Key Considerations With The Costs And Use Of Dalbavancin And Oritavancin

In my blog last month (https://tinyurl.com/kknvjw9 ) I mentioned I would write a follow-up to discuss my opinions on the use of dalbavancin (Dalvance, Actavis) and oritavancin (Orbactiv, the Medicines Company) for lower extremity infections. I have not yet had the opportunity to try either so these are really “top line” thoughts taking into consideration what I know, have read or heard from others.

• These drugs are expensive and I wonder who will cover the cost. The two doses of dalbavancin reportedly cost somewhere in the neighborhood of $4,500 while the single dose of oritavancin is considerably less at around $2,600 for the required single dose. Given that hospital pharmacies are always worried about their budgets (they complained about the cost of linezolid when it was originally only about $1,500), can anyone convince them to stock these drugs? What about insurance companies when they can demand patients receive generic vancomycin for next to no cost at all?

• The companies argue that these drugs will keep patients out of the hospital, thus saving costs. That does make a lot of sense … on the surface. If you do not admit the patient, you do not run up costs for the actual stay and only the outpatient treatment. The problem with this line of thinking is that many hospitals, especially for-profit hospitals, make money by having “heads in beds.” The last thing they would want to do is decrease the number of admissions from the emergency department. I make this statement with the disclosure that I am far from an expert in hospital reimbursement economics. It is just what I have heard from some hospital administrators.

• Who will make the decision to administer these drugs? The emergency physician? I doubt most would feel comfortable with these antibiotics. Furthermore, would they just stock it in the emergency department? Whose budget does it go under: the pharmacy or the emergency department? What about the outpatient infusion center? This is probably the most likely scenario, especially if it is run/owned by an infectious disease specialist, depending on reimbursement considerations.

• If the patient did receive a dose in the emergency department and the physician decided to admit the patient, the patient no longer needs intravenous antibiotics. Would the admission be denied as not meeting hospital level care?

• What if the patient developed an adverse event? Neither of these drugs is dialyzed out of the blood. Will the adverse event be present for the entire length of the half-life? That being said, the clinical trials showed that adverse events were rare and those that did occur were self-limiting. Of course, with widespread use of any new drug, previously untoward reactions can come to light.

I guess my bottom line is that I am totally fascinated by these drugs and their unique pharmacokinetics. I can see using weekly doses to treat osteomyelitis (although neither are FDA-approved for this nor even tested). I can see taking a patient with an infection who is not doing well on oral methicillin resistant Staphylococcus aureus (MRSA) drugs, such as doxycycline (Vibramycin, Pfizer) or trimethoprim/sulfamethoxazole (Bactrim, Roche), and just treating them with an IV dose or two of one of the new drugs. Perhaps a potential use of dalbavancin or oritavancin is treating a patient who for whatever reason cannot take oral linezolid (Zyvox, Pfizer) or tedizolid (Sivextro, Cubist Pharmaceuticals) but does not require hospitalization for the infection.

I will continue to watch and learn about these two new drugs whenever I can, and pass along any information I can.

This blog originally appeared on the Handbook of Lower Extremity Infections Website at https://www.leinfections.com/antibiotics/dalbavancin-oritavancin-part-2/ and has been adapted with permission from Warren Joseph, DPM, FIDSA, and Data Trace Publishing Company. For more information about the Handbook of Lower Extremity Infections, visit www.leinfections.com/ .