[atourgates]

I have a little insight here from working with ophthalmologists.

When the article mentions "using a cancer drug to treat a leading cause of blindness" it's talking about using Bevacizumab (brand name Avastin) to treat macular degeneration.

Avastin and Lucentis are molecularly the same drug. The difference is that Avastin isn't packaged to be injected into eyeballs, and Lucentis is. Also, Avastin costs about $50/dose, and Lucentis costs around $1,500/dose.

There are compounding pharmacies that will repackage Avastin into a format that can be injected into eyeballs.

However, many ophthalmologists are hesitatnt to use Avastin because that process introduces the potential for contamination. Not that it happens frequently, but every ophthalmologist I know lives in fear of introducing an infection into their patient's eyeballs. And what level of risk is worth saving $1,450 per dose on an injection? 1/100? 1/1000?

I know at least one ophthalmologist who would use Avastin, but would culture a sample from every batch she got from the compounding pharmacy, and had at least one batch that cultured bacteria.

Assumedly, if she hadn't, every patient she injected with that batch would have been at risk of contracting endophthalmitis, and endophthalmitis is no joke. Not infrequently, it can mean losing vision.

I know several of that ophthalmologist's colleagues who had been using compounded Avastin to try and save their patients money, stopped after that incident.

I don't really have a conclusion beyond "drug pricing is insane and the issue is complex for providers."

[unacorner]

Compounding pharmacies can get injectibles wrong in a deadly way. Many families are still waiting for justice after the MECC pharmacy caused the deaths of 64 people:

https://en.wikipedia.org/wiki/New_England_Compounding_Center...

[thombat]

This note in that WP link is wild:

"On July 7, 2021, Barry Cadden's original 9-year sentence was increased to 14.5 years. An appeals court court decision required the trial judge to consider patients, and not only hospitals, as victims of the crime."

The law is always more complex than a layman like me thinks, questions of standing, etc. But I would have simply assumed that the patients hurt and killed would naturally be counted among the victims and not just the organisations left out-of-pocket.

[sapphicsnail]

> And what level of risk is worth saving $1,450 per dose on an injection? 1/100? 1/1000?

I've have plenty of friends that would struggle to afford that. I have friends that buy black market drugs because they can't get/afford a prescription. I don't know if I would make the same choice but I can I can understand why some people do.

[QuantumGood]

You can get some branded prescription pharmaceuticals in the U.S. from outside the U.S. via workarounds (1), and find heavily tested peptides via (2), in both cases avoiding the worst of the black or gray markets. If peptides, it's worth passing the hurdles and tests to access resources at https://pep-pedia.org/

(1) Start by filtering for Brand (not generic) and then going though lowest-cost results for reliable branded manufacturing locations (e.g. Germany, New Zealand, Singapore, NOT India) at https://www.pharmacychecker.com/ . Some sources are less picky about accurately checking prescriptions (e.g. https://www.inhousepharmacy.vu/ ). US Gov't allows buying outside U.S. for personal use, but reserves right to block incoming packages, but practically speaking does not.

(2) Filter for vendors with the best results at https://www.finnrick.com/about/testing-methodology

[epmaybe]

The reason people get endophthalmitis is rarely due to a contaminated batch, but it certainly happens. But frankly it’s unsustainable to have all patients on branded drug, it would be too costly for patients and payers. Not to mention it is slightly unethical in the US due to drug rebates incentivizing branded drug use.

Endophthalmitis is bad, but we can treat it if caught promptly. Patient education, informed consent, good hygiene practices, and easy access to their ophthalmologist can make a tremendous difference.

Source: I do these injections for a living.

[atourgates]

> Not to mention it is slightly unethical in the US due to drug rebates incentivizing branded drug use.

This is an area I'm only perephrially aware of, but the way I understand it is:

* Manufacturer sells very expensive injectible eye drug, in the range of $2k/injection.

* It's typically covered by insurance, but patients (in this demogrpahic who are often on medicare) can still have high deductibles and copayments/coinsurance costs.

* To get around this, the manufacturer funds a nonprofit organization that patients can apply to for financial help paying for their deductibles.

* The manufacturer gets a write-off for donating to a nonprofit, and while they might cover, say, $2k or $5k of a patient's deductible over the course of a year, they still get $22k in revenue covered by Medicare for a year's worth of injections for that patient.

* There was some issue recently where maybe someone realized that "a charity funded by a drug manufacturer exclusively for the purpose of reimbursing purchases of that manufacturer's drugs" might not be a wholly above board charity, but I'm not sure if that was resolved.

All this is hearsay from my perspective, but am I in the ballpark of what you were talking about?

[munk-a]

> But frankly it’s unsustainable to have all patients on branded drug, it would be too costly for patients and payers.

This is incorrect, the Canadian healthcare system negotiates drug costing at a per province rather than per patient manner and has managed to negotiate down drugs pretty significantly especially in Ontario. A national drug plan doesn't currently exist but it's likely that drug and dental coverage is going to be a goal in the near term.

In the US there is also a complex drug reimbursement program run by most manufacturers to offer rebates to patients in the form of trial cards or direct refunds that does help widen accessibility but those programs are generally limited to patients on private insurance due to the nature of incentives and, well, greed.

I think it's very fair to say "Within this current system brand name drugs are a ridiculous ask for most patients due to the availability of generic alternatives" but the system itself is deeply broken. Generics are sometimes whitelabeled versions of the same product but often what are considered inactive ingredients may be modified significantly from brand name versions leading to issues, especially when it comes to neurological drugs, of drastically different effects to patients. The brand name vs. generic problem is a lot more complex than most people give it credit for and while patients should always prefer generics when they're similarly functional there are very notable scenarios where they are not equivalent for treatment. This comment shouldn't be read in direct opposition to the full comment above as this drug is outside my wheelhouse but rather as a comment on generics in general.

Source: I work in a company that analyzes drug pricing and, more generally, comparative insurance reimbursement for a living.

[maxerickson]

They have similar targeting but are not the same molecule.

[3eb7988a1663]

My quick searching is showing that bevacizumab is the full antibody, but lucentis (ranibizumab) is just the fab. So, very similar, but indeed not the same thing. I would generally expect them to have the same effect, but biology is full of surprises.

[peterbecich]

The higher manufacturer price of the eyeball-safe formulation is clearly justified, then, i.m.o. Also, is it the doctor's responsibility to assume risk to save the patient money?

[duskdozer]

Assuming the compounding process is inherently more at risk of contamination. It also gets complicated when the extreme prices are involved: what risk of infection balances out with the risk that the patient will not be treated due to cost or will suffer whatever negative consequences due to bearing the cost? One in two? Probably not. One in a billion? Probably.

Considering that the doctor was able to test the batches and verify contamination, it seems like this is an important step that was skipped by the pharmacy.

[peterbecich]

Given the litigious nature of medical patients these days, I think most doctors would justifiably avoid the additional responsibility of pharmaceutical QA.

[benj111]

How does that justify a 30 fold increase?

If an individual Dr can get a batch checked while saving the patient money, it obviously isn't justified.

[peterbecich]

In my opinion this is an unfair risk to the doctor's career in assuming responsibility for the quality of the compounded drug.

In the absence of any other evidence, I assume the 30-fold increase is the cost to the manufacturer of preparing the drug for eye injection "according to Hoyle."

[benj111]

So why isn't the batch checker taking on that responsibility?

Doctors aren't responsible for anything and everything that happens. If they've had a drug tested to check it's safe, after informing the patient, what else is there for them to do? You're creating a hypothetical to enforce the status quo. That's why we end up with this bs to start with.

[Buttons840]

How does a lowly pharmacy transform a drug that is not for eye injection into one that is?

[chasd00]

They are not transforming the drug just the form. For example, elderly patients may have a hard time swallowing pills, for some medicines (not all) a compounding pharmacy can turn the pill into a lollipop. They can also turn things into like a cream or lotion.

/use to write code for a small independent pharmacy that had a couple compounding labs

[pvaldes]

> How does a lowly pharmacy transform a drug that is not for eye injection into one that is?

New research probably discovered new applications for their product. Investors agree to diversify. Company developed a system to inject it. The system was approved by government agency at charge of this, and they give the green light to put it in the market.

This is totally normal. See Ozempic history.

The price of a treatment reflects also the collateral risks and probability to be sued for the physician and the company. The problem is not that it cost 1000 dollars, the real problem is that US government should be subsiding at least a part of this cost. Tax money is collected exactly for cases like this. The problem is that they are instead burning 14 millions to paint a pool in "American Idiot Green" dye and nobody says, this bill must be wrong. What they used to paint this? titanium?

[duskdozer]

The US government already was subsidizing the cost: https://www.nei.nih.gov/research-and-training/research-news/...

It subsidizing the cost of developing many drugs. The question is whether their pricing reflects that.

[maxaw]

Just went down a chatgpt rabbit hole because I was also curious - seems it’s literally physical repackaging, no modification of the drug itself- as another commenter pointed out it’s not quite the same molecule but they have the same effect? Someone correct me if I’m wrong

[loeg]

E.g., by physically crushing up tablets and dissolving them in a solution.