Cost Appropriate Treatment with Oral Vancomycin for C. difficile Infection

Oral vancomycin capsules are still “inexplicably expensive” but yet not universally covered by insurers, despite its rising importance in the treatment of Clostridium difficile (C. difficile) infection, according to a new report.

Led by Stuart Johnson (pictured), MD, professor of infectious disease, researchers from Loyola University Chicago Stritch School of Medicine reviewed the current trends in C. difficile treatment with vancomycin in order to shed light on the potential negative effects of cost-related medication non-adherence to vancomycin therapy patients. The researchers also wanted to examine the challenges that clinicians face when they prescribe this C. difficile therapy.

First, the study authors presented a clinical vignette, where a 56-year-old woman was hospitalized for C. difficile infection. She had been treated for 2 previous episodes with metronidazole, but this time, received oral vancomycin in the hospital. She was discharged with a prescription for vancomycin capsules and was told that they were covered by her insurance plan. However, the cost exceeded $1,000 when she reached the pharmacy. While she waited for authorization from insurance, she had to be re-hospitalized because she had not been treated for her C. difficile infection for 3 days.

The study authors said, because of studies like this, more consideration in the selection of appropriate C. difficile infection therapy is required.

Estimates put the per dose cost of oral vancomycin at $5 to $33, but the researchers wrote that the Wholesale Acquisition Cost said the 125mg capsule rates range from $12.50 per capsule (of the newest generic company) to $25 per capsule (for the generic manufacturers). The cost to patients can be more though, depending on contracts, discounts for nonprofit organizations, competitions, supply chain disruptions, and overhead costs. The 56-year-old woman’s experience of $1,000 prescription is not uncommon, they explained, but in other countries, such as Canada, prescriptions can be about $200 for a 10-day supply of 125mg capsules.

The study authors added that pharmacies often compound an oral solution from intravenous vancomycin or compounding kits for a patient who needs oral vancomycin as a cost-containment measure. While this is less expensive than a prescription for vancomycin capsules, it is debatable how appropriate this is for patients.

Even standardizations across geographic areas make oral vancomycin insurance policies incompatible, the researchers found. For example, in Illinois, Medicaid programs say generic vancomycin is a formulary agent, but Medicare Part D classifies vancomycin in a specialty tier that oftentimes requires a prior authorization for payment.

This problem is unique to vancomycin, the study authors concluded, partly because the consistently high cost is not discussed on the news. In turn, prescribers who do not specialize in these treatments might not be aware of the financial implications to patients. Payment tools for patients do not exist for generic medications such as vancomycin, either. And finally, they wrote, vancomycin is time sensitive — as opposed to other expensive pharmacotherapy for chronic disease – where a delay in dispensing can lead to poor outcomes, such as rehospitalization.

“Until insurance coverage of oral vancomycin products is expanded, clinicians are urged to be proactive in determining the financial impact to patients and in submitting authorizations or switching to lower-cost alternatives before patients leave the point of care,” the researchers wrote. “Given the increasing role of vancomycin in the management of C. difficile infection, efforts should be made to lower the costs and improve access to this antibiotic.”

The study, titled “Economic Barriers in the Treatment of Clostridium difficile Infection With Oral Vancomycin,” was published online in the journal Open Forum Infection Diseases.

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