Octreotide for Tumor-Induced Osteomalacia

Abstract

To the Editor: The report by Walsh et al. (Jan.24 issue) 1 of a trial of voriconazole, as compared with liposomal amphotericin B, for patients with neutropenia and persistent fever and the accompanying editorial and letter to the editor 2,3 leave many questions about what the trial actually demonstrated and how the findings should be applied.The abstract implies that the study showed equivalence and concludes, "Voriconazole is a suitable alternative to amphotericin B preparations."Yet the text and the accompanying editorial point out that the prespecified statistical criterion for equivalence was not met.To confuse the issue further, correspondents from the Food and Drug Administration provide alternative data, indicating that voriconazole was actually statistically inferior to liposomal amphotericin B with respect to overall success rates. 3Thus, whether the study showed equivalence, near equivalence, or frank inferiority remains unclear.Even if equivalence had been demonstrated, the clinical implications of the findings would remain uncertain.Therapeutic decision making must take into account not just efficacy and safety, as emphasized in the editorial, 2 but also cost.Avoidance of toxic effects may allow a net cost savings despite higher drug acquisition costs, 4 but that possibility requires empirical demonstration.