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Abraham I, Crawford J, Schwartzberg L. On-body injector pegfilgrastim for chemotherapy-induced neutropenia prophylaxis: Current Status. Cancer Treat Res Commun 2024; 40:100824. [PMID: 38865836 DOI: 10.1016/j.ctarc.2024.100824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 05/28/2024] [Accepted: 05/28/2024] [Indexed: 06/14/2024]
Abstract
INTRODUCTION Myelosuppression, a challenge in cancer treatment, often results in severe complications. Prophylactic granulocyte colony-stimulating factors, particularly pegfilgrastim, mitigate chemotherapy-induced neutropenia. This narrative review evaluates the role of on-body injector (OBI) devices for pegfilgrastim administration. A comprehensive search strategy of PubMed and AI-powered intuitive search tools, complemented by authors' contributions, yielded a body of papers presenting evidence on OBI devices, their effectiveness and safety, the benefits and challenges of OBI versus pre-filled syringe administration, patient preferences for pegfilgrastim administration, and economic considerations. DISCUSSION OBI devices prove effective and safe, with advantages such as reduced clinic visits and enhanced adherence. Studies highlight cost-efficiency and expanded access, emphasizing the socioeconomic context. Patient and provider preferences underscore the potential of OBI devices in cancer care, with implications for healthcare resource utilization and pharmacoeconomics. CONCLUSION The value proposition of OBI devices lies in improving patient outcomes, convenience, resource optimization, and enhancing the overall cancer care experience. As biosimilar OBIs enter the market, they may offer cost savings, further influencing their adoption and their positioning as a cost-efficient alternative in cancer care. Ongoing research and technological advancements are expected to contribute to the broader acceptance of OBI devices in cancer care delivery.
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Affiliation(s)
- Ivo Abraham
- Center for Health Outcomes and Pharmacoeconomic Research Center, R. Ken Coit College of Pharmacy, University of Arizona, Tucson, AZ, USA; The University of Arizona Cancer Center, Tucson, AZ, USA.
| | | | - Lee Schwartzberg
- William N. Pennington Cancer Institute at Renown Health, Reno, NV, USA; School of Medicine, University of Nevada - Reno, Reno, NV, USA
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Clarke K, Ainslie-Garcia M, Ferko N, Shastri K. Modelling the opportunity for cost-savings or patient access with biosimilar adalimumab and tocilizumab: a European perspective. J Med Econ 2024; 27:952-962. [PMID: 39015093 DOI: 10.1080/13696998.2024.2379212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 07/09/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVES Biosimilars improve patient access by providing cost-effective treatment options. This study assessed the potential for savings and expanded patient access with increased use of two biosimilar disease modifying anti-rheumatic drugs (DMARDs): (a) approved adalimumab biosimilars and (b) the first tocilizumab biosimilar, representing an established biosimilar field and a recent biosimilar entrant in France, Germany, Italy, Spain, and the United Kingdom (UK). METHODS Separate ex-ante analyses were conducted for each country, parameterized using country-specific list prices, unit volumes annually, and market shares for each therapy. Discounting scenarios of 10%, 20%, and 30% were tested for tocilizumab. Outputs included direct cost-savings associated with drug acquisition or the incremental number of patients that could be treated if savings were redirected. Two biosimilar conversion scenarios were tested. RESULTS Savings associated with a 100% conversion to adalimumab biosimilar ranged from €10.5 to €187 million (UK and Germany, respectively), or an additional 1,096 to 19,454 patients that could be treated using the cost-savings. Introduction of a tocilizumab biosimilar provided savings up to €29.3 million in the most conservative scenario. Exclusive use of tocilizumab biosimilars (at a 30% discount) could increase savings to €28.8 to €113 million or expand access to an additional 43% of existing tocilizumab users across countries. CONCLUSION This study demonstrates the benefits that can be realized through increased biosimilar adoption, not only in an untapped tocilizumab market, but also through incremental increases in well-established markets such as adalimumab. As healthcare budgets continue to face downwards pressure globally, strategies to increase biosimilar market share could prove useful to help manage financial constraints.
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Affiliation(s)
| | | | | | - Kunal Shastri
- Fresenius Kabi SwissBioSim GmbH, Eysins, Switzerland
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Alkhatib NS, Halloush S, Abraham I. The status and preparation for the next decade of biosimilars in the Middle Eastern and North African region. Expert Opin Biol Ther 2023; 23:671-677. [PMID: 37493610 DOI: 10.1080/14712598.2023.2241346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 07/24/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION Little is known about the status and the future potential of biosimilars in the Middle East and North Africa (MENA) region. AREAS COVERED This perspective provides insights into the current regulatory landscape of some MENA countries, currently available biosimilars, the potential of biosimilars in the next decade, and challenges to overcome. EXPERT OPINION Given the economic and demographic heterogeneity across the MENA countries, biosimilars could reduce significant economic unmet needs in these countries. In the next decade, biosimilars may witness higher approval rates and market share over their originators in the MENA countries. We argue that the regulatory bodies in the MENA countries should adopt the new policies of the FDA, the EMA, and the WHO, that aim to ease the biosimilar approval process. These policies are to adopt technology in the process of approval; engage health technology assessment bodies in price assessment; provide educational materials to increase awareness among providers, patients, and payers. Further, MENA countries should upgrade the external-reference pricing systems to more sophisticated ones that consider the heterogeneity in economics and needs.
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Affiliation(s)
- Nimer S Alkhatib
- Faculty of Pharmacy, Al-Zaytoonah University of Jordan, Amman, Jordan
- Center for Health Outcomes and PharmacoEconomic Evaluation, University of Arizona, Tucson, AZ, USA
- Pi Pharma Intelligence, LLC, Amman, Jordan
| | - Shiraz Halloush
- Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Ivo Abraham
- Center for Health Outcomes and PharmacoEconomic Evaluation, University of Arizona, Tucson, AZ, USA
- Matrix45, LLC, Tucson, Arizona
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Ismail S, Abu Esba L, Khan M, Al-Abdulkarim H, Modimagh H, Yousef C. An Institutional Guide for Formulary Decisions of Biosimilars. Hosp Pharm 2023; 58:38-48. [PMID: 36644755 PMCID: PMC9837324 DOI: 10.1177/00185787221138007] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Biologics have changed the landscape for the management of many debilitating chronic diseases but account for a significant expenditure of medications globally. Fortunately, advances in technology paved the way for the introduction of biosimilars, which are highly similar to the originator biologics. In the quest to reduce the budget impact of biologics, organizations have begun to adopt biosimilars. Institutions evaluating biosimilars for inclusion in the hospital formulary must make informed formulary decisions by conducting a thorough review of key elements for evaluation of biosimilars and address the multidimensional aspects during the selection process of different biosimilar products. Therefore, we aim to present an institutional guide of these elements to inform formulary decisions. These key elements include biosimilar evaluation for formulary addition; regulatory approval; substitution, interchangeability, and switching; extrapolation; product characteristics, manufacturing, and supply chain issues; pharmacoeconomic evaluations; traceability, nomenclature, and coding; education; and pharmacovigilance.
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Affiliation(s)
- Sherin Ismail
- Pharmaceutical Care Department, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
- University of North Carolina, Chapel Hill, NC, USA
| | - Laila Abu Esba
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
- College of pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mansoor Khan
- Pharmaceutical Care Department, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
| | - Hana Al-Abdulkarim
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
- Doctoral School of Applied Informatics and Applied Mathematics, Óbuda University, Budapest, Hungary
- Drug Policy and Economic Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Hind Modimagh
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
- College of pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Consuela Yousef
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, Ministry of National Guard Affairs, Dammam, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Al Ahsa, Saudi Arabia
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Yousef CC, Khan MA, Almodaimegh H, Alshamrani M, Al-Foheidi M, AlAbdalkarim H, AlJedai A, Naeem A, Abraham I. Cost-efficiency analysis of conversion to biosimilar filgrastim for supportive cancer care and resultant expanded access analysis to supportive care and early-stage HER2+ breast cancer treatment in Saudi Arabia: simulation study. J Med Econ 2023; 26:394-402. [PMID: 36815700 DOI: 10.1080/13696998.2023.2183680] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
AIMS This study estimated, for Saudi Arabia, the cost-efficiency of converting patients from reference Neupogen and Neulastim to one of two filgrastim biosimilars (Nivestim, Zarzio); the budget-neutral expanded access to supportive care with biosimilar filgrastim and therapeutic care to ado-trastuzumab emtansine thus afforded; and the number-needed-to-convert (NNC) to provide supportive or therapeutic treatment to one patient. MATERIALS AND METHODS Replicating prior studies, we modeled the cost-efficiencies gained from converting varying proportions of a hypothetical panel of 4,000 patients undergoing six cycles of cancer treatment from Neupogen or Neulastim to one of the two biosimilar G-CSF formulations, using national cost inputs. Cost-savings in USD were used to estimate the additional doses of biosimilar G-CSF and expanded access to ado-trastuzumab emtansine on a budget-neutral basis, and NNC to purchase one additional dose of supportive or therapeutic treatment. RESULTS Savings from conversion from reference to a biosimilar filgrastim were $3,086,400 (Nivestim) and $3,460,800 (Zarzio). With reference pegfilgrastim, savings from conversion were $11,712,240 (Nivestim) and $12,086,640 (Zarzio). Biosimilar conversion from reference to biosimilar filgrastim enabled expanded access to ado-trastuzumab emtansine ranging from 61 patients (5 days, Nivestim) to 191 patients (14 days, Zarzio). For supportive care, biosimilar conversion enabled expanded access ranging from 8,244 patients (5 days, Nivestim) to 25,882 patients (14 days, Zarzio). For biosimilar conversion from daily filgrastim, the NNC for treatment with ado-trastuzumab emtansine decreased as days of injections increased [5 days: 395 (Nivestim), 352 (Zarzio); 14 days: 141(Nivestim), 126 (Zarzio)]. Alternately, for biosimilar conversion from single-injection pegfilgrastim to daily biosimilar filgrastim, the NNC for treatment with ado-trastuzumab emtansine rose as days of injections increased, being highest under the 14-day scenario (146, Nivestim; 130, Zarzio). CONCLUSION This simulation study demonstrated significant potential cost-savings from biosimilar conversion. These savings provide budget-neutral increased access to supportive and therapeutic cancer care.
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Affiliation(s)
- Consuela Cheriece Yousef
- Pharmaceutical Care Department, Ministry of National Guard - Health Affairs, Dammam, Saudi Arabia
- King Abdullah International Medical Research Center, Al Ahsa, Saudi Arabia
- King Saud bin Abdul-Aziz University for Health Sciences, Al Ahsa, Saudi Arabia
| | - Mansoor Ahmed Khan
- Pharmaceutical Care Department, Ministry of the National Guard-Health Affairs, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- King Saud bin Abdul-Aziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Hind Almodaimegh
- College of Pharmacy, King Saud bin Abdul-Aziz University for Health Sciences, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Majed Alshamrani
- Pharmaceutical Care Department, Ministry of the National Guard-Health Affairs, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- King Saud bin Abdul-Aziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Meteb Al-Foheidi
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- College of Medicine, King Saud bin Abdul-Aziz University for Health Sciences, Jeddah, Saudi Arabia
- Department of Oncology, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Hana AlAbdalkarim
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Drug Policy and Economic Center, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- Doctoral School of Applied Informatics and Applied Mathematics, Obuda University, Budapest, Hungary
| | - Ahmed AlJedai
- Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
- Colleges of Pharmacy and Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Anjum Naeem
- Pharmaceutical Care Department, Ministry of the National Guard-Health Affairs, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- King Saud bin Abdul-Aziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Ivo Abraham
- Center for Health Outcomes and PharmacoEconomic Research, University of Arizona, Tucson, AZ, USA
- Matrix45, Tucson, AZ, USA
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Real-World Use of Granulocyte-Colony Stimulating Factor in Patients with Breast Cancer from Alberta, Canada. Cancers (Basel) 2022; 14:cancers14246197. [PMID: 36551681 PMCID: PMC9777054 DOI: 10.3390/cancers14246197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/09/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND There are limited published data in the Canadian healthcare system on the use of granulocyte colony-stimulating factor (G-CSF) among patients with breast cancer. This study characterized real-world G-CSF use during the period surrounding the introduction of filgrastim biosimilar. METHODS Electronic medical records were reviewed retrospectively for patients with breast cancer who received moderately or highly myelosuppressive (neo)adjuvant chemotherapy from 2008 to 2019 in Alberta, Canada. Trends in G-CSF usage were plotted to elucidate temporal variations and multivariable regression models were constructed to identify clinical factors associated with G-CSF use. RESULTS We included 6662 patients in our analyses. G-CSF was used in 57.1% of patients during their treatment trajectory. Among the 3801 patients who were treated with G-CSF, the majority received pegfilgrastim only (91.5%; n = 3477) versus filgrastim only (5.7%; n = 217). G-CSF use increased linearly more than two-fold over the 11-year study period. Predictors of G-CSF use included younger age, south zone of residence, higher neighborhood education, inferior disease stage, highly neutropenic risk chemotherapy, and more recent chemotherapy initiation. CONCLUSIONS Despite increasing G-CSF usage over time, an appreciable proportion of patients for whom G-CSF prophylaxis is recommended did not receive it. G-CSF use could be further optimized to align with supportive care clinical guidelines and reduce the impact of neutropenia and its associated complications.
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Kaiser PK, Schmitz-Valckenberg MS, Holz FG. ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR BIOSIMILARS IN OPHTHALMOLOGY. Retina 2022; 42:2243-2250. [PMID: 36394884 PMCID: PMC9665947 DOI: 10.1097/iae.0000000000003626] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 09/17/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE Anti-vascular endothelial growth factor therapies have proven effective in treating retinal diseases but come with a high financial burden to the patient and health care system. Biosimilar drugs present an opportunity to decrease the cost of these important ophthalmic medications, and several ophthalmic biosimilars are expected to be approved and enter the market in the coming years. The objectives of this review are to educate ophthalmologists on the safety and efficacy of biosimilars in ophthalmology in the United States and European Union, review the biosimilar manufacturing and approval process, and describe the upcoming ophthalmic biosimilars. RESULTS Two ranibizumab biosimilars are currently approved in the United States and European Union. Additional ranibizumab biosimilars, as well as biosimilars for aflibercept and bevacizumab, are currently in clinical development. CONCLUSION Biosimilar use in ophthalmology is expected to grow with the patent expiration of two major anti-vascular endothelial growth factor drugs, ranibizumab and aflibercept, and the development of an ophthalmology-specific bevacizumab biosimilar. Financial savings from biosimilar use in ophthalmology have the potential to reduce economic burden, increase treatment adherence, and ultimately improve health outcomes.
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Affiliation(s)
| | - Marc Steffen Schmitz-Valckenberg
- Department of Ophthalmology, University of Bonn, Bonn, Germany; and
- John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah, Salt Lake City, Utah
| | - Frank G. Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany; and
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Cornes P, Kelton J, Liu R, Zaidi O, Stephens J, Yang J. Real-world cost-effectiveness of primary prophylaxis with G-CSF biosimilars in patients at intermediate/high risk of febrile neutropenia. Future Oncol 2022; 18. [PMID: 35354304 DOI: 10.2217/fon-2022-0095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Real-world data suggests superiority of pegfilgrastim (PEG) over filgrastim (FIL) in reducing the incidence of chemotherapy-induced febrile neutropenia (FN), probably attributable to underdosed FIL in practice. We used real-world data to assess the cost-effectiveness of primary prophylaxis with PEG versus FIL in cancer patients at intermediate-to-high risk of FN from a US payer perspective. Methods: A Markov model with lifetime horizon. Results: For the high-risk group, PEG (vs FIL) biosimilars resulted in 0.43 FN events prevented (FNp), 0.27 quality-adjusted life-years gained (QALYg) and a cost saving of USD$5703. For the intermediate-risk group, PEG biosimilar led to 0.18 FNp and 0.12 QALYg, at USD$9674/FNp and USD$14,502/QALYg. Conclusion: PEG biosimilars may provide opportunities to optimize FN management in patients with intermediate-to-high FN risk.
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Affiliation(s)
| | | | | | | | | | - Jingyan Yang
- Patient Health & Impact (PHI), Pfizer, Inc., New York, NY 10017, USA
- Institute for Social & Economic Research & Policy, Columbia University, New York, NY 10027, USA
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Wong G, Wang K, Pasetka M, Zhang L, Lou J, Majeed H, Flores J, Lam E, DeAngelis C. The Real-World Experience of the Biosimilar (Grastofil®) to the Reference Biologic (Neupogen®) in Breast Cancer and Lymphoma: A Canadian Single-Centre Retrospective Study. Curr Oncol 2022; 29:1349-1369. [PMID: 35323315 PMCID: PMC8947031 DOI: 10.3390/curroncol29030115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/18/2022] [Accepted: 02/20/2022] [Indexed: 12/04/2022] Open
Abstract
Febrile neutropenia (FN) is a common side effect of cytotoxic chemotherapy that may result in poor treatment outcomes. The short acting granulocyte colony stimulating factors (G-CSF) act to stimulate granulocytes to increase production of white blood cells. The filgrastim biosimilar is useful, as it may provide a cheaper and equally effective treatment to FN. This study explored the usage of the filgrastim biosimilar (Grastofil®) and the reference biologic (Neupogen®) in breast cancer and lymphoma patients. A retrospective chart review of patients receiving Grastofil® from January 2017 to June 2019 or Neupogen® for primary prophylaxis of FN from January 2013 to December 2017 was conducted. The endpoints included the incidence of FN and the occurrence of dose reduction (DR) and dose delay (DD). One hundred and fifty-three Grastofil® patients were matched to 153 Neupogen® patients. This cohort was further split into breast cancer (n = 275) and non-Hodgkin’s lymphoma (n = 31) cohorts. After adjusting for chemotherapy cycles, the biosimilar filgrastim was non-inferior to the reference biologic based on FN incidence in addition to related outcomes including DR and DD.
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Affiliation(s)
- Gina Wong
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada; (K.W.); (M.P.); (H.M.); (E.L.); (C.D.)
- Correspondence:
| | - Katie Wang
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada; (K.W.); (M.P.); (H.M.); (E.L.); (C.D.)
| | - Mark Pasetka
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada; (K.W.); (M.P.); (H.M.); (E.L.); (C.D.)
| | - Liying Zhang
- Macrostat Inc., Toronto, ON L4B 4P4, Canada; (L.Z.); (J.L.)
| | - Julia Lou
- Macrostat Inc., Toronto, ON L4B 4P4, Canada; (L.Z.); (J.L.)
| | - Habeeb Majeed
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada; (K.W.); (M.P.); (H.M.); (E.L.); (C.D.)
| | - Jerome Flores
- Department of Pharmacy, University Health Network, University of Toronto, Toronto, ON M5G 2C4, Canada;
| | - Emily Lam
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada; (K.W.); (M.P.); (H.M.); (E.L.); (C.D.)
| | - Carlo DeAngelis
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada; (K.W.); (M.P.); (H.M.); (E.L.); (C.D.)
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van Laar SA, Gombert-Handoko KB, Wassenaar S, Kroep JR, Guchelaar HJ, Zwaveling J. Real-world evaluation of supportive care using an electronic health record text-mining tool: G-CSF use in breast cancer patients. Support Care Cancer 2022; 30:9181-9189. [PMID: 36044088 PMCID: PMC9633501 DOI: 10.1007/s00520-022-07343-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 08/24/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE Chemotherapy-induced febrile neutropenia (FN) is a life-threatening and chemotherapy dose-limiting adverse event. FN can be prevented with granulocyte-colony stimulating factors (G-CSFs). Guidelines recommend primary G-CSF use for patients receiving either high (> 20%) FN risk (HR) chemotherapy, or intermediate (10-20%) FN risk (IR) chemotherapy if the overall risk with additional patient-related risk factors exceeds 20%. In this study, we applied an EHR text-mining tool for real-world G-CSF treatment evaluation in breast cancer patients. METHODS Breast cancer patients receiving IR or HR chemotherapy treatments between January 2015 and February 2021 at LUMC, the Netherlands, were included. We retrospectively collected data from EHR with a text-mining tool and assessed G-CSF use, risk factors, and the FN and neutropenia (grades 3-4) and incidence. RESULTS A total of 190 female patients were included, who received 77 HR and 113 IR treatments. In 88.3% of the HR regimens, G-CSF was administered; 7.3% of these patients developed FN vs. 33.3% without G-CSF. Although most IR regimen patients had ≥ 2 risk factors, only 4% received G-CSF, of which none developed neutropenia. However, without G-CSF, 11.9% developed FN and 31.2% severe neutropenia. CONCLUSIONS Our text-mining study shows high G-CSF use among HR regimen patients, and low use among IR regimen patients, although most had ≥ 2 risk factors. Therefore, current practice is not completely in accordance with the guidelines. This shows the need for increased awareness and clarity regarding risk factors. Also, text-mining can effectively be implemented for the evaluation of patient care.
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Affiliation(s)
- Sylvia A. van Laar
- grid.10419.3d0000000089452978Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, The Netherlands
| | - Kim B. Gombert-Handoko
- grid.10419.3d0000000089452978Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, The Netherlands
| | - Sophie Wassenaar
- grid.10419.3d0000000089452978Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, The Netherlands
| | - Judith R. Kroep
- grid.10419.3d0000000089452978Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk-Jan Guchelaar
- grid.10419.3d0000000089452978Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, The Netherlands
| | - Juliette Zwaveling
- grid.10419.3d0000000089452978Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, The Netherlands
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McBride A, Alrawashdh N, MacDonald K, Abraham I. Expanded access to anticancer treatments from conversion to biosimilar pegfilgrastim-cbqv in US breast cancer patients. Future Oncol 2021; 18:363-373. [PMID: 34747185 DOI: 10.2217/fon-2021-0979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Aim: To estimate cost-savings from conversion to biosimilar pegfilgrastim-cbqv that could be reallocated to provide budget-neutral expanded access to AC (doxorubicin/cyclophosphamide) and TCH (docetaxel/carboplatin/trastuzumab) in breast cancer (BC) patients. Methods: Simulation modeling in panels of 20,000 BC and 5000 HER2-positive (HER2+ BC) patients, varying treatment duration (one-six cycles) and conversion rates (10-100%), to estimate cost-savings and additional AC and TCH treatment that could be provided. Results: In 20,000 patients, cost-savings of $1,083 per-patient per-cycle translate to $21,652,064 (one cycle) to $129,912,397 (six cycles). Savings range from $5,413,016 to $32,478,097, respectively, in the 5000-patient HER2+ BC panel. Conclusion: Conversion to pegfilgrastim-cbqv could save up to $130 million and provide more than 220,000 additional cycles of antineoplastic treatment on a budget-neutral basis to BC patients.
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Affiliation(s)
- Ali McBride
- Center for Health Outcomes & PharmacoEconomic Research, University of Arizona, Tucson, AZ USA.,University of Arizona Cancer Center, Tucson, AZ, USA.,Department of Pharmacy Practice & Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Neda Alrawashdh
- Center for Health Outcomes & PharmacoEconomic Research, University of Arizona, Tucson, AZ USA
| | | | - Ivo Abraham
- Center for Health Outcomes & PharmacoEconomic Research, University of Arizona, Tucson, AZ USA.,University of Arizona Cancer Center, Tucson, AZ, USA.,Department of Pharmacy Practice & Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA.,Matrix45, Tucson, AZ, USA
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Maltz RM, McNicol M, Wingate L, Buchanan S, Sandell A, Kim SC, Rubin DT. There Is No Substitute for Effective Education About Biosimilars. CROHN'S & COLITIS 360 2021; 3:otab047. [PMID: 36777278 PMCID: PMC9802262 DOI: 10.1093/crocol/otab047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ross M Maltz
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Megan McNicol
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Laura Wingate
- Crohn's & Colitis Foundation, New York, New York, USA
| | | | - Angela Sandell
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Golisano Children's Hospital, Rochester, New York, USA
| | - Sandra C Kim
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois, USA
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Abstract
In 1991, the U.S. Food & Drug Administration (FDA) approved rmetHuGCSF for human use. This recombinant methionyl human granulocyte colony-stimulating factor, or filgrastim, saw use in over 1 million patients in its first 5 years on the market. In 2002, the FDA approved a version of filgrastim with covalent linkage to a monomethoxypolyethylene glycol, increasing the molecular size and half-life to replace multiple days of dosing with a single injection. These medications remained standard of care for neutropenia until the Biologics Price Competition and Innovation Act of 2009 created an abbreviated pathway to licensure for biologic products. Practitioners now have their pick of numerous and expanding options for pegfilgrastim biosimilars.
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Affiliation(s)
- Christopher Selby
- Texas Tech University Health Sciences Center Jerry H. Hodge School of Pharmacy, Dallas, Texas
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MacDonald K, Alrawashdh N, McBride A, Abraham I. Conversion to biosimilar pegfilgrastim-cbqv enables budget-neutral access to FOLFIRINOX treatment for metastatic pancreatic cancer. Future Oncol 2021; 17:4561-4570. [PMID: 34382416 DOI: 10.2217/fon-2021-0718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To estimate the cost-savings from conversion to biosimilar pegfilgrastim-cbqv that can be reallocated to provide budget-neutral expanded access to FOLFIRINOX in patients with metastatic pancreatic cancer. Methods: Simulation modeling in a panel of 2500 FOLFIRINOX-treated patients, using varying treatment duration (1-12 cycles) and conversion rates (10-100%), to estimate cost-savings and additional FOLFIRINOX treatment that could be budget neutral. Results: In a 2500-patient panel at 100% conversion, savings of US$6,907.41 per converted patient over 12 cycles of prophylaxis translate to US$17.3 million and could provide 72,273 additional FOLFIRINOX doses or 6023 full 6-month regimens. Conclusion: Conversion to biosimilar CIN/FN prophylaxis can generate significant cost-savings and provide budget-neutral expanded access to FOLFIRINOX treatment for patients with metastatic pancreatic cancer.
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Affiliation(s)
| | - Neda Alrawashdh
- Center for Health Outcomes & PharmacoEconomic Research, University of Arizona, Tucson, AZ 85721, USA
| | - Ali McBride
- Center for Health Outcomes & PharmacoEconomic Research, University of Arizona, Tucson, AZ 85721, USA.,University of Arizona Cancer Center, Tucson, AZ 85724, USA.,Department of Pharmacy Practice & Science, College of Pharmacy, University of Arizona, Tucson, AZ 85721, USA
| | - Ivo Abraham
- Matrix45, Tucson, AZ 85743, USA.,Center for Health Outcomes & PharmacoEconomic Research, University of Arizona, Tucson, AZ 85721, USA.,University of Arizona Cancer Center, Tucson, AZ 85724, USA.,Department of Pharmacy Practice & Science, College of Pharmacy, University of Arizona, Tucson, AZ 85721, USA
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McBride A, MacDonald K, Abraham I. Conversion to supportive care with biosimilar pegfilgrastim-cbqv enables budget-neutral expanded access to R-CHOP treatment in non-Hodgkin lymphoma. Leuk Res 2021; 106:106591. [PMID: 33957339 DOI: 10.1016/j.leukres.2021.106591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/05/2021] [Indexed: 10/21/2022]
Abstract
This pharmacoeconomic simulation (1) assessed the cost-efficiency of converting a panel of 20,000 patients at risk of chemotherapy-induced (febrile) neutropenia (CIN/FN) from reference pegfilgrastim to biosimilar pegfilgrastim-cbqv; (2) estimated how savings can be used to provide budget-neutral expanded access to R-CHOP therapy for non-Hodgkin lymphoma patients; and 3) determined the number-needed-to-convert (NNC) to purchase one additional dose of R-CHOP (US payer perspective). Model inputs included biosimilar conversion from pre-filled syringe [PFS] or on-body injector [OBI] reference pegfilgrastim; age-proportional blended costs for reference pegfilgrastim PFS and OBI, pegfilgrastim-cbqv and R-CHOP; medication administration costs; biosimilar conversion rates of 10-100 %; and 1-6 cycles of prophylaxis. Cost-savings were used to estimate the number of doses of R-CHOP that could be purchased and the NNC to purchase one additional dose. Converting a panel of 20,000 patients requiring CIN/FN prophylaxis to biosimilar pegfilgrastim-cbqv from a low of 1 cycle and 10 % conversion to a high of 6 cycles and 100 % conversion yielded savings from $1,567,195 to $96,668,126. The budget-neutral acquisition of R-CHOP doses afforded by these savings ranged from 227 to 13,999 doses, the latter enabling 2333 patients to receive 6 cycles of R-CHOP treatment with no additional cost to the payer. These results are achieved if all 20,000 panel patients requiring GCSF support are prophylacted with biosimilar pegfilgrastim-cbqv for 6 cycles, yielding an NNC of 1.43 patients per additional R-CHOP dose. This simulation underscores the clinic-economic benefit of prophylaxis with biosimilar growth factor and pegfilgrastim-cbqv specifically.
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Affiliation(s)
- Ali McBride
- Center for Health Outcomes and PharmacoEconomic Research, University of Arizona, Tucson, AZ, USA; University of Arizona Cancer Center, Tucson, AZ, USA; Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | | | - Ivo Abraham
- Center for Health Outcomes and PharmacoEconomic Research, University of Arizona, Tucson, AZ, USA; University of Arizona Cancer Center, Tucson, AZ, USA; Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA; Matrix45, Tucson, AZ, USA.
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McBride A, MacDonald K, Fuentes-Alburo A, Abraham I. Conversion from pegfilgrastim with on-body injector to pegfilgrastim-jmdb: cost-efficiency analysis and budget-neutral expanded access to prophylaxis and treatment. J Med Econ 2021; 24:598-606. [PMID: 33866947 DOI: 10.1080/13696998.2021.1916863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIMS Therapeutic guidelines recommend prophylaxis against chemotherapy-induced (febrile) neutropenia (CIN/FN). Pegfilgrastim (Neulasta), biosimilar pegfilgrastim-jmdb (Fulphila), and pegfilgrastim with on-body injector (OBI; Neulasta Onpro) are options for CIN/FN prophylaxis. We aimed to simulate the cost-savings and budget-neutral expanded access to CIN/FN prophylaxis or anticancer treatment achieved through conversion from pegfilgrastim-OBI to pegfilgrastim-jmdb and to evaluate the economic impact of FN-related hospitalization costs due to pegfilgrastim-OBI failure. METHODS Cost-savings from conversion from pegfilgrastim-OBI to biosimilar pegfilgrastim-jmdb were simulated in a panel of 15,000 patients with cancer from the US payer perspective. The primary analyses included conversion rates of 10% to 100%. Adjusted analyses also considered OBI device failure rates of 1% to 7% and associated costs of FN-related hospitalization. Simulations of budget-neutral expanded access to prophylaxis with pegfilgrastim-jmdb or to rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) for diffuse large B-cell lymphoma (DLBCL) were also performed. RESULTS In a 15,000-patient panel, conversion from pegfilgrastim-OBI to pegfilgrastim-jmdb resulted in cost-savings ranging from $481,259 (10% conversion) to $4,812,585 (100% conversion) in a single cycle. Over 6 cycles at 100% conversion, savings were $28,857,510 and could provide 9,191 additional doses of pegfilgrastim-jmdb or 4,463 cycles of R-CHOP to patients with DLBCL. Adjusted for OBI failure, cost-savings over 6 cycles ranged from $2,935,565 (10% conversion; pegfilgrastim-OBI failure rate of 1%) to $32,236,499 (100% conversion; 7% failure). These cost-savings could provide 943 doses of pegfilgrastim-jmdb or 454 doses of R-CHOP (10% conversion; 1% pegfilgrastim-OBI failure) or provide 10,261 doses of pegfilgrastim-jmdb or 4,982 cycles of R-CHOP (100% conversion; 7% failure). CONCLUSION Conversion from pegfilgrastim to pegfilgrastim-jmdb is associated with significant cost-savings which increase markedly when also accounting for pegfilgrastim-OBI failure and associated FN-related hospitalizations. These general and failure-related cost-savings could be allocated on a budget-neutral basis to provide more patients with additional CIN/FN prophylaxis or antineoplastic treatment.
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Affiliation(s)
- Ali McBride
- The University of Arizona Cancer Center, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, The University of Arizona College of Pharmacy, Tucson, AZ, USA
- Banner University Medical Center, Tucson, AZ, USA
| | | | | | - Ivo Abraham
- The University of Arizona Cancer Center, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, The University of Arizona College of Pharmacy, Tucson, AZ, USA
- Matrix45, Tucson, AZ, USA
- Center for Health Outcomes and PharmacoEconomic Research, University of Arizona, Tucson, AZ, USA
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McBride A, MacDonald K, Fuentes-Alburo A, Abraham I. Cost-efficiency and expanded access modeling of conversion to biosimilar trastuzumab-dkst with or without pertuzumab in metastatic breast cancer. J Med Econ 2021; 24:743-756. [PMID: 34003067 DOI: 10.1080/13696998.2021.1928515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIMS To investigate the cost-efficiency and budget-neutral expanded access of biosimilar intravenous trastuzumab-dkst versus reference intravenous (trastuzumab-IV) and subcutaneous trastuzumab (trastuzumab-SC) (with/without pertuzumab) in metastatic breast cancer (MBC). METHODS Economic simulation modeling in a panel of 1,000 MBC patients to estimate: 1) cost-savings by conversion from trastuzumab-IV or trastuzumab-SC to trastuzumab-dkst at 10-100% conversion rates in 3 weight groups: first quartile (Q1:62.2 kg), median (73.1 kg), third quartile (Q3:88.6 kg), and 2) budget-neutral expanded access to trastuzumab-dkst from cost-savings. RESULTS In monotherapy, conversion (%) from trastuzumab-IV generates one-year cost-savings from $2,272,189 (Q1;10%) to $31,506,804 (Q3;100%) and from trastuzumab-SC monotherapy savings range from $2,071,277 (Q3;10%) to $35,775,475 (Q1;100%). In combination with pertuzumab, trastuzumab-dkst is cost-efficient in all patient weights with one-year savings over trastuzumab-IV up to $32,662,714 (Q3;100%) and over trastuzumab-SC up to $35,322,461 (Q1;100%). Savings from conversion from trastuzumab-IV monotherapy could provide between 3,087 (Q1;10%) and 30,911 (Q3;100%) additional trastuzumab-dkst doses-enough to treat 58 to 583 patients for one year. Conversion from trastuzumab-SC monotherapy could provide between 1,559 (Q3;10%) and 48,598 (Q1;100%) additional trastuzumab-dkst doses or 38 to 918 additional one-year treatments with trastuzumab-dkst. In combination with pertuzumab, conversion from trastuzumab-IV could provide from 311 (Q1;10%) to 3,939 (Q3;100%) maintenance doses (pertuzumab + trastuzumab-dkst) or 17 to 210 additional one-year regimens (all agents). Savings from conversion from trastuzumab-SC could expand access to 226 (Q3;10%) to 4,782 (Q1;100%) additional maintenance doses or 12 to 254 one-year regimens. CONCLUSIONS This first cost-efficiency and expanded access study of biosimilar therapeutic cancer agents shows that trastuzumab-dkst is cost-efficient over trastuzumab-IV and trastuzumab-SC across all patient weights in both monotherapy and combination with pertuzumab and paclitaxel. These cost savings could provide more patients with trastuzumab-dkst treatment on a budget-neutral basis.
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Affiliation(s)
- Ali McBride
- The University of Arizona Cancer Center, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, The University of Arizona College of Pharmacy, Tucson, AZ, USA
- Banner University Medical Center, Tucson, AZ, USA
| | | | | | - Ivo Abraham
- The University of Arizona Cancer Center, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, The University of Arizona College of Pharmacy, Tucson, AZ, USA
- Matrix45, Tucson, AZ, USA
- Center for Health Outcomes and PharmacoEconomic Research, University of Arizona, Tucson, AZ, USA
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MacDonald K, McBride A, Alrawashdh N, Abraham I. Cost-efficiency and expanded access of prophylaxis for chemotherapy-induced (febrile) neutropenia: economic simulation analysis for the US of conversion from reference pegfilgrastim to biosimilar pegfilgrastim-cbqv. J Med Econ 2020; 23:1466-1476. [PMID: 33023360 DOI: 10.1080/13696998.2020.1833339] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
AIMS In this pharmacoeconomic simulation, we: (1) modeled the cost-efficiency of converting patients from reference pegfilgrastim to biosimilar pegfilgrastim-cbqv for prophylaxis of chemotherapy-induced (febrile) neutropenia (CIN/FN) from the US payer perspective, (2) simulated how savings enable, on a budget-neutral basis, expanded access to pegfilgrastim-cbqv, and (3) estimated the number-needed-to-convert (NNC) to purchase one additional dose of pegfilgrastim-cbqv. METHODS In a hypothetical panel of 20,000 patients, we modeled cost-savings utilizing: two reference formulations (pre-filled syringe [PFS] and on-body injector [OBI]), three medication cost inputs (average sales price [ASP], wholesale acquisition cost [WAC], and an age-proportionate blended ASP/WAC rate), administration cost for injection (PFS) and device application (OBI), conversion rates of 10-100%, and 1-6 cycles of prophylaxis. Cost-savings were used to estimate additional doses of pegfilgrastim-cbqv that could be purchased and the NNC to purchase one additional dose. RESULTS Using ASP and 10% conversion from reference OBI to pegfilgrastim-cbqv, savings range from $326,744 (1 cycle) to $2.0M (6 cycles) which could provide 93-556 additional doses of pegfilgrastim-cbqv, respectively; the NNC to purchase one additional dose of pegfilgrastim-cbqv ranges from 21.6 (1 cycle) down to 3.6 patients (6 cycles). The WAC model saves $41.1M per cycle and $246.7M over 6 cycles at 100% conversion from reference PFS which could provide 9,709-58,253 additional pegfilgrastim-cbqv doses; the NNC ranges from 2.1 (1 cycle) to 0.3 (6 cycles). Using the blended ASP/WAC rate, converting 50% from reference OBI to pegfilgrastim-cbqv would save $10.2M per cycle and $60.9M over 6 cycles providing 2,638-15,829 additional doses of pegfilgrastim-cbqv; NNCs are 3.8 (1 cycle) and 0.6 patients (6 cycles). CONCLUSIONS Converting 20,000 patients from reference to pegfilgrastim-cbqv over 6 cycles can generate savings up to $246.7M, enough to purchase up to 58,253 additional doses of pegfilgrastim-cbqv. This simulation provides economic justification for prophylaxis with biosimilar pegfilgrastim-cbqv.
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Affiliation(s)
| | - Ali McBride
- Medical Center, Banner University, Tucson, AZ, USA
- Cancer Center, University of Arizona, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Neda Alrawashdh
- Center for Health Outcomes and PharmacoEconomic Research, University of Arizona, Tucson, AZ, USA
| | - Ivo Abraham
- Matrix45, Tucson, AZ, USA
- Cancer Center, University of Arizona, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
- Center for Health Outcomes and PharmacoEconomic Research, University of Arizona, Tucson, AZ, USA
- Department of Family and Community Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA
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