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• W4282932801 abstract "To the Editor: We thank Davis and Davis for their interest in our paper analyzing utilization, cost, and prescription trends of onychomycosis medications among Medicare patients.1Wang Y. Lipner S.R. Analysis of utilization, cost and, prescription trends of onychomycosis medications among Medicare patients.J Am Acad Dermatol. 2021; 86: 440-442Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar We chose to focus on United States Food and Drug Administration–approved antifungals for onychomycosis treatment in our research letter.1Wang Y. Lipner S.R. Analysis of utilization, cost and, prescription trends of onychomycosis medications among Medicare patients.J Am Acad Dermatol. 2021; 86: 440-442Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar We agree with the authors that oral fluconazole is an effective and safe off-label antifungal for onychomycosis treatment. Our senior author uses this drug in her practice routinely to treat cases of terbinafine failure and for patients with mixed infections of dermatophytes and Candida spp. In this letter, we present our analysis of oral fluconazole prescribing in the Medicare provider utilization and payment database, 2014-2019. We found that oral fluconazole claims steadily increased during the study period. The average annual growth rate was 8.7%, which was equivalent to the topical ciclopirox growth rate, and exceeded rates for all other onychomycosis therapies. Total fluconazole spending increased by 18% overall; however, the increase in claims outpaced the corresponding increase in the total spending due to a 52% overall decrease in cost per supply day ($0.88-$0.58) (Table I). Compared to the other oral onychomycosis antifungals, on average, fluconazole use was roughly equivalent to terbinafine use (1.11-fold greater) and 167-fold greater than itraconazole use. Oral fluconazole use was 30- and 194-fold greater than topical efinaconazole and tavaborole use, respectively, but 0.39-fold less than topical ciclopirox use.Table ITotal number of claims, drug supply days, and cost, as well as cost per supply day, for off-label oral fluconazole, 2014-2019YearTotal number of claimsTotal drug supply daysTotal cost, $Cost per supply day, $201430,182753,842661,593.960.88201532,223824,298683,118.460.83201635,245938,497701,014.340.75201738,5561,046,854705,716.700.67201842,8621,204,879746,064.990.62201947,5121,380,829807,576.820.58 Open table in a new tab Our data suggest that utilization of oral fluconazole is similar to oral terbinafine and topical ciclopirox usage and much greater than oral itraconazole and topical efinaconazole and tavaborole. Previous analyses of Medicare prescription claims showed that cost impacts dermatologic drug prescribing.2Falotico J.M. Lipner S.R. Balancing medication cost, safety, and efficacy among Medicare beneficiaries with dermatologic conditions.J Am Acad Dermatol. 2022; 87: e35-e36Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Cheaper medications within a given drug class are generally prescribed more often, although there are physician knowledge gaps regarding out-of-pocket drug costs. Our results support the trend that dermatologists are cost-conscious when managing conditions with multiple efficacious therapies available. Prescribing fluconazole for onychomycosis is advantageous because it is conveniently dosed once-weekly, has better absorption than other agents, and can be used safely in patients with comorbidities, including cardiac dysfunction.3Lipner S.R. Joseph W.S. Vlahovic T.C. et al.Therapeutic Recommendations for the Treatment of Toenail Onychomycosis in the US.J Drugs Dermatol JDD. 2021; 20: 1076-1084PubMed Google Scholar,4Lipner S.R. Scher R.K. Onychomycosis: treatment and prevention of recurrence.J Am Acad Dermatol. 2019; 80: 853-867Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar Therefore, cost, efficacy, safety, and dosing convenience may explain increased prescribing of fluconazole among dermatologists, despite lacking United States Food and Drug Administration approval for onychomycosis treatment. Since we could not associate diagnosis codes, some prescriptions were likely written for indications other than onychomycosis. We analyzed data for dermatologist prescribing only, limiting analysis of trends and cost for other prescribers, including podiatry and primary care physicians. There is no “one-size-fits-all” approach to onychomycosis management. It is essential for dermatologists to carefully consider medication safety and efficacy, drug interactions, disease severity, comorbidities, microbiology, and cost, prior to initiating treatment. Given the complexity of treating onychomycosis, dermatologists should not be hesitant to prescribe off-label therapies, such as oral fluconazole, for appropriate patients or when there are barriers to prescribing other therapeutic options, including insurance coverage, contraindications, and patient preference or compliance. Future analyses beyond the Medicare population are warranted for a complete understanding of utilization, cost, and prescribing patterns for onychomycosis treatment. Dr Lipner has served as a consultant for Ortho Dermatologics, Verrica, Hoth Therapeutics, BelleTorus Corporation, and Hexima. Ms. Falotico, Dr Yang, and Dr Rahman have no conflicts of interest. Response to Wang et al's “Analysis of utilization, cost and, prescription trends of onychomycosis medications among Medicare patients”Journal of the American Academy of DermatologyVol. 88Issue 5PreviewTo the Editor: On analyzing the prescribing trends of US dermatologists and associated costs of treating onychomycosis among Medicare patients, Wang and Lipner chose to focus on therapies approved by the US Food and Drug Administration (FDA). Specifically, terbinafine and itraconazole were the only oral therapies included.1 It is understandable that griseofulvin, despite its FDA approval for onychomycosis, would be omitted; griseofulvin has lower cure rates, higher recurrence rates, and higher risk of adverse events than the other oral agents, and it is rarely used. Full-Text PDF" @default.
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• W4282932801 title "Increased fluconazole usage by dermatologists in the Medicare provider utilization and payment database, 2014-2019" @default.
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