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Dr. Bill's Commentaries

Dr. Bill Quick began writing at HealthCentral's diabetes website in November, 2006. These essays are reproduced at D-is-for-Diabetes with the permission of HealthCentral.

An Unexpected Letter from my Insurance Company   (September 18, 2012)

Yesterday I received an unexpected and misleading letter from my insurance company, kindly pointing out that I could save money by switching off one of my medications. It was sent out over the signature of someone with the fancy title of “Director, Humana Pharmacy Solutions Clinical Strategies.” According to the letter, he’s a PharmD (Doctor of Pharmacy) and a BCPS (Board Certified Pharmacotherapy Specialist). I’ve spoken to several customer service reps and other staffers at Humana, and most of them have never heard of him; one supervisor has assured me that she is sending him an urgent message to call me back.

He may have fancy titles, but he doesn’t know squat about a drug called Zetia. I’m on Zetia (AKA ezetimibe) as well as a statin for treatment of high cholesterol, and the combination has kept my lipid levels under much better control than when I was on a statin alone. I’ve been on Zetia for years, previously by using the combination drug Vytorin, which is Zetia plus simvastatin, and more recently, as the two separate drugs. I’m aware of the high cost for Zetia (which has no generic equivalent) and have often thought about discontinuing it, but based on the theory that if it ain’t broke, don’t fix it, I’m staying on it. (Full disclosure: I previously worked for Schering Plough, who participated in a joint venture, Merck/Schering-Plough Pharmaceuticals, that sold Vytorin.)

Anyhow, in his letter, our friendly PharmD points out “Personalized savings options for William,” and proposes I switch from Zetia to a statin – totally ignoring the fact that I’m already on a statin (simvastatin). He continues that “You may be able to start saving today!” by switching from Zetia to the “Lower-cost option” of pravastatin or atorvastatin. Doubling up with two statins isn't a recommended concept that I ever heard of.

The letter points out the dollar cost savings in a very impressive-looking table, but nowhere does he even begin to hint that Zetia is in a different class of lipid-lowering drugs, and that it has a different side effect profile than the statins.  Which, to me, is sort of like telling a driver of a diesel car or truck that he/she should switch from diesel fuel to gasoline to save money without alerting the driver to how the cheaper fuel will perform in their vehicle.

My concern is that any hypothetical Zetia patient who had previously been on a statin and had the misfortune to have severe side effects from the statin (for example, look up rhabdomyolysis), would run the risk of again having the same side effects of the statin all over again, if a physician who was unaware of the patient’s prior history were to follow the horrendous advice proposed by Humana and authorize the change back to a statin merely to save money.

For those who are interested, I’ll point out that Zetia is approved by the FDA for combination therapy with the statins, as most, but not all, studies have shown better lipid-lowering than with statins alone. For example, in one 8-week clinical study that’s quoted in the Zetia USPI, people who had Zetia added to their previous statin (including atorvastatin, simvastatin, pravastatin, fluvastatin, cerivastatin, or lovastatin) had their mean LDL (bad) cholesterol decrease an additional 25%, compared with 4% in people who were given a placebo. Zetia’s mechanism of action is different from that of the statins:  it works in the digestive tract by inhibiting the absorption of cholesterol by the small intestine. I might add that it doesn’t take long to learn this info: it’s all in the Zetia label. Am I suggesting that readers of this blog should start taking Zetia? Absolutely not. That’s a physician’s decision, and adding Zetia or drugs from other classes of lipid-lowering medications might be appropriate if the patient’s lipid levels are uncontrolled on high-dose statins, or if the patient has had a severe adverse reaction while on a statin.

So why did the Humana PharmD authorize this letter to go out? I don’t know, but I wonder how many people are getting similar letters. For instance, I wonder how many PWD who previously survived lactic acidosis while on metformin and are now taking some other class of diabetes pills are getting letters urging them to save money by starting/resuming metformin? Or are people on insulin being advised that it would be cheaper to stop their insulin and start metformin? Or maybe, carrying it to the extreme, people with T2D could be advised to stop their medications completely and control their diabetes with diet and exercise (just kidding!).

I wonder if my physician may have gotten a similar letter, suggesting that he switch me from Zetia to a statin. I wouldn’t be at all surprised.

IMHO, I think insurance companies are playing with fire when they start sending these oh-so-friendly letters from corporate hotshots with impressive titles in which the insurance company advises their customers to pressure their physicians to switch classes of drugs to save money. My advice: If you or a family member or friend gets a letter like this from an insurance company, don’t assume that your physician is familiar with the proposed alternative drug and its side effect profile: take the effort to look the drug up yourself before you even begin to think about suggesting the switch to your physician.

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