Patients must pay for improved drugs

Priscilla Cole, 74, has given up golf and cross-country skiing. In fact, she can’t vacuum or even lift a bag of milk.

Margot Conway, 66, says she can no longer romp with her grandchildren, and trying to put on pantyhose or cut her toenails is torture – because she might fracture a bone.

Both women have osteoporosis, the bone-wasting disease that for its many victims makes a lie of all those articles we read about today’s seniors enjoying vigorous later years.
“As far as quality of life is concerned,” says Cole, who has endured four fractures, one being her hip, “it’s a disaster.”

Government won’t pay for new drugs
Incredibly, though, the Ontario Drug Benefit Plan (ODBP) is refusing to pay for new drugs that have a proven record in treating and preventing osteoporosis, leaving many
medical specialists incensed.

“It’s ridiculous, absolutely ridiculous,” says Dr. Rick Adachi, a Hamilton rheumatologist and professor of medicine at McMaster University in Hamilton, Ont. He estimates he spends the equivalent of two weeks a year writingetters to the ODBP, trying to get exemptions for his patients, only to have his judgments questioned by bureaucrats and his requests too often denied.

“It’s really stupid,” charges Dr. Gillian Hawker, an osteoporosis specialist at the Sunnybrook and Women’s College Health Sciences Centre in Toronto. Exemptions, even when granted, can take as long as eight to nine months to be processed. Meanwhile, her patients “are seeing their longevity getting shorter and their quality of life going down, down, down.”

Since coming to power in 1995, Mike Harris’ Conservative government has approved scores of new drugs for inclusion in the Ontario drug formulary, many of them for heart disease and high cholesterol. Yet not a single one for osteoporosis has made the list. Hawker believes she knows why.

The newly approved drugs, she says, are predominantly for male-oriented diseases.
“Those lobbying for this disease are little old ladies who don’t have the clout of younger, more powerful and wealthy organizations” – organizations which, she says, often advocate on behalf of comparatively rare diseases.

Osteoporosis is a growing concern for a population that’s living longer. Today, 1.4 million Canadians have osteoporosis and 27,000 a year experience hip fracture. According to the Osteoporosis Society of Canada (OSC), the incidence of the disease will more than triple in the next few decades.

“Osteoporosis,” says Dr. Hawker, “does kill people.” Up to 20 per cent die in the year following a hip fracture – usually from complications, especially pneumonia resulting from immobility – and 50 per cent are disabled.

Yet Ontario doctors find their hands tied when it comes to treating patients who have experienced a fracture or are in danger of fracturing. Only two options for prevention or treatment are available under the ODBP: hormone therapy (which many women reject because of a slight risk of breast cancer) and Etidronate, a first-generation drug in a non-hormone family of pharmaceuticals called bisphosphonates.

Newer bisphosphonates, says Gordon, “show proven and substantive benefits” – but they’re not yet available under the drug plan. But Hawker says government-commissioned best-practice guidelines about to be distributed to physicians recommend these medications, presumably at the patient’s cost.

Ontario, like the other provinces, has been concerned about the increasing cost of its drug plan for seniors, yet so far there are no (cheaper) generic versions of the three osteoporosis drugs available.

Pay now or later
However, for taxpayers, it’s a case of pay now or pay later: the drugs cost between $700 and $875 a year per patient while the treatment cost for a hip fracture averages $30,000.
With the exception of Prince Edward Island, the other nine provinces have all made Fosamax (one of the newest bisphosphonates to hit the market) available, although usually on a limited basis. Quebec, however, has made Fosamax and other bisphosphonate drugs available without restriction.

An Ontario Health Ministry official confirmed that while Fosamax isn’t listed on the Ontario plan, doctors who want to prescribe the drug for particular patients can use the “section eight appeal procedure,” and the osteoporosis drugs fall in an “expedited classification” to avoid delays.

However, says Hawker, the patient must already be on the approved Etidronate, and the doctor must prove there’s a side effect or a failure to respond. This involves gathering the evidence, writing several letters – and waiting for a review.

The choice for many Ontario seniors with osteoporosis is a tough one: find the money for the drugs themselves or accept the added risk of fractures. “I put myself on Fosamax,” says Margot Conway of Kitchener-Waterloo, Ont. “I’m retired. I can’t afford it. So part of our holidays had to go.”

Says Priscilla Cole, in Toronto: “Two dollars a day [the cost of some of the new drugs] to a senior on $12,000 a year is a problem, especially for older women without pension plans. They don’t eat.”