Out-of-pocket costs are on the rise for commonly prescribed neurologic medications.

OBJECTIVE: To determine out-of-pocket costs for neurologic medications in 5 common neurologic diseases. METHODS: Utilizing a large, privately insured, health care claims database from 2004 to 2016, we captured out-of-pocket medication costs for patients seen by outpatient neurologists with multiple sclerosis (MS), peripheral neuropathy, epilepsy, dementia, and Parkinson disease (PD). We compared out-of-pocket costs for those in high-deductible health plans compared to traditional plans and explored cumulative out-of-pocket costs over the first 2 years after diagnosis across conditions with high- (MS) and low/medium-cost (epilepsy) medications. RESULTS: The population consisted of 105,355 patients with MS, 314,530 with peripheral neuropathy, 281,073 with epilepsy, 120,720 with dementia, and 90,801 with PD. MS medications had the fastest rise in monthly out-of-pocket expenses (mean [SD] $15 [$23] in 2004, $309 [$593] in 2016) with minimal differences between medications. Out-of-pocket costs for brand name medications in the other conditions also rose considerably. Patients in high-deductible health plans incurred approximately twice the monthly out-of-pocket expense as compared to those not in these plans ($661 [$964] vs $246 [$472] in MS, $40 [$94] vs $18 [$46] in epilepsy in 2016). Cumulative 2-year out-of-pocket costs rose almost linearly over time in MS ($2,238 [$3,342]) and epilepsy ($230 [$443]). CONCLUSIONS: Out-of-pocket costs for neurologic medications have increased considerably over the last 12 years, particularly for those in high-deductible health plans. Out-of-pocket costs vary widely both across and within conditions. To minimize patient financial burden, neurologists require access to precise cost information when making treatment decisions.

Nusinersen treatment of spinal muscular atrophy: current knowledge and existing gaps.

Spinal muscular atrophy (SMA) is a recessive disorder caused by a mutation in the survival motor neuron 1 gene (SMN1); it affects 1 in 11 000 newborn infants. The most severe and most common form, type 1 SMA, is associated with early mortality in most cases and severe disability in survivors. Nusinersen, an antisense oligonucleotide, promotes production of full-length protein from the pseudogene SMN2. Nusinersen treatment prolongs survival of patients with type 1 SMA and allows motor milestone acquisition. Patients with type 2 SMA also show progress on different motor scales after nusinersen treatment. Nusinersen was recently approved by the European Medicines Agency and the US Food and Drug Administration; it is now reimbursed in several European countries and in the USA. In Australia, the transition from expanded access programme to commercial availability is coming soon. In New Zealand, an expanded access programme is opened, and in Canada price negotiation for the treatment is in progress. In this review we exemplify the clinical benefit of nusinersen in subgroups of patients with SMA. Nusinersen represents the first efficacious marked approved drug in type 1 and type 2 SMA. Different knowledge gaps, such as results in older patients, in patients with permanent ventilation, in patients with neonatal forms, or in patients after spinal fusion, still need to be addressed. WHAT THIS PAPER ADDS: Identifies gaps in knowledge about the efficacy of nusinersen in broader populations of patients with spinal muscular atrophy. Identifies open questions in populations of patients where proof of efficacy is available.

1-cyclohexyl-x-methoxybenzene derivatives, novel psychoactive substances seized on the internet market. Synthesis and in vivo pharmacological studies in mice.

INTRODUCTION: Among novel psychoactive substances notified to EMCDDA and Europol were 1-cyclohexyl-x-methoxybenzene stereoisomers (ortho, meta, and para). These substances share some structural characteristics with phencyclidine and tramadol. Nowadays, no information on the pharmacological and toxicological effects evoked by 1-cyclohexyl-x-methoxybenzene are reported. The aim of this study was to investigate the effect evoked by each one stereoisomer on visual stimulation, body temperature, acute thermal pain, and motor activity in mice. METHODS: Mice were evaluated in behavioral tests carried out in a consecutive manner according to the following time scheme: observation of visual placing response, measures of core body temperature, determination of acute thermal pain, and stimulated motor activity. RESULTS: All three stereoisomers dose-dependent inhibit visual placing response (rank order: meta > ortho > para), induce hyperthermia at lower and hypothermia at higher doses (meta > ortho > para) and cause analgesia to thermal stimuli (para > meta = ortho), while they do not alter motor activity. CONCLUSIONS: For the first time, this study demonstrates that systemic administration of 1-cyclohexyl-x-methoxybenzene compounds markedly inhibit visual response, promote analgesia, and induce core temperature alterations in mice. This data, although obtained in animal model, suggest their possible hazard for human health (i.e., hyperthermia and sensorimotor alterations). In particular, these novel psychoactive substances may have a negative impact in many daily activities, greatly increasing the risk factors for workplace accidents and traffic injuries.

Patterns of use and health expenses associated with triptans among adults with migraines.

OBJECTIVES: To determine patterns of use, socioeconomic factors, and the impact on total health expenses associated with triptan therapy among patients with migraines. MATERIALS AND METHODS: Patients with migraines were identified from the Medical Expenditure Panel Survey household component files (2006 to 2011) and were restricted to those who were 18 years or older and had a migraine diagnosis. The major outcome measures were triptan use during the 2-year period and annualized average total and migraine-related health care expenses and medical utilization. Socioeconomic factors associated with triptan use were analyzed by using logistic regression. The impact of triptan use on total and migraine-related health expenses was assessed by linear regression models with log transformations. RESULTS: Among 1961 patients with a migraine diagnosis (representing 45.6 million individuals in the United States for years 2006 to 2011), 501 received triptans to treat acute migraines (representing 13.1 million individuals in the United States, 28.6%). Patients who were females and had higher income and education levels were more likely to receive triptans to treat migraines. Triptan expense accounted for 49.6% of total migraine-related expenses and 21.9% of total all-cause prescription drug expenses respectively. Compared with nontriptan users, the annualized total health expenses increased by 19.7% in triptan users after adjusting for demographic and health-related variables. DISCUSSION: The study suggested that socioeconomic factors were associated with triptan use in migraineurs. Higher total and migraine-related health expenses were observed in triptan users.

The Partnership Access Line: evaluating a child psychiatry consult program in Washington State.

OBJECTIVE: To evaluate a telephone-based child mental health consult service for primary care providers (PCPs). DESIGN: Record review, provider surveys, and Medicaid database analysis. SETTING: Washington State Partnership Access Line (PAL) program. PARTICIPANTS: A total of 2285 PAL consultations by 592 PCPs between April 1, 2008, and April 30, 2011. INTERVENTIONS: Primary care provider-initiated consultations with PAL service. MAIN OUTCOME MEASURES: The PAL call characteristics, PCP feedback surveys, and Medicaid claims between April 2007 and December 2009 for fee-for-service Medicaid children before and after a PAL call. RESULTS: Sixty-nine percent of calls were about children with serious emotional disturbances, and 66% of calls were about children taking psychiatric medications. Primary care providers nearly always received new psychosocial treatment advice (87% of calls) and were more likely to receive advice to start rather than stop a medication (46% vs 24% of calls). Primary care provider feedback surveys reported uniformly positive satisfaction with the program. Among Medicaid children, there was significant increases in attention-deficit/hyperactivity disorder and antidepressant medication use after the PAL call but no significant change in reimbursements for mental health medications (P < .05). Children with a history of foster care experienced a 132% increase in outpatient mental health visits after the PAL call (P < .05). CONCLUSIONS: Primary care providers used PAL for psychosocial and medication treatment assistance for particularly high-needs children and were satisfied with the service. Furthermore, PAL was associated with increased use of outpatient mental health care for some children.

Communication of potential benefits and harm to patients and payers in psychiatry: a review and commentary.

BACKGROUND: Communicating potential benefits and harm to patients and payers is essential for high-quality care. However, there are no published guidelines or consensuses on how to communicate potential benefits and harm to patients and payers. OBJECTIVE: The goal of this review was to identify key elements for communication between clinicians, patients, and payers to achieve maximal benefits and minimal risk. METHODS: Literature published from January 1980 to July 2011 and cited on MEDLINE was searched using the terms communication, benefit, harm, effectiveness, cost, cost-effectiveness, psychiatry, bipolar disorder, schizophrenia, and major depressive disorder. Elements related to communicating benefits and/or harm to patients and payers were identified, with only key elements discussed in detail here. RESULTS: Evidence-based medicine, number needed to treat to benefit (NNTB) or harm (NNTH), and the likelihood of being helped or harmed (LHH) have been advocated as the basis for communication in all specialties of medicine. Phase-dependent communication of benefits and harm is novel, especially in patients with different phases of illness, such as bipolar disorder. Duration-dependent (short-term versus long-term) communication is essential for all psychiatric disorders to reduce the burden of relapse and adverse events with long-term treatment. For drugs with multiple therapeutic indications, a disease-dependent approach is crucial to maximize benefits and minimize harm. The exclusion of comorbid psychiatric disorders in pivotal efficacy trials affects their generalizability. Communicating cost (direct versus indirect) is an essential component in reducing health care expenditures. The results of available cost-effectiveness analyses of psychiatric pharmacotherapy have been inconsistent and/or contradictory. CONCLUSIONS: Evidence-based communication of potential benefits and harm to patients and payers, using NNTB, NNTH, and LHH, should be the key principle that guides decision making. Phase-, duration-, and disease-dependent communication and evidence-based cost-saving principles can maximize benefit and reduce harm.