A comprehensive evaluation of rationality of cough and cold medicines available in Indian market

To analyse various cough and cold formulations available in the Indian market and to study their pharmacological rationale and cost effectiveness, a cross-sectional, observational study was carried out for evaluation of the drugs listed in Current Index of Medical Specialities (CIMS) India, September 2010.The formulations were assessed for their total number, type of dosage form, number of constituents in each formulation, their pharmacological group and rationality. The total daily cost and its association with type of dosage form was analysed. Out of a total 1297 preparations evaluated, 94% were fixed dose combination. The mean number of constituents was 3.20 +/- 1.03. Liquid oral formulations were largest in number (64.4%). The formulations contained various antitussives (30.30%), expectorants (33.92%), antihistamines (71.09%), mucolytics (35.62%), decongestants (56.28%), bronchodilators (16.81%) and analgesics/antipyretics (31.30%). None of the preparation was listed in the Model list of Essential Medicines, WHO (March 2011) under section 25 of "Medicines acting on the respiratory tract". Only 2% of the preparations had pharmacological rationale for their use in cough and common cold; 9.6% were containing more than one ingredient of the same pharmacological group and 6.85% were containing both antitussive and expectorant having opposing action. Highest number of preparations (36.85%) was having cost of therapy of Rs 6-10 per day. Liquid oral dosage forms had significantly higher cost than solid dosage form (p < 0.0001) and topical nasal dosage forms had significantly higher cost than liquid (p < 0.03) and solid (p < 0.001) dosage forms. It is conducted that various cough and cold medicines available in Indian market lacked therapeutic rationale for their use, leading to wasteful expenditure.

Simultaneous determination of cyclodol and diprazin by thin layer chromatography and high performance liquid chromatography

Ciklodol (trihexyphenidil)--the central and peripheral m-cholinoblocker is currently used with other antipsychotic drugs such as phenotiazines and tricycle antidepressants. For the purpose of simultaneous determination of ciklodol and diprazine, were selected two methods of analysis: Thin Layer Chromatography (TLC) and High Performance Liquid Chromatography (HPLC). During development of TLC method was studied the 10 visualizing system and 24 mobile systems. For individual or simultaneous determination of ciklodol and diprazine were recommended the following solvents' systems: 1. Toluene-acetone-ethanole-25%NH(4)OH (45:45: 7.5:2.5), 2. Hexane-ethyl acetate (15:5), 3. Chloroform-heptene-25%NH(4)OH (16:3:3), 4. Ethylacetate-hexane (10:10), 5. Acetonitrile-metanol (10:10) and 6.Heptene-chloroform-ethanol-25% NH(4)OH (5:10:3:1). As visualizing systems were chosen: Iodine vapors, blacklight (UV254) and reagent of FNP. Reagent of FNP gives colored spot just with diprazine and it is also could be used for separation of both objects in simultaneous analysis. Developed HPLC method of simultaneous determination of ciklodol and diprazine: like mobile phase is recommended: Acetonitril- 0.05M KH(2)PO4 (55:45) (v/v) +H(3)PO(4) (pH3.5), column EC250 x 4.6mm, with solid phase Nucleosil, flow rate 1ml/min, sample volume 40 microl. In given conditions, the retention time of ciklodol is 6.005min and diprazine 7.227min. Developed method of simultaneous determination and separation of ciklodol and diprazine in respective mixtures could be successfully applied as in the pharmaceutical, as well in the chemical-toxicological laboratories.

Costs of second-generation antihistamines in the treatment of allergic rhinitis: US perspective

OBJECTIVE

To review the pharmacoeconomic literature evaluating use of antihistamines in treating allergic rhinitis (AR) in the US.

METHODS

Three independent reviewers conducted a comprehensive search of the current literature with PubMed. They identified articles describing original research comprising US cost analyses or pharmacoeconomic evaluations that reported both costs and consequences of using second-generation anthistamines (SGAs), first-generation antihistamines (FGAs), or both for the treatment of patients with AR. The search was limited to studies performed in humans and published in English between 1998 and 2008.

RESULTS

Five of 200 articles met the inclusion criteria and examined costs associated primarily with chlorpheniramine, diphenhydramine, cetirizine, and fexofenadine. The first two studies retrospectively analyzed a claims database and concluded that fexofenadine was associated with slightly lower overall costs than loratadine and cetirizine. A third study compared total healthcare costs associated with FGAs and SGAs, concluding that despite their higher prescription cost, SGAs result in lower medical resource use and lower cost for treatment of AR versus FGAs, although no individual SGA could be distinguished as providing substantial healthcare cost savings or increased cost-effectiveness over the other SGAs. Two studies investigated the impact of transitioning a prescription SGA to over-the-counter status and concluded that such a transition would provide cost savings to healthcare plans, but did not address the cost or health effect of such a switch on specific populations whose plans might no longer cover prescription SGAs.

CONCLUSIONS

Preliminary evidence suggests that newer SGAs offer clinical, pharmacodynamic, and pharmacokinetic advantages that may translate into superior cost-effectiveness in the treatment of AR. Further study is warranted to clarify the pharmacoeconomic impact of the newer SGAs and to establish their relative cost-effectiveness.

Pharmacotherapy of allergic eye disease

Allergic eye disease is a term that refers to a number of disease processes that affect about one-fifth of the world's population. Although the more advanced forms of the disease can be sight threatening, the most disabling effects are due to the clinical manifestations, and hence quality of life, with some patients having seasonal exacerbations of their symptoms, whereas others have symptoms that are present throughout the year. Recent increased understanding of the cellular and mediator mechanisms that are involved in the various disease manifestations has greatly facilitated the development of more effective treatment options. Newer topical medications are being used that have multiple actions, such as an antihistaminic effect coupled with mast-cell stabilisation, and which require reduced daily dosing due to their longer duration of action. With greater research into newer therapies and more effective modes of delivery, improved healthcare outcomes with a lower economic burden will be achieved for patients with allergic eye disease.

Medication characteristics beyond cost alone influence decisions to underuse pharmacotherapy in response to financial pressures

BACKGROUND AND OBJECTIVE

Little is known about how patients facing medication cost pressures make choices about whether to underuse one or more of their prescription drugs. We calculated the probability that older adults would underuse prescription medications for common chronic illnesses because of cost concerns. We also identified differences in cost-related underuse between symptom-relief medications (e.g., analgesics) and primarily "preventive" medications (e.g., antihypertensives).

MATERIALS AND METHODS

Older chronically ill patients using both symptom-relief and preventive medications (N = 2,008) were identified as part of a nationwide survey in the United States and reported information about their cost-related underuse of 16 medication types. We used regression models to estimate the probability of underuse for each medication type, assuming average out-of-pocket costs, no prescription coverage, and the sociodemographic characteristics of a typical American aged 50+.

RESULTS

23% of respondents reported forgoing medication in the prior year due to cost. The likelihood of cost-related underuse was higher for symptom-relief medications (27%) than for primarily preventive medications (20%, P < .001). Among the subset of patients who cut back on adherence due to cost, the likelihood of forgoing symptom-relief medication (69%) was higher than that for preventive drugs (54%, P < .001).

CONCLUSIONS

Medication characteristics beyond cost alone influence decisions to underuse treatment in response to financial pressures.

[Comparison of clinical efficacy and cost-quality of antihistamines in early treatment for Japanese cedar pollinosis]

BACKGROUND

Japanese cedar pollinosis (JCP) affects more than 16% of the Japanese population. The estimated direct and indirect costs for this disease totaled 286 billion yen in 1998. In JCP therapy, antihistamines are first line agents. It is well known that starting treatment for JCP with antihistamines before initial day of the pollen scattering can relieve nasal symptom severity during pollen season. The aim of this study is to assess the clinical efficacy and cost-quality of 7 major second-generation antihistamines in early treatment for Japanese cedar pollinosis (JCP).

METHODS

Patients were randomly selected from 16 ENT clinical sites in Osaka and Wakayama between February 24 and March 8, 2003 (peak pollen season). Effectiveness was assessed using patient'ratings of nasal and ocular symptoms and overall assessment in their condition compared to previous season ones. Costs include direct costs of the drugs used for treatment to JCP from January to March.

RESULTS

One hundred seventy-five patients who were treated with antihistamine monotherapy (azelastine: n=15, cetirizine: n=15, ebastine: n=36, epinastine: n=16, fexofenadine: n=16, loratadine: n=60, oxatomide: n=17) and 510 non-treatment patients were evaluated. Among 8 groups, there were significant differences in sneezing, rhinorrhea, ocular itching and overall health condition. However, among 7 monotherapy groups, there were no differences in each symptom or the overall assessment. In cost-quality analysis, there were significant differences in a cost for each effective patient (defined as those with improvement in their overall condition) among 7 drugs. The top three cost-efficacious drugs resulted in azelastine, loratadine and fexofenadine.

CONCLUSION

These results show that there were no significant differences in clinical efficacy in early treatment for JCP among 7 antihistamines. But Japanese National Health Insurance drug price scheme led to significant differences in cost-quality.

Analysis of the cost-effectiveness of varicella vaccine programmes based on an observational survey in the Latium region of Italy

Varicella is the most widespread childhood disease in Italy. However, as in many parts of the world, the country does not yet have a unified approach to the management of the disease. A cost-effectiveness analysis of varicella vaccination strategies, using the Latium region in Italy as a case study, was undertaken. Mass vaccination is only recommended if the immunization programme can achieve coverage of over 85% in a short time. However, experience in Italy with non-compulsory vaccinations has shown this is difficult to achieve. Consequently, eradication of the disease is not seen as an attainable short-term goal. For mass varicella vaccination to be successful, it must be run at a national as well as regional level in combination with education programmes, and a reliable surveillance system. The interaction between varicella and herpes zoster must also be taken into account when considering vaccination strategies, as zoster vaccination strategies may have an impact on varicella coverage.

Effects of an increase in prescription copayment on utilization of low-sedating antihistamines and nasal steroids

BACKGROUND

Health plans are using 3-tier copayment designs and other methods to control utilization that shifts drug costs to plan members. There is a need to determine the effects of increased member cost sharing on drug utilization and drug costs.

OBJECTIVE

To assess the impact of a 10 US dollars increase in prescription copayment in a public employer health plan for 2 classes of drugs used for allergic rhinitis.

METHODS

Changes in the number of prescriptions dispensed for 2 therapeutic classes.low-sedating antihistamines (LSAs) and nasal steroids (NSs).were examined 1 year prior to and 1 year after copayment increase. Relative price effects were measured as arc price elasticity, the ratio of the percent change in prescription utilization over the percent change in price, an indicator of how responsive patients are to the copayment increase.

RESULTS

Of 8,643 continuously enrolled health plan beneficiaries, 2,150 patients (24.8%) received at least 1 NS or LSA during the 2-year period of the study, from January 1, 1998, through December 31, 1999. An average 10 US dollars increase in copayment per prescription was associated with no statistically significant change in utilization of combined LSA and NS prescriptions, 2.89 per patient in 1998 and 2.94 in 1999 (P = 0.597). Health plan costs for study drugs, unadjusted for inflation, decreased by 16.3% from 86.86 US dollars per patient in 1998 to 72.68 US dollars in 1999 (P = 0.004). Health plan costs per patient per month (PPPM) for all drugs for the 2,150 allergic rhinitis patients decreased by 13% from 41.33 US dollars PPPM in 1998 to 35.93 US dollars in 1999 (P<0.001), and health plan drug costs for all 8,643 members decreased by 13% from 14.93 US dollars per member per month (PMPM) in 1998 to 12.99 US dollars in 1999 (P<0.001). The actual average copayment increase was 7.23 US dollars (a 41% increase) for LSAs, which was associated with a 14.8% increase in utilization of LSAs and an 11.8% increase in the number of patients using LSAs; the number of LSA prescriptions per patient per year was unchanged at 2.68 in 1999 versus 2.61 in 1998 (P = 0.429). The actual average copayment increase was 10.98 US dollars (71%) for NSs, which was associated with an 11.3% decrease in utilization of NSs and a 10.2% decrease in the number of users of nasals steroids in 1999; the number of nasal steroid prescriptions per patient per year was unchanged at 2.05 in 1999 versus 2.07 in 1998 (P =.842). The combined utilization of LSA and NS prescriptions increased by 8.9% following the increase in copayments for these 2 therapeutically interchangeable drugs for allergic rhinitis. LSA prescriptions were less elastic, with an unadjusted arc elasticity of 0.39, while nasal steroid prescriptions were more responsive to the copayment change, with an unadjusted arc elasticity of.0.22.

CONCLUSIONS

An average 10 US dollars increase in patient cost sharing per prescription (46.9% copayment increase) was associated with an increase in combined utilization of 2 drug classes used for allergic rhinitis (LSAs and NSs) but no change in the number of prescriptions per patient. Health plan costs decreased significantly for allergic rhinitis drugs, all drugs used by allergic rhinitis patients, and all drugs used by continuously enrolled health plan members. NSs exhibited a greater arc price elasticity compared with low-sedating oral antihistamines.

The economic burden of allergic rhinitis: a critical evaluation of the literature

Although a large number of economic analyses of allergic rhinitis have been published, there are relatively few empirically based studies, particularly outside the US. The majority of these analyses can be classified as burden-of-illness studies. Most estimates of the annual cost of allergic rhinitis range from dollars US 2-5 billion (2003 values). The wide range of estimates can be attributed to differences in identifying patients with allergic rhinitis, differences in cost assignment, limitations associated with available data and difficulties in assigning indirect costs (associated with reduced productivity) of allergic rhinitis. Approximately one-third of burden-of-illness studies include direct and indirect costs of allergic rhinitis, about one-third focus on direct costs only, and the remaining one-third focus exclusively on indirect costs due to reduced productivity. Indirect costs attributable to allergic rhinitis were higher in studies only estimating indirect costs (dollars US 5.5-9.7 billion) than in those estimating both direct and indirect costs (dollars US 1.7-4.3 billion). Although there are many economic evaluations of allergic rhinitis treatments in the published medical literature, very few represent formal cost-effectiveness evaluations that compare the incremental costs and benefits of alternative treatment strategies. Those that are incremental cost-effectiveness analyses have several limitations, including small samples, short study periods and the lack of a standardized measure of effectiveness. To date, the medical literature is lacking a comprehensive economic evaluation of general treatment strategies for allergic rhinitis. In undertaking such an analysis, serious consideration must be given to the study population of interest, the choice of appropriate comparators, the perspective from which the analysis is conducted, the target audience, the changing healthcare marketplace and the selection of a measure of effectiveness that incorporates both positive and negative aspects of treatments for allergic rhinitis. Future work would benefit from the development of a consensus on a summary measure of effectiveness that could be used in cost-effectiveness analyses of therapies for allergic rhinitis as well as additional empirical work to measure the association between severity of disease and its impact on worker productivity.

Cost-benefit analysis of first-generation antihistamines in the treatment of allergic rhinitis

BACKGROUND

The majority of individuals with allergic rhinitis in the US take first-generation antihistamines (FGAs). Although FGAs have been proven effective in alleviating allergic rhinitis symptoms, they have been associated with an increased risk of motor vehicle, aviation and occupational injuries and deaths, reduced productivity and impaired learning.

OBJECTIVE

The objective of this analysis was to quantify the total costs and benefits of FGA use in the US from the societal perspective.

METHODS

We used a decision-analytic model to quantify the annual societal costs and benefits of treatment with FGAs compared with the hypothetical alternative of no treatment for the population of individuals with allergic rhinitis and taking FGAs in the US in 2001. The benefit associated with FGA use was estimated using the willingness-to-pay framework and projected to the US population using published estimates of the prevalence of allergic rhinitis. The costs of FGA-associated sedation included lost productivity and the direct and indirect cost of unintentional injuries (including motor vehicle, occupational, public and home injuries and fatalities). The incidence of injuries and fatalities associated with FGA use was estimated using the risk of injury attributable to the sedentary effects of FGAs in the allergic rhinitis population. To evaluate uncertainty in the model assumptions, a probabilistic sensitivity analysis was conducted using Bayesian second-order Monte Carlo simulation. Costs and benefits are expressed in 2001 US dollars, using a 3% discount rate.

RESULTS

Based on current utilisation, the total societal benefit (95% credible interval) associated with the use of FGAs for the treatment of allergic rhinitis was US 7.7 billion dollars (US 1.3 billion dollars to US 21 billion dollars). The societal cost of purchasing FGAs was only US 697 million dollars. However, the societal cost of FGA-associated sedation was US 11.3 billion dollars (US 2.4 billion dollars to US 50.8 billion dollars). The annual societal net benefit of FGA use for the treatment of allergic rhinitis in the US was -US4.2 billion dollars (-US 36 billion dollars to +US 0.296 billion dollars). The net benefit was negative in 97% of the 10,000 Monte Carlo simulations.

CONCLUSIONS

The societal benefits of FGA use in alleviating the symptoms of allergic rhinitis are significant. However, based on the assumptions, probability distributions and parameter estimate ranges used in the current model, it is very likely that the costs associated with sedation exceed the benefits of FGA use in the US. The cost of FGA-associated sedation is comparable to estimates of the cost of all medical care expenditures on respiratory conditions in the US (US 12.1 billion dollars to US 31.3 billion dollars) [1996 values] and provides compelling evidence of the economic burden of sedation associated with FGA use.

Cost-effective pharmacotherapy for inhalant allergic rhinitis

The otolaryngologist is one of the decision leaders for patients who seek to learn more about their problems of respiratory allergy. Although these patients do not have a life-threatening illness, the reduction of quality of life and performance can significantly restrict their overall sense of well being. Patients with allergic rhinitis desire the relief of the bothersome problems without other side effects. Second-generation antihistamines were introduced to reduce the significant impairment brought on by the sedation of the first-generation products. Most physicians prescribe the intranasal corticosteroids as the prescription drug of first choice for most patients with chronic allergic rhinitis. Second-generation H1 receptor antagonists are better for the patient than the first-generation drugs because of the reduced side-effect profile and improved tolerance. Compliance factors certainly need to be addressed with medications that need more than once-daily dosing. Patients with only sporadic problems in season or on limited exposure are best treated with oral antihistamines, topical cromolyn, and short-term decongestant therapy.

The economic burden and symptom manifestations of chronic rhinosinusitis

BACKGROUND

The aim of this study was to delineate patient symptoms and economic burdens of chronic rhinosinusitis (CRS).

METHODS

Adult patients with CRS were assessed prospectively with a survey instrument. Symptom scores for major and minor symptoms of CRS, medication use, physician visits for CRS, and work days missed were determined. Cost analyses were conducted.

RESULTS

Three hundred twenty-two patients were studied prospectively (mean age, 42.3 years). Nasal obstruction and facial congestion were the most common and severe major symptoms, and headache and fatigue were the most common and severe minor symptoms. Patients received an average of 2.7 antibiotic courses and used nasal steroids and prescription antihistamines 18.3 and 16.3 weeks, respectively, in a 12-month period. Mean medical resource costs were 921 dollars per patient-year. CRS caused an average of 4.8 days of missed work per 12-month period. The overall yearly economic cost of CRS was 1539 dollars per patient.

CONCLUSION

Nasal and facial symptoms prevail over systemic and oropharyngeal symptoms in CRS. Significant medical resource expenditures and global economic costs accompany CRS.

Cost-effectiveness of H1-antihistamines

In the health care arena, assessment of a medication's clinical efficacy is no longer enough. It is important to confirm the medication's cost-effectiveness and the improvement in quality of life it provides in relationship to other options in therapy. H1-antagonists are widely used in the treatment of many atopic disorders, especially allergic rhinitis. This review has pointed out cost-effectiveness and quality-of-life studies comparing the different H1-antagonists among themselves, and with other treatments used in allergic rhinitis, such as intranasal corticosteroids and allergen immunotherapy. Cost-effective analyses among H1-antagonists in other allergic diseases, such as atopic dermatitis, urticaria and angioedema, and asthma, are lacking at this time.

The cost of treating allergic rhinitis

Allergic rhinitis is a high-cost, high-prevalence disease. In the year 2000, over $6 billion was spent on prescription medications to treat this illness. Although it is not associated with severe morbidity and mortality, allergic rhinitis has a major effect on the quality of life of the more than 50 million Americans with this illness. Intranasal corticosteroids (INCS) and nonsedating antihistamines (NSAH) are the most common prescription medications for this disease. INCS are recognized as the most effective treatment regimen for chronic symptoms. NSAH are perceived as important in the treatment of patients with mild disease, or as add-on therapy to INCS. When the literature is reviewed, the INCS produce the greatest decrease in total nasal symptom scores, the largest effect size, when compared with NSAH. Both classes of medications produce similar effects on concurrent allergic conjunctivitis. Further recent studies indicate that the INCS are also superior when used on an as-needed basis, and that there is little clinical benefit from the addition of loratadine to intranasal fluticasone. INCS have lower average wholesale prices as a class than the NSAH. Since the INCS are the dominant medication in efficacy studies and cost less, cost-effectiveness studies always favor intranasal corticosteroids.

The effect on social welfare of a switch of second-generation antihistamines from prescription to over-the-counter status: a microeconomic analysis

BACKGROUND

The US Food and Drug Administration (FDA) recently held a meeting to determine whether the status of second-generation antihistamines (SGAs) should be switched from prescription (Rx) to over-the-counter (OTC) status.

OBJECTIVE

This article provides a conceptual microeconomic framework for addressing issues regarding the impact of such a switch on social welfare.

METHODS

A review of the economic literature on Rx-to-OTC switches was conducted. Relevant articles published in English between 1990 and 2001 were identified through searches of ABI Info, EconLit, PsychInfo, MEDLINE, CANCERLIT, AIDSLINE, and HealthStar, as well as a general Internet search for statements in the press or on the FDA Web site. The search terms used were Rx, prescription, OTC, over-the-counter, second-generation antihistamines, nonsedating antihistamines, first-generation antihistamines, and sedating antihistamines. Microeconomic models focusing on consumer surplus were employed to determine the potential price response and social-welfare implications of a switch of SGAs to OTC status.

RESULTS

Unlike the agents involved in previous Rx-to-OTC switches, SGAs are still under patent protection. Economic theory suggests that a firm that is protected by a patent will price aggressively. The market for OTC SGAs is likely to be more elastic due to a lack of insurance coverage for OTC products; hence, drug manufacturers would be likely to charge a lower price if SGAs were sold OTC. However, a lower price does not necessarily guarantee an improvement in social welfare; the net impact is determined by whether the increase in consumer surplus outweighs the deadweight loss (losses of consumer and producer surplus not transferred to other parties). Additionally, the assumption of a price reduction would be called into question if there were inequalities in marginal costs between the Rx and OTC markets. In this situation, the postswitch price might increase or not be reduced significantly.

CONCLUSIONS

It is uncertain whether granting OTC status to SGAs would be cost saving to society, particularly as these drugs are patent protected. The social-welfare implications of such a switch would depend heavily on pricing strategies and consumer behavior. Further analyses are needed to determine how both factors influence social welfare; only then can the costs and benefits of a switch be understood completely.

The costs of nonsedating antihistamine therapy for allergic rhinitis in managed care: an updated analysis

OBJECTIVE

To update a prior study evaluating the use and costs of new-generation antihistamines for the treatment of allergic rhinitis in a managed care population.

STUDY DESIGN

A retrospective database review of rhinitis-related medical and pharmacy-related claims during a treatment period of 12 months.

METHODS

Patients who had been diagnosed as having allergic rhinitis and had at least 1 prescription claim were identified from a database containing patient-level medical and pharmaceutical claims. The treatment patterns for patients meeting study criteria were documented for a 12-month period to describe how nonsedating antihistamines are being used in allergic rhinitis, and to assess the associated costs of various medications. Subanalyses of patients categorized by comorbidity status were also performed.

RESULTS

A total of 105,696 patients were included in this updated analysis, covering calendar year 1999. Nonsedating antihistamines were used by 68% of the sample, with loratadine and fexofenadine being the most commonly prescribed agents. The mean annual rhinitis-specific charge for fexofenadine-treated patients was $409 (standard deviation [SD] 727), which was significantly lower compared with charges for loratadine-treated patients, $424 (SD 740), P = .0144, or cetirizine-treated patients, $444 (SD 625), P < .0001. This trend was also observed in comparisons of patient subgroups.

CONCLUSIONS

Consistent with our prior study, loratadine and cetirizine were generally associated with significantly higher treatment charges than fexofenadine. This result was observed across different stratifications of patients, including those with comorbid respiratory illness, concomitant use of nasal steroids, and asthma and/or sinusitis. These results provide further useful insights into the differential costs associated with the use of nonsedating antihistamines for allergic rhinitis treatment.

A descriptive analysis of the use and cost of new-generation antihistamines in the treatment of allergic rhinitis: a retrospective database analysis

OBJECTIVE

This retrospective database analysis was conducted to evaluate the use and cost of new-generation antihistamines (i.e., those that are nonsedating) in the treatment of allergic rhinitis in a managed care population.

STUDY DESIGN

The study is a retrospective database review of medical and pharmacy-related claims linked by episodes of care.

METHODS

Patients who had been diagnosed as having allergic rhinitis and had at least 1 prescription claim were identified from a database containing patient-level medical and pharmacy-related claims. The treatment patterns of patients with allergic rhinitis who met the study criteria were documented for a 12-month period in which the use of nonsedating antihistamines was described and the associated costs of various medications were assessed. Subanalyses of patients categorized by comorbidity status were also performed.

RESULTS

A total of 202,426 patients participated in the study. Nonsedating antihistamines were used by 71% of the patients; the most commonly prescribed drugs were loratadine and fexofenadine. The mean annual charges per patient for the treatment of allergic rhinitis in the study population were $465.21 (standard deviation [SD], 548). The greatest departmental cost was that of pharmacy-related charges (mean, $236.02; SD, 233); the next highest cost was that of outpatient charges (mean, $216.31; SD, 396). Comparisons of departmental charges indicated the use of loratadine was associated with significantly higher treatment costs than that of fexofenadine in a number of patient subgroups.

CONCLUSION

In this analysis, loratadine was associated with significantly higher treatment charges than was fexofenadine. This result was observed consistently across different stratifications of patients, including the presence of comorbid respiratory infection, concomitant use of nasal steroids, and the presence of asthma and/or sinusitis. These results provided useful insights into the differential costs associated with the use of nonsedating antihistamines in the treatment of rhinitis.

Mirtazepine: heir apparent to amitriptyline?

"What's new in therapeutics?" will examine and evaluate drugs that may have a place in hospice, palliative, and long-term care. Mirtazepine will be examined and evaluated. Mirtazepine is a potential alternative anti-depressant with multiple additional benefits. It is an atypical anti-depressant, which has both noradrenergic and specific serotonergic receptor antagonism (NaSSa), and a unique pharmacological profile. Mirtazepine appears to be a "designer drug" for palliative medicine with a number of benefits, but cost may be a drawback.

Impact of interventions designed to increase market share and prescribing of fexofenadine at HMOs

The impact of interventions designed to shift prescribing from loratadine to fexofenadine at HMOs was studied. Pharmacy claims data for a six-month preintervention period at four HMOs were analyzed to identify all new and refill prescriptions for loratadine, fexofenadine, astemizole, and cetirizine. The interventions consisted of a mandatory lockout of loratadine in favor of fexofenadine (at HMO A), a voluntary switch to fexofenadine promoted through letters to both physicians and members (HMO B), and a voluntary switch promoted through letters to physicians only (HMO C). There was no intervention at HMO D. Pharmacy claims data for the six months after each intervention program was implemented were analyzed to determine changes in the market share and prescribing of the study drugs. After the intervention programs were implemented, the market share of fexofenadine increased from 18.9% to 65.2% at HMO A, from 14.8% to 21.0% at HMO B, and from 20.7% to 23.8% at HMO C. Loratadine's market share decreased from 62.3% to 8.7% at HMO A, from 67.5% to 58.6% at HMO B, and from 70.5% to 65.3% at HMO C. HMOs A, B, and C each had greater shifts in market share for fexofenadine and loratadine than the control HMO. Changes in prescribing followed a similar pattern for the 25 physicians at each HMO who had most frequently prescribed loratadine during the preintervention period. The average cost per antihistamine prescription decreased 22.3% at HMO A. Prescription costs continued to rise at HMOs B, C, and D. Mandating the use of fexofenadine produced a significant increase in its market share, reduced the cost of nonsedating antihistamines, and successfully influenced prescribing behavior. Voluntary programs had a more modest impact on market share and did not stop increases in prescription costs.

[Treatment of depression and cost efficiency. The cost of a tablet is a poor indicator seen from a socioeconomic perspective]

Direct costs for treating depression, i.e. the cost of out-patient and in-patient care together with drug costs, have increased by 55 per cent during the period 1987-1997 in Sweden. Drugs incurred the greatest increase, whereas the cost of in-patient care has decreased. Indirect costs, i.e. sick leave, morbidity and premature mortality due to depression, have also increased during this period. Cost-effectiveness calculations comparing mirtazapine with amitriptyline show that it is less expensive to initiate treatment with mirtazapine, both when direct costs are compared and when indirect costs are included. In a comparison between mirtazapine and fluoxetine, initial treatment with fluoxetine is less expensive with respect to direct cost, but these two alternatives are equivalent when indirect costs are taken into consideration. The price of drug is a poor criterion of resource expenditures and of rational pharmacological therapy in the treatment of depression.

Cost-effective pharmacotherapy for allergic rhinitis

This article provides guidelines for pharmacotherapy to maximize symptom relief from allergic rhinitis. Consideration of frequency, severity, and site of symptoms is important in directing pharmacotherapy efficacy and maximizing cost-effectiveness. The agents available include antihistamines, decongestants, steroids, mast cell stabilizers, anticholinergic agents, and mucolytics. Appropriate indications for each and combinations of various agents are discussed within the context of drug efficacy, side effects, affordability, and ease of compliance. The direct and indirect costs of allergic rhinitis are not well delineated but are explored to put the costs of therapy in perspective.

Ancillary therapy of bovine respiratory disease

Ancillary therapy for bovine respiratory disease is covered with an emphasis on anti-inflammatories. Theoretic rationale and any available clinical data are reviewed for glucocorticosteroids as well as nonsteroidal anti-inflammatory drugs such as phenylbutazone, flunixin meglumine, and aspirin. Antihistamines, immunomodulators, diuretics, and bronchodilators are also discussed.

Drug interactions with the nonsedating antihistamines

The nonsedating antihistamines are frequently prescribed agents. Well-documented drug-drug interactions with two of these agents, terfenadine and astemizole, may result in serious adverse effects, including death, when they are prescribed along with macrolide antibiotics and/or the antifungal agents itraconazole or ketoconazole. Fexofenadine and loratadine appear to be the least likely nonsedating antihistamines to interact with other medications and to result in a life-threatening interaction. This article reviews the known drug-drug interactions involving nonsedating antihistamines and provides a basis from which the clinician can predict potential interactions.

Considerations in pharmaceutical conversion: focus on antihistamines

The practice of pharmaceutical conversion, which encompasses three types of drug interchange (generic, brand, and therapeutic substitution), is increasing in managed care settings. Pharmaceutical conversion has numerous implications for managed care organizations, their healthcare providers, and their customers. Although drug cost may be a driving consideration in pharmaceutical conversion, a number of other considerations are of equal or greater importance in the decision-making process may affect the overall cost of patient care. Among these considerations are clinical, psychosocial, and safety issues; patient adherence; patient satisfaction; and legal implications of pharmaceutical conversion. Patient-centered care must always remain central to decisions about pharmaceutical conversion. This article discusses the issues related to, and implications of, pharmaceutical conversion utilizing the antihistamines class of drugs as the case situation.

Sedation and performance issues in the treatment of allergic conditions

This article evaluates and summarizes the results of studies investigating the central nervous system effects of second-generation antihistamines, with particular emphasis on psychomotor and cognitive effects. The data sources were computer-assisted MEDLINE searches using the search terms histamine H1 antagonists, psychomotor performance, sleep, and specific drug names, including astemizole, cetirizine, loratadine, and terfenadine; the searches were limited to studies in humans. Only controlled studies (placebo or active control or both) using standardized or quantitative methods for defining drug-induced effects on sedation, psychomotor performance, or cognition were reviewed. Additional published studies were identified within the references of the first group of studies. Finally, representative studies were selected for summarization. Objective and subjective measures of sedation show that loratadine and terfenadine produce sedation at a rate comparable with placebo. Moreover, these agents, when used at standard therapeutic doses, do not produce detrimental effects on objective measures of psychomotor or cognitive function. Cetirizine is associated with sedation or psychomotor impairment in some studies but not in others. The data on central nervous system effects of astemizole are limited and were not evaluated. The absence of sedation and psychomotor or cognitive impairment in patients receiving loratadine or terfenadine justifies the cost of these agents, particularly for patients who drive, pilot aircraft, or operate machinery. Whether the potential for rare but serious cardiovascular events (associated with astemizole and terfenadine) is justifiable must be decided on a case-by-case basis.

Cost of therapy for allergic rhinitis

OBJECTIVE

To describe the cost of medicines used in the treatment of allergic rhinitis in South Africa.

DESIGN

MIMS was used as the reference for the list of drugs, drug formulation and size, and recommended dosage. These figures were then checked against the package insert of each agent. The cost of each agent was originally derived from the same source, but for standardisation purposes the blue book price was used. Measure of effectiveness was derived from the International Consensus Report on the Diagnosis and Management of Rhinitis. Costs per treatment periods of 10 days (course) and 30 days (month) were calculated. The 'cost' differs from the 'price' in that it takes efficacy into account.

MAIN OUTCOME MEASURES

Cost of drugs used in the treatment of allergic rhinitis.

RESULTS

The least costly treatments for allergic rhinitis are the intranasal corticosteroids. Sodium cromoglycate was the most costly, being nearly 20 times more expensive than the nasal steroids. Anticholinergic sprays and topical decongestants were also more costly than nasal steroids, as were the antihistamines. The older-generation antihistamine, ketotifen, was not only more costly than the four oral newer-generation agents in this class but has the added disadvantage of greater sedative side-effects. All oral antihistamines were outclassed by the topical antihistamine, levocabastine.

CONCLUSIONS

This study in no way aims to recommend treatment for allergic rhinitis. However, it highlights the need to consider efficacy of a drug before unit price in the selection of treatment regimens. It is therefore a comment on practical issues in drug selection in the treatment of allergic rhinitis.

The eternal triangle: benefit, risk, and cost of therapeutic agents

Some people can undoubtedly tolerate a first-generation H1-receptor antagonist without sedation or other CNS adverse effects, but others cannot. There is no rapid, reliable way of differentiating these two populations. A history of presence or absence of subjective somnolence from one H1-receptor antagonist is not necessarily reliable and has no consistently useful predictive value for subsequent experience with other H1-receptor antagonists. As H1-receptor antagonists are used primarily to treat non-life-threatening disorders, safety should be a prime consideration in selecting one for use, and is surely as important a concern as efficacy and low cost. If your pilot is not permitted to take these medications before going to work, why should your taxi driver, your child's school bus driver, your dentist, your nurse, or your office assistant, to name a few examples, be allowed to do so? When the broad issue of safety is considered, first-generation H1-receptor antagonists may not be as cost-effective as they appear to be. The inherent benefit of any medication is inextricably linked with the inherent risk. It is incumbent on those promulgating the use of the older H1-receptor antagonists to define these benefits and risk further. Lowering the cost of the second-generation, relatively nonsedating H1-receptor antagonists so they are no longer the most expensive medications used in treatment of allergic rhinitis would also help solve the problem of the eternal triangle as it pertains to therapeutic use of H1-receptor antagonists.

Treating allergic rhinitis with second-generation antihistamines

Allergic rhinitis afflicts close to 40% of the nation's population and costs more than $1.8 billion a year. The toll exacted by this disorder has been greatly alleviated by nonsedating second-generation antihistamines loratadine, terfenadine, and astemizole. The three agents effectively reduce symptoms without the sometimes intolerable adverse effects of older drugs, but they are not completely equivalent. For example, terfenadine requires twice/day dosing, whereas the others can be given once/day. Astemizole has a slow onset and extremely prolonged duration of action. Both terfenadine and astemizole may have cardiotoxic effects (e.g., torsades de pointes) when serum concentrations rise due to overdosing or drug interactions. Cetirizine, a recently approved second-generation antihistamine, has sedative and anticholinergic effects, although to a lesser degree than the first-generation antihistamines.

The effect of education and drug samples on antihistamine prescribing costs in an HMO

OBJECTIVE

To examine the effect of an intervention designed to reduce antihistamine prescribing costs in an HMO.

DESIGN

A quasi-experimental design with clinicians at one HMO site receiving an intervention. Their prescribing behavior before and after the intervention was compared to the prescribing behavior of clinicians at other HMO sites in a non-randomized control group.

SETTING

A mixed model HMO in metropolitan Washington, DC.

PARTICIPANTS

Group model clinicians at a single site received the intervention; network and group model clinicians at other sites composed the control group.

INTERVENTION

An education memo addressed to clinicians discussing antihistamine prescribing costs and strategies for initial use of nonprescription or less expensive prescription agents, coupled with free antihistamine sample "trial packs" for patient use.

OUTCOME MEASURE

The prescribing costs of the intervention group were compared to the prescribing costs of the non-randomized control group. The intervention group was surveyed regarding their attitudes toward the intervention.

RESULTS

A 2% decline in costs was noted between the baseline and intervention year for both the intervention and control groups. Though clinicians indicated they were well disposed toward the intervention, they believe patient expectations were a major obstacle to the use of cheaper agents.

CONCLUSION

We conclude that an effective intervention would require the targeting of major patient-related barriers to clinician behavior change.

Economic outcomes for the treatment of allergic rhinitis

The purpose of this article is to review the literature related to economic outcomes associated with treating allergic rhinitis. A literature review was conducted using 'Medline' and the in-house database of the publishers of this journal for articles published between January 1991 and January 1996. Only 3 cost-outcome analyses that compared alternative treatments for allergic rhinitis were found. Given the limited number of full economic evaluations, much of this article focuses on issues related to direct and indirect costs and outcome measures that should be considered when performing an economic evaluation of allergic rhinitis. We conclude that more comprehensive analyses using a wide array of costs and outcomes are needed. At present, it is not possible to draw general conclusions regarding the economic value of alternative treatments for allergic rhinitis.

Model for outcomes assessment of antihistamine use for seasonal allergic rhinitis

BACKGROUND

Drug selection for optimal treatment of common medical conditions may be difficult and involve many diverse factors.

OBJECTIVE

The efficacy, safety, quality of life, and cost of treatment of seasonal allergic rhinitis with cetirizine, chlorpheniramine, or terfenadine were compared in a prospective, two-phase, randomized, single-blind clinical trial conducted in a managed care setting.

METHODS

In phase I, which lasted 2 weeks, patients were randomized to receive one of the study drugs. In phase II, which lasted 4 weeks, the initial treatment was continued unless patients were dissatisfied, in which case they could be randomly assigned to receive another study drug. In both phases pseudoephedrine could be taken as needed. Patients kept daily diaries of symptoms and costs, and study drugs were evaluated at the end of each phase for efficacy, safety, and effect on quality of life by means of a validated questionnaire. A multiattribute outcomes assessment model for formulary decision making was used to rank the antihistamines.

RESULTS

Physicians' and patients' assessments in phases I and II indicated that cetirizine and chlorpheniramine were significantly more effective than terfenadine (p < 0.05). Incidence of sedation in phase I and phase II was 40.5% and 16.7% for chlorpheniramine, 11.6% and 9.8% for cetirizine, and 6.7% and 5.1% for terfenadine, respectively. At the end of phase I, 28.9% of the patients treated with chlorpheniramine, 50% of the patients treated with terfenadine, and 69.4% of the patients treated with cetirizine were satisfied with their therapy and chose not to switch their medication. Quality of life scores improved most after treatment with cetirizine and least after treatment with terfenadine.

CONCLUSION

The result of this trial indicate that antihistamine selection is best made with the use of a multiattribute evaluation that includes quality of life. In this study cetirizine was favored by patients and physicians most often, followed by chlorpheniramine and then terfenadine.

Promotion of OTC products within a network-model HMO

The drug benefits of most health plans do not include reimbursement for over-the counter (OTC) drugs. However, one PMB found that significant savings could be obtained if the OTC option was encouraged.

H1-antihistamines and prescription compliance

H1-antihistamines (H1A) have been used for more than 50 years in the treatment of allergic pathology. Their widespread consumption and the growing pharmaceutical offer is noteworthy. Despite this, we have not found any study on the compliance of these drugs in the scientific literature reviewed. The aims of this study are to evaluate compliance with the prescription of H1A in a sample of allergic patients diagnosed as pollen rhinoconjunctivitis (PRC), and to evaluate the possible association between the degree of compliance and certain patient-dependent parameters (age, sex, cultural level, knowledge of the prescription and treatment [duration, number of drugs, posology, method of administration and appearance of adverse drug reactions]). The sample size was 300, and 164 were attended. Of these 164 patients, 123 claimed to have taken correctly the H1A prescribed by the allergologist. Of the group of patient claiming to have followed treatment correctly, only 8 patients did not remember the number of packs of H1A bought, nor their price, nor the appearance of the tablets (or solution). Regarding the frequency of use, 101 patients took the H1A daily, and the remaining 22, depending on symptoms. Administration of the H1A was always oral-tablets in 114 cases and solution in 9. The compliance we have found is at a medium level, similar to that reported in other studies (although on other drugs), and no significant differences were found in relation to the parameters studied.

A pharmacologic continuum in the treatment of rhinorrhea: the clinician as economist

The economics of medications are now of great concern to health-care providers. Pharmacoeconomic issues are by no means simple, and yet, ironically, they assume greater importance in prescribing for modest disorders like rhinorrhea than for life-threatening conditions. The therapeutic continuum of quality and cost becomes foreshortened, and safety is an additional concern. Choosing the appropriate medication for rhinorrhea, then, can pose a challenge to the clinician, just as choosing a vital medication. This paper reviews the usage, quality, and cost of major therapies for the rhinorrhea that occurs secondary to various conditions, including nasal steroids, antihistamines and anticholinergics, and discusses the role of the clinician in factoring costs into therapy.

An overview of current pharmacotherapy in perennial rhinitis

BACKGROUND

Individuals with rhinitis experience significant morbidity due to their disease. Research and clinical care to reduce this suffering are important.

OBJECTIVE

To review the pharmacological agents that have been developed for the treatment of perennial rhinitis.

METHOD

Literature review of human studies.

RESULTS

Medication classes include antihistamines, decongestants, anticholinergics, cromolyn sodium, and corticosteroids. These vary in regard to their pharmacology, efficacy, and adverse effects. Compliance and cost issues are also critical components of the therapeutic regimen.

CONCLUSION

Carefully chosen pharmacotherapy based on an understanding of the pathophysiology of the disease, knowledge of the potential of medications, and commitment to an ongoing patient/physician education and monitoring program can lead to improved well-being for individuals with perennial rhinitis.