Price Check! Genital Herpes. How Much is Nursing Time Worth?

It is worthwhile to check drug prices now and then (once a quarter seems about right) to see what is happening in the pharmaceutical world.  When you do this, you will find some drugs that have inexplicably shot up in price.  One recent example was doxycycline, which went from around ten cents a tablet to over two dollars a tablet in a couple of months.

On the other hand, drugs that we think of as expensive in the back of our minds sometimes are no longer expensive.  Olanzapine (Zyprexa) is now cheaper than haloperidol.  Risperidone is cheaper still.

And sometimes, a drug that is a bit more expensive than its alternative is still the most cost-effective treatment based on “the hassle factor,” meaning frequency of dosing, ease of administration, potential for diversion–that sort of thing. Drugs prescribed for outbreaks of genital herpes are like that, in my opinion.  Valacyclovir can be more cost-effective than acyclovir for the treatment of recurrent genital herpes.herpes1

Acyclovir for genital herpes outbreaks has three different dosing regimens:  You can prescribe 200mg five times a day for five days.  But why would you?  Five times a day dosing is basically impossible to achieve in the real world.  We are certainly not going to pass meds five times a day in correctional facilities.  And even if acyclovir is a KOP med at your facility, numerous studies have shown that dosing compliance declines precipitously as the number of doses per day increases.   Five times a day?  Isn’t going to happen.

Fortunately, there are two other friendlier dosing regimens for acyclovir.  You can prescribe 400mg three times a day for five days. Best of all is 800mg twice a day for five days.  Acyclovir 400mg tablets cost around 14 cents apiece and 800mg tablets cost around 25 cents.  So the total cost for each of these treatment regimens (including the fill fee, which I will estimate to be $5.00) is:

Acyclovir 400mg TID for 15 doses costs $2.10 plus a $5.00 fill fee equals $7.10.

Acyclovir 800mg BID for 10 doses costs $2.50 plus the fill fee equals $7.50.

(My source for drug prices is Idaho Medicaid’s Actual Acquisition Cost List.  The prices at your facility are likely to be a little different from these–but usually are close enough).

Now the numbers for valacyclovir. Valacyclovir for outbreaks of genital herpes can be prescribed as 500mg twice a day for only three days or 1000mg just once a day for five days.  The tablets do cost a little more than acyclovir.  Valacyclovir 500mg tablets are 92 cents each and the 1000mg tablets cost $1.27.  So the total cost for a course of treatment for each of these options is:

Valacyclovir 500mg BID for six doses costs $5.52 plus a $5.00 fill fee equals $10.52.

Valacyclovir 1000mg a day for five days costs $6.35 plus the fill fee totals $11.32.

So, a course of therapy using valacyclovir costs around $3.00 more than one using acyclovir, but with the benefit of many fewer doses.  Using valacyclovir 1000mg instead of acyclovir 800mg saves five med passes for your facility’s nurses.  Is the savings in nursing time worth $3.00?  Absolutely, in my opinion!

If your facility allows KOP of these drugs, then acyclovir 800mg BID for five days may be the way to go.  But if, as is the case most places, these drugs are on the Direct Observation med pass, valacyclovir is the better deal, in my opinion.

And Now a Word About Over-Prescribing

If you are concerned about cost-effective utilization of medications (as I am), a bigger source of wasted pharmaceutical dollars is over-prescribing.  If any medication is prescribed to a patient who has no chance of benefiting from that prescription, then that money has been absolutely wasted! The obvious example is antibiotics prescribed for viral illnesses.  In my experience, drugs for Herpes are often prescribed inappropriately both in correctional facilities and in the community at large.  Here are some mistakes I have seen:

1.  Prescribing anti-virals for non-herpetic problems.  Patients sometimes do not know exactly what genital herpes is.  They sometimes will say “I have herpes'” but if you look, they really have a genital wart or fungal “crotch rot” or “pickin’ pox” or even (heaven forbid) a syphilitic chancre!  The key here is looking.  Herpes, of course, has a characteristic appearance that is unlike any other lesion you will see on the groin:  a bunch of blisters on a red base.  Anything else is something else and will not benefit from valacyclovir.

2.  Prescribing acyclovir or valacyclovir too late in the illness.

Too late to treat

Too late to treat

The herpetic anti-virals only have clinical efficacy if they are prescribed within the first 48 hours of the outbreak–even better in the first 24 hours. At this stage, the blisters look like blisters.  During the several day course of the illness, the blisters will rupture and weep and then crust over and finally resolve.

By the time the lesions have crusted, at the very latest, it is too late for acyclovir or valacyclovir to work.  Don’t prescribe them.

3.  Prescribing the anti-virals too soon.  The clinical scenario goes something like this”  “Doc, I can always tell when I am about to get herpes.  I feel a tingling.  I need a prescription now.”  The problem is that if you treat the “infection” based on a feeling and the patient does not go on to get a rash, he will attribute this to getting treatmented early–so will always want a course of treatment whenever he gets the tingly feeling.  Inevitably, the patient will be taking anti-virals when there is no need.  In a correctional facility especially, it is better to see the rash before initiating therapy.

What do you use to treat genital herpes outbreaks in your facility?  How bad of a problem is it?  Please comment!Herpes

 

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6 thoughts on “Price Check! Genital Herpes. How Much is Nursing Time Worth?

  1. Bill Wright

    I’ve been using Acyclovir 500 BID x 5 days because it’s on the formulary. I agree that Valacyclovir may be able to save the nursing time, but it costs my time to wrestle with the non-formulary committee to get the drug. By the time it’s approved (if ever) the time for treatment has passed.

    Reply
    1. Jeffrey Keller MD Post author

      Hi Bill! You seem to be a victim of “Formulary Stasis Syndrome.” What happens is that a formulary is developed based on drug prices at the time–and then is never changed. Months, even years later, the formulary is exactly the same even though drug prices have changed dramatically and the formulary now makes no financial sense.

      Do you have a formulary committee that you can appeal to? Or a supervising pharmacist? Or anyone with the authority to look at the data and make the change?

      Here is the data as of now (assuming a $5.00 fill fee): Price of a five day course of acyclovir 200mg five times a day: $7.38

      Price of a five day course of acyclovir 800mg BID: $7.50

      I personally call that essentially equivalent. Acyclovir 800 non-formulary? Makes no sense.

      Reply
  2. mark schaffield

    I seems to me that antiviral medications when used for genital herpes are hardly worth the money, no matter how inexpensive they might be. The usual benefit noted is that they can “shorten the duration of pain, healing time, new lesion formation and viral shedding by 1-2 days” (The Medical Letter). If this is the first outbreak, I use the visit to explain what is going on and it they are “sick” will treat. If this is a recurrence, I don’t treat. As far as suppressive therapy, I don’t use it in jail because I think it is unlikely to be transmitted to another inmate. If the inmate is HIV positive or on HAART, however, I will treat because of the chance of contagion. What do you think of the use of other antivirals (Tamiflu) in otherwise healthy individuals when they “shorten the course” of the flu by a day or two? Thanks, enjoy your blog immensely. Mark Schaffield

    Reply
    1. Jeffrey Keller MD Post author

      Hi Mark,

      Lots of practitioners agree with you. In fact, I agree with you that the benefit of anti-virals for genital herpes is not that great. On the other hand, there is a spectrum of herpes oubreaks from very mild to pretty dang impressive. So I do prescribe anti-virals sometimes for a bad case presenting early enough. But most cases show up in the clinic too late, anyway.

      I do NOT prescribe anti-virals for cold sores!

      Reply
    2. Jeffrey Keller MD Post author

      Part two: Tamiflu. Probably even less effective than herpes drugs. Almost worthless, IMO. That would be a good blog topic, though!

      Reply
  3. Bill Wright

    I agree that treatment for genital herpes is often too little and too late, but I’m more encouraged with treatment for frequent recurrences. If a patient is having a recurrence every month, I think suppressive therapy is worthwhile in preventing the recurrences and (less valuable in a jail setting) in preventing spread. Acyclovir 400 mg BID or Valacyclovir 500-1000 once daily for several months (I usually go for 6 mos, although the literature quotes a year).

    Reply

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