Say no to Flomax, save up to $3,000 a year

How much do men really need to spend to treat the symptoms of enlarged prostate? For most men, doxazosin—a generic alpha-blocker—works just as well and is as safe as the heavily-advertised drug Flomax (a brand-name alpha-blocker). But the kicker here is the difference in price: doxazosin can cost $10 or less a month, whereas Flomax can set you back up to $246.

Our new Best Buy Drugs report is based on a systematic review of more than 60 studies, and the results clearly show that no one alpha blocker is better than another at relieving enlarged prostate symptoms. This type of research, known as comparative effectiveness, is the basis for all our Consumer Reports Best Buy Drugs reports.

But why doesn’t the public know that an effective, safe and cheaper drug already exists to treat the symptoms associated with this condition? One reason is advertising. And lots of it.

Drug makers spend enormous sums of money to get their drug’s name into your living room and emblazon it on your mind. In fact, in 2007 branded drug makers spent more than $5 billion on advertising to consumers, and another $15 to $20 billion promoting their drugs to doctors.

When it comes to Flomax, what the ads won’t tell you is that another drug—actually several drugs—already exist to treat the symptoms of enlarged prostate and they work just as well.

Flomax—actually considered to be a "me too" drug, one that isn’t a breakthrough drug and that is very similar to drugs already on the market for a specific condition—is a great case study on how that much advertising can result in more prescriptions written.

Roughly half of all men over age 55 have an enlarged prostate, and by age 80 about nine out of 10 men have it. It’s a normal part of aging. Many men won’t have any symptoms or their symptoms will be mild and not that bothersome. But about half will require medication or treatment, so there is a huge market of millions of men who need these drugs. And don’t think the drug makers haven’t noticed.

In 2008 alone, the makers of Flomax, Boehringer Ingelheim, spent more than $115 million advertising the drug to consumers—14 percent more than they did the year before, according to figures from Nielsen Media Research. All that advertising paid off. Flomax was among the top 20 most-commonly prescribed drugs that year, with 11 million prescriptions written, up almost 5 percent from the year before.

And here is the most jaw-dropping part: Consumers and their insurance companies shelled out more than $1.2 billion dollars for Flomax last year—a whopping 23 percent increase from 2007. (I mean somebody has to pay for those expensive print and television ads.)

Flomax, in particular, has another quality associated with it: sticker shock if you need a higher dosage. Flomax is only available in one dosage strength, 0.4 mg, so if you need to increase your dose to 0.8 mg—and some men do—you will need to take two pills, which doubles the cost. All the other alpha-blockers are available in varying strengths for about the same price, so even if you need a stronger dose, it won’t cost you much, if any, more.

And you may be able to slash your costs even further with your doctor or pharmacist’s approval: For some of these drugs, you may be able to get larger dosages of your pills and then split them in half with a $5 pill splitter available at most pharmacies. Keep in mind you can’t split extended-release or sustained-release drugs.

Bottom line: Flomax is an expensive drug and it’s no more effective or safer than other drugs in the same category for treating symptoms associated with having an enlarged prostate. If you find that you need treatment, ask your doctor first for a generic. Doxazosin is our Best Buy pick because it is as safe, effective and considerably less expensive than other similar drugs.

Read our latest Consumer Reports Best Buy Drugs report to learn more about the symptoms of enlarged prostate and the drugs used to treat it. Find out more about our Best Buy Drugs program that evaluates more than 200 drugs for dozens of common conditions.

—Lisa Gill, editor, Prescription Drugs

Read the full Best Buy Drugs report on drugs to treat enlarged prostate .

Comments

[Steve M]

I am 68 and went through an extensive protocol of Chemo, hormones and the irradiated pins to stop an advanced case of prostate cancer 5 years ago. The oncological urologist started me on Flomax at the time and still prescribes it for me. Little or no problems with dizziness. Until I retired the copay was high but not completely painful. The coverage I have now makes the copay $1.46 each, a bit more.
I only have to get up once a night and flow is full with no hesitation at any time of day. The price is painful now but the ease of urination and the fact that Flomax is going generic next year make it a lot easier to live with. Talk it over thoroughly with your physician, and HMO/PPO/AARP if you have them. It is worth it to me.

[Shaun Snapp]

I have read several emails on this post stating that "my doctor knows best." I really question that. Pharamceuticals are comping my doctor to prescribe the most expensive medicines. That is why I look to sources like Consumer Reports Health. After all we know about misleading pharmaceuticals research and sales, the idea that my doctor knows best, is not beleivable, and I wish it would stop being said because it sounds quite a bit like propaganda. This is like saying my pharam rep knows best. Some of the opinions written by doctors on this article seems extrmely biased. I would like them to declare how much money they get from drug companies on this topic. One of the statements that the drug is not used because of advertizing.....well is ludicrous.

[Johnny]

Doxazosin is an antiquated blood pressure medication proven to be dangerous by the ALLHAT Study (please google and read results) for it's side effects of orthostatic hypotension (feeling dizzy upon standing) and general dizziness. Doxazosin has serious side effects and Flomax has very very minimal side effects. How much will a fall that causes a hip fracture cost you? Maybe your life? It's all down hill after you break a hip... Flomax is a far better and safer option. Also Flomax has no "step therapy" or dose titration like doxazosin. If you want to stay on Doxazosin, you better take it every single day faithfully, because if you miss a dose or two you will have to start the step therapy all over again or risk an increase in side effects (dizziness). Folks, don't believe CR... There is a reason Flomax is the gold standard for BPH and your doctor is not prescribing it to cost you more money or because they are swayed by commercials. The commercials are for you to self diagnose, but Doctor knows best!

[David]

I have taken Flomax for the past four months and it worked. My prescription just ran out and I am wondering if Flomax or generic equivilent is something that will have to take for the rest of my life?

[Lisa Gill]

Many great comments have been made in regards to the side effects of alpha blockers, including Flomax. I thought it might be useful to highlight the section regarding Side Effects of these drugs in our Best Buy Drug report on Drugs to Treat Enlarged Prostate (http://www.consumerreports.org/health/best-buy-drugs/prostate.htm)

Please note that these side effects apply to all alpha-blockers, including Flomax.

From the report, page 12:

"Side effects
You and your doctor’s choice of a BPH drug may be based more on its side effect profile than effectiveness. The most common side effects of alpha-blockers are reduced semen during ejaculation, headache, upset stomach, and stuffy or runny nose. The drugs can also cause low blood pressure, dizziness, and fainting, especially when you first start taking them, so it’s important to take precautions to prevent any injuries that could result from this. That includes taking the drug before you go to sleep, so you’re already laying down if problems do occur, and not driving or operating machinery when you first start taking it.

With the older drugs—doxazosin, terazosin, and prazosin— your doctor should start you on a low dose and build up to a higher dose over a period of a few weeks to give your body time to adjust to the medicine. That process is not necessary with the newer alpha-blockers (Flomax, Rapaflo, and Uroxatral).

Low blood pressure caused by the alpha-blocker medicines can fall to dangerous levels if you’re also taking a high blood pressure drug or erectile dysfunction medicines such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis). So don’t take an alpha-blocker with those other drugs without first discussing it with your doctor."

Thanks for reading,
Lisa Gill
ConsumerReportsHealth.org

[JamesB]

Thanks, Dr.Dave! That is some very important information that was left out of CR's article.

[Don]

I have been taking Doxasosin for close to a year as treatment for BPH. Because I already have low blood pressure, my urologist covered the differences between Flomax and Doxazosin very carefully with me. Because of the huge price difference and no insurance coverage, I decided to try the generic. To counteract the potential for depressed blood pressure, and hence the dizziness, he recommended that I take it shortly before going to bed at night. I do, and it has never caused me a problem at all. I get three months worth at a time for $10 at Wal-mart.

[Harvey J Gardner, Ph.D.]

Readers should be aware that alpha blockers are not without risky side effects. I am a 78 year old man and have always had normal blood pressure. Over the past 8 years or so, because of BPH, I took nightly 5mg doses of terazosin, a generic equivalent of Hytrin. In 2007, I required an increase to 10mg. The frightening side effect of both strengths was extreme lightheadedness when rising from the floor, the bed, or even from a seated position. This symptom worsened in bright sun (I once fainted when working in the garden). Thanks to outpatient greenlight laser prostate surgery in June 2008 I now urinate normally. I no longer take prescription medications.

[Dr. Wojciech]

HI,
I agree with Dr, Dave. In addition this are two different medications - despite being from the same group of alfa-blockers. Often minimal change in structure, shape or different atoms makes huge difference on effects on human body. In addition in my experience sometimes I come across in very big discrepancy in the action of the same medication but one is generic and one is brand. Sometimes it is a life and death difference like in generic coumadin. Similar differences i found in some other medications like synthroid, lopressor and few more.

[Dr. Keith]

As a family physician, I would mirror the comments of Dr. Dave. I personally am a big fan of generic medications and often prescribe them. On the other hand,safety and not efficacy always needs to be taken in to consideration. The doxazosin is appropriate in many men and I am OK with my patients bringing up the idea of switching medications to something cheaper. My advice is to sit down with your own doctor and discuss whether the medication is appropriate for you. The American Academy of Faamily Physicians periodically reviews medications using the STEPS approach. STEPS stands for Safety, Tolerability, Efficacy, Price, Simplicity of Use. Please note that efficacy is intentionally placed after Safety and tolerability. Although I did not see any STEPS listed for Flomax, you can go to www.aafp.org and research other drugs you may have questions about.

[tdncz]

I was on Flomax for 8 years, then tried doxazosin. It made me dizzy, tired, and only was much less effective at controlling my prosate problem and urinary flow issues.
I went back to Flomax after 2 months, and am much better.

[Steve Austin]

"What should a subscriber to AARP drug plan do?" Since the drug is listed in the formulary, ask your doctor to prescribe it to you. (and for a pharmaceutical free sample.) I found Doxazosin Mesylate very effective for moderate BPH at 57. I also experienced some dizziness when rising from a crouch to a standing position. For that reason alone I am trying a Flomax sample.

[Tom]

I am an engineer with no medical training, yet I notice that my comment was the first one to raise a question about substituting a blood-pressure medicine for Flomax. My comment was then followed by alarms raised by physicians. I sure hope this leads to better checking. I also notice you thanked Lisa Gil, yet I do not see any comments posted by her.

[Richard Rushing]

I appreciate this article and it appears that the commentators are knowledgable people too. Wouldn't an independent review of this topic indicate some natural herbs that are as helpful as these drugs? From my research it would seem so. I took an herbal concoction for about 6 months and the problem not only disappeared, it's been almost 2 years and it hasn't returned. The drug companies want our money forever, kind of like a subscription service!

[Jon]

As a pharmacy student I would say that the same population that requires BPH treatment is largely on Medicare Part D. Many of these plans under Medicare Part D may cover Flomax, however when the patient falls in the "donut hole" this is often the first medication they cannot afford to stay on.

The reason Doxazosin is no longer used as a hypertensive medication is because it's relatively ineffective for treating hypertension. Also syncope (falls) occur in less than 1% of patients and orthostatic hypotension can occur in up to 10% of patients, however this is generally associated with the first dose of Doxazosin (i.e. the first pill you take) rather than all subsequent doses (i.e. every pill you take). With careful titration (starting at a lower dose and gradually increasing) and monitoring of blood pressure within 2-6 hours after taking your first dose, doxazosin can be a very acceptable alternative for treating BPH.

When Flomax does go generic in about a year don't expect $4 pricing anytime soon. It can take up to 6 months for significant cost decreases, as more manufactures sign up to produce the drug and create competition in the market (driving down prices).

In terms of efficacy and side effects Flomax is the superior choice, which is why physicians prescribe it. Doxazosin is also more difficult for your physician to monitor in terms of efficacy and side effects, which is why he/she won't prescribe it as first line therapy. If you cannot afford Flomax (Or simply don't want to), ask your physician if doxazosin is right for you!

[WD]

The other point that is frequently missed when the problems with DTC adds are highlighted are the number of patients that talk to their health care professionals about problems they did not realize they could treat. The advertising for Flomax has highlighted an issue that many would not otherwise discuss with their physician, reducing their quality of life. Once the conversation takes place, physicians like Dr. Dave work with the patient to find the best fit for each patient. Clearly the drug company is making a bet that their product will frequently be the better choice often enough that driving patients to their physicians will pay off.

[RC]

Thanks for the good information Lisa Gill and Dr. Dave

[andy cha]

Generic alpha blockers which include doxazosin and prazosin have a higher side effect profile such as dizziness, orthostasis, and falls. They come in many doses to minimize side effects by titrating the minimum effective dose. Newer agents (also alpha blockade) like Flomax and Uroxatral have less risks of side effects, orthostasis and falls. Subsequently an agent like Uroxatral is FDA indicated at only a 10 mg dosage.

[Dr. Dave]

As a family physician who prescribes these drugs and with almost 13 years of experience, I can safely say the one crucial item left out of this review is this: Although the *efficacy* is similar between Flomax and it's generic counterparts, the *tolerability* is RADICALLY DIFFERENT.

Doxazosin and other older generics were originally designed as BLOOD PRESSURE medicines, they relax the smooth muscle in the wall of the artery so as to make the heart work less hard and lower blood pressure. They were also found to relax the smooth muscle in the urethra and bladder neck making them useful in treating lower urinary tract symptoms in men with BPH.

Unfortunately, there is a large proportion of patients that experience orthostatic hypotension (dizziness caused by too low of blood pressure) when they take generic alpha-blockers, which can cause falls. Given that this population of men also may have heart conditions, be on "blood-thinners" for various problems, or even may have osteoporosis, the last thing I would want to do is give them a medicine that might cause them to fall, injure themselves, or in some cases, even end up in the hospital with a hip fracture (or worse.)

Flomax has very little orthostatic hypotension associated with it, and thus is a MUCH SAFER and MUCH BETTER TOLERATED alpha-blocker. Very few patients even experience lower blood pressure when they're on it. I use it in BPH patients of varying ages, mostly so I don't have to worry about them getting injured.

Generic drugs in many circumstances can be a HUGE money saver, provided they offer comparable risks/benefits to their branded counterparts. In this case, since almost all insurance formularies list Flomax, the cost to patients is not $3000 per year, but more like $300, or even less. The benefits are the same, and the risk is much less. THAT'S why FLOMAX is used, not because of advertising! The cardinal rule of prescription medicines is this: The insurance companies decide what medicines are on the formulary and which ones aren't. Therefore, it is the insurance companies that decide what a doctor may prescribe (unless the patient is independently wealthy, that is!)

You're right on the cost, that's for sure. Fortunately, in about a year, Flomax goes generic, too!

Just thought I'd offer my 2-cents worth.

[Tom]

The AARP 2009 Formulary lists Flomax as a tier 2 drug (medium copay). The only tier 1 drug (lowest copay) listed in the same category as Flomax is Finasteride. Although it does not list Doxazosin, it does list Doxazosin Mesylate, as a tier 1 blood pressure drug. What should a subscriber to AARP drug plan do?