Brand-name drugs not necessarily more expensive than OTC

To the Editor:

Compliance today has become a major challenge to a primary eye care practice. As a result, the use of over-the-counter drugs when treating allergy patients has contributed to and enhanced this problem.

In the article, “Studies: Comfort, cost may affect patient compliance with medication regimen,” (February 2012, page 8), Dr. William Edmondson implied that OTC agents are just as effective as brand prescriptions. That’s like comparing an apple to an orange. One knows that the efficacy and strength of the drugs, including the preservatives, are very different.

For example, Bepreve (1.5% bepotastine besilate, Ista) contains 0.005% BAK, while Pataday (0.2% olopatadine, Alcon) contains 0.01% BAK, and Zaditor (0.025% ketotifen fumarate, Novartis), the OTC agent frequently mentioned, contains 0.01% BAK.

One should also point out that the mechanisms of action of these drugs are different. Bepreve is the only true H1-specific agent; Pataday and Zaditor have H1 and H4 properties, but are not H1-specific drugs.

When considering cost, Dr. Edmondson stated that brand name drugs were much higher than OTC drugs. The study failed to take into account that companies such as Alcon, Allergan and Ista all have rebates that bring down the co-payments from $50 to $15 and, in some cases, $10. When one calculates the cost of a 10-mL bottle with a co-pay of $15, one finds the cost to be about $0.25 per drop as compared to Zaditor’s $0.75 per drop. For those patients without insurance and in economic stress, pharmaceutical companies are always willing to make sure that they are supplied with samples.

Finally, consider the fact that an OTC agent makes managing a patient’s allergies more difficult. Patients tend to treat themselves with OTC allergy agents after the first recommendation by their physician, only this time, one might be dealing with limbal vernal conjunctivitis or giant papillary conjunctivitis, both exhibiting symptoms similar to seasonal allergy but with drastically different treatments.

Studies like these do nothing for the patient or the doctor in the management of allergies; they only give the insurance companies a stronger argument, under a false pretense, that OTC agents are equal to brand drugs in cost and efficacy, thus dictating to the physician what he or she can prescribe.

M.A. Friedman, OD

Memphis, Tenn.

Dr. Edmondson responds:

As Dr. Friedman points out, medication compliance has become a major challenge to not only practitioners, but to their patients, with fewer and fewer being covered by medical insurance benefits.

Primary Care Optometry News provided an excellent summary of two recent studies, both comparing the comfort and cost of some ophthalmic dual-action anti-allergy drops.

In the initial study, data were analyzed with single factor ANOVA testing and on a pair-wise basis using a two-tailed t-test for a difference of means. Three significantly distinct groups (P < 0.05) of comfort rankings resulted.

The two prescription medications, 1.5% bepotastine (Bepreve, Ista) and 0.2% olopatadine (Pataday, Alcon), were rated significantly more comfortable than the two OTC anti-allergy agents. Statistically, the OTC 0.025% ketotifen (Zaditor, Novartis) was rated in the mid-range of comfort, while 0.025% ketotifen (Alaway, Bausch + Lomb) was the least comfortable.

When Zaditor, like oral Claritin (MSD Consumer), went from a prescription anti-allergy medication to an OTC medication, several companies began providing 0.25% ketotifen formulations. The second study compared four of these ketotifen formulations for comfort and cost. Of the most available products, Zaditor again was rated significantly more comfortable than Alaway, with Alaway being less costly to use per day.

The studies also discussed the per-day costs to the patient. For patients with insurance covering prescriptions and the best tier deductable, per-day costs with a 10-mL bottle size could, in some cases, approach that of OTC ketotifen drops. Without insurance, the cost could be more than $4.00 per day.

Responsible clinicians discuss available choices in chronic medications with multiple refills needed during allergy season. In this economic era, insurance coverage cannot be taken for granted. The point of both studies is that the clinician can aid compliance by responsibly discussing medication comfort and cost whether he and the patient are considering prescription anti-allergy drops or available OTC ketotifen drops.

William Edmondson, MAT, OD, FAAO

Southern College of Optometry

Memphis, Tenn.