Oli Hudson, Content Director at Wilmington Healthcare, analyses prescribing data in three key disease areas
In common with many other aspects of clinical practice, Covid-19 seems to have accelerated pre-existing trends in prescribing, hence it has become more community-based and the use of intravenous drugs has declined as outpatient clinics have been closed or scaled back.
In this article, we will examine three key disease areas: COPD, rheumatoid arthritis and multiple sclerosis to determine which drug types have been the winners and losers in terms of usage over the past nine months. We will also look ahead to what may happen during 2021.
COPD patients were discouraged from attending hospital-based clinics and almost exclusively managed in primary care during the first wave of the pandemic. Some patients used existing medications and bronchodilators under GP supervision; while others were switched onto treatment plans that could be safely administered through primary care alone.
This is echoed in prescribing data, with figures for hospital prescribing going down marginally in the spring, before reverting to normal over the summer as clinics reopened. Given that 98 per cent of prescriptions were being administered in primary care before the pandemic, its net effect was marginal.
However, the data confirms that prescribing remains primary care-led for COPD, with efforts during the first wave focused on stabilising patients in a Covid-safe way. Since both national policy and clinical guidelines steer towards community-based care, the situation is unlikely to change in 2021.
Rheumatoid arthritis has seen a significant rise in prescribing rates for biosimilars. From March 2019, use of on-patent Etanercept, Adalimumab and Rituximab went down, while the Adalimumab biosimilar went up and so did Etanercept and Rituximab biosimilars. This is to be expected because as generic biologics get approved, use of branded biologics goes down and the arthritis pathway becomes cheaper to run.
A challenge for pharma now is how to capitalise on this knowledge in the new integrated healthcare systems. Some Integrated Care Systems (ICSs) may not have a particular rheumatoid arthritis pathway but they may have a workstream to look at all older patients, many of whom will have rheumatoid arthritis.
The key commercial question heading into 2021 will be discovering who best to talk to about treatments and the impact of biosimilars on their patient communities.
Theoretically, the system should have more money to spend as there should be cost savings and this may open up opportunities to invest elsewhere in the rheumatology pathway, or maybe elsewhere in the workstream for older people.
Multiple sclerosis presents a more challenging story for pharma. Between May 2019 and May 2020, there was a reduction in several key treatments: Lemtrada, Tysabri and Gilenya. Lemtrada is a monoclonal antibody (MAB) given by infusion. Tysabri, or natalizumab, is also an infusion injection. For both of these treatments, the prescribing figures are down.
This is almost certainly because of the way they are administered. They would not have been able to be given to multiple sclerosis patients during the initial phase of the pandemic and this is reflected in the patterns across our data.
The mystery though is what has happened to these MS patients in the meantime? How are they being managed and what have they been switched to, if anything? Our initial instinct was that the orally-administered Gilenya picked up the slack, but we found that this was also down minus 0.6 percent during this time-frame.
Yet, Gilenya aside, we found the medications trending upward were orally administered, which demonstrates a market leverage in having an oral alternative to biologics and biosimilars.
An important driver for this is surely the NICE rapid response guidelines, which made it clear that vulnerable patients should be switched to oral or subcutaneous or homecare-based medications where possible.
The question is how much, if at all, we will see the re-emergence of intravenous treatment as the pandemic subsides? Also, we need to confront the possibility that some MS patients may have experienced poorer clinical outcomes as a result of being shifted away from established drugs during the peak of the first wave.
Applying the spotlight to these three specific disease areas is obviously selective, but it does start to build a more universal message about the importance of looking into the nuances of prescribing patterns in 2021.
The fuller research we’re conducting suggests that pharmaceutical companies need to be very sensitive to pandemic-led changes to care pathways potentially leaving patients facing sub-optimal treatment plans.
Yet there is also the prospect that wholesale shifts in prescribing, notably from branded to generic medicines, could result in significant cost-savings – and with this may come potential opportunities for new investment elsewhere in a care pathway.
Or, for companies with on-patent drugs experiencing a sustained drop in sales, conversations could be had about whether patent biologic medicine could be used on other patient cohorts within the same pathway.
Furthermore, while the pandemic has clearly left its mark on prescribing patterns, not all of these trends are driven wholly or even partially by Covid-19. However, many of these patterns and nuances will persist into 2021 and beyond, and they underline the importance of understanding purchasers’ needs and thinking holistically across whole care pathways.
Formulary insights and competitive landscape
To help companies understand the changing picture, Wilmington Healthcare has launched a new system that enables pharma to gain a clear understanding of formulary status across therapy areas and territories in the UK. InFormulary XD is a cloud-based platform that enables users to gather data and real-world evidence on formularies and see how their product is performing in the competitive landscape.