Study of a new generic cyclosporine, Consupren, in de novo renal transplant recipients

Generic immunosuppression in solid organ transplantation: a Canadian perspective

The introduction of generic immunosuppressant medications may present an opportunity for cost savings in solid organ transplantation if equivalent clinical outcomes to the branded counterparts can be achieved. An interprofessional working group of the Canadian Society of Transplantation was established to develop recommendations on the use of generic immunosuppression in solid organ transplant recipients (SOTR) based on a review of the available data. Under current Health Canada licensing requirements, a demonstration of bioequivalence with the branded formulation in healthy volunteers allows for bridging of clinical data. Cyclosporine, tacrolimus, and sirolimus are designated as "critical dose drugs" and are held to stricter criteria. However, whether this provides sufficient guarantee of therapeutic equivalence in SOTR remains controversial, and failure to maintain an appropriate balance of immunosuppression may have serious consequences, including rejection, graft loss, and death. Published evidence supporting therapeutic equivalence of generic formulations in SOTR is lacking. Moreover, in the setting of multiple generic formulations the potential for uncontrolled product switching is a major concern, since generic preparations are not required to demonstrate bioequivalence with each other. Although close monitoring is recommended with any change in formulation, drug product switches are likely to occur without prescriber knowledge and may pose a significant patient safety risk. The advent of generic immunosuppression will require new practices including more frequent therapeutic drug and clinical monitoring, and increased patient education. The additional workload placed on transplant centers without additional funding will create challenges and could ultimately jeopardize patient outcomes. Until more robust clinical data are available and adequate regulatory safeguards are instituted, caution in the use of generic immunosuppressive drugs in solid organ transplantation is warranted.

Healthcare costs in renal transplant recipients using branded versus generic ciclosporin

BACKGROUND

Generic ciclosporin A modified (CsA) does not have an equivalent pharmacokinetic profile to branded CsA in some transplant populations, potentially leading to negative clinical consequences and increased long-term costs.

OBJECTIVE

To assess direct healthcare costs for de novo renal transplant recipients in the US receiving branded versus generic CsA in the first month after transplantation.

METHODS

Administrative claims data from eight private US health plans were linked to the Organ Procurement and Transplantation Network data. A total of 227 renal transplant cases between 1996 and 2004 were included: 183 were dispensed branded CsA and 44 received generic CsA. Log transformed multiple linear regression was used to model total first-year healthcare costs after the initial CsA claim, controlling for both patient demographics and clinical characteristics and clustering at the transplant centre level.

RESULTS

After controlling for patient factors and pre-CsA costs, total healthcare costs were significantly higher (p = 0.04) for patients receiving generic CsA versus branded CsA. The main driver for the difference was the cost associated with immunosuppressants other than CsA (p = 0.01).

CONCLUSION

Despite initial perceived cost savings associated with generic CsA, de novo renal transplant recipients incurred greater total healthcare costs than those treated with branded CsA. Patients receiving generic CsA may need higher doses or other immunosuppressants to maintain the transplanted kidney than patients receiving branded CsA. Providers and payers need to be aware of potential differences in total healthcare costs between formulations of bioequivalent critical-dose drugs to make the best choice for patient care.

Generic cyclosporine formulations: more open questions than answers

The introduction of cyclosporine (CsA) in clinical practice has significantly improved patient and allograft survival after organ transplantation. The new microemulsion CsA formulation, Neoral, has been associated with a more reproducible absorption and a better patient outcome as compared to the old formulation Sandimmune. Recently, several generic CsA formulations have been tested as bioequivalent to Neoral. Bioequivalence tests have been performed in selected groups of young, healthy male volunteers usually in single-dose studies, and then extended to completely different population, such as transplant recipients. However, growing body of evidence shows that CsA pharmacokinetics in healthy subjects is different from that of transplant patients, treated chronically with CsA. Therefore, converting patients from Neoral to the new generic formulations could be detrimental, exposing patients to increased risk of graft function deterioration and graft loss. Thus, more research and more accurate bioequivalence tests are required to address the unanswered problems dealing with the generic CsA formulations.