Today's post from uofmhealth.org (see link below) puts forward the premise that if all drugs used to treat neuropathy symptoms work much the same, doctors should prescribe the cheapest first to help save money. It's claimed that all neuropathy drugs will bring relief, which this blog seriously doubts and the article's aim seems more about bringing down costs than effectively treating the patient. It may be true that most neuropathy drugs work equally well but that often means, they don't work well at all - just equally! Apart from the issue of side effects with older drugs, everybody reacts differently and individually to particular treatments. It's not for nothing that there is a treatment cascade of drugs for nerve damage symptoms and that most people work their way through 5 or 6 of them before getting any relief and the reason for that is that they are just not that effective in suppressing nerve pain. If doctors are encouraged to always go for the cheaper option, patients could well have problems for longer and face rejection for better-directed but more expensive options. Cutting costs is a world wide trend at the moment and that may be necessary but then governments need to exert pressure on drug companies to lower their prices, reduce their profits and put the patient first. Cost should never be an issue when treating a serious medical condition.
Brian Callaghan, M.D. Eva Feldman, M.D., Ph.D ANN ARBOR, Mich.
Since new analysis of current evidence finds expensive and cheaper drugs both work well, doctors should consider costs until more studies are done
— Millions of people with diabetes take medicine to ease the shooting, burning nerve pain that their disease can cause. And new research suggests that no matter which medicine their doctor prescribes, they’ll get relief.
If all treatments for the condition provide roughly the same relief, doctors should start by prescribing lower-cost ones, the U-M experts say.
But some of those medicines cost nearly 10 times as much as others, apparently with no major differences in how well they ease pain, say a pair of University of Michigan Medical School experts in a new commentary in the Annals of Internal Medicine.
That makes cost -- not effect -- a crucial factor in deciding which medicine to choose for diabetic neuropathy, or diabetes nerve pain, the U-M researchers say.
Their commentary accompanies a paper from Mayo Clinic researchers and their colleagues, who analyzed a wide range of data from clinical trials of different treatments for painful diabetic neuropathy. The Mayo-led team concluded that several options appear to work well, though they need to be compared head-to-head to tell for sure which is best.
Until new studies can make those head-to-head comparisons, say the U-M experts, doctors should consider the cost of the drug, and any other conditions a patient has, when deciding what to prescribe.
Brian Callaghan, M.D., the article’s first author, says the new Mayo study, national guidelines and other efforts have focused on how well different treatments work against diabetic nerve pain. Half of all people with diabetes develop neuropathy sometime during their experience with the disease, and it can keep patients from exercising or walking. Neuropathy plays a role in many diabetes complications.
But cost hasn’t figured into these studies, he says. That’s why he and fellow U-M neurologist Eva Feldman, M.D., Ph.D., decided to look at the dollars side of diabetic neuropathy for their article.
“These treatments all work about the same, but what’s different is their side effects and cost. The older medications are an order of magnitude cheaper, about $15 to $20 a month, compared with the newer ones at nearly $200 per month,” he says. “Patients are on these medications for many years, and it really starts to add up. Given that the effects of the medications are similar, why should we start patients on the expensive drugs until we’ve determined whether or not they respond to the less-expensive ones?”
The newer drugs, of course, have marketing campaigns behind them – and in the case of diabetic neuropathy, their manufacturers may have sought and received specific approval for diabetic neuropathy from the Food and Drug Administration.
The newer drugs have earned the highest level of recommendation in national treatment guidelines, which requires that at least 80 percent of people taking part in a clinical trial complete it in order for the study to be considered for high-level guideline approval. This helps create an artificial appearance that the newer drug is the better choice, says Callaghan.
But in fact, the trials of other medications for diabetic neuropathy had 70 percent or more completion rates, he says – not an appreciable difference.
And even though older generic drugs without a specific indication for diabetes pain must be prescribed “off label” by doctors, the evidence that they work is powerful – including the evidence from the new meta-analysis by the Mayo-led team.
Callaghan, who sees diabetic neuropathy patients at the U-M Health System, says he prescribes generic drugs, gabapentin or one of the tricyclic antidepressants, routinely as the first option for new pain.
The authors looked at the cost of one month of the typical starting dose for each of these medications. According to Drugstore.com, pregabalin is the most expensive at $189.98 per month, followed by duloxetine at $170.99 per month. Although venlafaxine is generic, its cost remains high at $119.98 per month. In contrast, gabapentin comes in at $18.99 per month, amitriptyline at $12.99 per month, and nortriptyline at $19.99 per month. A topical cream of capsaicin, available over the counter without a prescription, costs the least: $13.99 per month.
“The Mayo study supports other systematic reviews on this issue,” he says. “We hope that adding in the cost consideration will be useful to neurologists and primary care physicians alike, since we all treat patients with painful diabetic neuropathy.”
Callaghan, an assistant professor in the Department of Neurology, is also a member of the U-M Institute for Healthcare Policy and Innovation. Feldman is the Russell DeJong Professor of neurology and director of the A. Alfred Taubman Medical Research Institute.
Reference: Annals of Internal Medicine: Mayo study: doi:10.7326/M14-0511 U-M commentary: doi:10.7326/M14-2157
http://www.uofmhealth.org/news/archive/201411/cost-and-effect-cheaper-remedies-should-rule-diabetes-nerve
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