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2015 March 31

Third weight-loss progress report

Filed under: Uncategorized — gasstationwithoutpumps @ 20:22
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In 2015 New Year’s resolution , I said that I want to lose 10–15 pounds by June 2015. In Weight-loss progress report and Second weight-loss progress report, I provided a monthly updates.

For March, I continued the same diet and exercise as in January and February, except for March 20–29, when I had Spring “break” (a huge pile of grading, rewriting the book for my applied electronics class, and other administrative and course preparation tasks).  I wasn’t cycling up to campus everyday, so my average exercise dropped to 4.31 miles/day of bicycling. Also, my son, a freshman at UCSB, had his Spring break at the same time, and so came home for the break.  Because he is very thin (as I was at a corresponding age), his mother served a number of comfort foods while he was here, to encourage hearty eating.  So I put on a little weight and am trying to lose it again.

A simple linear extrapolation would have me reaching the upper end of my target range by 2015 Apr 23, but an exponential decay predicts that I won't reach it until June 13.

A simple linear extrapolation would have me reaching the upper end of my target range by 2015 Apr 23, but an exponential decay predicts that I won’t reach it until June 13.

I am at the lowest weight I’ve been since I bought the scale in 2011 and started recording my weight.  Although I was losing 1.24 lbs/week in January and 0.74 lbs/week in February, I only lost 0.52 lbs/week in March.  Because of this progressive slowdown, I fit an exponential decay to my weight loss, as well as the simpler linear fit.  The exponential predicts an eventual minimum weight of 157 lbs with a decay time constant of 89 days. This asymptotic weight is comfortably within my target range—but if the exponential holds up, then it will take me longer than I had originally expected even to get within my target range.

During break I had a checkup with my physician, who thinks my target weight range is fine, but she’d be happy even if I just managed to maintain my current weight. Interestingly, my cholesterol was at the lowest level since I’ve had it measured (starting in 1989), and the desirable HDL was actually up.  Unfortunately, I did not check the cholesterol levels before starting my diet, so I don’t know whether the low levels are due to the diet or to the rather high levels of atorvastatin (60mg/day) that I’ve been taking for the past 2 years.  In any case, I’m cutting back to 40mg of atorvastatin a day, and I will check my cholesterol levels again over the summer.


2014 January 23

Pill prices are not uniform

Filed under: Uncategorized — gasstationwithoutpumps @ 10:44
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This year UC eliminated the health care plan that I’ve been using for the past several years, and the closest similar plan was quite expensive.  I decided to switch to a low-cost plan that has a high deductible, which means that I’ll be paying cash for my prescriptions and doctor visits this year, at least until I reach the deductible (which probably won’t happen—unless I have a major bike accident or someone in the family gets seriously ill).

I take generic atorvastatin, a very cheap drug, on a daily basis for controlling cholesterol. I decided to check whether I should continue with the pharmacy I’ve been using (the closest one) or look for a cheaper one.  Under the previous insurance plan, I could select pharmacies for convenience, since my co-pay was the same no matter what.  I checked online, and found that Consumer Reports had found a big difference between pharmacies for generic atorvastatin, so I called both my current pharmacy and Costco (the one that Consumer Reports had found cheapest).

If I stay with the CVS I’ve been using, my atorvastatin would cost me $9.40 a day.  At Costco, it would be 77¢ a day (both based on 100-pill purchases of both 2omg and 40mg pills and no Costco card or other discounts). I had expected some difference in price, but not a 12-to-1 difference!

If I used a pill splitter, I could reduce the costs to $7.05 a day at CVS or 61¢ a day at Costco, but the hassle of splitting pills is not worth 16¢ a day.  Needless to say, I’ve asked my doctor to switch my prescription to Costco.

2012 March 1

New FDA labels for statins

Filed under: Uncategorized — gasstationwithoutpumps @ 09:07
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In earlier posts, I talked about statin drugs (Simvastatin warning and Health Net screws me on their formulary).  This week, the FDA has made some changes in the labeling for all statins, based on the ongoing monitoring of the millions of patients taking the drugs:

There are 4 parts to the new changes:

  1. Liver Injury Called Rare It turns out that liver damage (the main side effect of statins that I’ve worried about) is rare enough that monitoring liver enzymes is no longer recommended.  The reasoning is that “no data exist to show that routine periodic monitoring of liver biochemistries is effective in identifying the very rare individual who may develop significant liver injury from ongoing statin therapy.”
  2. Reports of Memory Loss This one seems to be a scare message only—there have been anecdotal reports of cognitive loss in patients taking statins, but no controlled studies showing there is even a correlation, much less causation.  With millions of older people taking statins, one would expect reports of cognitive loss.  The question is whether the numbers are higher than among those not taking statins.  The data are not there to determine this, so the warning seems a bit misleading to me.
  3. The Risk of Diabetes There have been studies showing blood sugar increases in people taking statins, resulting in a 9% higher risk of diabetes.  I’m not at high risk of diabetes (I think), so multiplying that risk by 1.09 does not worry me, but I wonder whether doctors will be more likely to order tests for diabetes in their patients who take statins.
  4. The Potential for Muscle Damage The potential for rhabdomyolysis has always been present with statins (about 0.44 cases per 10,000 person years of treatment doi:10.1136/bmj.a2286. PMID 18988647), but is greatly increased when certain other drugs are taken at the same time, because of inhibition of the  metabolic machinery is involved in breaking down the statin.  The FDA is tightening the warnings for lovastatin being prescribed with certain other drugs.  It is not clear to me whether the warnings are restricted to lovastatin because that was the most commonly prescribed statin, and so the rare events were seen most often with it, or because lovastatin is metabolized differently from the other statins, and so the risks are higher, or whether the warnings were already in place for the other statins.  The statins do behave somewhat differently in the body (hence the large differences in effect as a function of dosage), so any of these explanations is plausible.  The FDA explains the interactions:

    Lovastatin is a sensitive in vivo cytochrome P450 3A4 (CYP3A4) substrate. Strong CYP3A4 inhibitors are predicted to significantly increase lovastatin exposure. A literature review indicates that itraconazole, a strong CYP3A4 inhibitor, increases lovastatin exposure up to 20-fold and the drug interaction appears to result in rhabdomyolysis. The effect of itraconazole on lovastatin exposure can therefore be extrapolated to other strong CYP3A4 inhibitors, including ketoconazole, posaconazole, erythromycin, clarithromycin, telithromycin, human immunodeficiency virus (HIV) protease inhibitors, boceprevir, telaprevir, and nefazodone.

    Note that grapefruit juice is an inhibitor of CYP3A4, which is why statin users are recommended not to eat grapefruit or drink grapefruit juice. According to the Wikipedia article on CYP3A4, atorvastatin, lovastatin, simvastatin, and cerivastatin are all CYP3A4 substrates, but pravastatin and rosuvastatin are not. If this is accurate, then the FDA warnings should probably have been extended to atorvastatin, simvastatin, and cerivastatin as well. Of course, cerivastatin has already been withdrawn from the market because of much higher rates of rhabdomyolysis than the other statins.

I’m switching from rosuvastatin to a higher dose of atorvastatin this week, thanks to Health Net making the copayment for rosuvastatin so high.  The only change that the new FDA labeling should have for me is that I’m unlikely to be getting liver enzyme tests in future—though I’ll still have to get a blood test every 6 months to monitor the cholesterol levels.

2011 December 23

Health Net screws me on their formulary

Filed under: Uncategorized — gasstationwithoutpumps @ 14:08
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In my post Simvastatin warning, I discussed the analysis I did of available statin drugs after my doctor informed me of the FDA warning about high doses of simvastatin.  Based on a careful analysis of the publicly available information about the drugs, I determined that Crestor was the best choice for me, as I needed to raise my HDL as well as needing a large dose of statins to keep my LDL levels down. Vytorin was a second choice, and atorvastatin a distant third (since it does not increase HDL).

Today I got a letter from Health Net telling me that they were moving Crestor from Tier 2 ($20/month copayment) to Tier 3 ($35/month copayment), suggesting that I use lovastatin, pravastatin, or simvastatin (all of which would require doses higher than the FDA recommends).  Health Net’s Director of Pharmacy (Janice Kjell) was completely out of line in suggesting the use of these generics without checking my dosage or LDL and HDL levels. Although I’m sure that there are many patients on Crestor who would do just as well on the generics, and I prefer to use generics when I can, the choice to use Crestor was a carefully considered one based on my body’s responses to the generics. Statin drugs are not exactly equivalent, and it is not always possible to replace one with another.

Her form letter also recommended atorvastatin, since it has just gone off patent and should be available as a generic now. That one would be possible for me (the dose I’d need is not above FDA guidelines), but it would probably make my HDL/LDL ratio worse, based on the available data.  So I’m faced with the decision whether Crestor is enough better than atorvastatin to be worth spending an extra $360 a year on it (generics are only $5 a month, Tier 3 $35/month).  I had already made the decision that it was worth an extra $180 a year, but now they’ve doubled the price difference.

There has been one change in the information available since my decision in October.  In November the SATURN trial was published doing direct comparisons between atorvastatin and rosuvastatin (Crestor).  The dosages were not exactly comparable (the Crestor was at a dose designed for greater LDL reductions), but the Crestor did end up with a better HDL/LDL ratio (0.8 instead of 0.7) and less elevation of liver enzymes (0.7% vs. 2%) [source].  I wish that they had done the study for comparable doses (20mg rosuvastatin vs. 80mg atorvastatin, rather than 40mg vs. 80mg), but when studies are funded by drug companies, they try to stack the deck so that they can report things like “CRESTOR resulted in significantly lower LDL-C levels compared to atorvastatin (62.6 vs. 70.2 mg/dL, p<0.001),” even though this particular difference is just one of dosage. I also wish that they had published in a journal, rather than just at an American Heart Association conference, as UC subscribes to most major medical journals, but I have no access to AHA conferences without paying some huge fee.

It irks me that Health Net informed me of this change to their formulary after the Open Enrollment period is over (a legal form of bait-and-switch), and despite an enormous increase in my health insurance costs this year.  Unfortunately, there are very few options for health insurance at UCSC (some of the plans popular at other UCs are useless here, as we don’t have a UC medical  school nor Kaiser, and there is only two sizable medical groups for HMOs to contract with, and only one plan that contracts with the group we’ve been going to).

I wonder who (if anyone) I can complain to about Health Net changing their formulary just after Open Enrollment.  Perhaps the University needs to require that health insurers list any changes to their formulary before Open Enrollment, and not allow any increase in copayments during the year.

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