Maybe not. I have the Alanis Morissette approach to irony, more of the situational variety.

I am, as you may know, an Infectious Disease doctor. One of the diseases I am seeing more of recently is infections from the yeast Cryptococcus gattii. In the great Pacific NW has had increasing disease due of this organism since it was introduced into Vancouver Island about a decade ago. It causes pneumonia and meningitis and C. gattii is more virulent and more resistant to antibiotics.

The guidelines suggest various forms of amphotericin B for meningitis. There are two forms of amphotericin: regular and lipid. There is probably no difference in efficacy between the two formulations, the lipid form is less toxic and way more expensive.


So on balance if you have two drugs that have equal efficacy you go with the drug with the less toxicity. Unless it is more expensive.

Whereas the 50-mg vial of dAmB required to administer a typical 0.7-mg/kg dose of dAmB to a 70-kg adult costs ∼$20 (US currency), the licensed doses of the LFABs are 3–6 mg/kg, and the acquisition cost of a single dose for the same 70-kg adult is ∼10–50 times the cost of dAmB.

I have had several patients of late I wanted to treat with lipid amphotericin but it would not be paid for in the outpatient setting by Care Oregon. They preferred to use regular amphotericin. Cheaper. Maybe more toxic. But not worse.

I had not real issues with the change. Most patients do fine with regular amphotericin if you know how to give it and I do. I gave regular amphotericin for years before the lipid form and I can follow for complications.

The odd thing is that Care Oregon does pay for acupuncture for headache. So they may pay for a pseudo-medicine with no efficacy and only complications, but they will not pay for a real medicine with good efficacy and fewer complications.

Or another way to think about it, they can get a worthless therapy for the headache caused by the Cryptococcal meningitis, but not the least toxic therapy to treat the Cryptococcal meningitis.

That’s ironic? Right?

Of Mice and Pain