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Invited Commentary
January 2016

Patient and Physician Convenience and the Choice of Intravitreal Anti–Vascular Endothelial Growth Factor Medications

Author Affiliations
  • 1Department of Ophthalmology, Greater Baltimore Medical Center, Baltimore, Maryland
JAMA Ophthalmol. 2016;134(1):49-50. doi:10.1001/jamaophthalmol.2015.4115

The article by Holfinger and colleagues1 in this issue of JAMA Ophthalmology provides an important analysis of how enforcement of patient-specific prescriptions (PSPs) alters the use of bevacizumab (Avastin). Bevacizumab for intravitreal use must be repackaged under sterile conditions in adherence to the US Pharmacopoeia 797 guidelines (http://www.usp.org). Retina specialists before 2012 were accustomed to ordering bevacizumab in syringes from compounding pharmacies. Multiple syringes of bevacizumab could be ordered without any requirement for identifying which patient received a particular dose or a particular lot. As a result of the tragic outbreak of meningitis from contaminated methylprednisolone for spinal injection prepared by New England Compounding Center, many states created or enforced existing regulations concerning the preparation of medications by compounding pharmacies. Patient-specific prescriptions were required in about one-third of the states by 2013. This requirement meant that retina specialists had to order bevacizumab for a particular patient 1 to 2 weeks before the patient came for an appointment (owing to compounding pharmacy processing and shipping times), or the patient had to return 1 to 2 weeks after his or her appointment to receive the bevacizumab. In the meantime, some patients with recurrent activity of their choroidal neovascularization or increased macular edema would experience visual loss while waiting for their dose of bevacizumab to arrive. The net effect of these requirements was less convenience for patients who had to return for their injection, many of whom are elderly and depend on others to drive them to their appointments. If retina specialists ordered bevacizumab in anticipation of their patient’s appointment, they would not infrequently have to discard unused syringes of bevacizumab when patients did not return for appointments or did not need the bevacizumab injection. Because the patient did not receive the medication, the patient could not be billed and the retina specialist lost the cost of the bevacizumab dose.

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