Author Archives: Jane

What are the dangers of taking Mucinex DM and Tylenol simultaneously?

Taking guaifenesen and dextromethorphan (Mucinex DM) with acetaminophen (Tylenol) should not pose a risk of drug-drug interactions, since the metabolism (clearance) of these products do not directly interfere with each other:

Guaifenesin/Guaiphenesin

Use as expectorant (thins mucus to make cough productive)
Metabolized via hydrolysis: Unknown if metabolism via liver enzyme cytochrome P450 (CYP450)
Dextromethorphan

Use as a cough suppressant (anti-tussive) and pseudobulbar affect (uncontrolled crying/laughing)
Metabolized via liver, CYP450 2D6
Acetaminophen/Paracetamol

Use to reduce fever and pain
Metabolized via liver, CYP450 2E1
The main dangers in these medications have to do with excessive concentration of the drug in your body, i.e. overdosing.

Overdosing on dextromethorphan causes breathing problems including no breathing, blurred vision, coma, hallucinations, gastrointestinal spasms (see Dextromethorphan overdose: MedlinePlus Medical Encyclopedia).

Overdosing on acetaminophen causes liver damage serious enough to require transplantation or result in death. You should not take more than 4 grams or 4000 mg per day. Brand name Tylenol comes in doses of 500mg each pill or caplet, which means you should not take more than 8 pills or caplets per day. If you take 2 pills or caplets each dose, you can only take 4 two-pill doses each day to stay on the safer side of liver damage.

Fortunately, guaifenesin toxicity is relatively low, but doses for an adult should not exceed 2400mg per day.

Mucinex DM comes in “regular” and “maximum” strength. Regular strength contains 30mg dextromethorphan hydrogen bromide (HBR) and 600 mg guaifenesin, which you can take 1 or 2 pills (2 pills yield 60mg dextromethorphan 1200mg guaifenesin) every 12 hours. Maximum strength contains 60 mg dextromethorphan and 1200mg guaifenesin, which you can take 1 tablet every 12 hours.

Source: Cough & Chest Congestion Medicine | Mucinex®

You can calculate which is cheaper, by buying either maximum strength and taking 1 pill every 12 hours, or regular strength but taking 2 pills every 12 hours. People tend to prefer swallowing 1 pill versus 2 or more, so less pills per dose is better for patient compliance.

Do Mylan shareholders want the CEO to keep raising the price of the EpiPen?

Do Mylan shareholders want the CEO to keep raising the price of the EpiPen? We don’t know yet.

Investors like a company to deliver positive earning results and increased guidance, and the recent negative public opinion has given investors a reason to sell, which was what happened. Currently $MYL is in “oversold” territory.

Mylan 1 year and 5 year trends:
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Keep in mind that 68% of Mylan is institutionally owned. Thus the market makers’ decisions will determine whether “shareholders” truly want the CEO to keep raising prices of the EpiPen. Retail (individual) investors’ outrage makes little difference to $MYL stock price, unless you happen to be an individual who owns millions of shares of $MYL.

I suspect that there is a sweet spot that is not being discussed, which is, the institutional investors want to ensure that the EpiPen continues to dominate the market (which is temporarily the case, given the set backs of potential major competitors) but also not be priced to the point where backlash from the reimbursement side triggers costly events.

If $600 is too much for public opinion to stomach, what about $500? $400? It’s not so much about what the “real” price ends up being on the consumer-side, but the publicity around the price itself, as well as the defense of the price by a CEO who hasn’t been successful pitching the coupon/assistance angle. That’s about as effective as a U.S. private university saying, “Sure, our tuition is $65,000 a year, but our students almost never pay full price!!!”

SOMEONE is absorbing the escalating cost of a life-saving product, and we’ve been around the block long enough to know that at the end of the convoluted cost justification conveyor belt, we consumers will end up getting bitten on the butt.

Entities investing in businesses can claim an interest in public good, but only based on the extent that the cost/risks from actual (lawsuits, sanctions, blacklists) or perceived (bad PR) harm not exceed the revenues earned from pushing-moral-envelope decisions.

Once that risk begins to overshadow the rewards, you will see major shareholders send a message by selling $MYL shares. Then we can say for sure whether shareholders want the CEO to keep raising prices. Even Turing and Valeant had their glory days of astronomical stock prices, so you can’t say that shareholders aren’t enamored by questionable business practices, at least in the short term.

It’s all about risk:reward.

Update 8/29/2016

Within a week of the public outrage, Mylan will Launch Cheaper Generic EpiPen Alternative. Sounds like a good response, until you consider the fact that Mylan’s ability to launch this generic version in “several weeks after labeling revisions” means Mylan has always had within its capacity to offer a more affordable product (keep in mind, the generic version is still a 300% price hike from the original $100 tag). When was Mylan ever going public with this generic?

Also in question is 1) the growing public awareness of the CEO’s 600%+ hike in compensation that is being linked to the company’s pricing “strategy” and 2) less public awareness of the CEO selling 100,2000 shares of company stock at $50/share for a gross $5,010,000 after the earnings report, but before the price hike frenzy (SEC FORM 4). You can’t convince me that any executive shrewd enough to get to a C-level position can’t foresee the possible public backlash to a 600% price hike of a cheap drug delivered in the medical device that is really the main “product”.

The fact that Mylan did this in response to negative publicity reinforces the public perception that the pharmaceutical industry does indeed have “affordable alternatives” but chooses to withhold them to the public to rake in more profits. Even though reality is what Bruce Booth wrote in Forbes (Innovators vs Exploiters: Drug Pricing And The Future Of Pharmaforbes.com), where differential pricing exists for the industry to offset the steep discounts in other countries by making “countries that can pay”, pay much, much more.

The average consumer is not going to care to understand the complex pharma industry supply chain or convoluted regulatory maneuvers. The consumer knows that healthcare is at a tipping point that somehow hasn’t been tipping in the right direction, and industries like pharma spending a lot of money lobbying and advertising. More and more, social media is enabling consumers to coalesce into groups and transform into activist voices that can change how companies make decisions.

This means the pharmaceutical industry should start paying attention to actually educating consumers on the brutal realities of opaque drug pricing versus perennially showcasing the bloating belly of “cost of discovering and bringing drugs to market.” Let’s face it, that argument has not convinced the public on why drugs cost so much, and it’s a failed strategy. The industry needs to spend money on what actually works to engage consumers, not on new versions of the same graphs that had thus far convinced few and far between.

Theranos’ AACC Presentation: Not the Reboot We Were Hoping For

Move over, Edison: here comes miniLab.

And yet: “Every piece of technology they presented has been known for many years, and exists in other platforms largely in the same configuration, or in some cases in much more compact form in competitor’s platforms.” ~ associate professor in U. Washington’s dept of laboratory medicine.

Data has not been independently verified.

Holmes did not clarify that the 11 tests she presented would require at least 3-4 pricks if each prick yields only 160-uL amounts.

https://www.wsj.com/articles/theranos-founder-elizabeth-holmes-introduces-new-blood-testing-device-1470089582

https://www.wired.com/2016/08/theranos-chance-clear-name-instead-tried-pivot/