Would you suggest a different drug brand to a patient?

[MunoRN, RN]

A debate came up at work regarding Vimovo and other pills that combine two generics, the combination is considered a new drug and given exclusivity. Vimovo is naproxen and esomeprazole in one pill (Aleve and Nexium), a month's supply of generic naproxen and exomeprazole in separate pills costs about $40, a month's supply of Vimovo ranges from $2,300 to $3,000.

Even though the active ingredient is the same, not all formulations have the same effect, some patients absorb warfarin more predictably with some formulations than with others, so there are times where using the brand name formulation makes a difference. The justification for Vimovo and other generic combination pills is only that it's easier to take one pill instead of two.

The debate that came up was if you were doing a med rec for instance, and a patient told you they take this drug, would you use the opportunity to point out that the same medications are available separately at 1/60th the price? Would you suggest they ask their doctor why they need the two medications in one pill instead of two? Or would you just stay out of it and not mention it at all?

[JKL33]

You mean like:

Pt: "....and I take...Vimvo? Vivo?"

RN: "Vimovo? The new combination pill that is a mix of Aleve and Nexium? Now...do you have other conditions? I mean...did your doctor say why s/he wanted you to have those medications by prescription?"

No ethical issue. This is a conversation that should have taken place already. So any nurse who is doing a med rec is simply acknowledging the conversation that the patient already had with their provider, and looking for further health information that may be related.

What?! They may not have had such a conversation with their provider? NMP.

Preaching/ranting, giving medical advice, etc., is out of bounds CLEARLY. But the person who merely brings up this conversation is certainly not the one who is on the wrong side of ethics.

[KatieMI, BSN, MSN, RN]

I would not RECOMMEND the generic drug (at least as an RN). But I most definitely WILL explain that, although there can be subtle individual differences in speed of adsorbtion (and therefore start of action) due to different fillers/packages and that it can be more convenient to take one pill istead of two, there is no practical reason to spend X more $$$$ for the "brand" name med, should my patient has the question about it. This is well within nursing scope of practice, and I see no reason for not doing so.

We all know now about shameless greediness of pharm companies and the ways they push their not-so-exclusive products to people who think that they have no other choice but to shell out their $$$$$$. It is our job to educate patients so that they and their providers could make informed choices - as long as we know what we are talking about. I see no ethical dillemma here. It is just a part of education, like everything else we teach patients about management of their health conditions.

[mmc51264, BSN, MSN, RN]

I don't know if I would recommend a medication, not sure that is in my scope, but I would definitely discuss it with the provider. It is very frustrating that they put 2 meds together that are cheap on their own and then charge a fortune for the combo one. I have a hard enough time trying to explain Percocet to my ortho patients.

Lots of BP meds are combos and we have to explain that the combo is not formulary but that is it is made up of two meds that we can give together, just as separate pills. It's aggravating and part of the problem of people not being able to afford their medications.

[Sour Lemon]

I probably wouldn't "suggest" it ...but I would mention it and answer the patient's questions if any came up.

[kp2016]

I feel like it depends on the situation, especially my professional relationship with patient and the ordering provider. I have no problem helping patients talk to their providers about their personal health care needs. I would never outright tell a patient to request a particular drug as I am not licensed to prescribe. But if for example a patient expressed to me that the cost of a drug was an issue or asked why they have been switched to this particular drug I will always facilitate a conversation between the patient and the provider. A little bit of tact can go a lot way.

[MunoRN, RN]

I don't know if I would recommend a medication, not sure that is in my scope, but I would definitely discuss it with the provider. It is very frustrating that they put 2 meds together that are cheap on their own and then charge a fortune for the combo one. I have a hard enough time trying to explain Percocet to my ortho patients.

Lots of BP meds are combos and we have to explain that the combo is not formulary but that is it is made up of two meds that we can give together, just as separate pills. It's aggravating and part of the problem of people not being able to afford their medications.

I think there's an important distinction between discussing a different drug and discussing the same drug. Whether it's naproxen and esomeprazole in different pills or the same pill it's still the same drug, no suggestions about what drug is appropriate for the patient are being made by the nurse.

Personally, I think if nursing plays the role it's supposed to then these formulations most likely don't exist.

[MunoRN, RN]

I feel like it depends on the situation, especially my professional relationship with patient and the ordering provider. I have no problem helping patients talk to their providers about their personal health care needs. I would never outright tell a patient to request a particular drug as I am not licensed to prescribe. But if for example a patient expressed to me that the cost of a drug was an issue or asked why they have been switched to this particular drug I will always facilitate a conversation between the patient and the provider. A little bit of tact can go a lot way.

I would agree that it comes down to what our professional role is between the patient and provider. I would disagree that we aren't supposed to get involved in the decisions made by the MD.

[lindseylpn]

I'd probably mention that it's a combination of OTC meds if they mentioned the med was too expensive but, idk if I'd suggest they request sometime else. I'd suggest they talk to their provider about it though.

I've actually been prescribed Vimovo for my back and my provider/FNP discussed with me that it was expensive and some insurances wouldn't pay for it etc. She said if my insurance wouldn't pay or it was too expensive she'd prescribe the meds separately. She sent the prescription into a discount mail order pharmacy and my kinda crappy insurance paid for it with a $10 copay. She's great about considering insurance and med prices when prescribing but, not all providers are.

I once worked for a Dr that was clueless when it came to insurance/med prices. She'd sign prescriptions dispense as written and didn't want to prescribe generics at all. We'd constantly be getting calls from patients/pharmacies saying that insurance wouldn't cover a med and a request to give the generic instead or change to a different med. She'd get a little ticked off about it and always wanted to know why insurance wouldn't pay. She'd always say, "That's the med I want the patient to have that's why I prescribed it, the pharmacy should give them that med." I frequently had to explain to her that most insurances wouldn't pay if there was a generic or cheaper alternative available and most of our patients couldn't afford to pay thousands or even hundreds of dollars for one med. She eventually caught on about prescribing generics but, she never really got things like meds with step therapy/pre-authorization. Example: she'd always prescribe Protonix as a first step for gerd when insurances required Zantac,Prilosec, Nexium etc to be prescribed first so, they'd deny the Protonix and the pharmacy/patient would call.. just stuff like that. I know if she'd prescribed something like Vimovo she'd have been irked if she'd had to prescribe the 2 generic equivalents instead. I never mentioned to a patient to request an equivalent for something but, I did mention to the Dr from time to time if I knew it was a med that the patient might have trouble getting covered.

I know it's a different role but, I've had pharmacists/techs tell me if something is cheaper or recommend a different med. I don't remember what the med was but, my husband was prescribed something once and it was like $200 after insurance. They were like, "oh if you just buy (OTC med) and (OTC med), it's basically the same thing."

[DeeAngel]

I would not say a word about it unless it was a family member, no good will come from recommending this to a regular patient.

[traumaRUs, MSN, APRN]

Moved to Pt Meds

[TriciaJ, RN]

I think when doing med reconciliation I would just ask the patient: "Oh, does this work better than taking the 2 generics separately?" The patient will then ask questions and you can provide medication education. "The two drugs in this combination pill are both sold separately over the counter. Does the combination give you better results?" If the patient expresses interest, the next step would be to encourage the patient to have a conversation with his/her provider about cost and appropriate but less-expensive alternatives. Lindseylpn is right; sometimes doctors just don't take cost/insurance coverage into account and some patients don't think to ask. That's where informed nurses (and hopefully pharmacists) come in.

If the pharmaceutical companies can tell TV viewers "Ask your doctor if X is right for you" then surely it is not unethical for a nurse to make a similar suggestion. Only we're not suggesting a specific medication; only that the patient have a conversation with their provider about acceptable and affordable alternatives.