Reply to Williams et al

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To the Editor—We appreciate the opportunity to provide a response to Williams et al regarding our study published in Open Forum Infectious Diseases in 2023 [1].

In general, we agree with most of the comments raised by the authors and believe that they accurately illustrate a continuing problem of inadequate support for the use of mold-active triazoles (MATs) by insurance companies, plans, and/or pharmacy benefit managers directing care in non–clinically relevant ways, resulting in high out-of-pocket costs to patients who need life-saving antifungal therapy. As a result, access to MATs, drug prices, and payor coverage are still major problems in the United States. However, our study was not designed to address costs to patients, but instead to focus on epidemiological, mycological, safety, and outcome data in real-world patients who received MAT prophylaxis.

Moreover, there are several key differences between our study and that of Williams et al, which may be responsible for the differences observed. First, our study extracted data primarily from large academic centers, which may reflect care that is different to that of the community hospital investigated by Williams et al. Additionally, among the 3 MATs assessed in our study, only voriconazole was generically available during the study period, and the availability of isavuconazole and posaconazole may have impacted overall treatment costs. Since then, posaconazole has now also become generically available and there are programs to ameliorate the burden for those patients in whom the cost of MATs is prohibitive. With that said, we do acknowledge that posaconazole is still very expensive from retail outlets.

Notably, we consider the finding of Williams et al that almost half of their patients transitioned from MATs to non-MATs of particular interest to this therapy area. Use of non-MAT therapies (such as echinocandins, amphotericin B, or fluconazole) may well be an acceptable cost-effective alternative; however, in cases where alternative therapy is used, careful monitoring of signs and symptoms of invasive fungal disease is warranted, as evidenced by their case of breakthrough Aspergillus infection occurring during treatment with fluconazole.