Formulary ReviewSM ANTIFUNGAL MEDICATIONS August 2012 Confidential Executive Summary Issues • Are there sufficient antifungal options on the formulary for treatment of common superficial as well as less frequent, severe systemic fungal infections? • Are there specific fungal infections where generic options are insufficient, such that branded products should be added to formulary? • Is there evidence that any brand name product provides additional benefit or value relative to other available options? Conclusion (Product Value) • Generic products are sufficient to address the majority of superficial fungal infections (external, mucocutaneous, vaginal). The one exception is fungal eye infections, as natamycin (Natacyn) is the only currently available ophthalmic. • Branded products, including lipid-based amphotericins, echinocandins and extended spectrum azoles, need to be on the formulary as generics are inadequate therapy for certain systemic infections, such as aspergillosis, histoplasmosis, fusariosis, zygomycosis (mucormycosis) and some CNS fungal infections. • There is no reliable evidence demonstrating superiority of one brand antifungal product over another. However, because of variability of disease (severity, specific organism, immune status, infection site, antifungal susceptibility, etc.), several choices are needed for specific fungal infections and their use supported by high quality guidelines. (See “Formulary Recommendations”) Background The following classes of systemic antifungals have branded products that may provide additional value in treating severe infections, based on antimicrobial activity, availability of generic treatment options, current standards of practice (guidelines), comparative safety, and relative value to other treatment options: • Lipid-based amphotericins: liposomal (AmBisome®), lipid complex (Abelcet®), colloidal dispersion (Amphotec®). • Extended-spectrum azoles: voriconazole (Vfend® IV and oral suspension), posaconazole (Noxafil®). • Echinocandins: anidulafungin (Eraxis®), caspofungin (Cancidas®), micafungin (Mycamine®). Page 1 of 10 © 2012 RegenceRx. All rights reserved. Formulary Considerations for brand name antifungal products Practical Considerations Consideration Efficacy Description - Based upon a large body of literature and years of clinical experience, there is high certainty that antifungals are effective for treatment of fungal infections, including many generics. - Liposomal amphotericin (L-AMB; AmBisome) is superior to other amphotericins for treating CNS fungal infections and other complicated infections, however the evidence is limited to a few randomized controlled trials, as well as pharmacokinetic data. - Branded echinocandins and extended-spectrum azoles (posaconazole, voriconazole) are superior to generic options for certain systemic infections, based on limited randomized controlled trial evidence, along with antifungal activity in vitro and resistance patterns. - Posaconazole (Noxafil) may be the only effective oral option for treatment of zygomycosis, based on antimicrobial susceptibility. - Many generic options are available within most of the therapeutic areas where antifungals are Other used, including newly-approved generic voriconazole tablets. Treatment - Several branded systemic products are preferred primary therapy for life-threatening infections, Options based on in vitro sensitivity and in vivo efficacy. - Natamycin (Natacyn®) is the only currently available ophthalmic antifungal. - All antifungals have an established track record of safety of more than five years. - Hepatotoxicity, nephrotoxicity and drug interactions are significant safety concerns associated Safety with antifungal agents. Differences in adverse effects are significant between medication classes. Adverse effects and drug interactions may guide treatment selection. - Brand name antifungal products are substantially more costly than generically available Cost products. (Systemics: > $1000 vs. <$100; Topicals >$100 vs. <$20). - L-AMB (AmBisome) is more costly than other lipid-based amphotericins ($5000 vs. $20,000). - Common fungal infections, such as onychomycosis, may not require treatment. - Though less common, systemic fungal infections can be life-threatening (i.e. aspergillosis, Disease fusariosis, histoplasmosis, and zygomycosis). Characteristics - Prophylactic antifungal therapy may prevent life-threatening infections in seriously ill, immunocompromised patients. - Treatment guidelines recommend use of generics, for the majority of fungal infections.[1-13] - The Infectious Diseases Society of America (IDSA) publishes a series of high quality guidelines that are recognized as the current standard of care for the treatment of most systemic fungal infections. [7-13] Standard of - Branded lipid-based amphotericins, echinocandins, voriconazole IV (Vfend) and posaconazole Care (Noxafil) are IDSA-recommended as preferred therapies for severe infections. - Though guidelines recommend specific echinocandins based on their different antifungal activity, experts queried for this review consider echinocandins clinically interchangeable for most situations. Impact on No branded antifungal reduces or eliminates significant barriers to care. Intravenous products Clinical are used primarily in the inpatient setting, then changed to oral azoles when possible, for Burden outpatient therapy. Commercial Formulary Decision Azoles (systemic) Add posaconazole oral suspension (Noxafil) as preferred/formulary Ophthalmics Add natamycin (Natacyn) as preferred/formulary Rationale (See Appendix D, “Rule 6”) Fills unmet need. IDSA-preferred oral therapy for zygomycosis, based on antifungal activity. Rationale (See Appendix D, “Rule 8”) Fills unmet need. Only ophthalmic antifungal available. Medicare Part D Formulary Decision No changes to the Medicare Part D formulary are recommended at this time. Page 2 of 10 © 2012 RegenceRx. All rights reserved. I. Product Information and Cost A. Current antifungals – Systemic and Topical therapies Systemic therapies Drug Products FDA approvala Patent Expiration(s)b FDA approved indications Forms and Usual Dose/Duration Cost 3 to 5 mg/kg/day IV 240-400mg $8,10013,400d 3 to 4 mg/kg/day IV $5,4007,200d 3 to 6 mg/kg/day IV $13,20021,980d Potential Off-label Uses e Amphotericins Generic Products: amphotericin B deoxycholate injection (AMB-D) [Cost: $564]d Branded Products: amphotericin B lipid complex injection (ABLC; Abelcet®)[14] [sigma-tau Pharmaceuticals] amphotericin B cholesteryl sulfate complex injection (ABCD; Amphotec®)[15] 11/1995 6/2019 Invasive infections in patients who are resistant to or intolerant of amphotericin B deoxycholate including aspergillosis, candidiasis, zygomycosis, cryptococcosis, and fusariosis Aspergillosis (with renal impairment or amphotericin B deoxycholateresistant) 11/1996 Expired 8/1997 10/2016 - Febrile neutropenia - Cryptococcal meningitis - Aspergillus, Candida infections resistant to ampho B deoxycholate - Pulmonary aspergillosis - Visceral leishmaniasis Blastomycosis, coccidioidomycosis, histoplasmosis, sporotrichosis, leishmaniasis, systemic mycosis Candidiasis; leishmaniasis; mycosis (a.k.a. amphotericin B colloidal dispersion, ABCD) [Three Rivers] amphotericin B liposome injection (L-AMB, AmBisome®)[16] [Astellas] Variety of candidal infections; cryptococcosis; blastomycosis; coccidioidomycosis; histoplasmosis; mycosis; sporotrichosis a Date applies to approval date for the original brand name medication where there are now generics available. Based on patents listed in Orange Book as of April 12, 2012. c Cost listed in RegenceRx PriceGuide of April 12, 2012 for one course of therapy. Typical course of therapy is 14 days. d Based on AWP as listed in MediSpan as of April 12, 2012 for one course of therapy, assuming an 80 kg patient and a 14-day course of therapy or an approximate one prescription fill (for topicals, ophthalmics). e As listed in © 1974 - 2012 Thomson MICROMEDEX database or as referenced. b Page 3 of 10 © 2012 RegenceRx. All rights reserved. (Systemic therapies continued) Patent Drug FDA Expira Products approval ation(s)b FDA approved indications Forms and Usual Dose/Duration Cost Potential Off-label Uses e Azoles Generic Products: fluconazole injection, oral tablets/suspension, itraconazole oral capsules/suspension, ketoconazole oral [Cost: $676 IV; $5-351oral d] Branded Products: posaconazole oral suspension (Noxafil®)[17] [Merck] voriconazole oral tablet (generic) 9/15/06 5/24/02 7/2019 - Prophylaxis of aspergillus and candida infections - Oropharyngeal candidiasis (OPC) - Fluconazole-refractory OPC (rOPC) Prophylaxis: 200 mg PO TID Expired - Invasive aspergillosis - Mycosis, serious infections. - Candidemia and disseminated candidiasis - Serious infections caused by Scedosporium and Fusarium spp - Esophageal candidiasis 6 mg/kg IV every 12 hr for 2 doses, followed by 3-4 mg/kg IV every 12 hr may switch to oral dosing as tolerated (anticipated date of IV generic unknown) oral suspension, injection (Vfend®)[18] [Pfizer] $2,445c OPC: 100 mg PO BID x 3 days, then 100 mg PO once daily for up to 28 days Aspergillus infections, esophageal candidiasis, Fusarium infection; mycosis r-OPC: 400 mg PO BID Esophageal candidiasis: 200 mg PO q12 hrs $2,500 (generic tablet)c $2,9005,800 (Vfend tabs)d Allergic bronchopulmonary aspergillosis; aspergillosis prophylaxis; blastomycosis; variety of candida infections; febrile neutropenia; mycosis. $6,800 (IV)d Echinocandins Generic Products: no generics expected prior to 2017. Branded Products: anidulafungin injection (Eraxis®)[19] [Pfizer] 2/17/06 4/2021 - Candidemia - Disseminated candidiasis – intraabdominal/peritonitis - Esophageal candidiasis Candidemia: 200 mg IV load, then 100 mg IV daily Esophageal candidiasis: 100 mg IV load, then 50 mg IV daily $1,6203,240d Treatment and prophylaxis of a variety of candidal infections. Empirical antifungal therapy. a Date applies to approval date for the original brand name medication where there are now generics available. Based on patents listed in Orange Book as of April 12, 2012. c Cost listed in RegenceRx PriceGuide of April 12, 2012 for one course of therapy. Typical course of therapy is 14 days. d Based on AWP as listed in MediSpan as of April 12, 2012 for one course of therapy, assuming an 80 kg patient and a 14-day course of therapy or an approximate one prescription fill (for topicals, ophthalmics). e As listed in © 1974 - 2012 Thomson MICROMEDEX database or as referenced. b Page 4 of 10 © 2012 RegenceRx. All rights reserved. (Systemic therapies continued) Drug Products FDA approvala Patent Expiration(s)b FDA approved indications 1/26/01 9/2017 - 3/16/05 1/2021 - Candidemia - Esophageal candidiasis - Candida prophylaxis in stem cell transplant patients Forms and Usual Dose/Duration Cost Potential Off-label Uses e Echinocandins caspofungin injection (Cancidas®)[20] [Merck] micafungin injection (Mycamine®)[21] [Astellas] Invasive aspergillosis Febrile neutropenia Esophageal candidiasis Candidemia and other Candida infections. Initial dose: 70 mg IV on day 1; subsequent dosing: 50 mg/day IV; if clinical response inadequate, may increase up to 70 mg/day if tolerated Candidemia: 100 mg IV daily $5,670d Treatment and prophylaxis of a variety of candidal, aspergillus and other invasive fungal infection. $3,136d Esophageal: 150 mg IV daily Prophylaxis: 50 mg IV daily Miscellaneous Orals (systemic) Generic Products: flucytosine [$3,800-11,400/14 days d], griseofulvin microsize suspension [$77 c], terbinafine [$8c] Branded Products: griseofulvin ultramicrosize tablet (Gris-PEG®)[22] [Pedinol] griseofulvin microsize tablet (Grifulvin V®)[23] 4/16/75 Expired - Onychomycosis - Tinea barbae, capitis, corporis, cruris, pedis 375 to 750 mg orally per day (single or divided dose) 8/22/62 Expired - Onychomycosis - Tinea barbae, capitis, corporis, cruris, pedis 500 to 1000 mg orally per day (single or divided dose) $141c Lichen planus; pityriasis versicolor; systemic sclerosis $156c [Valeant] Topical therapies Oro-mucosal Topicals: buccal tablet, oral lozenge, oral suspension, oral troche Generic Products: clotrimazole troche/lozenge [$46 c], nystatin oral powder/suspension/tablet[$36-51c] Branded Products: none a Date applies to approval date for the original brand name medication where there are now generics available. Based on patents listed in Orange Book as of April 12, 2012. c Cost listed in RegenceRx PriceGuide of April 12, 2012 for one course of therapy. Typical course of therapy is 14 days. d Based on AWP as listed in MediSpan as of April 12, 2012 for one course of therapy, assuming an 80 kg patient and a 14-day course of therapy or an approximate one prescription fill (for topicals, ophthalmics). e As listed in © 1974 - 2012 Thomson MICROMEDEX database or as referenced. b Page 5 of 10 © 2012 RegenceRx. All rights reserved. (Topical therapies continued) FDA Patent approvala Expiration(s)b Drug Products FDA approved indications Forms and Usual Dose/Duration Cost Potential Off-label Uses e Ophthalmic Topicals Generic Products: none Branded Products: natamycin ophthalmic suspension (Natacyn®)[24] 1/1/82 Expired [Alcon] Fungal blepharitis, conjunctivitis and keratitis 1 drop in affected eye(s) 4 to 8 times/day $228d none External Topicals Generic Products: Cream: clotrimazole, econazole, ketoconazole, miconazole, nystatin [$21-36 c]; OTC: terbinafine, tolnaftate [~ $10 d] Foam: ketoconazole [$162-300d] Gel: ciclopirox [$92 c]; OTC: terbinafine [~ $10d] Nail lacquer solution: ciclopirox [$13c] Ointment: miconazole, nystatin ointment [$10-24c] Powder: miconazole spray/powder, nystatin powder [$10-33c]; OTC: tolnaftate powder/spray [~ $10 d] Shampoo: ciclopirox [$123c], ketoconazole 2% [$17 c] Solution: clotrimazole, miconazole [$10-13 c]; OTC: terbinafine, tolnaftate [~ $10 d] Branded Products: butenafine 1% topical cream (Mentax®, OTC Lotrimin Ultra)[25] [Bertek Pharmaceuticals] 10/1996 Expired Topical treatment of tinea – pedis, cruris, corporis, and versicolor Apply once or twice daily to affected area $125c Onychomycosis; seborrheic dermatitis a Date applies to approval date for the original brand name medication where there are now generics available. Based on patents listed in Orange Book as of April 12, 2012. c Cost listed in RegenceRx PriceGuide of April 12, 2012 for one course of therapy. Typical course of therapy is 14 days. d Based on AWP as listed in MediSpan as of April 12, 2012 for one course of therapy, assuming an 80 kg patient and a 14-day course of therapy or an approximate one prescription fill (for topicals, ophthalmics). e As listed in © 1974 - 2012 Thomson MICROMEDEX database or as referenced. b Page 6 of 10 © 2012 RegenceRx. All rights reserved. (Topical therapies continued) 7/2006 Patent Expiration(s) b 12/2018 [Aqua] naftifine 1-2% topical cream, gel (Naftin®)[27] 2/1988 Expired Tinea superficial corporis, cruris, pedis Apply topically to affected area once or twice daily $308c none [Merz] oxiconazole 1% topical cream, lotion (Oxistat®)[28] 12/1988 Expired Pityriasis versicolor; tinea – superficial, corporis, cruris, pedis Apply topically to affected area and surrounding areas 1-2 times daily for 2-4 weeks $153c none [Pharma Derm] sertaconazole 2% topical cream (Ertaczo®)[29] 12/2003 5/2014 Tinea pedis, interdigital Apply cream topically twice daily for 4 weeks $169c Tinea 2/1989 Expired Topical treatment of tinea – cruris, corporis, and versicolor Apply once or twice daily to affected area $106c Candidiasis of skin Drug Products ketoconazole 2% topical gel (Xolegel®)[26] [Bertek] sulconazole 1% topical cream, solution (Exelderm®)[30] FDA approvala FDA approved indications Potential Off-label Uses e Forms and Usual Dose/Duration Cost Seborrheic dermatitis Apply topically to affected area once daily for 2 weeks $376d Candidiasis of the skin; pityriasis versicolor; tinea [Ranbaxy] a Date applies to approval date for the original brand name medication where there are now generics available. Based on patents listed in Orange Book as of April 12, 2012. c Cost listed in RegenceRx PriceGuide of April 12, 2012 for one course of therapy. Typical course of therapy is 14 days. d Based on AWP as listed in MediSpan as of April 12, 2012 for one course of therapy, assuming an 80 kg patient and a 14-day course of therapy or an approximate one prescription fill (for topicals, ophthalmics). e As listed in © 1974 - 2012 Thomson MICROMEDEX database or as referenced. b Page 7 of 10 © 2012 RegenceRx. All rights reserved. (Topical therapies continued) Drug Products FDA approvala Patent Expiration(s) b FDA approved indications Forms and Usual Dose/Duration Cost Potential Off-label Uses e Vaginals Generic Products: Rx: miconazole vaginal suppository 200 mg [Cost: $10c], nystatin vaginal tablets [Cost: $74d], terconazole cream/suppository [Cost: $40d] OTC: clotrimazole vaginal cream/tablet, miconazole vaginal cream/suppository 100 mg, tioconazole vaginal ointment [Cost: ~$8-14d] Branded Products: none a Date applies to approval date for the original brand name medication where there are now generics available. Based on patents listed in Orange Book as of April 12, 2012. c Cost listed in RegenceRx PriceGuide of April 12, 2012 for one course of therapy. Typical course of therapy is 14 days. d Based on AWP as listed in MediSpan as of April 12, 2012 for one course of therapy, assuming an 80 kg patient and a 14-day course of therapy or an approximate one prescription fill (for topicals, ophthalmics). e As listed in © 1974 - 2012 Thomson MICROMEDEX database or as referenced. b B. Classification of topical products (by mechanism of action)[1,23] Imidazoles: clotrimazole, econazole, ketoconazole, miconazole, oxiconazole, sertaconazole, sulconazole, terconazole, tioconazole Allylamines: naftifine, terbinafine Benzylamine: butenafine Ciclopirox Polyene antibiotics: amphotericin, natamycin, nystatin Miscellaneous: benzoic acid preparations, tolnaftate C. Pipeline products Pipeline Medication isavuconazole (oral) Manufacturer Anticipated Potential Indication Launch Basilea 2014 Invasive fungal Pharmaceutica, infections and Ltd and esophageal candidiasis Astellas Pharma, Inc Comments Fast track designation April 2008; first trial results expected in 2013. Page 8 of 10 © 2012 RegenceRx. All rights reserved. IX. References 1. Drake, LA, Dinehart, SM, Farmer, ER. Guidelines of care for superficial mycotic infections of the skin: onychomycosis. Guidelines/Outcomes Committee. American Academy of Dermatology. J Am Acad Dermatol. 1996 Jan;34(1):116-21. PMID: 8543680 Drake, LA, Dinehart, SM, Farmer, ER. Guidelines of care for superficial mycotic infections of the skin: mucocutaneous candidiasis. Guidelines/Outcome Committee. American Academy of Dermatology. J Am Acad Dermatol. 1996 Jan;34(1):110-5. PMID: 8543679 Drake, LA, Dinehart, SM, Farmer, ER, et al. 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East Hanover, NJ: Novartis Pharmaceuticals Corporation; November 2011 Ancobon (flucytosine oral capsules) [package insert]. Costa Mesa, CA: Valeant Pharmacueticals International; August 2006 Meletiadis, J, Chanock, S, Walsh, TJ. Defining targets for investigating the pharmacogenomics of adverse drug reactions to antifungal agents. Pharmacogenomics. 2008 May;9(5):561-84. PMID: 18466103 Meletiadis, J, Chanock, S, Walsh, TJ. Human pharmacogenomic variations and their implications for antifungal efficacy. Clin Microbiol Rev. 2006 Oct;19(4):763-87. PMID: 17041143 PubMed Health Project. "Diseases and Conditions." National Library of Medicine, National Institutes of Health. [cited updated periodically]; Available from: http://www.ncbi.nlm.nih.gov/pubmedhealth/s/diseases_and_conditions/a/ Ascioglu, S, Rex, JH, de Pauw, B, et al. Defining opportunistic invasive fungal infections in immunocompromised patients with cancer and hematopoietic stem cell transplants: an international consensus. Clin Infect Dis. 2002 Jan 1;34(1):7-14. PMID: 11731939 The PubChem Project. National Center for Biotechnology Information. National Library of Medicine, National Institutes of Health. [cited updated periodically]; Available from: http://pubchem.ncbi.nlm.nih.gov/ Disclaimer: The information contained within this document best reflects the current state of medication information at the date of publication. Conclusions may be subject to change over time because of many factors, including but not limited to: emerging scientific evidence for safety and efficacy, evolving best-practices for critical appraisal of scientific evidence, market availability of medications, medication cost information, and evolving medical practice standards. Page 10 of 10 © 2012 RegenceRx. All rights reserved.