A discussion on the benefits of combination drug therapy for adherence.
Casey Butrus, PharmD: I know there have been some new therapies, but I wouldn’t say necessarily a lot, that have been FDA approved within the past 4 to 5 years for acne. Steve, I was wondering if you could go into some of the newer therapies and what unmet needs they filled, other than the topical that Hilary just mentioned.
Steven Feldman, MD, PhD: Much of my research has been on how patients use their treatment…. I think the big unmet need is things that the patients will actually do. And when we’re taught to treat acne and taught to treat all 4 of the underlying causes, we tend to create these quite complicated regimens. We are going to have you use a moisturizer and we’re going to have you use a retinoid, and we’ll have you use a benzoyl peroxide, and we’ll use an antibiotic. The regimens just get extraordinarily complicated. It’s hard enough to get patients to do 1 thing well. Sometimes I think that we do stuff that we wouldn’t expect would work in any other field of endeavor. If somebody wasn’t playing the piano well, we wouldn’t give them a second musical instrument to play at the same time—we’d try to get them to play better. It’s just crazy the stuff we do. I think one of the major advancements has been in the use of combination treatments. We’ve had combination treatments for a long time. For example, benzoyl peroxide and topical antibiotic combination products. And when I was in medical school, they taught me to avoid combination drugs, that you want to give separate products so that you can have better control and maybe lower costs and things. There may be some logic to that if you assume that humans are like test tubes and they do what you tell them to do. But they’re not; they don’t do what you tell them to do. And the more complicated you make it, the less they do it. I think that the greater use of combinations that include retinoids plus benzoyl peroxide, 2 things that Hilary said are at the foundation of treatment, having that in 1 tube is a real advance.
Casey Butrus, PharmD: And as you mentioned, there are some retinoids plus benzoyl peroxide combinations, and usually those products are brand name only or currently only available as brand name. We do have some generic entrants coming on the market, which is exciting for the combination product space. But I think that’s something important, just from the managed care perspective, to consider: That even though these combination products are expensive and there are chemicals available separately that can be taken together, maybe the patient is more likely to take the medication if it is available in a combination product. And if they’re taking the medication, then it hopefully is working for them, vs if they’re not adherent and they’re not taking it, then that’s an extra cost, not only for the patient but also for the health plan that’s paying for the medication.
Arash Mostaghimi, MD, MPH: I agree with that, Casey. I think there’s a unique quality with dermatologic drugs, and one is that when we think about generic substitution or generic drugs, when you’re taking a pill, you’re looking what’s the active ingredient and that’s that. But as Steve just mentioned…layering 2 drugs is different than taking 1 in combination. Some of these real advances are not in the active ingredients but in the vehicles that they’re in, which allow drugs to be stabilized and to be administered together in a way that wouldn’t work if you put them on serially. And as Hilary was suggesting with the neck, one way to think is, what can we do to get people to take these medications? Another way to look at it [is to ask,] what are the reasons that people stop? And irritation is a really common reason for people to stop it. If things come in slightly different vehicles, one’s a gel, one’s a cream, and one’s a lotion, it gets not only complicated how to do it but what about the added impact of this on drying out your skin, just from the chemicals and the vehicles that they’re in? The unique part about dermatology is that you may be getting, let’s say, dapsone in a prescription formula vs a generic formula but the vehicle that it’s in may not be exactly the same. So the experience of taking it is very different vs if I gave you a pill of amoxicillin vs brand name amoxicillin; it’s probably more or less the same experience of taking it.
Casey Butrus, PharmD: That’s a good point that different vehicles and different, newer novel therapies coming to market may allow for the stability of products that weren’t able to be used traditionally separate, especially benzoyl peroxide and tretinoin, which can degrade and disintegrate if exposed to sunlight.
Hilary Baldwin, MD: Exactly.
Casey Butrus, PharmD: That was one of the big things with that newer combination product.
Hilary Baldwin, MD: And when we layer products that have not been studied together, who knows if they’re compatible, if one drug is going to inactivate the other? And the other thing is if one of the products is easy to use and has no tolerability issues and the other product is a little harder to use, that product probably won’t get used. Steve, you showed us with your MEMS cap study with benzoyl peroxide that no one was [adherent] at the 80% level. And Andrea Zaenglein, MD, showed us that if you send a patient to the pharmacy to get their benzoyl peroxide, that half of the people forgot that they were even told to do that, and the rest of them came back with products that didn’t contain benzoyl peroxide. So benzoyl peroxide’s hard to use. If it’s not in combination with the other product, people are going to say, I’m going to use this one and later I’ll use my benzoyl peroxide, and later never happens.
Casey Butrus, PharmD:Even going back to the guidelines, I know they addressed that benzoyl peroxide should be used in combination with a lot of other active ingredients too. So making sure that the patient’s getting the right medication at the right dose at the right time is just from the pharmacy perspective, something that I think everyone should be focusing on.
Transcript edited for clarity.