A Matter of Lifestyle by Elvira Maricic While raising many issues, Lifestyle Drugs can make good lives even better print article      send to a friend

Across the ocean, Viagra gave new meaning to the "special of the day" when government inspectors in France found a restaurant serving beef piccata in Viagra sauce, the key ingredient being 10 mg of the drug.

Although Viagra was intended to treat serious medical conditions, anecdotes like the above quickly gave it the label of "lifestyle drug," a product often taken not to cure an illness, but to improve the quality of life of the user. But while these medications can often make life better for healthy individuals, they are not necessarily risk- or cost-free (see A Price to Pay, below).

Not Your Father's Cure

As seen in the growing interest in alternative medicine and nutritional supplements, today's consumers, unlike their forebears, are more likely to take health matters into their own hands. Direct-to-consumer advertising has sent them to the doctor demanding a cure for what ails them, and physicians often comply. 

"For some physicians, it gets the patients in and out [of the office] quickly," says a Minneapolis physician speaking on condition of anonymity. "Of course, patients can now get prescriptions filled on the Internet by a doctor who hasn't even seen them," he adds. Worse yet, some web sites will allow patients to order drugs without a prescription, merely requiring them to fill out a form and pay a "consultation" fee.  With such unscrupulous online cyber pharmacies in mind, consumers are urged to talk plainly with their physicians about the risks of taking any drug, rather than taking the easy road to lifestyle enhancement.

A Lifestyle Guide

While most lifestyle drugs are FDA approved, patients should make an appointment with a physician before taking them.  Here is a look at some of the more popular ones:

Viagra. Designed to treat erectile dysfunction--the inability to achieve and maintain an erection--Viagra has been shown to improve erections in men around 75 percent of the time. The drug works by enhancing the release of nitric oxide, which in turn relaxes the blood vessels in the penis, increasing blood flow and resulting in an erection.  Results can vary depending on the man's age, the degree of dysfunction, and the dosage strength.  Contrary to what John Rico may believe, Viagra won't improve sex drive and will only result in an erection if the man becomes sexually excited. It's been shown to work well in younger men with erectile dysfunction as well as those with spinal injuries, but at $10 a pill, it's not a cheap antidote.

Xenical
According to the National Institutes of Health, nearly 97 million Americans--55 percent of the population--are overweight or obese, so the interest in Xenical (also known as Orlistat) is not surprising. Designed to treat the clinically obese, the drug works in the intestinal tract to prevent absorption of 30 percent of fat in a person's diet by making the enzymes that digest fat less effective. Clinical trials have shown an average weight loss of 10 percent. Xenical is approved only for those with a body mass index (BMI) of 30 or more (27 if the individual also has high blood pressure, high cholesterol, or diabetes). (BMI is defined as a person's weight relative to their height.) Expect to pay around $115 dollars for 90 tablets.

Propecia. Finasteride, the chemical compound in the hair-loss drug Propecia, was originally prescribed to treat an enlarged prostate gland. As an added benefit, it was shown to produce new hair growth for those with male pattern baldness, a condition estimated to affect 30 percent of 30-year-old men and 50 percent of 50-year-old men. The drug produces improved growth in those with mild to moderate hair loss, but will not re-grow a full head of hair and is not recommended or prescribed for women or children with hair loss. A month's supply (30 tables) costs around $50.

More Meds

In addition to the heavy hitters above, pharmaceutical companies are working to make the quality of life better in a number of other areas. Those who are embarrassed by toenail fungus can now go barefoot in the park, thanks to drugs like Lamisil, Sporanox, and Diflucan. Injections of Botox, at a cost of approximately $300 each, are making crow's feet and frown lines disappear from faces everywhere, and medications that attack social anxiety are sending former wallflowers back onto the dance floor.

This is not necessarily a bad thing, says the Minneapolis physician. "If a drug like Viagra can improve the quality of life of someone with erectile dysfunction, then why not use it?" he says. "My concern, however, is that we don't know what adverse effect some of these drugs might have in the future. Back when physicians started prescribing the pill, they didn't know it could cause cancer later on," he adds, citing the study that shows an increase risk of breast cancer in women who started taking birth control pills prior to 1975.

For many healthy individuals who look to these medications to make life better, the risk is worth it. "I'm young and healthy, so I'm not worried about side effects," John Rico says, referring to his Viagra use. "Now, the price, however, may make me want to reconsider."

A Price to Pay

It took a lung tumor to convince Damia Milic that it was time to kick her 38-year smoking habit.  Even though surgery showed that the tumor was benign, the scare was enough to send her in search of a remedy that could help her stop smoking for good.  She found it in a prescription for Zyban.

After a year without a cigarette, Milic, 61and on a fixed income, took up the habit again. "I hated smoking and hated the fact that I started up again," she says. "However, I didn't want to go back to Zyban, since it wasn't covered by my insurance. My doctor put me on Wellbutrin, which was covered, but it made me nauseous.  As soon as I have an extra $100, I'll get the Zyban prescription filled again."  (Wellbutrin is an antidepressant that also helps in smoking cessation.)

Milic's story illustrates that while lifestyle drugs can be covered by insurance, some consumers who are looking to improve their lives are going to have to pay out of pocket. As pharmaceutical costs continue to rise, health care plans are looking for ways to control costs. One solution is the three-tiered approach, which features different levels of co-pays for generic drugs, brand-name formulary drugs, and brand-name non-formulary drugs.  However, Viagra and other lifestyle drugs are increasingly not on this list, and even though some plans are adding a fourth tier specifically for theses medications, the coverage usually amounts to a slight discount. Some HMOs limit the number of times a prescription can be filled, restricting the number of doses they will cover each year. And other health plans are not covering some lifestyle drugs at all.

In 1998, Kaiser Permanente decided to exclude coverage of Viagra upon the renewal of benefits contracts. In announcing the decision, Francis J. Crosson, MD, executive director of The Permanente Federation stressed the need to guarantee the continued affordability of members' health care. Noting that the decision was a difficult one, he added, "We could, of course, build the cost of Viagra into everyone's premium, but is that the right thing to do?

"As more and more similar drugs appear with increasing frequency, we are facing the very real possibility that health care in America will become so expensive that no one will be able to afford medical care," Dr. Crosson added.

And eventually, it might also mean that lifestyle drugs will be available only to those who can afford them.

Viagra: User Beware

While lifestyle drugs can improve quality of life for those who are not necessarily ill, they are not risk-free and can often cause side effects. Some drugs, like Viagra, can even be dangerous in certain circumstances.

"Men are at particular risk if they are taking nitroglycerin. In fact, Viagra should never be prescribed to patients receiving any form of nitrate therapy. In addition, if the patient has recently had an acute cardiac event such as unstable angina or myocardial infarction, he should probably avoid Viagra," says Bernard Gersh, MD, editor-in-chief of the new Mayo Clinic Heart Book -- Second Edition. "The drug is also potentially hazardous in patients with congestive heart failure and borderline low blood pressure, including patients on multiple antihypotensive drug treatment."

 Dr. Gersh says normal, healthy individuals can experience some minor side effects that come from the drug's dilating effect on the blood vessels, such as headache, flushing and small blood pressure decrease.

In extreme cases, Viagra may also cause visual side effects, according to the American Academy of Ophthalmology.

Michael F. Marmor, MD, Professor of Ophthalmology at Stanford University and spokesperson for the Academy, said that a moderate percentage of people (3%) taking twice the recommended dose of Viagra have experienced problems with their vision. "Federal Drug Administration (FDA) clinical trials show that taking the medication, especially at higher doses, can affect the way we see for a number of hours," said Dr. Marmor. Patients reported visual disturbances described as bluish color tinge and light sensitivity. 

The FDA also recommends that Viagra should be administered with caution to patients with retinitis pigmentosa, an inherited disease affecting the retina. According to the FDA, "There is no safety information on the administration of Viagra to patients with retinitis pigmentosa." Dr. Marmor urges patients with retinal eye conditions to consult their ophthalmologist before taking Viagra.

"On the surface, seeing the world with a bluish tinge may just be annoying," said Dr. Marmor. It is not known, however, whether long-term use causes any permanent changes in vision. Until that data is in, Dr. Marmor suggests that people "stay at the lowest dose level possible." According to the FDA, the recommended dose level for most people is 50 mg.