The effect of drug pricing on cataract surgery
Dropless or less drops may improve cost, convenience, compliance
In a recent wave of drug price increases that can only be explained by pharmaceutical manufacturers’ desire for profit maximization and which doctors and patients may call price gouging, the drug price war has been brought to the doorsteps of many eyecare providers. As optometrists are increasing their practice of medical optometry, patients are now calling their doctors about prior authorizations and unaffordable drug copays.
Recently, we called our local CVS Pharmacies in Panama City, FL asking for the cash prices for common medications we prescribe, such as Pred Forte 1% (prednisolone acetate, Allergan)—a 5 mL bottle costs $135, and generic costs $57. A branded 5 mL-bottle of Tobradex (tobramycin and dexamethasone, Alcon) costs $356, and generic costs $199.
We are combating high drug prices by being creative because a majority of our patients are uninsured, underinsured, or using governmental assistance. We send our patients to retailers’ generic $4 drug lists, which typically includes a handful of tobramycin, neomycin-polymyxin b-dexamethasone, or timolol maleate ophthalmic drops. GoodRx.com provides patient drug coupons to offset prices. As a last resort for special branded drugs, we utilize manufacturer drug assistance programs for patients unable to afford their medications. However, a newcomer in the pharmaceutical industry, is getting involved in the battle for high drug prices.
Imprimis Pharmaceuticals made the headlines recently when Turing Pharmaceuticals acquired the antiprotozoal human immunodeficiency virus-(HIV) treating drug, Daraprim, in its portfolio and raised the price from $13 per pill to $750 per pill.1 Imprimis decided to produce a similar alternative to Daraprim for just $1 per pill. Imprimis is expanding its more economical drug alternative portfolio into eye care with the introduction of formulations for dropless cataract surgeries and fewer drops for post-operative medications for laser-assisted in situ keratomileusis (LASIK) and other ocular surgeries.
Dropless cataract surgery
Cataract surgery is traditionally a refined and painless procedure. However, the required pre- and post-surgical topical pharmacotherapy regimen is often problematic for patients, especially the elderly. Some experience cost difficulties in obtaining their drops, and many find them inconvenient or difficult to administer, creating compliance concerns. These problems have been lessened with Imprimis’s injectable compounds, Tri-Moxi (triamcinolone acetonide and moxifloxacin hydrochloride) and Tri-Moxi-Vanc (triamcinolone acetonide and moxifloxacin hydrochloride with vancomycin).
These compounded formulations are prepared for an individual patient undergoing surgery at the order of the operating surgeon. In the case of Tri-Moxi and Tri-Moxi-Vanc, these steroid/antibiotic combinations are injected at the time of cataract surgery, typically through a transzonular approach at the conclusion of the procedure. The medication remains suspended in the anterior vitreous space where it releases over several days post surgery in order to help prevent infection and speed healing.7
Patients with diabetes or epiretinal membrane or those receiving a multifocal intracocular lens (IOL) can be pretreated with a single daily drop of a topical NSAID (nonsteroidal anti-inflammatory drug) the day before surgery. This is continued for two to four weeks post surgery in order to prevent cystoid macular edema (CME) in patients at increased risk for macular edema or in whom any macular edema would be problematic, such as multifocal patients.
Approximately 10 percent of our patients have slight breakthrough inflammation at one to four weeks post surgery with the dropless approach. We treat these cases with a topical NSAID as well. However, most patients will not need any additional drops.
In addition to eliminating cost, convenience, and compliance concerns, studies have proven the efficacy of dropless cataract surgery.7 Previously, topical therapies were necessary in order to combat infection and inflammation in post-operative eyes. However, with the injectible medications, these risks are greatly reduced without the concerns posed by ocular drops.
Intracameral vancomycin has repeatedly demonstrated its ability to significantly reduce and often eliminate cases of endophthalmitis.2-6 One such study of 1,575 consecutive eyes concluded with no eyes developing endophthalmitis. Additionally, at three weeks post procedure, 98 percent remained free from anterior chamber inflammation and CME.6
A similar study of nearly 4,000 surgeries, in which either Tri-Moxi or Tri-Moxi-Vanc was injected using a transzonular approach during cataract surgery, resulted in no intraocular pressure (IOP) elevation, with 95 percent of patients healing without the use of supplemental steroids. A remarkable 98 percent remained free from CME, and the incidence of endophthalmitis or infection was significantly low with a rate of less than 0.005 percent.7