‘Primum non nocere’ – Do no harm; the Hippocratic injunction.
It could be argued that perhaps were are too ready to dose our expectant patients with the next golden ticket in MS. Mayhap, withdrawal of the long list of medications that they are already on, can prove to be just as efficacious?
Yet, I am not a great supporter of masterful inactivity on the part of the physician. I’m equally put out by the currency of living a healthy life. Market statistics and our employers now require us to understand costs of treatment – the lesser of two evils, followed shortly after by a greater evil, restriction of treatment. In my mind, only the blatantly wealthy can afford to take the moral high ground when it comes to this. There is little to loose, when your coffers are overflowing!
In this interesting review, Batcheller and Baker study the cost effectiveness of MS disease modifying therapies (DMTs), trying to make sense of the murky world of list prices (see below) and off setting these against their effectiveness. In their efforts to get usable outcomes, they quickly realise that there are several limitations. But all is not lost, and they do come up with some defining conclusions.
Firstly, the second-line therapies are the most-cost effective, despite the first-line therapies being relatively safe and cheaper.
“Currently, the drugs with the most benefit tend to be those that carry the most risk and the highest price tag”.
Secondly, front-loading the treatment costs in MS may be more cost-effective than paying for continuous long-term treatment. The induction treatments rarely require repeated courses after 1-2years, thus lowering the cost of disease associated complications and cost to society. However, we do not have enough long-term data on how the different treatments pan out.
“CEAs support the idea that it may be worth using more aggressive measures earlier on as front-loading the cost means the cost of long-term disability progression is reduced. It is difficult to say what the long term outcomes of different therapies may be as there is not enough long-term follow-up data”.
Last year several of the Big Pharma agreed to put a freeze of treatment costs after coming under heavy pressure from the Trump administration (probably the only thing that unites both Democrats and Republicans). But, the war on drug price hikes continues, as some pharma companies continue to increase prices on some drugs, while decreasing prices on others.
J Neurol Sci. 2019 Jul 9;404:19-28. doi: 10.1016/j.jns.2019.07.009. [Epub ahead of print]
Cost of disease modifying therapies for multiple sclerosis: Is front-loading the answer?
Batcheller L, Baker D.
There are now over a dozen disease modifying therapies (DMTs) available to treat multiple sclerosis (MS). They vary in efficacy and safety as well as in cost. The literature on the cost effectiveness of these is often confusing and contradictory. There is a lack of quality evidence enabling the comparison of different DMTs. There are scarce randomized controlled trials which look at one DMT compared with another that is not IFN or GA. There is also a lack of systematic reviews comparing the efficacy and safety of different DMTs. This makes it difficult to perform good quality cost-effectiveness analyses (CEAs). Furthermore, CEAs in and of themselves are difficult to interpret or compare due to the variation in methods and cost estimations as well as the use of outcome measures which cannot be proven over a reasonable timeframe. This review looks at the different DMTs available for MS and attempts to draw some conclusions on their cost-effectiveness. It also considers the costs and benefits of front loading the cost of treatment for MS by using more expensive and effective treatment earlier on.