Dear Editor,
The costs of antipsychotic drugs (APDs) used in the treatment of mental disorders with psychosis are mentioned in treatment guidelines (APA 2021, NICE 2014). While the American Psychiatric Association guideline states that every specialist should make decisions according to the rules and conditions of their country and their region, the National Institute of Health and Clinical Excellence guideline emphasizes that drug costs must be taken into consideration in the treatment process. Classical or first-generation antipsychotic drugs (FAPDs) are relatively cheaper in terms of sales prices compared to atypical or second-generation antipsychotic drugs (SAPDs) with a slightly different effect mechanism. The price difference between the two drug groups can be so large that sometimes it may be necessary to consider whether the cost of a second-generation drug is worth its benefit. While deciding on the use of first-generation or second-generation drugs, a multifaceted assessment should be made, such as the patient’s level of compliance with the treatment, the possibility of occurrence of side effects, the possible effects of these side effects on body health and treatment compliance, and whether or not the costs are covered. The most important criterion that determines the choice of medication for psychiatrists is of course the multi-dimensional benefit/harm ratio that the drug used will reveal in the long term.
We think that in our country, which, in terms of economic indicators is not in a strong position as an importer of pharmaceutical raw materials from abroad, APDs’ cost calculation should be considered because drug costs constitute an important part of the direct treatment costs of psychotic disorders in developing countries such as Turkey (Yıldız and Cerit 2006). We calculated the unit (mg) price based on the box prices of the APDs in use in 2020, thinking that it might work when calculating the cost of the illness using APDs as the main component of the treatment and calculated the annual average drug costs with the daily average dosage. Although the daily treatment dose varies with the stage of the illness and the individual characteristics of the patient, the average doses recommended for maintenance treatment were used here (Öztürk and Ulusahin 2018). The daily and annual cost calculations based on the assumption that the average maintenance treatment dose was used with the unit price obtained from (Drug Prices 2020) the drugs in the Turkish pharmaceutical market in September 2020 are shown in Table 1. A similar study was done in 2005 (Yıldız 2005). The purpose of this article is to redetermine the average costs of APDs in the Turkish pharmaceutical market every 15 years and to bring them to the attention of experts in terms of cost-effectiveness studies.
When the costs in 2005 are examined, it is seen that the annual costs of the FAPDs were around 450 TRY, and the annual cost of oral preparations of SAPDs was 2,500 TRY (5 times the first generation). In 2005, there was only one depot of SAPD (risperidon consta) that allowed intramuscular (IM) administration, and its average annual cost was 5,400 TRY, 3 times more than the tablet form (1,700 TRY). In 2005, when the price of risperidone consta, which was the first second-generation depot APD, were compared with the prices of the first-generation depot drugs (fluphenazine = 380 TRY, flupentixol = 876 TRY, zuclopentixol = 730 TRY), the cost difference was 6-14 times. This almost-10-fold difference between the cost of the first and second generation APDs was remarkable. It is seen that this difference (risperidone consta = 10,807 TRY, fluphenazine = 916 TRY, flupentixol = 1,007 TRY, zuclopenthixol = 2,372 TRY, and haloperidol deconate 237 TRY) did not change in 2020. In 2020, the average
RETHINKING THE COST OF ANTIPSYCHOTIC TREATMENT: THE AVERAGE COST OF THE DRUGS USED IN TURKEY IN 2020
2 Türk Psikiyatri Dergisi 2
Turkish Journal of Psychiatry
Letter to the Editor
146
147
annual cost of oral use preparations of FAPDs is 925 TRY, while the average annual cost of oral forms of SAPDs is 2,580 TRY. The 5-fold difference observed in 2005 between the first and second-generation ones of the oral APDs decreased to 2.5 times in 2020. It is clear that while the difference between the cost of oral use of first- and second-generation drugs was halved in 2020, the difference between the costs of depot preparations applied with IM did not change.
In 2005, the average dollar rate was 1.34 TRY, and in 2020 it was 7.02 TRY (Republic of Turkey Central Bank Exchange Rates, 2021). It is understood that the 5-fold increase in dollar exchange rate is not reflected in all drug prices in the same way. For example, there was a 3 to 4-fold increase in the prices of haloperidol, chlorpromazine, fluphenazine, trifluperazine and zuclopenthixol, while a less than two-fold increase in pimozide, flupenthixol, sulpiride, amisulpride and quetiapine and a decrease in the prices of clozapine, olanzapine, ziprasidone and risperidone in the tablet form. There is also a two-fold increase in the price of risperidone consta. The fluctuations in drug prices in 2005 and 2020 are shown in Table 2 in 500, 1,000, 2,000, 3,000 and 5,000 TRY brackets. It is noteworthy that while some drugs have moved into an upper price bracket in terms of annual costs, some have fallen into a lower price bracket.
The prices of the second generation long-acting (depot) antipsycotic drugs (LA-APDs), which were not available in the Turkish pharmaceutical market in 2005, are quite high compared to others. In 2020, the annual cost of all of them, including risperidone consta, is over 10 thousand TRY.
It is understood that the underlying reason for such price increase is the fact that the drug is wanted/sought after/new/marketed rather than the dollar exchange rate. For example, while there was a certain increase in the price of FAPDs, the increase in the price of some of the SAPDs (sulpiride, amisulpride, quetiapine tablet) was low, while the price of some others (clozapine, olanzapine, ziprasidone, risperidone tablet) decreased. It should also be taken into account that the effect of generic drugs entering the market during this period may have had an impact on price changes. It is noteworthy that while the annual cost of risperidone consta was approximately 3 times higher than the tablet form (5,400 TRY versus 1,700 TRY) in 2005, this difference reached 14 folds (10,807 TRY versus 742 TRY) in 2020.
In 2005, the difference between the lowest daily cost (0.07 TRY) and the highest daily cost (14.80 TRY) was 211 times (Yıldız 2005), this difference had receded to 111 times (0.35 TRY versus 38.72 TRY) in 2020. Still a huge difference, isn’t it?
Table 1. Current Forms, Box Prices, Daily and Annual Costs in For Maintenance Treatment of Antipsychotic Drugs Available in the Pharmaceutical Market in September 2020 in Turkey
No
Generic name
Trade name
Dosage forms (mg)
BV
Price#
TRY/Mg
ADD
Cost/d
Cost/y
2005**
1
Haloperidol
Norodol
5, 10, 20 tb
5/50
17.57
0.070
5
0.35
127
26
5, 10 amp
5/5
5.35
0.214
5
1.07
390
-
50, 150 LAI
50/1
9.80
0.196
1/15*
0.65
237
-
2
Chlorpromazine
Largactil
25,100 tb
100/30
17.92
0.006
300
1.79
653
197
3
Fluphenazine
Prolixin
25 LAI
25/1
17.57
0.703
1/7*
2.51
916
380
4
Trifluoperazine
Stilizan
1, 2, 5 drj; 1 amp
5/30
14.52
0.096
10
0.97
354
91
5
Pimozide
Nörofren
2 tb
2/30
19.33
0.322
4
1.29
470
365
6
Flupenthixol
Fluanxol
3 drj
3/50
65.75
0.438
6
2.63
960
526
20 LAI
20/1
19.33
0.966
1/7*
2.76
1,007
876
7
Zuklopenthixol
Clopixol
2, 10, 25 tb
2/50
38.65
0.386
20
7.72
2,817
701
200 LAI, 50 acu
200/1
45.55
0.227
1/7*
6.50
2,372
730
8
Sulpirid
Dogmatil
200 tb
200/24
23.15
0.005
600
3.00
1,095
876
9
Amisulpirid
Solian
200 tb
200/60
146.92
0.012
600
7.20
2,628
2,387
10
Quetiapine
Seroquel
25, 50, 100, 200, 300, 400 tb
300/30
137.17
0.015
600
9.00
3,285
2,628
11
Clozapine
Leponex
25, 100 tb
100/50
32.56
0.006
400
2.40
876
1,898
12
Olanzapine
Zyprexa
5, 10, 20 tb
10/28
152.96
0.546
10
5.46
1,992
2,606
13
Ziprasidone
Zeldox
20, 40, 60, 80 tb
60/56
189.89
0.056
120
6.72
2,452
3,541
14
Sertindole
Serdolect
4, 12, 16, 20 tb
16/28
453.53
1.012
16
16.19
5,909
-
15
Risperidone
Risperdal
1, 2, 3, 4 tb; 1 sol
2/20
20.34
0.508
4
2.03
741
1,719
Ris. Consta
25, 37.5, 50 LAI
37.5/1
444.17
11.840
1/15*
29.61
10,807
5,402
16
Paliperidone
Invega
3, 6, 9 tb
6/28
213.15
1.268
6
7.61
2,777
-
Xeplion
50, 75, 100, 150 LAI
100/1
1161.56
11.615
1/30*
38.72
14,132
-
Trevicta
175, 263, 350, 525 LAI
350/1
3426.95
9.788
1/90*
38.08
13,899
-
17
Aripiprazole
Abilify
5, 10, 15, 20 tb; 1 sol
20/28
113.25
0.404
20
8.08
2,949
-
Abilify Main.
400 LAI
400/1
971.17
2.420
1/30*
32.37
11,815
-
BV: Baseline value (in mg of the form and the number in the box), Price#: Box price of the base value in TRY, TRY/mg: Value per milligram in Turkish Lira, ADD: Average daily dose, Cost/d: Daily cost in TRY, Cost/y: Annual cost in TRY, mg: Milligram, tb: Tablet, drj: Dragee, amp: Ampoule, LAI: Long-acting injectable, acu: Acuphase, d: Day, TRY: Turkish Lira, *LAI per 7,15,30 or 90 days, **Annual cost in TRY in 2005.
148
Received: 14.01.2021, Accepted: 31.03.2021, Available Online Date: 07.01.2022
1Prof., 2Res. Assis., Kocaeli University School of Medicine, Department of Psychiatry, Kocaeli, Turkey.
e-mail: myildiz60@yahoo.com
https://doi.org/10.5080/u26315
The difference in 2005 between oral FAPDs prices and SAPDs prices seems to have halved in 2020. In 2020, the average daily treatment cost of oral drugs, whether for the first generation or the second generation, is 3 TRY (approximately the same for FAPDs applied with IM), while the daily cost of LA-SAPDs is around 33 TRY. It is seen that the difference between costs is approximately 11 times. This difference increases to 50 times for haloperidol deconate. From here, the following judgment can be made: in order for LA-SAPDs to be preferred, they must be at a value that will constitute at least 11 times higher cost. This cost can and should be taken, especially for patients who are non-adherend with treatment and who do not adapt to LA-FAPDs. Because for clinicians, preventing the multi-dimensional destructiveness of psychosis in the individual, families and the society should be the priority. In this case, calculating the cost should not be a primary consideration. However, it is also known that patients who are non-adherend with treatment gain the ability to understand their illness and make consistent evaluations with its’ results. If a psychosocial therapy has been carried out for a patient using IM medication for six months or a year, it is likely that this period provides insight and increases the level of treatment compliance. After one year of IM application, whether or not the patient will comply with oral treatment should be re-evaluated and the transition to oral treatment should be considered. If there is no problem in the patient’s oral treatment compliance, it should be taken into account that the benefit of this transition will be at least 11-folds a year with this transition. Naturally, it will be necessary to apply IM for some patients for years. Moreover, there will be patients who need to switch from monthly administration of LA-SAPDs to quarterly usage patterns. However, we can say that most patients using LA-APDs will not need such use after a while, based on our clinical practice, although there is no study done in this field.
With this study, we wanted to emphasize that while prescribing drugs used in the treatment of illnesses with psychotic symptoms, they should take into account the side effects of the drugs, as well as the daily, monthly, annual, and lifetime costs of the drugs. The principle of ‘using an effective drug recommended for a specific disorder at the required dose, in sufficient time, at the lowest cost’ adopted in the rational drug use guidelines should not be forgotten. It is expected that the modification of drug treatments, considering their costs as well as their efficiency, will contribute significantly to the country’s economy in the long run.
Mustafa Yıldız1, Emre Osman2
REFERENCES
American Psychiatric Association (2021) The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. Third edition. Washington, DC: American Psychiatric Association.
Drug Prices. https://www.ilacrehberi.com/ilac-fihrist/ Accession date: 25th September 2020.
National Institute for Health and Clinical Excellence (NICE) (2014) Psychosis and schizophrenia in adults: prevention and management. NICE Guideline CG178; https://www.nice.org.uk/guidance/cg178. Accession date: 4th April 2018.
Öztürk MO, Uluşahin NA (2018) Mental Health and Disorders. 18th Edit. Ankara: Nobel Tıp Kitapevleri. (In Turkish)
Republic of Turkey Central Bank Exchange Rates. https://www.tcmb.gov.tr/kurlar/kurlar_tr.html Accession date: 10th January 2021.
Yıldız M (2005) The cost of treatment of psychotic disorders. Turk Psikiyatri Derg 16:146-7. (In Turkish)
Yıldız M, Cerit C (2006) Annual cost of treatment for schizophrenia: Estimation from a university hospital data in Turkey. Bulletin of Clinical Psychopharmacology 16:239-44.
Table 2. Comparison of the Annual Costs of Antipsychotic Drugs Calculated By The Daily Standard Average Dose Use, at Certain Price Ranges, for the Years 2005 and 2020
Price bracket (TRY)
2005
2020
500 ↓
Haloperidol tb, amp, Trifluoperazine drj, Chlorpromazine tb, Pimozid tb, Fluphenazine LAI
Haloperidol tb, amp, depo, Trifluoperazine drj, Pimozid tb
500-1,000
Flupenthixol drj, LAI, Zuklopenthixol tb, acu, LAI,
Sulpirid tb
Chlorpromazine tb, Fluphenazine LAI, Flupenthixol drj, LAI, Clozapine tb, Risperidone tb
1,000-2,000
Clozapine tb, Risperidone tb
Olanzapine tb, Sulpirid tb
2,000-3,000
Amisulpirid tb, Olanzapine tb, Quetiapine tb
Zuklopenthixol tb, acu, LAI, Amisulpirid tb, Ziprasidone tb, Paliperidone tb, Aripiprazole tb
3,000-5,000
Ziprasidone tb
Quetiapine tb
5,000-10,000
Risperidone consta
Sertindole tb
10,000 ↑
Risperidone consta, Paliperidone monthly, Paliperidone 3 monthly, Aripiprazole maintana
tb: Tablet, drj: Dragee, amp: Ampoule, LAI: Long-acting injectable, acu: Acuphase,