Category: Medications

What to Know About Xofluza for the Flu

Most people don’t understand that we have limited options to treat folks with the flu.

They still think that Tamiflu is some kind of wonder drug.

It isn’t. At best, if you take it within 48 hours of the start of your flu symptoms, you might “shorten the duration of fever and illness symptoms, and may reduce the risk of complications from influenza.”

Other flu drugs aren’t that much better, which is why they are typically reserved for those who are considered at high risk for flu complications.

What to Know About Xofluza for the Flu

That’s why many of us welcomed news of a new flu drug – Xofluza (baloxavir marboxil).

“This is the first new antiviral flu treatment with a novel mechanism of action approved by the FDA in nearly 20 years. With thousands of people getting the flu every year, and many people becoming seriously ill, having safe and effective treatment alternatives is critical. This novel drug provides an important, additional treatment option.”

Scott Gottlieb, M.D., FDA Commissioner

Unfortunately, while it has a new mechanism to treat the flu, there are plenty of reasons to not get too excited about Xofluza, despite what the headlines might be telling you:

  • the clinical benefit seems similar to Tamiflu
  • the two studies that were used to get Xofluza approved only looked at folks with mild to moderate flu symptoms (those with severe flu symptoms were excluded) and only looked at folks without complex medical problems, so we don’t know if it reduces hospitalizations, flu complications, or deaths from flu
  • flu virus strains might be able to mutate and develop resistance to Xofluza, although it is not clear if these strains could then be passed to others
  • the single dose treatment is only approved for adults and kids who are at least 12 years old
  • at $120 to $150, it is more expensive than generic Tamiflu

Still, if it works just as well as Tamiflu, but really does have fewer side effects, then that is a good thing, especially if it isn’t overused.

“The significant reduction in influenza viral replication with baloxavir treatment suggests the potential for reducing influenza virus spread to close contacts and should be studied through randomized, controlled trials in households and during institutional influenza outbreaks such as in longterm care facilities.”

Timothy M. Uyeki, M.D., M.P.H., M.P.P. on A Step Forward in the Treatment of Influenza

Could Xofluza make you less contagious to others?

That would be a good way to control outbreaks.

Why isn’t it approved for younger kids? The pediatric studies haven’t been completed yet, but among the postmarketing studies that the FDA are requiring are in infants, children between the ages of 12 months to less than 12 years, and the final report of a pediatric study from Japan.

Other postmarketing studies of Xofluza will include hospitalized patients, the use of Xofluza as post-exposure prophylaxis to prevent influenza in household contacts of an index case, and to monitor resistance.

Are you excited about Xofluza?
Are you excited about Xofluza?

Should folks be excited about Xofluza? While it is certainly nice to have an alternative to Tamiflu, an alternative that worked a lot better would have really gotten most of us excited.

Right now we’ll settle for folks only using anti-viral flu medications, whether it is Tamiflu, Relenza, or Xofluza, when they are truly necessary – for high risk children and adults.

Remember, not everyone with the flu needs these medications.

And they are certainly not a substitute for a flu vaccine, unless you have a true medical contraindication to getting vaccinated.

More on Xofluza

What Is the Evidence for CBD Oil?

Are you wondering if your kids should be taking CBD oil?

That’s probably not a question you would be thinking of asking just a few years ago, but now that CBD products are everywhere, with hundreds of millions of dollars in sales, and claims that it can treat everything from seizures and anxiety to cancer, you might be thinking you need to jump on this new fad.

What Is CBD Oil?

Many folks are likely skeptical when they hear about all of the benefits of CBD oil.

This is the stuff that is extracted from marijuana plants, right?

How is it even legal to sell CBD oil or gummies infused with CBD?

To understand that, you have to understand that cannabidiol (CBD) oil is the part of the marijuana plant that doesn’t get you high. That comes from tetrahydrocannabinol (THC).

And many of the products you see with CBD oil that is sold over-the-counter aren’t even derived from marijuana, but instead come from hemp plants.

Labeling something as hemp doesn’t necessarily make it legal though. Regulators in Ohio, for example, recently announced that CBD oil derived from hemp is illegal and that the only legal CBD oil will be dispensed in state-licensed dispensaries.

What Is the Evidence for CBD Oil?

There is definitely evidence that CBD oil can have beneficial effects in some medical conditions.

Except for treating some types of resistant seizures, there is no good evidence that CBD oil has all of these other benefits.
Except for treating some types of resistant seizures, there is no good evidence that CBD oil has all of these other benefits.

In fact, the FDA recently approved Epidiolex oral solution for the treatment of seizures associated with two rare and severe forms of epilepsy, Lennox-Gastaut syndrome and Dravet syndrome. Epidiolex is an oral solution of oil-based CBD that is extracted from marijuana plants.

What other medical conditions?

While it is not approved to treat any other medical conditions, cannabidiol is being studied to treat people with ADHD, anxiety, autism, schizophrenia, chronic pain, Multiple Sclerosis, Parkinson disease, Tourette syndrome, and substance use disorders.

Should You Try CBD Oil?

What does that mean right now if you have a child with anxiety or another disorder and you are interested in CBD oil?

Although it might be tempting to buy and try the CBD oil that you can find at your local health food store, remember that they aren’t the same thing as Epidiolex, the prescription version of CBD. When you buy an over-the-counter CBD product, you have no idea what dosage of CBD you are really getting.

Anyway, until further testing is done, you have no idea what dose to give your child with anxiety or any other disorder besides seizures anyway.

And like other drugs, CBD oil can have side effects.

So unless you can get in a clinical trial, you should likely wait and continue your current therapies.

But since Epidiolex is approved to treat certain seizures, can’t your doctor simply prescribe it off-label to treat other conditions, like anxiety, if they wanted to? While that does often happen for other medications, it is very unlikely to happen for Epidiolex, even after the rescheduling process is completed and it is no longer a Schedule I substance and can be prescribed in states where it is illegal to prescribe medical marijuana.

It is estimated that Epidiolex will cost over $30,000 a year.

More on the Evidence for CBD Oil

Have Questions About the First Generic Version of EpiPen?

Have you heard the news that the FDA has approved the first generic version of the EpiPen?

“The U.S. Food and Drug Administration today approved the first generic version of EpiPen and EpiPen Jr (epinephrine) auto-injector for the emergency treatment of allergic reactions, including those that are life-threatening (anaphylaxis), in adults and pediatric patients who weigh more than 33 pounds.”

FDA Press Announcement on FDA approves first generic version of EpiPen

That’s likely surprising news to all of those folks who have been prescribing and using generic epinephrine injectors this past year.

Is This Really the First Generic Version of EpiPen?

Many remember that we all talk about EpiPens so much because their cost jumped from about $100 in 2006 to over $600 in recent years.

The current generic epinephrine injectors are authorized generics, so didn't need FDA approval.
The current generic epinephrine injectors are authorized generics, so didn’t need extra FDA approval.

That prompted Mylan, the company that makes the EpiPen 2-Pak and EpiPen Jr 2-Pak, to come out with a half-price authorized generic version last year.

“An authorized generic is made under the brand name’s existing new drug application using the same formulation, process and manufacturing facilities that are used by the brand name manufacturer.”

An authorized generic Adrenaclick injector also became available for a cash price of $109.99 CVS pharmacies. Combined with a $50 coupon, that’s often your best deal on an epinephrine injector if you don’t have insurance.

How Much Will the First Generic Version of EpiPen Cost?

And now we have a true generic version of the EpiPen 2-Pak and EpiPen Jr 2-Pak, from Teva Pharmaceuticals USA.

“The reduction in upfront research costs means that, although generic medicines have the same therapeutic effect as their branded counterparts, they are typically sold at substantially lower costs.”

FDA on Generic Drug Facts

Will it be cheaper than current EpiPens?

“When multiple generic companies market a single approved product, market competition typically results in prices about 85% less than the brand-name.”

FDA on Generic Drug Facts

It should be, but how much cheaper will it be?

“A company spokeswoman declined to say when it would be available, or how much it would cost.”

F.D.A. Approves Generic EpiPen That May Be Cheaper

While most folks would be happy with a $90 EpiPen and a tier 1 generic copay, I wouldn’t count on it. For one thing, we technically don’t have multiple generic EpiPens competing against the TEVA EpiPen yet.

And looking at drug prices of some of TEVA’s other medications, you can get a clue about their pricing plan:

  • Airduo generic (similar to Advair, but about 1/4 the price) – $98
  • Qvar (similar to Flovent) – $200
  • ProAir (albuterol inhaler) – $71
  • Budesonide Inhalation Suspension (generic Pulmicort Respules) – $176
  • Levalbuterol Inhalation Solution, USP (generic Xopenex) – $121
  • Clindamycin Phosphate and Tretinoin Gel (generic Ziana) – $600
  • Cefdinir oral suspension (generic Omnicef) – $45
  • Syprine (generic trientine hydrochloride) – $18,375

Their drugs typically ain’t cheap…

Will the first generic version of the EpiPen simply be a little cheaper than the authorized generic or can we expect TEVA to offer it at substantially lower cost?

What’s your guess?

More on the First Generic Version of EpiPen

Helping Kids Avoid Sea Sickness on a Cruise

Planning a cruise with your kids?

How do kids not get sea sick on cruises?
How do kids not get sea sick on cruises? Photo by Vincent Iannelli, MD

You’re not alone.

Cruises have become a popular family vacation.

Helping Kids Avoid Sea Sickness on a Cruise

Are you going to call your pediatrician about a prescription for some Scopolamine patches?

I’ll save you some time.

Scopolamine patches are not approved for young children or teens. They can be prescribed for adults.

Fortunately, most kids don’t have problems with sea sickness on large cruise ships.

And there are other options if they do, including:

  • Dramamine for Kids – chewable tablets (dimenhydrinate) that kids between the ages of 2 and 12 years can take every 6 to 8 hours
  • Dramamine – tablets (dimenhydrinate) for kids over age 12 that they can take every 4 to 6 hours
  • Dramamine All Day Less Drowsy – tablets (meclizine) for kids over age 12 that they can take once a day

It is also nice that Dramamine is over-the-counter, so you don’t even need a prescription. Just grab some before your trip, along with sunscreen, insect repellent, and whatever else you think you need.

Keep in mind that there are also motion sickness treatments to avoid, mostly because they don’t work. This includes the Sea Band acupressure wrist bands that you see everywhere.

What about ginger?

While most alternative treatments don’t live up to their hype, there are studies to suggest that taking ginger can help relieve and prevent sea sickness and other types of motion sickness.

You can even get Dramamine Non-Drowsy Naturals with ginger root for your kids.

“Remarkably fewer symptoms of nausea and vertigo were reported after ginger root ingestion, but the difference was not statistically significant.”

Grøntved  et al on Ginger root against seasickness. A controlled trial on the open sea

Will it work? Most of the studies about ginger and motion sickness have been small and can probably be explained by the placebo effect.

Also keep in mind that newer, non-sedating antihistamines that work for allergies, like Zytrec, Claritin, and Allegra, don’t work for motion sickness. Neither does Zofran.

Helping Kids Avoid Motion Sickness in a Car

An even more common problem than sea sickness seems to be motion sickness in the car. As with sea sickness, Dramamine can be an option for long car rides.

For some young children, even short car rides, like to the store or across town, can be a trigger for car sickness.

What can you do then?

You may have to try different things, but it may help to:

  • avoid letting your child read, watch movies, or play video games in the car
  • have her listen to music or audio books, etc.
  • avoid big meals right before traveling, but also don’t travel on an empty stomach
  • encourage her to look at things outside the car, in the distance, preferably toward the front of the car
  • wear sunglasses

If motion sickness continues to be a routine problem for your child, an evaluation by a Pediatric Neurologist might be helpful.

What to Know About Avoiding Sea Sickness

Sea sickness isn’t often a problem for kids on big cruise ships, but you do have some options to treat and prevent motion sickness, whether it is in a boat, plane, or car.

More on Avoiding Sea Sickness

Prescribe These Inexpensive Medications for Kids, Not Tho$e

The Auvi-Q epinephrine injector retails for over $2,500 each.
The Auvi-Q epinephrine injector retails for over $2,500 each, but it is recommended that folks have at least two!

Folks are no longer surprised when outrageous drug prices make the news.

Remember the $600 EpiPens?

We got less expensive alternatives after folks complained and there was a lot of media attention, but many other drugs are still expensive.

Did you know that there is a diaper rash cream on the market that costs over $600? What’s startling, is that the cream, Vusion, is simply made up of three ingredients that are available over the counter – miconazole (an antifungal drug), zinc oxide, and petroleum jelly.

There is also a pill for pinworms, Emverm, that costs $600!

Saving Money on Pediatric Prescriptions

There is one very easy way to save money on your next pediatric prescription.

That’s right, make sure your child really needs it.

No, that doesn’t mean not filling your pediatrician’s prescription, but it can mean simply asking if a prescription medication is really necessary the next time your kids get sick. Unfortunately, many conditions are over-treated, from ear and sinus infections to pink eye and reflux.

Also, when your child does need a prescription, instead of asking for a coupon, ask if a lower cost, generic alternative might be appropriate.

You can also:

  • make sure the medication is covered by your drug plan, if you have one
  • get a 90 day supply if it is a medication that your child uses long-term, like to control asthma
  • ask about optimizing your child’s dose so that they don’t need multiple pills, for example, taking one 30mg capsule is likely less expensive than taking two 15mg capsules each day
  • see if an alternative form of the same medication might be less expensive. For example, a tube of mupirocin (Bactroban) cream is a lot more expensive than a tube of mupirocin ointment, although both forms of the topical antibiotic can be used in the same situations. Similarly, ondansetron (Zofran) syrup is more expensive than ondansetron orally disintegrating tablets, which is often used when kids have nausea and vomiting.

To save money on prescriptions, you might also use a service like GoodRx, to search for the lowest prices at nearby pharmacies. Especially if you have a high deductible or if a medicine isn’t covered by your insurance, it can sometimes be cheaper to use GoodRx, or a similar service with discount cards, than to go through your insurance plan. And remember that some pharmacies, like at Walmart, offer many $4 generic drugs.

Lastly, ask your pediatrician for samples and go through the manufacturer’s patient assistance plan for help paying for your medicines.

Prescribe These Inexpensive Medications, Not Tho$e

Still can’t afford your child’s prescription?

Fortunately, there is almost always an alternative medication that is less expensive, but will work just as well, that you can ask your pediatrician about. It doesn’t do your child any good if your pediatrician prescribes a medication, but you don’t get it because you can’t afford it. Ask about an alternative instead.

In general, if you need a coupon to get the drug, you can expect that it is an expensive medication. And even if the coupon makes it affordable for you, remember that someone is still paying for it, and in the end, that’s likely going to be you in the form of higher insurance rates.

Will any of these alternatives work for your child?

 

Expensive Drug Less Expensive Alternative*
Vusion (diaper rashes) use Lotrimin + Triple Paste
Advair, Dulera, Symbicort (asthma) generic AirDuo1
Moxeza or Vigamox (pink eye) ofloxacin oph drops2
Auvi-Q (epineprine inj) generic Adrenaclick or EpiPen3
Emverm (pinworms) Reese’s Pinworm Medicine (OTC)
Omnaris, QNasl, Veramyst (allergies) generic Flonase (fluticasone propionate) or Nasacort (triamcinolone) (OTC)
Patanase (allergies) azelastine
 Suprax (UTI) trimethoprim/sulfamethoxazole or Cefdinir4
Suprax (ear infection) high dose amoxicillin or Augmentin or Cefdinir
Ciprodex, Cipro HC (ear drops) ofloxacin oph drops5
Vyvanse, Mydayis (ADHD) generic Adderall XR or Adderal6
Aptensio, Cotempla XR-ODT, Daytrana, QuilliChew ER & Quillivant XR (ADHD) generic Concerta or Ritalin6
EpiDuo, Ziana (acne) benzoyl peroxide/clindamycin
or Differin (OTC)
Solodyn, Doryx (acne) minocycline, doxycycline
Sklice, Ulesfia (lice) spinosad (Natroba) or an OTC treatment
Nexium (GERD) lansoprazole (Prevacid)7 OTC
Cutivate, Elocon, Topicort (eczema) triamcinolone 0.1% cream
 Clarinex (allergies) loratadine (Claritin)8 OTC
Xyzal (allergies) cetirizine (Zyrtec)8 OTC
levalbuterol (Xopenex) (asthma) albuterol8
Patanol, Pataday, Pazeo  (allergies) Zaditor9 (OTC)

*To be clear though, these aren’t direct brand name to generic equivalents. Most are less expensive alternative medications that many pediatricians use every day though. Many were once the primary treatment and were found to work well. They were eventually replaced by newer medications, which were thought to work better, even though there are rarely head-to-head studies that actually prove that they work better than older, now less expensive medicines.

  1. AirDuo – this is a generic preventative asthma inhaler, which like Advair, combines fluticasone propionate and salmeterol. The main downside? It can’t be used with a spacer.
  2. Before looking for lower cost antibiotic eye drops to treat pink eye, you should maybe reconsider the need to treat pink eye in the first place. Most experts now think that pink eye is usually a viral infection, and even when it is caused by a bacteria, unless it is severe, it will likely go away without treatment. Most importantly, keep in mind that according to the AAP, “exclusion is no longer required” for kids with pink eye if they are in daycare or school, which is often why many parents seek treatment in the first place.
  3. Epinephrine injectors are lifesaving medicines for kids with food allergies. They were one of the first medicines to expose how drug coupons helped drug prices soar (the $600 EpiPens), while parents got free medicines for their kids – at least if they had insurance and a co-pay to worry about. Those paying cash or who had a high deductible plan were stuck with high priced drugs. Less expensive epinephrine injectors are now available, but one of the most expensive medicines on our list is back – Auvi-Q. Although the manufacturer advertises that it is available for just $0 for commercially insured patients, each injector pack (comes with 2 injectors and a trainer) actually costs up to $2,500! And since it is recommended that kids have multiple injector packs to store in multiple places, the real price is at least $5,000.
  4. Suprax (cefixime) was once a popular antibiotic for UTIs, especially once it became generic. Then, because it was maybe not popular enough, they stopped making it. It came back though, but not with a generic price tag. Some push it as a better choice for kids with persistent ear infections, but keep in mind that when mentioned on the list of antibiotics in the AAP ear infection treatment guide, it is suggested that when multiple antibiotics have failed, “a course of clindamycin may be used, with or without an antibiotic that covers nontypeable H influenzae and M catarrhalis, such as cefdinir, cefixime, or cefuroxime.” There is likely no benefit to using Suprax by itself or over a less expensive antibiotic.
  5. Can you really use ofloxacin ophthalmic drops in a child’s ear? Yes, although it is an off-label treatment. You just can’t use otic (ear) drops in a child’s eyes. While eye drops are sterile, ear drops aren’t. And for some reason, eye drops are less expensive than ear drops.
  6. Most newer, once a day ADHD medicines are expensive. Some aren’t even covered on insurance plans. Generic medicines are going to be less expensive than newer brand name medicines and short acting stimulants, like Adderall and Ritalin, are the cheapest. Your child just has to take a repeat dose around lunch time.
  7. In many ways, we have come a long way in treating infants with reflux. Gone are the days of using medicines with dangerous side effects, like Propulsid (cisapride) and Reglan (Metoclopramide). Now, if they have gastroesophageal reflux disease (GERD), they are usually treated with an antisecretory agent to reduce acid and pain, but not necessary reduce the amount of spitting up. This can include histamine H2 receptor antagonists, like Zantac (ranitidine), and proton pump inhibitors (PPIs). Before Nexium packets for delayed release oral suspension became available, we had Prevacid Solutabs, which are now available OTC. This would be an off-label treatment.
  8. Clarinex and Xyzal are new classes of medications that turn a drug made up of a racemic mixture (Claritin and Zyrtec) into a single enatiomer. Basically, these drugs are made up of two mirror images of themselves. The theory is that if you make a new drug with just one of those mirror images, then it will work better and cause less side effects. For the great majority of people, these new drugs just cost more. Xopenex was one of the first drugs to use this method, as it is just the R-enantiomer or isomer of albuterol = levalbuterol. Does it work better than albuterol? No. Some people do think that it has fewer side effects, so it might be worth a try if your child gets very jittery or gets an elevated heart rate when he takes albuterol.
  9. Why try an over-the-counter medicine when prescription medications are available? Many medicines that are now over-the-counter, from Allegra and Claritin to Flonase and Nasacort, used to only be available with a prescription. Like these and many more medications, Zaditor allergy eye drops was once a prescription drug. It is available for kids who are at least three years old and might be worth a try before you spend money on a more expensive allergy eye drop.

In general, just remember that the “latest and greatest” medication isn’t always the greatest. Sometimes it is just newer and more expensive. Don’t be afraid to ask about an alternative if it is too expensive.

What to Know About Saving Money on Pediatric Prescriptions

Medications can be expensive, but there are things you can do to try and save money the next time your kids get a prescription from their pediatrician.

More on Saving Money on Pediatric Prescriptions

What to Do About QVAR Being Redesigned

Do your kids have asthma?

What medicines do they take?

Asthma Medications

Kids with asthma basically get treated with five types of medications, including:

  • inhaled short acting bronchodilators – albuterol nebulizer solution, levalbuterol nebulizer and HFA (Xopenex), ProAir HFA, ProAir Respiclick, Proventil HFA, Ventolin HFA
  • oral steroids – prednisolone, prednisone
  • inhaled steroids -Alvesco, Asmanex Twisthaler, Flovent HFA or Diskus, Pulmicort Respules, Pulmicort Flexhaler, QVAR RediHaler
  • inhaled long acting bronchodilators
  • montelukast (Singulair) – a leukotriene receptor antagonist that can help prevent asthma and allergy symptoms

Two of these, inhaled steroids and inhaled long acting bronchodilators, which are typically used in combination products (Advair, AirDuo, Dulera, and Symbicort), are commonly used every day to prevent asthma symptoms and asthma attacks.

How Kids Take Asthma Medications

Asthma is one of those conditions that should be a lot easier to control than it usually is.

Although many preventative medications are available, they typically have to be used every day and the medications have to be given with a nebulizer (takes time) or an inhaler (requires good technique).

A spacer allows younger kids to use asthma inhalers.
A spacer allows younger kids to use asthma inhalers. Photo by Vincent Iannelli, MD

Fortunately, younger kids who can’t yet learn to use an inhaler can get around this by using their inhaler with a spacer or a spacer with a mask.

How do spacers work with your child’s asthma inhaler?

The medicine from the inhaler goes in the spacer and then the child can just breath it in, not having to coordinate, or time when they breath, with when the medicine actually comes out of the inhaler.

What’s the problem?

More and more drug companies are switching to dry powder inhalers. These are great for older kids, who can easily master the necessary technique – a quick, deep breath. But they are still too hard to use for younger kids and can’t be used with a spacer.

“In a systematic review, the mean percentages of patients who used their inhalers without mistakes were 63% for metered dose inhalers (MDIs); 75% for breath-actuated MDIs; and 65% for dry powder inhalers (DPIs).”

Haughney et al. on Choosing inhaler devices for people with asthma: Current knowledge and outstanding research needs

Others are switching to breath-actuated aerosol inhalers that are also too difficult for younger kids to use (they must close their lips around the mouth piece and inhale deeply) and also can’t be used with a spacer.

The Redesigned QVAR Inhaler

While some companies still make two versions of their inhalers, a traditional metered dose inhaler (MDI) and a dry powder inhaler (DPI) or breath-actuated device, more and more have just one option.

QVAR, which has long had the popular inhaled steroid QVAR HFA in 40 and 80 mcg strengths, has now switched to a breath-actuated device.

While the availability of the QVAR RediHaler is good news, as some experts think that breath-actuated devices are better than coordinated devices, the bad news is that they dropped their older QVAR inhalers which could be used with a spacer.

Be careful that your pharmacy doesn’t switch your child from QVAR to QVAR RediHaler unless you think it is appropriate.

So what are your options if your child needs an inhaled steroid?

  • Is your child old enough to learn how to use the QVAR RediHaler or a DPI inhaler, like Asmanex Twisthaler, Flovent Diskus, or Pulmicort Flexhaler? Online videos and demonstration devices can help teach your child.
  • Is your child’s asthma under poor control, so that QVAR wasn’t a good option anymore anyway, in which case your child might need a step up to a combination inhaler that can be used with a spacer, such as Advair, AirDuo, Dulera, or Symbicort?
  • Is your child’s asthma under such good control that your pediatrician might consider a step down off daily inhaled steroid therapy, so that you can stop using QVAR?
  • Do you have a nebulizer and so can use budesonide (Pulmicort) respules instead?

Although the fact that it has “a spacer-free design” is being used as a selling point for the new QVAR RediHaler, that doesn’t help those kids who still need to use a spacer. For them, the easiest option is to simply switch to another brand of steroid inhaler that can still be used with a spacer. These include Flovent HFA (44, 110, and 220mcg) and Alvesco (80 and 160mcg). Both are usually more expensive than QVAR though, which is what made QVAR popular. These other inhalers also might not be covered by your insurance plan.

The Future of Asthma Inhalers

Now that the patents on HFA inhalers are expiring, instead of making inexpensive HFA inhalers, to keep drug prices high, drug companies are developing new delivery devices that they can patent. What’s surprising, is that QVAR is made by Teva, which traditionally makes “lower cost” generic medications.

“Daddy, why can’t they put my asthma medicine in a spray-can like they do hair spray?”

Stein et al. on The History of Therapeutic Aerosols: A Chronological Review

In 1955, a young girl asked her father a simple question and a few months later, the first MDI for asthma was developed.

Can asking a simple question about asthma inhalers get us such quick results today?

Let’s see…

AirDuo-RespiclickWhy isn’t someone making inexpensive asthma inhalers?

Teva did recently get approval for their AirDuo brand and generic inhaler.

A combination of fluticasone propionate and salmeterol, AirDuo is similar to Advair. It is different in that the three strengths of AirDuo (55/14, 113/14 and 232/14 mcg) don’t exactly match the three strengths of Advair (45/21, 115/21 and 230/21 mcg), but at about 25% of the cost, few folks likely care. They might care that AirDuo is only available in a RespiClick version (a dry powder inhaler), and so can’t be used with a spacer.

Ironically, Teva’s AirDuo generic inhaler, a combination inhaler, is less much expensive than their QVAR inhaler, which only contains a steroid.

We will hopefully see more generic versions of more inhalers, including more that stay in a traditional non-breath-actuated, non-DPI form. And more asthma inhalers that are much less expensive.

What to Know About QVAR Being Redesigned

The redesign of QVAR and other asthma inhalers to breath actuated and dry powder versions can mean that they can’t be used with spacers and so can’t be used by infants, toddlers, preschoolers, and younger school aged children with asthma.

More on QVAR HFA Being Redesigned

Choosing the Best ADHD Medication for Your Child

There are a lot of options when it comes to treating kids with ADHD.

In addition to behavioral therapy, there are a number of different stimulant and non-stimulant medications.

How do you choose the best ADHD medication for your child?

Is there a best ADHD medication for your child?

What Types of ADHD Medication Are Available?

When DSM-II was published, in 1968, Ritalin had already been studied and was being used to treat hyperkinetic children with minimal brain dysfunction syndrome.
When DSM-II was published, in 1968, Ritalin and Adderall had already been studied and were being used to treat hyperkinetic children with minimal brain dysfunction syndrome.

Whether your child’s ADHD symptoms include problems with inattention, hyperactivity and impulsivity, or both, the treatments are the same:

  • Stimulants – Adderall/Amphetamine vs Ritalin based
  • Non-Stimulants – Intuniv (extended release guanfacine), Kapvay (extended release clonidine), Strattera

Remember, that although often underused, it is recommended that behavior therapy be the first treatment for younger, preschool children with ADHD. Both medication and behavior therapy are typically recommended for older children with ADHD.

Other off-label medications for ADHD that are also sometimes used include bupropion (Wellbutrin), tricyclic antidepressants such as desipramine (Norpramin), and imipramine (Tofranil), and modafinil (Provigil or Nuvigil).

Yes, we have come a long way from Dr. Charles Bradley’s first studies of benzedrine (racemic amphetamine) in 1937.

How to Choose ADHD Medication for Your Child

Once you start looking at medication options, the first thing to keep in mind is that there is no one single ADHD medication that is better than others for all kids.

The best ADHD medication is going to be the one that your child will take and which controls your child’s symptoms without side effects (or with minimal side effects) for as long as you need it to, without costing an arm and a leg.

So, do you want an ADHD medication that comes as a chewable pill, a pill or capsule that your child can swallow, a capsule that can be opened and sprinkled on food, a dissolvable tablet (ODT), a liquid, or a patch?

How long do you want it to last? 4, 6, 8, 10, 12 or 15 hours?

Is your child going to take it every day or just on school days?

What ADHD medicines has your child already tried?

Answering those questions will help to narrow down which ADHD medicine might be best for your child.

ADHD Medications

Again, there is really no one best ADHD medicine.

“…stimulant medications are highly effective for most children in reducing core symptoms of ADHD.”

American Academy of Pediatrics ADHD Clinical Practice Guideline

And you don’t even have as many options as you think you do.

While it may seem like there are dozens of medications available to treat ADHD now, most are really just different variations of the same few active ingredients.

And if you don’t have insurance or if you have have a high deductible, you will want to know that those that aren’t yet generic (in bold) are going to be much more expensive than the others:

  • Short Acting Stimulants (4 to 6 hours) – Adderall, Evekeo, Focalin, Methylin (chewable), ProCentra (liquid), Ritalin, and Zenzedi (often taken twice a day)
  • Intermediate Acting Stimulants (6 to 8 hours) – Dexedrine, Ritalin SR, Methylin ER
  • Intermediate to Long Acting Stimulants (8 to 10 hours) – Focalin XR, Metadate CD, Metadate ER, and Ritalin LA
  • Long Acting Stimulants (10 to 12 hours) – Adderall XR, Adzenys XR-ODT, Aptensio XR, Concerta (Methylphenidate ER), Cotempla XR-ODT, Daytrana (patch), Dyanavel XR (liquid) Mydayis, Quillichew ER (chewable), Quillivant XR (liquid), and Vyvanse (capsule and chewable)
  • Non-Stimulants – Intuniv, Kapvay, Strattera

In general, stimulants are thought to work better than non-stimulants, but again, there isn’t one stimulant that is consistently better than another.

And there isn’t one medication that targets specific symptoms better than another, so you don’t need to look for a specific medication just because your child has the inattentive type of ADHD vs another who is also hyperactive and impulsive.

Deciding Which Medication Is Best for Your Child

Which ever medicine you choose, you typically want to start at a low dose and slowly adjust the dose up or down as necessary based on how well it is working and whether or not your child is having any side effects.

“…more than 70% of children and youth with ADHD respond to one of the stimulant medications at an optimal dose when a systematic trial is used.”

American Academy of Pediatrics ADHD Clinical Practice Guideline

Keep in mind that:

  • generic, short acting Ritalin (methylphenidate) is often going to be your least expensive option
  • coupons are often available for newer medications to lower or eliminate your copay, but that doesn’t help you if you don’t have insurance, have a high deductible, or if a medication isn’t covered by your insurance
  • it often takes a few days for kids to adjust to being on an ADHD medication, so don’t judge them too quickly
  • it doesn’t take weeks or months for an ADHD medication to work, so don’t wait too long to make adjustments
  • if your child is having major side effects, don’t just switch medications, be sure to switch the active ingredient too. For example, if a low dose of Metadate CD made your child very irritable and caused trouble sleeping, then switching to Ritalin LA doesn’t make much sense, as they are both time release versions of methylphenidate. Other ADHD that contain methylphenidate as an active ingredient include Aptensio, Concerta, Cotempla XR-ODT, Daytrana, Methylin, QuilliChew ER, and Quillivant XR.
  • some of the newest medications, like Zenzedi, are really just different forms of Dexedrine, one of the first ADHD medicines.
  • Mydayis (mixed salts of a single-entity amphetamine) is just Adderall XR, but modified to a three-bead delivery system to make it last longer
  • Dyanavel XR is similar to Mydayis and Adderall XR, but contains a 3.2 to
    1 ratio of d-to l- amphetamine
  • you can open and sprinkle the contents of Adderall XR, Aptensio XR, Focalin XR, Metadate CD, Ritalin LA, and Vyvanse on applesauce if your child can’t swallow these capsules. The contents of Vyvanse is a powder and will easily dissolve in a small amount of water! These are often less expensive options than a newer chewable, liquid, or dissolvable tablets.
  • you can not open Concerta and Metadate CD or you will ruin the time release delivery system. They must be swallowed whole.
  • while there is an authorized generic for Concerta, there are some generic versions that do not have the same therapeutic effect because they do not have the same extended delivery system. Make sure you are getting an authorized Concerta generic.
  • some extended release ADHD medications simply mimic taking the medication twice a day, giving 50% of the dose in the morning and another 50% later in the day, like Adderall XR, Focalin XR, Metadate ER, Ritalin LA, and Vyvanse
  • other extended release ADHD medications have different time release schedules. For example, Concerta gives 22% of the dose immediately and then slowly time releases the rest throughout the day. Similarly, Metadate CD releases 30% of the dose immediately and the rest later. Aptensio XR uses a 40/60 delivery system. And Daytrana, the patch, slowly time releases the dose throughout the day. Quillivant XR uses a 20/80 delivery system. QuilliChew ER uses a 30/70 delivery system. And Cotempla XR-ODT tablets use a 25/75 delivery system
  • although some people start the day with an intermediate or long acting medication to get their child through school and then a short acting medication after school, before doing this, consider increasing the dose of the intermediate or long acting medication to see if it will last longer
  • non-stimulants are pills that must be swallowed and they typically must be given to your child every day for them to work properly
  • genetic tests to try and see which medications will work best for your child have not been tested on kids
  • even if you are only going to be giving your child medication on school days, be sure to give it every single day at first, even weekends, so that you can more easily see what side effects it might be causing. Otherwise, since it could wear off by the time you see your child after school, you might miss uncommon side effects, like if it made him too calm or more irritable.
  • being able to concentrate and do your work and not getting distracted and talking with your friends all of the time is not a side effect – it is the desirable effect.

Most importantly, know that you can take out a lot of what might seem like guess work if you have a good understanding of how these medications work.

What To Know About Choosing an ADHD Medication

For the great majority of kids with ADHD, one of the many available medications will help to control their symptoms of inattention, hyperactivity, and impulsiveness. Learn how to choose the best one for your child.

What To Know About Choosing an ADHD Medication

Updated March 2, 2018