pharmacoeconomic analysis of cephalosporins …

www.wjpps.com Vol 9, Issue 3, 2020.

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Priyanka et al. World Journal of Pharmacy and Pharmaceutical Sciences

PHARMACOECONOMIC ANALYSIS OF CEPHALOSPORINS

AVAILABLE IN INDIAN PHARMACEUTICAL MARKET

Priyanka S.*, Sara Yeldhos, Sanoop J. and Shindya B.

Department of Pharmacy Practice, Karpagam College of Pharmacy, S. F. 762, Pollachi Main

Road, Othakkalmandapam, Coimbatore-641032, Tamil Nadu, India, (Affiliated to The

Tamil Nadu Dr. M. G. R. Medical University).

ABSTRACT

Background: Cephalosporins are antibiotics used to treat a wide

variety of bacterial infections, such as respiratory tract infections, skin

infections and urinary tract infections. Different brands of the same

medications are available in market leading to immense cost variation.

This can affect medication compliance by the patient.

Pharmacoeconomics research can take us toward the final aim of

making drugs affordable to all. The present study was undertaken to

evaluate the variation and minimization in costs of Cephalosporins

available in India. Materials and methods: The cost of the drugs were

obtained from CIMS, July to Oct, 2019, and cost range, mean cost,

cost ratio and percentage cost variation for individual drug brands was

calculated. The cost of 10 tablets or capsules and 1 vial/ampoule was

taken in case of oral and parenteral preparations respectively. Results:

There is a gross variation in the prices of branded drugs of

Cephalosporins in India. The highest cost range is for IV Cefuroxime 750mg (1,695) and

mean cost is for oral Cefaclor 750mg (772.34). The highest cost ratio and percentage price

variation is for oral Cefuroxime 500mg (19.29, 1829.825). Conclusions: Higher medication

costs are often being considered as an important factor for medication non-adherence,

dropouts/lost follow-ups and drug resistance. Hence, the practitioner must be sensitized about

the cost of therapy to make sure adequate patient compliance.

KEYWORDS: Cephalosporins, Cost range, Mean cost, Cost ratio, Percentage cost variation,

Compliance.

WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

SJIF Impact Factor 7.632

Volume 9, Issue 3, 1205-1216 Research Article ISSN 2278 – 4357

Article Received on

30 Dec. 2019,

Revised on 20 Jan. 2020,

Accepted on 10 Feb. 2020

DOI: 10.20959/wjpps20203-15635

*Corresponding Author

Priyanka S.

Department of Pharmacy

Practice, Karpagam college

of Pharmacy, S. F. 762,

Pollachi Main Road,

Othakkalmandapam,

Coimbatore-641032, Tamil

Nadu, India, (Affiliated to

The Tamil Nadu Dr. M. G.

R. Medical University).


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INTRODUCTION

In developing countries, the main source of dead weight loss are due to unreasonable or

uneconomic treatment costs making the healthcare system outworn. Total health expenditures

about 50-90% drugs are paid out-of – pocket payments. It is estimated that 20 million people

in India fall below the poverty line each year because of indebtedness due to healthcare needs

(Pricewaterhouse Coopers, 2007). This is indeed an alarming figure.[1]

Bacterial disease emerges as a major concern of risk factors for spread and exists as an high

burden to the developing countries. In low income countries bacterial infection such as lower

respiratory tract infections (LRTI) accounts for the main cause of death and for middle low

income countries it remains the 3rd

leading cause of death (91; 53/1lakh population

respectively).[2]

India faces the challenge of treating a range of infectious diseases like

tuberculosis, malaria, respiratory infection, dengue fever from acute to chronic with the

potential to cause morbidity and mortality. In every country, the obtainable life saving

antimicrobials is of supreme importance. There are various antibiotics available primarily

indicated for the prophylaxis, and treatment of bacterial infections caused by both Gram-

positive as well as Gram-negative organisms which include penicillins, cephalosporins,

fluoroquinolones, aminoglycosides,and tetracyclines.[3]

In a healthcare setup, the basic services that hospitals offer are primary care, serve as

referral institutes for higher-level care, and train health care workers but benefits are

expensive.[4]

Apart from clinical setup, the major non clinical factors leads to price variation

of drugs include professional decision making, the availability and distribution of resources,

physician incentives, financing and reimbursement models. The main policy challenge is thus

to find the root cause rather than eliminating the variation altogether.[5]

The Government of India regulates prices of essential drugs through Drug Price Control

Order (DPCO) implemented by National Pharmaceutical Pricing Policy (NPPA) but the

government regulated essential drug price list do not cover 80% of medications. This leads to

economic burden to common people.[6]

Pharmacoeconomics research can take us toward the final aim of making drugs affordable to

all. Though pharmacoeconomics is in its infancy in India, it is rapidly evolving and good

quality studies are being conducted across the nation. The first proposed Pharmacoeconomics

guidelines draft was recently prepared by experts in the field (Gupta et al., 2013).[7]


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As health resources are limited, increased attention is being given to the assessment of

healthcare measures in terms of money. This is achieved by comparing costs and

consequences of alternative interventions. Different brands of the same mediations are

available in market leading to immense cost variation. This can affect medication compliance

by the patient. The present study was undertaken to evaluate the variation in costs of

Cephalosporins available in India.

MATERIALS AND METHODS

1. The cost of 8 oral and 8 parenteral preparations of cephalosporins available under

different brands in Indian pharmaceutical market was analyzed as of data available in

CIMS, July to Oct, 2019.

2. The cost of 10 tablets/capsules and 1 vial/ampoule was calculated for each strength in a

generic group.

3. Cost range and mean cost of the drugs are calculated and cost range is the range of the

drug from minimum to maximum cost and mean cost is calculated by adding the cost of

all brands of the same generic drug divided by number of brands available. Cost is

calculated in Indian National Rupees (INR).

4. Cost ratio gives the ratio of the cost of costliest to the cheapest brand of proton pump

inhibitors of the same strength available in the Indian market and it gives an idea about

how many times the costliest brand costs more than the cheapest brand available in each

generic group.

5. Percentage price variation for each strength of the same generic group was calculated

using the equation,

6. The drug Manufactured by or a definite strength of drug manufactured by a single

company is excluded.

7. The different brands of the drug whose price is not disclosed in CIMS, July to Oct 2019

are excluded.

8. Fixed dose combinations and other formulations are not analyzed.

9. The numbers of trades of Cephalosporins in the Indian pharmaceutical market are

analyzed.


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RESULTS

The study shows that there are currently 769 brands of Cephalosporins are available in India

and Cefpodoxime holds the highest number of brands 194 (25.227%), Cefuroxime has 171

brands (22.236%), Cefixime has 154 brands (20.026%), Ceftriaxone has 131 brands

(17.035%), Cefalexin has 28 brands (3.641%), Ceftazidime has 21 brands (2.730%), Cefaclor

has 18 brands (2.340%), Cefadroxil has 16 brands (2.080%), Cefotaxime has 11 brands

(1.430%), Cefaperazone has 8 brands (1.040%), Cefdinir has 6 brands (0.780%), Cefpirome

has 5 brands (0.650%), Cefazolin has 3 brands (0.390%), Cefetamet has 2 brands (0.260%),

Ceftizoxime has 1 brand (0.130%)(Fig-1).

Fig-1: Total number of brands of each cephalosporins available in India.

Cefaclor is available at 125mg, 250mg, 375mg, 500mg and 750mg strengths as oral

formulation in 2,8,3,3 and 2 brands of each respectively. Cefadroxil is available at 125mg,

250mg and 500mg strengths as oral formulations in 5, 6 and 5 brands of each respectively.

Cefetamet is available at 250mg and 500mg strengths as oral formulation in 1,1 brand of each

respectively. Cefdinir is available at 100mg, 300mg strengths as oral formulation in 1 and 5

brands of each respectively. Cefalexin is available at 125mg, 250mg, 375mg, 500mg, 750mg

strengths as oral formulation in 3, 12, 2, 9 and 2 brands of each respectively. Cefpodoxime is

available at 50mg, 100mg and 200mg strengths as oral formulation in 31, 75 and 88 brands of

each respectively. Cefixime is available at 50mg, 100mg, 200mg and 400mg strengths as oral

formulation in 25, 61, 67 and 1 brands of each respectively. Cefuroxime is available at

125mg, 250mg and 500mg strengths as oral formulation and 2.5mg, 250mg, 500mg, 750mg


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and 1500mg strengths as parenteral formulation in 9, 54, 62 and 1, 6, 1, 19 and 19 brands of

each respectively. Ceftriaxone is available at 125mg, 250mg, 500mg, 1000mg and 2000mg

strength as parenteral formulation in 10, 35, 37, 47 and 2 brands of each respectively.

Ceftizoxime is available at 1000mg strength as parenteral formulation in 1 brand.

Ceftazidime is available at 125mg, 250mg, 500mg, 1000mg and 2000mg strengths as

parenteral formulation in 1, 5, 2, 11 and 2 brands of each respectively. Cefpirome is available

at 500mg and 1000mg strengths as parenteral formulation in 1 and 4 brands of each

respectively. Cefotaxime is available at 125mg, 250mg, 500mg, 1000mg and 1500mg

strengths as parenteral formulation in 2, 3, 3, 2 and 1 brands of each respectively.

Cefoperazone is available at 250mg, 1000mg and 2000mg strengths as parenteral formulation

in 2, 5 and 1 brands of each respectively. Cefazolin is available at 250mg, 500mg and

1000mg strengths as parenteral formulation in 1, 1 and 1 brand of each respectively.

The cost range of oral Cefaclor 125mg, 250mg, 375mg, 500mg and 750mg is in between

156.81 -216.66 INR, 169.86 – 446.66 INR, 376.66 – 457.00 INR, 465.00 – 620.00 INR and

686.35 – 858.33 INR respectively. Cost range of oral Cefadroxil 125mg, 250mg and 500mg

is in between 10.48 – 14.00 INR, 18.98 – 31.20 INR and 36.30 – 42.38 INR respectively.

Cost range of oral Cefdinir 300mg is in between 230.00 – 550.00 INR. Cost range of

Cefalexin 125mg, 250mg, 375mg, 500mg and 750mg is in between 30.00 – 68.50 INR, 51.22

– 145.70 INR, 102.50 – 181.00 INR, 99.90 – 162.00 INR and 184.50 – 315.00 INR

respectively. Cost range of Cefpodoxime 50mg, 100mg and 200mg is in between 52.10 –

90.00 INR, 71.50 – 245.70 INR and 90.00 – 290.00 INR respectively. Cost range of Cefixime

50mg, 100mg, 200mg and 400mg is in between 28.60 – 154.50 INR, 32.00 – 130.00 INR and

53.10 – 200.00 INR respectively. Cost range of Cefuroxime 125mg, 250mg and 500mg is in

between 74.00 – 250.65 INR, 59.00 – 660.00 INR, and 76.00 – 1466.667 INR respectively

(Table-1).


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Table 1: Cephalosporins with their number of brands, minimum and maximum cost,

cost range and mean cost of each oral formulations in India.

S.no Drug

(Tab/Cap)

Dose

(mg)

No. of

brands

Minimum

Cost(INR)

Maximum

Cost(INR)

Cost

Range

Mean

Cost

1. Cefaclor

125

250

375

500

750

2

8

3

3

2

156.81

169.86

376.66

465.00

686.35

216.66

446.66

457.00

620.00

858.33

59.85

276.8

80.34

155

171.98

186.735

315.368

414.831

544.88

772.34

2. Cefadroxil

125

250

500

5

6

5

10.48

18.98

36.30

14.00

31.20

42.38

3.52

12.22

6.08

12.052

27.73

39.988

3. Cefdinir 100*

300

1

5

-

230

-

550

-

320

-

366

4. Cefetamet 250*

500*

1

1

-

-

-

-

-

-

-

-

5. cefalexin

125

250

375

500

750

3

12

2

9

2

30.00

51.22

102.50

99.90

184.50

68.50

145.70

181.00

162.00

315.00

38.50

94.48

78.5

62.1

130.5

50.833

79.91

141.75

127.463

249.75

6. cefpodoxime

50

100

200

31

75

88

52.10

71.50

90

90

245.70

290

37.9

174.2

200

70.832

115.582

187.310

7. cefixime

50

100

200

400*

25

61

67

1

28.60

32.00

53.10

-

154.50

130.00

200.00

-

125.9

98

146.9

-

57.390

80.139

120.838

-

8. Cefuroxime

125

250

500

9

54

62

74

59

76

250.65

660.00

1466.667

176.65

601.00

1390.667

140.572

274.169

500.336

*prices are not available: hence cost range and mean cost cannot be calculated

Whereas in case of parenteral preparations, the cost range of injectable Cefoperazone 250mg

and 1000mg is in between 56.00 – 75.00 INR and 156.00 – 295.00 INR respectively. cost of

injectable Cefotaxime 125mg, 250mg, 500mg and 1000mg is in between 13.35 – 27.71 INR,

12.92 – 24.60 INR, 17.31 – 45.80 INR and 28.50 – 64.25 INR respectively. Cost of injectable

Cefpirome 1000mg is in between 351.00 – 744.00 INR. Cost of injectable Ceftazidime

250mg, 500mg, 1000mg and 2000mg is in between 66.00 – 132.10 INR, 171.00 – 202.20

INR, 193.75 –340.00 INR and 495.90 – 505.00 INR respectively. Cost of injectable

Ceftriaxone 125mg, 250mg, 500mg, 1000mg and 2000mg is in between 18.00 – 64.14 INR,

24.00 – 35.00 INR, 33.57 – 60.00 INR, 50.00 – 500.34 INR and 113.75 – 126.80 INR


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respectively. Cost of injectable Cefuroxime 250mg, 750mg and 1500mg is in between 32.00

– 66.50 INR, 95.00 – 1790.00 INR and 175.00 – 325.00 INR respectively (Table-2).

Table 2: Cephalosporins with their number of brands, minimum and maximum cost,

cost range and mean cost of each parenteral formulations in India.

S.no Drug

(1 Vial)

Dose

(mg)

No. of

brands

Minimum

Cost(INR)

Maximum

Cost(INR)

Cost

Range

Mean

Cost

1. cefuroxime

2.5*

250

500*

750

1500

1

6

1

19

19

-

32

-

95

175

-

66.50

-

1790

325

-

34.5

-

1695

150

-

54.15

-

208.91

224.48

2. ceftriaxone

125

250

500

1000

2000

10

35

37

47

2

18

24

33.57

50

113.75

64.14

35

60

500.34

126.80

46.14

11

26.43

450.34

13.05

27.501

29.25

47.29

72.13

120.27

3. Ceftizoxime 1000* 1 - - - -

4. ceftazidime

125*

250

500

1000

2000

1

5

2

11

2

-

66.00

171.00

193.75

495.90

-

132.10

202.20

340.00

505.00

-

66.1

31.2

146.25

9.1

-

85.932

186.6

239.86

500.45

5. cefpirome 500*

1000

1

4

-

351.00

-

744.00

-

393.00

-

495.97

6. cefotaxime

125

250

500

1000

1500*

2

3

3

2

1

13.35

12.92

17.31

28.50

-

27.71

24.60

45.80

64.25

-

14.36

11.68

28.49

35.75

-

20.53

17.79

27.98

46.37

-

7. cefoperazone

250

1000

2000*

2

5

1

56.00

156.60

-

75.00

295.00

-

19

138.4

-

65.5

248.52

-

8. cefazolin

250*

500*

1000*

1

1

1

-

-

-

-

-

-

-

-

-

-

-

-

*Prices are not available: hence cost range and mean cost cannot be calculated.

The current study reveals that there is a wide variation in the cost of different brands of

cephalosporins available in the Indian pharmaceutical market. The highest cost ratio and

percentage cost variation among orally available cephalosporins was found for the drug oral

Cefuroxime 500mg [19.29,1829.825] and least cost ratio and least percentage price variation

is for the drug Cefadroxil 500mg[1.167,16.749] and for other Cephalosporins are described in

Table-3.


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Table 3: Drug costs, cost ratio and percentage cost variation of oral cephalosporins

available in India.

S.no Drug

(Tab/Cap)

Dose

(mg)

No.of

brands

Minimum

Cost(INR)

Maximum

Cost(INR)

Cost

Ratio

Percentage

price

variation

1. Cefaclor

125

250

375

500

750

2

8

3

3

2

156.81

169.86

376.66

465.00

686.35

216.66

446.66

457.00

620.00

858.33

1.386

2.629

1.213

1.333

1.250

101.938

162.957

21.329

33.333

25.057

2. Cefadroxil

125

250

500

5

6

5

10.48

18.98

36.30

14.00

31.20

42.38

1.335

1.643

1.167

33.587

64.38

16.749

3. Cefdinir 100*

300

1

5

-

230

-

550

-

2.391

-

139.130

4. Cefetamet 250*

500*

1

1

-

-

-

-

-

-

-

-

5. cefalexin

125

250

375

500

750

3

12

2

9

2

30.00

51.22

102.50

99.90

184.50

68.50

145.70

181.00

162.00

315.00

2.283

2.844

1.765

1.621

1.707

128.333

184.459

76.585

62.162

70.73

6. cefpodoxime

50

100

200

31

75

88

52.10

71.50

90

90

245.70

290

1.727

3.436

3.222

72.744

243.636

222.222

7. cefixime

50

100

200

400*

25

61

67

1

28.60

32.00

53.10

-

154.50

130.00

200.00

-

5.402

4.062

3.766

-

440.209

306.25

276.647

-

8. Cefuroxime

125

250

500

9

54

62

74

59

76

250.65

660.00

1466.667

3.3871

11.18

19.298

238.716

1018.64

1829.825

Among the parenteral preparations of the Cephalosporins, the highest cost ratio and

percentage cost variation was seen with Cefuroxime 750 mg [18.84, 1784.210] and the least

with the drug Ceftazidime 2000mg [1.018, 1.835] and for others are depicted in Table -4.


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Table 4: Drug costs, cost ratio and percentage cost variation of parenteral

cephalosporins available in India.

S.no Drug

(1 Vial)

Dose

(mg)

No. of

brands

Minimum

Cost(INR)

Maximum

Cost(INR)

Cost

Ratio

Percentage

price

variation

1. cefuroxime

2.5*

250

500*

750

1500

1

6

1

19

19

-

32

-

95

175

-

66.50

-

1790

325

-

2.07

-

18.84

1.85

-

107.81

-

1784.21

85.714

2. ceftriaxone

125

250

500

1000

2000

10

35

37

47

2

18

24

33.57

50

113.75

64.14

35

60

500.34

126.80

3.56

1.45

1.787

10.00

1.114

256.33

45.833

78.73

900.68

11.472

3. Ceftizoxime 1000* 1 - - - -

4. ceftazidime

125*

250

500

1000

2000

1

5

2

11

2

-

66.00

171.00

193.75

495.90

-

132.10

202.20

340.00

505.00

-

2.001

1.182

1.754

1.018

-

100.1515

18.245

75.58

1.835

5. cefpirome 500*

1000

1

4

-

351.00

-

744.00

-

2.119

-

111.965

6. cefotaxime

125

250

500

1000

1500*

2

3

3

2

1

13.35

12.92

17.31

28.50

-

27.71

24.60

45.80

64.25

-

2.075

1.904

2.645

2.25

-

107.565

90.402

164.586

125.438

-

7. cefoperazone

250

1000

2000*

2

5

1

56.00

156.60

-

75.00

295.00

-

1.339

1.887

-

33.928

88.378

-

8. cefazolin

250*

500*

1000*

1

1

1

-

-

-

-

-

-

-

-

-

-

-

-

*Prices are not available: hence cost ratio and percentage cost variation cannot be calculated.

DISCUSSION

A number of cephalosporins have been widely trial led and are becoming available in the

world. From the analysis, Cefpodoxime holds the highest number of 194 brands in India and

Ceftizoxime has the least number of marketed brands with only 1 brand. Cefuroxime is

available in both oral and parenteral forms and remaining drugs are available in either in oral

or parenteral forms. Among the oral formulations, cefadroxil 500mg is the cheapest

preparation available in the market whereas, Ceftazidime 2000mg is the cheapest parenteral


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preparation available in which whose prices are made available in the CIMS, July to Oct

2019.

The mean cost has been calculated for all Cephalosporins available except some preparations

whose price is not mentioned in the CIMS, July to Oct, 2019 and the mean cost for oral

Cefaclor 125mg, 250mg, 375mg, 500mg and 750mg strengths is 186.735 INR, 315.368 INR,

414.831 INR, 544.88 INR and 772.34 INR respectively. For Cefadroxil 125mg, 250mg and

500mg strengths is 12.052 INR, 27.73 INR and 39.988 INR respectively. For Cefdinir 300mg

strength is 366 INR. For Cefalexin 125mg, 250mg, 375mg, 500mg and 750mg strengths is

50.833 INR, 79.91 INR, 141.75 INR, 127.4633 INR and 249.75 INR respectively. For

Cefpodoxime 50mg, 100mg and 200mg strengths is 70.833 INR, 115.582 INR and 187.310

INR respectively. For Cefixime 50mg, 100mg and 200mg strength is 57.3904 INR, 80.139

INR and 120.838 INR respectively. For Cefuroxime available at 125mg, 250mg and 500mg

strengths as oral formulation and 250mg, 750mg and 1500mg strengths as parenteral

formulation is 140.5722 INR, 274.1694 INR, 500.336 INR and 54.15 INR 208.911 INR and

224.484 INR respectively. For Ceftriaxone available at 125mg, 250mg, 500mg, 1000mg and

2000Mg strengths as parenteral formulation is 27.501 INR, 29.2517 INR, 47.29 INR,

72.1373 INR and 120.27 INR respectively. For Ceftazidime 250mg, 500mg, 1000mg and

2000Mg strengths as parenteral formulation is 85.932 INR, 186.6 INR, 239.866 INR and

500.45 INR respectively. For Cefpirome 1000mg parenteral formulation is 495.975 INR. For

Cefotaxime available at 125mg, 250mg, 500mg and 1000mg strengths as parenteral

formulation is 20.53 INR, 17.79 INR, 27.986 INR and 46.375 INR respectively. For

Cefoperazone is available at 250mg and 1000mg is 65.5 INR and 248.52 INR respectively.

The highest cost range among the oral preparation of Cephalosporin is for the drug

Cefuroxime 500mg and the least for the drug Cefadroxil 125mg whereas among parenteral

preparations, the highest cost range is for the drug Cefuroxime 750mg and the least for

Ceftazidime 2000mg.

This study discloses that there is a major dissimilarity in costs of cephalosporins available in

India. There were 9696 adult National Health Interview Survey (NHIS) participants who

reported chronic illness; Approximately 1 in 3 chronically ill NHIS participants are unable to

afford food, medications, or both. WIC and public health insurance participation are

associated with less food insecurity and cost-related medication underuse.[8]

Many

chronically ill patients frequently cut back on medication use owing to cost. Patients are


1215


selective about the treatments they forgo. Out-of-pocket costs and inadequate prescription

coverage may lead to adherence problems for many important medication types.[9]

The above

analysis shows that the highest cost ratio and percentage cost variation among orally

available cephalosporins was found for the drug Cefuroxime 750mg [19.298,1829.825] and

least for the drug Cefadroxil 500mg [1.167,16.749] and among the parenteral preparations,

the highest cost ratio and percentage cost variation was seen with Cefuroxime 500 mg

[18.84,1784.210] and the least with the drug Ceftazidime 2000mg [1.018,1.835].

Cephalosporins are the class of agents which are very commonly prescribed for the treatment

and prophylaxis of various infectious diseases. The complete resolution of the disease

depends a lot on the patient compliance. Higher medication costs are often being considered

as an important factor for medication non-adherence, dropouts/lost follow-ups and drug

resistance. Hence, the practitioner must be sensitized about the cost of therapy to make sure

adequate patient compliance.[10]

CONCLUSION

Ebullient pricing leads to increasing economic burden on the general public. Practitioners

should consider the socio-economic background of the patients, while prescribing the drugs.

To control the expense, generic medicines must be preferentially prescribed. Thus the need of

the hour is a joint cooperation from practitioners, pharmacists and general public at large to

take some action to reduce this price variation without compromising therapeutic efficacy.

ACKNOWLEDGEMENTS

Primarily, I would thank God for being able to complete this work with success. We would

like to express our sincere gratitude to Department of pharmacy practice, Karpagam College

of pharmacy for providing us all the facilities and guidance throughout the study. Then I

would like to thank our parents and friends who have helped me with their valuable

suggestions and guidance which has been helpful in various phases of completion of their

work. Last but not the least we thank all our friends for their moral support and

encouragement.

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