Compounded Drugs Improve Compliance, Affordability
HOW THESE MEDICATIONS CAN HELP WITH CATARACT, REFRACTIVE AND GLAUCOMA PATIENTS.
By R. Luke Rebenitsch, MD, and Michael C. Stiles, MD; Featured in Ophthalmology Management
Advantages for cataract and LASIK patients
By R. Luke Rebenitsch, MD
Cost and confusion over medications are two commonly cited reason for patient non-adherence after surgery. These factors can negatively affect the postoperative course, cause anxiety and frustration in patients and increase the time staff spends on the phone.
As a high-volume refractive lens and laser vision correction practice, we knew that we needed to find a solution to postop medication issues. It needed to be safe, cost-effective and, ideally, simple. Using compounded medications has met all three requirements.
USE IN CATARACT, REFRACTIVE AND IMPLANTABLE COLLAMER LENS SURGERY
Endophthalmitis is one of the worst complications for any IOL procedure. As such, we wanted to decrease the risk as much as possible. Given the impressive data on using intracameral antibiotics to decrease that risk, we now use either intracameral moxifloxacin or cefuroxime in every case (examples of that data are from Haripriya et al, Ophthalmology, 2016; Haripriya et al, Ophthalmology, 2017; and Haripriya et al, Journal of Cataract & Refractive Surgery, 2019). We also wanted to make sure that each patient was able to get an antibiotic, steroid and NSAID postoperatively without each medication diluting the other. While there are many compounding pharmacies, we have successfully used three in the last few years: OSRX, Imprimis and Leiters.
Although it could be argued that preoperative betadine and intraoperative intracameral antibiotic is sufficient, we felt that it was still prudent to continue with postoperative antibiotic drops as well. Thankfully, given the advent of easily accessible compounded medications, this adds minimal cost and no additional difficulty for the patient. Formulations that include combinations of moxifloxacin, gatifloxacin, prednisolone acetate, dexamethasone, ketorolac and bromfenac are all readily available.
In our practice, we are now most commonly using prednisolone acetate/gatifloxacin/bromfenac four times a day in each eye for 1 week. We then use prednisolone acetate/bromfenac as a taper over 3 more weeks. With this regimen, we have found an even lower rate of rebound iritis than we did with separate branded drops, most likely due to improved compliance.
A collection of OMNI (OSRX) compounded medications.
USE IN LASER VISION CORRECTION
For many patients, laser vision correction (LVC) is their first medical procedure. This is exciting yet can also be anxiety-provoking. As such, we wanted to make the process especially simple and cost-effective for these younger patients. Prior to our new system, we provided a prescription that patients would pick up and have ready the day of the procedure. Unfortunately, with rising costs of medications, increasing co-pays and variabilities among pharmacies, it was not uncommon for patients to show up to surgery without medications or to call the office asking for different, less costly (and effective) options. Thankfully, the advent of safe and cost-effective compounded medications again provided us with a solution.
We wanted to take customer service to a new level, however. Although it is common for practices to charge separately for the medications, whether compounded or not if dispensed in the office, we felt this was more of a “cafeteria approach” rather than a patient-centric “palatable pricing approach.” Given our goal of making the process simple and cost-effective for young patients, we now just include compounded medications in the global fee for LVC procedures and dispense at the time of surgery. With this new system, patients now rarely call our office for LVC medication or cost-related questions, which saves our technicians and front desk staff countless hours. In addition, we are now almost always able to use our preferred regimen of moxifloxacin or gatifloxacin with prednisolone acetate four times a day for a week in LASIK and SMILE rather than sometimes having to resort to other regimens.
Safe and cost-effective compounded medications have been a game changer in our practice — for us and our patients. Gone are the days of irritated, pharmacy-related phone calls and significant medication non-compliance. With more options available every year, patients and practices have a win-win in compounded medications.
About the Author
R. Luke Rebenitsch, MD, is the chief medical director of ClearSight Center in Oklahoma City. Dr. Rebenitsch is board-certified by the American Board of Ophthalmology and holds memberships with the ASCRS, AAO, American-European Congress of Ophthalmic Surgeons and Refractive Surgery Alliance.
Dr. Rebenitsch reports no relevant financial disclosures.
Compounded drops and glaucoma care
By Michael C. Stiles, MD
Glaucoma management can be challenging. As physicians, we realize that the natural course of the disease is permanent vision loss. However, many glaucoma patients are not suffering any immediate, noticeable quality of life decline due to their disease. The challenge is preventing permanent and noticeable vision loss yet avoiding immediate side effects or complications with treatment. Current treatment paradigms typically include medical therapy before or after laser trabeculoplasty in an effort to effectuate IOP lowering without the risk of immediate visual compromise from potential surgical complications.
Although glaucoma medical treatment avoids the risks of surgical treatment, topical medications have their own pitfalls in glaucoma management. Past studies have proven that patient adherence to glaucoma medications is less than desired.1-3 Several factors increase the likelihood of subpar adherence, including multiple medications and more complex regimens to control a patient’s disease.
Given that nearly half of glaucoma patients require more than one class of medication to control their disease, many of our patients are at risk for poor regimen compliance. Steps that can reduce the number of medications and drops per day can improve compliance, and this is one of the benefits of combination medications. Imprimis and OSRX are two compounding pharmacies that offer combination glaucoma medications that conveniently include from two to four different classes of glaucoma agents in one bottle.
Improved convenience translates to improved compliance. For instance, a patient who requires multiple classes of medications to provide adequate IOP control could be using three to four bottles of medications multiple times a day. The same patient can administer the OSRX OMNI AM Formula in the morning and the PM Formula in the evening, for example, and have the benefit of four glaucoma medication classes with only two drops per day. Less time is necessary in the office to review and reinforce the medication regimen instructions, and I feel more confident that a patient can more reliably adhere to the latter medication regimen over the former.
503A vs 503B pharmacies
By R. Luke Rebenitsch, MD
Safety of our patients was of the utmost importance when exploring compounded medications. No cost savings would be worth a single medication-related complication. As such, although there are many compounding pharmacies, we chose to work only with pharmacy partners with a good reputation and that met 503A or 503B criteria. The list of requirements is long, but below are some key differences.
- Patient-specific ordering
- Compliance with United States Pharmacopeia (USP) regulations
- Environmental monitoring every 6 months
- Beyond Use Dating (BUD)
- 503A regulations plus Current Good Manufacturing Practice (CGMP regulations)
- Not patient specific (bulk ordering)
- Independent quality department
COST AND TIME SAVINGS
Medication cost is another factor that can negatively impact patient compliance with glaucoma medical management. In a perfect world, physicians could simply prescribe all brand-name products; however, many patients cannot afford them despite having adequate insurance coverage. This can produce another barrier to patients not taking their medications, particularly for an asymptomatic disease state. OneRx lists the total cost of generic latanoprost dorzolamide-timolol and brimonidine as $194.07, for example, while the OSRX PM formulation, which contains the same four medications, lists for $60.
Cost burdens of brand-name glaucoma medications not only produce problems for patients but also for our offices. The myriad insurance plans with differing formularies, coverage tiers and coverage policies produce mass confusion for the physicians and office staff in reliably prescribing affordable medications within each glaucoma medication class. Valuable time is needlessly wasted on staff phone calls to pharmacies, insurance plans and frustrated patients in obtaining the desired yet affordable glaucoma medications. My staff estimates 20 or more calls per day involve medication callbacks with pharmacies, insurance plans or patients. The 2018 Impact Report: Prescription Price Transparency, from the Surescripts health information network, found clinicians spend 2 hours weekly consulting with patients about medications and costs, 1.7 hours working on prior authorization forms and an hour working to understand drug pricing for patients.
Glaucoma medications from compounding pharmacies can significantly help with these issues, for similar reasons that they help with compliance. Patients can either purchase the compounded medication from our office or have it shipped directly to their homes.
Cost and other convenience concerns give the advantage of compounded glaucoma medications over traditional medication regimens. With the available compounding pharmacies, glaucoma medications can be purchased in the office at an affordable price. The staff and I know exactly what affordable medications the patient will be using before the patient leaves the office. We will not have to later respond to phone calls or faxes regarding medication switches, “sticker shock” calls or requests for prior authorizations. Also, patients do not have to look for letters or emails regarding formulary tier changes, unannounced and unsubstantiated switches or dramatic price increases along the way.
In a health-care system in which the glaucoma patients and treating physicians have lost significant control over the daily battle to preserve visual function, compounding pharmacies allow both parties to gain back that control. I believe this will improve patient outcomes by reducing some of the significant barriers to medication treatment adherence. In addition, the use of compounded glaucoma regimens improves daily satisfaction among patients, office staff and physicians within the world of glaucoma medical treatment. OM
- Patel SC, Spaeth GL. Compliance in patients prescribed eyedrops for glaucoma. Ophthalmic Surg. 1995;26:233-236.
- Schwartz GF. Compliance and persistency in glaucoma follow-up treatment. Curr Opin Ophthalmol. 2005;16:114-121.
- Tsai JC, McClure CA, Ramos SE, et al. Compliance barriers in glaucoma: a systematic classification. J Glaucoma. 2003;12:393-398.
About the Author
Michael C. Stiles, MD, is in private practice and is the medical director of Stiles Eyecare Excellence and Deer Creek Surgery Center in Overland Park, Kan. He is also clinical assistant professor at the University of Kansas School of Medicine.
Dr. Stiles reports no relevant financial disclosures.