The Cost of Psoriasis Therapies: Considerations for Therapy Selection

Daniel J. Pearce; Crystal G. Thomas; Alan B. Fleischer, Jr.; Steven R. Feldman

Disclosures

Dermatology Nursing. 2004;16(5) 

In This Article

Results

Corticosteroids. Corticosteroids (see Table 1 , Table 2 , Table 3 , Table 4 , Table 5 , Table 6 ) come in differing potencies and are organized into a class system, with class I representing the strongest and class VI the weakest. For the superpotent class I medications, the AWP per gram (or mL) ranged from $1.55 to $2.77, while the online price per gram ranged from $0.46 to $1.62. The overall average for class I cortico-steroids was $1.65 per gram (or mL). Class II corticosteroids had a wider range of prices with AWPs, $0.01 to 1.56, and online pricing at $0.24 to 1.51 per gram (or mL) representing generic betamethasone and Diprolene®, respectively. The average AWP and online pricing for class II was $0.96 per gram (or mL). Mid-potency corticosteroids, consisting of classes III, IV, and V, had an average wholesale price/online price per gram (or mL) of $0.82/$0.74, $0.64/$0.70, and $0.71/$0.70, respectively. The overall mean price per gm (or mL) for all mid-potency corticosteroids was $0.72 per gram (or mL). Class VI, or low-potency, corticosteroids were the least expensive overall. The range for this category was a low of $0.23 per gram (or mL) to a high of $1.28 per gram. The AWP for this entire class was $0.86 per gram (or mL).

Overall the AWP and average online pricing between different categories of corticosteroids do differ and also seem to relate directly with potency; as a class, higher-potency medications are more expensive. However, when comparing individual corticosteroids, there are examples of a higher-potency medication that is less expensive than a medication in a lower-potency class (see Table 7 & Figure 1).

Range of AWP per Gram among Corticosteroid Classes (Branded and Generic)

(see Table 8 & Table 9 )

Vitamin D Analogues. Vitamin D analogues were first investigated for their possible role in the treatment of psoriasis after witnessing the development of various forms of psoriasis in patients with hypocalcemia (Federman, Froelich, & Kirsner, 1999). Calcipotriene is the only vitamin D analogue currently available for treating psoriasis. With its documented efficacy as well as low side effect profile, it is a popular treatment choice. Calcipotriene is not associated with many of the local adverse effects that are seen with inappropriate corticosteroid use, but does have its own disadvantages; calcipotriene can be irritating and is inactivated by agents containing acid. At an AWP of $1.96 per gram (or mL), it compares similarly to other nonsteroidals, superpotent topical corticosteroids (as a class), and to many nongeneric corticosteroids.

Topical Retinoids. In June 1997, the FDA approved the topical retinoid tazarotene for the treatment of localized psoriasis (Federman et al., 1999). Due to the potential teratogenicity of retinoids as a class, females of childbearing age should be educated and adequate birth control measures should be taken. Using the AWP to determine an average price, at $2.61 per gram, tazarotene is the most expensive nonsteroidal treatment available. If used daily, the monthly (18 gram supply) AWP of tazarotene is approximately $46.98/1% BSA.

Tacrolimus (FK-506). Topical tacrolimus is FDA approved for treating atopic dermatitis (Mendonca & Burden, 2003). Tacrolimus may be effective for treating psoriasis when applied to areas of the body with a thinner stratum corneum, such as the face (Freeman et al., 2003). The AWP per gram of 0.1% tacrolimus is $2.14 ($38.52/1% BSA/month), which lies between that of calcipotriene and tazarotene, two other noncorticosteroids for psoriasis.

Other Topical Medications. The therapeutic effects of coal tar for skin disorders was described by the Greek philosopher Dioscorides nearly 2,000 years ago (Arnold, 1997). Many formulations of tar-containing topicals and shampoos are on the market. Although typically lower in efficacy compared to many prescription topicals, most of these are on the low end of the cost spectrum. The benefit of these preparations is that many of them are available over-the-counter (OTC), allowing the patient to choose the one that is most effective and cost-appropriate for them. While these relatively inexpensive medications may provide a cost-effective adjunct to other therapies, their odor and messy quality limit their acceptability. Another important consideration is that paying for OTC medications is the sole responsibility of the patient, as there is no insurance coverage. These preparations range from approximately $5 to $15 for an 18 gram (or mL) supply.

Emollients are a basic, yet important part of the psoriasis treatment regimen. Moisturizers are capable of improving the appearance of the lesions by providing hydration and reducing the scaly presentation (Feldman, 1998). They may decrease pruritus and tenderness while allowing other concurrent topical treatments, including corticosteroids, to be applied less often. There are many preparations and brands available at a wide range of cost. Many creams found on drugstore.com are around $0.50 per 18 gram supply; however, most of these are used on noninvolved areas as well, are used more liberally and, therefore, determining an approximate monthly cost may be complex.

Phototherapy (UVB and Excimer Laser). In spite of the efficacy and relative safety of phototherapy, its use has been declining in the United States. The decrease in physician reimbursement and increase in regulations and requirements associated with it seem to be the cause of this decline. In addition, there can be significant expense associated with ultraviolet therapy. Depending on the type of ultraviolet radiation, the clinic and insurer coverage, the total cost for each light treatment can range form $25 to $100 (Lebwohl, Martinez, Weber, & DeLuca, 1995). The cost faced by patients is highly dependent on the co-pay they are contracted to pay for each visit/treatment.

For long-term treatment of psoriasis for select patients, a home ultraviolet phototherapy unit may be considered. The cost of a UVB unit is approximately $1,500 which may prove to be the most economical option for these select patients in the long term (Feldman, 1998). Vigilant protection of sensitive areas and frequent monitoring for signs of skin cancer are required.

Other forms of phototherapy such as narrowband and photochemotherapy (PUVA) are also available. Narrowband phototherapy, an excimer laser, is typically used for stubborn localized disease and is more expensive than traditional broadband treatment. The advantages of faster plaque clearance and longer remission of disease with appropriate dosing may negate any potential increase in cost. Costs associated with PUVA are a combination of the oral medication, oxsoralen, and the frequency of UVA light treatment. Light treatment costs are discussed above and the prices associated with 1 month supply of oxsoralen (10 mg capsules) are an AWP of $203.15 and a drugstore.com price of $207.52.

Methotrexate. Methotrexate is the most commonly used systemic psoriasis treatment in the United States (Yamauchi, Rizk, Kormeili, Patnaik, & Lowe, 2003). The cost of methotrexate varies significantly depending on the manufacturer of the medicine. The intravenous solution is less expensive than the pill form and may be taken orally (Feldman, 2000). Based on the AWP, the average cost of methotrexate is $1.31/mg for the pill versus $0.10/mg for the solution. The typical dose is approximately 15 mg per week with an adjusted monthly AWP of $90.75 for the pill form, and approximately $6.00 for the solution; online pricing is $20.80 for 1 month of pills. The cost of necessary monitoring and potential liver biopsy are not considered here, but may be significant.

Systemic Retinoids. Systemic retinoids are appropriate treatment for patients with moderate-to- severe psoriasis, particularly those with difficult to treat as in palmoplantar, pustular, and erythrodermic varieties. Acitretin is currently the systemic retinoid most commonly used for managing psoriasis. The adjusted monthly AWP and online prices based on a 25 mg daily dose are $406.62 and $347.40, respectively.

Cyclosporine. Secondary to its long-term use adverse effects, cyclosporine is probably most valuable for acute management of psoriasis flares (Feldman, 1998). Assuming a maximum dose of 5 mg/kg/day dose in a 70 kg patient, a daily dose of cyclosporine is 350 mg, and this translates into monthly AWP and online pricing of $602.70 and $507.15, respectively. These estimates are based on the generic preparation only.

Alefacept. Alefacept is another promising therapeutic option for managing psoriasis. It is the first FDA-approved biologic for treating moderate-to-severe psoriasis (Krueger & Callis, 2003). It is dosed as an intermittent 12-week therapy and administered once weekly (15 mg) in the physician's office. This cycle of therapy allows patients to experience 12-week drug holidays between courses. Although alefacept is not continuously dosed, based on a typical regimen for 1 year, the amortized monthly AWP associated with alefacept is $2,155.83.

Efalizumab. Efalizumab represents the most recent addition to the biologic medications for moderate-to-severe psoriasis. Approved by the FDA in late October 2003, it is the only once weekly subcutaneous injection and has cost similar to etanercept. Dosing is weight based (mg/kg) and monthly AWP for this medication is $1,372. Online pricing is not yet available.

Etanercept. Etanercept has been FDA approved for several years for many rheumatologic diseases and Crohn's disease and was recently approved for psoriasis. The approved dose of etanercept is 50 mg twice weekly; however, based on 25 mg SC twice weekly, the monthly AWP is $1,306. The online pricing of etanercept is slightly less at $1,132.99.

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