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Many common conditions respond to inexpensive treatment options
It is possible to relieve symptoms, maintain standard of care and save the patient money at the same time.
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In cases where patients have no insurance or have limited prescription coverage, a management plan can be challenging.
Most clinicians have probably experienced the scenario where they prescribe the latest antibiotic, the patient discovers a high out-of-pocket cost at the pharmacy, and either the patient foregoes the medication or the pharmacy calls the doctor’s office for an alternative, taking the doctor away from a full clinic schedule.
Oftentimes cheaper treatment options are available for conditions such as blepharitis, hordeolum, simple bacterial conjunctivitis, contact lens acute red eye, episcleritis and allergic conjunctivitis.
Corneal abrasion
A prime example of a simple corneal abrasion is in the case of a female patient who accidently poked herself in the eye with her mascara brush. In this situation we are not treating an active infection; we are preventing an infection until the corneal epithelium is intact again.
Although one could certainly use a powerful antibiotic such as gatifloxacin or moxifloxacin for prophylaxis, this may be likened to using a “shotgun to kill a fly” and may indeed be overkill in strength and cost. In this particular case of uncomplicated corneal abrasion (ruling out any medical/drug allergies, of course), I routinely use tobramycin or polymyxin/trimethoprim drops, as they continue to be a justifiable and potent medication. Some clinicians may argue that tobramycin has the potential to be toxic to the cornea, but this is unlikely to occur when used for a short duration of time, when corneal abrasions typically heal completely within 1 to 3 days.
Christopher J.
Borgman
To further justify the potency of tobramycin, it is commonly used by many corneal specialists in a fortified solution in cases of resistant bacterial corneal ulcers. On the other hand, of course, if the patient presented with an ominous, vision-threatening issue such as a corneal ulcer secondary to contact lens overwear, a more potent antibiotic such as a fourth-generation fluoroquinolone would be standard of care and would be the better option. But in the vast majority of simple red eyes we have a large armamentarium of viable and potent medications available at a significantly reduced cost to our patients.
Allergic conjunctivitis
I commonly run into allergic conjunctivitis during my regular patient exams. Most mast-cell stabilizers/antihistamine eye drops generally take about 2 weeks of daily use to reach their maximum therapeutic effect, although sometimes sooner. While it is no secret that low-dose topical steroids can sometimes bridge the gap and bring faster relief to patients who are suffering from more severe itching and watering eyes, the “go-to” drop tends to be loteprednol 0.2% or 0.5%. Although this drop is undeniably efficacious, safe and works very well in many people, it is still nonetheless expensive for those who are underinsured or have no insurance coverage at all.
One commonly forgotten topical steroid is fluorometholone (FML) 0.1%. This medication will typically bring rapid relief of itching much like loteprednol would, but usually at a much lower price. FML is also considered to be one of the safer topical steroids, as it is a milder steroid with a decreased risk of intraocular pressure spikes similar, although not identical, to loteprednol. A mast-cell stabilizer/antihistamine combination medication is usually prescribed concurrently with the steroid for long-term allergy control, as these anti-allergy drops tend to have a safe long-term profile compared to long-term steroid use.
In the case of minimal or no insurance coverage I commonly will prescribe an over-the-counter (OTC) allergy drop such as ketotifen 0.025% compared to a more expensive bottle of olopatadine, epinastine, azelastine, or bepotastine. Ketotifen used to be available only by prescription but otherwise remains the same efficacious molecule, so it can still be expected to be a reliably potent allergy medication despite being available over-the-counter.
CLARE
All practitioners are familiar with contact lens-associated red eye (CLARE): a contact lens-wearing patient reports that they slept in their daily disposable lenses overnight by accident and woke up with a red, watery and photophobic eye. They present to your office and show no signs of contact lens-associated bacterial keratitis, so you immediately tell the patient to discontinue their contact lens wear until further notice and prescribe drops. A combination drop works well in situations such as this, as the steroid component helps calm the inflammation of the eye and the antibiotic component helps prevent secondary bacterial infection. Many times tobramycin/dexamethasone or tobramycin/loteprednol drops are justifiably used, but these, again, can be expensive to patients with no or limited insurance coverage.
In these instances, I will routinely consider using neomycin/polymyxin B/dexamethasone drops for a few days to help calm the eye and prevent infection concurrently. This combination drop is readily available and works well, but best of all it is inexpensive. The only downside is the increased incidence of allergy to the neomycin component of the medication. However, there is a good possibility the patient will respond nicely to the medication without incident because of the steroid component of the drop, which will help negate or minimize any allergic response.
In addition to this, the drop is typically used for only a handful of days then discontinued once the eye stabilizes, so any lingering allergic reaction, if present, is usually fairly short in duration. If an allergic reaction is noticed, substituting one of the other, more expensive, antibiotic/steroid combination drops would be a reasonable clinical decision.
Hordeolum
Internal/external hordeola are treated with warm compresses and/or antibiotic ointments in conjunction with oral antibiotics, which can help eradicate the localized bacterial infection and speed up recovery. Generally, oral azithromycin or levofloxacin capsules or tablets can be used with good success. However, oral cephalexin is also a good alternative, as it is a generic cephalosporin class antibiotic that works well against gram-positive bacteria, the most common class of microorganisms associated with hordeolum formation and other eyelid infections.
In addition, cephalexin is widely available and inexpensive. The only caveat is that if the patient has a history of penicillin allergy, cephalosporins should be avoided, as there is a reported cross-sensitivity to cephalosporins about 10% of the time. However, this relationship has been questioned, with recent studies showing that it is more likely about 1% rather than 10%.
Dendritic keratitis
The historical standard of topical trifluridine drops or the newer option of topical ganciclovir gel work well for herpes simplex dendritic keratitis. However, both tend to be rather expensive for most patients, sometimes even to those who are fortunate enough to have good insurance coverage.
An alternative to these topical antivirals is good old oral acyclovir. It tends to be drastically cheaper than any of the topical antivirals or later-generation oral antivirals such as valacyclovir or famciclovir, although valacyclovir is generically available now and is becoming less expensive. The only downside is the patient must take acyclovir more frequently, as one pill five times per day is the standard of care. Also, as a side note, kidney function needs to be monitored if any level of kidney failure is present, as the drug is excreted via the kidneys.
In my experience, patients are more than willing to take a drug more frequently for a short period of time if they get the same desired effect for a much lower price. However, every patient is different, and all should be clinically judged on a case-by-case basis. I know my patients appreciate my efforts to keep costs down when feasible.
Patient assistant programs
For those patients who require a specific product to treat their condition, remember the patient assistant programs from most of the major pharmaceutical companies. These are great ways to get low-income patients the medication they need at a discounted price or at no cost. The patient needs to prove that their income meets the program requirements, but in my experience, the pharmaceutical companies do a good job running these programs in an efficient and timely manner.
Your pharmaceutical representatives can tell you about such programs, and the information is also available online.
You can help keep costs down
It is important to note that I am not advocating sacrificing the health or well-being of a patient for a chance to lower costs by prescribing a cheaper medication. My goal is to do what is best for the patient. Given the rising costs of health care and increasing limitations of what some insurances cover, we, as a profession, should become more aware of what medications cost nowadays. We can all do our part to help keep costs down, especially for the sake of public programs such as Medicare and our state Medicaid programs, which are running low on funding that eventually comes out of our taxpaying pockets in one way or another.
I urge optometrists to check out the cost of the most common medications you are prescribing in your hometowns. I use GoodRx.com and the GoodRx app predominantly, but I also use the Epocrates app. You might be surprised at how much your patients spend on their ocular medications. Proudly, our primary concern as a profession always has been and always should be the well-being of our patients’ ocular and overall health. But if you can relieve the patient’s symptoms, maintain standard of care and save the patient money at the same time, you truly have his or her best interest in mind. And if your patients know how hard you work to help them save money and maintain their eye health, you will gain their unwavering loyalty, which is something money cannot buy.