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The director of Children’s Colorado’s Food Challenge and Research Unit, Matthew Greenhawt, MD and Marcus Shaker, MD of Dartmouth-Hitchcock Medical Center based in Lebanon, New Hampshire, recently shared results of a partnered study. The study sought to identify whether a value-based price could be determined for epinephrine autoinjectors given that a wide variation in costs currently exists. The results were shared in the most recent issue of the JAMA Network Open. They found that in a simulation of children with a peanut allergy, a value-based epinephrine price has a ceiling of $24 for a personal autoinjector, even at an exaggerated fatality risk.
For children and adults who live with food allergies, personal self-injectable epinephrine devices are an important part of anaphylaxis preparedness. While accurate diagnosis of a food allergy allows appropriate prevention, unintended allergen ingestions still occur and are a source of concern. Epinephrine use for food allergy reactions is an important resource that is credited with saving lives, in particular in severe reactions such as anaphylaxis, where other medications do not address the underlying symptoms. As awareness of anaphylaxis has risen in recent years, so has the cost of the autoinjector devices.
“Our analysis shows that these devices are significantly overpriced at current costs given the fact that fatalities from food allergies are relatively rare,” said Dr. Greenhawt. “While the exact risk reduction associated with carrying personal epinephrine devices is unknown, it is widely accepted that this practice is a bedrock of food allergy management because it promotes early access to emergency treatment for severe reactions.”
The study scenario presumed a tenfold increased fatality risk associated with not having an autoinjector, even though there is no data to substantiate that the risk is this high. In further sensitivity analyses, even at 100-fold increased risk and assuming a perfect carriage and usage rate, the price of an autoinjector would still have to be less than $400 to be cost-effective.
Epinephrine cost has been a well-publicized issue in the food allergy community and mainstream media, and it continues to be controversial. At the core of the issue is what is alleged to be a very high price for a device that uses technology developed in the 1970s and was subsidized by the U.S. government, delivering a very cheap drug that is a century old, and was available for $100 or less prior to 2010. Currently, three device types are available, sold as four brands, representing two basic technologies. However, all devices deliver the same drug for the same indication.
The retail purchase price of autoinjectors is varied and often expensive even with insurance. In 2016 some instances reached $690 per dual-pack package, although retail device costs rarely exceeded $100 before 2010.
Devices expire within 18 months and are generally renewed annually, although in August 2018 the US Food and Drug Administration (FDA) temporarily extended the expiration an additional six months for specific product batches given device shortages. Incorporating value-based pricing into epinephrine market price decisions has the ability to add reasonable and rational benchmarks to a controversy that continues to baffle patients, practitioners and payers.