Wednesday, 7 September 2016

Time to Reduce costs

Kister I, Corboy JR. Reducing costs while enhancing quality of care in MS. Neurology. 2016. pii: 10.1212/WNL.0000000000003113. [Epub ahead of print]
The rapid escalation in prices of disease-modifying therapies (DMTs) for multiple sclerosis (MS) over the past decade has resulted in a dramatic overall increase in the costs of MS-related care. In this article, we outline various approaches whereby neurologists can contribute to responsible cost containment while maintaining, and even enhancing, the quality of MS care. The premise of the article is that clinicians are uniquely positioned to introduce innovative management strategies that are both medically sound and cost-efficient. We describe our "top" recommendations, including strategies: for (1) customizing relapse treatment; (2) developing alternative dosing schedules for Food and Drug Administration-approved MS DMTs; (3) using off-label therapies for relapse suppression; and (4) limiting the use of DMTs to those who clearly fulfill diagnostic criteria, and who might benefit from continued use over time. These suggestions are well-grounded in the literature and our personal experience, but are not always supported with rigorous Class I evidence as yet. We advocate for neurologists to take a greater role in shaping clinical research agendas and helping to establish cost-effective approaches on a firm empiric basis.
Few neuros put their head above the parapet to ask for a shake-up.

However, does the MS world really want to reduce costs levied by Pharma Treatments?

Some do very well out of it, like the "infusion clinics" that can be a nice little earner for some neuros, compared to a pill taken at home that you don't need to visit the Doc for a Ker-Cling Appointment

If they it did want a change, would they try and adopt any of the recommendations above?

In the age of personalised medicine you could argue that you could monitor the blockade of CD49d on white blood cells to help inform if you need to re-dose with natalizumab so could it be every 5-6 weeks rather than every 4weeks, for example. However, should it be less, a number of pwmS have said that they can feel their tysabri has worn off before their next dose.

Importantly what are the safety aspects of changing the dosing? 
Pharma invest hugely in working out the safety of dosing.

Should Neuros be working out dosing schedules?
First we had 20mg copaxone daily and now 40mg copaxone three times weekly. If neuros did a study 60mg copaxone twice a week or 120mg copaxone once a week,. Would this bring the price down? or give pharma information to file a patent?

Can Neuros come together to get enough information to support off-label prescription?

Having witnessed this first hand, it is like getting teeth pulled. 

There has not been much evidence of this, maybe an azapioprine study in Italy and what about rituximab in Sweden? 
Surely the thousands of people who have been prescribed the drug should be enough to make recomendations. But where are they?

However off-label agents may give some people access to drugs as they or their countries cannot afford them.
You would think the MS Societies would invest in this?

However cutting people off treatment after it is seemingly not woking enough or is not cost -effective is an interesting one. 
What do you think?

In NICEland UK this is a familiar issue

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