September 7th, 2015

Two Drugs with High Prices — One is (Surprise!) Good Value, The Other is Truly a Rip-off

catBy now, the fact that HCV treatment carries a high price is a fact as well known to the medical and non-medical public as 1) a million dollars doesn’t get you much in Manhattan or Bay-area real estate; 2) a Rolex is an expensive way to know what time it is; and 3) even though a Tesla doesn’t need gas, buying one won’t save you money.

But you know what? Something interesting has happened since the initial sticker-shock of the $1000/day pill and the cries of injustice from patients, the medical community, and activists. First, the price has been aggressively negotiated, and now is substantially lower — various unofficial estimates suggest the actual cost is around 50% of the wholesale acquisition cost. Still high, yes, but much less than the dizzying cost of HCV treatment during the “SIM-SOF” days in early 2014.

Second, a careful analysis of this miraculous therapy shows it’s actually decent value. In other words, you pay a lot, but you get a lot too — this is what the cost-effectiveness literature shows (several citations in bullet number two at this link), and the public is starting to take notice. An editorial last week in the Times got it right (though it could have used a bit of quick medical editing, which I’ve provided):

The benefits of these new drugs are undeniable. They can essentially cure [not essentially cure — they do cure] the infection in eight to 24 weeks… Curing the patient decreases by more than 80 percent the risk of liver cancer, liver failure and the need for a liver transplant, thus saving money in the long run. Successful treatment can also greatly reduce the number of new cases of hepatitis C by preventing transmission of the virus through needle-sharing among drug addicts infected with HIV [HIV has nothing to do with it]… the Institute for Clinical and Economic Review, previously a skeptic, estimated that a likely course of treatment with Harvoni would make it a high value for individual patients and for most health care systems.

The editorial goes on to recommend lifting restrictions on treatment, in particular for those who don’t have advanced liver disease. This makes all kinds of medical sense, and will be great comfort to those of us battling with payors to get treatment to people before they have irreversible liver damage from HCV.

Meanwhile, one of our relatively obscure antimicrobials — pyrimethamine — has suddenly become staggeringly expensive. Used as part of treatment of toxoplasmosis (in particular for patients with AIDS), and rarely for malaria, pyrimethamine has been around for decades. A single pyrimethamine tablet, previously $13.50, now costs $750 — that’s a more than 50-fold increase.

It’s not as if new research funded by industry has found some novel indication for a previously underused drug. Nope, this is pure monopolistic pricing — in mid-August, a company purchased the rights to pyrimethamine, becoming the exclusive US distributor. As with the colchicine saga, this exclusivity allows them to dramatically drive up the price because, well, they can.

In short, sometimes you get what you pay for — and, at least in the case of pyrimethamine, sometimes you don’t.

Hey, this video doesn’t cover treatment, but it sure is funny!


7 Responses to “Two Drugs with High Prices — One is (Surprise!) Good Value, The Other is Truly a Rip-off”

  1. Alex says:

    Should have known by the kitty pic toxo would be involved! Do you think the high price of pyrimethamine and limited distribution will influence some to treat with SMX-TMP instead? I noticed it is considered an alternative regimen based on a small study.

    As far as HCV treatment goes hopefully the more approved regimens will bring costs down. It seems the price of everything is going up regardless and this can be more or less justified with some drugs but not all.

    PS great vid!

  2. Mehri McKellar says:

    This just happened to us down here in Durham. We had to scramble to get pyrimethamine for our patient’s discharge. Hospitals are on short supply as well.

  3. Helmut Albrecht says:

    Two additional pieces of information.
    Pyrimethamine is on WHO’s list of essential medications. To me this implies that national authorities should have an obligation to secure access to reasonably priced drug. Given FDA’s history with such “disasters”, however, nothing will be done.
    It may therefore be helpful if providers, press and public attack this atrocity by a) boycotting the use of any ImpaxLab products such as RYTARY® and Zomig®/Zomig-ZMT® whenever possible and b) informing the public and the company (including its CEO/president G. Frederick Wilkinson) that this is not tolerable (for contacts see
    This brings me to the second piece of information. Interestingly, the company has reportedly lowered the price of this medication for 340 entities to $1 for a 100 count bottle (all others are expected to pay $75,000 for the same bottle). Our hospital, however, has not yet been able to find a way to obtain drug at this reduced price.
    Trimethoprim may be the most viable alternative, either combined with sulfadiazine for which there are good animal data but few clinical data (still my first choice) or in fixed-dose combination as SMX/TMP for which there is some decent clinical data, including prospective, randomized studies, which were, however, quite small.
    There is, however, a lot of additional anecdotal or unpublished data regarding non-pyrimethamine based therapies that often has only been presented at local or regional meetings. Many European providers who tend to see a lot more toxo, for instance, have seen decent outcome with using iv SMX/TMP for comatose patients that could not be treated with enteral sulfadiazine/pyrimethamine.

  4. Helmut Albrecht says:

    In a surprise move the stock market value of ImpaxLabs has increased by 12.3% since they announced the price hike for pyrimethamine

  5. Ryan Cooper says:

    Have you heard that cycloserine has also recently gone up in price dramatically?

    Appears to be a similar story – new company (in this case, Rodelis) bought the monopoly rights and promptly jacked the price by a ridiculous and seemingly unfair amount. Link:

  6. Barbara Johnston says:

    See Ezekial Emmanuel’s article in Nytimes today on drug pricing.
    May be helpful if you post a comment there and write letter to editor.

  7. Need for more transparency and rationality in drug pricing…

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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