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Costing of antiepileptic drugs
Costing of antiepileptic drugs
Case reports
SiR-It is widely accepted in neurology that up to 80% of those who develop seizures can eventually achieve-provided that effective medications are available-a complete remission, and that the remainder will have recurrent seizures, notwithstanding treatments. At our centre, between 1984 and 1985, we studied the frequency of seizures reported by patients at their first referral, along with treatments received, and found that 58% had refractory epilepsy. Furthermore, these patients were receiving polymedication, with minimum doses of each traditional drug. In a follow-up study in 1992, we showed that, by following international treatment criteria, we could reduce the numbers with refractory epilepsy to 32%,’ and the availability of new drugs should help in this regard.
SIR-We are pleased that The Lancet has added case reports the ways in which it instructs and entertains, but without reference intervals for assays the reports are not going to be "an efficient way to grasp new knowledge". What should we make of an alanine aminotransferase of 0-82 u,Kat/L in the woman with portal vein thrombosis (Nov 11, p 1270)’ at presentation, or a plasma viscosity of 1-59 mPa in the patient (p 1269)2 with Streptococcus agalacticae uveitis and meningitis? The jjKat may be the approved unit for reporting enzyme assay results but is not in widespread use in the UK or the USA. The Harkness plasma viscometer is preferred to the erythrocyte sedimentation rate in some hospitals in the south west of England, but not many of us elsewhere are familiar with the reference range. Reports burdened with reference intervals make turgid reading. The New England _7oumal’s solution was to provide a pamphlet of laboratory values for its readers. The Lancet is charging [,15 for that information. Are the case reports perhaps a cunning means of promoting sales of The Lancet diary: "every doctor should have one" to comprehend the reports? We are promised international converson tables but the "normal values" shown in the advertisement do not cite the reference interval for amylase or acid phophatase in u-Kat/L. The admission that a single reference interval cannot be given for amylase illustrates the limited usefulness of these tables: enzyme assays are method dependent, and one assay’s normal range is another assay’s pathological evaluation. Alkaline phosphatase is an example that frequently causes confusion. Of course, some analyses are commonplace and reference intervals are not required. However, it is still important to provide results that are numerically correct (blood leucocyte and platelet counts in the Nov 11 reports are a factor of 103 too low). Whatever units receive The Lancet’s imprimatur, reference ranges applicable to the method in use at the hospital from which the case is reported and appropriate to the patient’s age and sex should be given within the article.
Drug
Phenobarbltol (generic price) Carbamazepme (generic price) Ciba
Phenytoin (generic price) Parke Davis
Valproate (generic price) Abbott
Vigabatnn (Dow) Lamotrlgrlne (Glaxo) Felbamate (Wallace) Gabapentin (Parke Davis) *Cost m$US of 30 days’ treatment with lowest recommended wholesale pnce. (AWP), 1995.
dosage according to
Table :
Comparative cost of some antiepileptic drugs European Community, and Argentina
in
USA,
new antiepileptic agents have been approved for use Argentina: oxcarbazepine (adjunctive or monotherapy in children and adults with partial seizures), vigabatrin, lamotrigine, and gabapentin (for partial and tonic-clonic seizures). These medications can certainly benefit patients with refractory epilepsy: they have unique clinical spectrums, and are reported to be safer and better tolerated than drugs hitherto available, although comparative trials with conventional regimens need to be carried out, and their appropriateness in the initial treatment of epileptic patients
Four
in
be established. Unfortunately, the local currency cost of these new drugs is about 250% higher than that of agents usually relied upon.2 In Argentina, as in most developing countries, more than 50% of the population lacks medical insurance, and patients with epilepsy often are among those with the lowest incomes (minimum salary$US300/month, mean salary $US600/month). It is therefore difficult for many patients to meet the cost of these new treatments. Cost burdens can therefore frustrate efforts at our specialised centres to follow international criteria and guidelines in the treatment of epilepsy. It is also noteworthy that, in Argentina, the average price of standard antiepileptic drugs is 25% higher than in the USA, and 14% higher than in Europe. The average price of the new medications is 86% higher than in the USA, and 55% higher than in Europe3(table). needs
Silvia Kochen Epilepsy, Division of Neurology, Hospital Ramos Mejia, University of Buenos Aires (1182), Argentina
2 3
Kochen S, Saidón P, Olandini E. Study of refractory epilepsy in a reference centre. Seizure 1992; 1 (suppl A): 13-23. Pharmaceutical Market Argentina, International Medical Statistics, 1992-93. The Medical Letter 1995 (April 28); 37: 40.
266
Godfrey
T
Gillett, Anne C Tarn
Clinical Biochemistry, GOS Hospitals NHS Trust, London WC1N 3JH, UK; and Chemical Pathology, University College London Hospitals
1
to
Centre for
1
to
2
de Celis G, Mir J, Casal J, Gómez D. 31-year-old woman with an enlarged tender liver. Lancet 1995; 346: 1270. MacConnell TJ, Ferro A. A sore eye and meningitis. Lancet 1995; 346: 1269.
Inquiring into
sex
SiR-Your editorial’ on ethical and political implications of research into the causes of sexual orientation is timely. Recent research advances by LeVay, Hamer, and Zhou and the public reactions to it have brought once again to our attention the fact that scientific inquiry cannot be disconnected from the social and political realities in which it takes place. The history of homosexuality research provides examples of results being used against homosexual people.2 The acceptance of homosexuality as normal is quite recent. Since we do not know how future knowledge of the of sexual orientation might be used, the only causes experience to which we can refer lies in our past, and what we know from that does not lead us to predict enlightened use of such research.2 In addition, we have strong recent evidence supporting the view that research could be used against homosexual people.3 Much of the ethical issues in homosexuality research in the USA are a direct result of legislation. Biological causes of
Case reports
SiR-It is widely accepted in neurology that up to 80% of those who develop seizures can eventually achieve-provided that effective medications are available-a complete remission, and that the remainder will have recurrent seizures, notwithstanding treatments. At our centre, between 1984 and 1985, we studied the frequency of seizures reported by patients at their first referral, along with treatments received, and found that 58% had refractory epilepsy. Furthermore, these patients were receiving polymedication, with minimum doses of each traditional drug. In a follow-up study in 1992, we showed that, by following international treatment criteria, we could reduce the numbers with refractory epilepsy to 32%,’ and the availability of new drugs should help in this regard.
SIR-We are pleased that The Lancet has added case reports the ways in which it instructs and entertains, but without reference intervals for assays the reports are not going to be "an efficient way to grasp new knowledge". What should we make of an alanine aminotransferase of 0-82 u,Kat/L in the woman with portal vein thrombosis (Nov 11, p 1270)’ at presentation, or a plasma viscosity of 1-59 mPa in the patient (p 1269)2 with Streptococcus agalacticae uveitis and meningitis? The jjKat may be the approved unit for reporting enzyme assay results but is not in widespread use in the UK or the USA. The Harkness plasma viscometer is preferred to the erythrocyte sedimentation rate in some hospitals in the south west of England, but not many of us elsewhere are familiar with the reference range. Reports burdened with reference intervals make turgid reading. The New England _7oumal’s solution was to provide a pamphlet of laboratory values for its readers. The Lancet is charging [,15 for that information. Are the case reports perhaps a cunning means of promoting sales of The Lancet diary: "every doctor should have one" to comprehend the reports? We are promised international converson tables but the "normal values" shown in the advertisement do not cite the reference interval for amylase or acid phophatase in u-Kat/L. The admission that a single reference interval cannot be given for amylase illustrates the limited usefulness of these tables: enzyme assays are method dependent, and one assay’s normal range is another assay’s pathological evaluation. Alkaline phosphatase is an example that frequently causes confusion. Of course, some analyses are commonplace and reference intervals are not required. However, it is still important to provide results that are numerically correct (blood leucocyte and platelet counts in the Nov 11 reports are a factor of 103 too low). Whatever units receive The Lancet’s imprimatur, reference ranges applicable to the method in use at the hospital from which the case is reported and appropriate to the patient’s age and sex should be given within the article.
Drug
Phenobarbltol (generic price) Carbamazepme (generic price) Ciba
Phenytoin (generic price) Parke Davis
Valproate (generic price) Abbott
Vigabatnn (Dow) Lamotrlgrlne (Glaxo) Felbamate (Wallace) Gabapentin (Parke Davis) *Cost m$US of 30 days’ treatment with lowest recommended wholesale pnce. (AWP), 1995.
dosage according to
Table :
Comparative cost of some antiepileptic drugs European Community, and Argentina
in
USA,
new antiepileptic agents have been approved for use Argentina: oxcarbazepine (adjunctive or monotherapy in children and adults with partial seizures), vigabatrin, lamotrigine, and gabapentin (for partial and tonic-clonic seizures). These medications can certainly benefit patients with refractory epilepsy: they have unique clinical spectrums, and are reported to be safer and better tolerated than drugs hitherto available, although comparative trials with conventional regimens need to be carried out, and their appropriateness in the initial treatment of epileptic patients
Four
in
be established. Unfortunately, the local currency cost of these new drugs is about 250% higher than that of agents usually relied upon.2 In Argentina, as in most developing countries, more than 50% of the population lacks medical insurance, and patients with epilepsy often are among those with the lowest incomes (minimum salary$US300/month, mean salary $US600/month). It is therefore difficult for many patients to meet the cost of these new treatments. Cost burdens can therefore frustrate efforts at our specialised centres to follow international criteria and guidelines in the treatment of epilepsy. It is also noteworthy that, in Argentina, the average price of standard antiepileptic drugs is 25% higher than in the USA, and 14% higher than in Europe. The average price of the new medications is 86% higher than in the USA, and 55% higher than in Europe3(table). needs
Silvia Kochen Epilepsy, Division of Neurology, Hospital Ramos Mejia, University of Buenos Aires (1182), Argentina
2 3
Kochen S, Saidón P, Olandini E. Study of refractory epilepsy in a reference centre. Seizure 1992; 1 (suppl A): 13-23. Pharmaceutical Market Argentina, International Medical Statistics, 1992-93. The Medical Letter 1995 (April 28); 37: 40.
266
Godfrey
T
Gillett, Anne C Tarn
Clinical Biochemistry, GOS Hospitals NHS Trust, London WC1N 3JH, UK; and Chemical Pathology, University College London Hospitals
1
to
Centre for
1
to
2
de Celis G, Mir J, Casal J, Gómez D. 31-year-old woman with an enlarged tender liver. Lancet 1995; 346: 1270. MacConnell TJ, Ferro A. A sore eye and meningitis. Lancet 1995; 346: 1269.
Inquiring into
sex
SiR-Your editorial’ on ethical and political implications of research into the causes of sexual orientation is timely. Recent research advances by LeVay, Hamer, and Zhou and the public reactions to it have brought once again to our attention the fact that scientific inquiry cannot be disconnected from the social and political realities in which it takes place. The history of homosexuality research provides examples of results being used against homosexual people.2 The acceptance of homosexuality as normal is quite recent. Since we do not know how future knowledge of the of sexual orientation might be used, the only causes experience to which we can refer lies in our past, and what we know from that does not lead us to predict enlightened use of such research.2 In addition, we have strong recent evidence supporting the view that research could be used against homosexual people.3 Much of the ethical issues in homosexuality research in the USA are a direct result of legislation. Biological causes of