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Finocchietti M, Marino ML, Rosa AC, Bellini A, Masiero L, Cardillo M, Massari M, Spila Alegiani S, Pierobon S, Ferroni E, Zanforlini M, Leoni O, Ledda S, Garau D, Davoli M, Addis A, Belleudi V. Immunosuppression with Generics in Liver and Kidney Transplantation: A Real-World Evidence Study. Drug Des Devel Ther 2024; 18:53-69. [PMID: 38229916 PMCID: PMC10790661 DOI: 10.2147/dddt.s431121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/22/2023] [Indexed: 01/18/2024] Open
Abstract
Purpose This study evaluates the use, benefit-risk profile, and economic impact of generic immunosuppressants (tacrolimus-TAC, cyclosporine-CsA, and mycophenolate-MYC) in kidney and liver transplant recipients compared to brand-name drugs. Patients and Methods A retrospective multicentre observational study, involving four Italian regions, was conducted based on the national transplant Information system and regional healthcare claims data. The analysis focused on incident patients who received kidney and liver transplants between 2013 and 2019 and evaluated the use of generic of CsA, TAC, and MYC during the 30-day period following discharge. For each type of transplant and immunosuppressive agent, the benefit-risk profile of generic vs branded drugs in a two-year window was estimated by multivariate Cox models (HR; 95% CI). Furthermore, the potential cost savings per person associated with one year of treatment using generics were calculated. Results The utilization of generic drugs showed a significant increase; over the study years, the proportion of users among kidney recipients ranged from 14.2% to 40.5% for TAC, from 36.9% to 56.7% for MYC, and from 18.2% to 94.7% for CsA. A great variability in generic uptake for region was found. A comparable risk-benefit profile between generic and branded formulations was shown for all immunosuppressors considered. Choosing generic immunosuppressants during maintenance could result in yearly savings of around 2000 euros per person for each therapy ingredient. Conclusion The study shows an increasing proportion of patients using generic immunosuppressive drugs over time suggesting a growing acceptance of generics within the transplant community and reveals comparable risk-benefit profiles between the generic and branded formulations of TAC, CsA, and MYC. A significant variability in the use of generics immunosuppressive agents was found both at the regional level and among transplant centers and future research should delve into regional prescribing variations.
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Affiliation(s)
- Marco Finocchietti
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Maria Lucia Marino
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Alessandro C Rosa
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Arianna Bellini
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Lucia Masiero
- Italian National Transplant Center, Istituto Superiore di Sanità, Rome, Italy
| | - Massimo Cardillo
- Italian National Transplant Center, Istituto Superiore di Sanità, Rome, Italy
| | - Marco Massari
- National Center for Drug Research and Evaluation, Istituto Superiore Di Sanità, Rome, Italy
| | | | | | | | - Martina Zanforlini
- The innovation and procurement regional company, A.R.I.A. S.p.A.-Lombardy Region, Milan, Italy
| | - Olivia Leoni
- Regional Epidemiological Observatory, Lombardy Region, Milan, Italy
| | - Stefano Ledda
- General Directorate for Health, Sardinia Region, Cagliari, Italy
| | - Donatella Garau
- General Directorate for Health, Sardinia Region, Cagliari, Italy
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Antonio Addis
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Valeria Belleudi
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - On behalf of CESIT Study Group
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
- Italian National Transplant Center, Istituto Superiore di Sanità, Rome, Italy
- National Center for Drug Research and Evaluation, Istituto Superiore Di Sanità, Rome, Italy
- Azienda Zero, Veneto Region, Padua, Italy
- The innovation and procurement regional company, A.R.I.A. S.p.A.-Lombardy Region, Milan, Italy
- Regional Epidemiological Observatory, Lombardy Region, Milan, Italy
- General Directorate for Health, Sardinia Region, Cagliari, Italy
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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3
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Cochrane AB, Veasey TM. Is tacrolimus by any generic name as sweet? J Heart Lung Transplant 2021; 40:573-574. [PMID: 34030973 DOI: 10.1016/j.healun.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 04/16/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
| | - Tara M Veasey
- Allegheny General Hospital, Pittsburgh, Pennsylvania
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5
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Report from the 2018 consensus conference on immunomodulating agents in thoracic transplantation: Access, formulations, generics, therapeutic drug monitoring, and special populations. J Heart Lung Transplant 2020; 39:1050-1069. [DOI: 10.1016/j.healun.2020.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 06/29/2020] [Indexed: 01/06/2023] Open
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Gantar K, Škerget K, Mochkin I, Bajc A. Meeting Regulatory Requirements for Drugs with a Narrow Therapeutic Index: Bioequivalence Studies of Generic Once-Daily Tacrolimus. Drug Healthc Patient Saf 2020; 12:151-160. [PMID: 32982466 PMCID: PMC7489937 DOI: 10.2147/dhps.s256455] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/15/2020] [Indexed: 12/21/2022] Open
Abstract
Despite growing clinical confidence in generics and their potential to reduce long-term healthcare costs, the transplant community have had real concerns about the use of generic immunosuppressants. One such immunosuppressant is tacrolimus, a cornerstone of lifelong treatment for patients who have undergone a solid organ transplant. Tacrolimus has a narrow therapeutic index (NTI), giving rise to questions about the potential for clinically relevant altered drug exposure. Its use in transplant patients also gives rise to questions about the most discriminative subject population for bioequivalence studies. The recognised need for stringent criteria to support approval of generic drugs with an NTI led the European Medicines Association and Health Canada to provide detailed information on requirements for bioequivalence studies and introduce tighter bioequivalence limits for these drugs, including tacrolimus. The aim of this article is to illustrate how regulatory guidance is implemented during the clinical development of generic immunosuppressants, using a generic, once-daily prolonged-release formulation of tacrolimus as an example.
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Affiliation(s)
- Kaja Gantar
- Sandoz Development Center Slovenia, Lek Pharmaceuticals d.d, Ljubljana1526, Slovenia
| | - Katja Škerget
- Sandoz Development Center Slovenia, Lek Pharmaceuticals d.d, Ljubljana1526, Slovenia
| | - Ilya Mochkin
- Sandoz International GmbH, Holzkirchen83607, Germany
| | - Aleksander Bajc
- Sandoz Development Center Slovenia, Lek Pharmaceuticals d.d, Ljubljana1526, Slovenia
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7
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Clinical and safety outcomes of conversion original tacrolimus to generic tacrolimus in Turkish kidney transplant recipients. TRANSPLANTATION REPORTS 2020. [DOI: 10.1016/j.tpr.2020.100056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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The Association of Tacrolimus Formulation Switching with Trough Concentration Variability: A Retrospective Cohort Study of Tacrolimus Use Post-Kidney Transplantation Based on National Drug Code (NDC) Numbers. Adv Ther 2019; 36:1358-1369. [PMID: 31004326 PMCID: PMC6824386 DOI: 10.1007/s12325-019-00950-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION It was hypothesized that patients experiencing at least one tacrolimus formulation switch may require more frequent therapeutic drug monitoring, subsequent dose adjustments, and a potential for untoward clinical outcomes than patients who remain on a single formulation. METHODS Eligible patients were adult kidney transplant recipients with stable renal function at month 3 post-transplant and no evidence of acute rejection, receiving an oral, tacrolimus-based regimen. Patients were categorized into two groups (fixed or variable formulation) using the US National Drug Code (NDC) on the basis of tacrolimus formulation usage over the 12-month period. RESULTS A total of 305 patients were enrolled from four US transplant centers; 44 (14.4%) received multiple formulations and 261 (85.6%) received a single formulation. Mean number of tacrolimus dose adjustments and mean cumulative milligram dose change were not statistically different between the two groups. Mean trough-to-dose ratio, frequency of trough level measurements, and mean number of excursions above 120% or below 80% of the patient's mean trough concentration were significantly higher in the variable compared to the fixed formulation group. CONCLUSION A variable tacrolimus formulation regimen was associated with a higher frequency of trough level measurements and a greater number of excursions in trough levels compared with continuing on a fixed formulation regimen of tacrolimus in this retrospective chart review study. FUNDING Astellas Pharma Global Development, Inc. Plain language summary available for this article.
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Lichvar A, Tremblay S, Naik D, Lipscomb J, King E, Vinks AA, Christians U, Alloway RR. Evaluation of Clinical and Safety Outcomes Following Uncontrolled Tacrolimus Conversion in Adult Transplant Recipients. Pharmacotherapy 2019; 39:564-575. [PMID: 30892704 DOI: 10.1002/phar.2260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
PURPOSE To compare clinical and safety outcomes of transplant recipients converted between different tacrolimus formulations to those patients who remained on a single formulation in an outpatient environment. METHODOLOGY This was a single-center, retrospective cohort study at a large tertiary care medical center with an associated institutional outpatient pharmacy system. Adult transplant recipients with institutional pharmacy refill from August 1, 2009, to May 31, 2016, were assessed. Patients were allocated into four separate groups: Group (A) innovator tacrolimus (no conversion), Group (B) generic tacrolimus (no conversion), Group (C) single conversion (from innovator to single generic or from generic to innovator tacrolimus), and Group (D) multiple conversions. Index date was either the date of first tacrolimus product conversion (Groups C and D) or a pre-specified post-transplant time (Groups A and B). RESULTS Overall, 100 patients were included in the analysis, 63% were male, 62% were Caucasian, and 59% were renal transplant recipients. When compared between groups, linear trends in dose-normalized tacrolimus levels were similar in the pre-index date period (p=0.52) and in the post-index date period (p=0.08). When groups were compared individually, linear trends in dose-normalized tacrolimus levels were significantly different pre- versus post-index date for Group B (p=0.008). There were no differences in the linear trends of dose-normalized tacrolimus levels across the other groups (p>0.05 for all). After the index date, 43% of patients across all groups required tacrolimus dose modification with no differences by group (p=0.32). Allograft function and hospitalizations were similar across all groups. CONCLUSIONS Conversion between tacrolimus generic formulations has been suggested to be unsafe. This study demonstrates that switching tacrolimus products in post-transplant recipients does not alter dose-normalized tacrolimus trough concentrations, renal or hepatic function, pathology, or hospitalizations.
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Affiliation(s)
- Alicia Lichvar
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Simon Tremblay
- Department of Surgery, Division of Transplantation, University of Cincinnati, Cincinnati, OH.,Department of Environmental Health, Division of Epidemiology, University of Cincinnati, Cincinnati, OH
| | - Devanshi Naik
- University of Cincinnati, James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Jessi Lipscomb
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Eileen King
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alexander A Vinks
- Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Uwe Christians
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Denver, Colorado
| | - Rita R Alloway
- Department of Surgery, Division of Transplantation, University of Cincinnati, Cincinnati, OH
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10
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Helmuth ME, Liu Q, Turenne MN, Park JM, Oguntimein M, Dutcher SK, Balkrishnan R, Sharma P, Zee J, Leichtman AB, Smith AR. Secular Trends in the Cost of Immunosuppressants after Solid Organ Transplantation in the United States. Clin J Am Soc Nephrol 2019; 14:421-430. [PMID: 30819667 PMCID: PMC6419280 DOI: 10.2215/cjn.10590918] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/16/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Immunosuppressive medications are critical for maintenance of graft function in transplant recipients but can represent a substantial financial burden to patients and their insurance carriers. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS To determine whether availability of generic immunosuppressive medications starting in 2009 may have alleviated some of that burden, we used Medicare Part D prescription drug events between 2008 and 2013 to estimate the average annualized per-patient payments made by patients and Medicare in a large national sample of kidney, liver, and heart transplant recipients. Repeated measures linear regression was used to determine changes in payments over the study period. RESULTS Medicare Part D payments for two commonly used immunosuppressive medications, tacrolimus and mycophenolic acid (including mycophenolate mofetil and mycophenolate sodium), decreased overall by 48%-67% across organs and drugs from 2008 to 2013, reflecting decreasing payments for brand and generic tacrolimus (21%-54%), and generic mycophenolate (72%-74%). Low-income subsidy payments, which are additional payments made under Medicare Part D, also decreased during the study period. Out-of-pocket payments by patients who did not receive the low-income subsidy decreased by more than those who did receive the low-income subsidy (63%-79% versus 24%-44%). CONCLUSIONS The decline in payments by Medicare Part D and by transplant recipients for tacrolimus and mycophenolate between 2008 and 2013 suggests that the introduction of generic immunosuppressants during this period has resulted in substantial cost savings to Medicare and to patients, largely reflecting the transition from brand to generic products.
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Affiliation(s)
| | - Qian Liu
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Marc N. Turenne
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Jeong M. Park
- College of Pharmacy, University of Michigan, Ann Arbor, Michigan
| | - Murewa Oguntimein
- Center for Drug Evaluation and Research, US Food and Drug Administration, Washington, DC; and
| | - Sarah K. Dutcher
- Center for Drug Evaluation and Research, US Food and Drug Administration, Washington, DC; and
| | - Rajesh Balkrishnan
- Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Pratima Sharma
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
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Barbour S, Lo C, Espino-Hernandez G, Gill J, Levin A. The BC Glomerulonephritis Network: Improving Access and Reducing the Cost of Immunosuppressive Treatments for Glomerular Diseases. Can J Kidney Health Dis 2018; 5:2054358118759551. [PMID: 29581884 PMCID: PMC5863862 DOI: 10.1177/2054358118759551] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 10/09/2017] [Indexed: 11/23/2022] Open
Abstract
Glomerulonephritis (GN) is a common cause of end-stage renal disease in Canada and worldwide, and results in significant health care resource utilization and patient morbidity. However, GN has not been a traditional priority of provincial renal health care organizations, despite the known benefits to health services delivery and patient outcomes from integrated provincial care in other types of chronic kidney disease. To address this deficiency, the British Columbia (BC) Provincial Renal Agency created the BC GN Network in 2013 to coordinate provincial GN health services delivery informed by robust population-level data capture on all GN patients in the province via the BC GN Registry. This report describes the use of the BC GN Network infrastructure to systematically develop and evaluate a provincial GN drug formulary to improve patient and physician access to evidence-based immunosuppressive treatments for GN in a cost-efficient manner that successfully halted historical trends of increasing medication costs. An example is provided of using the provincial infrastructure to implement and subsequently evaluate an evidence-informed health policy of converting brand to generic tacrolimus for the treatment of GN. The BC GN Network, including the provincial drug formulary and data infrastructure, is an example of the benefits of expanding the mandate of provincial renal health administrative organizations to include the care of patients with GN, and constitutes a viable health delivery model that can be implemented in other Canadian provinces to achieve similar goals.
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Affiliation(s)
- Sean Barbour
- BC Provincial Renal Agency, Vancouver, Canada.,Division of Nephrology, University of British Columbia, Vancouver, Canada.,Centre for Health Evaluation and Outcomes Research, St. Paul's Hospital, Vancouver, Canada
| | - Clifford Lo
- BC Provincial Renal Agency, Vancouver, Canada
| | | | - Jagbir Gill
- BC Provincial Renal Agency, Vancouver, Canada.,Division of Nephrology, University of British Columbia, Vancouver, Canada.,Centre for Health Evaluation and Outcomes Research, St. Paul's Hospital, Vancouver, Canada
| | - Adeera Levin
- BC Provincial Renal Agency, Vancouver, Canada.,Division of Nephrology, University of British Columbia, Vancouver, Canada.,Centre for Health Evaluation and Outcomes Research, St. Paul's Hospital, Vancouver, Canada
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Rottembourg J, Rostoker G. [The use of generics in transplantation: Towards rational and safe solutions!]. Presse Med 2018; 47:199-210. [PMID: 29555162 DOI: 10.1016/j.lpm.2017.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 11/27/2017] [Accepted: 12/13/2017] [Indexed: 10/17/2022] Open
Abstract
Generic immunosuppressive drugs are available in Europe Canada and the United States. Between countries, there are large differences in penetration of generic drugs in general, and for immunosuppressive drugs in particular. The registration for generic immunosuppressive drugs are slightly different, but the criteria for registration of narrow therapeutic index drugs and bioequivalence studies, performed only in healthy volunteers, will remain in the medical landscape. About 50 studies compare the clinical efficacy and bioequivalence of the generic immunosuppressive drugs in patients with solid organ transplants. To allow for safe substitution, a number of criteria need to be fulfilled. Consensus statements were made by most transplant organizations. Authorities and payers should refrain from forcing pharmacists to dispense generic drugs in patients on maintenance immunosuppressive treatment. Generic substitution could be safe if realized by the treating physician, for a well-informed patient. Substitution must be followed by control visits to check if the patient is taking the medication correctly and if the drug exposure, through a close monitoring, remains stable. Substitution from one generic to another generic should be avoided, in all cases.
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Affiliation(s)
- Jacques Rottembourg
- Groupe hospitalier Pitié-Salpêtrière, service de néphrologie, 83, boulevard de l'Hôpital, 75013 Paris, France.
| | - Guy Rostoker
- Hôpital privé Claude-Galien, Ramsay-Générale de Santé, service de néphrologie et de dialyse, 91480 Quincy-sous-Sénart, France
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Jones-Hughes T, Snowsill T, Haasova M, Coelho H, Crathorne L, Cooper C, Mujica-Mota R, Peters J, Varley-Campbell J, Huxley N, Moore J, Allwood M, Lowe J, Hyde C, Hoyle M, Bond M, Anderson R. Immunosuppressive therapy for kidney transplantation in adults: a systematic review and economic model. Health Technol Assess 2018; 20:1-594. [PMID: 27578428 DOI: 10.3310/hta20620] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND End-stage renal disease is a long-term irreversible decline in kidney function requiring renal replacement therapy: kidney transplantation, haemodialysis or peritoneal dialysis. The preferred option is kidney transplantation, followed by immunosuppressive therapy (induction and maintenance therapy) to reduce the risk of kidney rejection and prolong graft survival. OBJECTIVES To review and update the evidence for the clinical effectiveness and cost-effectiveness of basiliximab (BAS) (Simulect(®), Novartis Pharmaceuticals UK Ltd) and rabbit anti-human thymocyte immunoglobulin (rATG) (Thymoglobulin(®), Sanofi) as induction therapy, and immediate-release tacrolimus (TAC) (Adoport(®), Sandoz; Capexion(®), Mylan; Modigraf(®), Astellas Pharma; Perixis(®), Accord Healthcare; Prograf(®), Astellas Pharma; Tacni(®), Teva; Vivadex(®), Dexcel Pharma), prolonged-release tacrolimus (Advagraf(®) Astellas Pharma), belatacept (BEL) (Nulojix(®), Bristol-Myers Squibb), mycophenolate mofetil (MMF) (Arzip(®), Zentiva; CellCept(®), Roche Products; Myfenax(®), Teva), mycophenolate sodium (MPS) (Myfortic(®), Novartis Pharmaceuticals UK Ltd), sirolimus (SRL) (Rapamune(®), Pfizer) and everolimus (EVL) (Certican(®), Novartis) as maintenance therapy in adult renal transplantation. METHODS Clinical effectiveness searches were conducted until 18 November 2014 in MEDLINE (via Ovid), EMBASE (via Ovid), Cochrane Central Register of Controlled Trials (via Wiley Online Library) and Web of Science (via ISI), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Health Technology Assessment (The Cochrane Library via Wiley Online Library) and Health Management Information Consortium (via Ovid). Cost-effectiveness searches were conducted until 18 November 2014 using a costs or economic literature search filter in MEDLINE (via Ovid), EMBASE (via Ovid), NHS Economic Evaluation Database (via Wiley Online Library), Web of Science (via ISI), Health Economic Evaluations Database (via Wiley Online Library) and the American Economic Association's electronic bibliography (via EconLit, EBSCOhost). Included studies were selected according to predefined methods and criteria. A random-effects model was used to analyse clinical effectiveness data (odds ratios for binary data and mean differences for continuous data). Network meta-analyses were undertaken within a Bayesian framework. A new discrete time-state transition economic model (semi-Markov) was developed, with acute rejection, graft function (GRF) and new-onset diabetes mellitus used to extrapolate graft survival. Recipients were assumed to be in one of three health states: functioning graft, graft loss or death. RESULTS Eighty-nine randomised controlled trials (RCTs), of variable quality, were included. For induction therapy, no treatment appeared more effective than another in reducing graft loss or mortality. Compared with placebo/no induction, rATG and BAS appeared more effective in reducing biopsy-proven acute rejection (BPAR) and BAS appeared more effective at improving GRF. For maintenance therapy, no treatment was better for all outcomes and no treatment appeared most effective at reducing graft loss. BEL + MMF appeared more effective than TAC + MMF and SRL + MMF at reducing mortality. MMF + CSA (ciclosporin), TAC + MMF, SRL + TAC, TAC + AZA (azathioprine) and EVL + CSA appeared more effective than CSA + AZA and EVL + MPS at reducing BPAR. SRL + AZA, TAC + AZA, TAC + MMF and BEL + MMF appeared to improve GRF compared with CSA + AZA and MMF + CSA. In the base-case deterministic and probabilistic analyses, BAS, MMF and TAC were predicted to be cost-effective at £20,000 and £30,000 per quality-adjusted life-year (QALY). When comparing all regimens, only BAS + TAC + MMF was cost-effective at £20,000 and £30,000 per QALY. LIMITATIONS For included trials, there was substantial methodological heterogeneity, few trials reported follow-up beyond 1 year, and there were insufficient data to perform subgroup analysis. Treatment discontinuation and switching were not modelled. FUTURE WORK High-quality, better-reported, longer-term RCTs are needed. Ideally, these would be sufficiently powered for subgroup analysis and include health-related quality of life as an outcome. CONCLUSION Only a regimen of BAS induction followed by maintenance with TAC and MMF is likely to be cost-effective at £20,000-30,000 per QALY. STUDY REGISTRATION This study is registered as PROSPERO CRD42014013189. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Tracey Jones-Hughes
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Tristan Snowsill
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Marcela Haasova
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Helen Coelho
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Louise Crathorne
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Chris Cooper
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Ruben Mujica-Mota
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jaime Peters
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jo Varley-Campbell
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Nicola Huxley
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jason Moore
- Exeter Kidney Unit, Royal Devon and Exeter Foundation Trust Hospital, Exeter, UK
| | - Matt Allwood
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jenny Lowe
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Chris Hyde
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Martin Hoyle
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Mary Bond
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Rob Anderson
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
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Interchangeability Problems of Drugs with Narrow Therapeutic Indices. Pharm Chem J 2017. [DOI: 10.1007/s11094-017-1681-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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15
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Alloway RR, Vinks AA, Fukuda T, Mizuno T, King EC, Zou Y, Jiang W, Woodle ES, Tremblay S, Klawitter J, Klawitter J, Christians U. Bioequivalence between innovator and generic tacrolimus in liver and kidney transplant recipients: A randomized, crossover clinical trial. PLoS Med 2017; 14:e1002428. [PMID: 29135993 PMCID: PMC5685573 DOI: 10.1371/journal.pmed.1002428] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 10/06/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Although the generic drug approval process has a long-term successful track record, concerns remain for approval of narrow therapeutic index generic immunosuppressants, such as tacrolimus, in transplant recipients. Several professional transplant societies and publications have generated skepticism of the generic approval process. Three major areas of concern are that the pharmacokinetic properties of generic products and the innovator (that is, "brand") product in healthy volunteers may not reflect those in transplant recipients, bioequivalence between generic and innovator may not ensure bioequivalence between generics, and high-risk patients may have specific bioequivalence concerns. Such concerns have been fueled by anecdotal observations and retrospective and uncontrolled published studies, while well-designed, controlled prospective studies testing the validity of the regulatory bioequivalence testing approach for narrow therapeutic index immunosuppressants in transplant recipients have been lacking. Thus, the present study prospectively assesses bioequivalence between innovator tacrolimus and 2 generics in individuals with a kidney or liver transplant. METHODS AND FINDINGS From December 2013 through October 2014, a prospective, replicate dosing, partially blinded, randomized, 3-treatment, 6-period crossover bioequivalence study was conducted at the University of Cincinnati in individuals with a kidney (n = 35) or liver transplant (n = 36). Abbreviated New Drug Applications (ANDA) data that included manufacturing and healthy individual pharmacokinetic data for all generics were evaluated to select the 2 most disparate generics from innovator, and these were named Generic Hi and Generic Lo. During the 8-week study period, pharmacokinetic studies assessed the bioequivalence of Generic Hi and Generic Lo with the Innovator tacrolimus and with each other. Bioequivalence of the major tacrolimus metabolite was also assessed. All products fell within the US Food and Drug Administration (FDA) average bioequivalence (ABE) acceptance criteria of a 90% confidence interval contained within the confidence limits of 80.00% and 125.00%. Within-subject variability was similar for the area under the curve (AUC) (range 12.11-15.81) and the concentration maximum (Cmax) (range 17.96-24.72) for all products. The within-subject variability was utilized to calculate the scaled average bioequivalence (SCABE) 90% confidence interval. The calculated SCABE 90% confidence interval was 84.65%-118.13% and 80.00%-125.00% for AUC and Cmax, respectively. The more stringent SCABE acceptance criteria were met for all product comparisons for AUC and Cmax in both individuals with a kidney transplant and those with a liver transplant. European Medicines Agency (EMA) acceptance criteria for narrow therapeutic index drugs were also met, with the only exception being in the case of Brand versus Generic Lo, in which the upper limits of the 90% confidence intervals were 111.30% (kidney) and 112.12% (liver). These were only slightly above the upper EMA acceptance criteria limit for an AUC of 111.11%. SCABE criteria were also met for the major tacrolimus metabolite 13-O-desmethyl tacrolimus for AUC, but it failed the EMA criterion. No acute rejections, no differences in renal function in all individuals, and no differences in liver function were observed in individuals with a liver transplant using the Tukey honest significant difference (HSD) test for multiple comparisons. Fifty-two percent and 65% of all individuals with a kidney or liver transplant, respectively, reported an adverse event. The Exact McNemar test for paired categorical data with adjustments for multiple comparisons was used to compare adverse event rates among the products. No statistically significant differences among any pairs of products were found for any adverse event code or for adverse events overall. Limitations of this study include that the observations were made under strictly controlled conditions that did not allow for the impact of nonadherence or feeding on the possible pharmacokinetic differences. Generic Hi and Lo were selected based upon bioequivalence data in healthy volunteers because no pharmacokinetic data in recipients were available for all products. The safety data should be interpreted in light of the small number of participants and the short observation periods. Lastly, only the 1 mg tacrolimus strength was utilized in this study. CONCLUSIONS Using an innovative, controlled bioequivalence study design, we observed equivalence between tacrolimus innovator and 2 generic products as well as between 2 generic products in individuals after kidney or liver transplantation following current FDA bioequivalence metrics. These results support the position that bioequivalence for the narrow therapeutic index drug tacrolimus translates from healthy volunteers to individuals receiving a kidney or liver transplant and provides evidence that generic products that are bioequivalent with the innovator product are also bioequivalent to each other. TRIAL REGISTRATION ClinicalTrials.gov NCT01889758.
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Affiliation(s)
- Rita R. Alloway
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
- * E-mail:
| | - Alexander A. Vinks
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Eileen C. King
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
- Division of Biostatistics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Yuanshu Zou
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
- Division of Biostatistics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Wenlei Jiang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food & Drug Administration, Silver Spring, Maryland, United States of America
| | - E. Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Simon Tremblay
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Jelena Klawitter
- iC42 Clinical Research and Development, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Jost Klawitter
- iC42 Clinical Research and Development, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Uwe Christians
- iC42 Clinical Research and Development, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
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Naicker D, Reed PW, Ronaldson J, Kara T, Wong W, Prestidge C. Nationwide conversion to generic tacrolimus in pediatric kidney transplant recipients. Pediatr Nephrol 2017; 32:2125-2131. [PMID: 28660366 DOI: 10.1007/s00467-017-3707-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 05/13/2017] [Accepted: 05/15/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Bioequivalence between Tacrolimus Prograf® and generic tacrolimus formulations has been demonstrated in adult populations, however clinical experience and safety data regarding generic tacrolimus in pediatric transplant recipients is limited. This study aimed to evaluate conversion from Tacrolimus Prograf® to Sandoz® in pediatric renal transplant recipients nationwide. The primary outcome was a change in mean trough tacrolimus concentration. Additionally, changes in tacrolimus intra-patient coefficient of variation (CoV), allograft function, requirement for dose adjustments, and episodes of biopsy-proven rejection were evaluated. METHODS Retrospective cohort study in 37 pediatric renal transplant recipients who switched to Tacrolimus Sandoz®. Each patient had three pre-conversion tacrolimus trough and creatinine concentrations within the 4 months prior and three post-conversion concentrations on day 3, 10, and the next subsequent level. Mean pre- and post-conversion tacrolimus trough concentrations and glomerular filtration rate (eGFR) were calculated. Tacrolimus concentration, CoV, and creatinine differences were compared by paired t test. RESULTS Thirty-seven patients (41% females, age 3-18 years) were included. Average intra-patient difference in trough tacrolimus concentration was 0.05μg/l (95% CI -0.37 to 0.47). Average intra-patient difference in eGFR was -1.20 ml/min/1.732 (95% CI -3.53 to 1.13). Three patients had acute rejection during 12 months post-conversion compared to none during 12 months pre-conversion. CONCLUSIONS Pediatric renal transplant recipients can be converted from Tacrolimus Prograf® to Sandoz® with negligible change in trough concentration, dose adjustments, or immediate allograft function. Of concern was the number of acute rejection episodes, however non-adherence contributed to at least one episode and this difference was determined clinically and statistically not significant.
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Affiliation(s)
- Derisha Naicker
- Department of Pediatric Nephrology, Starship Children's Hospital, Park Road, Private Bag 92024, Auckland, 1142, New Zealand.
| | - Peter W Reed
- Children's Research Centre, Starship Children's Hospital, Auckland, New Zealand
| | - Jane Ronaldson
- Department of Pediatric Nephrology, Starship Children's Hospital, Park Road, Private Bag 92024, Auckland, 1142, New Zealand
| | - Tonya Kara
- Department of Pediatric Nephrology, Starship Children's Hospital, Park Road, Private Bag 92024, Auckland, 1142, New Zealand
| | - William Wong
- Department of Pediatric Nephrology, Starship Children's Hospital, Park Road, Private Bag 92024, Auckland, 1142, New Zealand
| | - Chanel Prestidge
- Department of Pediatric Nephrology, Starship Children's Hospital, Park Road, Private Bag 92024, Auckland, 1142, New Zealand
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Pharmacokinetics and Clinical Outcomes of Generic Tacrolimus (Hexal) Versus Branded Tacrolimus in De Novo Kidney Transplant Patients. Transplantation 2017; 101:2780-2788. [DOI: 10.1097/tp.0000000000001843] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Reimers A, Olsson P, Nilsson J, Hoff E, Reis M, Strandberg M, Lundgren A, Källén K. Impact of generic substitution on levetiracetam serum concentration—A prospective study in an outpatient setting. Epilepsy Res 2017; 134:54-61. [DOI: 10.1016/j.eplepsyres.2017.04.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 03/22/2017] [Accepted: 04/22/2017] [Indexed: 10/19/2022]
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19
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Elek P, Harsányi A, Zelei T, Csetneki K, Kaló Z. Policy objective of generic medicines from the investment perspective: The case of clopidogrel. Health Policy 2017; 121:558-565. [DOI: 10.1016/j.healthpol.2017.02.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 12/23/2016] [Accepted: 02/24/2017] [Indexed: 10/20/2022]
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20
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Ericson JE, Zimmerman KO, Gonzalez D, Melloni C, Guptill JT, Hill KD, Wu H, Cohen-Wolkowiez M. A Systematic Literature Review Approach to Estimate the Therapeutic Index of Selected Immunosuppressant Drugs After Renal Transplantation. Ther Drug Monit 2017; 39:13-20. [PMID: 28081041 PMCID: PMC5235278 DOI: 10.1097/ftd.0000000000000364] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Drugs that exhibit close margins between therapeutic and toxic blood concentrations are considered to have a narrow therapeutic index (NTI). The Food and Drug Administration has proposed that NTI drugs should have more stringent bioequivalence standards for approval of generic formulations. However, many immunosuppressant drugs do not have a well-defined therapeutic index (TI). METHODS We sought to determine whether safety, efficacy, and pharmacokinetic data obtained from the medical literature through a comprehensive literature search could be used to estimate the TI of cyclosporine, tacrolimus, and sirolimus. In this analysis, we considered TI ≤2 as a criterion to define a drug as having an NTI. RESULTS Published literature indicates that cyclosporine has a TI of 2-3, which falls just short of our criteria to be classified as having an NTI. We found sirolimus and tacrolimus to have a therapeutic range of 5-12 ng/mL and of 5-20 ng/mL, respectively, but were unable to calculate the TI. CONCLUSIONS Although the current literature does not provide a clear indication that these drugs have an NTI, the routine use of therapeutic drug monitoring in clinical practice suggests that more stringent testing of their pharmacokinetic and pharmacodynamic properties should be performed before the approval of generic formulations.
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Affiliation(s)
- Jessica E. Ericson
- Departments of Pediatrics, Pennsylvania State University, Hershey, PA
- Duke Clinical Research Institute, Durham, NC
| | - Kanecia O. Zimmerman
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | | | - Kevin D. Hill
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - Huali Wu
- Duke Clinical Research Institute, Durham, NC
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
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Son SY, Jang HR, Lee JE, Yoo H, Kim K, Park JB, Kim SJ, Oh HY, Huh W. Comparison of the long-term efficacy and safety of generic Tacrobell with original tacrolimus (Prograf) in kidney transplant recipients. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:203-210. [PMID: 28138224 PMCID: PMC5238812 DOI: 10.2147/dddt.s118154] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This study aimed to evaluate the long-term efficacy and safety of a generic tacrolimus (Tacrobell [TCB]) compared to the original tacrolimus (Prograf [PGF]) in kidney transplant recipients. In this retrospective observational study, we analyzed the data from 444 patients who took TCB as a first-line immunosuppressive drug and 245 patients who took PGF. The 5-year graft survival rate was 92% for patients in the PGF group and 97% for patients in the TCB group, respectively. Cox proportional hazards for a one-sided, noninferiority model showed noninferiority (upper confidence interval [CI] limit of the hazard ratio [HR]<1.2) for TCB compared to PGF (HR: 0.58; 95% CI: 0–1.14). The 5-year patient survival rate was 96% for patients in the PGF group and 97% for patients in the TCB group. Cox proportional hazards for a one-sided, noninferiority model showed noninferiority (upper confidence interval limit of the HR<2.0) for TCB compared to PGF (HR: 0.83; 95% CI: 0–1.95). The 5-year acute rejection-free graft survival rate was not significantly different between the groups (TCB 67%, PGF 68.8%; P=0.6286). The incidence of adverse events including adverse cardiovascular or cerebrovascular events, malignancies, new-onset diabetes after transplantation, and infection events did not differ significantly between the two groups. We conclude that TCB is a comparable alternative to the original tacrolimus as a first-line immunosuppressive drug. Producers of generics should support further study of their products after approval to assure physicians of their efficacy and safety.
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Affiliation(s)
- Seung Yeon Son
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Hye Ryoun Jang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Jung Eun Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Heejin Yoo
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center
| | - Kyunga Kim
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center; Department of Digital Health, SAIHST
| | - Jae Berm Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Joo Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ha Young Oh
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Wooseong Huh
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
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Switching Stable Kidney Transplant Recipients to a Generic Tacrolimus Is Feasible and Safe, but It Must Be Monitored. J Transplant 2017; 2017:5646858. [PMID: 28246556 PMCID: PMC5299171 DOI: 10.1155/2017/5646858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 11/13/2016] [Accepted: 12/25/2016] [Indexed: 11/18/2022] Open
Abstract
Background. Tacrolimus is the primary immunosuppressive drug used in kidney transplant patients. Replacing brand name products with generics is a controversial issue that we studied after a Chilean Ministry of Health mandate to implement such a switch. Methods. Forty-one stable Prograf (Astellas) receiving kidney transplant patients were switched to a generic tacrolimus (Sandoz) in a 1 : 1 dose ratio and were followed up for up to 8 months. All other drugs were maintained as per normal practice. Results. Neither tacrolimus doses nor their trough blood levels changed significantly after the switch, but serum creatinine did: 1.62 ± 0.90 versus 1.75 ± 0.92 mg/dL (p < 0.001). At the same time, five graft biopsies were performed, and two of them showed cellular acute rejection. There were nine infectious episodes treated satisfactorily with proper therapies. No patient or graft was lost during the follow-up time period. Conclusion. Switching from brand name tacrolimus to a generic tacrolimus (Sandoz) is feasible and appears to be safe, but it must be monitored carefully by treating physicians.
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Duong SQ, Lal AK, Joshi R, Feingold B, Venkataramanan R. Transition from brand to generic tacrolimus is associated with a decrease in trough blood concentration in pediatric heart transplant recipients. Pediatr Transplant 2015; 19:911-7. [PMID: 26497983 DOI: 10.1111/petr.12608] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2015] [Indexed: 12/18/2022]
Abstract
There are limited data available on the bioequivalence of generic and brand-name tacrolimus in pediatric and heart transplant patients. We characterized changes in 12-hour trough concentrations and clinical outcomes after transition from brand to generic tacrolimus in pediatric thoracic organ transplant recipients. Patients with a pharmacy-confirmed date of switch between generic and brand tacrolimus were identified, as well as a matched control group that did not switch for comparison. We identified 18 patients with a confirmed date of switch, and in 12 patients that remained on the same dose, trough concentrations were 14% less than when they were on brand (p = 0.037). The average change was -1.15 ± 1.76 ng/mL (p = 0.045). The control group did not experience a change in trough concentration and was different than the switched group (p = 0.005). There were no differences in dosage changes or kidney or liver function. In the year after switch, 24% of patients who were switched to generic experienced a rejection event vs. 18% in the patients on brand. We suggest a strategy of monitoring around the time of transition, and education of the patient/family to notify the care team when changes from brand to generic or between generics occur.
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Affiliation(s)
- Son Q Duong
- Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Ashwin K Lal
- Pediatric Cardiology, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Rujuta Joshi
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian Feingold
- Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.,Clinical and Translational Science, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Thomas Starzl Transplant Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Hauch A, John M, Smith A, Dortonne I, Patel U, Kandil E, Killackey M, Paramesh A, Lee B, Zhang R, Buell JF. Generics: Are all immunosuppression agents created equally? Surgery 2015. [PMID: 26206317 DOI: 10.1016/j.surg.2015.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Gothe H, Schall I, Saverno K, Mitrovic M, Luzak A, Brixner D, Siebert U. The Impact of Generic Substitution on Health and Economic Outcomes: A Systematic Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2015; 13 Suppl 1:S21-S33. [PMID: 26091709 PMCID: PMC4519629 DOI: 10.1007/s40258-014-0147-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Generic drugs are considered therapeutically equivalent to their original counterparts and lower in acquisition costs. However, the overall impact of generic substitution (GS) on global clinical and economic outcomes has not been conclusively evaluated. OBJECTIVE To test whether (1) generics and original products yield the same health outcomes, and (2) generic therapies save economic resources versus original therapies. METHODS We performed a systematic literature review in Medline, Embase, and the Cochrane Database of Systematic Reviews to identify original studies that examine clinical or economic outcomes of GS. After standardized data extraction, reported outcomes were categorized as supporting or rejecting the hypotheses. Each reported outcome was assessed and accounted for supporting and opposing GS. One publication could provide multiple outcome comparisons. RESULTS We included 40 studies across ten therapeutic areas. Fourteen studies examined patients on de novo therapy; 24 studies investigated maintenance drug therapy, and two studies considered both settings. Overall, 119 outcome comparisons were examined. Of 97 clinical outcome comparisons, 67% reported no significant difference between generic drugs and their off-patent counterparts. Of 22 economic comparisons, 64% suggested that GS increased costs. Consequently, hypothesis (1) was supported but hypothesis (2) was not. We found no major differences among studies that investigated clinical outcomes with de novo or maintenance therapy. CONCLUSION The review suggests that clinical effects are similar after GS. However, economic savings are not guaranteed. More systematic research comparing clinical and economic outcomes with or without GS is needed to inform policy on the use of generic substitution.
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Affiliation(s)
- H. Gothe
- />Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT, University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, 6060 Hall i.T., Austria
- />Division of Public Health, Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL, Center for Personalized Cancer Medicine Innsbruck, Karl Kapferer Strasse 5, 6020 Innsbruck, Austria
- />Dresden Medical School “Carl Gustav Carus”, Dresden University of Technology, Fetscherstraße 74, 01307 Dresden, Germany
| | - I. Schall
- />Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT, University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, 6060 Hall i.T., Austria
| | - K. Saverno
- />Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT, University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, 6060 Hall i.T., Austria
- />Department of Pharmacotherapy, University of Utah, 30 S 2000 E, Rm 4410, Salt Lake City, Utah 84112 USA
| | - M. Mitrovic
- />Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT, University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, 6060 Hall i.T., Austria
| | - A. Luzak
- />Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT, University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, 6060 Hall i.T., Austria
| | - D. Brixner
- />Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT, University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, 6060 Hall i.T., Austria
- />Department of Pharmacotherapy, University of Utah, 30 S 2000 E, Rm 4410, Salt Lake City, Utah 84112 USA
| | - U. Siebert
- />Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT, University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, 6060 Hall i.T., Austria
- />Center for Health Decision Science, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115 USA
- />Institute for Technology Assessment, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 101 Merrimac St., 10th FL, Boston, MA 02114 USA
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Melilli E, Crespo E, Sandoval D, Manonelles A, Sala N, Mast R, Padulles A, Grinyo JM, Bestard O, Cruzado JM. De novouse of a generic formulation of tacrolimus versus reference tacrolimus in kidney transplantation: evaluation of the clinical results, histology in protocol biopsies, and immunological monitoring. Transpl Int 2015; 28:1283-90. [DOI: 10.1111/tri.12626] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 03/06/2015] [Accepted: 06/15/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Edoardo Melilli
- Bellvitge University Hospital; Department of Nephrology; Renal Transplantation Unit carrer de la feixa llarga L'Hospitalet de Llobregat; Barcelona Spain
| | - Elena Crespo
- IDIBELL; Department of Experimental Nephrology; Carrer de la feixa llarga L'Hospitalet de Llobregat; Barcelona Spain
| | - Diego Sandoval
- Bellvitge University Hospital; Department of Nephrology; Renal Transplantation Unit carrer de la feixa llarga L'Hospitalet de Llobregat; Barcelona Spain
| | - Anna Manonelles
- Bellvitge University Hospital; Department of Nephrology; Renal Transplantation Unit carrer de la feixa llarga L'Hospitalet de Llobregat; Barcelona Spain
- IDIBELL; Department of Experimental Nephrology; Carrer de la feixa llarga L'Hospitalet de Llobregat; Barcelona Spain
| | - Neus Sala
- Bellvitge University Hospital; Department of Nephrology; Renal Transplantation Unit carrer de la feixa llarga L'Hospitalet de Llobregat; Barcelona Spain
| | - Richard Mast
- Department of Radiology; Bellvitge University Hospital; Carrer de la feixa llarga L'Hospitalet de Llobregat; Barcelona Spain
| | - Ariadna Padulles
- Department of Pharmacy; Bellvitge University Hospital; Carrer de la feixa llarga L'Hospitalet de Llobregat; Barcelona Spain
| | - Josep M. Grinyo
- Bellvitge University Hospital; Department of Nephrology; Renal Transplantation Unit carrer de la feixa llarga L'Hospitalet de Llobregat; Barcelona Spain
| | - Oriol Bestard
- Bellvitge University Hospital; Department of Nephrology; Renal Transplantation Unit carrer de la feixa llarga L'Hospitalet de Llobregat; Barcelona Spain
- IDIBELL; Department of Experimental Nephrology; Carrer de la feixa llarga L'Hospitalet de Llobregat; Barcelona Spain
| | - Josep Maria Cruzado
- Bellvitge University Hospital; Department of Nephrology; Renal Transplantation Unit carrer de la feixa llarga L'Hospitalet de Llobregat; Barcelona Spain
- IDIBELL; Department of Experimental Nephrology; Carrer de la feixa llarga L'Hospitalet de Llobregat; Barcelona Spain
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Molnar AO, Fergusson D, Tsampalieros AK, Bennett A, Fergusson N, Ramsay T, Knoll GA. Generic immunosuppression in solid organ transplantation: systematic review and meta-analysis. BMJ 2015; 350:h3163. [PMID: 26101226 PMCID: PMC4476317 DOI: 10.1136/bmj.h3163] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare the clinical efficacy and bioequivalence of generic immunosuppressive drugs in patients with solid organ transplants. DESIGN Systematic review and meta-analysis of all studies comparing generic with innovator immunosuppressive drugs. DATA SOURCES Medline and Embase from 1980 to September 2014. REVIEW METHODS A literature search was performed for all studies comparing a generic to an innovator immunosuppressive drug in solid organ transplantation. Two reviewers independently extracted data and assessed quality of studies. Meta-analyses of prespecified outcomes were performed when deemed appropriate. Outcomes included patient survival, allograft survival, acute rejection, adverse events and bioequivalence. RESULTS 1679 citations were screened, of which 50 studies met eligibility criteria (17 randomized trials, 15 non-randomized interventional studies, and 18 observational studies). Generics were compared with Neoral (cyclosporine) (32 studies), Prograf (tacrolimus) (12 studies), and Cellcept (mycophenolate mofetil) (six studies). Pooled analysis of randomized controlled trials in patients with kidney transplants that reported bioequivalence criteria showed that Neoral (two studies) and Prograf (three studies) were not bioequivalent with generic preparations according to criteria of the European Medicines Agency. The single Cellcept trial also did not meet bioequivalence. Acute rejection was rare but did not differ between groups. For Neoral, the pooled Peto odds ratio was 1.23 (95% confidence interval 0.64 to 2.36) for kidney randomized controlled trials and 0.66 (0.40 to 1.08) for observational studies. For kidney observational studies, the pooled Peto odds ratios were 0.98 (0.37 to 2.60) for Prograf and 0.49 (0.09 to 2.56) for Cellcept. Meta-analyses for non-renal solid organ transplants were not performed because of a lack of data.There were insufficient data reported on patient or graft survival. Pooling of results was limited by inconsistent study methods and reporting of outcomes. Many studies did not report standard criteria used to determine bioequivalence. While rates of acute rejection seemed similar and were relatively rare, few studies were designed to properly compare clinical outcomes. Most studies had short follow-up times and included stable patients without a history of rejection. CONCLUSIONS High quality data showing bioequivalence and clinical efficacy of generic immunosuppressive drugs in patients with transplants are lacking. Given the serious consequences of rejection and allograft failure, well designed studies on bioequivalence and safety of generic immunosuppression in transplant recipients are needed.
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Affiliation(s)
- Amber O Molnar
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6 Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Canada, K1H 8L6
| | - Dean Fergusson
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6 Division of Nephrology, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Canada, K1H 8L1
| | - Anne K Tsampalieros
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6 Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Canada, K1H 8L6
| | - Alexandria Bennett
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6 Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Canada, K1H 8L6
| | - Nicholas Fergusson
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6 Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Canada, K1H 8L6
| | - Timothy Ramsay
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6
| | - Greg A Knoll
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6
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Talawila N, Pengel LHM. Does belatacept improve outcomes for kidney transplant recipients? A systematic review. Transpl Int 2015; 28:1251-64. [PMID: 25965549 DOI: 10.1111/tri.12605] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 01/19/2015] [Accepted: 05/07/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Belatacept was intended to provide better outcomes for kidney transplant (KT) recipients by allowing minimization/withdrawal of calcineurin inhibitors (CNI) and steroids. METHODS We searched for randomized controlled trials (RCTs) in adult KT comparing belatacept with CNIs. Methodological quality was assessed. Meta-analyses were performed to calculate odds ratios (OR) and mean differences (MD). RESULTS Six RCTs were included. Pooled analyses found no differences for acute rejection at any time point. Renal function [Calculated glomerular filtration rate (cGFR)] was better with belatacept at 12 and 24 months (MD = 11.7 and 13.7 ml/min/1.73 m(2) ). New onset diabetes after transplantation was lower with belatacept at 12 months (OR = 0.43). Systolic and diastolic blood pressures were lower at 12 months (MD -7.2 and -3.1 mmHg) as were triglycerides at 12 and 24 months (MD = -32.9 and -41.7 mg/dl). Total and low-density lipoprotein cholesterol were lower with belatacept at 24 months (MD = -19.8 and -10.6 mg/dl). There were no differences for other outcomes. CONCLUSION Limited available data suggest a potential benefit for belatacept by reducing the risk of CNI toxicity, especially renal function, without evidence of increased acute rejection. There were no safety issues apart from a possible risk of post-transplant lymphoproliferative disorder in Epstein-barr virus-seronegative recipients. Further studies are required to confirm this benefit.
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Affiliation(s)
- Nishanthi Talawila
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England and the London School of Hygiene and Tropical Medicine, University of London, London, UK
| | - Liset H M Pengel
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England and the London School of Hygiene and Tropical Medicine, University of London, London, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Yu Y, Teerenstra S, Neef C, Burger D, Maliepaard M. Investigation into the interchangeability of generic formulations using immunosuppressants and a broad selection of medicines. Eur J Clin Pharmacol 2015; 71:979-90. [PMID: 26062932 PMCID: PMC4500859 DOI: 10.1007/s00228-015-1878-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 05/25/2015] [Indexed: 11/08/2022]
Abstract
Purpose To date, the interchangeability of generic drugs has only been investigated for a limited number of medicines. The objective of this study was to investigate generic-generic drug interchangeability in a large subset of generic formulations in order to cover a broad spectrum of drugs. Methods Orally administered drugs for investigation in this study were selected using strict, predefined criteria, with the purpose to avoid bias. This selection procedure yielded atorvastatin, bicalutamide, naratriptan, olanzapine, perindopril, and venlafaxine. Further, ciclosporin, tacrolimus, and mycophenolate mofetil were investigated as test immunosuppressants. Adjusted indirect comparisons were conducted between generic drugs containing the same active substance, and the 90 % confidence interval (CI) for AUC and Cmax was calculated. Results In total, 120 bioequivalence studies were identified in the Dutch medicine regulatory agency’s database, allowing 292 indirect comparisons between generic drugs. The indirect comparison results indicated that in the vast majority of cases, i.e., 80.5 %, the 90 % CIs for both AUCt and Cmax fell within the bioequivalence criteria (in 90.1 and 87.0 % for AUCt and Cmax, respectively). In 1 % of the 292 indirect comparison for AUCt and 3 % for Cmax, a wider range of 75–133 % (or 80–125 %) was exceeded. Conclusions Overall, our study suggests that exposure-related risks associated with the exchange of different generic drugs in clinical practice are not increased to a relevant extent compared to the situation in which a generic is exchanged with the innovator. Electronic supplementary material The online version of this article (doi:10.1007/s00228-015-1878-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yang Yu
- Department of Pharmacology and Toxicology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands,
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Söderlund C, Rådegran G. Safety and efficacy of the switch to generic mycophenolate mofetil and tacrolimus in heart transplant patients. Clin Transplant 2015; 29:619-28. [PMID: 25981927 DOI: 10.1111/ctr.12564] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Generic immunosuppressants may offer economic advantages, but their use is still controversial. At our center, 55 heart transplant patients were switched from CellCept(®) to Myfenax Teva(®) (MT) (n = 51, 18% female, 8.1 ± 6.6 yr post-transplantation) and/or Prograf(®) to Tacrolimus Sandoz(®) (TS) (n = 17, 41% female, 6.6 ± 5.8 yr post-transplantation). METHODS We conducted an acute monitoring and a retrospective follow-up with regard to safety and efficacy. Acute cellular rejections (ACRs) on endomyocardial biopsies (EMBs) four wk after the MT switch were specifically compared to a matched retrospective control group. RESULTS Tacrolimus C0 levels (TS switch) as well as hemoglobin, leukocytes, and thrombocytes (MT switch) did not change (p = NS) during the three wk after each respective switch (8.7 ± 2.9 vs. 8.4 ± 1.9 μg/L, 129.1 ± 12.6 vs. 130.1 ± 12.8 g/L, 6.3 vs. 6.2 × 10(9) /L, and 217.4 ± 56.6 vs. 219.3 ± 61.8 × 10(9) /L, respectively). 0% of the EMBs in the MT switch vs. 3% of the EMBs in the control group showed ACR>grade 1R (p = NS). After six months, survival was 96% (MT switch) and 100% (TS switch), and the frequency of severe ACR was low. Safety parameters measured at the next annual follow-up were also stable following each switch. CONCLUSION Switching to MT and/or TS several years after heart transplantation appeared safe in the short-term perspective, showing no detectable changes in tacrolimus C0 levels, safety or efficacy, during an average follow-up of six months.
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Affiliation(s)
- Carl Söderlund
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, The Clinic for Heart and Lung Disease, Skåne University Hospital, Lund, Sweden.,Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Göran Rådegran
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, The Clinic for Heart and Lung Disease, Skåne University Hospital, Lund, Sweden.,Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
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El Hajj S, Kim M, Phillips K, Gabardi S. Generic immunosuppression in transplantation: current evidence and controversial issues. Expert Rev Clin Immunol 2015; 11:659-72. [DOI: 10.1586/1744666x.2015.1026895] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Tichy EM, Pilch NA, Smith LD, Maldonado AQ, Taber DJ. Building a business plan to support a transplantation pharmacy practice model. Am J Health Syst Pharm 2014; 71:751-7. [PMID: 24733139 DOI: 10.2146/ajhp130555] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Eric M Tichy
- Eric M. Tichy, Pharm.D., BCPS, is Senior Clinical Pharmacy Specialist, Solid Organ Transplant, and Director, Postgraduate Year 2 Pharmacy Residency-Transplant, Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT. Nicole A. Pilch, Pharm.D., M.S.C.R., BCPS, is Clinical Specialist, Solid Organ Transplantation, and Clinical Assistant Professor, Department of Pharmacy and Clinical Sciences, South Carolina College of Pharmacy, Medical University of South Carolina, Charleston. Lonnie D. Smith, Pharm.D., is Manager, Department of Solid Organ Transplant, and Director, Postgraduate Year 2 Pharmacy Residency-Transplant, University of Utah Hospitals and Clinics, Salt Lake City. Angela Q. Maldonado, Pharm.D., BCPS, is Clinical Pharmacy Specialist-Transplant Services, Vidant Medical Center, Greenville, NC. David J. Taber, Pharm.D., BCPS, is Director, Clinical Research, and Assistant Professor of Surgery, Medical University of South Carolina
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Madian AG, Panigrahi A, Perera MA, Pinto N. Case report: Inability to achieve a therapeutic dose of tacrolimus in a pediatric allogeneic stem cell transplant patient after generic substitution. BMC Pharmacol Toxicol 2014; 15:69. [PMID: 25472557 PMCID: PMC4287354 DOI: 10.1186/2050-6511-15-69] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 11/18/2014] [Indexed: 11/24/2022] Open
Abstract
Background Tacrolimus is an immunosuppressive drug that is used to lower the activity of the patient’s immune system to prevent organ rejection. Unfortunately, there is limited data regarding the therapeutic equivalency of generic tacrolimus formulations especially in children. We report the case of a pediatric patient having an inability to achieve a therapeutic trough level for tacrolimus after conversion from brand name to the generic formulation. Case presentation A 17-month-old male patient diagnosed with T-cell acute lymphoblastic leukemia underwent allogeneic stem cell transplantation. The patient initially received intravenous (IV) tacrolimus for graft-versus-host disease (GVHD) prophylaxis and achieved therapeutic levels. The patient was then switched to an oral brand formulation of tacrolimus, and was able to maintain trough levels within the therapeutic range. After being discharged, the patient received the generic formulation of tacrolimus from an outside pharmacy and the care team was unable to reach therapeutic levels despite multiple dose escalations. Returning to brand name tacrolimus resulted in prompt achievement of therapeutic levels. Conclusions A likely etiology for the inability to achieve therapeutic trough levels in this patient is the change in formulation from brand formulation to generic version. Other factors including drug-drug interaction, preparation of the medication by a different pharmacy, drug-food interaction and genetic factors were also considered. Physicians and pharmacists must be aware of the inability to achieve targeted therapeutic concentrations of tacrolimus resulting from the conversion of brand name to the generic formulation until these generic formulations are tested in clinical trials in a pediatric population.
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Affiliation(s)
| | | | | | - Navin Pinto
- Committee of Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL, USA.
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35
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Dannhorn E, Cheung M, Rodrigues S, Cooper H, Thorburn D, Patch D, Burroughs A, O'Beirne J. De novouse of generic tacrolimus in liver transplantation - a single center experience with one-yr follow-up. Clin Transplant 2014; 28:1349-57. [DOI: 10.1111/ctr.12455] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2014] [Indexed: 12/17/2022]
Affiliation(s)
- E. Dannhorn
- The Royal Free Sheila Sherlock Liver Centre and University Department of Surgery; Royal Free Hospital; London UK
| | - M. Cheung
- The Royal Free Sheila Sherlock Liver Centre and University Department of Surgery; Royal Free Hospital; London UK
| | - S. Rodrigues
- The Royal Free Sheila Sherlock Liver Centre and University Department of Surgery; Royal Free Hospital; London UK
| | - H. Cooper
- Department of Pharmacy; Royal Free Hospital; London UK
| | - D. Thorburn
- The Royal Free Sheila Sherlock Liver Centre and University Department of Surgery; Royal Free Hospital; London UK
| | - D. Patch
- The Royal Free Sheila Sherlock Liver Centre and University Department of Surgery; Royal Free Hospital; London UK
| | - A.K. Burroughs
- The Royal Free Sheila Sherlock Liver Centre and University Department of Surgery; Royal Free Hospital; London UK
| | - J. O'Beirne
- The Royal Free Sheila Sherlock Liver Centre and University Department of Surgery; Royal Free Hospital; London UK
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Heavner MS, Tichy EM, Yazdi M, Formica RN, Kulkarni S, Emre S. Clinical outcomes associated with conversion from brand-name to generic tacrolimus in hospitalized kidney transplant recipients. Am J Health Syst Pharm 2014; 70:1507-12. [PMID: 23943182 DOI: 10.2146/ajhp120783] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The safety of converting kidney transplant recipients on brand-name tacrolimus to generic tacrolimus during hospitalization was evaluated. METHODS A single-center observational study compared tacrolimus dosages and trough tacrolimus levels in kidney transplant recipients who had a kidney transplant more than 90 days before hospital admission. Patients in the "brand" group were maintained on brand-name tacrolimus throughout the entire study period. Patients in the generic group were maintained on brand-name tacrolimus before hospital admission, converted to the generic formulation during hospitalization, and returned to the brand-name product at discharge. Tacrolimus dosages were converted on a milligram-per-milligram basis and adjusted, if needed. Outcomes evaluated included the percentage of patients requiring a dosage change, absolute change in average tacrolimus trough level, and frequency of biopsy-proven acute rejection within six months of discharge. RESULTS A total of 100 patients were evaluated for inclusion in the brand group, with 42 meeting study criteria; 98 patients were evaluated in the generic group, with 36 qualifying for the study. There were no significant differences between the brand and generic groups with respect to dosage adjustments required or trough tacrolimus levels at any point in the transition of care. Mean trough concentrations were similar between groups during all periods of care. The only occurrence of new-onset acute rejection within six months after admission occurred in the brand group. CONCLUSION Substitution of a generic formulation of tacrolimus for the innovator product during hospitalization of kidney transplant recipients was safely implemented. Tacrolimus dosage adjustments were common throughout the transitions of care, regardless of the formulation used.
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Affiliation(s)
- Mojdeh S Heavner
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT 06510, USA
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Taube D, Jones G, O'Beirne J, Wennberg L, Connor A, Rasmussen A, Backman L. Generic tacrolimus in solid organ transplantation. Clin Transplant 2014; 28:623-32. [PMID: 24750309 DOI: 10.1111/ctr.12336] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2014] [Indexed: 11/28/2022]
Affiliation(s)
- D. Taube
- Imperial College Academic Health Science Centre; London UK
| | - G. Jones
- UCL Centre for Nephrology; Royal Free Hospital; London UK
| | - J. O'Beirne
- Shelia Sherlock Liver Centre; UCL Institute of Liver and Digestive Health; Royal Free Hospital; London UK
| | - L. Wennberg
- Department of Transplantation Surgery; Karolinska University Hospital; Stockholm Sweden
| | - A. Connor
- South West Transplant Centre; Derriford Hospital; Plymouth UK
| | - A. Rasmussen
- Department of General Surgery and Transplantation; Rigshospitalet; Copenhagen Denmark
| | - L. Backman
- Transplantation Surgery; Uppsala University Hospital; Uppsala Sweden
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Rosenborg S, Nordström A, Almquist T, Wennberg L, Bárány P. Systematic conversion to generic tacrolimus in stable kidney transplant recipients. Clin Kidney J 2014; 7:151-155. [PMID: 24944783 PMCID: PMC3970341 DOI: 10.1093/ckj/sfu015] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Accepted: 02/13/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Tacrolimus (Prograf®) is a key drug in the immunosuppressive treatment of renal transplant patients. Since the expiration of the patent for Prograf®, generic preparations have been approved in Europe as bioequivalence has been shown in healthy volunteers. However, few studies have investigated whether patients can be successfully converted from Prograf® to generic tacrolimus. Tacrolimus drug costs are by far the largest single item in the total drug expenditure for patients with renal disease in the Stockholm area. Considerable reductions in drug costs could be achieved if generic tacrolimus were to be used. The aim of this quality assurance study was to evaluate whether a switch from Prograf® to generic tacrolimus (Tacrolimus Sandoz®) could be safely performed in renal transplant patients. It further aimed to investigate changes of renal function (measured in estimated glomerular filtration rate, eGFR), need for dose changes and to calculate potential drug cost savings as a result of the conversion. METHODS We planned to recruit at least 50 patients. Plasma creatinine levels and trough concentrations of tacrolimus were collected from patients with renal transplants at three occasions during treatment with Prograf® and three times after conversion to Tacrolimus Sandoz®. The eGFR was calculated before and after the conversion. RESULTS Sixty-three of 67 enrolled patients (69% males, age 28-80 years) are included in this analysis. The ratio of mean trough concentrations of tacrolimus after comparison with before conversion was 1.02 (90% confidence interval 0.95-1.09). Fourteen patients experienced a change in tacrolimus levels >20% compared with baseline, no patients changed >20% in eGFR. The drug cost saving per daily dose was 33.40 SEK (∼€3.60, -23%). CONCLUSIONS Stable kidney transplant patients treated with Prograf® can be converted to Tacrolimus Sandoz® if trough concentrations of tacrolimus and plasma creatinine levels are closely monitored. The conversion brought savings, despite costs for extra monitoring.
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Affiliation(s)
- Staffan Rosenborg
- Department of Clinical Pharmacology , Karolinska University Hospital , Stockholm , Sweden ; Department of Renal Medicine , Karolinska University Hospital , Stockholm , Sweden
| | - Annica Nordström
- Department of Clinical Pharmacology , Karolinska University Hospital , Stockholm , Sweden
| | - Tora Almquist
- Department of Transplantation Surgery , Karolinska University Hospital , Stockholm , Sweden
| | - Lars Wennberg
- Department of Renal Medicine , Danderyd University Hospital , Stockholm , Sweden
| | - Peter Bárány
- Department of Renal Medicine , Karolinska University Hospital , Stockholm , Sweden
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Min SI, Ha J, Kim YS, Ahn SH, Park T, Park DD, Kim SM, Min SK, Hong H, Ahn C, Kim SJ. Therapeutic equivalence and pharmacokinetics of generic tacrolimus formulation in de novo kidney transplant patients. Nephrol Dial Transplant 2013; 28:3110-9. [DOI: 10.1093/ndt/gft300] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Johnston A. Equivalence and interchangeability of narrow therapeutic index drugs in organ transplantation. Eur J Hosp Pharm 2013; 20:302-307. [PMID: 24089632 PMCID: PMC3786630 DOI: 10.1136/ejhpharm-2012-000258] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 07/30/2013] [Accepted: 08/01/2013] [Indexed: 01/05/2023] Open
Abstract
The calcineurin inhibitors (CNIs), ciclosporin and tacrolimus, are the mainstay of immunosuppression in solid organ transplantation. Generic formulations of these drugs are now available. With increasing pressure on healthcare budgets and the consequent need to match health expectations to available resources, substitution with a generic product appears an attractive option to reduce costs. Approval of generic products differs from innovator drugs, and narrow therapeutic index drugs (NTIs; including CNIs) bring their own particular considerations. With NTIs, small variations in drug exposure could result in reduced immunosuppression or drug toxicity with potentially adverse effects on patient outcomes. NTIs are subject to stricter regulatory approval versus many other generic drugs. However, different generic formulations may still not necessarily be therapeutically equivalent in individuals, raising the possibility of significant differences in exposure between products. Although regional recommendations vary, many guidelines emphasise the need for NTI drug substitution to be initiated by the transplant physician, thus ensuring careful therapeutic monitoring and reduced negative patient impact. The need for therapeutic monitoring during generic substitution has important implications for the overall costs of generic treatment as these costs have to be factored in to the potential savings made from using generic formulations. The reduced acquisition costs of generic products may not necessarily translate into lower overall healthcare costs. This article examines the issue of equivalence and interchangeability of NTI drugs used in organ transplantation, the implications of the approval process for generic drugs on treatment efficacy and safety, and the effective management of substitutions between products.
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Castillo G, Rossano-García A, Gutiérrez D, Diliz-Pérez HS, Córdova J. [Acute cellular rejection in a liver transplantation patient due to changing the brand of a generic immunosuppressant]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2013; 78:198-200. [PMID: 23866966 DOI: 10.1016/j.rgmx.2013.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 01/15/2013] [Accepted: 01/28/2013] [Indexed: 10/26/2022]
Affiliation(s)
- G Castillo
- Servicio de Gastroenterología, Hospital General de México «Dr. Eduardo Liceaga» O.D, México DF, México
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42
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Devaney A, Lee M. The use of generic immunosuppression for transplant patients: a UK perspective. Eur J Hosp Pharm 2013. [DOI: 10.1136/ejhpharm-2013-000336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Connor A, Prowse A, Newell P, Rowe PA. A single-centre comparison of the clinical outcomes at 6 months of renal transplant recipients administered Adoport ® or Prograf ® preparations of tacrolimus. Clin Kidney J 2012; 6:21-28. [PMID: 27818747 PMCID: PMC5094386 DOI: 10.1093/ckj/sfs154] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 10/03/2012] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The use of generic formulations of immunosuppressive drugs in place of brand name drugs offers considerable cost savings. Brand name tacrolimus (Prograf®) came off patent in April 2008. However, published evidence supporting therapeutic equivalence of generic formulations of tacrolimus in solid organ transplantation is lacking. The South West Transplant Centre switched from administering Prograf® to a generic formulation (Adoport®) for de novo transplant recipients in November 2010. This study sought to compare the clinical outcomes of renal transplant recipients administered Prograf® with those receiving Adoport®. METHODS Data regarding patient characteristics and clinical outcomes were collected retrospectively for all patients undergoing renal transplantation at the South West Transplant Centre between 8 November 2009 and 8 November 2011 to whom tacrolimus was prescribed. RESULTS A total of 48 patients received Prograf® and 51 received Adoport®. At 6 months, no statistically significant differences were identified in the rates of patient survival, graft survival, acute allograft rejection, delayed graft function, calcineurin inhibitor toxicity or cytomegalovirus infection occurring within the two groups. CONCLUSIONS This is the first study to compare the clinical outcomes of patients receiving Adoport® with those receiving brand name tacrolimus. We report comparable clinical outcomes at 6 months in patients receiving either Prograf® or Adoport® from the time of renal transplantation. These early outcome data therefore support the use of Adoport® in place of Prograf® as a potential cost-saving measure.
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Affiliation(s)
- Andrew Connor
- South West Transplant Centre , Derriford Hospital , Plymouth , UK
| | - Andrew Prowse
- South West Transplant Centre , Derriford Hospital , Plymouth , UK
| | - Paul Newell
- Centre for Health & Environmental Statistics , Plymouth University , Plymouth , UK
| | - Peter A Rowe
- South West Transplant Centre , Derriford Hospital , Plymouth , UK
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Spence MM, Nguyen LM, Hui RL, Chan J. Evaluation of Clinical and Safety Outcomes Associated with Conversion from Brand-Name to Generic Tacrolimus in Transplant Recipients Enrolled in an Integrated Health Care System. Pharmacotherapy 2012; 32:981-7. [DOI: 10.1002/phar.1130] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Michele M. Spence
- Pharmacy Outcomes Research Group; Kaiser Permanente; Downey; California
| | - Lynda M. Nguyen
- Department of Pharmacy; San Francisco Veterans Affairs Medical Center; San Francisco; California
| | - Rita L. Hui
- Pharmacy Outcomes Research Group; Kaiser Permanente; Oakland; California
| | - James Chan
- Pharmacy Outcomes Research Group; Kaiser Permanente; Oakland; California
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Alloway RR, Sadaka B, Trofe-Clark J, Wiland A, Bloom RD. A randomized pharmacokinetic study of generic tacrolimus versus reference tacrolimus in kidney transplant recipients. Am J Transplant 2012; 12:2825-31. [PMID: 22759200 PMCID: PMC3472020 DOI: 10.1111/j.1600-6143.2012.04174.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Pharmacokinetic analyses comparing generic tacrolimus preparations versus the reference drug in kidney transplant patients are lacking. A prospective, multicenter, open-label, randomized, two-period (14 days per period), two-sequence, crossover and steady-state pharmacokinetic study was undertaken to compare twice-daily generic tacrolimus (Sandoz) versus reference tacrolimus (Prograf®) in stable renal transplant patients. AUC(0-12h) and peak concentration (C(max) ) were calculated from 12 h pharmacokinetic profiles at the end of each period (days 14 and 28). Of 71 patients enrolled, 68 provided evaluable pharmacokinetic data. The ratios of geometric means were 1.02 (90% CI 97-108%, p = 0.486) for AUC(0-12h) and 1.09 (90% CI 101-118%, p = 0.057) for C(max) . Mean (SD) C(0) was 7.3(1.8) ng/mL for generic tacrolimus versus 7.0(2.1) ng/mL for reference tacrolimus based on data from days 14 and 28. Correlations between 12 h trough levels and AUC were r = 0.917 for generic tacrolimus and r = 0.887 for reference drug at day 28. These data indicate that generic tacrolimus (Sandoz) has a similar pharmacokinetic profile to the reference drug and is bioequivalent in kidney transplant recipients according to US Food and Drug Administration and European Medicines Agency guidelines.
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Affiliation(s)
- R R Alloway
- Division of Nephrology, Section of Transplantation, University of CincinnatiCincinnati, OH,*Corresponding author: Rita R. Alloway,
| | - B Sadaka
- Division of Nephrology, Section of Transplantation, University of CincinnatiCincinnati, OH
| | - J Trofe-Clark
- Renal Division, Perelman School of Medicine, University of Pennsylvania, and Department of Pharmacy, Hospital University of PennsylvaniaPhiladelphia, PA
| | - A Wiland
- Novartis Pharmaceuticals CorporationEast Hanover, NJ
| | - R D Bloom
- Renal Division, Perelman School of Medicine, University of PennsylvaniaPhiladelphia, PA
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Remport A, Dankó D, Gerlei Z, Czebe K, Kiss I. [Special considerations in generic substitution of immunosuppressive drugs in transplantation]. Orv Hetil 2012; 153:1341-9. [PMID: 22913916 DOI: 10.1556/oh.2012.29429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Long-term success in solid organ transplantation strongly depends on the optimal use of maintenance immunosuppressive treatment. Cyclosporin and tacrolimus are the most frequently administered immunosuppressants and they are designed to narrow therapeutic index drugs. The substitution of the branded formulation by their generic counterparts may lead to economic benefit only if equivalent clinical outcomes can be achieved. There is no published evidence to date on the guarantee of their long-term therapeutic equivalence and cases of therapeutic failures have been reported due to inadvertent drug conversion. The disadvantageous clinical consequences of a non medical, mechanistic forced switch from the original to generic formulation of tacrolimus and the estimated loss of the payer's presumed savings are presented in a kidney transplant recipient population. Special problems related to pediatric patients, drug interactions with concurrent medications and the burden of additional therapeutic drug monitoring and follow up visits are also discussed. The authors are convinced that the implementation of the European Society of Organ Transplantation guidelines on generic substitution may provide a safe way for patients and healthcare payers.
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Affiliation(s)
- Adám Remport
- Szent Imre Kórház Nefrológia-Hypertonia Profil Budapest Tétényi.
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Abstract
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.
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Hulbert AL, Pilch NA, Taber DJ, Chavin KD, Baliga PK. Generic immunosuppression: deciphering the message our patients are receiving. Ann Pharmacother 2012; 46:671-7. [PMID: 22570436 DOI: 10.1345/aph.1r028] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The introduction of generic immunosuppressants elicited controversy within the transplant community and it is unknown whether patient attitudes mirror the ambiguity of provider perceptions. With the current health care economic crisis, it is necessary to consider generic immunosuppression as an option. A greater understanding of patient perceptions would enhance vital communication between providers and patients to facilitate education and appropriate monitoring. OBJECTIVE To evaluate transplant recipients' perceptions of generic versus brand immunosuppressants based on experience with these agents and the willingness of patients to convert treatment from brand to generic formulations based on socioeconomic variables and baseline demographics. METHODS Key informant interviews were conducted to inform the development of the survey instrument. The survey was distributed to solid organ transplant recipients at a large, academic medical center from October to December 2010. RESULTS Nine patients participated in key informant interviews. Financial considerations and provider recommendations were the most commonly identified factors to influence perceptions of generic immunosuppressants. A total of 255 patients completed the survey; treatment in 81 (32%) participants had been converted to a generic immunosuppressant. Those currently receiving a generic immunosuppressant expressed higher beliefs of generic and brand equivalency (75% vs 54%, p = 0.006) and an increased willingness to convert treatment to a generic given equivalent cost (51% vs 32%, p = 0.024). African American participants were found to have a decreased belief of generic and brand equivalency compared to other ethnicities (60% vs 75%, p = 0.013). Participants with an annual income of less than $30,000 had higher beliefs of generic and brand equivalency (60% vs 40%, p = 0.0001). Education level and age did not impact beliefs of generic efficacy or willingness to convert therapy. CONCLUSIONS Patient ethnicity, income, and experience with generic immunosuppressants appear to contribute to perceptions of generic immunosuppressants. The prevalence of generic immunosuppressant use supports the importance of communication of this issue between providers and patients.
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Affiliation(s)
- Amanda L Hulbert
- Department of Pharmacy Services, The Ohio State University Medical Center, Columbus, OH, USA
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50
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Trofe-Clark J, Gabardi S, McDevitt-Potter L, Alloway RR. Immunosuppression, generic drugs and the FDA. Am J Transplant 2012; 12:792-3; author reply 794. [PMID: 22176626 DOI: 10.1111/j.1600-6143.2011.03875.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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