Hidden costs of antiretroviral treatment: the public health efficiency of drug packaging.

While the overall percentage of unused antiretroviral medicines returned to the hospital pharmacy is low, their cost is quite high. Adverse events, treatment failure, pharmacokinetic interactions, pregnancy, or treatment simplification are common reasons for unplanned treatment changes. Socially inefficient antiretroviral packages prevent the reuse of drugs returned to the hospital pharmacy. We defined antiretroviral package categories based on the excellence of drug packaging and analyzed the number of pills and costs of drugs returned during a period of 1 year in a hospital-based HIV unit attending to 2,413 treated individuals. A total of 6,090 pills (34% of all returned antiretrovirals) - with a cost of 47,139.91 € - would be totally lost, mainly due to being packed up in the lowest efficiency packages. Newer treatments are packaged in low-excellence categories of packages, thus favoring the maintenance of these hidden costs in the near future. Therefore, costs of this low-efficiency drug packaging, where medication packages are started but not completed, in high-cost medications are substantial and should be properly addressed. Any improvement in the packaging by the manufacturer, and favoring the choice of drugs supplied through efficient packages (when efficacy, toxicity, and convenience are similar), should minimize the treatment expenditures paid by national health budgets.

Hidden costs of HIV treatment in Spain: inefficiency of the antiretroviral drug packaging.

INTRODUCTION: Antiretroviral drugs in Spain are delivered by law only in hospital pharmacies. Commercial packages meet variable quality standards when dispensed drugs are returned due to treatment changes or adherence problems Nearly 20-25% of the initial regimens will be changed at 48 weeks for different reasons. We evaluated the economic impact on public health system of the inability of using returned drugs due to inefficient packaging. MATERIALS AND METHODS: We defined socially efficient packaging as the best adapted one to being delivered in unit dose to outpatients and classified: Class A - Drug packed in unit doses with complete info (name of drug, dosage in mg, lot, and expiring date) in each unit, maintaining complete information of the drug if returned when the external package is opened. Class B - packed in blisters with complete info in the blister, but not in unit doses, without special conservation conditions (should be re-packed in unit doses in the pharmacy before its dispensation to assure a class A excellence). Class C - packed in plastic containers with complete info written only on a label over the container, would allow repackaging only before its initial delivery, but not when returned. Class D - drug packed in plastic containers with manufacturer's warning that the product cannot be placed outside of the original package due to special conditions of conservation (fridge, humidity) that doesn't allow a unit dose repackaging or reusing an opened container. We analysed a 12-month period (July 2011-June 2012) in a hospital-based HIV outpatient pharmacy that serves 2413 treated individuals. RESULTS: Patients generated 23,574 visits to pharmacy, and received 48,325 drug packages, with 2.529.137 pills delivered. The patients suffered 1051 treatment changes for any reason. A total amount of 122.945€ in treatment were returned to pharmacy in opened packages during the study period. 47.139.91€ would be totally lost, mainly due to being packaged in class C and D boxes, the equivalent of treating 78 patients with rilpivirine/TDF/FTC during 1 month. Class A and B packages in bad condition represented only 1.1% of the cost. However, 75.805€ came from returned packages in good condition that could potentially be reused. Most of the treatment changes were not foreseeable. CONCLUSIONS: A significant economic budget is lost through socially inefficient antiretroviral packages. Newer treatments are packaged in C and D categories, therefore maintaining these hidden costs in the near future. Any improvement in the excellence of packaging by the manufacturer, and favouring the choice of drugs supplied through efficient packages (when efficacy, toxicity and convenience are similar) should minimize the treatment expenditures paid by national health budgets.

[Study of effectiveness of 3 schedules of administration of erythropoietic colony-stimulating factors in anemic patients under chemotherapy for solid or hematology malignancy]. / Estudio de la efectividad de tres esquemas de administración de factores estimuladores de la eritropoyesis en pacientes con anemia asociada a quimioterapia por una neoplasia sólida o hematológica.

BACKGROUND AND OBJECTIVE: The treatment of chemotherapy associated anemia in patients with cancer has varied greatly in recent years. The objective of this study was to verify whether the most frequently used therapeutic schedules of erythropoietin administration demonstrate equivalent effectiveness. PATIENTS AND METHOD: Treatments corresponding to 1,103 patients with cancer receiving treatment with erythropoietic colony-stimulating factors from January 2003 to April 2006 were reviewed. After applying a selection algorithm, 170 cases were analysed: 55 treated with epoetin alpha 10,000 IU 3 times per week, 63 receiving darbepoetin alpha 150 microg weekly and 52 treated with darbepoetin alpha 500 microg every 3 weeks. The main variables used to compare effectiveness were the increase in serum hemoglobin levels during treatment and the percentage of patients with hemoglobin values > or = 120 g/l. RESULTS: The differences in maximum hemoglobin values achieved at baseline and during the study period, and those between the final and baseline hemoglobin values were similar in the 3 groups. The percentage of patients with hemoglobin values > or = 120 g/l during and at the end of treatment was equivalent for the group receiving epoetin alpha 10,000 IU three times per week and darbepoetin alpha 150 microg per week. However this parameter war inferior for the group treated with darbepoetin alpha 500 microg every 3 weeks. CONCLUSIONS: Epoetin alpha 10,000 IU 3 times per week was found to be as effective as darbepoetin alpha 150 microg per week in all the studied parameters, while darbepoetin alpha 500 microg every 3 weeks was not in one of them.

Estudio de la efectividad de tres esquemas de administración de factores estimuladores de la eritropoyesis en pacientes con anemia asociada a quimioterapia por una neoplasia sólida o hematológica / Study of effectiveness of 3 schedules of administration of erythropoietic colonystimulating factors in anemic patients under chemotherapy for solid or hematology malignancy

FUNDAMENTO Y OBJETIVO: El tratamiento de la anemia asociada a quimioterapia en los pacientes con cáncerha variado de forma notable en los últimos años. El objetivo de este estudio ha sido verificar si losesquemas terapéuticos de administración de eritropoyetina más utilizados en la práctica clínica habitualpresentan una efectividad equivalente.PACIENTES Y MÉTODO: Se han revisado los tratamientos correspondientes a 1.103 pacientes con tumoressólidos o neoplasias hematológicas que incluyeron factores estimuladores de la eritropoyesis desdeenero de 2003 a abril de 2006. Después de aplicar un algoritmo de selección se obtuvieron 170 casos:55 tratados con epoetina alfa, a dosis de 10.000 U 3 veces por semana; 63 con darbepoetinaalfa, 150 μg por semana, y 52 con darbepoetina alfa, 500 μg cada 3 semanas. Las variables principalesutilizadas para comparar la efectividad fueron el incremento de la hemoglobina plasmática duranteel tratamiento y el porcentaje de pacientes que consiguieron valores de hemoglobina iguales o superioresa 120 g/l.RESULTADOS: Las diferencias entre la cifra máxima de hemoglobina alcanzada en el período de tratamientoy la inicial, así como las diferencias entre las cifras de hemoglobina final y la inicial, fueron similaresen los 3 grupos. El porcentaje de pacientes que alcanzaron durante el tratamiento y al final deéste un valor de hemoglobina superior o igual a 120 g/l fue equivalente para los grupos de 10.000 Ude epoetina alfa 3 veces por semana y 150 μg de darbepoetina alfa por semana. Dicho porcentaje fueinferior en los pacientes del grupo que recibió 500 μg de darbepoetina alfa cada 3 semanas.CONCLUSIONES: En los pacientes con anemia asociada a quimioterapia por una neoplasia sólida o hematológica,los tratamientos con epoetina alfa a dosis de 10.000 U 3 veces por semana y darbepoetinaalfa, 150 μg por semana, han mostrado ser igualmente eficaces en todos los parámetros estudiados,mientras que la darbepoetina alfa a dosis de 500 μg cada 3 semanas no lo fue en uno de ellos

BACKGROUND AND OBJECTIVE: The treatment of chemotherapy associated anemia in patients with cancerhas varied greatly in recent years. The objective of this study was to verify whether the most frequentlyused therapeutic schedules of erythropoietin administration demonstrate equivalent effectiveness.PATIENTS AND METHOD: Treatments corresponding to 1,103 patients with cancer receiving treatment witherythropoietic colony-stimulating factors from January 2003 to April 2006 were reviewed. After applyinga selection algorithm, 170 cases were analysed: 55 treated with epoetin alpha 10,000 IU 3 timesper week, 63 receiving darbepoetin alpha 150 μg weekly and 52 treated with darbepoetin alpha500 μg every 3 weeks. The main variables used to compare effectiveness were the increase in serumhemoglobin levels during treatment and the percentage of patients with hemoglobin values 120 g/l.RESULTS: The differences in maximum hemoglobin values achieved at baseline and during the study period,and those between the final and baseline hemoglobin values were similar in the 3 groups. The percentageof patients with hemoglobin values 120 g/l during and at the end of treatment was equivalentfor the group receiving epoetin alpha 10,000 IU three times per week and darbepoetin alpha 150 μg perweek. However this parameter war inferior for the group treated with darbepoetin alpha 500 μg every 3weeks.CONCLUSIONS: Epoetin alpha 10,000 IU 3 times per week was found to be as effective as darbepoetinalpha 150 μg per week in all the studied parameters, while darbepoetin alpha 500 μg every 3 weekswas not in one of them