An effective eye drug is $50, but many doctors choose a $2,000 alternative

"Ophthalmologist here.

As a physician responsible for prescribing and injecting these drugs, I can tell you that this article glosses over the single most important factor involved in deciding between the three currently-available Anti-VEGF options: compounding pharmacies, and the lack of regulation thereof. Any Ophthalmologist at this point is very familiar with the results of the CATT study which confirmed the equal efficacy and safety of bevacizumab (Avastin) and ranibizumab (Lucentis). The reality is that the actual drug injected into the patient's eye either comes from the manufacturer in a sterile, ready-to-inject form (Lucentis), or an appropriate amount was prepared for intraocular injection by a local compounding pharmacy (Avastin).

Compounding pharmacy regulation is notoriously poor, and the risk of an intraocular infection is not one many retina specialists are eager to take unnecessarily. Endophthalmitis frequently leads to blindness, even with early diagnosis and treatment. As much as everyone wants to think doctors are only interested in lining their pockets, the reality is that most of us simply don't want your grandparent going blind in one eye because a minimum-wage tech at a compounding pharmacy failed to follow appropriate sterile procedure. The American Society of Retina Specialists have been advocating for increased regulation of compounding pharmacies since Lucentis became available. Check out their website.

I guess I should also point out that we get paid the same for injecting any medicine into the eye, regardless of the cost of the drug. And we purchase and stock both drugs in the clinic, and bill insurance for whichever is used. So we don't benefit financially for injecting one versus the other."

http://www.reddit.com/r/politics/comments/1sdxz6/an_effectiv...

Eye doctor here. Avastin is currently used off-lable for eye conditions (most commonly wet AMD and macular edema in diabetes). It is only FDA approved for use in treatment of some colon and lung cancers. Generally speaking, even though it fits standard of care within the field of ophthalmology to use this drug, there are still some inherent risks in doing so for the practitioner, thusly, Lucentis is still preferred by some. Also, I've not encountered this (as MOST insurance companies would prefer practitioners to use the cheaper drug) but I've heard of difficulty with third party payer coverage/ reimbursement when using the off-lable drug.

Another thing to consider, as ajrw pointed out, they ARE NOT as the article mentions "the same drug." Some people respond more favorably to one versus the other. Commonly, the two will be used in succession on the same patient as though no double blind clinical trial has been done to confirm this; both drugs tend to exhibit a slight tachyphylaxis over time (diminished effect). Practitioners have found that when one drug starts becoming less effective, switching to the other VEGF inhibitor can show recapture of the previous level of therapeutic benefit.

I would advise all to take this article with a huge grain of salt. Most practitioners are not aiming to increase insurance costs (obviously, as generally speaking, the higher the bill, the harder it is to get the reimbursement.) Many are probably apprehensive to use an off-lable drug from a medical-legal stand point.

Note: I am not a surgeon. So some of this is slightly presumptive.

1: http://www.reddit.com/r/politics/comments/1sdxz6/an_effectiv...

The rest of the world is very grateful for the US pharmaceutical market. Its unregulated and "free" nature, like consumer advertising for prescription drugs - something completely unheard of in civilized countries - allows for massive profits for the pharmaceutical industry.

those profits do not happen anywhere else. european agencies control and negotiate prices centrally, emerging markets seems to follow the european model (brazil, china, etc.).

those profits do get invested back into r&d, the patent system forces pharma companies to move forward. the recent patent cliff is a great indicator for the system working.

pharma r&d would be severly constrainted if not for the profits generated in the US market. on a global scale it looks like a subsidiy by the US people, paying high markups and taking way more drugs than needed - for the good of the rest of the planet.

thank you. and keep swallowing pills.

I found it especially misleading that they used anecdotal evidence to claim that the cheaper drug is equivalent in function and safety.

That said, Genentech is on the wrong side of the PR angle here and unfortunately for them, some internal documents got exposed which make them seem less than angelic here. If the cost differential of producing the drugs really is small, then they don't have a strong position, because it makes them appear as if they are using one of the drugs as a profit center to fund future R&D.

Anyway, the article really glosses over stuff, but you'd need to spend about 5-7 years getting a PhD in pharmaceutical chemistry, plus working in industry for a few years before you understand the business and science of what genentech does.

If you are ever in a situation where you have to pay for drugs out of pocket or your insurance doesn't cover enough of the drug call your doctor and ask for a lower cost alternative. They can call the pharmacy and often times find a lower cost alternative to fit your budget.

At least this has been my experience with my doctors. I have also had my primary physician straight up tell me the price difference between the best choice and second-best choice doesn't justify the benefits.

But doctors don't buy the drug, patients and Medicare do. So it is straight up bribery of people abusing legally protected positions of trust?

I do not understand why anyone thought this was a good idea, or even one that made sense. What was the purpose here?

It seems that patients aren't agents who have any involvement in anything, in the authors world. They're just objects to be pushed around by insurance companies, doctors, and drug makers.

Regardless of the details of these two drugs, right there you have the problem with health care in America.

As any chemist worth their salt will tell you, small differences to molecules doesn't necessarily make them just as easily produced. And similarly any biochemist worth their salt will be able to tell you that small differences can indeed matter a lot!

Reading the wikipedia article for the more expensive drug (http://en.wikipedia.org/wiki/Ranibizumab), it does appear that there are therapeutic differences between the two drugs in terms of associated infections.

The real thing, however, to check when talking about medicines is the Specific Product Characteristics sheet. This is, in essence, what doctors refer to when looking up medicines. http://www.medicines.org.uk/emc/medicine/19409/SPC/Lucentis+... and http://www.medicines.org.uk/emc/medicine/15748/SPC/Avastin+2... . Avastin is used for a lot more than just eye conditions, it seems, and has shall we say a number of issues.

Something most people fail to realise is exactly how expensive new drug development actually is. You've got experimental labs doing in-vivo tests of thousands of molecules (at least), animal studies to ensure the human trials will be safe, multiple stages of clinical trials in humans with associated insurance, etc. The sole means of recuperating the cost of all of this is through product sales. There are very few actual grants awarded for developing medicines all the way through to production. No tie-in marketing of lunch boxes. No crowdfunding from patient groups.

I do wholeheartedly agree, however, that there are perverse incentives on doctors to prescribe more expensive medication, and the modern pharmaceutical industry is messed up in so many ways. Most doctors too don't even understand properly what it is they are prescribing[1], and the 21st century medical representative system has more in common with jingles and home appliance sales than the clinical educators of the 20th century.

Disclosure: I have family and friends working in this field

[1] Reasons why people become doctors: money, power and helping people. Good doctors get to chose two of out of three. And to be fair to doctors, they have to remember a hell of a lot of academic material in a constantly changing field, and /then/ have social skills and physical skills to master

Take the anti-viral drugs acyclovir and valacyclovir. They're both anti-virals used to treat diseases caused by the herpes simplex virus (e.g. shingles, chicken pox, cold sores, herpes, etc.), and are both commonly prescribed to patients of all ages. The only difference between them is that valacyclovir is a pro-drug -- it metabolizes to acyclovir -- and has slightly higher bioavailability, which means that patients can take three doses a day, instead of five. Otherwise, they're equivalently effective medications.

Granted, three doses a day is easier on patients than five doses a day, but that convenience comes at a cost: valacyclovir costs about five times as much as acyclovir. Your doctor won't tell you this -- she'll just prescribe the valacyclovir, in nearly all cases -- and your private insurance company won't do anything to encourage you to take one drug over the other. About the only way you'd know is if you tried to buy the drug without insurance, and your pharmacist told you that you could use this other, cheaper medication to save a lot of money.

Not only are "entitlement programs" not the problem here, they could actually be the solution: a single-payer health system would have an economic incentive to push back on providers, and encourage them to use more cost-effective drugs. Our current, private insurance system is almost totally blind to cost effectiveness, because nobody in the chain has any incentive to care. The final costs of the system get passed back to employers in the form of annual rate increases, when it's too late to do anything about them.

These companies are just looking out for their own like good Americans.

The answer is that drugs aren't priced by how much they cost to manufacture a dose -- nor should they be!

Roughly, they're priced by the cost of R&D (a fixed cost) and the benefit to patients (a fixed benefit per patient). So it makes complete sense that Lucentis is more expensive, because the does size is so much smaller. It's still vastly less expensive to get eye treatment with Lucentis than cancer treatment with Avastin, which runs at ~$100,000/year.

http://www.fiercepharma.com/story/novartis-digs-safety-data-...

medical research is stupidly expensive and companies need to recover their costs for their to be progress at all. incidentally its the /only/ valid argument i have seen for patents. it also explains a lot of the high expenses involved... its a shame, i feel that this is an industry that desperately needs to be nationalised because, even with the best of intentions, a business must be profitable to survive.

we regularly see layers of rhetoric and polical manuveuring attacking e.g. Obama care, the NHS and similar initiatives and from this i feel we lose out - they criticise the specifics for a political agenda. imo the spirit of these programs is exactly right - the problem is always sloppy implementation by politicians (as with any case where nationalisation is not effective - which is /provable/ almost in the mathematical sense). We can't expect them to do well though - they are winners of popularity contests which essentially boil down to competitions of rhetoric and salesmanship - they have no reason to have any of the prerequisite skills for us to expect them to do a good job in that arena - or even leadership in general. it is a massive failing of our particular flavour of democracy imo.

on the other side doctors are supposed to be bound by the Hippocratic oath. this utterly rules out not helping people because they can't afford it - and yet many physicians have to make that choice regularly - which is not just breaking their word, but against the entire spirit of medicine and morality.

all in all its a horrible situation, but one that i believe is incredibly fixable... however articles like this are attacking the institutions which currently allow us to have medicine and portraying it in a way that the common man will empathize with. its just another pile of rhetoric distracting us from being productive imo... if you dig into any of the details as other commenters have mentioned, the factual basis is weak.

Since we are talking about taxpayer money, this seems like a great opportunity for a Congressional hearing on the matter.