This is off the subject of AC but I know many of you are experiencing the same dilemma. I have many patients with mixed hyperlipidemias resulting in both LDL and triglyceride elevations and low HDL's. Many are also diabetic. In the past I was comfortable prescribing just about any statin along with a fenofibrate as the studies seem to indicate the risk of myopathy with this combination is small and the negative effects on blood glucose are much less than with the niacins, etc. Inevitably I would get a request for preauth for the fenofibrate and could usually get it to go through after documenting the need for a statin as well. Then I started getting denials saying the insurance would only pay for gemfibrozil and not a fenofibrate. OK, so then I would prescribe gemfibrozil and change the statin to Crestor. Those then went through for a while after obtaining a preauth.
Now, however, one insurance plan in particular insists they will not pay for either Crestor or any fenofibrate and tell me that I should prescribe gemfibrozil and pravastatin and have alluded to the patient that this is an acceptable alternative. I do not believe it is, nor do any of the studies I can find. I had a 30 minute phone conversation with a pharmacist employed by this company who was very understanding. He also said he understands and agrees with my concerns. He said they (the working pharmacists there) have taken this matter several times to "the higher ups" but have made no progress. He told me these upper level people "looked at the topic and decided it was no big deal".
Well, although I tend to agree with them clinically (I really have not seen all that many problems) my drug interaction checker, the PDR, and all the online info I can find disagree and advise me NOT to use any statin with gemfibrozil. At this point however, it is only contraindicated with simvastatin. Granted, some statins may be better than others depending on their metabolic pathway but, when there are much safer alternatives, why should I even have to concern myself with this issue?
So my question is....who is going to take the heat and have to face the jury if my patients (who have been deluded by the insurance company into believing this was my idea to use this combination of medicines) develop complications? I have spoken directly with each patient that makes the choice to use these generics rather than the Trilipx, Tricor or Crestor that I have recommended. I have documented my concerns to them. But, money talks, and my "BS" walks so most of them say they want to take what the insurance will pay for. Consequently I am feeling like I am being forced to practice bad medicine. Every day my frustrations with this profession increase. Are any others handling situations like this in a better way?
