Effect of ipilimumab treatment on 18-month survival: Update of patients (pts) with advanced melanoma treated with 10 mg/kg ipilimumab in three phase II clinical trials

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Background: The monoclonal antibody ipilimumab targets cytotoxic T lymphocyte antigen-4. Updated survival data (≤32.5 months follow-up) from 3 Phase II trials of ipilimumab in pts with mostly pretreated advanced melanoma are reported. Methods: Study CA184008 was an open-label, single-arm study of ipilimumab 10 mg/kg. Study CA184022 was a randomized, dose-ranging study of ipilimumab 0.3, 3, or 10 mg/kg. Study CA184007 was a randomized, placebo-controlled study of the effect of budesonide on gastrointestinal immune-related adverse events in pts receiving ipilimumab 10 mg/kg. In all studies, ipilimumab was given every 3 weeks (Q3W) × 4 (induction); eligible pts could continue to receive maintenance ipilimumab Q12W from week 24. Pts continue to be followed-up to determine long-term survival. Results: With a median follow-up ranging from 10.1 to 16.3 months and reaching up to 32.5+ months, pts receiving 10 mg/kg ipilimumab showed durable survival; 12- and 18-month survival rates are presented [ Table ]. The tail of the Kaplan-Meier curve flattened at 18 months, indicating that a substantial proportion of patients continued to survive beyond the updated follow-up period in all three studies. Long-term survivors include pts with disease progression (PD) per modified World Health Organization (mWHO) criteria. Conclusions: Ipilimumab may result in a long-term survival benefit in pts with advanced melanoma, where 18-month survival rates across 3 Phase II studies range from 34.5% to 39.4% for previously treated pts. These results indicate that more than 1/3 of ipilimumab-treated pts with advanced melanoma experience a long-term survival benefit, including some pts characterized as PD by mWHO. The survival data continue to mature, and follow-up is ongoing.

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Product Selection and Pharmaceutical Comparison of Two Anti-D Immune Globulins

Purpose

Two anti-D immunoglobulin (anti-D) products, Rhophylac and WinRho, have been approved by the US Food and Drug Administration for the treatment of chronic immune thrombocytopenic purpura. There is a significant difference in acquisition cost—and perhaps in preparation cost—of the products. This time-and-motion study was designed to evaluate the difference in time and relevant costs required for preparation of a single dose of anti-D immunoglobulin using these 2 products.

Methods

To evaluate the difference in time required for preparation of a single dose (3,600 mcg) of the 2 anti-D immunoglobulins for a patient weighing 72 kg, each product was prepared 9 times and the time for each preparation was recorded. The cost analysis was limited to comparison of the acquisition costs of both anti-D products and the incremental labor costs associated with their preparation.

Results

The results showed that the average total time for 9 preparations of WinRho was 1 minute 30.1 seconds, with the assembly time comprising 46.7 seconds. The average total time for the 9 preparations with Rhophylac was 5 minutes 7.1 seconds, with an average assembly time of 2 minutes 59.2 seconds. The difference in total average time between the 2 products was 3.62 minutes.

Conclusion

The cost comparison showed that the acquisition cost for as single dose of WinRho for a patient weighing 72 kg was $2,647 and that the cost for the same dose of Rhophylac was $946. Even with a personnel cost of $20 per hour, the increased labor cost is only $1.20 per preparation of Rhophylac. This is a minor cost compared to the $1,850 savings in product acquisition per average dose of Rhophylac.

Reporting disease activity in clinical trials of patients with rheumatoid arthritis: EULAR/ACR collaborative recommendations

OBJECTIVE

To make recommendations on how to report disease activity in clinical trials of rheumatoid arthritis (RA) endorsed by the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR).

METHODS

The project followed the EULAR standardised operating procedures, which use a three-step approach: (1) expert-based definition of relevant research questions (November 2006); (2) systematic literature search (November 2006 to May 2007); and (3) expert consensus on recommendations based on the literature search results (May 2007). In addition, since this is the first joint EULAR/ACR publication on recommendations, an extra step included a meeting with an ACR panel to approve the recommendations elaborated by the expert group (August 2007).

RESULTS

Eleven relevant questions were identified for the literature search. Based on the evidence from the literature the expert panel recommended that each trial should report the following items: (1) disease activity response and disease activity states; (2) appropriate descriptive statistics of the baseline, the endpoints and change of the single variables included in the core set; (3) baseline disease activity levels (in general); (4) the percentage of patients achieving a low disease activity state and remission; (5) time to onset of the primary outcome; (6) sustainability of the primary outcome; (7) fatigue.

CONCLUSIONS

These recommendations endorsed by EULAR and ACR will help harmonise the presentations of results from clinical trials. Adherence to these recommendations will provide the readership of clinical trials with more details of important outcomes, while the higher level of homogeneity may facilitate the comparison of outcomes across different trials and pooling of trial results, such as in meta-analyses.

Impact of Medicare changes in pharmacy reimbursement on patient care: two case reports

PURPOSE

Two case reports illustrate the impact of changes in pharmacy reimbursement associated with the Medicare Prescription Drug Improvement and Modernization Act (MMA) on patient care.

SUMMARY

The Medicare Part D benefit is complex and difficult for patients to understand. A patient's personal financial situation and quality of life issues may enter into decisions about enrolling in Part D and the use of drug therapy. Local coverage decisions by the Centers for Medicare and Medicaid Services can limit access to drug therapy and raise ethical dilemmas.

CONCLUSION

Changes in pharmacy reimbursement associated with MMA has the potential to markedly impact patient care and outcomes.

Efficacy and tolerability of diclofenac potassium sachets in migraine: a randomized, double-blind, cross-over study in comparison with diclofenac potassium tablets and placebo

A randomized, controlled, cross-over trial compared single doses of 50 mg diclofenac potassium sachets and tablets with placebo in 328 patients with migraine pain, treating 888 attacks. For the primary endpoint 24.7% of the patients were pain free at 2 h postdose with sachets, 18.5% for tablets and 11.7% for placebo. Treatment differences were significant for sachets vs. placebo (P<0.0001), tablets vs. placebo (P=0.0040) and for sachets vs. tablets (P=0.0035). The numbers needed to treat compared with placebo to achieve pain free at 2 h were 7.75 [95% confidence interval (CI) 5.46, 13.35] for sachets and 15.83 (95% CI 8.63, 96.20) for tablets. Sachets were also statistically superior to tablets for sustained headache response, sustained pain free and reduction in headache intensity within the first 2 h postdose measured on a visual analogue scale (P<0.05). Onset of analgesic effect was 15 min for sachets and 60 min for tablets. Fewer patients needed rescue medication, and there were marked improvements in accompanying symptoms and working ability with both sachets and tablets vs. placebo. No safety issues were identified. This study demonstrates that sachets offer patients suffering from migraine pain a more effective treatment with a faster onset of analgesia when compared with tablets.

Impact of the Medicare Prescription Drug Improvement and Modernization Act on the management of colorectal cancer

PURPOSE

The potential impact of changes in reimbursement for drugs and biologicals associated with the Medicare Prescription Drug Improvement and Modernization Act (MMA) on the management of colorectal cancer is described from the perspectives of health care providers and patients.

SUMMARY

The introduction of new chemotherapeutic agents and supportive therapies over the past several decades has increased survival in patients with colorectal cancer. The changes in reimbursement for these therapies associated with MMA may affect the financial viability of private physician office practices and hospital-based outpatient clinics where such therapies are administered. The MMA-related changes also have the potential to decrease patient access to treatment and adversely affect treatment choices, scheduling, and outcomes.

CONCLUSION

The reimbursement changes brought about by implementation of MMA could affect health care delivery and patient care.

The product: All intravenous immunoglobulins are not equivalent

The first intravenous formulation of intravenous immunoglobulin (IGIV) was introduced in the United States in the early 1980s. At that time, the only indication was for treatment of primary immunodeficiency. By the mid-1990s, IGIV was mainly used for indications approved by the United States Food and Drug Administration, but as new indications are found, use of IGIVs is increasing. In fact, today, IGIV is mostly used for off-label indications. The specific characteristics of individual IGIV products must be directly addressed in the manufacturing process, as clinical efficacy may be affected. In addition, the safety profile of the ideal IGIV should be maximized by ensuring inactivation of the widest spectrum of viruses and prions. Some IGIV products are more suitable than others for certain patients; the challenge is to understand the different characteristics among products and select the most appropriate IGIV product for each patient. Convenience factors must be considered, for both the health care provider and the patient, without jeopardizing the more important features of the IGIV, such as tolerability and safety.

Safety considerations in IGIV utilization

One of the primary patient concerns about IGIV infusions is safety. Patients and physicians are both concerned about transmission of infectious agents and product tolerability. Since the documented transmission of hepatitis C virus in 1994, the manufacturers of IGIV products have added additional steps to remove and/or deactivate viruses. There are numerous different methods employed to accomplish this goal. It is desirable to utilize methods that are separate and additive to decrease the likelihood of viral or prion transmission with the infusion of IGIV products. This article describes the different methods and the impact on enveloped and non-enveloped viruses and prions. IGIV tolerability is impacted by the pharmaceutical differences in these products. Different stabilizers such as sugars, amino acids and sodium chloride affect the osmolality of the products and their potential for adverse events. Patients with co-morbid conditions including age and impaired renal status could require a change in product, concentration and rate of administration.

Efficacy and tolerability of diclofenac potassium sachets in acute postoperative dental pain: a placebo-controlled, randomised, comparative study vs. diclofenac potassium tablets

This double-blind, randomised, parallel-group trial compared the analgesic efficacy of single 50 mg doses of diclofenac potassium sachets and tablets with placebo in 184 patients with moderate/severe pain after third molar extraction. The primary efficacy variable was the average pain reduction from baseline during the first 2-h postdose, using a visual analogue scale (VAS). During the first 2-h postdose, sachets and tablets significantly reduced pain (p < 0.05) vs. placebo with an incremental benefit seen for sachets over tablets (p < 0.05). Onset of analgesic effect (VAS) was at 30 min for sachets and 45 min for tablets. Pain reduction vs. placebo (VAS) was maintained for 8 h for sachets and tablets (p < 0.05). VAS-findings were confirmed by pain relief and intensity verbal scale assessments. Fewer patients re-medicated vs. placebo. No safety issues were identified. This study demonstrates that both diclofenac potassium sachets and tablets offer patients suffering from acute pain conditions an effective treatment with incremental analgesic benefits seen for sachets.