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Eye care providers prefer branded to generic glaucoma drugs
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Representing nearly 80% of prescriptions filled in the U.S., generic medications play a large role in the lives of health care providers and patients alike.
The driving force behind the use of generic medications is cost. As detailed on the FDA’s website, the cost of a generic medication can be 80% to 85% lower than the brand-name version. Generics approved by the FDA saved $158 billion in 2010, according to the agency.
“It is well-established that cost of medicines is the greatest deterrent to enduring use,” Primary Care Optometry News Editorial Board member Randall Thomas, OD, FAAO, said in an interview. “Taking any medicine for any asymptomatic disease is a basic challenge. Two notable examples are systemic hypertension and glaucoma.”
PCON Editorial Board member John A. Hovanesian, MD, FACS, agreed.
“If you run out of meds before the end of the month and you’re out of cash, patients will forego their glaucoma medications in favor of putting food on the table or for medications that treat symptoms,” he said. “Human nature is such that we give in to short-term benefits.”
Adherence to glaucoma medications poses a specific challenge, PCON Editorial Board member Murray Fingeret, OD, said.
Murray
Fingeret
“Glaucoma is a condition in which there are no symptoms, especially in the early stages of the disease,” he explained. “The fact that damage is starting to occur is difficult for patients to fathom.”
He continued: “The damage usually starts in the periphery of the field so that it is not obvious, and damage starts in one eye, not two at the same time, so that the good eye’s field will fill in and cover up any gaps in vision. On top of this, the medications are expensive, people have to remember to take them and they often cause red or burning eyes. Most will get the first prescriptions filled, but then stop over time.”
Generics and compliance
A study recently published in Ophthalmology found that patients who switched to generic glaucoma medications were more likely to adhere to their drug regimens.
PCON Editorial Board member John A. Hovanesian, MD, FACS, said in his practice he keeps patients with ocular surface disease on brand name drugs.
Image: Hovanesian J
“With the introduction of generic latanoprost, the authors showed improved adherence with the use of generic latanoprost compared to name-brand agents,” Blair Lonsberry, MS, OD, MEd, FAAO, wrote in a perspective for PCON. “Additionally, higher co-pays during the pregeneric period, lower co-pays during the postgeneric period and black race were also determined to be factors influencing postgeneric adherence.”
The study was constructed as a longitudinal cohort analysis of 8,427 patients with open-angle glaucoma who were older than 40 years.
In the study, Stein and colleagues recorded the rate of adherence for topical prostaglandin analog (PGA) use 18 months before and after they introduced generic latanoprost. To analyze the effect of this introduction, researchers compared the adherence rates of patients who switched to generic latanoprost with the adherence rates of patients who continued to use the branded prostaglandin analogs.
Researchers reported that patients who continued to use the branded prostaglandin analogs were 28% less likely to demonstrate improved adherence and 39% more likely to demonstrate reduced adherence than patients who switched to generic latanoprost.
“This study highlights the impact of medication cost and access to generic PGAs on medication adherence,” Stein and colleagues concluded. “We identified a subset of patients who clearly exhibited an improvement in adherence when they were switched from a brand-name PGA to generic latanoprost.
“When clinicians know or suspect that a patient is struggling with adherence, attempts should be made, whenever feasible, to switch such patients to generic glaucoma medications,” they continued. “This can be particularly helpful for patients with high copays and racial minorities.”
Issues with study
In their report, Stein and colleagues noted some of the study’s limitations.
“When relying on claims data to study medication adherence, all researchers can tell is the extent to which medication prescriptions are filled, not whether they are taken as directed or whether the patient is successful at placing the medications in the eye,” they wrote.
The researchers continued: “The database does not contain information on samples dispensed in the office or medications purchased outside of the plan.”
Despite agreement in cost as a barrier, the eye care providers who spoke with PCON were cautious regarding the study and its results.
“Whenever you collect data in a retrospective fashion, there may be issues,” Fingeret said. “This study used claims data from thousands of individuals but still needs to be used cautiously until the results are confirmed.”
J. James Thimons, OD, FAAO, agreed that the results needed to be thoroughly vetted.
J. James Thimons
“The study has several weaknesses, among which is the lack of data on the use of samples by clinicians to support patient care, a fairly common practice,” Thimons stated. “This could lead to a bias in the rate of compliance by falsely identifying a branded product patient as noncompliant when instead they did not use the refill because they had received a sample from their clinicians.”
“Anytime cost is reduced, compliance increases, but doctor and patient education is still most critical,” Thomas added. “Anytime there is a ‘switch’ in any two medicines, compliance is transiently enhanced.”
In a written perspective for PCON, Lonsberry addressed some of his clinical concerns.
“One should be cautioned that this study only addressed the refill rate of patients and their medications,” he said. “No data is presented on the effectiveness of the generic and whether there was a potential increase in adherence secondary to the increased ‘observation’ by the health care professional after switching to the generic.”
Thimons also told PCON that, despite some inconsistencies in the study, the results have a valid point.
“We all need to be concerned about cost,” he said. “Conversely, every doctor in eye care needs to be vigilant that we need peer-reviewed data about the drugs and generics that we’re using. Generic companies won’t do that because it costs too much money.”
Dealing with cost
The doctors acknowledged that while drug manufacturers provide opportunities for patients to save money, they are still companies that need to make money.
“Most of us think of drug companies as being very wealthy,” Hovanesian said. “It’s difficult for them to reduce margins in many cases. In many states, to be on the formulary, they have to lower prices so that they actually lose money on every prescription.”
He continued: “The drug companies give you a lot of samples, create rebate programs and coupons. They can try to make retail prices more reasonable, but when you consider that it can cost $1 billion to bring a drug to market, it’s no surprise that these companies are not able to make the price as low as we’d like them to. There’s a cost of innovation.”
Fingeret agreed, stating that it is not feasible for the companies to further reduce the cost of their medications.
“The drug companies already discount to the insurers and they are for-profit companies,” he said. “The cost is in line with what other medications cost. This is not just about the drug companies, but the way we pay for drugs in this country and how insurers manage health care.”
Thomas said that the coupons drug companies may provide are not helpful for all patients.
“Use of generic medicines or industry-provided coupons can be a considerable cost advantage for many patients,” he said. “A major drawback is that these coupons are typically not applicable to Medicare patients, who compose the lion’s share of glaucoma patients.”
Thimons noted that, in his market, most of his patients are able to afford branded drugs, as generic medications have gotten more expensive.
“About 50% to 60% of my patients have easy access to branded product at about $20 to $25,” he said.
Using generics in a clinical setting
All of the doctors PCON spoke to strongly advised other optometrists and ophthalmologists to take the time to educate their patients regarding differences between branded and generic medications.
“In some cases, the effectiveness in lowering pressure may not be as good,” Hovanesian explained. “Additionally, generic drug makers are required to include the same active ingredient in the bottle, but the formulas can include differing inactive ingredients. Because you’re putting the medications directly on the target organ, you may have long-term effects. We have a better safety profile on the actual drug compared to the generic drug.”
Hovanesian also urged eye care providers to utilize an electronic health record system to create a database of medications that are covered by insurance and affordable to keep a patient on a brand name drug.
Specifically, in his practice, he makes sure to keep patients with ocular surface disease on brand name drugs.
Blair
Lonsberry
Lonsberry told PCON that he has seen IOP fluctuations in patients who switch between a brand name medication and its generic equivalent.
“The important consideration after switching a patient to a generic formulation is to monitor that patient a bit more closely to ensure that the IOP is at an acceptable level,” he said. “The other difficulty with generics is that it could be one of several different companies that is manufacturing the generic.”
Lonsberry continued: “If I am able, I will prescribe a brand name medication. By prescribing a brand name, I feel more comfortable that I know what my patient will be getting and I won’t have to worry which generic company has manufactured it.”
Thomas stated that while cost can be a barrier to adherence, it should not deter care providers or patients.
“They key in glaucoma patient care is protecting and preserving vision,” he said. “The cost of profound vision loss or blindness is not quantifiable.” – by Chelsea Frajerman