Yesterday's NY Times has a good article about a minor controversy. The NEJM published a paper showing that treating superficial vein thrombosis could have a small but significant benefit.
The study of 3,002 people with superficial-vein thrombosis showed that the condition worsened to deep vein thrombosis or pulmonary embolism in 1.3 percent of those who took a placebo for 45 days and 0.2 percent of those who took the drug Arixtra.
It was an excellent, randomized, double-blind study that reported statistically significant results, Dr. Goldman and Dr. Jeffrey S. Ginsberg, a blood expert, wrote in the editorial.
But the study did not talk about the costs, they wrote, which could range from $2,124 to $7,380 a person for 45 days of injections, or at least $186,000 for 88 people to avoid one new problem.
“The paradox is, it’s effective, but for a condition that’s usually not considered an overwhelmingly serious medical problem,” Dr. Goldman said in an interview. “The fact that it’s a medicine that’s expensive really raises an issue, not just for this trial, but we tried to make the point more broadly.”
Drs. Goldman and Ginsberg deserve commendation. Obviously the drug company will promote their expensive drug widely, and likely make money from its use. I hope insurance companies do not pay for this drug for this indication. This is too much.
We must draw the line somewhere. The editorial makes the point clearly and, I believe, well.
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DB,
The NEJM paper was essentially one of VTE prophylaxis. 2.5 mg of fonda daily is not therapeutic anticoagulation. To fully evaluate this paper one should compare the cost effectiveness to other studies of VTE prophylaxis, and it stands up pretty well. These authors looked only at symptomatic VTE. Had they looked at asymptomatic DVT as most studies on prophylaxis have done the cost effectiveness would have been very good in comparison to studies on medical prophylaxis in hospitalized patients. I've been reviewing this background literature today and will post on my blog Monday. I think the Times article is distorted because it left out this important background.
Some might consider the article as a proof of concept-namely that a fairly low dose of a parenteral anticoagulant prevents DVT in patients with superficial thrombophebltis. If one used Lovanox the cost calculus changes significantly. Preventing DVT and PE in patients with various procedures and in many hospitalized patients has become a holy grail type crusade and for the most part for good reasons.I'll bet that a number of physicians will think prophylaxis makes sense in the superficial phelbitis setting.Considering this issue as one of prophylaxis as opposed to therapy might give a different spin and I think makes the NEJM editorial appear not as nuanced as it might have been.
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