Free-of-charge medicine schemes in the NHS: A local and regional drug and therapeutic committee's experience

INTRODUCTION

Free-of-charge (FoC) medicine schemes are increasingly available and allow access to investigational treatments outside clinical trials or in advance of licensing or NHS commissioning.

METHODS

We retrospectively reviewed FoC medicine schemes evaluated between 2013 and 2019 by a single NHS trust and a regional drug and therapeutics committee (DTC). The details of each locally reviewed FoC scheme, and any nationally available Medicines and Healthcare products Regulatory Agency Early Access to Medicines Scheme (MHRA EAMS) in the same period, were recorded and categorised.

RESULTS

Most FoC schemes (95%) allowed access to medicines intended to address an unmet clinical need. Over 7 years, 90% were company-FoC schemes and 10% were MHRA EAMS that were locally reviewed. Phase 3 clinical trial data were available for 44% of FoC schemes, 37% had phase 2 data and 19% were supported only by phase 1 data, retrospective observational studies or preclinical data. Utilisation of company-FoC schemes increased on average by 50% per year, while MHRA EAMS schemes showed little growth.

CONCLUSION

Company-FoC medicine schemes are increasingly common. This may indicate a preference for pharmaceutical companies to independently co-ordinate schemes. Motivations for company-FoC schemes remain unclear and many provide access to treatments that are yet to be evaluated in appropriately conducted clinical trials, and whose efficacy and risk of harm remain uncertain. There is no standardisation of this practice and there is no regulatory oversight. Moreover, no standardised data collection framework is in place that could demonstrate the utility of such programmes in addressing unmet clinical need or to allow generation of further evidence.

AB0326 REAL-WORLD EXPERIENCE ON SWITCHING ADALIMUMAB ORIGINATOR TO BIOSIMILAR IN INFLAMMATORY ARTHRITIS – A RETROSPECTIVE STUDY

Background:

The patent for adalimumab originator expired in 2018 in the United Kingdom. Subsequently, four adalimumab biosimilars were launched. National Health Service England undertook a managed market share tender to ensure plurality of suppliers and price competition over the longer term. Each hospital was subsequently allocated a preferred brand of adalimumab biosimilar. Here we describe our experience of switching patients with inflammatory arthritis from adalimumab originator to the biosimilar, ABP 501 in a single centre.

Objectives:

To evaluate the proportion of patients successfully switched from adalimumab originator to ABP 501 focusing on drug retention, reasons for remaining on originator and reasons for switching back from biosimilar to originator.

Methods:

A retrospective analysis was completed on the cohort of 287 rheumatology patients who were prescribed adalimumab originator prior to the switch to ABP 501. Case notes were analysed to identify whether patients remained on biosimilar 24 weeks after switching from originator.

Results:

99% patients on adalimumab originator (283/287) were switched to ABP 501 within 32 weeks, starting from February 2019. 1% (4/287) remained on originator due to a confirmed latex allergy, as the needle cover of the ABP 501 pre-filled syringe consists of dry natural rubber. 4% (12/283) of patients who switched to biosimilar reverted to originator (1 patient per 2 weeks over 24 weeks). 3% (9/283) of patients who switched to biosimilar were no longer receiving any adalimumab therapy. Reasons for ceasing therapy included recurrent infections (4/9) and progression to the next line of biologics/small molecule therapy (5/9). 93% (262/283) remained stable on ABP 501 (Table). Applications to revert to originator were reviewed by a Biosimilar Steering Group (BSG). The BSG assessment included a review of disease activity, reported symptoms and adverse reactions before and after the switch to biosimilar. Approval to revert to originator occurred in patients who had a clear increase in disease activity or newly reported adverse reactions. If the patient had active disease prior to switch, a change to non-adalimumab therapy would be recommended instead. Of the 12 patients who reverted to originator, 7 (58%) did so due to reduced effectiveness, 3 (25%) due to adverse reactions, and 2 (17%) due to both. Adverse reactions reported within 24 hours of the first injection included nausea, anxiety, insomnia, tinnitus, dizziness, headaches and injection-site reactions. Patients also reported hair loss, fatigue and mouth ulcers. Reported adverse reactions ceased once biosimilar was stopped and/or switching back to originator. All patients who reverted to originator due to reduced effectiveness reported a reduction in disease activity and improvement in symptoms.

Conclusion:

The vast majority of patients in our cohort on adalimumab were successfully switched from originator to ABP 501. The adalimumab biosimilar has been generally well-tolerated. 93% remained on biosimilar 24 weeks after switching, 4% have switched back to originator and 3% have either stopped or changed treatment. Reasons for switching back to originator from biosimilar included adverse reactions, most of which occurred within 24 hours, and also worsening of symptoms.

Table 1.

The dynamics of the disease activity during treatment with TOFA

Baseline characteristics/outcomeTotalN = 283RAN = 90 (32%)SpAN = 108 (38%)PsAN = 77(27%)OtherN = 8(3%)Mean age (SD)49.8 (14.6)58.5 (14.9)43.6 (11.0)48.4 (13.2)46.1 (15.2)Female, n (%)126 (45)67 (74)29 (38)26 (34)4 (50)Reverted to Originatorn (% of patients within subgroup)12 (4)4 (4)6 (6)1 (1)1 (13)Reasons for switching back to OriginatorInefficacy71411Adverse reactions32100Both21100Switched to another biologic agentn (% of patients within subgroup)5 (2)3 (3)2 (2)0 (0)0 (0)Stopped biologicsn (% of patients within subgroup)4 (1)1 (1)1 (1)2 (3)0 (0)

Disclosure of Interests:

None declared

A novel approach to support implementation of biosimilars within a UK tertiary hospital

Aims To assess the transfer of patients treated with originator biological therapies to biosimilar products in a large UK tertiary referral hospital reflecting practice within the National Health Service (NHS) using prospectively collected data by a hospital-based registry administered by the Biologics Steering Group (BSG).

METHODS

We analysed data collected prospectively in a hospital-based registry in a large NHS tertiary referral hospital in the UK. The registry was administered by the hospital's BSG, which considered requests for patients to remain on or revert to originator products. The registry contained prospectively collected data on patients switching therapy from an originator to a biosimilar. The data included clinical circumstances or rationale for each request, whether it was granted, and the results of clinical reviews at 3-6 months.

RESULTS

In a 12-month period, we identified 1299 patients who could switch to the respective biosimilar and, of these, 1196 (92%) did so. Of the 260 patients taking infliximab, 250 (96%) switched to infliximab biosimilar; of the 390 patients taking etanercept 50 mg, 298 (76%) switched to etanercept 50 mg biosimilar; and of the 649 patients taking rituximab, 648 (99%) switched to rituximab biosimilar. The BSG received 39 applications: 12 (out of 39) applications were to remain on the originator and 27 (out of 39) were to switch back to the originator. Of the applications to remain on the originator 10 (out of 12) were approved. At 3-6 month review, 2 of these approvals reported continued efficacy, 3 switched to the biosimilar, 3 switched to an alternative therapy and 2 stopped treatment. Two (out of 10) applications were not approved, both applicants reported efficacy with the biosimilar at follow up. Of the 27 applications to switch back to the originator, 16 (out of 27) applications were approved. At 3-6 months, 9 (out of 16) applicants reported regain of efficacy, 6 (out of 16) reported cessation of reported adverse effects and 1 (out of 16) switched to alternative therapy. Eight (out of 27) applications were not approved, and, at point of follow up, 50% reported efficacy with the biosimilar and 50% had switched to an alternative therapy. Three (out of 27) applications were withdrawn by the clinical team as efficacy was achieved with the biosimilar.

CONCLUSION

We have set up a system within a busy NHS clinical practice to successfully switch patients to biosimilars, and established a mechanism to guide decisions on continuing with or reverting back to the originator. Such a system could be of use more broadly within the NHS and other health care systems.

A time-driven, activity-based costing methodology for determining the costs of red blood cell transfusion in patients with beta thalassaemia major

OBJECTIVES

To describe the methodology to estimate the total cost of administration of a single unit of red blood cells (RBC) in adults with beta thalassaemia major in an Australian specialist haemoglobinopathy centre.

BACKGROUND

Beta thalassaemia major is a genetic disorder of haemoglobin associated with multiple end-organ complications and typically requiring lifelong RBC transfusion therapy. New therapeutic agents are becoming available based on advances in understanding of the disorder and its consequences. Assessment of the true total cost of transfusion, incorporating both product and activity costs, is required in order to evaluate the benefits and costs of these new therapies.

METHODS

We describe the bottom-up, time-driven, activity-based costing methodology used to develop process maps to provide a step-by-step outline of the entire transfusion pathway. Detailed flowcharts for each process are described. Direct observations and timing of the process maps document all activities, resources, staff, equipment and consumables in detail. The analysis will include costs associated with performing these processes, including resources and consumables. Sensitivity analyses will be performed to determine the impact of different staffing levels, timings and probabilities associated with performing different tasks.

RESULTS

Thirty-one process maps have been developed, with over 600 individual activities requiring multiple timings. These will be used for future detailed cost analyses.

CONCLUSIONS

Detailed process maps using bottom-up, time-driven, activity-based costing for determining the cost of RBC transfusion in thalassaemia major have been developed. These could be adapted for wider use to understand and compare the costs and complexities of transfusion in other settings.