EU doctors’ perceptions of rheumatoid arthritis drug market

Physicians in Europe's Big 5 think current market leaders will continue to lead, with biosimilars making the greatest inroads in the field up to 2018, if clearer guidance on efficacy and safety is provided.

The maturing rheumatoid arthritis (RA) market is dominated by big-name blockbuster drugs which have so far managed to stave off competition from a large number of biologic agents. However, the recent launch of the first biosimilars and the impending arrival of additional pipeline biologics have raised questions about whether the current market leaders will stay ahead.

A panel of around 200 physicians treating RA across Europe (France, Germany, Italy, Spain and the UK) were asked¹ how they currently treat their patients and what they expect to be doing in 2018. The findings suggest that the market leaders can breathe easy, for the moment at least.

Physicians expect current market leaders Enbrel (etanercept) and Humira (adalimumab) to continue to lead the market and to be used to treat over a third of RA patients in three years' time. Nevertheless, the anti-TNF segment is predicted to experience a strong downturn, with a 19 per cent loss in share in this period.

According to the research findings, biosimilars (the approved follow-on products to innovator biologics) will make the greatest gains in this market shift. Physicians predict a fourfold increase in their use of Hospira's Inflectra and Celltrion's Remsima. But, despite heavy discounting of some biosimilars in certain markets, such as France, the overall market share for these infliximab biosimilars is projected to remain relatively small.

Less than 25 per cent of physicians currently report prescribing biosimilars and, while almost half have reported that they expect they will prescribe them in the future, the agents are only expected to account for up to 17 per cent of physicians' biologic patients over the next three years.

The main reason that biosimilars are not prescribed is that many physicians continue to express concern over the efficacy and safety of these agents. They also feel there is a lack of clear guidance surrounding their use.

This is particularly the case among doctors in the UK. In Spain, local guidelines are expected to have the greatest impact on physicians prescribing biosimilars, whereas in France they said they were more likely to be influenced by guidelines given at a national level. In Germany, almost a third of physicians (30 per cent) said they wouldn't be influenced by guidelines at all. This shows the disparity in attitude and behaviour across markets.

"More than three quarters of doctors across Europe have yet to integrate these drugs into their RA armoury"

At this point in time, more than three quarters of doctors across Europe have yet to integrate these drugs into their RA armoury. There is clearly a need for both biosimilar manufacturer and government healthcare services to address these barriers at a local level.

While biosimilars need to try to change physician perceptions in order to drive growth, other pipeline agents need to raise awareness of their brands to compete against the established biologics. Physicians currently report very low levels of familiarity, with the greatest awareness and interest focused on oral small molecules, which may provide a novel alternative to injectable anti-TNFs. Many patients are concerned about having to inject themselves, so an oral alternative would be a big advantage to them.

Celgene's Otezla (apremilast) and Pfizer's Xeljanz (tofacitinib), which are both oral formulations for patients who fail to respond adequately or are intolerant to traditional disease-modifying treatments, are the most familiar to physicians and of those who are aware of them, 89 per cent said they would prescribe Otezla and 83 per cent stated they would prescribe Xeljanz in the next three years. Clearly there are opportunities here for manufacturers of oral products, as long as they can increase awareness among physicians.

The research asked physicians a number of questions about overall satisfaction and performance on specific product attributes to provide an understanding of what was driving the success of the current market leaders. Enbrel and Humira achieved the highest scores, in terms of satisfaction and likelihood to recommend, by quite some margin. Interestingly, this is despite the fact that there is little significant differentiation between the biologics on top-tier product attributes such as long term efficacy, reduction in symptoms, safety and ability to inhibit radiographic progression (although Enbrel edges ahead marginally on almost all attributes).

Biosimilars' performance on key attributes is still much lower than established biologics (even versus their originator drug, Remicade) and they score particularly low on perception of manufacturer and patient request. This is perhaps why physicians expect the market leaders to hold their lead in the future and highlights the need for biosimilar companies to work with physicians and patients to improve understanding of bioequivalence and increase trust.

Overall, physicians continue to predict an increase in their overall use of biologic agents, which is good news for all players. Those with novel mechanisms of action (such as Roche's RoActemra) are expected to outperform the overall EU biologics market with 15 per cent growth over the next three years.

"While anti-TNFs are expected to see a reduction in market share, they will continue to account for the lion's share"

And while anti-TNFs are expected to see a reduction in market share, they will continue to account for the lion's share. Doctors predict that biosimilars will capture up to 8 per cent of patients. This picture may change as biosimilar versions of other, more popular, biologics are launched.

Undoubtedly the RA biologics market will continue to shift and change in the next few years as newer entrants jostle to compete with the established brands. It remains to be seen if Enbrel and Humira's lead position is further challenged in the future, and perhaps depends on the ability of these manufacturers to defend themselves using their established reputation and obvious customer loyalty.

However, if biosimilars are successful in changing current perceptions around efficacy and safety and if clearer guidance is given by national or local bodies, they could see some more of their market share eroded by these cheaper alternatives over the coming years. Similarly, if some of the newer agents succeed in raising awareness of their brands, they may also be able to gain a larger slice of the pie.

¹ The research referenced in this article is called RA Perceptions (an adjunct study to Therapy Watch) and is carried out monthly among around 200 physicians across Europe covering different topics in RA.

About the author:

Laurent Chanroux is Research Director for Therapy Watch, Research Partnership's syndicated research programme for monitoring the global pharmaceutical market. Laurent specialises in auto-immune and manages a number of syndicated studies covering rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease and psoriasis, among others.

For more information please contact laurentc@researchpartnership.com or visit www.researchpartnership.com

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