Higher Pharmacy Costs for Brand-Name vs Generic Onychomycosis Treatments

Dermatology: onychomycosis. Thickened, yellowish-white cracked great toe and second toe nails of an elderly man with onychomycosis.
Investigators sought to determine trends in pharmacy costs of generic and brand-name medications prescribed for onychomycosis in the United States.

Pharmacy costs of brand-name topical and systemic medications for the treatment of onychomycosis are higher than those for generic alternatives, according to results of an analysis of National Average Drug Acquisition Cost (NADAC) data from the Medicaid Pharmacy Pricing database.  Results of the analysis were published in the Journal of the American Academy of Dermatology.

In their analysis, the investigators used NADAC data, which were developed to increase medication cost transparency and to represent more accurately the prices paid by pharmacies for medications, including manufacturer-to-pharmacy discounts. State Medicaid agencies use NADAC to establish reimbursement for ingredient costs of medications to more accurately reflect the spending burden associated with outpatient prescription medications.

The NADAC data from between November 28, 2013 and August 22, 2018 were evaluated. The costs of all topical medications were computed per milliliter of medication, whereas the costs of systemic medications were computed according to a single treatment course per patient for toenail onychomycosis. All of the costs were adjusted for inflation.

The cost per milliliter for topical onychomycosis treatments in 2018 ranged from $2.35 for ciclopirox 8% solution to $145.53 for brand-name tavaborole 5% solution. In addition, in 2018 the per-patient cost of a single course of systemic treatment ranged from $12 for terbinafine to $2807 for brand-name fluconazole. The annual rate of change in the inflation-adjusted cost for generic medications ranged from −18.2% for itraconazole to −3.4% for terbinafine. For brand-name medications, the annual rate of change in the inflation-adjusted cost ranged from 3.7% for brand-name tavaborole 5% solution to 17.2% for brand-name fluconazole.

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The analysis showed that the pharmacy costs of brand-name topical and systemic medications for the treatment of onychomycosis are higher than those for the generic alternatives, with these costs having increased significantly over the last 5 years. In contrast, the costs of generic medications, all of which are produced by ≥8 manufacturers, have declined slightly over the past 5 years. Notably, oral medications are generally more effective than topical agents for the treatment of onychomycosis, with both formulations indicated in patients with mild to moderate disease. Only oral medications are appropriate for the treatment of patients with severe onychomycosis, however, as topical therapies are frequently ineffective in these individuals.

A major limitation of the current study is the fact that the NADAC is calculated only for medications that are covered by Medicaid, with sufficient cost data submitted by retail pharmacies. Thus, certain medications approved for the treatment of onychomycosis were unavailable for analysis.

The researchers concluded that random use of topical agents for the treatment of onychomycosis can be costly and contribute substantially to the growing national prescription drug spending burden. Further investigation into the efficacy and costs of onychomycosis treatments is necessary in order to deliver the most cost-effective care for those patients with this common nail condition.

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Yang EJ, Lipner SR. Pharmacy costs of medications for the treatment of onychomycosis in the United States [published online January 25, 2019]. J Am Acad Dermatol. doi:10.1016/j.jaad.2019.01.032