Should fidaxomicin be the preferred treatment for C. difficile?
New guidelines issued in 2021 stated a preference for fidaxomicin as first-line treatment for Clostridioides difficile infection, despite concerns about its cost.
We asked Infectious Disease News Editorial Board Member Jeff Brock, PharmD, MBA, BCPS-AQ ID, an infectious disease pharmacy specialist at Mercy Medical Center in Des Moines, Iowa, if the new guidelines got it right.
As most clinicians know, the Infectious Diseases Society of America and Society for Health Care Epidemiology of America’s clinical practice guidelines for the treatment of Clostridioides difficile infection (CDI) were recently updated.
This latest iteration now recommends fidaxomicin as the preferred treatment for initial and first recurrence episodes of CDI. Since fidaxomicin was approved for CDI treatment, I have been an avid proponent of its use because clinical trials have shown a substantial decrease in the risk for recurrent CDI if used for initial or first recurrent cases. I also appreciate the fact that fidaxomicin has a narrow spectrum of activity and less overall impact on the human microbiome compared with vancomycin and metronidazole.
Regrettably, over the years, the cost of treatment has been a substantial barrier for its implementation. The average wholesale price of a course of fidaxomicin is approximately four times higher than that for vancomycin oral capsules. If fidaxomicin is started in hospitalized patients, hospitals are not reimbursed for this cost, which can greatly impact any pharmacy budget.
Discharging hospitalized patients on fidaxomicin also can be difficult, even if the patient has insurance. Although insurance companies are providing some coverage for fidaxomicin, many patients are still faced with hundreds of dollars in copays at the pharmacy when picking up their prescription. This often results in calls to the prescriber for a prescription for vancomycin.
At this time, it is unknown if providing hospitalized patients fidaxomicin and transitioning to oral vancomycin at discharge is associated with the same benefits of reducing recurrence rates. The manufacturer of fidaxomicin provides a patient assistance program that can reduce the fidaxomicin copay for qualified patients. However, patients who have Medicare or Medicaid are not eligible for patient assistant programs. Unfortunately, I’ve found that many of our patients who present with CDI are covered by one of these programs.
Although I see fidaxomicin as the best treatment option for CDI based on its pharmacokinetics and pharmacodynamics and its ability to reduce recurrent disease, I’m not in agreement that it should be given preferred status due to the high cost of treatment and barriers to patient access. If the cost of fidaxomicin was more reasonable, my opinion would change.
- Johnson S, et al. Clin Infect Dis. 2021;doi:10.1093/cid/ciab549.
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