Is the Least Expensive Drug the Most Cost-Effective Treatment?

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Is the Least Expensive Drug the Most Cost-Effective Treatment?

Nearly a dozen topical antifungal agents are currently available for treating dermatophytoses of keratinized skin, some available over the counter and others only by prescription. A major consideration in selecting one of these agents is the cost of therapy; for tinea pedis, for example, the cost of treatment can vary by a factor of 14, depending on the agent used. This study, conducted from the perspective of a health care purchaser, looked at the extra cost of using higher-priced drugs as initial therapy for tinea pedis.

The analysis compared two regimens in a hypothetical setting: giving patients terbinafine cream (high-priced) twice a day for 4 weeks, or giving miconazole cream (low-priced) twice a day initially and prescribing terbinafine at a follow-up visit for patients who do not respond to miconazole. The estimated cost for a month of therapy (a total of 120 grams of medication) was $9.04 for miconazole cream and $174.39 for terbinafine cream. Using a range of efficacy rates and "standard costs" of office visits, the authors concluded that a low-cost agent such as miconazole should be used initially, and that a more expensive prescription drug such as terbinafine cream should be given only to those who do not respond to the inexpensive agent.

Comment: This study raises many interesting issues. According to this analysis, in a primary care practice in an HMO it would be cost efffective to treat any patient with a complaint of foot dermatosis with miconazole twice a day for 4 weeks. In a dermatology practice, 40% to 50% of patients with foot dermatoses have already used over-the-counter products without satisfactory response. The dermatologist usually takes time to diagnose tinea pedis by KOH preparation or fungal culture, ruling out scaling dermatoses, and to explain proper use of topical agents and methods of reducing the incidence of relapse or reinfection. The extra time increases the cost of the office visit significantly above the $21.98 allocated in this study. The use of terbinafine cream twice a day for 4 weeks seems excessive; a recent study reported that it produces a mycological cure in 78% of patients with tinea pedis after only a single application (Evans EGV; et al. Br J Dermatol 1994; 130:83-7), which could make terbinafine cream the most cost-effective agent in this study. In some patients, such as those with recurrent cellulitis following saphenous vein harvest with tinea pedis as a portal of entry, an oral agent such as itraconazole or terbinafine may be the most cost effective, even though these agents are expensive. In many clinical situations, the greatest cost comes from the time spent managing the problem. In interpreting this study we must also consider that the prices of antifungal agents may vary from country to country and are subject to change.

— RA Johnson, NH Shear

Published in Journal Watch Dermatology March 1, 1995