Clinical Briefs: Osteoarthritis; sinusitis; hepatitis C
December 30, 2001 3 minutes read
Cost Implications of Using an Alternative Treatment for Patients with OA of the Knee in Managed Care
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Management of osteoarthritis (OA) occupies an important position in day-to-day practices of clinicians. Commonly used tools for appropriate pharmacologic management include NSAIDs, opioid analgesics, physical therapy, glucocorticoids, and alternative medicine regimens. Viscosupplementation—instillation of hyaluronic acid (HYL) or its derivatives intra-articularly—is much less frequently used as a foundation treatment for OA. Waddell and colleagues calculated the cost savings associated with use of hyaluronic acid (Hylan G-F 20) incorporated into the treatment pathway for OA of the knee. The hypothetical clinical scenario included persons followed for 3 years in a managed care setting.
The clinical benefits in symptom reduction following viscosupplementation average approximately 1 year. Such treatment forestalls, or sometimes obviates, the need for total knee replacement. Waddell et al calculate that adding at least 1 course of HYL to a treatment pathway for OA of the knee results in an estimated savings of $4706 per patient over a 3-year period.
Clinicians have been slow to adopt viscosupplementation into the typical OA therapeutic plan. HYL may be both clinically effective and cost saving when included as basic management in persons with OA of the knee.
Waddell D, et al. Am J Manag Care. 2001;7:981-991.
First-Line vs. Second-Line Antibiotics for the Treatment of Acute Uncomplicated Sinusitis
Recent data suggest that sinusitis is the fifth most common diagnosis for which clinicians prescribe antibiotics in the ambulatory setting. At a time when bacterial resistance, which may be related to outpatient antibiotic prescribing, is an ever-growing dilemma, considerations of when to prescribe and which agent to prescribe become increasingly relevant. Piccirillo and associates examined antibiotic use, efficacy, and cost based upon data obtained from the Express Scripts Patient Treatment Episode registry, which includes 29,102 antibiotic prescriptions for sinusitis in adults.
The 3 most commonly prescribed antibiotics (in descending order of frequency) were amoxicillin, trimethoprim-sulfamethoxazole (TMP-SMX), and clarithromycin. Approximately one third of subjects received antibiotics not FDA-approved for sinusitis. For the purposes of this study, first-line antibiotics are defined as amoxicillin, TMP-SMX, and erythromycin.
Primary care physicians were more likely to prescribe first-line antibiotics than specialists. The success rates for treatment were essentially identical between first- and second-line treatments (90.1% vs 90.8%); relapse rates were similarly indistinguishable (3.3% vs 3.5%). On the other hand, the mean cost per patient of first-line therapy ($68.98) was approximately half that of strategies using second-line agents ($135.17).
This analysis demonstrates that there no significant demonstrable added clinical benefit to using second-line antimicrobial agents, which cost almost twice as much as first-line agents.
Piccirillo JF, et al. JAMA. 2001;286: 1849-1856.
Treatment of Acute Hepatitis C with Interferon Alfa-2b
The disease management model of the HIV virus suggests that early intervention may allow host defenses to subsequently control viral replication. Delay in clearing viral load may result in deletion of virus-specific CD4 T cells and CD8 T cells, rendering the host less able to respond to culprit virus.
The current trial evaluated the effect of daily interferon alfa-2b (IA2b) on acute hepatitis C (HCV). Subjects had known/suspected HCV exposure in the past 4 months, documented seroconversion, or new abnormal liver function tests (LFTs), coupled with positive HCV virus RNA testing. Patients received IA2b daily for 4 weeks, followed by thrice weekly subcutaneous doses for 20 further weeks (traditional therapy has been thrice-weekly without initial daily dosing).
All patients (n = 44) achieved undetectable HCV RNA levels by 12 weeks of therapy, and 98% continued to undetectable levels at 24 weeks. LFT abnormalities normalized within 11 weeks after initiation of treatment and remained so through 24 weeks of treatment. All but 1 patient tolerated treatment well. Jaeckel and colleagues conclude that an early intervention for patients with acute hepatitis C.
Jaeckel E, et al. N Engl J Med. 2001; 345:1452-1457.
Dr. Kuritzky, Clinical Assistant Professor, University of Florida, Gainesville, is Associate Editor of Internal Medicine Alert.
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