Compounded drugs often preferred for cost, availability

• Some doctors will continue use of compounded drugs
• The drugs are at the center of the meningitis outbreak
• Lower cost and availability are advantages over brand-name versions

NASHVILLE, Tenn. -- Some pain management doctors say they plan to continue using compounded drugs despite the national fungal meningitis outbreak linked to contaminated batches of a popular steroid injection.

The lower cost and greater availability of the drug from compounding pharmacies are among the biggest advantages to using the medicine over the brand-name versions, the doctors said.

Dr. Tim Smyth, an anesthesiologist in Johnson City, said his practice started buying a compounded version of methylprednisolone acetate, a steroid used for decades to treat back pain, a few years ago after his office had a hard time finding a brand-name version of it.

"Mostly initially because of the supply," Smyth said. "And after that we just stuck with them."

Smyth's practice did not purchase from New England Compounding Center, a compounding pharmacy in Massachusetts that shipped 17,676 vials of potentially tainted methylprednisolone acetate to 23 states. So far, at least 169 people have been stricken by fungal meningitis, which has resulted in 14 deaths, the U.S. Centers for Disease Control and Prevention said Thursday.

In the wake of the outbreak, lawmakers have called for greater scrutiny and regulation of compounding pharmacies, which in recent years have operated largely outside the supervision of the U.S. Food and Drug Administration.

Traditionally, compounding was used by pharmacists to create a custom medication specifically for one patient.

After Smyth learned that a Massachusetts compounding pharmacy had sold the tainted batches of the steroid, the doctor reached out to his drug supplier in Arkansas to be reassured.

"They don't send out any lots until it's been sent to a third-party testing center," he said. "They have several safeguards in place."

In addition to the reliable supply of the drug, the lower cost also has been a key factor in his firm using the compounded version, Smyth said.

"If you're going to lose money every time you do a procedure, you're going to stop doing it," he said.

Depo-Medrol is a brand-name version of the steroid, produced by Pfizer. The FDA initially approved Depo-Medrol in 1959, but its patent has since expired. For years, generic versions of the drug were available.

But the injectable steroid has become more scarce in recent years as supplies of generic versions shrank. Teva Pharmaceuticals stopped making it when the company voluntarily shut down its Irvine, Calif., plant in 2010, spokeswoman Denise Bradley said. The closure followed a bacterial outbreak linked to contaminated propofol manufactured at the plant.

Another generic manufacturer, Sandoz Inc., said in February 2011 that it would be unable to supply its version for a "period of time," according to Cardinal Health, a health care services company based in Dublin, Ohio.

Sandoz more recently said it doesn't expect to have any of its generic Depo-Medrol available until next year, according to the American Society of Health-System Pharmacists. Sandoz did not respond to email and telephone requests for comment.

Dr. Autry Parker, an anesthesiologist in Memphis whose firm switched to using a compounded version five or six years ago, said the cost of of the drug skyrocketed after supplies dropped.

For years, his practice was able to buy the drug for about $3 for a multidose vial. Then prices jumped to about $40 for the same amount, he said.

"I was flabbergasted by how expensive it got," Parker said. "After that, the prices were so high, these other companies came into play. Most of us have been using them for the last five or six years because the cost has been far less."

Smyth's practice typically pays between $15 and $20 for a multidose vial of the compounded version of the drug, roughly half the going rate for a name brand.

The contaminated drug from a pharmacy compounder made both doctors ponder whether they should switch back to a brand-name version, they said.

"It crossed our mind, of course," Smyth said. "But then again you start to worry about supply and availability, and we don't want to risk that."

The situation made Parker pause, too, he said.

"I don't think companies get paid extra to take extra precaution," he said. "So we're all morally required to try to do the right thing."

But at this point he has no plans to switch back to the name-brand version, reassured that his supplier had safeguards in place to prevent contamination.

Despite the shortages and rising prices in recent years, some pain management doctors said they've continued to use the brand-name version.

"I never use compounding pharmacies for any injectable medication because they are not as well-regulated," said Dr. Anna-Louise Molette, a pain physician in Smyrna. Molette plans to continue using brand-name steroids, although that choice is becoming pricier.

"The price has gone up, but it has not gone up enough for me to use a compounding pharmacy," Molette said. "I'll just keep eating the cost, even though reimbursements have gone down and costs keep going up. It's a double whammy."

Dr. Alan Krauss, a pain management doctor in Germantown, has long used the brand-name version. Despite the shortages in recent years, he said his practice has always been able to get it.

His practice, which doesn't use multidose vials, has paid as little as $5.22 for a single dose of the brand-name version, or the equivalent of a little more than $20 for a multidose vial.