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EW FEATURE 52 by Michelle Dalton EyeWorld Contributing Writer Combined procedures for glaucoma November 2014 U.S. clinics are "inundated" with calls from insurance compa- nies, noting prescription X is "too expensive, can we substitute some- thing else?" Dr. Samuelson said, adding, "You have to hire several full-time equivalents just to handle the calls." Often, someone from the clinic needs to be vigilant about contacting a pharmacy to ensure a name brand is dispensed. "Industry is working hard to ensure name brand medications are not significantly more expensive than the generic," he said. "Quite often now with certain programs that are available, we're able to get a patient the branded product for a lower cost than the generic." However, because some physi- cians do not believe that a "certain class of drugs has a meaningful difference between a generic and a branded product, I think there are a large number of physicians who will just write the script for a generic, which may explain the responses to the question," Dr. Samuelson said. However, with the recent, often dramatic, increase in pricing of ge- neric medications, the cost savings has diminished, opening the door for those branded products that are priced competitively. EW Editors' note: Drs. Ahmed and Samuelson have no financial interests related to their comments. Contact information Ahmed: ike.ahmed@utoronto.ca Samuelson: twsamuelson@mneye.com The responses may not accurately represent the "real world," however, said Thomas W. Samuelson, MD, attending surgeon and a co-founder of Minnesota Eye Consultants, Minneapolis. For instance, in Europe, a number of countries have specialized centers for various surgical procedures, and in other countries, treatment leans toward medical management rather than surgery, he said. "In the U.S. cataract surgeons treat a lot of glaucoma," Dr. Samuelson said, adding the percent of his patients who would qualify for MIGS is "probably even higher because the majority of my cataract patients have some element of glaucoma." Dr. Ahmed said there are still questions about the role of MIGS, and that may have skewed the responses a bit. Also, a significant number of general ophthalmologists would refer patients with either glaucoma or cataract to other physicians and would therefore not have a good grasp on the number who would qualify for MIGS. "MIGS is going to bring back the cataract or glaucoma patient to practices that may have otherwise referred them out," Dr. Ahmed said. Dr. Samuelson does not perform "combined procedures in patients without some evidence of optic nerve or nerve fiber layer loss. I don't tend to do combined cataract and glaucoma procedures in patients with purely ocular hypertension and no evidence of structural change." He attributed the fairly large number of respondents who believed more than 16% of their patients qualified for MIGS as potentially including ocular hypertensives as well. Name brand versus generic Some generic medications may be biosimilar to their name brand counterparts, but may not be formu- lated similarly (the former only need to include the active ingredient; other components such as vehicle can differ from the name brand). Almost half of the 2014 ASCRS Clinical Survey respondents be- lieve patients are switched from a physician-authorized name brand to a generic version by the pharma- cy (Figure 2). The percentages are slightly higher for U.S.-based physi- cians, which was not surprising, Dr. Ahmed said. In Canada, if Dr. Ahmed writes a script for a name brand pharma- ceutical, it will automatically be substituted for a generic if one is available. Since all ophthalmologists in Canada are aware of the substitution policies, when a generic is available, they write the prescription for the generic to avoid patient confusion. MIGS, generic glaucoma medications, and the impact on patient care Figure 1. The 2014 ASCRS Clinical Survey asked: What percentage of your cataract patients would you estimate are candidates for a MIGS device? Figure 2. The 2014 ASCRS Clinical Survey asked: What percentage of the time do you believe that your brand name glaucoma prescriptions are actually being substituted with generic pharmaceuticals by pharmacies? Source: ASCRS Experts weigh in on how MIGS may affect cataract patient care and the impact of pharmacies substituting generics for name brand drugs A surprising number of cataract patients have concurrent glaucoma, yet ophthalmologists lack confidence for long-term management of patients with IOP-lowering drugs because of compliance issues. With the upsurge in surgeons using microinvasive glaucoma surgery (MIGS), some cataract patients are likely to be MIGS candidates as well. "Many of our cataract patients have glaucoma," said Iqbal "Ike" K. Ahmed, MD, assistant professor of ophthalmology, University of Toronto, Canada, and clinical assistant professor, University of Utah, Salt Lake City. "A good number of those are candidates for MIGS. In our specialized glaucoma practice, more than 50% of my patients [who are] going to have cataract surgery have glaucoma. " According to the 2014 ASCRS Clinical Survey, about 8.6% of all respondents' cataract patients are candidates for a MIGS device (Figure 1). Global Trends in Ophthalmology ™ Copyright © 2014 Global Trends in Ophthalmology and the American Society of Cataract & Refractive Surgery. All rights reserved.