The Medicare Prescription Champion

The May 1, 2015 issue of The New York Times included an article on the top 10 drugs prescribed in 2013 under Medicare Part D, listed by cost. The drug that cost Medicare the most was the proton pump inhibitor Nexium ($2.53 billion), and we will discuss that in an upcoming article of The Medical Letter. But among the top 10 drugs by cost, more prescriptions were written for Crestor (more than 9 million, at a cost of $2.22 billion) than for any other drug.

The Medical Letter reviewed each new HMG-CoA reductase inhibitor (statin) when it was first approved by the FDA, starting with lovastatin. Each successive new entry lowered serum cholesterol further than the last. But in every case, we warned against jumping to the new drug before the manufacturer demonstrated that the new drug’s superior cholesterol-lowering potential led to a commensurate improvement in clinical outcomes. And in every case, it did. When rosuvastatin (the generic name for Crestor) became available in 2003, atorvastatin (Lipitor) was the most potent statin; we concluded then that recommended doses of rosuvastatin decreased LDL cholesterol and triglycerides slightly more than recommended doses of atorvastatin, and more than other statins, at a lower price. But we also pointed out that no data were available on the effects of rosuvastatin on morbidity and mortality from coronary heart disease.

That has changed now. In a paragraph on Choice of a Statin in our last (2014) article on Drugs for Lipids, we said that rosuvastatin, like lovastatin, pravastatin, simvastatin, and atorvastatin, has been shown to improve clinical outcomes. And rosuvastatin no longer costs less than atorvastatin. It costs more. Much more. The wholesale acquisition cost of a month’s supply of Crestor is $205.80, compared to less than $40 for generic atorvastatin. Is it worth it? A table in our article indicates that the usual decrease in LDL cholesterol with the recommended initial dose of atorvastatin is 35-40%, and the decrease with the maximum dose is 50-60%. With rosuvastatin, the decrease in LDL with the initial dose is 45-50%, and with the maximum dose it is also 50-60%. There is no evidence that the small advantage in LDL-lowering with rosuvastatin has led to better clinical outcomes.

Maybe Medicare should encourage its prescribers to read The Medical Letter.

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  1. Victor G Ettinger, MD, MBA, FACE, FACP says:

    Everyone should read TML; we then ?might? get more rational drug use which may or may not be less expensive, tho’ I think it would be.

    We now need an equivalent ‘The Surgical Letter’ to disect surgical therapies as thoroughly and thought fully as TML does drugs.


  2. mark s hoskinson says:

    how can nexium an isomer of omeprazole that is generic and now nexium over the counter be the number one drug used
    this shows a complete lack of understanding about the identical clinical action of nexium and omeprazole by our fellow physicians
    i would guess that lexapro and celexa are also in the same quandary
    also that when your patent runs out just separate the isomers and then you have another patent to tap the money flow with no real patient benefit and no real new drug

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