Financial Burden of Drugs Prescribed for Cirrhosis-Associated Symptoms

Introduction: Symptomatic burden of decompensated cirrhosis has a progressive trajectory as the condition advances. As health declines, the financial burden from symptomatic medications can be profound. Well-rounded gastroenterologists and other clinicians should know the costs of these medications and the alternatives that may be available to maximize possible savings for patients living with a high financial toxicity condition. We present the costs of commonly used drugs for symptom management in a patient with decompensated cirrhosis in 2 counties in the state of Kentucky. Methods: We reviewed the AASLD practice guidelines and compiled a composite list of 4 of the most common decompensated cirrhosis symptoms and medications used for relief of each symptom. These include hepatic encephalopathy (HE), ascites, muscle cramps, and pruritus. Due to its complex nature and various management options, we excluded pain from this study. The GoodRx website/smartphone application were used to identify both the average retail price (ARP) and the lowest discounted price (LDP, i.e. the cheapest out of pocket option) for anticipated 1 month supply of medications at competing pharmacies in Fayette county (urban) and Harlan county (rural) in Kentucky. Results: For management of HE, lactulose carried an ARP of $48.16 in the urban county as opposed to $72.5 in the rural county. However, when LDP is taken into consideration, the costs were similar (i.e., $17.5 in urban county and $16.49 in rural). Rifaximin carried the most out-of-pocket expense with ARP of $3713 vs $3810 in the urban and rural county, respectively. For ascites, the cheapest option was furosemide in both counties at $4 due to the availability of Walmart and its $4 list of medications. The ARP for ascites management ranged from $6.94 for furosemide to $122 for eplerenone in Fayette County as opposed to $4.02 for furosemide to $136 for eplerenone in Harlan County. For pruritus, the ARP was $89.95 in Fayette County and $102 in Harlan County. LDP was again relatively similar in the 2 counties: $31.89 vs $33.97. Conclusion: Symptom management in decompensated cirrhosis can carry a high average retail price out-of-pocket monthly cost for the patient in both urban and rural areas. Awareness of the GoodRx discount tool for the uninsured or underinsured patient and their clinicians can help guide selection of cost-effective medication for management (Table 1). Table 1. - Out of pocket costs in 2 counites Symptom Drug name Dosage/quantity (1 month) Cost Fayette county Harlan county Hepatic encephalopathy (HE) Lactulose 10 g/ 15 ml - BID Average retail price (Range) $48.16 ($37.49-66) $72.5 ($66-79) 900 mL bottle Lowest discounted price $17.50 $16.49 Rifaximin 550 mg BID Average retail price $3713 ($3046-3792) $3810 ($3629-3991) 60 tablets Lowest discounted price $3,046 $3,060 Polyethylene Glycol (PEG) 17 g daily Average retail price $21.43 ($12.89-23.31) $20.5 ($18-23) 1 bottle Lowest discounted price $12.89 $13.48 HE/muscle cramps Zinc 50 mg daily Average retail price $6.43 ($5.99-6.88) $6.43 ($5.99-6.88) Varies per pharmacy Lowest discounted price NA NA Ascites Furosemide 40 mg daily Average retail price $6.94 ($4-16) $4.02 ($4-4.05) 30 tablets Lowest discounted price $4.00 $4.00 Torsemide 20 mg daily Average retail price $22.5 ($9-33) $22.5 ($9-36) 30 tablets Lowest discounted price $6.73 $6.73 Bumetanide 1 mg daily Average retail price $29.5 ($14.55-41) $64 ($33-95) 30 tablets Lowest discounted price $11.50 $14.09 Spironolactone 100 mg daily Average retail price $31.87 ($15-51) $40 ($15-54) 30 tablets Lowest discounted price $10.29 $7.85 Eplerenone 50 mg daily Average retail price $122 ($115-131) $136 ($131-141) 30 tablets Lowest discounted price $27.40 $29.30 Pruritus Cholestyramine 4 g daily - uptitration to QID Average retail price $89.95 ($73.86-121) $102 ($75-129) 1 can (378 g) Lowest discounted price $31.89 $33.97 Colestipol 2 g daily Average retail price $68.3 ($57-79) $72.5 ($57-88) 60 tablets Lowest discounted price $23.94 $23.94 Muscle cramps Baclofen 5-10 mg TID Average retail price $51.94 ($41-62) $159 ($54-244) 90 tablets Lowest discounted price $12.90 $12.90 Methocarbamol 500 mg TID (varies) Average retail price $40.69 ($27-48) $53 ($48-58) 90 tablets Lowest discounted price $12.09 $12.22