Brilinta or Clopidogrel, Maximum Benefit or Social Responsibility?

Brilinta, at $6.50 per pill, twice a day, reduces cardiovascular events more than generic Plavix, which costs 50 cents per pill, once a day. But only a little – 20% relative or 2% absolute risk reduction. The event risk was 10% with the more expensive drug and 12% with the one that costs 82% less.

Put differently, if 100 patients were treated with Brilinta for a year, at a cost of $4,680 for each patient, 10 patients would still have an event. With clopidogrel, 100 patients, each one at a cost of $180, 12 events would occur. That means two fewer events would happen per 100 patients on Brilinta at an extra cost of $450,000, or $225,000 per avoided cardiovascular emergency (Number Needed to Treat, NNT=50).

This is described in a New York Times article as a profound ethical dilemma in medicine today:

“Some of us believed that a doctor’s job is to deliver the best possible care, period. Others argued that doctors should aim to find some balance between medical benefit, financial cost and social responsibility. It’s the kind of question that we aren’t really trained to solve. Are costs something that an individual doctor should do something about? What is a doctor supposed to do?”

As a Swedish born and trained physician, even though I now work in the United States, I guess I would claim that I was trained to solve this kind of question. Therein lies the fundamental dilemma of American medicine.

The American ethic of wanting to do absolutely everything possible for each patient has its roots in a different era from the one we live in now. It is a relic of a time when diagnostic tests, surgical interventions or medicines for everyday diseases didn’t cost multiples of average people’s annual incomes. It also came about in he era before the Government (Medicare and Medicaid) or risk pools of ordinary people (insurance companies, in stewardship of employers’ and wage earners’ premiums) became the payers of health care expenses. Back then, patients paid for their own health care, or it was offered as more or less charity care.

Americans don’t like to use the term Socialized Medicine, but that is what it works like when someone else pays for our care. We may use different words, like Socially Responsible Medicine. But “social” is part of it.

If I had just survived a heart attack and had a choice between clopidogrel and Brilinta, would my choice be different if I had to pay an extra $4,500 per year myself than if I could have someone else pay for it?

Would the latter choice possibly deprive other people of medicines, surgeries or vaccines they needed because of the vast number of people making the same choice at their fellow citizens’ expense?

Would my choice indirectly be someone else’s death sentence? All for a jump from an 88% chance of me being okay to a 90% chance? I could get the more expensive drug and make bad dietary choices, or forget a dose here and there and the nuance in efficacy between the two drugs might be moot – but certainly not the cost differential.

The operative word here, in English, is stewardship. I can’t even remember what it is in Swedish: Spending resources wisely, especially when those resources belong to all of us.

3 Responses to “Brilinta or Clopidogrel, Maximum Benefit or Social Responsibility?”

  1. 1 csthelen April 7, 2018 at 10:43 pm

    Thanks for the succinct and helpful essay. In a related musing, what to do about the fact that the right hand does not know what the left hand is doing…How can it be cost effective to have people staff an anticoagulation clinic for a patient to succeed in using warfarin, when they could instead be taking a medication which does not need frequent monitoring?? Save on drugs, pay on professional services??

  2. 3 Trevin Cardon (@RefinedMedicine) April 23, 2018 at 4:39 pm

    Reminds me of Milton Friedman’s “4 ways to spend money.” When we spend other’s money on ourselves we only worry about the quality–give me the best. It isn’t until we have to spend our money on ourselves that we look to find the best deal–the best outcome at the best price. Would be interesting to see how medical decisions change if this were to be the case. Regardless, wish the discussion of these types of things would be part of that decision making process, with the patient and their values/wishes at the center. Thanks!

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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