Cost Analysis of Different Antibiotic Brands Available in Indian Market with Reference to National List of Essential Medicines.

BACKGROUND: About 60%-90% of healthcare spending in India is on medicine which is mainly out of pocket. Almost all the drugs including antibiotics are available as brands with variable cost. Indian government formulated National List of Essential Medicines (NLEM) to ensure availability of affordable medicines to the population. Prescribing drugs from NLEM and considering the cost of drug, especially antibiotics in practice, can reduce cost of treatment and patient's out-of-pocket expenditure.
OBJECTIVE: The objective of the study is to analyze cost variation of different antibiotic brands available in Indian market with reference to NLEM.
MATERIALS AND METHODS: List of antibiotics listed in the NLEM 2015, India, was prepared. Percentage cost variation and cost ratio of different brands of these antibiotics were calculated and compared.
RESULTS: We found 17 antibiotics listed in NLEM 2015. The number of brands varied from 2 to 102. We found wide cost variations among different brands of same antibiotics. Minimum cost variation was 7.34% (for ciprofloxacin 200 mg/100 ml vial) while maximum 1049.82% (for azithromycin 500 mg tablet).
CONCLUSION: There is wide cost variation in different brands of same antibiotics listed in the NLEM. Prescribers should prescribe cheaper brands of antibiotics to ensure that patients complete the course of treatment and thus reduce development of resistance to antibiotics. Copyright:

INTRODUCTION

Out-of-pocket expenditure is the main source of health funding. About 58% of India's health expenditure is being spend out of pocket of the patient.[1] The Indian pharmaceutical market is flooded with more than 3000 pharmaceutical companies, 10,500 manufacturing units, and more than 60,000 generic brands across 60 therapeutic categories.[2] In India, antibiotic consumption became double between 2000 and 2015. Use of antibiotic in India increased from 3.2 billion defined daily dose (DDD) to 6.5 billion in 2015.[3] Of the total medicines sales worth USD 12.6 billion in India between 2013 and 2014, anti-infective contributed around 16.8% of the pharmaceutical market (USD 2.12 billion).[4] Misuse or overuse of antibiotics is commonly reported in India. In India, most of the drugs are available in brands. Prescribing of costly brands of antibiotics leads to increase treatment cost, and patient may not able to afford complete course of antibiotic treatment, which can contribute to the development of resistance to antibiotics. It has been observed that there is wide variation in the cost of different brands of same generic drug.[56789] In 2013, India framed Drug Price Control Order which aims to ensure that essential drugs are available to all those who require them at affordable prices, under which prices of 814 scheduled formulations has revised and fixed by the National Pharmaceutical Pricing Authority.[10] National List of Essential Medicines (NLEM) in India has been formulated with the aim to promote rational use of medicines. The NLEM, 2015 comprises a total of 376 medicines including 17 different antibiotics.[11]

To the best of our knowledge, there is no study that compares the cost variations of different brands of NLEM-listed antibiotics available in the Indian market. This study was aim to find out the most economic and expensive brands of antibiotics available in the Indian market with reference of NLEM. Data from this study may be useful for prescribers and pharmacists to promote cost-effective use of antibiotics.

MATERIALS AND METHODS

The complete list of antibiotics included in NLEM, 2015, India, was prepared. Information regarding cost of different brands of antibiotics available in the Indian market was taken from latest edition of Current Index for Medical Specialties 41st Issue published in 2019. The price of antibiotics was measured in cost per DDD unit. The cost/DDD is calculated by multiplying the unit cost of suitable strength of the formulation with the number of units required to maintain the DDD. Percent cost variation and cost ratio were calculated for each antibiotic using the formula given below. Cost variation of an individual antibiotic of selected strength was compared.

Percent cost variation = (Maximum cost − Minimum cost/Minimum cost) × 100.

Cost ratio = Cost of most expensive brand/Cost of least expansive brand of same antibiotic.

RESULTS

A total of 17 antibiotics were found in NLEM, 2015, and all were included for analysis. Number of brands varied from 2 for ciprofloxacin 200 mg vial, gentamicin 80 mg vial, and cotrimoxazole (sulfamethoxazole 800 mg + trimethoprim 160 mg) to 102 for amoxicillin 500 mg + clavulanic acid 125 mg tablet. Wide cost variation was among different brands of antibiotics. The highest percent cost variation was found 1049.82 for azithromycin 500 mg tablet followed by 958.44 for doxycycline 100 mg tablet and 726 for nitrofurantoin 100 mg tablet, whereas the least percent cost variation was found as 7.34 for ciprofloxacin 200 mg vial followed by 8.83 for azithromycin 500 mg vial and 10.62 for cotrimoxazole (sulfamethoxazole 800 mg + trimethoprim 160 mg) tablet. On calculation of cost ratio between most and least expensive brand of individual antibiotic, we found the highest cost ratio as 11.4 for azithromycin 500 mg tablet followed by 10.5 for doxycycline 100 mg tablet and 8.3 for nitrofurantoin 100 mg tablet whereas the least cost ratio as 1.0 for ciprofloxacin 200 mg vial and azithromycin 500 mg vial followed by 1.1 for cotrimoxazole (sufamethoxazole 800 mg + trimethoprim 160 mg) tablet and 1.2 for cefadroxil 500 mg tablet. Price range between least and most expensive brand of individual antibiotic was found maximum as 775–1360 for ceftazidime 1000 mg vial followed by 69.24–183.20 for cefotaxime 500 mg vial and 100–196 for ceftriaxone 1000 mg vial. Minimum price range was found as 3.20–3.54 for cotrimoxazole (sulfamethoxazole 800 mg + trimethoprim 160 mg) tablet followed by 7.08–7.60 for ciprofloxacin 200 mg vial followed by 14.52–16.92 for cefadroxil 500 mg tablet. Table 1 shows antibiotics that listed in NLEM, 2015 and have cost variation above 2%.

Table 1

ATC code and defined daily dose of antibiotics listed in national list of essential medicines 2015 and have cost variation above two percent

Category	Drug	ATC Code	DDD (mg)	Strength	Number of brands available	Cost in INR					Cost variations (%)	Cost ratio
						Minimum cost/unit	Minimum cost/DDD	Maximum cost/unit	Maximum cost/DDD	Price range
Penicillin group
Oral (monotherapy)	Amoxicillin	J01CA04	1000	500 mg	33	2.8	4.5	14.3	28.7	4.5-28.7	533.9	6.3
Oral (combination)	Amoxicillin + Clavulanic acid	J01CA04	1000	500 mg + 125 mg	102	10.6	21.2	38.00	76.0	21.2-38.0	258.1	3.5
Parenteral (combination)	Piperacillin + Tozabactum	J01CR05	14000	4 g + 500 mg	39	150	525	750	2625	525-2625	500	5
Cephalosporin group
Oral (mono therapy)	Cefadroxil	J01DB05	2000	500 mg	5	3.6	14.5	4.2	16.9	14.5-16.9	16.5	1.2
	Cefixime	J01DD08	400	200 mg	72	5.3	10.6	21.0	42.0	10.6-42.0	295.4	4.0
	Cefotaxime	J01DD01	4000	500 mg	3	17.3	69.2	45.8	183.2	69.2-183.2	164.5	2.6
	Ceftazidime	J01DD02	4000	1000 mg	10	193.7	775	340.0	1360	775-1360	75.4	1.7
	Ceftriaxone	J01DD04	2000	1000 mg	48	50.0	100	98.0	196	100-196	96.0	2.0
Macrolide group
Oral (mono therapy)	Azithromycin	J01FA10	300	500 mg	87	5.7	5.7	66.0	66.0	5.7-66.0	1049.8	11.4
	Clarithromycin	J01FA09	500	500 mg	11	26.2	26.2	68.7	68.7	26.2-68.7	162.0	2.6
Parenteral (monotherapy)	Azithromycin	J01FA10	500	500 mg	3	185.7	185.7	202.1	202.1	185.7-202.1	8.8	1.0
Quinolone group
Oral (monotherapy)	Ciprofloxacin	J01MA02	1000	500 mg	33	1.6	3.3	7.7	15.4	3.3-15.4	358.3	4.6
Parenteral (monotherapy)	Ciprofloxacin	J01MA02	800	200 mg/100 ml	2	1.7	7.0	1.9	7.6	7.0-7.6	7.3	1.0
Aminoglycoside group
Parenteral (monotherapy)	Gentamicin	J01GB03	240	80 mg/ml	2	4.9	14.9	8.6	25.9	14.9-25.9	73.4	1.7
Tetracycline group
Oral (monotherapy)	Doxycycline	J01AA02	100	100 mg	9	0.7	0.7	8.1	8.1	0.7-8.1	958.4	10.5
Antibiotic combinations
Oral (combination)	Cotrimoxazole (Sulfamethoxazole + Trimethoprim)	J01EE01	2000	800 mg + 160 mg	2	1.6	3.2	1.7	3.5	3.2-3.5	10.6	1.1
Miscellaneous
Oral (monotherapy)	Nitrofurantoin	J01XE01	200	100 mg	6	1.0	2.0	8.2	16.5	2.0-16.5	726.0	8.3

DDD: Defined daily dose

DISCUSSION

In 2000, India made a policy “Health for All” and one of the main objectives of this policy was to ensure the availability of quality medicines at a reasonable cost to the society.[12] An increased cost is related with decreased medication adherence, which ultimately results in poorer health outcomes.

We found wide cost variation between different brands of essential medicines. In our study, minimum percent cost variation was 7.34 and maximum percent cost variation was 1049.82. The minimum value is comparable with a previously published study from India done by Mir et al., where the minimum cost variation was nine for tigecylcine. Maximum cost variation in this study was 2000 for ciprofloxacin which was higher than our study.[7] Another study done by Srivastava and Kantharia reported maximum cost variation as 21.05 for levofloxacin which is lower than in our study.[8] In our study, we found the maximum cost ratio as 11.4 for azithromycin 500 mg tablet which was different from previous reported where the maximum cost ratio was 19.3 and 21.64, respectively.[78] The difference in percent cost variation and cost ratio between current study and previously published study may be because our study mainly focused only on NLEM-listed antibiotics where previous studies included all the antibiotics available in Indian market.

The concept of essential medicines was first launched in 1977 by the WHO, and it was one of the eight pillars of WHO's primary healthcare plan. Although the main objective of NLEM is to ensure a regular availability and access of affordable medicines to the Indian population, physicians do not follow NLEM in practice which results in an increased financial burden to patients. One of the major impacts of the NLEM is that, currently, it has become the reference point for price regulation.

The present study compared the cost variation of drugs without considering the quality, which is a limitation. Quality data on individual brands of drugs are not readily available on public domain which makes it difficult to find this information. The government, during policy-making, should carefully study these price variations among antibiotic brands and take steps to ensure price regulation. Prescribers should prescribe medicines from NLEM and consider the cost of drug in practice to reduce drug-related financial burden on patients.

CONCLUSIONS

There is wide cost variation in different brands of same antibiotics listed in NLEM. Following NLEM concept and considering cost of antibiotics during practice can reduce health-related patient's out-of-pocket expenditure. Prescribing cheaper brands of antibiotics can help to ensure that patients complete the course of treatment and thus reduce development of resistance to antibiotics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.