Category Archives: Cost Savings

What is a Fungal Nail Cure Worth? Ask Jublia

Would you pay $11,260 for a safe topical medication to treat fungal toenail infection that has a 15% chance of  complete cure?  It seems this is unlikely but that’s what the Jublia® folks at Valient are trying to sell.  If it seems like there must be some mistake here is the math:

  • Cost of one 4 ml bottle of Jublia® at the lowest cost local pharmacies per $470 using a “free” coupon available online from the manufacturer.
  • There are about 20 drops in one ml, so that means about 80 drops per bottle.
  • Treatment requires two drops per affected great toenail daily, and one drop per each other nail affected. For this example I assume 2 great toenails and 2 other nails affected, so a  use of 6 drops daily meaning a bottle would last 80/6= about 14 days.
  • For a 48 week course of therapy this would require 24 bottles of Jublia at $470 / bottle, or a total cost of $11,260. If only one great nail were affected the cost would be $3948 and if all 10 nails were affected it would be $22,560.

This is incredible when the low success rates of Jublia, a 15 – 17% complete success rate means that per complete cure (no fungus on testing and normal appearing nails after treatment) the cost per complete cure would range from $26320 for the single great toenail patient to $150,400 for the patient with all 10 toenails affected.

Compare this to the cost of $12 for a 90 day course of generic terbenafine with a 38% complete success rate making it cost about $32 per complete cure using this oral medication.

About the same time that I started seeing TV ads for Jublia® I began to have patients asking me if I recommended Jublia® for their fungal toenail infections.  Fungal toenails are both common and difficult to treat.  I was skeptical when I first heard of Jublia because up to this time topical therapy has been generally ineffective.  Oral treatment has been somewhat more effective, but modest cure rates and high recurrence rates combined with potential serious side effects have kept me from encouraging patients to undertake oral therapy.  Unless their nails are bothering them enough to make the low success rate worth a try many patients shy away from treatment and put up with their fungal nails. Looking at the details of Jublia success rates as presented in the prescribing information available from Valeant Pharmaceuticals does little to make me excited about prescribing Jublia.  Here are some of the data from the clinical trials used to gain FDA approval:

  • Jublia needs to be applied to the whole of all affected toenails daily for up to 48 weeks. It should be applied to the surface of the nail as well as the underside of the nail, and the skin immediately adjacent to the nail.
  • A complete cure, i.e. a normal appearing nail and no evidence of the fungus on follow up testing was achieved in only 15.2% and 17.8% of study participants (vs. 3.3% and 5.5% with placebo vehicle use)
  • 26.4% and 23.4% of participants in the two studies had either complete or almost complete improvement in the nail appearance and no fungus found on follow up testing.
  • The prescribing information does not discuss recurrence rates, but with oral treatment of fungal nails recurrence rates at 1 year after successful treatment are approximately 15%. It seems unrealistic to expect lower recurrence rates with Jublia.
  • Jublia seems to be quite safe with about 1-2% or patients having annoying topical irritation or ingrown toenail as side effects but no systemic ill effects reported.

I understand that insurance companies negotiate discounts on medications from the drug companies, and that only insured patients are likely to consider Jublia given its extraordinary price tag.  Still I don’t see myself prescribing a tedious, 48 week course of daily topical therapy that costs the health care system several years of health insurance premiums for most families for fungal nail infections. I tend to discuss the risks of oral terbenafine with patients and many choose not to take the potential risk of liver inflammation associated with this drug given the relatively low success rates and high recurrence rates.  Somewhat incredibly Jublia has priced itself in the range of new therapies like the new Hepatitis C drugs we use for life threatening diseases and yet wonder if the extraordinary costs are viable for a much more serious disease. .

DIY Hay Fever Therapy- The Time is Now

Do-it-yourself (DIY) management is now something many if not most hay fever sufferers can effectively accomplish. The approval of an over-the-counter nasal corticosteroid, Nasacort OTC in October 2013 makes this the first spring where the drug most of us prescribe as the mainstay of hay feverpre therapy is available without a prescription. This is an… Continue Reading

Watchful Waiting: Not just a Prostate Cancer Option

Watchful waiting has become a term often thougt of as an alternative to surgery, radiation, or other interventions for early stage prostate cancer. Watchful waiting is actually a viable option for many other conditions too. Most Mom’s know that tincture of time with watchful waiting lets their children have the opportunity to recover without intervention… Continue Reading

Supreme Court Ruling on Gene Patents: It is Personal

For many women and many families the recent U.S. Supreme Court ruling that naturally occurring genes in the human genome cannot be patented is highly personal.  I’ve been waiting to decide on whether to post on this topic here on  My wife has ovarian cancer and has been found to have a BRCA2 gene… Continue Reading

Breakthrough Prizes in Life Sciences are Cool

Research we need even more is boring, uninteresting, and has little or no funding. I was pleased to read the news last week of the Breakthrough Prizes in Life Sciences, giving $3 million each to 11 actively working basic scientists in medical and biological research. This is a great idea and a way to promote… Continue Reading

U.S. Health Care Costs in Comparison to Other Developed Countries – One FP’s Comments

Everyone knows that in the U.S. we spend far more on healthcare than in every other country in the world.  I recently read a PBS interview looking at this issue primarily looking not at the gross spending but to look at what we spend our money on compared to other developed countries, how much we… Continue Reading

Generic Lexapro Finally: Understanding Isomers

With the FDA approval yesterday of Teva’s generic Lexapro (escitalopram) I’m taking this opportunity to remember my years as a chemistry major at Bowdoin College and talk about a subject that is fascinating and not really that complicated. The movement toward the use of isolated isomers (also called sterioisomers or enantiomers ) as medication seems… Continue Reading

Pfizer Strategy to Get You to Buy Lipitor not Generic Atrovastatin

The patent on Lipitor expires this month, and inexpensive generic atorvastatin should be available within months. I cannot think of any good reason that generic atorvastatin prices should be higher than the prices of the other generic statins once true competition comes to the marketplace. Pfizer has in place a strategy to try to keep… Continue Reading