Is Descovy really the better option? [PODCAST]

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“As individual patients, we often don’t think about these costs. In my Instagram poll, nearly everyone taking Descovy reported receiving the drug effectively for free, largely due to Gilead’s copay coupons. However, as with anything in life, nothing really ever is free. More patients taking Descovy rather than generic Truvada means higher overall spending by insurance companies. This eventually comes back to haunt us in the form of higher premiums, and is why we shouldn’t simply adopt a costlier drug like Descovy without good reason to do so.”

Frank F. Zhou is a medical student.

He shares his story and discusses his KevinMD article, “Is Descovy really the better option?”

Reflect and earn 1.0 AMA PRA Category 1 CME for this episode.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Frank Zhou. He is a medical student. He wrote the KevinMD article “Is Descovy really the better option?” Frank, welcome to the show.

Frank F. Zhou: Thanks so much for having me, Kevin.

Kevin Pho: We’re going to get to the article in a little bit, but first off, can you share your story and journey to where you are today?

Frank F. Zhou: Sure. I grew up in New Zealand, and then I came to the States when I was 18 to do my undergraduate education. I did my bachelor’s in chemistry at Harvard, then stayed in Boston for three more years to do health care consulting, where we worked with clients making drugs, devices, and diagnostics. I just moved to L.A. five months ago to start medical school at UCLA.

Kevin Pho: So you were a health care consultant after undergrad for three years. What made you decide to step back into the classroom and go to medical school?

Frank F. Zhou: I’ve always been really interested in health care and the idea of improving the lives of people through medicine and health innovations. I think ultimately, at a certain point, I just really missed that patient interaction. I wanted to have more of a direct impact on patients. I thought that my work was helping companies make products to help patients, but I really wanted to have more direct impact.

Kevin Pho: A lot of medical students go straight from undergrad through medical school. You have the benefit of some real-world experience. Can you comment on how that makes a difference at the beginning of your medical education?

Frank F. Zhou: Oh, I think it’s been so valuable for me, having those three years out of school. I just feel like I have a lot more real-world experience in how the health care industry and health systems work. I can come to medical school with a much better perspective on the various stakeholders that are involved in making health care and delivering these services that we as clinicians will rely on, and hopefully have these innovations for our patients in the future as well. But also to understand how drug companies work, how drug development works, and how insurance and all these different things work that are so important to clinicians but aren’t taught particularly comprehensively in medical school.

Kevin Pho: What are some things about how drugs are developed and how drug companies work that you’ve learned that may not be immediately apparent to some of your other medical students who did not have this type of experience?

Frank F. Zhou: Oh, I mean, it’s a very complicated process. First of all, you’ve really got to understand the amount of resources that are poured into drug development and the amount of failures there are along the way. But then you also realize some of the things that go on in terms of pricing and making sure that a drug is covered by insurance, and the different tips and tricks that companies play to get things covered. But then there are also the things that insurers try to do to make sure that they limit costs. I think that really just gives you a better perspective as a medical student to understand: OK, where are the drug companies coming from? Where are the insurance companies coming from? How does policy maybe play into this, and how do you design policy that understands that each stakeholder has their own issues and motivations?

I think that as a medical student, if you don’t understand this, you might only say, “Well, drug corporations are bad,” or whatever. You may come into it with a very naive view. But I think I do have more of a nuanced understanding of how all of these different stakeholders come together to form our health care ecosystem, which, of course, is in no way perfect. I do have my own biases and interests as a future provider, but I do think I can at least see more perspectives than maybe a typical medical student who didn’t have this real-world experience.

Kevin Pho: All right, let’s transition now to your KevinMD article. It’s titled “Is Descovy really the better option?” Descovy is HIV pre-exposure prophylaxis, one of two options, with Truvada being the other one. Now, just to get all my listeners up to speed, give us some context and tell us what HIV pre-exposure prophylaxis is.

Frank F. Zhou: Of course. Truvada has been the main drug that’s been used for HIV pre-exposure prophylaxis for a while now, and it’s a pretty amazing drug. Basically, it’s a once-daily pill that you take if you’re at a heightened risk of contracting HIV, and it’s really, really effective. If you take it as prescribed, your chances of getting HIV drop by 99 percent or more, so it’s really effective at preventing HIV.

It’s made by a company called Gilead, and they’ve recently, in the last couple of years, launched a new drug called Descovy. I think what my article is talking about is whether this new drug, Descovy, is worth it from a health care system perspective. What are the benefits and disadvantages of using this drug compared to the original one, Truvada? And it’s complicated by the fact that Truvada is now a generic drug, whereas Descovy is still a branded product.

Kevin Pho: All right, let’s go into more details. Tell us about some of the pros and cons. From a patient’s standpoint, what are some of the decision-making processes that go into choosing one treatment over the other?

Frank F. Zhou: I was really interested in this from the patient perspective as well, so I did an informal Instagram poll where I basically asked all of my followers who are on either of these medications to let me know why they chose one drug over the other. I was interested to see that a lot of people have switched to Descovy. About 30 percent of my Instagram followers are on Descovy rather than Truvada, which is mostly generic. Their reasons for going on Descovy were pretty varied. A lot of them thought that it had fewer side effects than Truvada. They thought that their physician had recommended it to them because apparently it was theoretically better for the kidneys or the liver, or something that they’d heard. And then others liked the idea of a smaller pill, or maybe they didn’t really think about it much and just assumed it would be more effective.

Kevin Pho: In terms of some of the research behind these two medications, how valid are some of the reasons patients chose Descovy over Truvada? Does Descovy have a better side effect profile than Truvada?

Frank F. Zhou: I think that’s how Gilead will market it to physicians, that Descovy is better. But when I really looked into the studies and the clinical trials for Truvada and Descovy, it’s not so clear. I would like to characterize it as Descovy having a different side effect profile than Truvada. We do see in the head-to-head trial between Descovy and Truvada that there were a couple of indicators of bone health or kidney health that were in favor of this therapy, so a slightly, and significantly, higher glomerular filtration rate and change in bone mineral density.

But when you talk to the experts, they aren’t sure that these significantly higher numbers really translate to clinical differences, because statistically significant doesn’t always mean clinically significant. And then in the same analysis, you don’t actually see significantly more bone fractures when people are on Truvada versus Descovy. So is the bone health thing really warranted? Is that really a significant improvement when you use Descovy? It’s not so clear.

And then Descovy has a few other drawbacks compared to Truvada as well. It has been associated with weight gain and increased cholesterol. So I think they’re just different side effects, and you just have to look at it from individual perspectives. Maybe if you have some risk of kidney disease, or heightened, pre-existing kidney issues, then maybe you don’t go on Descovy. But I would characterize it as not one drug being better than the other; they just have slightly different side effect profiles. The efficacy is equivalent, so I think there really is not a huge swing in favor of Descovy.

Kevin Pho: And what is the cost difference between Truvada and Descovy?

Frank F. Zhou: Well, it’s hard to say these things exactly, because everyone tries to keep prices pretty under wraps. But as far as I can tell, you can get generic Truvada for less than $50 a month, and the list price for Descovy is $1,900 a month. That’s not the exact price that insurers will pay, but it does highlight the staggering amount of difference there is.

Kevin Pho: So if a patient was prescribed Descovy by their clinical team, should they inquire about Truvada? If the efficacy is similar and the side effect profile is not appreciably worse, but there’s a significant cost difference, is this something that they should ask their clinical team about?

Frank F. Zhou: I would say that it would be prudent to ask. I think from an individual patient perspective, I don’t fault them if they just go with whatever drug is recommended to them. The reason I say they should ask is more from a health system perspective, let’s say, to try and save overall costs when the two drugs are so similar. Because as we know, excess spending is never warranted unless there’s actually a clinical benefit. It raises the prices of insurance premiums for everyone, so why not save costs when the drugs are so similar?

But as an individual patient, you’re not really thinking about these things. You’re just thinking, “Do I have a drug to use right now? They’re both basically the same. I don’t see any cost difference, probably because my insurance covers it.” And then you might not be tempted to ask. But I would say to patients: Do have a conversation with your physicians and think about whether the generic Truvada is basically good enough and just as efficacious for you, and why not stick to that?

Kevin Pho: We’re talking to Frank Zhou. He’s a medical student. He wrote the KevinMD article “Is Descovy really the better option?” Frank, in your informal Instagram poll, in the comment section, in general, what’s the sentiment of your followers when it comes to Truvada versus Descovy? Do they have a preference for one over the other, taking into account the cost difference?

Frank F. Zhou: I think some people really did believe that the side effects were hugely in favor of Descovy, maybe through marketing or what their physicians had told them. And then when I did try to explain some of the research that I did, they were pretty convinced, or wanted to take a second look. What was surprising was that I actually had a lot of friends who already had the same viewpoint as me. They had talked to their doctors or done a bit of extra research themselves and come to the same conclusion, thinking, “Why would they go on Descovy when it’s basically the same drug, as far as they could tell?” So I had a lot of support for my article from my Instagram followers as well.

Kevin Pho: And my final question: What are some of the take-home messages that you want to leave with the KevinMD audience?

Frank F. Zhou: I think as a physician, I’ve been thinking that there are so many new drugs that come out, and it’s hard to do the full diligence of your research on every new drug. So you do rely a lot on marketing and sales reps and companies coming to you with proposals. I don’t really fault doctors for just pushing Descovy if they think it’s a newer and better drug. But I think it’s good ultimately, and this is something I hope to remember in the future, to just do a bit of extra diligence on every new drug that comes out. Maybe don’t buy the hype immediately, and think about how you can sometimes save costs for the system, because health care costs are so high in the U.S. right now. Every little bit doesn’t matter.

Kevin Pho: Frank, thank you so much for sharing your time and insight, and thanks again for being on the show.

Frank F. Zhou: Thanks for having me.

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