Prostanoids in scleroderma microangiopathy: clinical and pharmacoeconomic comparison between two intravenous regimens.

Objectives: Intravenous iloprost (ILO) has widely demonstrated its effectiveness and safety in systemic sclerosis (SSc) patients. Unfortunately, there is no clear consent about dosage, duration, frequency, and infusion modality. The aim of this study was to compare two different therapeutic schemes in the same cohort of consecutive SSc subjects, evaluating differences in terms of effectiveness [digital ulcer (DU) outcome], safety, and direct healthcare costs.Method: This was a retrospective observational study of 47 patients classified with SSc treated with intravenous ILO for severe Raynaud's phenomenon and/or DUs. Two regimens were compared: a continuous inpatient scheme and a daily outpatient scheme. Demographics and clinical data, concomitant therapies, adverse events, and data on resource use and costs were collected.Results: The number of DUs rose slightly with the switch from the continuous to the daily scheme (0.61 ± 1.2 vs 1.1 ± 1.7). Moreover, in the daily scheme there was an increase in the number of therapeutic cycles (2.4 ± 0.7 vs 4.71 ± 1.4, p < 0.001) and an increase in patients treated with other vasoactive drugs. There was a reduction in ILO tolerability and more than half of the patients suspended the treatment. Five patients required hospitalization for severe and refractory DUs in the daily scheme. Moreover, the costs of the two treatments were comparable [median 7174 (range 2748-18 524) EUR vs 6284 (3232-22 706) EUR, p = 0.712].Conclusion: Treatment with a daily scheme of ILO is characterized by worse tolerability and a higher dropout rate compared to a low-flow regimen, with similar costs. We suggest that a low-flow continuous therapeutic scheme is preferable in SSc patients.

Maximizing cost-effectiveness by adjusting treatment strategy according to glaucoma severity.

BACKGROUND: The aim of this study is to determine the most cost-effective strategy for the treatment of primary open-angle glaucoma (POAG) in Brazil, from the payer's perspective (Brazilian Public Health System) in the setting of the Glaucoma Referral Centers. METHODS: Study design was a cost-effectiveness analysis of different treatment strategies for POAG. We developed 3 Markov models (one for each glaucoma stage: early, moderate and advanced), using a hypothetical cohort of POAG patients, from the perspective of the Brazilian Public Health System (SUS) and a horizon of the average life expectancy of the Brazilian population. Different strategies were tested according to disease severity. For early glaucoma, we compared observation, laser and medications. For moderate glaucoma, medications, laser and surgery. For advanced glaucoma, medications and surgery. Main outcome measures were ICER (incremental cost-effectiveness ratio), medical direct costs and QALY (quality-adjusted life year). RESULTS: In early glaucoma, both laser and medical treatment were cost-effective (ICERs of initial laser and initial medical treatment over observation only, were R$ 2,811.39/QALY and R$ 3,450.47/QALY). Compared to observation strategy, the two alternatives have provided significant gains in quality of life. In moderate glaucoma population, medical treatment presented the highest costs among treatment strategies. Both laser and surgery were highly cost-effective in this group. For advanced glaucoma, both tested strategies were cost-effective. Starting age had a great impact on results in all studied groups. Initiating glaucoma therapy using laser or surgery were more cost-effective, the younger the patient. CONCLUSION: All tested treatment strategies for glaucoma provided real gains in quality of life and were cost-effective. However, according to the disease severity, not all strategies provided the same cost-effectiveness profile. Based on our findings, there should be a preferred strategy for each glaucoma stage, according to a cost-effectiveness ratio ranking.

Induction of labor using prostaglandin vaginal gel: cost analysis comparing early amniotomy with repeat prostaglandin gel.

BACKGROUND: In a randomized controlled trial of two policies for induction of labor (IOL) using Prostaglandin E2 (PGE2) vaginal gel, women who had an earlier amniotomy experienced a shorter IOL-to-birth time. OBJECTIVE: To report the cost analysis of this trial and determine if there are differences in healthcare costs when an early amniotomy is performed as opposed to giving more PGE2 vaginal gel, for women undergoing IOL at term. STUDY DESIGN: Following an evening dose of PGE2 vaginal gel, 245 women with live singleton pregnancies, ≥37+0 weeks, were randomized into an amniotomy or repeat-PGE2 group. Healthcare costs were a secondary outcome measure, sourced from hospital finance systems and included staff costs, equipment and consumables, pharmacy, pathology, hotel services and business overheads. A decision analytic model, specifically a Markov chain, was developed to further investigate costs, and a Monte Carlo simulation was performed to confirm the robustness of these findings. Mean and median costs and cost differences between the two groups are reported, from the hospital perspective. RESULTS: The healthcare costs associated with IOL were available for all 245 trial participants. A 1000-patient cohort simulation demonstrated that performing an early amniotomy was associated with a cost-saving of $AUD289 ($AUD7094 vs $AUD7338) per woman induced, compared with administering more PGE2. Propagating the uncertainty through the model 10,000 times, early amniotomy was associated with a median cost savings of $AUD487 (IQR -$AUD573, +$AUD1498). CONCLUSIONS: After an initial dose of PGE2 vaginal gel, a policy of administering more PGE2 when the Modified Bishop's score is <7 was associated with increased healthcare costs compared with a policy of performing an amniotomy, if technically possible. Length of stay was the main driver of healthcare costs.

Cost-effectiveness of term induction of labour using inpatient prostaglandin gel versus outpatient Foley catheter.

OBJECTIVE: Evaluating cost-effectiveness of induction of labour (IOL) using outpatient mechanical cervical ripening using a Foley catheter (OFC) compared to inpatient chemical ripening using prostin gel (IPG). STUDY DESIGN: Cost-effectiveness analysis from a hospital perspective alongside a RCT. Women in a metropolitan Australian maternity hospital with an unfavourable cervix requiring IOL at term were randomised to IPG (n = 51) or OFC (n = 50). Primary economic measures were mean patient costs, incremental cost per predelivery inpatient hour prevented, and incremental cost per vaginal delivery within 12 h of admission to the birthing unit. Bootstrapping estimates were used to construct 95% confidence intervals. Estimates of net monetary benefit were calculated to aid interpretation of the results. RESULTS: Mean hospital costs per woman were nonsignificantly higher ($6524 OFC vs $5876 IPG) and mean difference $643; 95% CI -$366 to $1652. OFC group experienced fewer predelivery inpatient hours, resulting in an incremental cost per inpatient hour prevented of $57 (95% CI -$79.44 to $190.65). However, OFC patients were less likely to deliver vaginally within 12 h of admission to birthing unit. Other cost influencing clinical outcomes, including caesarean section rates and total inpatient hours, were not statistically different. Results were not sensitive to changes in costs or the cost-effectiveness thresholds. CONCLUSION: OFC had fewer inpatient hours and costs prior to birth. However, OFC did not reduce overall inpatient hours and failed to achieve comparable rates of vaginal delivery within 12 h of birthing unit admission. Therefore, OFC is unlikely to be considered cost-effective compared to IPG in current hospital settings.

Topical glaucoma therapy cost in Mexico.

Glaucoma is an important cause of irreversible blindness that represents a significant economic burden; most direct costs of glaucoma are drug-related. We calculated the annual cost of some of the most commonly prescribed glaucoma medications in Mexico, according to their average wholesale price (AWP) and dose regimen. Annual costs ranged from USD4.97 for Imot 15 ml (timolol 0.5 %; Laboratorios Sophia) to USD675.39 for Alphagan 5 ml (brimonidine 0.2 %; Allergan, Inc.). ß-Blockers were the least expensive glaucoma medications (range USD20.44-55.44). Alphagan 5 ml was 250 % more expensive than other selective α(2)-agonists. Of the carbonic anhydrase inhibitors, dorzolamide 2 % was less expensive than brinzolamide 1 % (USD326.91 vs. USD418.96). The annual cost for prostaglandin analogs ranged from USD235.58 for bimatoprost 0.03 % to USD337.78 for latanoprost 0.005 %. Some fixed combinations were less expensive than separate combinations. The average annual cost for all treatments increased by 27.87 ± 10.09 % between 2009 and 2012. Annual glaucoma therapy cost seems to be lower in Mexico than in other countries, due to a lower AWP, especially for some medications made by Mexican laboratories.

[Comparative pharmacoeconomic analysis of prostanoids for peripheral arterial occlusive].

Peripheral arteries occlusive disease (PAOD) is a prevalent illness that needs improved pharmacological management, especially for patients not eligible for surgical revascularization. Prostanoids (alprostadil or iloprost) were shown to be effective in PAOD and critical limb ischemia (CLI) but are rather costly. The results of our pharmacoeconomic study (cost estimation based on randomized control trial results) showed that iloprost does not increase cost of treatment when only direct medical costs are taken into account. If indirect costs are included into the analysis iloprost saves up to 27 thousand rubles per patient. Clinical efficacy is still high. Thus iloprost is a better alternative than alprostadil for CLI.

[Efficiency of initiation with ambrisentan versus bosentan in the treatment of pulmonary arterial hypertension]. / Eficiencia del inicio con ambrisentan frente a bosentan en el tratamiento de la hipertensión arterial pulmonar.

OBJECTIVE: To evaluate the efficiency of initiation with endothelin receptor antagonists, ambrisentan or bosentan, followed by sequential combination with phosphodiesterase-5 inhibitors and prostanoids in the treatment of pulmonary arterial hypertension, from the Spanish National Health System perspective. METHODS: A Markov model was developed based on the four New York Heart Association functional classes. A panel of three experts reached a consensus on patient management based on clinical practice. Patients revised their treatment every 12 weeks, based on their health status and previous medication records. Pharmacological treatment costs and costs associated with very frequent adverse events (AE) were considered in a horizon of 60 weeks. Outcomes were measured in qualityadjusted life years (QALY). A probabilistic sensitivity analysis was performed. RESULTS: No clinically relevant differences in QALY per-patient and year were found for initiation with ambrisentan and bosentan: 0.6853 and 0.6902, respectively. Initiation with ambrisentan resulted in lower pharmacological treatment and AE management costs: ?35,550 and ?117 versus ?40,224 and ?171. In the sensitivity analysis, initiation with ambrisentan resulted in a negative significant cost difference: ?-4,982; CI95%[?- 8,014; ?-2,500]; while no significant differences in QALY were found: -0.0044; CI95%[-0.0189; 0.0101]. CONCLUSIONS: Initiation with ambrisentan followed by sequential combination with phosphodiesterase-5 inhibitors and prostanoids yields comparable outcomes at lower costs than initiation with bosentan.

Objetivo: Se pretende evaluar la eficiencia del tratamiento secuencial de combinación de la hipertensión arterial pulmonar iniciado con antagonistas del receptor de la endotelina, ambrisentan o bosentan, seguido de inhibidores de la fosfodiesterasa- 5 y prostanoides, desde la perspectiva del Sistema Nacional de Salud. Métodos: Se desarrolló un modelo de Markov basado en las cuatro clases funcionales de la New York Heart Association. Un panel de tres expertos alcanzó un consenso sobre el manejo del paciente basado en la práctica clínica. Los pacientes revisaron su tratamiento cada 12 semanas, en función de su estado de salud y de la medicación recibida previamente. Se incluyeron costes farmacológicos y costes asociados al manejo de eventos adversos (EA) muy frecuentes, en un horizonte de 60 semanas. Los resultados se expresaron en términos de los años de vida ajustados por calidad (AVAC). Se realizó un análisis de sensibilidad probabilístico. Resultados: No se encontraron diferencias clínicamente relevantes en los AVAC por paciente y año para el inicio con ambrisentan y bosentan: 0,6853 y 0,6902, respectivamente. El inicio con ambrisentan resultó en un coste farmacológico y asociado al manejo de EA menor: 35.550 ??y 117 ??frente a 40.224 ??y 171 ?. En el análisis de sensibilidad, el inicio con ambrisentan presentó una diferencia de costes totales negativa y significativa: -4.982 ?; IC95%[-8.014 ?; -2.500 ?]; mientras que no se detectaron diferencias significativas en los AVAC: -0,0044; IC95%[-0,0189; 0,0101]. Conclusiones: El tratamiento secuencial de combinación de la HAP iniciado con ambrisentan, seguido de inhibidores de la fosfodiesterasa- 5 y prostanoides, proporciona resultados en salud comparables y menores costes que el tratamiento iniciado con bosentan.

Daily cost of glaucoma medications in China.

PURPOSE: To determine and compare the daily cost of various glaucoma medications in China. MATERIALS AND METHODS: The majority of glaucoma medications commercially available in China were included in this research. The total number of drops in 1 bottle of each medication was counted drop by drop. The mean volume per bottle of each medication was calculated. The cost per drop, number of days for both eyes usage per bottle, and daily cost was calculated. RESULTS: (1) The volume per drop ranged from 0.03 mL (brinzolamide 1%, travoprost 0.004%, bimatoprost 0.03%, and latanoprost 0.005%) to 0.05 mL (timolol 0.5%-Chengrui and pilocarpine 0.5% and 2%-Zhenrui). (2) The cost per bottle ranged from $0.69 (US dollar) (timolol 0.5%-Malaisuan Saimaluo'er) to $40.78 (latanoprost 0.005%). (3) The number of days for both eyes usage per bottle ranged from 52 days (bimatoprost 0.03%) to 11 days (pilocarpine nitrate 0.5%-Zhenrui). (4) The daily cost for both eyes usage from expensive to cheap were latanoprost 0.005%-$0.91, travoprost 0.004%-$0.77, brimonidine 0.2%-$0.61, bimatoprost 0.03%-$0.46, D-timolol 1%-$0.36, brinzolamide 1%-$0.34, pilocarpine 2%-Zhenrui-$0.28, levobunolol 0.5%-$0.25, betaxolol 0.25%-$0.24, pilocarpine 0.5%-Zhenrui-$0.18, pilocarpine 2%-Huming-$0.16, carteolol 1%-Mikelan-$0.15, carteolol 2%-Mikelan-$0.15, pilocarpine 1%-Huming-$0.10, timolol 0.5%-Chengrui-$0.08, timolol 0.5%-Malaisuan Saimaluo'er-$0.03. CONCLUSIONS: The daily cost of glaucoma medications in China ranged much more wildly than developed countries. These data may be useful in selecting medications for glaucoma therapy. The ophthalmic solution of prostaglandins is powerful in reducing intraocular pressure. However, its high price should be considered when selecting glaucoma medications in China.

Adoption of new antiglaucoma drugs in Finland: impact of changes in copayment.

BACKGROUND: Copayments are common measures intended to control drug expenditures and promote rational prescribing. In Finland, new antiglaucoma drugs start with a high copayment, but once sufficient clinical experience is available, they are reevaluated and can receive a lower copayment status. OBJECTIVE: This study assessed the effect of changes in copayment level on the adoption of 2 antiglaucoma drugs. METHODS: A retrospective analysis was performed from 1997 to 2001 using the Finnish national register of reimbursed drug purchases, which covers approximately 98% of all antiglaucoma drug purchases in the country. There were 172,293 purchases of dorzolamide (plain or combined with timolol) and 281,377 purchases of latanoprost. An interrupted time-series design from approximately 30 months before and 20 months after the change in copayment was used in the analysis. The main outcome measures were the numbers of defined daily doses (DDDs) purchased and the monthly numbers of patients who purchased the study drugs for the first time before and after the change in copayment. RESULTS: A substantial increase in consumption of both dorzolamide and latanoprost was seen immediately after the introduction of the lower copayment. The monthly consumption of dorzolamide was 60,713 DDDs higher and the monthly consumption of latanoprost was 49,330 DDDs higher than expected according to the utilization trend during the higher copayment period. Twelve months later, the observed consumption of dorzolamide was 109% higher and that of latanoprost was 21% higher than if the copayment had remained the same. The number of new patients using the study drugs peaked within 2 months of the lower copayment, but the amount consumed per patient per day remained quite stable. CONCLUSIONS: Decreasing the copayment of a new antiglaucoma drug to the same level as the copayments of alternative drugs accelerated the adoption of these new products in Finland.

Estimated first-year costs of prostaglandin analogs with/without adjunctive therapy for glaucoma management: a United States perspective.

OBJECTIVE: To evaluate costs associated with prostaglandin analogs among newly-diagnosed glaucoma patients in a managed-care population. RESEARCH DESIGN AND METHODS: A cost minimization model compared annual costs for patients initiating therapy with one of the three prostaglandin analogs (bimatoprost, latanoprost, travoprost). The study cohort was identified from pharmacy claims and eligibility files of patients who met study inclusion criteria. Annual costs were estimated for patients initiating therapy with each prostaglandin based on treatment patterns and medication use over the year. Costs for outpatient physician visits and medications were estimated from standard sources. RESULTS: A total of 4444 patients met study criteria: 674 received travoprost, 729 received bimatoprost, and 3041 received latanoprost. More than 80% stayed on monotherapy for 1 year (82.9% of travoprost patients, 82.8% of bimatoprost patients, and 80.5% of latanoprost patients). Of those who required adjunctive therapy, the average number of days until starting adjunctive therapy was 130 days for travoprost patients, 94 days for bimatoprost patients, and 104 days for latanoprost patients. Average annual costs were $1198, $1290, and $1217 for patients treated with travoprost, bimatoprost, and latanoprost, respectively. CONCLUSIONS: The use of adjunctive therapy in glaucoma is an important driver of glaucoma management costs. This study demonstrates that the longer duration of monotherapy and the likelihood to use single rather than combination adjunctive agents contribute to lower annual costs among patients starting on travoprost compared with the other available prostaglandin analogs. Study limitations include the lack of clinical indicators in the study database; further, results may not be generalizable to patients who discontinue prostaglandin analogs or to the population of patients with glaucoma as a whole. Future studies with clinical and compliance indicators would further identify distinctions among treatment regimens.

The rising cost of glaucoma drugs in Ireland 1996-2003.

BACKGROUND: Glaucoma affects approximately 2% of the population in developed countries and is estimated to affect 67 million people worldwide. The authors investigated the effect of the introduction of new medications on the volume and cost of drugs for glaucoma in two countries, Northern Ireland (NI, population approximately 1.7 million) and the Republic of Ireland (ROI, population approximately 3.9 million) in the 8 years from 1996 to 2003. They also looked at the surgical rates for glaucoma within the same time period for the two countries. METHODS: A retrospective analysis was performed of drug costs, prescribing data, and operation rates for glaucoma in Ireland from January 1996 to December 2003. Information regarding costs and volume were obtained for each type of glaucoma drug and these were then grouped into the glaucoma treatment subsections as found in the British National Formulary. The drug information was obtained from the Central Services Agency in NI and IMS Health in the ROI and included both public and private prescriptions. The information on surgical rates for glaucoma was obtained from the Department of Health and Social Services in NI and the Hospital In-patient Enquiry (HIPE) data national files in the ROI. RESULTS: There was a 30% increase in prescription items for glaucoma in NI and a 59% increase in the ROI from 1996 to 2003. The costs increased more rapidly than the number of items: 227% in the ROI and 78% in NI from January 1996 to December 2003. In the ROI, there was an average 19% year on year increase in costs. In NI, new drugs accounted for 40% of the quantity of prescription items for glaucoma and 63% of the market cost in 2003. In the ROI new drugs accounted for 57% of the quantity and 77% of the market cost for glaucoma in 2003; prostaglandin analogue drugs alone accounted for 53% of the cost. The number of trabeculectomies performed decreased by more than 60% in both countries. CONCLUSION: Volume and cost of glaucoma drugs increased dramatically in both NI and the ROI from 1996 to 2003, probably the result of a combination of changing demographics and a changing approach towards the management of patients with glaucoma and ocular hypertension. In 2003 in the ROI, prostaglandin analogues were the most commonly prescribed class of drug for patients with glaucoma and/or ocular hypertension causing a profound rise in drug expenditure.

Medical therapy cost considerations for glaucoma.

PURPOSE: To determine the calculated daily patient cost (cost minimization) of medical glaucoma therapy and review cost trends. DESIGN: Experimental, controlled, prospective study. METHODS: The actual volume of various glaucoma medications or glaucoma medications with redesigned bottles was determined for most commercially available sizes of the tested products. The drops per milliliter based on the actual volume and the daily costs of the dosage schedules recommended by the manufacturers were compared. The cost of each bottle of medication was determined from the average wholesale price (AWP) in the United States. A comparison to 1999 prices where applicable will be analyzed to review costing trends. RESULTS: The generic timolol products (range, US dollars 0.38-US dollars 0.46 per day) were similar on a cost per day basis vs Betimol (Santen, Napa Valley, California, USA), Optipranolol (Bausch and Lomb Pharmaceuticals, Tampa, Florida, USA) and Timoptic (Merck, West Point, Pennsylvania, USA). Their percentage cost increase ranged from 5% to 22% since 1999, except for generic timolol XE gel-forming solution (48%). Betagan (Allergan, Irvine, California, USA), Betoptic S (Alcon Laboratories, Fort Worth, Texas, USA), and Ocupress (Novartis, Duluth, Georgia, USA) ranged from US dollars 0.88 to US dollars 1.11 per day, and their percentage cost increase ranged from 33% to 53%. Some brand-only products have raised their AWPs a greater percentage, including Betoptic S (37%), Iopidine (Alcon, Fort Worth, Texas, USA) (50%), Ocupress (Novartis Ophthalmics, Duluth, Georgia, USA) (53%), and Pilopine gel (Alcon, Fort Worth, Texas, USA) (32%). The mean cost per day for the topical carbonic anhydrase inhibitors Azopt (Alcon Laboratories; US dollars 1.33 per day) and Trusopt (Merck; US dollars 1.05 per day) differed from 1999 when prices were almost identical. Cosopt (Merck; timolol 0.5% plus dorzolamide 2%, US dollars 1.04 per day) was less than the cost of separate bottles of a topical carbonic anhydrase inhibitor and a beta-blocker. The selective alpha-2 agonist brimonidine 0.15% with Purite (Alphagan-P, Allergan, 5 ml) twice daily was US dollars 1.29 per day. The prostaglandin analogs were comparably priced with Lumigan (Allergan) US dollars 0.95 per day, Xalatan (Pharmacia and Upjohn, Kalamazoo, Michigan, USA) US dollars 1.25 per day, Travatan (Alcon Laboratories) US dollars 1.01 per day, and Rescula (Novartis) US dollars 0.90 per day. CONCLUSIONS: All generic timolol, Betimol, Optipranolol, Timoptic, and Timoptic XE (Merck) ranged from US dollars 0.38 to US dollars 0.50 per day. Other beta-blocker products were about twice as costly, ranging from US dollars 0.88 to US dollars 1.11 per day. Cosopt (US dollars 1.05 per day) was less costly than separate bottles of a topical beta-blocker and a topical carbonic anhydrase inhibitor dosed three times daily or twice daily. The prostaglandin analogs ranged from US dollars 0.90 per day (Rescula) to US dollars 1.25 per day (Xalatan). Newer glaucoma medications exhibit similar costs per day in many cases, compared with more traditional medications, especially with greater price increases in older brand-only products.

Prostaglandin analog treatment of glaucoma and ocular hypertension.

OBJECTIVE: To review available data related to the use of prostaglandin analogs (bimatoprost, latanoprost, travoprost, unoprostone) in the management of ocular hypertension and open-angle glaucoma. DATA SOURCES: Primary and review articles were identified from a MEDLINE search (1966-May 2001) and requested information from product manufacturers. STUDY SELECTION AND DATA EXTRACTION: All available information, including that published in articles and abstracts, which was deemed relevant was included in this review. Limited data have been published to date. DATA SYNTHESIS: The prostaglandin analogs appear to be effective, well-tolerated agents for the reduction of intraocular pressure (IOP) in patients with primary open-angle glaucoma and ocular hypertension. This drug class offers an alternative for patients who do not achieve control with another topical antiglaucoma agent or for those with a contraindication to first-line therapy with beta-adrenergic antagonists. Based on preliminary clinical data, bimatoprost, latanoprost, and travoprost appear to be at least as effective as timolol, while the effectiveness of unoprostone is similar or slightly less. Prostaglandin analogs may be used in conjunction with other antiglaucoma medications, although further studies must establish the optimal combination. Whether clinical experience will yield outcomes in favor of one of the prostaglandin analogs remains to be determined. Patients should be educated on adverse events associated with prostaglandin analogs, particularly the potential for changes in the pigmentation of the iris and eyelashes. CONCLUSIONS: Bimatoprost, latanoprost, and travoprost appear to be equivalent to the current standard of therapy in the topical treatment of elevated IOP. Further clinical data published in article versus abstract format is required to better assess potential differences among these 3 agents.

Primary drug treatment for glaucoma: beta-blockers versus other medications.

This set of Viewpoints articles examines the merits of beta-blockers versus other medications as the primary drug treatment for glaucoma. Ophthalmologists must balance issues such as efficacy, compliance, cost, and side effects when deciding on the appropriate medication to prescribe. Dr. Stamper stresses the advantages of tailoring the choice of medication to the needs of the individual patient. Drs. Wigginton and Higginbotham review the benefits of beta-blockers and present some of the disadvantages of the non-beta-blocker class of medications.

Daily cost of ophthalmic solutions for treating glaucoma in Japan.

PURPOSE: We conducted a study of the daily cost of various ophthalmic solutions used in Japan for treating glaucoma: beta-adrenergic blockers (11 products), epinephrine (3), cholinergics (3), prostaglandins (2), and carbonic anhydrase inhibitors (2). METHODS: The total number of drops in one bottle of each solution was counted drop by drop. The cost per drop was calculated by dividing the government-controlled standard prices by the total number of drops in one bottle. The daily cost of therapy was calculated by multiplying the cost per drop by the number of drops typically used per day. RESULTS: The average cost of each preparation was calculated based on the prices and the daily usage. The daily cost of the beta-adrenergic blockers studied ranged widely, from $0.43 to $1.04. CONCLUSIONS: These data may be useful in selecting ophthalmic products for glaucoma therapy in Japan.

Cost analysis of glaucoma medications.

PURPOSE: To evaluate the yearly cost in 1998 of glaucoma medications to patients and to the Health Plan at a university-affiliated teaching hospital with its own health maintenance organization. MATERIALS AND METHODS: Data concerning Health Plan glaucoma-medication prescriptions for 1998 were retrieved from the hospital pharmacy database. RESULTS: The most costly medication per patient per year was latanoprost (Xalatan; Pharmacia & Upjohn, Kalamazoo, MI [$337]), followed by betaxolol hydrochloride (Betoptic-S; Alcon, Fort Worth, TX [$336]), dorzolamide (Trusopt; Merck & Co., West Point, PA [$288]), brimonidine tartrate (Alphagan; Allergan Pharmaceuticals, Irvine, CA [$260]), timolol maleate 0.5% in a gel-forming solution (Timoptic-XE 0.5%; Merck & Co., West Point, PA [$199]), levobunolol hydrochloride (Betagan; Allergan Pharmaceuticals, Irvine, CA [$195]), and generic timolol maleate 0.5% ($132). Cost per unit was greatest for Betoptic-S ($51), exceeding that of Trusopt ($43) and Xalatan ($43), Alphagan ($42), Betagan ($38), Timoptic-XE 0.5% ($32), and timolol maleate 0.5% ($27). CONCLUSION: Variability in the cost of medications may influence the long-term medical management of glaucoma patients.

Cost considerations of medical therapy for glaucoma.

PURPOSE: To determine the calculated daily patient cost (cost minimization) of medical glaucoma therapy. METHODS: The actual volume of various glaucoma medications was determined for all commercially available sizes of the tested products. The drops per ml on the basis of the actual volume and the daily costs of the dosage schedules recommended by the manufacturers were compared. The cost of each bottle of medication was determined from the average wholesale price in the United States. RESULTS: The generic timolol products dosed twice daily and the once-daily gel-forming solutions (range, $0.30 to $0.46/day) were similar on a cost-per-day basis compared with the brand name metipranolol (Optipranolol; Bausch & Lomb Pharmaceuticals, Tampa, Florida, at $0.43/day) and timolol (Timoptic; Merck, West Point, Pennsylvania, at $0.46/day and Timoptic XE at $0.38/ day). Betaxolol (Betoptic S; Alcon Laboratories, Fort Worth, Texas, at $0.65/day), carteolol (Ocupress; CibaVision, Duluth, Georgia, at $0.57/day), levobunolol ($0.61/day), and brand name levobunolol (Betagan; Allergan, Irvine, California, at $0.81/day) all were dosed twice daily and were more costly on a per-day basis. The topical carbonic anhydrase inhibitors brinzolamide (Azopt; Alcon, at $0.96/day) and dorzolamide (Trusopt; Merck, at $1.02/day) were dosed three times daily and were similar on a cost-per-day basis. The combination product Cosopt (timolol 0.5% + dorzolamide 2.0%, Merck, at $1.12/day) was less costly than separate bottles of a topical carbonic anhydrase inhibitor (three times daily dosing) and a beta-blocker ($1.26 to $1.83/day), often even if the topical carbonic anhydrase inhibitor was dosed two times daily ($0.94 to $1.49). The selective alpha2-agonist brimonidine (Alphagan; Allergan, at $0.90/day) twice daily and the prostaglandin analog latanoprost (Xalatan; Pharmacia & Upjohn, Kalamazoo, Michigan, at $0.92/day) once daily were similarly priced. CONCLUSIONS: All generic timolol, Optipranolol, Timoptic, and Timoptic XE ranged between $0.30 and $0.46 per day. Betaxolol, Ocupress, generic levobunolol, and Betagan were more costly, ranging between $0.57 and $0.81 per day. Cosopt ($1.12/day) was less costly than separate bottles of a topical beta-blocker and a topical carbonic anhydrase inhibitor dosed three times daily ($1.26 to $1.83/day) and often twice daily ($0.94 to $1.49). Alphagan and Xalatan were similarly priced ($0.90/day and $0.92/day, respectively). This study is based on a best-case scenario for all medicines and does not account for wasted doses, the frequency of refills, or a medication's success or failure rate. New adjunctive glaucoma regimens exhibit similar costs per day compared with more traditional regimens.

NSAIDs, gastrointestinal injury, and cytoprotection.

Gastrointestinal toxicity caused by nonsteroidal anti-inflammatory drugs (NSAIDs) is the most frequent drug side effect in the United States. NSAIDs are implicated in the development of complicated peptic ulcer disease and injury to the small bowel and colon. NSAIDs interfere with prostaglandin-mediated epithelial defense mechanisms and also cause direct epithelial toxicity. Current and future approaches to the prevention and management of NSAID injury are reviewed.