bucket of money, sticker shock, rebates

Should you take your medication with food or on an empty stomach? Many people don’t pay much attention to how they swallow their pills. That could be in part because very few folks ever talk to a pharmacist any more. The pharmacy tech or clerk hands you a bag and off you go, often without even glancing at what’s inside. When it comes to a very pricey prostate cancer drug called abiraterone (Zytiga), that could make a huge difference to the bottom line.

Abiraterone (Zytiga): An Important Advance.

The story of Zytiga is quite fascinating. A group of British researchers at the Institute of Cancer Research in the UK developed a unique way to shut down the body’s ability to make testosterone. For men with advanced prostate cancer this was an important advance. A study published in the New England Journal of Medicine (July 27, 2017) concluded that if Zytiga were added to standard hormone suppression treatment it led to “Significantly higher rates of overall and failure-free survival.” That combo was compared to what is called ADT or androgen-deprivation therapy.

The lead author of the study was quoted in the British publication, The Guardian (June 3, 2017) after the data were presented at a big cancer meeting:

“These are the most powerful results I’ve seen from a prostate cancer trial. It’s a once in a career feeling. This is one of the biggest reductions in death I’ve seen in any clinical trial for adult cancers. Abiraterone not only prolonged life, but also lowered the chance of relapse by 70% and reduced the chance of serious bone complications by 50%. Based on the magnitude of clinical benefit, we believe the upfront care for patients newly diagnosed with advanced prostate cancer should change.”

Zytiga was approved by the FDA for the treatment of prostate cancer in 2012.

The Cost of Zytiga Keeps Skyrocketing:

Despite the good news about abiraterone (Zytiga), there is one giant problem. This medicine is pricey. Some might say that’s an understatement. A few years ago the drug cost about $7,500 for a month’s supply. Now, it is estimated to run between $8,000 and $11,000 a month. That means a year’s treatment could well exceed $100,000.

If an insurance company refuses to cover the cost of this medicine or if the co-pay is 20%, most men will not be able to afford this valuable medication. Cancer patients have a challenging enough time as it is. They shouldn’t have to face bankruptcy because they cannot afford an important medicine.

Taking Zytiga with Food Could Save Big Bucks!

The official prescribing information for Zytiga suggests a 1000 mg daily dose. It is often prescribed as four 250 mg tablets. There is the following admonition:

Important Administration Instructions:

“ZYTIGA must be taken on an empty stomach, either one hour before or two hours after a meal.”

For many men, that means they have to take the medication first thing in the morning, at least an hour before breakfast. That can be inconvenient if you have to go to work. Waiting an hour to eat means getting up quite early each day.

New research suggests that the old dosing instructions might require some rethinking. That’s because if Zytiga is taken with a low-fat meal, four to seven times as much medicine is absorbed into the body. In other words, one 250 mg pill can do the work of four pills. If taken with a high-fat meal, drug absorption goes up to 10- to 17 times that of a fasted state.

A study published in the Journal of Clinical Oncology (March 28, 2018) is a game changer! The investigators compared a low dose of abiraterone (one, 250 mg pill) taken with a low-fat meal, to a standard dose (four, 250 mg pills) taken on an empty stomach.

Abiraterone (Zytiga) When Taken with Food:

The results were quite encouraging. PSA reductions (prostate specific antigen…a measure of biological success against prostate cancer) were comparable in both groups. Testosterone and DHEA-S levels also dropped equally. That means one fourth the standard dose taken with a low-fat meal appeared to be biologically equal to the standard dose taken on an empty stomach.

How Much Does Food Save Patients?

The authors calculate that after three years, the savings from taking one-fourth the standard dose with a low-fat meal could save a patient more than $300,000. Dr. Allen Lichter, A former CEO of the American Society of Clinical Oncology, wrote a commentary in the same issue of the Journal of Clinical Oncology:

“This $10,000 per month drug is labeled to be given on an empty stomach, but the drug has been suggested to have a five-fold to 10-fold food effect. A pilot study of 72 patients randomly assigned between the fasting dose of 1,000 mg and one quarter of the dose (250 mg) administered with a low-fat meal showed identical clinical outcomes. If this study were enlarged and repeated successfully, the resulting cost savings over time would be in the billions of dollars.”

There is an added bonus. Taking the medicine with breakfast makes life a lot easier. Instead of having to get up an hour earlier and then wait for 60 minutes before having breakfast, a man could get on with his day in a normal fashion.

Don’t Do This At Home!

This is NOT a do-it-yourself project. Taking abariterone contrary to the manufacturer’s strict recommendations requires cautious medical oversight. Overdosing on Zytiga would not be a good thing.

Abariterone (Zytiga) Side Effects:

Side effects to be aware of include fatigue, joint pain, high blood pressure, digestive upset (nausea, heartburn, diarrhea), hot flashes, sweating, fluid retention, low potassium levels, cough and headache. The higher the dose the greater the likelihood of adverse reactions.

Getting too much medicine can be just as problematic as getting too little. If you cannot afford your medicine, though, it makes sense to discuss the food effect with your physician. She might be able to come up with a strategy that would allow you to get the benefit of the drug at one fourth the cost.

People’s Pharmacy Perspective:

Abiraterone (Zytiga) is an unusual case in that the food effect is so profound. But it is not the only medicine that is affected by food. Some medications are absorbed better on an empty stomach. Others are altered by specific foods. Here is a link to our free guide, Drug & Food Interactions.

Next time you get a new medicine in the pharmacy, take a few minutes to ask the pharmacist how to take your pills. In some cases it could make a huge difference in how well the medicine works. In other cases it could be a matter of life and death.

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  1. T

    At the end of this article, you stress discussing with the pharmacist whether to take the med with food or on an empty stomach. However, in the case of zytiga, the pharmacist would have advised taking it on an empty stomach according to instructions that come with the medication. What good would that do? Your article is proposing taking the med contrary to standard instructions. People should be talking to the doctor instead of the pharmacist, shouldn’t they!

    • Terry Graedon

      We actually think you should talk with both the doctor and the pharmacist.

  2. Ron A

    I have not been able to figure out how to hear your podcast 937 on my Android phone. Help!

  3. Carl

    Food indeed matters on other meds to: i’ve been taking statins for years for cholesterol. Just this month, i changed pharmacys and the CVS pharmacist “reminded” me to take my statin at night before i go to bed as it absorbs much better thru the night without food digestion. I had always taken it 1st thing in morn. I also just started on thyroid med. He said (and I had researched it to) to take it in the morning 1hr before breakfast and coffee …. so I opted for the more expensive tiroset because it does absorb with food & caffeine, although I still wait 1/2 hr or so. I talked to a friend taking thyroid med and he had never heard of fasting for the 1st hour of his med. he always takes it with breakfast… Pays to ask, the Dr doesn’t tell you or even know about all,drug interactions but your pharmacists does!

  4. Janet

    I think pharmaceutical companies knew this, and chose to put dosage instructions to sell the most pills and make a lot more money.

    It would not surprise me if this is fairly common. They make money treating us, not curing us or keeping us healthy.

  5. SJ

    Just another example of pharmaceutical greed. The CEOs of these drug companies should be brought up on charges of “Crimes against Humanity”.

  6. Dennis F.

    Rapamycin is another expensive drug that has been reported to be more active when taken w/ food/drink, in this case grapefruit juice. I believe the report I saw mentioned a 3 fold increase in activity but my doctor was skeptical about this much enhancement of activity so I am guessing that 1/2 the recommended dose might work. Thoughts?

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