Drugs for exceptionally rare diseases: do they deserve special status for funding?

Ultra-orphan drugs are medicines used to treat exceptionally rare diseases that are chronically debilitating or life-threatening. Low patient numbers make it difficult for pharmaceutical companies to recoup research and development costs, and consequently these medicines are generally expensive on a per patient basis. European Union (EU) regulations promote the development of orphan drugs; but to contain costs, some EU healthcare systems assess the cost-effectiveness of therapies when deciding if they should be funded. As ultra-orphan drugs are invariably cost-ineffective, factors in addition to cost-effectiveness need to be considered if ultra-orphan drugs are to be provided by public health services. Health service funding of ultra-orphan drugs, which varies across the EU and within the UK, has led to geographical inequities in patients' access to treatment. In some instances, support for these drugs would appear to have been approved on the basis that diseases that are rare and severe are a special case. We explore whether ultra-orphan drugs merit special status by considering efficiency, effectiveness and equity criteria. Mechanisms are discussed for creating a policy that would reduce geographical inequalities in provision across Europe.

Hypereosinophilic syndrome associated with acute necrotizing myocarditis and cardiomyopathy

We report the rare case of a 55-year-old female with massive eosinophilic myocarditis and severe, however reversible, impairment of left ventricular function. The patient presented with reduced physical condition, progressive dyspnea on exertion and peripheral edema. The white blood count revealed a leukocytosis and markedly elevated peripheral blood eosinophilics (48.8%). An endomyocardial biopsy demonstrated massive myocardial infiltration with eosinophilic granulocytes and necrosis. The symptoms and laboratory parameters indicate the presence of a hypereosinophilic syndrome. The differential diagnosis of a Churg-Strauss syndrome is discussed. Medical heart failure treatment according to international guidelines and an immunosuppressive treatment with prednisolone (Decortin H) 1.5 mg/kgBW) were initiated. This therapy led to a dramatic reduction of the eosinophilic granulocyte count and normalization of the peripheral blood count, which correlated with a significant improvement of clinical symptoms. Consistently, an increase of left-ventricular function was observed. Upon successive dose reduction to a maintenance dosage of 10 mg prednisolone, the patient's clinical status and peripheral blood count remained stable.

Orphan drugs and the NHS: should we value rarity?

The growing number and costs of drugs for rare diseases are straining healthcare budgets. Decisions on funding these treatments need to be made on a sound basis

Commissioning for rare diseases: view from the frontline

Deciding whether to fund treatments that do good one by one tends to lead to a positive decision. However, this can cause wider harmful effects, as West Midlands' experience in the funding of enzyme replacement therapy for lysosomal storage diseases shows

A new era of hope for the world's most neglected diseases

There are good reasons to be optimistic that tropical infectious diseases can be controlled, argue the PLoS Medicine editors.

[Unusual infection with pulmonary round foci obtained through "hay packs"]

A 71-year-old female, who has been treated with steroids for 3 weeks, developed a severe pneumonia with septic shock and acute respiratory distress syndrome (ARDS). Despite broad antibiosis due to the detection of pseudomonas aeruginosa (blood culture) the inflammatory markers remained high and the respiratory situation went critical. No proof of a malignoma or autoimmune process was found, despite multiple round foci in x-ray and computer tomography. Finally the delayed diagnosis of pulmonary nocardiosis was adjusted, due to the long incubation period of the pathogen Nocardia farcinica. The infectious origin may be assumed in so called "hay packs" used during the patient's residence at a health resort. After adequate change of the antibiotic regimen stabilization was achieved and the patient meanwhile recovered from the disease.

The European rare diseases therapeutic initiative

For many rare diseases, doctors have nothing to offer in the way of specific treatments to alter the disease. A new public- private partnership aims to address this problem.

A breakthrough in R&D for neglected diseases: new ways to get the drugs we need

New research suggests that long-held beliefs on neglected disease drug development activity are no longer accurate.

[A rare case of isolated prostate metastasis from primary pancreatic cancer]

An otherwise healthy 66 year old male presented with a suspicious intraprostatic lesion detected by digito-rectal examination. Serum PSA levels were normal. A CT scan of the abdomen revealed a nondistinctive mass within the pancreatic head. A transrectal biopsy confirmed the intraprostatic lesion as a metastatic lesion from pancreatic cancer. Therefore, we report this unusual case of a primary pancreatic carcinoma, clinical stage IV, which led to metastases in the liver and prostate.

Managing drugs for rare genetic diseases: trends and insights

Managed care organizations generally pay for expensive drugs that treat rare genetic diseases because few patients have these conditions, the conditions are often life threatening, and the benefit design mandates coverage. In most cases, the cost-control measures and management restrictions applied to many other specialty pharmaceuticals do not make sense for the orphan drugs used to treat extremely rare genetic conditions because treatment alternatives usually are lacking for rare conditions (e.g., Gaucher's disease) and because the per member per month costs for truly rare conditions are low. The increasing number of biologic and injectable therapies for more common conditions, however, is prompting managed care decision makers to manage these new therapies more actively. There is a potential that treatments for rare disorders will be swept up in this broad-based response. This article provides definitions, background, and stakeholder perspectives on this topic and describes recent trends and challenges in health system management of exceedingly rare genetic diseases. The author suggests that current protocols are appropriate for managing rare and ultra-rare diseases, and that applying more active management practices to less rare diseases is neither efficient nor productive; in fact, it may be counter-productive.

Doxorubicin and cisplatin chemotherapy in high-grade spindle cell sarcomas of the bone, other than osteosarcoma or malignant fibrous histiocytoma: a European Osteosarcoma Intergroup Study

There are limited data that define the role of chemotherapy in the treatment of high-grade spindle cell sarcomas of bone, other than osteosarcoma or malignant fibrous histiocytoma (MFH-B). This prospective study evaluates the effect of doxorubicin and cisplatin on these tumours. Thirty-seven patients, age 65 years, with spindle cell sarcoma of bone, except osteosarcoma or MFH-B, were included. Chemotherapy consisted of doxorubicin and cisplatin every 3 weeks for six cycles. Resection was performed after three cycles. In 15 patients with metastases, response assessment showed three complete responses (CR), four stable disease (SD), five progression; three were not evaluable. Median time to progression was 30 months (95% Confidence Interval (CI), 8-51 months) for the operable non-metastatic patients; median survival 41 months (95% CI, 16-82 months). Median time to progression in the metastatic group was 10 months (95% CI, 0-18 months) and median survival was 14 months (95% CI, 4-45 months). This study suggests a limited role for doxorubicin and cisplatin in metastatic high-grade spindle cell sarcoma of bone, other than osteosarcoma or MFH-B cases.

The utility of tumour necrosis factor blockade in orphan diseases

A variety of rheumatic disorders have been successfully treated with tumour necrosis factor (TNF) blockers. However, TNF blockade may be useful in a number of rare diseases. Preliminary data suggest that several forms of vasculitis appear responsive to TNF antagonists-Behcet's disease, Churg-Strauss vasculitis, polyarteritis nodosa, and giant cell arteritis, among others. Wegener's granulomatosis and sarcoidosis have been shown to improve with infliximab but not with etanercept. These results lend further support for the concept of differential mechanism(s) of action of the two antagonists with infliximab being more effective for the treatment of granulomatous diseases. Polymyositis/dermatomyositis may also be responsive to TNF blockade. TNF likely plays little role in Sjogren's syndrome as evidenced by the lack of efficacy of both TNF antagonists. Etanercept has been shown to be useful in the treatment of hepatitis C both in reducing the viral load and improving liver function. A number of other more rare disorders also may be responsive to TNF blockade. Further studies with larger numbers of well characterised patients and treatment regimens are necessary to provide more definitive evidence of the utility of the TNF antagonists in these serious and often life threatening diseases.