Drugs approved for the same problem often show equal efficacy on average, but their effects can vary widely between individuals, the authors explain. "This can be misinterpreted to support either unnecessarily broad or inappropriately restrictive formulary policies." If it's not possible to predict at the beginning of treatment which drug will have the best effect, then starting with the most affordable alternative makes sense, the authors contend. But a more expensive medication is often justified for patients who respond poorly to first-line treatment.
The authors use the class of drugs for depression known as serotonin reuptake inhibitors (SRIs) as an example. Direct randomized comparisons of SRIs show no difference in average effectiveness. But studies also show that half the patients who fail to respond to one SRI may do well on another. It's not possible to predict who will do well on which drug at the beginning of treatment. Therefore, it makes sense for an insurance company to only cover the most affordable drug for anyone starting treatment for the first time, the authors write. Patients who do poorly with the first medication should be allowed to use one of the more expensive alternatives.
5. Understand that variation in effects argues against requiring changes in ongoing treatment.
With this principle, the authors argue that formulary changes should not necessarily result in requirements that patients switch to new drugs. "In addition to concern about variability in effect, decisions must consider added visits and other costs of medication changes, as well as the likelihood that many physicians and patients may be hesitant to disrupt stable treatment," the authors write.
About Group Health and the Center for Health Studies
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Contact: Joan DeClaire
declaire.j@ghc.org
206-287-2653
Group Health Cooperative Center for Health Studies
28-Oct-2005