuned for myMatrixx’s next ‘Drug of the Month’ blog!

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