Correspondence

Atovaquone Compared with Dapsone to Prevent Pneumocystis carinii Pneumonia

N Engl J Med 1999; 340:1512-1513May 13, 1999

Article

To the Editor:

Taken as a whole, the articles by El-Sadr et al.1 and Bozzette et al.2 and the accompanying editorial by Steinbrook3 (Dec. 24 issue) seem to argue against the conclusion of El-Sadr et al. that atovaquone may be the preferred choice for prophylaxis against Pneumocystis carinii pneumonia in patients who cannot tolerate trimethoprim, sulfonamides, or both. It is surprising that El-Sadr et al. never factored in cost issues related to their strategy of prophylaxis. Dapsone and atovaquone, although found to be of equal efficacy for the prevention of P. carinii pneumonia, have large differences in price.

On the basis of the average suggested manufacturer's wholesale prices, the cost of a year of atovaquone is $10,100, as compared with a cost of $72 for dapsone. Pentamidine, another alternative to atovaquone, costs $2,533 a year, including administration costs. If the retail prices of the drugs are considered, the cost differential between atovaquone and dapsone is even greater. According to the estimates of Bozzette et al., the average annual cost of health care per patient infected with the human immunodeficiency virus (HIV) was $22,200 in 1996, with 40 percent of the cost being for pharmaceuticals (approximately $8,800). Furthermore, Steinbrook estimates that the majority of patient care costs related to HIV infection in 1998 were paid for by public programs.

It is easy to see from these cost estimates that the strategy of using atovaquone rather than dapsone for the approximately 40 percent of patients with AIDS who are unable to tolerate trimethoprim–sulfamethoxazole (cost per year, $207, based on a dose of one double-strength tablet daily)4 would greatly increase the costs of treatment and have a substantial effect on the average annual pharmaceutical expenditures for the entire population with AIDS. Clearly, issues related to cost would be even more problematic in the developing world. In our opinion, the cost considerations are a persuasive argument for choosing a strategy other than that proposed by El-Sadr et al. and reserving atovaquone therapy for patients who cannot tolerate trimethoprim–sulfamethoxazole or dapsone.

Harold W. Horowitz, M.D.
Gary P. Wormser, M.D.
New York Medical College, Valhalla, NY 10595

4 References

1. 1

   El-Sadr WM, Murphy RL, Yurik TM, et al. Atovaquone compared with dapsone for the prevention of Pneumocystis carinii pneumonia in patients with HIV infection who cannot tolerate trimethoprim, sulfonamides, or both. N Engl J Med 1998;339:1889-1895
   Full Text | Web of Science | Medline

2. 2

   Bozzette SA, Berry SH, Duan N, et al. The care of HIV-infected adults in the United States. N Engl J Med 1998;339:1897-1904
   Full Text | Web of Science | Medline

3. 3

   Steinbrook R. Caring for people with human immunodeficiency virus infection. N Engl J Med 1998;339:1926-1928
   Full Text | Web of Science | Medline

4. 4

   Wormser GP, Horowitz HW, Duncanson FP, et al. Low-dose intermittent trimethoprim-sulfamethoxazole for prevention of Pneumocystis carinii pneumonia in patients with human immunodeficiency virus infection. Arch Intern Med 1991;151:668-692
   CrossRef | Web of Science

Author/Editor Response

Dr. El-Sadr replies:

To the Editor: Our study showed that in a subgroup of patients who were not receiving dapsone at the time of enrollment, atovaquone may be preferable to dapsone because it was better tolerated. Drs. Horowitz and Wormser are concerned by this conclusion because atovaquone is much more expensive than dapsone.

We refrained from commenting on the cost of the medications for two reasons. First, the study did not include any systematic collection of data on the cost of each treatment strategy. Second, a rigorous analysis is required to determine the comparative cost effectiveness of the two treatment options. This type of detailed analysis should take into account multiple factors in addition to the cost of a medication, such as efficacy, tolerability, and potential morbidity due to toxicity or disease. We agree that cost issues are important, and we believe that our data may be valuable to other investigators who want to conduct formal cost analyses.

Wafaa El-Sadr, M.D., M.P.H.
Harlem Hospital Center, New York, NY 10037

Citing Articles (1)

Citing Articles

1. 1

   Dongjiu Ye, Chao-Hung Lee, Sherry F. Queener. (2001) Differential splicing of Pneumocystis carinii f. sp. carinii inosine 5′-monophosphate dehydrogenase pre-mRNA. Gene 263:1-2, 151-158
   CrossRef