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Costs of anticonvulsant therapy.

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Costs of Anticonvulsant
Therapy
Mark A. Goldberg, MD, PhD
Control of epilepsy ultimately depends on the patient taking anticonvulsant medication as directed by his or her
physician. Failure to do so, noncompliance, is a major cause
of therapeutic failure and may be the single most important
limiting factor in drug therapy. Lack of patient understanding as well as social and psychological factors have
been implicated as causes of noncompliance, but the cost of
anticonvulsant treatment has received little attention. In
order to determine the potential role of this factor, I have
estimated the relative cost of several major anticonvulsants
and the laboratory tests associated with each.
Drug costs were estimated using prices available from
the Epilepsy Foundation of America pharmacy service,
which provides members with inexpensive prescription
medication. Typical daily doses were estimated and the
yearly cost determined for the leading brands based on the
usual dosage form when purchased as 1,000 units (Table).
The costs of laboratory tests done according to recommendations made in the package insert were determined
using the fee schedule of a large commercial medical laboratory; when no specific recommendations were made, I
used what I believe to be prevailing practice. Physician’s
fees and diagnostic tests were not included, as they presumably would not vary with different drugs. Similarly, the
cost of measuring drug serum concentration (approximately $26) is assumed for the purposes of this table to be
uniform.
The considerable variation in cost among these agents is
paralleled by the required laboratory investigations, with
the newest drugs costing the most. Some variation in the
laboratory information required by individual physicians
occurs, especially for Tegretol and Depakene, and the estimates for these two drugs may vary by as much as 20%.
Few Americans have medical insurance that covers prescriptions, and anticonvulsant costs are usually out-ofpocket expenses. This can strongly affect compliance. Partial coverage for laboratory tests and the fact that these are
ordered by physicians blunts the influence of this factor o n
patient compliance, but not on relative total cost.
If the use of a particular agent results in improved seizure control or removal of incapatitating side effects and
enables the patient to return to work or school, then the
cost is fully justified and problems with compliance are
more easily managed. If, however, ecpivalent benefits can
be obtained for a fraction of the cost, then there is little
justification for employing expensive new drugs. Unfortunately, many texts refer to the “drug of choice” as though
available research had determined what this is. In fact, very
little controlled data are available showing specific advantages of one agent over another for most types of seizures.
Choosing an anticonvulsant is a complex decision involving
many variables, and cost must be included as an important
component in this process.
Department of Nturology
Harbor-UCLA Medical Center
1000 W Carson St
Torrance, C A 90509
Absence of REM
SleeD in Patients
withLSpinocerebellar
Degeneration
a n d Slow Saccades
J. Masdeu, MD, S. Chokroverty, MD,
and P. Gorelick, MD
Osorio and Daroff [ 11reported absent rapid eye movement
(REM) sleep in two patients with spinocerebellar degeneration and slow saccadic eye movenients. Prompted by
their finding, we studied sleep in a 22-year-old man with a
similar clinical presentation. He had been symptomatic for
six years. Maximal velocity of his horizontal saccades was
40 degrees per second (Fig 1); vertical saccades were normal. Total sleep time recorded was 147 minutes, 14% of
Yearly Cost of Various Anticonvulsants
Drug
Cost of
Drug
Depakene (8 X 250 mg) $467
Dilantin ( 4 x 100 mg)
58
Mysoline (3 x 250 mg)
66
Phenobarbital”
6
( 3 x 60 mg)
Tegretol (5 x 200 mg)
248
Zarontin (4 X 250 ma)
203
PATIENT
HORIZONTAL
SACCADES
Cost of
Laboratory
Tests
Total
$420
30
60
30
$887
88
126
36
730b
120
“Generic price.
bIncludes $50 for ophthalmological consultation.
97 8
323
PATIENT
VERTICAL
SACCADES
HORIZONTAL
SACCADES
uuuuu~-
I SEC
Fig 1 . Electrooculogram shows normal vertical saccades but delayed horizontal saccades.
Letters
95
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