30 September 2011
Cost or Benefits?
Talk of the cost of drugs is another interesting topic. It is a question which also involves a certain amount of philosophy. Namely, should a prescriber solely consider clinical issues when selecting a drug or should the cost of preparations also be taken into account?
If resources are infinite then the question is answered. This was effectively the situation in the UK until the early nineties when people in the NHS began to consider, for the first time, what came to be called “cost-effectiveness”.
Nowadays “finite resources” are an accepted thing. The chief advisor to professionals on clinical and prescribing matters, NICE, is funded by central government and so the cost of therapies must be one of the elements taken into account when making recommendations.
Is this why NICE prefer isophane insulin to long-acting analogue insulins? It is, after all less than half the price of either lantus or levemir.
In diabetes, the question is an interesting one. There are many oral preparations which are used in the management of diabetes. The drug of choice, metformin, is luckily also one of the cheapest, so no problem there.
It is the next stage that is the problem. The choice is between a drug which:
- is cheap but has question marks over its safety with regard to cardiovascular disease
- costs 30 times as much as metformin but has a question mark over its safety as regards bladder cancer
- costs 30 times as much as metformin but for which no evidence with respect of either long term effectiveness or safety yet exists
- costs 60 times as much as metformin but for which no evidence with respect of either long term effectiveness or safety yet exists.
The case of non-steroidal drugs is also difficult. There is not much comparison evidence between drugs. Drugs which are better at reducing inflammation have a worse side-effect profile. The price varies between £1.27 and £28.20 a month.
Pity the poor prescriber.
The bottom line is one that the NHS has been banging on about for ages. This is when drugs are off patent and available in so-called “generic” form (such as furosemide) as well as a proprietary form (such as lasix). Unless there is a good reason not to, the generic form of the drug should always be preferred. The classic example of this is in gout. The drug allopurinol in its generic form costs £1.08 for 28 100mg tablets whereas in its proprietary form, zyloric, it costs £10.19 for the same number of tablets.
Pharmaceutical companies sometimes use the word “bio-availability”; remarking that their proprietary version of a drug has a greater bio-availability than the generic version. This means that gram for gram, their version is supposedly more potent than the generic version.
This may be true with some drugs, particularly anti-epileptic drugs, but generally it is not.