How pharma can support patients: Rheumatology

This is the latest in a series of interviews with members of Doctors.net.uk, part of the M3 group, about pharma's role in supporting patients. In today's update, a Senior Specialist Registrar Rheumatology explains changes in his field.

Can you describe the biggest challenges in your therapeutic area in terms of how pharma companies might be able to help?

We have been lucky in rheumatology over the last 10 years because there has been a wave of biologics that have transformed how these diseases are treated. The TNF inhibitors and other treatments have had a massive impact on our patients, but there has also been a downside.

These patients are often 30-40 years old, and will take these medicines for the rest of their lives. The cost per patient per year is around £10,000, and they are likely to be on these medications for the remainder of their life.

So the cost issue is head and shoulders above all other concerns. We are lucky in the UK to have NICE, which issues its recommendations based on cost and clinical effectiveness but it can't address the financial pressures.

The National Audit Office looked into spending on rheumatoid arthritis and in 2009, based on their health-economic analysis, they concluded that these treatments were worth the expenditure, because many of our patients are tax-payers of working age.

But I foresee problems in the future, with more and more patients taking these drugs. There are an extra 50 patients going on to the drugs each year at our trust alone, and that is a significant extra burden on NHS budgets.

The US system is very different to ours, with physicians having to trade off financial and clinical pressure directly – but actually I see us facing the same sort of problem in the future in this country. 18-25% of the pharmacological budget currently goes on rheumatology, and that is a big slice of a finite budget.

I've been involved in some studies for biosimilar drugs, but they are estimated to only be 20-30% cheaper, and as yet they don't have any efficacy data. It could be five years before they are on the market, so I don't see them changing the costs to the NHS dramatically.

There are a few avenues we are investigating in our Trust to help control costs – one is dose optimisation, and the other is vial sharing.

"The TNF inhibitors have transformed how these diseases are treated – but their cost is a major issue"

Can pharma help improve adherence rates? Can you name any companies that are taking the lead in this?

It was always anticipated that adherence rates would be good, but we've begun to understand that some patients are skipping doses. We have talked to many of the companies in the field, but they haven't been forthcoming in helping us study adherence. So again, my institution is undertaking its own research into how we can tackle that.

Our relationship with industry is good and our agendas are often aligned, leading to productive partnerships. For instance, several pharma companies have financed our research projects which have led to a PhD for the principal investigators. But there are other instances where you have to respectfully admit that our interests aren't the same, so you can't always work in partnership.

Is there a role for pharma in helping to educate patients about their condition? What are companies doing? Do any stand out?

When UCB entered the market with Cimzia, they wanted to help to educate patients, and set up outreach programmes which sent out nurses to their homes to help them with any issues around the condition or their medication that they had.

We are working with a number of other companies on developing other patient assistance programmes, which can be very helpful, and fill in the gaps between NHS services.

How do patients regard the industry and do any companies stand out in terms of reputation?

A patient has never asked me who makes a drug, and we never direct them to a particular biologic drug, unless there is a clear clinical reason for it. We are in the fortunate and honoured position as doctors that our patients trust our judgement and decision making when we recommend treatments for them, and put their trust in us that we do so impartially and always in their best interests.

We are lucky because in countries like the US and India, you have huge billboards on the street advertising these drugs, which say things like: has your doctor prescribed Drug X? If not, why not?'

"The research budgets of charities have dried up, and pharma companies have been filling the gap"

What kind of joint working projects with the NHS would you like to see pharma companies getting involved in?

In terms of funding for our own research, the budgets of the charities have dried up, and if you want to do good quality work you need substantial funding for a project. Pharmaceutical companies have been filling this research funding gap, and my experience of working with them has been very good. Everything is done in a transparent way, and everyone understands the terms of the sponsorship. Of course they want to look at the data before it is published, but we have never experienced any interference in the in the project/data dissemination in any way.

What is the single biggest thing you would like to see pharma doing to make your job easier?

The issue of prices is the most important, above all the other things we have discussed. The health budget is finite, and as a taxpayer as much a doctor, I am concerned about us paying high prices for some medicines, sometimes at the expense of patients with other needs.

"Digital channels let you catch up on learning when you only have 10 minutes to spare"

Do digital channels have a role to play in improving best practice in your therapeutic area? What kind of online resources are most valuable?

Yes, I think they have some mileage, particularly in the age of iPads and other mobile devices as they enable you to take advantage of some great learning experiences when you are at home, have 10 minutes to spare at work or are on the train travelling to meetings/conferences etc.

Valuable options include:

1) Webinars - these are good if they can be watched retrospectively as it can be difficult to guarantee logging in at a designated time.

2) Conference highlights - videos/audio of oral presentations (speakers and their slides) are very useful. They were available at EULAR 2013 and ACR 2013. Many of my colleagues used them.

3) Education - Doctors.net.uk has created online teaching videos on clinical examination of the musculoskeletal system. They have been extensively viewed, with good feedback.

4) Online education of clinicians using 5-10 min teaching cases. Doctors.net.uk and I have done this in collaboration with pharma, and created some peer-reviewed items of their own.

About the interviewee:

The doctor is a Senior Specialist Registrar Rheumatology working in teaching hospital in England.

This article was co-ordinated by Doctors.net.uk, the UK's largest and most active online professional network of doctors. It is part of the M3 network, which operates in the US, Asia and Europe with more than 1 million physician doctor members globally via its websites such as M3.com, MDLinx, Medigate and Doctors.net.uk.

Closing question: How can pharma address concerns about the cost of drugs in rheumatology?