Expert Perspectives on the Clinical Impact of Non-Medical Therapeutic Switching - Episode 3
Adam Friedman, MD, FAAD provides insight into how non-medical therapeutic switching affects clinical, economic, and psychological outcomes for patients.
Adam Friedman, MD, FAAD: When it comes to the economic impact of nonmedical switching on the patient, there are direct and indirect costs. I’m going to pull a doctor move and say that it has bigger costs. This is not just financial but also physical, social, and psychological. Let’s think about the immediate concerns. Nonmedical switching could possibly result, as we know from past studies in disease recurrence, in worsening or possibly exacerbating or causing the emergence of comorbidities that could end up putting a patient back in the doctor’s office or even in the hospital. That is a cost in terms of the cost of care, the cost of missing work, the cost of needing a dependent care, and also the emotional and psychological burden of their disease going backward, because this would be taking a step back in any progress.
Then we could think about the long-term costs. Now that this switch has affected patients’ care, they can experience an increased sense of distrust and a lack of confidence in the medical care system, which could affect compliance with this medication but also with going to physician visits. It could affect the overall cost of those comorbidities, which we know are rampant with the diseases we are thinking about psoriasis, atopic dermatitis, and hidradenitis suppurativa. We are in the age of comorbidities, and it is easier to say what is not associated with the conditions than what is. This switching has an immediate cost on multiple facets of daily life, but it also has a long-term cost on the comorbidities, which very often could be more costly than the condition or even the medication itself.
Let’s talk about the nocebo effect, which means that the patient has switched and has no impact from the medication whatsoever. Taking a step back, we do have to think about the mind-body or mind-skin connection. There are no questions: The mind-skin connection, given the embryological source, is the same for both the central nervous system and the integument. Say a patient who is doing well on a medication has finally gotten their life under control; the impact of their condition on their quality of life and daily activities has really improved. Now they’re being told, “Guess what? You are being switched to something similar.” That will have a massive impact on emotional state, on patient perception, and compliance, whether a patient even takes the medication, or how the patient even receives the efficacy if there is any. I can tell you, I’ve had patients tell me that the moment they take their medication—I am not going to name names here, of course—but they will say, “I feel better minutes after I have that injection.” We all know that’s not biologically possible, but the patient believes in that treatment course, believes in your medical decision-making, so they’re thinking that all that has overpowered the disease itself. This is the opposite situation; this patient now feels undermined. They feel that their physician, whom they trust and of course adore, is being undercut by an insurance company that does not know them and does not know what is best for them.
Transcript Edited for Clarity