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Commentary on the ICER Psoriasis Drug Cost Report

January 2, 2017

Determining the systemic therapy that will work best for a patient with moderate-to-severe plaque psoriasis who has been unresponsive to other therapies is a common clinical challenge for practitioners. 

Recently, the non-profit Institute for Clinical and Economic Review (ICER) published a comprehensive review of clinical data on the wide range of systemic therapies currently on the market to treat plaque psoriasis1 in an effort to determine which medications may provide the most cost-effective options.

In this commentary for Practical Pain Management (PPM), Jeffrey Fudin, PharmD, DAAPM, FCCP, FASHP, together with Erica Wegrzyn, PharmD, and Sooyoen Kwon, Ph.D., PharmD Candidate, provided insights regarding the ICER's cost-benefit analysis on systemic therapies for the treatment of moderate-to-severe plaque psoriasis. To read a news and research summary of the ICER report, including an interview with the ICER’s president and founder, Steven D. Pearson, MD, MSc, click here.

Fortunately, the market for pharmacological therapies aimed at moderate-to-severe plaque psoriasis has expanded considerably.

Members of the PPM editorial board were asked to respond to a series of questions about best practices when treating difficult cases of psoriasis.

Q.  Should the ICER findings influence future treatment decisions when dealing with patients suffering from moderate-to-severe plaque psoriasis, or, do these guidelines simply highlight the high cost of psoriasis therapies, leaving treatment decisions to fall on clinical experience and meta-analyses, rather than cost-benefit?

Drs. Fudin, Wegrzyn, and Kwon responded that in the clinical setting, the most important factors that should influence treatment decisions for patients with plaque psoriasis are, first and foremost, efficacy and safety, followed by reported and actual patient outcomes and quality of life potential. 

“While the cost-benefit analysis presented in ICER’s report postulates a plausible decision-making tool, we must not lose sight of the bigger picture,” Dr. Fudin told Practical Pain Management.

“An economic modeling approach is operationalized based on a set of assumptions with a base case scenario," said Dr. Kwon. "Then, through sensitivity analyses, a probable range of cost estimates around the base case are generated.”

“Although this approach is methodologically acceptable and provides some guidance, the assumptions can be unrealistic, and the base case scenario is grounded on limited information, such as clinical trial data, which is not always reflective of a real-life setting,”  Dr. Kwon added.

Drs. Fudin, Wegrzyn, and Kwon also felt there are significant costs to society that were overlooked by the ICER report.

Costs of Comorbidities 

Dr. Fudin suggested that up to 40% of patients with psoriatic arthritis may develop seronegative inflammatory arthritis, inflammatory bowel disease, and/or syndrome X, for which the sequelae are extremely costly.

“Societal costs of secondary cardiovascular disease, various malignancies, and severe depression resulting from inferior plaque psoriasis treatment are all missing from ICER’s cost-benefit model,” Dr. Fudin said.

Dr. Kwon observed that the ICER report suggested that the incremental cost of ixekizumab compared to etanercept per QALY (quality adjusted life year) gained was estimated to be $78,000 dollars. However, “presently, the cut-offs regarding how much society should pay or individuals are willing to pay to gain a QALY is highly debatable, and often depends on the specific diseases and conditions. Some may perceive the nearly $80k price tag as a reasonable cost, while others may view this as excessive," she said.

“In general, we prefer to reserve ixekizumab for the patients who do not respond to the other drug choices that have been on the market for quite a while with cumulated experience of use, and until its postmarketing surveillance data shows reliable efficacy and safety along with positive patient reported outcome information,” Dr. Kwon said.

One of the main findings of the ICER report was to highlight that most list prices for therapies to treat psoriasis are excessive, according to their perceived value.

Q.  Have you found in your own practices a noticeably prohibitory aspect to the price tags associated with these high-value treatments? Is this something that influences clinical decisions negatively, particularly if a patient’s insurance refuses to cover the new medications, such as, ixekizumab, for instance?

“Formulary preferences of third party payers often play a significant role, at times a limiting role, in therapy selection, particularly in disease states where all feasible options carry a hefty price tag,” said Dr. Wegrzyn. “With many different third-party plans and individual formularies, it can be challenging to provide a generalized response."

“While in an ideal world clinicians would be permitted to select the most efficacious therapy without regard to cost or third-party preference; this is not based in reality. In theory, this could require a trial of a more affordable and less efficacious therapy before a more efficacious treatment with a higher price tag was prescribed. Unfortunately, the typical third-party formulary structure does not allow for consideration of first-hand experience of the clinician.”

In a roundup of how the advisory council voted on a number of topics, the one question that seemed to totally divide the council was whether there had been enough evidence to conclude that IL-17A drugs as a class have a higher net health benefit over adalimumab. Obviously, this is a serious determination to make, considering Humira for years owned the lion’s share of the market for immunomodulators.

Q. Personally, have you found any clinical experience comparing patient outcomes with adalimumab versus some kind of new IL17A drug, like secukinumab? What do you make of the fact that clinicians still seem pretty split in opinion about this?

Dr. Wegrzyn shared an example of a patient on secukinumab currently showing significant improvement. “In this case, the patient is being treated for refractory psoriatic arthritis rather than plaque psoriasis. However, we have seen similar treatment trends with both disease states.

“The patient initially displayed treatment response to adalimumab and other biologic therapies, but eventually continued to progress significantly. The initial response to early secukinumab appears to be improved compared to adalimumab therapy.

“It is becoming increasingly clear that often treatment response with biologics is not a sustainable solution, rather the question translates to how long one can sustain a viable treatment response and overall remission – this demonstrates the need to focus on individualized therapy rather than lumping everyone into a single kettle with the focus on cost.”

Q. So why do clinicians seem to have split opinions about adalimumab versus IL-17A drugs as a class?

“Based on the network meta-analyses, ixekizumab and brodalumab were superior to adalimumab, but secukinumab failed to show superiority. So, when the panel was asked to do a comparative benefit between adalimumab versus IL-17A drugs ‘as a class’, which includes all 3 agents (ixekizumab, brodalumab, and secukinumab), ICER panel members might have simply taken into account the fact that one agent in the class, secukinumab, was not superior to adalimumab," said Dr. Kwon.

“I suspect that if the question were written for a specific comparison, i.e., ixekizumab versus adalimumab, the voting panel might have answered differently. Another possibility is that clinicians might feel less comfortable with a newer agent that comes with the limited experience of use in the population, especially when the direct head-to-head comparison data between older and newer is scarce," said Dr. Kwon.

“One example is the use of TNF-alpha inhibitors and non-TNF biologics in the treatment of rheumatoid arthritis. TNF-alpha inhibitors and non-TNF biologics are known to be equivalent in treating rheumatoid arthritis based on meta-analyses and guidelines," said Dr. Kwon. "However, in practice, many clinicians still consider TNF-alpha inhibitors, especially adalimumab, etanercept, and infliximab, as first-line agents because these agents have been on the market for the longest period, providing plenty of cumulated clinical experience.”  

Statements made are the sole opinion of the authors quoted and stated opinions/assertions do not reflect the opinion of employers or employee affiliates nor were they prepared as part of any duty as federal employees. Click here to read the PPM research summary on the study. A summary analysis and full copy of the ICER report is also available.

Last updated on: May 7, 2020
Continue Reading:
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