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The cost of psoriasis treatment

2001; Wiley; Volume: 15; Issue: 4 Linguagem: Inglês

10.1046/j.0926-9959.2001.00257.x

1468-3083

Ibrahim Galadari, Ethan G. Rigel, Mark Lebwohl,

Complementary and Alternative Medicine Studies

In the current issue, Finzi et al. correctly state that the medical and economic impact of psoriasis is underestimated by health-care professionals. While the study was performed in Italy, that statement can be made world-wide. Using data from 1994, they found that the average cost of psoriasis treatment was 905 Euros; a figure that should draw the attention of all health economists, considering that this disease affects 1–3% of the population world-wide, with a recent US study indicating a prevalence of 2.7%. All over the world the treatment of psoriasis is too expensive; medications are expensive and time off work for therapy is expensive. The data presented by Finzi et al. raise issues that are similar world-wide. Costs of lost productivity must also be considered. Psoriatic arthritis and psoriasis of the palms and soles interfere with work, not to mention pustular psoriasis and erythrodermic psoriasis, which can be life threatening. Similarly, generalized plaque psoriasis can impair productivity because of psychological as well as physical factors. Also similar around the world is the observation that the most severely affected 20% of patients generates most of the expenses associated with this disease. Just as there are similarities, there are also differences in psoriasis therapy world-wide. Hospitalization for psoriasis appears to be much more common in Italy than in the United States or the United Arab Emirates. In the study by Finzi et al. more than 80% of the cost of psoriasis treatment is related to hospitalization, whereas hospitalization is not very common in the United States and the United Arab Emirates except for erythrodermic or pustular psoriasis, and even then those patients are often treated on an outpatient basis. The data in the Italian study may have been skewed because the investigators were hospital and university based; but even in hospital and university centres in the United States and the United Arab Emirates, hospitalization for psoriasis is uncommon. Despite the fewer hospitalizations in the United States, psoriasis therapy is much more expensive than reported by Finzi et al. In 1998 Marchetti and others estimated the average cost of psoriasis treatment to range between $1500 and $6600. To compare the costs of treatments with those reported by the Italian hospital-based investigators, we inquired about the costs of similar treatments in Vail, Colorado, New York City and the United Arab Emirates. Topical corticosteroids remain the most commonly prescribed class of drug for psoriasis in the United States and the United Arab Emirates. The cost of generic corticosteroids in the United Arab Emirates is $7.00 for a 30-g tube ($0.23 per gram). In the United States, the least expensive generic corticosteroid, triamcinolone acetonide, costs $12.05 ($0.40 per gram) for a 30-g tube of ointment in Vail compared with $17.59 ($0.59 per gram) in New York. Even this least expensive of corticosteroids, is several times 0.174 Euros per gram reported by Finzi et al. Brand name corticosteroids cost more than twice as much with branded triamcinolone acetonide costing $43.99 ($1.47 per gram) in New York. Stronger corticosteroids are also more expensive with generic clobetasol costing $24.81 per 30-g tube in Vail ($0.83 per gram) and $42.49 in New York ($1.42 per gram); 30 g of generic fluocinonide ointment ranges from $30.91 ($1.03 per gram) in Vail to $37.69 or $1.26 per gram in New York. All of the generic corticosteroids cost only $7.00 for a 30-g tube in the United Arab Emirates ($0.23 per gram). Branded calcipotriene is the most single prescribed drug used only for psoriasis in the United States. The cost of a 30-g tube ranges from $60.09 ($2.00 per gram) in a Vail pharmacy to $63.49 ($2.12 per gram) in New York, compared with 0.454 Euros per gram in Italy. The cost in the United Arab Emirates is lower than that of the United States, but higher than in Italy at $18.00 for a 30-g tube ($0.60 per gram). Even more expensive than calcipotriene in the United States is the cost of tazarotene at up to $93.99 for a 30-g tube ($3.13 per gram) in New York. Tazarotene has the advantage of once-daily application, but still remains one of the most expensive topical therapies. Tars and anthralin are seldom prescribed in the United States and range widely in price depending on the brand. In the United Arab Emirates an 85-g container of tar costs $7.00 ($0.08 per gram) and a 50-g container of anthralin costs $10.00 ($0.20 per gram), compared with 0.268 Euros per gram for dithranol and 0.103 Euros for coal tar quoted in the Italian study. Systemic drug therapies are similarly expensive world-wide. The most expensive systemic therapy is cyclosporin A. A 100-mg capsule of generic cyclosporin costs $4.99 in Colorado compared with $19.69 for a brand name capsule in New York. In the United Arab Emirates the cost is $4.50 for a 100-mg capsule compared with 0.072 Euros/mg in the Italian study. Etretinate is no longer available, but was roughly half the price of acitretin when it was on the market. Acitretin costs $9.52 for a 25-mg capsule in Colorado and $11.50 for the same capsule in New York. In the United Arab Emirates the cost is only $2.50. The cost of etretinate in the study by Finzi et al. was 0.052 Euros/mg. Methotrexate has been available for a long time and is no longer under patent. Nevertheless, 2.5 mg of methotrexate costs $2.60, $4.99 and $7.59 in the United Arab Emirates, Colorado and New York, respectively. As the average patient requires approximately 15 mg/week, methotrexate is still expensive for some. This has led to widespread prescriptions of methotrexate liquid, which is highly bioavailable and can simply be squirted into fruit juice. A 2 mL (50 mg) vial of methotrexate costs only $30.00 in Colorado or New York and $16.00 in the United Arab Emirates. The cost of methotrexate per milligram in the Italian study was 0.074 Euros/mg. Phototherapy costs in the United States and in the United Arab Emirates are much more expensive than the 4.39 Euros for 3-weekly treatments of ultraviolet (UV) B and 23.24 Euro for 3-weekly psoralen + UVA (PUVA) treatments quoted in the Italian study. Each UVB or PUVA treatment in the United States costs between $35.00 and $75.00 depending on the person administering it, and that price does not include the cost of a concomitant phototherapist’s visit. In the United Arab Emirates, UVB treatments cost $60.00 per visit and PUVA treatments $80.00. Physicians visits are likewise less expensive in Italy at $20.66 Euros per visit. In the United States, physician visits range from $27.00 to $150.00 and in the United Arab Emirates an initial visit is $60.00 and a follow-up visit costs $25.00. From the data presented above, it is clear that the cost of most psoriasis therapies are higher in the United States and in the United Arab Emirates compared with Italy. Similarly, the costs of phototherapy are much greater in the United States and the United Arab Emirates compared with Italy. The low costs cited by Finzi et al. for phototherapy undoubtedly does not include the costs of phototherapy machines and technicians themselves, as even the American phototherapy reimbursement rates are quite low when the costs of running a phototherapy unit are considered. As a result, the use of phototherapy in the United States has declined, with some major phototherapy centres closing. Consequently, the Psoriasis Task Force of the American Academy of Dermatology is appealing to regulatory agencies in the United States to increase phototherapy reimbursement. The cost of medications has a large effect on the overall cost of psoriasis therapy in the United States and in the United Arab Emirates. The exorbitant cost of medications has led to programmes such as the United States National Psoriasis Foundation’s Medication for Needy Patients Program in which pharmaceutical companies provide free medication to patients who are unable to afford their treatment, but drug costs continue to drain health-care dollars. There has, however, been a positive effect to the large profits generated by psoriasis medications. Those profits have caught the attention of pharmaceutical companies and have stimulated intense interest in developing new products for psoriasis. As a result, there are dozens of investigational agents in various phases of development for psoriasis in the United States. With the advent of newer more expensive treatments such as narrowband UVB and excemer lasers, which were not available in 1994 when the Italian data were generated, psoriasis will become even more expensive. Moreover, the new biotechnology drugs that are rapidly approaching approval, are quite costly and will similarly raise the cost of psoriasis therapy. As these more expensive therapies become available, it is essential that we make those apportioning health-care dollars aware of how serious a disease psoriasis can be. We must simultaneously try to control health-care costs while making sure that the best treatments are available for our sickest patients.