Sep 28, 2010

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

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The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

The point is, ladies and gentleman, that greed, for lack of a better word, is good. Greed is right, greed works. Greed clarifies, cuts through, and captures the essence of the evolutionary spirit. Greed, in all of its forms; greed for life, for money, for love, knowledge has marked the upward surge of mankind. And greed, you mark my words, will not only save Teldar Paper, but that other malfunctioning corporation called the USA. Thank you very much. That famous speech was given by Michael Douglass character Gordon Gekko in the 1987 movie Wall Street. I really liked that movie and I remember that speech. In fact it was printed on the back of the Faculty of Commerce T-shirt while I was at University. Wall Street 2: Money Never Sleeps was just released, but I dont think I am going to see it. I cant imagine it is going to be as good as the original.

Im going to rebrand the catch phrase. Cheap is good. When my sister learned to drive in Pinawa, our small town in Eastern Manitoba, she wanted charge any of her friends that rode with her gas money per kilometer. My mom vetoed the idea, and my sister was really angry that she had to pay for gas and her friends got to ride for free. Some might call this cheap, but I call it frugal and smart. Frugal and smart people just want to get the most bang for their hard earned buck. I am proud to say many of these smart, frugal people are my customers at the Dauphin Clinic Pharmacy. They arent usually interested in a medication if Manitoba Healths Pharmacare program doesnt pay for it. Many of my customers are NOT medication early adopters. You see when a new medication is approved for sale in Canada, it usually not covered by Pharmacare for a few years. That gives Pharmacare time to see if the new medication gives good bang for the buck. So my frugal and smart customers wait for Pharmacare approval before paying with their hard earned money.

Spiriva was different. Spiriva is a once a daily inhaled medication for Chronic Obstructive Pulmonary Disease (COPD). It was first sold in Canada in November 2002. Many, many people did try Spiriva or tiotroprium. And once they tried it, they were so impressed with how much better they could breathe they agreed to pay for the Spiriva. They werent going to wait for Pharmacare to pay for it. Spiriva is the first drug I can remember that a large group of people from the Parkland agreed to pay for before Manitoba Health approved it for coverage.

Manitoba Health eventually did cover Spiriva. The latest news is that Spiriva may be good for more than just COPD. It may help in asthma too. Lets review what different medications we have to treat asthma right now. The most common medication used to treat asthma is still salbutamol or ventolin. It is a blue puffer and it quickly opens up the airways, but it doesnt last very long. There are longer acting airway openers like salmeterol (serevent) and formoterol (oxeze). Then there are medications that reduce the inflammation in the lungs. They are inhaled steroids with names like fluticsasone (flovent), budesonide (pulmicort), and beclomethasone (Qvar). We think asthma is caused by inflammation in the lungs, so almost everyone with asthma should be on an inhaled steroid regularly and we should add the short and long acting airway openers to the steroids as needed.

So where does Spiriva or tiotroprium fit in? At the moment, it isnt used in asthma at all. But Stephen Peters et. al. did an interesting study funded by the U.S. National Heart, Lung and Blood Institute. They did a three-way, double bind, triple dummy trial on 210 asthmatics. All study participants started on an inhaled steroid. Then they were randomly assigned to: double the dose of their steroid, add the long acting airway opener, salmeterol (serevent) or add spiriva (tiotroprium). The way the study was set up, all patients eventually tried all the different treatment options.

And the result was Spiriva was better than just doubling the dose of the steroid. And Spiriva was just as good as the salmeterol (serevent) at improving lung function. I think this was a very well done study, but it was only on 210 people. It will probably have to be reproduced in more people before it is approved for use in asthma. I wonder if it is approved if the smart and frugal asthmatics of the Parkland will like it?

I was surprised when it turned out my mother nixed my sisters plan to charge her friends for car rides. My mom is half Scottish and has been known to put ziplock bags in the dishwasher to clean and reuse them. She is another smart and frugal woman. One of my favorite smart and frugal customer stories came from Pat Lamborn. Pat used to work in a pharmacy in BC. Look at my new Scottish wallet, a customer said to Pat in a thick Scottish brogue. How can you tell its Scottish? Pat asked. Look, look at all the Velcro sealing it shut! said the little highlander excitedly. It SCREAMS when you open it! That is definitely a customer that would agree, Cheap is good.

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New England Journal of Medicine Article:

As always if you have any questions or concerns about these products, ask your pharmacist.


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