Eyeworld Daily News

EW SHOW DAILY 20 ASCRS Symposia Tuesday, April 21, 2015 Although there have been severe adverse reactions associated with generics, Dr. Vukich's practice switched to using only generics fol- lowing cataract surgery in 2011. "The switch to using generics was primarily driven by copay-relat- ed patient complaints," he said. "We had to have written justification for brand coverage for an increasing number of providers that increased the cost to the patient." This was a major factor in their decision, he said—calls from pharmacists asking if they could substitute a generic was the number one reason they were contacted after hours. Although research hasn't proven that generics are equivalent to name-brands drugs, Dr. Vukich said his practice will continue to use them in the future. EW Editors' note: The physicians have no financial interests related to their comments. by Lauren Lipuma EyeWorld Staff Writer brand-name versions. What they didn't do was show that the actual vehicle or other factors that affect the efficacy would be the same." In 2012, 84% of all prescriptions in the United States were generic, and many state pharmacies are required to dispense the generic version unless a doctor specifies otherwise, Dr. Vukich said. Patients view generics as a better value, but half of all doctors hold negative views about generic medications. The situation in ophthalmol- ogy is different than other areas of medicine because medications are administered topically as drops, Dr. Wittpenn said. "What makes drops different from pills is that we have no way to actually determine whether or not the drug formulation is accomplishing what it purports to do," he said. As a result, ophthal- mologists have become a minority of physicians prescribing brand- name drugs. rapidly. It has a broad spectrum but may not be effective against the most common cause of endophthal- mitis, coagulase-negative Staph- ylococcus. Both vancomycin and cefuroxime must be compounded by a pharmacy. Moxifloxacin directly inhibits DNA synthesis, so its effectiveness is concentration-dependent. It is a broad-spectrum fast killer that requires no compounding and provides good coverage for gram negatives, but it is expensive, Dr. Stiverson said. In addition to the variability between each antibiotic, physicians face a larger ethical dilemma when choosing a drug because of the issue of emerging resistance. "Our views on how important it is to keep vancomycin effective for everyone versus seeing one of our patients go blind are quite relevant," Dr. Stiverson said. "We have to weigh what matters most to us. Some of us do same-day bilateral surgery, so we must use an intracam- eral. Some of us may have to address MRSA in the community. "I use vancomycin in my practice, but if I were starting with intracamerals today, I would use moxifloxacin." The generics debate continues John A. Vukich, MD, Madison, Wis., and John R. Wittpenn Jr., MD, Port Jefferson, N.Y., shared their views on generic versus name-brand eye drops. The trend toward using generic drugs began with the Hatch-Wax- man Act of 1984, Dr. Vukich said. "You could say it opened up Pandora's box," he said. "It allowed companies to 'copycat' pharmaceuti- cals as long as they could prove the drugs were 'identical' to the S hould cataract surgeons use intracameral antibiot- ics? Are generic drops as safe as brand-name drops? Which intracameral is best? Experienced surgeons tackled these and other issues in Sunday afternoon's "Cataract Dilemmas and Controversies" symposium. When it comes to intracameral antibiotics, surgeons actually face 2 dilemmas—whether to adopt intra- cameral use and which agent is best. "This is quite a disruptive topic in industry and ophthalmology, and it's something a little out of the box because it breaks a lot of con- ventions that we're used to," said Robert J. Weinstock, MD, Largo, Fla. Dr. Weinstock said that he pre- fers to use intracameral antibiotics rather than topical because they are cheaper, save time, and eliminate the issue of compliance. "One of the biggest things that hurts us in cataract surgery is that we can't control whether the patient is getting the drops or not," he said. "This puts us back in control." Kent Stiverson, MD, Lakewood, Colo., debated the pros and cons of each of the available intracamer- als—vancomycin, cefuroxime, and moxifloxacin. Vancomycin kills Staphylococcus and Streptococcus, the main causes of infection, including methicillin-re- sistant Staphylococcus aureus (MRSA), but it only kills gram positives, so it has a narrower spectrum than other drugs. It persists in the eye for a long time at a good concentration even if the capsule breaks, but it is a slow killer because it inhibits cell wall synthesis. Cefuroxime also inhibits cell wall synthesis, so it is a slow killer, but its concentration also declines Cataract dilemmas dissected Attendees listen to experts debate the biggest dilemmas facing cataract surgeons today. "If I'm a Medicare participant, then I have to play by the rules," Dr. Serafano said. Another option for these types of patients would be to refer them to another ophthal- mologist who is not participating in Medicare and could do the proce- dure. Dr. Banja and Dr. Snyder then stressed the importance of not mak- ing assumptions on what a patient can or cannot afford. Dr. Banja said he tells healthcare providers that they should be careful about making assumptions about a patient's ability to pay. Dr. Snyder agreed and said he has had patients tell him that they could not afford certain premium treatments only to find out that they likely could have. People choose how they wish to allocate their funds and people also choose how they wish to present themselves at the office, he said. In the case example, a 92-year- old woman said she couldn't afford a premium IOL or the additional costs of the femtosecond laser, but the surgeon performing the surgery has a laser and believes that it would be advantageous in her case. Dr. Banja said that healthcare providers do not have an obligation to provide free care. EW Ethics continued from page 19

• Cover