Wednesday, January 30, 2013

Leukeran Price Gouging Causes Feline Chemo Cost to Skyrocket

Leukeran Price Gouging Causes Feline Chemo Cost to Skyrocket.



One Leukeran tablet is now more than $11 a pill and cat owners cannot afford that.


In my feline-exclusive veterinary practice, I am frequently presented with a middle-aged or elderly cat that has been losing weight.  Common causes for weight loss in this population of cats are diabetes, hyperthyroidism, and chronic kidney disease.  Cats with diabetes and hyperthyroidism tend to have excellent appetites.  Cats with chronic kidney disease often have poor appetites.  Diabetics and cats with kidney disease usually show excessive thirst and urination.  Some cats with hyperthyroidism also drink and urinate excessively.  Some don’t.  The bottom line is that there is a lot of overlap in the clinical signs of these three disorders.  Fortunately, some simple tests (namely, a “senior profile” consisting of a complete blood count, serum biochemistry panel, thyroid test, and urinalysis) are all that is usually needed to reliably distinguish between these three.
               
If a senior profile comes back showing normal kidney and thyroid function, and no diabetes, then the cause of the weight loss often ends up being a gastrointestinal issue. Performing abdominal ultrasound in these cats usually reveals thickening of the intestinal wall and enlargement of the mesenteric lymph nodes (the lymph nodes that reflect what is going on in the intestinal tract).  If this is identified on ultrasound, then a biopsy sample from the intestinal tract is needed in order to make a definitive diagnosis.  Biopsy can be achieved either through exploratory surgery (you get great biopsy specimens, but surgery is costly and invasive) or endoscopy (you can get decent biopsy samples, and it is less costly and invasive). At my hospital, we do endoscopy.  We take many biopsy samples, increasing the accuracy of our diagnoses.  In about 60 percent of the cases, we make a diagnosis of inflammatory bowel disease.  In the remaining 40% of cases, we diagnose low-grade lymphosarcoma. 

Lymphosarcoma is a common feline cancer.   It can strike any cat, at any age, in any organ, but there are sites in the body that are more commonly affected than others.   The gastrointestinal tract is probably the most common site affected.  The most common form of gastrointestinal lymphosarcoma is the “low-grade” form.  This form is less aggressive than the ominous “high-grade” form.  High grade gastrointestinal lymphosarcoma tends to appear as a tumor somewhere in the gastrointestinal tract.  Low-grade gastrointestinal lymphosarcoma tends to occur as a diffuse infiltration of the gastrointestinal tract, rather than as a discreet tumor.  Both respond to medication, however, the low-grade form has a much better prognosis. 

Treatment of the low-grade form consists of giving two medications – prednisolone and Leukeran.  Prednisolone is given twice daily, initially, and is then gradually tapered to a lower dose, usually given once daily.  Leukeran is typically given every other day. With this protocol, the median survival time is about 25 months.  In my practice, we’ve had cats survive much longer. Once cat, Oscar, survived almost five years.  A few others exceeded four years.  We’ve had very good success with this protocol.

One downside of the medical protocol for gastrointestinal lymphosarcoma is the cost of the Leukeran.  This little brown tablet is relatively expensive, costing almost $6 a tablet.  Given every other day, this comes to almost $90/month.  The other drug, prednisolone, is cheap. 

A median survival of 25 months is pretty darn good, considering that lymphosarcoma, despite being low-grade, is still cancer.  Ninety dollars a month for a drug that could keep your cat alive and happy and healthy to a degree that you wouldn’t know that the cat was even ill is a price most of my clients are willing to pay. 
                
Recently, however, the company that made Leukeran was purchased by another company. What did the new company do?  They immediately raised the price of Leukeran to almost DOUBLE what it was before!  

Those dirtbags! 

Leukeran might as well be made out of gold!!
One Leukeran tablet is now more than $11!  It’s outrageous and infuriating.  We have 11 cats in our practice who receive Leukeran every other day, and they are all doing very well.
               
At $11 per tablet, the cost of treating a cat with this drug comes to about $165/month. 

For some cat owners, this is simply cost-prohibitive.  However, my staff and I did some calling around, and working with some compounding pharmacies, we were able to come up with some very affordable alternatives to the brand name Leukeran tablets. 
                
Leukeran tablets are not available as a generic.  The drug – chlorambucil – is only available as the 2 mg brand name tablet Leukeran.  However, compounding pharmacies can prepare the generic drug in capsule or liquid form.  We tried to order 2 mg capsules, however, for legal reasons (which I don’t really understand), the compounding pharmacies are not allowed to make 2 mg capsules.  They can either make 1.9 mg. or 2.1 mg.  I chose 1.9 mg.  The pharmacy that I use is able to make 30 capsules for about $60. The capsules have a six-month shelf life.  30 capsules will last for 60 days (since the drug is given every other day), so the cost of treating is now merely $1/day.  Not bad.  Another pharmacy that we work with is able to prepare liquid chlorambucil at a strength of 2 mg per ml in a 30 ml bottle, at a cost of about $120.  The bottle has a two month shelf-life.  The dose is 1 ml every other day, so a 30 ml bottle will last 60 days. That’s $2/day.  Also not too bad. 
               
The question on everyone’s mind is whether the compounded generic form is as effective as the Leukeran tablets.  I don’t know if there’s a real answer to that question.  I can go into Duane Reade and look for Pepcid, and right next to the Pepcid is Walgreen’s antacid for half the price.  If you look at Pepcid’s ingredients, it says famotidine 10 mg.  Walgreen’s antacid is famotidine 10 mg.  They’re identical.  Do they work the same?  I think they do.  Some people will swear that the name brand Pepcid works better. 
                
A few of my clients are going to continue to give the Leukeran tablets, even at the new $11/tablet price, either because they don’t want to mess with success, or they’re in the fortunate position of not being financially limited.  For those clients who now find the tablets unaffordable, I would recommend the capsules, as I believe that powdered chlorambucil, in the capsule, is probably closer in composition to the native Leukeran tablet than liquid chlorambucil.  Some cats, however, are impossible to pill and can only be medicated if the medication is in liquid form.  For these cats, I would (obviously) recommend the liquid form.  Time will tell, I suppose, if the compounded medications are as effective as the Leukeran tablets. 

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