# Drug Price and Health Policy Knowledge Influence Prescription Behavior in Orphan Diseases: Pheochromocytoma and Paraganglioma As Prototypes of Orphan Drug Econometrics

## TL;DR

This study shows that doctors changed their prescription habits for rare diseases when they learned about rising drug prices and new policies.

## Contribution

It demonstrates how provider awareness of orphan drug pricing policies affects clinical decision-making in rare disease treatment.

## Key findings

- Use of phenoxybenzamine for perioperative blockade dropped significantly from 2015 to 2021.
- Nitroprusside use as an intraoperative vasodilator also declined over the study period.
- Alpha-1 selective agents replaced phenoxybenzamine as the preferred treatment.

## Abstract

Introduction

Two federal drug policies, the Orphan Drug Act of 1983 (ODA) and the Unapproved Drug Initiative of 2006 (UDI), created market exclusivity and arbitrage opportunities in pharmaceutical pricing for two rare diseases, namely, pheochromocytoma and paraganglioma (PPGL). Historically, phenoxybenzamine and nitroprusside, amongst other medications, have been the first-line drugs for the perioperative and intraoperative management of patients undergoing PPGL resection. We aimed to assess the prescription behavior in perioperative pheochromocytoma management at an institution where providers have knowledge of orphan drug pricing.

Methods

We performed a retrospective cohort study of adult patients who underwent PPGL resection from January 2015 to September 2021. Patients in the study were seen at a tertiary academic medical center. 96 patients were included in this study and all patients underwent the standard University of California, Los Angeles (UCLA) perioperative surgical and anesthetic management. We assessed incidence of phenoxybenzamine and nitroprusside utilization as a perioperative blockade and as an intraoperative vasodilator, respectively. Statistical comparison of drug utilization was performed using the Cochran-Armitage test.

Results

Between 2015 and 2021, six (86%), 15 (75%), six (35%), seven (64%), two (17%), five (42%), and two (12%) patients received phenoxybenzamine as perioperative blockade, respectively. Similarly, between 2015 and 2021, one (14%), five (25%), 11 (65%), four (36%), 10 (83%), seven (58%), and 15 (88%) patients received alpha-1 selective blockade as perioperative treatment, respectively. The inverse change in phenoxybenzamine and alpha-1-selective agent utilization was statistically significant (p < 0.0001). Between 2015 and 2021, four (57%), two (10%), one (6%), zero (0%), zero (0%), zero (0%), and zero (0%) patients received nitroprusside as an intraoperative vasodilator, respectively. Similarly, between 2015 and 2021, three (43%), 18 (90%), 16 (94%), 11 (100%), 12 (100%), 12 (100%), and 17 (100%) patients did not receive nitroprusside as an intraoperative vasodilator, respectively. The decreasing nitroprusside utilization was statistically significant (p = 0.0004).

Conclusion

From 2015 to 2021, in the setting of the UDI and ODA, utilization trends of perioperative phenoxybenzamine and intraoperative nitroprusside decreased among the 96 patients undergoing PPGL resection. This study illustrates that provider knowledge of drug price increases can drive prescription behavior change. Provider knowledge of drug econometrics in rare diseases provides a platform for value creation in care delivery.