If a medication label carries a warning message, it’s usually there for good reason. That’s how neurologist Robert Fekete, MD, views the FDA message on the non-interchangeability of injected medications called botulinum neurotoxins.
Neurologists like Dr. Fekete often use the injections to treat patients with cervical dystonia. The painful neurologic disorder causes involuntary neck twisting or jerking. There is no cure, but treatments like botulinum neurotoxins can reduce excess muscle activity, helping to keep the disruptive condition under control.
Four different botulinum neurotoxins are FDA approved to treat cervical dystonia. That does not, however, mean patients should be switched from one to another arbitrarily. In fact, the FDA has made clear that the medications are distinct. Most have different dosing, and there isn’t a metric for converting one to another.
But that hasn’t stopped insurers from switching stable patients to the treatment that offers the biggest financial benefit to them. The practice is called non-medical switching because it’s based not on medical factors but on saving the insurer money.
Non-medical switching for cervical dystonia patients concerns physicians.
“When insurers require health care providers to use a different neurotoxin than they are used to, the provider must reset their thinking and approach,” explained Dr. Fekete. “Each toxin has a unique dosing, side effects and efficacy profile.”
Changing between the medications isn’t a simple switch. Non-medical switching increases the risk of underdosing, overdosing and medical errors. Giving less than the intended dose can result in patients missing out on the intended benefit. Giving too much medication can lead to unintended side effects. For cervical dystonia patients, an excessive dose can lead to neck weakness, difficulty swallowing or choking.
Neurotoxins also vary in how effective they are for patients, and for how long. As a result, the insurer-preferred medication may be ineffective for a given patient, requiring him or her to undergo another treatment sooner than planned.
Beyond treatment risks and unintended physical consequences, non-medical switching impacts the physician-patient relationship.
“As a physician, I invest a lot of time in building good relationships with my patients,” said neurologist David Charles, MD, chairman of the Alliance for Patient Access. “Together, the patient and I decide on a treatment plan, and it is important that they have confidence in me and the neurotoxin we select.”
“Imagine the impact, then, if I have to go back to the patient and say, ‘Well, your insurance won’t let us use what we agreed upon.’ Being forced by the insurance company to change medications erodes the physician-patient relationship and the patient’s confidence that the alternate medication will work.”
Health care providers may vary on which botulinum neurotoxin they are most confident administering, but they align on at least one important aspect of treatment. When it comes to cervical dystonia, patients and health care providers – not insurance companies – should guide treatment choices.
