Many arthritis specialists persist in prescribing expensive brand-name drugs when generics work as well over the long term, an Omaha physician reported this week in a key medical journal.
Dr. James O'Dell, a rheumatologist at the VA Medical Center in Omaha, said a combination of generics, called “triple therapy,” performs as well as Enbrel, which he said is 25 times more expensive.
O'Dell, who also is on the University of Nebraska Medical Center faculty, led the study of 353 rheumatoid arthritis patients at 16 VA medical centers and 20 other sites in the United States and Canada. The report, funded largely by the nation's VA system, appeared in the New England Journal of Medicine's online publication Tuesday evening and is expected to appear in the print edition late next month.
O'Dell said in an interview that patients with rheumatoid arthritis typically start on an inexpensive generic called methotrexate, but 70 percent must supplement that therapy for relief from the disease, which causes swollen, painful joints.
The question is, what does a rheumatologist use to supplement methotrexate?
Two other generics, sulfasalazine and hydroxychloroquine, may be added (hence, “triple therapy”), or a brand-name drug, such as the popular Enbrel, may supplement methotrexate.
O'Dell said some patients do better on the triple-generic therapy and some do better on Enbrel, but overall the results are similar. Enbrel is injected weekly while triple therapy is taken in pills.
The majority of specialists go with a brand-name drug such as Enbrel, which costs $25,000 a year, compared with triple therapy, which costs about $1,000 a year. O'Dell said.
He said that while insurance plans at least partially cover Enbrel as well as the generics, the use of the brand-name drugs for rheumatoid arthritis costs America's health care system billions of dollars.
Dr. Curt Barr, associate professor of pharmacy practice at Creighton University, said taking three medications compared with two may increase the risk of side effects. Also, triple therapy involves taking multiple pills at differing times, so adherence may be a problem in triple therapy, Barr said.
Marketing also is a strong component in Enbrel's advantage. Enbrel commercials show children following golfer Phil Mickelson, who has psoriatic arthritis, around a golf course.
Barr said specialists should try the cheaper therapy first. “This is going to be an ongoing debate,” Barr said, “and studies like this are very valuable.”
O'Dell said his study found fewer side effects associated with these generics, which are synthetics, compared with Enbrel, which uses live cells.
O'Dell said some specialists are simply in the habit of prescribing Enbrel or believe it's better. “These habits die hard,” he said.
Enbrel retains its patent for about 15 more years, O'Dell said. Other brand-name rheumatoid arthritis drugs, such as Humira, will retain patents for at least a few years, he said.
O'Dell has addressed the disparity in price between the therapies before. He described a similar study in 2009 and participated in a discussion on the matter in Philadelphia.
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