It was this time last year, with back-to-school preparations and physicals in full swing, that uproar over the recent price surge of Mylan's brand-name epinephrine auto-injector — EpiPen — began to dominate headlines.
Between 2004 and 2016, Mylan raised the price of EpiPens by nearly 500 percent, but with no generic versions of the lifesaving allergy medicine and few comparable alternatives, physicians continued to prescribe EpiPen the majority of the time, and Mylan could continue raising prices.
This back-to-school season, after a year of Congressional hearings and public backlash against EpiPen, the market for epinephrine auto-injectors has shifted, but not as much as some might have expected. While there are now alternatives on the market, data from the athenahealth network shows that these options are prescribed just 30 percent of the time.
That situation may change following news that the Food and Drug Administration has accused Pfizer, which manufacturers EpiPen for Mylan, of not adequately investigating complaints that the device's injection mechanism sometimes fails to fire. But for now, data shows EpiPen to be more than holding its own in the marketplace.
Interest in alternatives levels off
According to athenahealth data, August is when as many as 90 percent of epinephrine auto-injectors are prescribed nationwide, 70 percent of which go to patients under 18 years old in preparation for school requirements to have the devices on hand.
When consumers balked and the media picked up the price-hike story, Mylan introduced an authorized generic option to EpiPen in December 2016. The new device has different packaging, but the same drug formulation and device functionality as EpiPen Auto-Injector, and is administered in the same way.
In February 2017, competitor Kaleo reintroduced Auvi-Q. It was at this time that athenahealth researchers saw a significant shift. Providers had begun to prescribe alternatives to EpiPen at four times the typical rates.
But despite all the uproar, alternatives to EpiPen have not gained much more of the market share since.
Athenahealth researchers analyzed more than 130,000 prescriptions written for epinephrine auto-injectors to approximately 100,000 patients by more than 3,700 providers since the beginning of 2016. While the sample is limited to reflect what the physician ordered — not what the patient ultimately received at the pharmacy — this data shows that after a dramatic increase in the beginning of 2017, prescriptions for alternatives to EpiPen have stabilized at approximately 30 percent of all epinephrine auto-injector prescriptions.
The data also details the slow rate in which providers are making the switch. Only 29 percent of providers, who wrote at least 10 prescriptions for epinephrine auto-injectors from June 2017 through August 2017, are now prescribing more epinephrine auto-injector alternatives than EpiPen.
Only a small portion — 7 percent and 4 percent of providers in the sample — appear to have made a more permanent switch, prescribing alternatives to EpiPen (including Mylan's own generic option) more than 80 percent and 90 percent of the time, respectively.
Phil Galebach, a data engineer at athenahealth who conducted this most recent analysis, explains that alternatives like Adrenaclick and Auvi-Q require a different injection method, which presents a special challenge in shifting providers and patients to a new mechanism for a life-saving drug. This is likely why physicians aren't making more dramatic moves to the alternatives, he says.
Physicians we spoke to in different regions and with different patient populations say they with consider EpiPen's injection mechanism to be most effective and straightforward in a life-threatening situation of anaphylaxis — though the FDA's warning may indicate otherwise.
Patient familiarity is the primary reason why doctors have continued to prescribe EpiPens and not alternatives in the majority of cases (though analyses indicates EpiPen's effective branding and long market dominance may also be a factor).
“In switching to the generic auto-injectors, if you don't make sure the [patients and their support system] know exactly how a different version works, that could put the patient at risk," says Kimberly Williams, M.D., owner of Main Street Pediatrics, a two-doctor pediatric practice in a rural area of north Georgia.
Williams has a special interest in food allergies and many patients who have experienced anaphylactic shock. “I prefer staying with one brand because of the comfort level of the patient and how important it is that they know how to use it when the need arises."
Ulrike Ziegner, M.D., an allergist/immunologist and founder of Riviera Allergy Medical Center in Redondo Beach, Calif., estimates she has prescribed at least 400 EpiPens this year alone. “Patients all ask for the EpiPen — they'd rather use what they're comfortable with."
While consumers are upset about the price hikes, Ziegner and Willams say, for most of their patients, the higher costs are being shifted onto payers.
When they do opt for an alternative to EpiPen, payers are influencing Ziegner's and Williams' prescribing decisions the majority of the time: Some state Medicaid programs stopped covering EpiPen, and other states and health insurance companies are now requesting providers to prescribe the cheapest alternative. When this occurs, Williams and Ziegner insist on the generic to EpiPen.
In the end, the decision might come down to a question of comfort, not just for patients, but for physicians as well. "We are creatures of habit, and we hate the most to change treatment unless it's medically indicated,” says Williams.
Chelsea Rice is a contributing writer to athenaInsight.
An earlier version of this article misrepresented the functionality of Mylan's generic epinephrine auto-injector.