Birth Control

Originally Posted by Shorty

I'm an avid fan of the shot. Depo Provera is by far, my most favorite form of birth control to date.

Here's one thing I'm always curious about when I see prescriptions for Depo Provera (or medroxyprogesterone acetate, or MPA): do you personally inject the shot yourself or do you take it to your doctor? I ask because both the vial and the prefilled syringe are available (at least at my pharmacy) but the vast majority of MPA prescriptions we dispense are for the vial and I assume most patients take it to their doctor when syringes are pretty cheap (if your pharmacy/state law allows you to buy them) and making a return trip to the doctor's office for an intramuscular injection you expect regularly probably means another office visit fee. I just figure if you can learn to inject yourself with the stuff, cutting out the middle man seems like a good idea?

I'm also curious to know if you get brand or generic and, if the brand, why?

Most amazing jew boots

Originally Posted by Shorty

Mine were close to $50 per vial.

Depending on your prescription plan, your co-pay may differ, but I can tell you that in most cases a generic will cost nowhere near $50. Most co-pays are $5, $10 or $15 for generics and $10, $20, $30, and sometimes higher for the next tier up. However, since the MPA shot is good for three months, it may just be that your insurance is being billed for a three-month supply (generally, triple the base tier co-pays, e.g. $30 for a generic that would be $10 for one month). Either way, the generic is just as effective as the brand and is generally cheaper.

Most amazing jew boots

Without knowing the laws in California, I can only guess that they are similar to those in Massachusetts, where if the generic for a drug is available the pharmacy by law must dispense it, regardless of personal wishes or doctor's orders (unless the prescriber includes "do not substitute" on the prescription). But every state has different laws: I think in Connecticut a patient may request the brand if it is available (regardless of whether it is covered) and the same was the case in New Hampshire when I worked there.

As I mentioned, generics must have some degree of bio-equivalence to the brands before being approved by the FDA. The common argument I sometimes hear is that people don't believe that the generic is as effective as the brand and that is a slippery slope discussion. Long story short, you can always ask your pharmacist whether you're being dispensed the brand or the generic and, if you're on the brand, what it would take to go to the generic.

I'm willing to bet you've been dispensed the generic. Since medication co-pays have become a major issue in the last 10-15 years, a number of changes have been made to ensure that generics do become available and they are required to be less expensive by law, and your pharmacy likely benefits more from dispensing the generic than the brand.

Most amazing jew boots

Originally Posted by Shin

Some degree of bio-equivalence? 99.9% of the time, generic medicine is exactly the same as branded stuff.

I realize I'm picking nits here (and me admitting it is far better than what you did), but an FDA study done between 1996 and 2007 demonstrated that the "average difference in absorption into the body between the generic and the brand name was only 3.5 percent". Furthermore...



...FDA regulations regarding approval of generics require a generic drug to meet two pharmacokinetic parameters between boundaries of 80% and 125%. You can read it here:

Spoiler:

The standard bioequivalence (PK) study is conducted using a two-treatment crossover study design in a limited number of volunteers, usually 24 to 36 adults. Alternately, a four-period, replicate design crossover study may also be used. Single doses of the test and reference drug products are administered and blood or plasma levels of the drug are measured over time. Pharmacokinetic parameters characterizing rate and extent of drug absorption are evaluated statistically. The PK parameters of interest are the resulting area under the plasma concentration-time curve (AUC), calculated to the last measured concentration (AUC(0-t)) and extrapolated to infinity (AUC(0-inf)), for extent of absorption; and the maximum or peak drug concentrations (Cmax), for rate of absorption. Crossover studies may not be practical in drugs with a long half-life in the body, and a parallel study design may be used instead. Alternate study methods, such as in-vitro studies or equivalence studies with clinical or pharmacodynamic endpoints, are used for drug products where plasma concentrations are not useful to determine delivery of the drug substance to the site of activity (such as inhalers, nasal sprays and topical products applied to the skin).

The statistical methodology for analyzing these bioequivalence studies is called the two one-sided test procedure. Two situations are tested with this statistical methodology. The first of the two one-sided tests determines whether a generic product (test), when substituted for a brand-name product (reference) is significantly less bioavailable. The second of the two one-sided tests determines whether a brand-name product when substituted for a generic product is significantly less bioavailable. Based on the opinions of FDA medical experts, a difference of greater than 20% for each of the above tests was determined to be significant, and therefore, undesirable for all drug products. Numerically, this is expressed as a limit of test-product average/reference-product average of 80% for the first statistical test and a limit of reference-product average/test-product average of 80% for the second statistical test. By convention, all data is expressed as a ratio of the average response (AUC and Cmax) for test/reference, so the limit expressed in the second statistical test is 125% (reciprocal of 80%).

For statistical reasons, all data is log-transformed prior to conducting statistical testing. In practice, these statistical tests are carried out using an analysis of variance procedure (ANOVA) and calculating a 90% confidence interval for each pharmacokinetic parameter (Cmax and AUC). The confidence interval for both pharmacokinetic parameters, AUC and Cmax, must be entirely within the 80% to 125% boundaries cited above. Because the mean of the study data lies in the center of the 90% confidence interval, the mean of the data is usually close to 100% (a test/reference ratio of 1). Different statistical criteria are sometimes used when bioequivalence is demonstrated through comparative clinical trials pharmacodynamic studies, or comparative in-vitro methodology.

The bioequivalence methodology and criteria described above simultaneously control for both, differences in the average response between test and reference, as well as the precision with which the average response in the population is estimated. This precision depends on the within-subject (normal volunteer or patient) variability in the pharmacokinetic parameters (AUC and Cmax) of the two products and on the number of subjects in the study. The width of the 90% confidence interval is a reflection in part of the within-subject variability of the test and reference products in the bioequivalence study. A test product with no differences in the average response when compared to the reference might still fail to pass the bioequivalence criteria if the variability of one or both products is high and the bioequivalence study has insufficient statistical power (i.e., insufficient number of subjects). Likewise, a test product with low variability may pass the bioequivalence criteria, when there are somewhat larger differences in the average response.

This system of assessing bioequivalence of generic products assures that these substitutable products do not deviate substantially in in-vivo performance from the reference product. The Office of Generic Drugs has conducted two surveys to quantify the differences between generic and brand name products. The first survey included 224 bioequivalence studies submitted in approved applications during 1985 and 1986. The observed average differences between reference and generic products for AUC was 3.5% (JAMA, Sept. 4, 1987, Vol. 258, No. 9). The second survey included 127 bioequivalence studies submitted to the agency in 273 ANDAs approved in 1997. The three measures reviewed include AUC(0-t), AUC(0-inf), and Cmax. The observed average differences between the reference and generic products were + 3.47% (SD 2.84) for AUC(0-t), + 3.25% (SD 2.97) for AUC(0-inf), and + 4.29% (SD 3.72) for Cmax (JAMA, Dec. 1, 1999, Vol. 282, No. 21).

The primary concern from the regulatory point of view is the protection of the patient against approval of products that are not bioequivalent. The current practice of carrying out two one-sided tests at the 0.05 level of significance ensures that there is no more than a 5% chance that a generic product that is not truly equivalent to the reference will be approved.

Or you could understand that while there is a small likelihood that a generic that isn't completely bioequivalent could be approved, the likelihood is still there. Nevertheless, "99.9%" bioequivalence isn't far off from 96.5%, but there's always people out there who'll take that 3.5% average (meaning there is a likelihood of variance) and run with it.

(Coincidentally Shorty, there is a study being worked on by Columbia University regarding self-administered vs. clinician-administered intramuscular injections.)

Most amazing jew boots

I assumed he was referring to opioids (like MS Contin versus OxyContin, or whatever the UK equivalent is).

How ya doing, buddy?