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How Cost-Effective are Drugs for Plaque Psoriasis?

January 1, 2017
As the market for systemic therapies for moderate-to-severe plaque psoriasis continues to expand, a new report evaluates the value of medication therapy.

Managing moderate-to-severe plaque psoriasis in patients often calls for the use of systemic therapies, and the market of available drugs for this condition has widened dramatically in recent years.

While around 80% of people with mild psoriasis respond well to topical therapies, some patients do not see any improvements with topical agents, phototherapy, or even older systemic therapies, like methotrexate and cyclosporine. 

New medications, such as the (IL)-17A inhibitor, secukinumab (Cosentyx; Novartis) and ixekizumab (Taltz; Eli Lilly & Co) and the litany of tumor necrosis factor (TNF) inhibitors, command high prices on the pharmaceutical market.

As the US Food and Drug Administration continues to approve generic versions of these newer drugs with the intent of lowering costs, it raises the question: Are these brand-name pharmaceuticals worth their high prices? For now, the answer may be yes.

“When you look at the average net price in the US system, all of these drugs fall within our cost-effectiveness range that essentially represents reasonable value,” Steven D. Pearson, MD, MSc, the founder and president of the Institute for Clinical and Economic Review (ICER) told Practical Pain Management.

The ICER is an independent, non-profit organization that conducts analyses of available medications and delivery systems to determine their cost-effectiveness to patients. Recently, the ICER conducted a cost-benefit analysis on the systemic therapies indicated for the treatment of moderate-to-severe plaque psoriasis.1

In the report, Dr. Pearson and his colleagues explored two questions:

  • What is the comparative clinical value and safety of all systemic therapies indicated for patients suffering from moderate-to-severe plaque psoriasis?
  • Is the economic cost of these medications in line with their clinical value to patients?

A Cost-Benefit Analysis of Psoriasis Therapies

Fortunately, clinical evidence shows all targeted immunomodulators for this condition have marked clinical benefits over placebo. This includes a number of biologics as well as the PDE4-inhibitor, apremilast (Otezla; Celgene).

The review also found that while all the medications indicated for moderate-to-severe plaque psoriasis showed comparable safety profiles, some medications offered a greater net health benefit to patients, namely ixekizumab, secukinumab, and brodalumab, which appeared superior to etanercept, ustekinumab, and apremilast.

As for the cost of these therapies, scarce research has looked at how medications’ price tags measure up to their benefits to patients.2 Using a simulation model  over 10 years, Dr. Pearson and his colleagues only looked at patients who had a significant response to treatment with the particular drug (PASI <75). To figure out an approximation of the price that is actually paid for these drugs, they used data from the SSR Health,3 which combines available information on US net dollar sales and unit sales of various medications to estimate their net price across all payer types.

All the drugs had a number of benefits and discounts available to keep costs down for patients. Based on drug class, these discounts estimated:

  • TNF-α: 30%
  • IL-17A: 40%
  • Anti-IL 12/23: 15%
  • Apremilast: 20%

“I think one of the major messages from our results is that right now, with competition having produced some of these rebates, (all the drugs) are pretty much fairly priced in alignment with the added benefit to patients. So we’re not seeing huge disparities in value over the long haul,” Dr. Pearson told Practical Pain Management.

This could have significant clinical implications, though. According to the ICER, clinicians should consider limiting or even wholly abolishing the practice of “step therapy” with these medications. It’s a typical requirement posed by a patient’s coverage.

For instance, while the researchers found newer IL-17A targeted therapies, namely brodalumab, ixekizumab, and secukinumab, provided a good monetary value compared to etanercept, many coverage plans require patients to first “try out” a TNFα before switching onto one of these drugs.

“Many insurers require a trial of a TNF inhibitor or two before you can move onto an IL17,” Dr. Pearson noted. “(Our findings) can be used to help in the broader discussion of how insurance coverage should be aligned with value because what we don’t want is restrictions thrown around that lead patients to have to hop from one drug to another,” or from one insurer to another, Dr. Pearson explained.

Prescription Prices: Feasible, For Now

Overall, the findings from the ICER report indicated that these systemic therapies, while high in price, do provide clinical value to patients when factoring in the estimated discounts and rebates afforded to patients, the positive impact on quality of life, and the costs saved from fewer clinic visits and use of other, non-targeted therapies.

“I think that in this instance, patients and clinicians are fortunate they have so many choices, and if anything, I think our report will support clinicians’ feelings that broad choice is both clinically reasonable and financially responsible, given that the prices are aligned with added value to patients,” Dr. Pearson said.

The problem is that list prices for these drugs are still astronomically high. Even with rebates and discounts, the cost-effective benefit to patients could cease if these prices become prohibitively over market value.

“It’s important to remember that if the price increases continue, then these drugs pretty quickly will not be well aligned anymore with the added value; they will be priced too high for their value,” Dr. Pearson said.

But it can be difficult to reverse-engineer why drug prices are so high, Dr. Pearson noted, especially since there are multiple explanations to consider.

“Drug companies often say the reason their list price is so high is because there are people in the middle of the pipeline for drug delivery who earn their cut off of the list price as a percent. So there is an incentive for some of them, in some contracts, to keep the list price high and to get a big rebate to keep part of that and only give some of it back to the employer or the health plan,” Dr. Pearson explained.

The subject of prescription drug prices in the US has become a contentious topic. Vermont recently became one of the first states to pass legislation requiring prescription drug companies to disclose information for any drugs that see a dramatic increase in price. The hope is that this legislation will add more transparency to prescription drug prices, something Dr. Pearson and his colleagues hope to do with the reports they are producing through ICER.

Dr. Pearson hopes that by performing these comprehensive cost-benefit analyses of prescription drugs, they too can steer the conversation towards what constitutes a fair drug price based on the benefits to patients, not the pockets of corporate entities and pharmacy benefit management plans.

“The only way, in my mind, is that you have to link [clinical benefit] in some way to an assessment of what a fair or sensible price is, looking at how much better the drug is than other drugs at helping patients," Dr. Pearson told Practical Pain Management. "I think when you put the two together, it allows you to make sense of some of these price increases and to know when we are getting ripped off and when we are not.”

The ICER team plans to continue producing cost comparison reports, especially as the IL17A inhibitor brodalumab is due to enter the market. The organization is also planning to publish a similar cost-benefit analysis on abuse-deterrent formulations of opioid medications, which is expected out at the end of June 2017.

To read the full ICER’s report, click here. A summary report also can be accessed here. Any relevant conflicts of interest regarding the authors involved in the making of the ICER report are available in ICER’s original documentation. For an extended commentary about the ICER analysis by members of the Practical Pain Management editorial board, click here.

Last updated on: January 5, 2017
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Psoriasis Treatments Get More Personalized

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