ED is a very prevalent condition in men, with increasing rates due to advancing age, cardiovascular disease, metabolic syndrome and diabetes.4 Etiologies range from organic, psychogenic, or multifactorial, and some patients may require investigations to investigate vascular, endocrine, neurological and psychological factors.1 Unfortunately, ED remains a taboo subject for many men due to embarrassment, misconceptions regarding the disease process and treatments, and even physician factors such as lack of comfort with discussing ED or time constraints in our health care system.5 This disconnect has resulted in the emergence of numerous legitimate online pharmacies offering PDE-5 inhibitors direct to consumers in Canada, a trend also seen in the United States.6,7 There are also many illegitimate online sellers that pose a risk to Canadian and global consumers.8 We sought to compare drug prices through these online pharmacies with conventional pharmacies that would usually entail obtaining a prescription from a patient’s family doctor or urologist. We also seek to discuss the implications of these online pharmacies on patient care for ED.
Five online pharmacies were selected for analysis, and when all included costs are accounted for, these services were priced comparably with conventional pharmacies. One online pharmacy was able to offer a significantly lower price for all three medications than conventional pharmacies and the other online pharmacies. Online pharmacy services offered very modest savings with increasing order quantity, if offered at all. When a conventional pharmacies’ dispensing fee was taken into account, the difference in cost per tab between online and conventional pharmacy disappeared at a low order quantity. Therefore, more significant savings can be acquired through higher order quantities at conventional pharmacies because a dispensing fee is a fixed cost, per prescription. Dispensing fees also differ between Canadian provinces, for example dispensing fees are maxed out at $13.25 in Ontario, and $10.00 in British Columbia. 9
All five of the online pharmacies advertise ease of use of their online platform, no need for a physical doctor’s visit, and discreet delivery. They are providing these additional services and benefits to the consumer, and we hypothesized that this would come at an increased cost to the consumer, which we now know is incorrect. This study also aims to provide the Canadian consumer with the necessary information to make an informed decision about how and where they seek healthcare for ED, and from our findings of competitive pricing, it is reasonable to assume that many Canadian men will utilize these services, especially as these companies directly advertise ED medications through online ads and social media campaigns. From the perspective of the healthcare provider and Urologist, the focus on “discreet delivery” as well as “no conventional doctors visit” further perpetuates the stigma surrounding ED. Although these websites do put some effort into normalizing this diagnosis by providing information on ED prevalence, there is minimal information regarding the relationship of ED with cardiovascular disease and diabetes. Thus, these advertising methods and services raise questions regarding the quality-of-care patients are receiving through online means and the potential for inadequately investigating underlying etiologies of ED. In addition, the advertisements of PDE-5 medications for ED by some online pharmacies include young men, presumably under 40 years of age based on appearance. Organic causes of erectile dysfunction do exist in this population, but the vast majority is of a psychogenic nature.10 Although PDE-5 inhibitors may be indicated in this population, lifestyle factors and conservative measures are important factors to consider before moving to medical therapy. Furthermore, it is conceivable that these additional factors will be less adequately addressed by health questionnaires and quick online virtual visits by a healthcare provider not known to the patient. This is a possible area of future research to ensure patients are not receiving suboptimal care due to use of online healthcare platforms.
The increasing prevalence of these online pharmacies serves as a reminder to the healthcare community and urologists specifically that the state of ED care in Canada remains suboptimal, with significant barriers. Whether attributed to the patient factors described above such as embarrassment, physician discomfort with speaking about the diagnosis or long wait times and specialist referral times11, Urologists, as the specialists of ED, may need to be more involved in helping to remove these barriers.
This study does have limitations. We did not make any orders from these online pharmacies; therefore, it is unclear if there are additional discounts with multiple orders or if there are hidden costs not seen when setting up an order. We did not actually observe an online medical visit or questionnaire review to comment on the quality of this medical review. We also only used comparator pharmacies in our local area which may not be representative of pharmacies across the country.