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Waks AG, Chen EL, Graham N, Frey AM, Almeida K, Attaya V, Ryding C, Abbass I, Fung A, Sussell J, Cortazar P, Harvey C, Leth D, Faggen M, Sinclair N, Walsh J, Tung N, Sinclair S, Lo S, Yardley D, Valero V, Meisel J, Ballinger TJ, Adams S, Carey LA, Rauch JK, Abramson VG, Williams NO, Chen WY, Leone JP, Schumer ST, Tayob N, Tolaney SM. Subcutaneous vs Intravenous Trastuzumab/Pertuzumab: A Time and Motion Substudy of a Phase II Trial of Adjuvant Trastuzumab/Pertuzumab for Stage I HER2+ Breast Cancer (ADEPT trial). JCO Oncol Pract 2024:OP2400021. [PMID: 39028923 DOI: 10.1200/op.24.00021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/18/2024] [Accepted: 06/11/2024] [Indexed: 07/21/2024] Open
Abstract
PURPOSE The time required for in-clinic drug administration can substantially affect breast cancer patients' quality of life. Subcutaneous (SC) drug administration, as opposed to intravenous (IV), may reduce this time commitment. This study sought to estimate the difference in time burden between IV and SC administration of trastuzumab and pertuzumab (HP). METHODS We prospectively enrolled a subcohort of patients participating in the ADEPT trial (ClinicalTrials.gov identifier: NCT04569747, investigating adjuvant HP plus endocrine therapy for stage I human epidermal growth factor receptor 2-positive breast cancer) to this single-arm crossover time and motion substudy. Patients received two cycles of IV HP followed by two cycles of SC HP. During each cycle, time points in drug preparation and administration were captured. The primary end point was total patient time in the treatment chair. Additional end points included total patient treatment experience time and total pharmacy workflow time. A sample size of 22 patients was estimated to provide 90.7% power with two-sided alpha .05 to detect a difference of 70 minutes in the primary end point by treatment arm (IV v SC). RESULTS Twenty-two patients were enrolled. The mean total patient time in the treatment chair was 61.8 minutes shorter with SC versus IV HP (22.5 v 84.3 minutes; P < .0001). The mean total patient treatment experience time (incorporating time spent waiting for treatment initiation and time spent in the treatment chair) was 81.8 minutes shorter for SC administration (96 v 177.8 minutes; P < .0001). The pharmacy workflow time was 78.2 minutes shorter for SC versus IV formulation (41 v 119.2 minutes; P < .0001). CONCLUSION SC administration of HP shortened patient time burden by approximately 1 hour. SC drug administration can facilitate faster workflows for health care professionals and improve patients' breast cancer treatment experience.
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Affiliation(s)
- Adrienne G Waks
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Noah Graham
- Data Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Anna Mae Frey
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Kenneth Almeida
- Pharmacy and Clinical Support, Dana-Farber Cancer Institute, Boston, MA
| | - Victoria Attaya
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Current Affiliation: Olema Oncology, San Francisco, CA
| | - Cari Ryding
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | - Caroline Harvey
- Pharmacy and Clinical Support, Dana-Farber Cancer Institute, Boston, MA
| | - Denise Leth
- Pharmacy and Clinical Support, Dana-Farber Cancer Institute, Boston, MA
| | - Meredith Faggen
- Dana-Farber Brigham Cancer Center in Clinical Affiliation With South Shore Hospital, Weymouth, MA
| | - Natalie Sinclair
- Dana-Farber Brigham Cancer Center-Foxborough and Milford, Foxborough, MA
| | - Jeanna Walsh
- Dana-Farber/New Hampshire Oncology-Hematology, Londonderry, NH
| | - Nadine Tung
- Harvard Medical School, Boston, MA
- Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Steve Lo
- Bennett Cancer Center, Stamford Health, Stamford, CT
| | | | - Vicente Valero
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jane Meisel
- Winship Cancer Institute at Emory University, Atlanta, GA
| | | | - Sylvia Adams
- Perlmutter Cancer Center, NYU Langone Health, New York, NY
| | - Lisa A Carey
- Department of Medicine, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | - Wendy Y Chen
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jose P Leone
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Susan T Schumer
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Nabihah Tayob
- Harvard Medical School, Boston, MA
- Data Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Sara M Tolaney
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
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Lei M, Li Q, O'Day K, Meyer K, Wang A, Jun MP. Practice efficiency and total cost of care with bispecifics and CAR-T in relapsed/refractory diffuse large B-cell lymphoma: an institutional perspective. Future Oncol 2024:1-13. [PMID: 38913826 DOI: 10.1080/14796694.2024.2354157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/08/2024] [Indexed: 06/26/2024] Open
Abstract
Aim: Novel treatment options for relapsed/refractory diffuse large B-cell lymphoma include T-cell targeting therapies. Practice efficiency and cost are important for informed treatment decisions.Materials/methods: An institutional decision-maker cost model was developed for 6-month, 1-year and median cycles of treatment time horizons comparing practice efficiency and costs of epcoritamab vs glofitamab and axicabtagene ciloleucel (axi-cel).Results: Overall, epcoritamab required the shortest personnel and chair time, except over 1 year (second shortest chair time). Across all time horizons, epcoritamab was cost-saving vs axi-cel and had similar costs to glofitamab on a per-month basis.Conclusion: Epcoritamab reduced personnel and chair time. Additionally, epcoritamab was cost-saving vs axi-cel and had similar costs to glofitamab on a per-month basis.
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Affiliation(s)
- Matthew Lei
- Pharmacy Department, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Qianyi Li
- Market Access & Healthcare Consulting, Cencora, Conshohocken, PA 19428, USA
| | - Ken O'Day
- Market Access & Healthcare Consulting, Cencora, Conshohocken, PA 19428, USA
| | - Kellie Meyer
- Market Access & Healthcare Consulting, Cencora, Conshohocken, PA 19428, USA
| | - Anthony Wang
- Health Economics and Outcomes Research, AbbVie Inc., North Chicago, IL 60064, USA
| | - Monika P Jun
- Center for Outcomes Research, Real-world Evidence and Epidemiology, Genmab US, Inc., Plainsboro, NJ 08536, USA
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Stevenson J, Poker R, Schoss J, Campbell M, Everitt C, Holly B, Stones N, Pettis RJ, Sanchez-Felix M. Pharmaceutical and biotech industry perspectives on optimizing patient experience and treatment adherence through subcutaneous drug delivery design. Adv Drug Deliv Rev 2024; 209:115322. [PMID: 38677443 DOI: 10.1016/j.addr.2024.115322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/06/2024] [Accepted: 04/19/2024] [Indexed: 04/29/2024]
Abstract
Subcutaneous (SC) drug delivery can be a safe, effective alternative to the traditional intravenous route of administration, potentially offering notable advantages for both patients and healthcare providers. The SC Drug Development & Delivery Consortium convened in 2018 to raise awareness of industry challenges to advance the development of patient-centric SC drug delivery strategies. The SC Consortium identified better understanding of patient preferences and perspectives as necessary to optimize SC product design attributes and help guide design decisions during SC product development. This manuscript provides a comprehensive overview of patient-centric factors for consideration in the SC drug delivery design and development process with the aim of establishing a foundation of existing knowledge for patient experiences related to SC drug delivery. This overview is informed by the outcomes of a multi-step survey of Consortium members and key pharmaceutical stakeholders. Framed in the context of the patient's treatment journey, the survey findings offer future perspectives to fill data gaps to advance patient-centric SC drug delivery.
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Affiliation(s)
| | - Rachel Poker
- AstraZeneca, Human Factors Engineering, BioPharmaceutical Development, Biopharmaceuticals R&D, 121 Oyster Point Blvd, South San Francisco, CA 94080, USA
| | | | | | - Claire Everitt
- Pfizer, Granta Park, Great Abington, Cambridge CB21 6GP, UK
| | - Brian Holly
- Pfizer, Granta Park, Great Abington, Cambridge CB21 6GP, UK
| | - Nicholas Stones
- Novartis Pharma AG, Lichtstrasse 35, CH-4056 Basel, Switzerland
| | - Ronald J Pettis
- Becton-Dickinson, 21 Davis Drive, Research Triangle Park, NC 27513, USA
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Filippi M, Grimaldi L, Conte A, Totaro R, Valente MR, Malucchi S, Granella F, Cordioli C, Brescia Morra V, Zanetta C, Perini D, Santoni L. Intravenous or subcutaneous natalizumab in patients with relapsing-remitting multiple sclerosis: investigation on efficiency and savings-the EASIER study. J Neurol 2024; 271:340-354. [PMID: 37715789 PMCID: PMC10769988 DOI: 10.1007/s00415-023-11955-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 09/18/2023]
Abstract
INTRODUCTION EASIER is a multicenter, observational, cross-sectional study investigating the consumption of healthcare resources, including healthcare professional (HCP) active working time, the costs associated with the current natalizumab intravenous (IV) administration, and the potential impact of the adoption of subcutaneous (SC) route. METHODS The EASIER study has three parts: (1) time and motion study to measure healthcare resources and working time needed for natalizumab IV administration using a digital data collection tool operated directly by HCPs; (2) HCP structured questionnaire-based estimation of the potential impact of natalizumab SC vs. IV administration; and (3) patient survey on the burden of natalizumab administration. RESULTS Nine Italian multiple sclerosis (MS) centers measured 404 IV natalizumab administration procedures and administered 26 HCP questionnaires and 297 patient questionnaires. Patients had a mean of 52 (range 1-176) previous IV administrations and spent a mean (median, IQR) of 152 (130, 94-184) minutes in the center per each IV procedure, with IV infusion covering 50% of the total. Including patient travel time, an average of 5 h was dedicated to each IV administration. Active working time by HCP amounted to 29 min per IV administration procedure, 70% of which by nursing staff. With adoption of the SC route, HCPs estimated a 50% reduction in patient procedure time and 55% lower HCP active working time. This translated into a 63% cost reduction for the MS center per natalizumab administration procedure. CONCLUSIONS SC natalizumab administration will consistently reduce consumption of patient and HCP times per procedure and associated costs.
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Affiliation(s)
- Massimo Filippi
- Neurology Unit, Neurorehabilitation Unit, Neurophysiology Service, and Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
| | - Luigi Grimaldi
- Multiple Sclerosis Center, Institute Foundation G. Giglio, Cefalù, PA, Italy
| | - Antonella Conte
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
- Multiple Sclerosis Center, Policlinico Umberto I Hospital, Rome, Italy
- IRCCS Neuromed, Pozzilli, IS, Italy
| | - Rocco Totaro
- Demyelinating Disease Center, Department of Neurology, San Salvatore Hospital, L'Aquila, Italy
| | - Maria Rosaria Valente
- Clinical Neurology, Santa Maria della Misericordia University Hospital, and Department of Medicine, University of Udine, Udine, Italy
| | - Simona Malucchi
- SCDO Neurologia, S. Luigi Gonzaga University Hospital, Orbassano, TO, Italy
| | - Franco Granella
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Cinzia Cordioli
- Multiple Sclerosis Center, ASST Spedali Civili di Brescia, Montichiari Hospital (Brescia), Brescia, Italy
| | - Vincenzo Brescia Morra
- Multiple Sclerosis Clinical Care and Research Center, Department of Neuroscience (NSRO), Federico II University Hospital, Naples, Italy
| | - Chiara Zanetta
- Neurology Unit, Neurorehabilitation Unit, Neurophysiology Service, and Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
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Pradelli L, Massaia M, Todisco E, Gherlinzoni F, Furlan A, La Targia M, Grande E, Tripoli IE, Occhipinti F, Comello F, Iannello F, Bellucci S. Improved efficiency of daratumumab treatment of multiple myeloma adopting the subcutaneous route: A micro-costing analysis in three Italian hematology centers. Cancer Med 2023; 12:21480-21489. [PMID: 37942566 PMCID: PMC10726826 DOI: 10.1002/cam4.6699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/09/2023] [Accepted: 10/26/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Daratumumab is a humanized monoclonal antibody approved for the treatment of adult patients with newly diagnosed or relapsed/refractory multiple myeloma (RRMM). Subcutaneous (SC) formulation proved to be non-inferior in comparison with intravenous (IV) administration route. This study aimed at assessing the economic and time impact associated with the use of SC versus IV daratumumab in patients with RRMM from the perspective of the hematology center. METHODS This was a 5-month multicenter time-and-motion cross-sectional micro-costing study conducted in three Italian hematology centers among adult patients diagnosed with RRMM with ongoing treatment with IV or SC daratumumab. Measurements were performed by an ad hoc App. RESULTS Nineteen (20%) IV and 76 (80%) SC administration procedures were measured. Patients spent a mean of 4.85 ± 0.91 or 1.08 ± 0.56 h in the hematology center to receive IV or SC daratumumab, respectively. Healthcare professionals (HCPs) spent a mean of 49.38 ± 16.13 and 20.37 ± 7.88 min of active working time to manage IV and SC administrations, respectively. The infusion chair was occupied for a mean of 4.85 ± 0.91 and 0.99 ± 0.55 h during IV or SC administration, respectively. On average, considering the costs due to HCP and chair time, materials, and overhead costs, every IV and SC administration costed €80.33 and 34.90, respectively. CONCLUSIONS In conclusion, as compared with IV administration, SC daratumumab was associated with 78%, 59%, 80% savings in terms of patient time, HCP active working time, and infusion chair, respectively, and 56.6% budget savings.
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Affiliation(s)
| | | | | | | | - Anna Furlan
- Divisione di EmatologiaOspedale Cà Foncello di Treviso–ASL 2TrevisoItaly
| | - Maria La Targia
- U.O. Ematologia ASST Valle Olona Busto ArsizioBusto ArsizioItaly
| | | | | | | | - Francesco Comello
- Divisione di EmatologiaOspedale Cà Foncello di Treviso–ASL 2TrevisoItaly
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Erfani A, Reichert P, Narasimhan CN, Doyle PS. Injectable hydrogel particles for amorphous solid formulation of biologics. iScience 2023; 26:107452. [PMID: 37593455 PMCID: PMC10428138 DOI: 10.1016/j.isci.2023.107452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/19/2023] [Accepted: 07/19/2023] [Indexed: 08/19/2023] Open
Abstract
The fast pace of breakthroughs in cancer immunotherapy, combined with the new paradigm of moving toward high-concentration dosages and combinatorial treatments, is generating new challenges in the formulation of biologics. To address these challenges, we describe a method of formulation that enables high-concentration injectable and stable formulation of biologics as amorphous solids in aqueous suspension. This technology combines the benefits of liquid formulation with the stability of solid formulation and eliminates the need for drying and reconstitution. This widely applicable formulation integrates the amorphous solid forms of antibodies with the injectability, lubricity, and tunability of soft alginate hydrogel particles using a minimal process. The platform was evaluated for anti-PD-1 antibody pembrolizumab and human immunoglobulin G at concentrations up to 300 mg/mL with confirmed quality after release. The soft nature of the hydrogel matrix allowed packing the particles to high volume fractions.
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Affiliation(s)
- Amir Erfani
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | | | | | - Patrick S. Doyle
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
- Harvard Medical School Initiative for RNA Medicine, Boston, MA 02215, USA
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Parra A, Hernández C, Prieto-Pinto L. Evaluation of the economic benefits, administration times, and patient preferences associated with the use of biotechnological drugs administered subcutaneously and intravenously in patients with cancer: a systematic review. Expert Rev Pharmacoecon Outcomes Res 2023; 23:1017-1026. [PMID: 37665685 DOI: 10.1080/14737167.2023.2249232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 08/14/2023] [Indexed: 09/06/2023]
Abstract
INTRODUCTION Cancer imposes a high economic burden with medical care and medication costs. We evaluate the costs, the use of resources, the administration time, and the patient preferences associated with the use of biotechnological drugs in SC and IV presentations. METHODOLOGY A systematic literature search was conducted in PubMed, Embase, and seven additional databases. The search was carried out in September 2021 and included only studies directly comparing SC and IV presentations. Evidence was synthesized narratively. RESULTS 34 references were included, which only analyzed bortezomib, daratumumab, rituximab, and trastuzumab. Reduction in preparation costs of SC compared to IV presentations ranged from 6.6% to 50.1%, and in administration costs from 4.5% to 95.3%. SC administration of rituximab and trastuzumab resulted in less productivity loss. More than 68% of patients reported greater satisfaction with the SC route. A reduction of time in the infusion chair, lower costs of resources for preparation, and health personnel for the administration process were identified with SC administration. CONCLUSIONS The use of SC daratumumab, rituximab, and trastuzumab in patients with cancer reduces direct and indirect costs and adverse events compared to IV use. Patients prefer the SC administration, perceiving more comfort, and less pain at the administration site.
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Affiliation(s)
- Ana Parra
- Evidence-Based Medicine Department, NeuroEconomix, Bogotá, Colombia
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Erfani A, Schieferstein JM, Reichert P, Narasimhan CN, Pastuskovas C, Parab V, Simmons D, Yang X, Shanker A, Hammond P, Doyle PS. Crystalline Antibody-Laden Alginate Particles: A Platform for Enabling High Concentration Subcutaneous Delivery of Antibodies. Adv Healthc Mater 2023; 12:e2202370. [PMID: 36745878 PMCID: PMC11469019 DOI: 10.1002/adhm.202202370] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/30/2023] [Indexed: 02/08/2023]
Abstract
Subcutaneous (SC) administration is a desired route for monoclonal antibodies (mAbs). However, formulating mAbs for small injection volumes at high concentrations with suitable stability and injectability is a significant challenge. Here, this work presents a platform technology that combines the stability of crystalline antibodies with injectability and tunability of soft hydrogel particles. Composite alginate hydrogel particles are generated via a gentle centrifugal encapsulation process which avoids use of chemical reactions or an external organic phase. Crystalline suspension of anti-programmed cell death protein 1 (PD-1) antibody (pembrolizumab) is utilized as a model therapeutic antibody. Crystalline forms of the mAb encapsuled in the hydrogel particles lead to stable, high concentration, and injectable formulations. Formulation concentrations as high as 315 mg mL-1 antibody are achieved with encapsulation efficiencies in the range of 89-97%, with no perceivable increase in the number of antibody aggregates. Bioanalytical studies confirm superior maintained quality of the antibody in comparison with formulation approaches involving organic phases and chemical reactions. This work illustrates tuning the alginate particles' disintegration by using partially oxide alginates. Crystalline mAb-laden particles are evaluated for their biocompatibility using cell-based in vitro assays. Furthermore, the pharmacokinetics (PK) of the subcutaneously delivered human anti-PD-1 mAb in crystalline antibody-laden alginate hydrogel particles in Wistar rats is evaluated.
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Affiliation(s)
- Amir Erfani
- Department of Chemical EngineeringMassachusetts Institute of TechnologyCambridgeMA02142USA
| | | | | | | | | | | | | | - Xiaoyu Yang
- Merck Research LaboratoriesKenilworthNJ07033USA
| | - Apoorv Shanker
- Department of Chemical EngineeringMassachusetts Institute of TechnologyCambridgeMA02142USA
- Koch Institute for Integrative Cancer ResearchMassachusetts Institute of TechnologyCambridgeMA02139USA
| | - Paula Hammond
- Department of Chemical EngineeringMassachusetts Institute of TechnologyCambridgeMA02142USA
- Koch Institute for Integrative Cancer ResearchMassachusetts Institute of TechnologyCambridgeMA02139USA
| | - Patrick S. Doyle
- Department of Chemical EngineeringMassachusetts Institute of TechnologyCambridgeMA02142USA
- Harvard Medical School Initiative for RNA MedicineBostonMA02215USA
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McCloskey C, Ortega MT, Nair S, Garcia MJ, Manevy F. A Systematic Review of Time and Resource Use Costs of Subcutaneous Versus Intravenous Administration of Oncology Biologics in a Hospital Setting. PHARMACOECONOMICS - OPEN 2023; 7:3-36. [PMID: 35996066 PMCID: PMC9395845 DOI: 10.1007/s41669-022-00361-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 06/07/2023]
Abstract
BACKGROUND The introduction of human epidermal growth factor receptor 2 (HER2)-targeted treatment options, including dual HER2 blockade, has improved the prognosis for patients with HER2-positive breast cancer (BC) substantially. However, most of these treatments are administered via the intravenous (IV) route, which can present many challenges, such as long infusion and observation times, issues associated with repeated IV access, and increased strain on time and resources of medical centers and healthcare professionals. A fixed-dose combination of pertuzumab and trastuzumab for subcutaneous (SC) injection (pertuzumab, trastuzumab, and hyaluronidase-zzxf (PHESGO®, F. Hoffmann-La Roche Ltd, Basel, Switzerland; PH FDC SC)) has been approved for use alongside chemotherapy for early-stage and metastatic HER2-positive BC. OBJECTIVES This systematic literature review was performed to identify evidence relating to time/resource use and resulting cost differences between SC and IV administration of oncology biologics in a hospital setting, and, ultimately, to inform economic modeling and associated health technology assessment of PH FDC SC. METHODS Electronic databases (Embase, MEDLINE, and EconLit) were searched on 9 April 2020. Additional hand searches were performed to identify publications not captured in the electronic database search. Publication screening and data extraction (study characteristics, participants, interventions, costs, and time/resource use) were carried out per the standard Cochrane review methodology. The quality of economic evidence of cost analyses was assessed using the 36-item checklist of the National Institute for Health and Care Excellence Single Technology Appraisal Specification for submission of evidence (January 2015). RESULTS The database search identified 2,740 records, of which 237 underwent full text screening. Full text screening, prioritization of publications about patients with a cancer diagnosis, and the addition of four citations identified during the hand search resulted in 72 final included publications, relating to 71 unique studies. This included 40 publications that described the time/resource use and/or costs associated with SC versus IV trastuzumab administration for the treatment of HER2-positive BC, and 28 publications that described time/resource use and/or costs associated with rituximab SC versus IV administration for the treatment of non-Hodgkin's lymphoma/follicular lymphoma and diffuse large B-cell lymphoma. The majority of publications showed substantial time savings for preparation and administration of SC versus IV therapy, and cost savings associated with reductions in healthcare professional time and resource use for SC administration. LIMITATIONS There was a lack of consensus between publications regarding time and cost measurements. In addition, the search was limited to publications related to anticancer drugs; the majority of the studies included were performed in European countries. CONCLUSIONS AND IMPLICATIONS This review indicated a substantial body of evidence showing time/resource and cost savings of SC versus IV administration of oncology biologics in a hospital setting, which can be used to inform economic evaluations of PH FDC SC.
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Affiliation(s)
| | | | | | - Maria João Garcia
- Pharmaceuticals Division, Global Access-Evidence Chapter, F. Hoffmann-La Roche Ltd, Grenzacherstrasse 124, 4070, Basel, Switzerland.
| | - Federico Manevy
- Pharmaceuticals Division, Global Access-Evidence Chapter, F. Hoffmann-La Roche Ltd, Grenzacherstrasse 124, 4070, Basel, Switzerland
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Muntañola A, Arguiñano‐Pérez JM, Dávila J, de Villambrosia SG, Carpio C, Jiménez‐Ubieto A, Salar A. Safety and tolerability of a 90-minute rapid infusion of Sandoz biosimilar rituximab in B-cell lymphoproliferative disorders in a real-world setting. Clin Transl Sci 2022; 16:305-312. [PMID: 36385738 PMCID: PMC9926065 DOI: 10.1111/cts.13450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/21/2022] [Accepted: 10/21/2022] [Indexed: 11/18/2022] Open
Abstract
Although rituximab is generally well-tolerated, infusion-related reactions (IRRs) are common with the initial dose when administered intravenously according to standard recommendations. To prevent IRRs, premedication and low-speed infusion rates have been recommended. Consequently, intravenous (i.v.) infusion of rituximab can become a labor-intensive process. Rapid i.v. rituximab infusion over 90 min has demonstrated a favorable safety profile for the second and subsequent infusions during the course of therapy. The aim of this study was to investigate the safety and tolerability of 90-min rapid infusion of Sandoz rituximab biosimilar (SDZ-RTX) for patients with CD20+ lymphoma or chronic lymphocytic leukemia (CLL). We retrospectively reviewed all patients with CD20+ lymphoma or CLL who received SDZ-RTX infusions in 90 min from July 2019 to July 2021 at seven Spanish hospitals. The primary end point was the incidence of IRRs. We identified 124 patients and 576 rapid administrations of SDZ-RTX, with an average of five rapid infusions per patient. Most rapid infusions of SDZ-RTX were in combination with CHOP/CHOP-like therapy (48.4%), followed by SDZ-RTX alone (15.1%), in combination with bendamustine (14.5%), or with other regimens (22%). The 90-min SDZ-RTX infusion schedule was well-tolerated with no grade 3/4 IRRs. The incidence of any grade IRR during the first rapid infusion was 1% (5 grade 1 IRRs and 1 grade 2 IRR). In conclusion, rapid 90-min i.v. administration of SDZ-RTX for the second and subsequent infusions during the course of therapy is well-tolerated in patients with CD20+ lymphoma or CLL.
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Affiliation(s)
- Ana Muntañola
- Department of HematologyHospital Universitari Mutua TerrassaTerrassaSpain
| | | | - Julio Dávila
- Department of HematologyComplejo Asistencial de ÁvilaÁvilaSpain
| | | | - Cecilia Carpio
- Department of Hematology, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO)Vall d'Hebron University HospitalBarcelonaSpain,Department of MedicineUniversitat Autònoma de BarcelonaBarcelonaSpain
| | | | - Antonio Salar
- Department of HematologyHospital del MarBarcelonaSpain,Group of Applied Clinical Research in HematologyCancer Research Program‐IMIM (Hospital del Mar Medical Research Institute)BarcelonaSpain,Pompeu Fabra UniversityBarcelonaSpain
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Harvey MJ, Zhong Y, Morris E, Beverage JN, Epstein RS, Chawla AJ. Assessing the transition from intravenous to subcutaneous delivery of rituximab: Benefits for payers, health care professionals, and patients with lymphoma. PLoS One 2022; 17:e0261336. [PMID: 35073335 PMCID: PMC8786206 DOI: 10.1371/journal.pone.0261336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 11/30/2021] [Indexed: 11/18/2022] Open
Abstract
Subcutaneous (SC) administration of rituximab provides an opportunity for reduced patient treatment burden and increased healthcare efficiencies as an alternative to intravenous (IV) rituximab. There is minimal evidence comparing costs associated with SC and IV rituximab in a US setting. This research assessed the impact of transitioning patients from IV to SC rituximab for treatment of non-Hodgkin’s lymphoma (NHL) from the US payer, provider, and patient perspective. We developed a model to estimate cost differences for transitioning 20% of a patient cohort from IV to SC rituximab. We included patients with incident diffuse large B-cell lymphoma, incident and recurrent follicular lymphoma, and incident and recurrent chronic lymphocytic leukemia. In the model, each patient received the same number of doses and that there was no difference in discontinuation between cohorts due to non-inferior efficacy and a similar safety profile. Model inputs were collected from published literature and publicly available data. Scenario analyses tested the impact of availability of low-cost biosimilars. In the base case (1,000,000 covered lives), we estimated a total of 157 patients, with 769 total drug administrations. A transition of 20% of patients from IV to SC was projected to generate $153,000 in payer savings, increase provider capacity by 270 hours, and free 470 hours of patient time. Scenario analyses suggest SC administration will be cost saving for payers even with a market where biosimilars approach 50% market share. A 20% transition to SC rituximab in a single cohort of patients has the potential to generate significant US health system value in the form of payer savings, increased practice capacity, and patient time.
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MESH Headings
- Administration, Intravenous/economics
- Cost of Illness
- Decision Support Systems, Clinical/economics
- Drug Costs
- Equivalence Trials as Topic
- Female
- Humans
- Injections, Subcutaneous/economics
- Insurance, Health/economics
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Lymphoma, Follicular/drug therapy
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Non-Hodgkin/drug therapy
- Male
- Models, Economic
- Rituximab/administration & dosage
- Rituximab/economics
- United States
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Affiliation(s)
| | - Yi Zhong
- Analysis Group, Inc., Menlo Park, California, United States of America
| | - Eric Morris
- Analysis Group, Inc., Menlo Park, California, United States of America
| | - Jacob N. Beverage
- Halozyme Therapeutics, San Diego, California, United States of America
| | - Robert S. Epstein
- Epstein Health, LLC, Woodcliff Lake, New Jersey, United States of America
| | - Anita J. Chawla
- Analysis Group, Inc., Menlo Park, California, United States of America
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12
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Roberts BC, Rini C, Klug R, Sherman DB, Morel D, Pettis RJ. Novel cannula design improves large volume auto-injection rates for high viscosity solutions. Drug Deliv 2021; 29:43-51. [PMID: 34962225 PMCID: PMC8725910 DOI: 10.1080/10717544.2021.2018069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A prototype reusable large-volume (2 mL) autoinjector (LVAI) was designed to compare injection performance of a novel 27 gauge ultra-thin wall (UTW) pre-filled syringe (PFS) cannula (8 mm external cannula length, 14.4 mm total needle length) against an existing 27 gauge special thin wall (STW) PFS cannula (12.7 mm external cannula length, 19 mm total needle length) across a range of injectate viscosities (2.3–30 cP) in a series of in vivo feasibility studies in swine. The UTW cannula had an approximately 30% greater cross-sectional lumen area than the STW cannula. The target exposed needle length was adjusted to ensure appropriate needle penetration depth and achieve injectate deposition in the subcutaneous (SC) tissue. Delivery time and volume, injection site leakage, injectate depot location, and local tissue effects were examined. The STW and UTW cannulae both provided effective SC delivery of contrast placebo solutions, and were able to accommodate injectate viscosity up to 30 cP without quantifiable leakage from the tissue and with minor tissue effects which resolved within 1–2 hours. Delivery times at each viscosity were significantly different between PFS types with the UTW PFS producing faster delivery times. In a histological substudy of the UTW cannula using injectate viscosities up to 50 cP, injection site reactions were rare and, when present, were of minimal severity. This series of studies demonstrates the feasibility of LVAI SC injection and informs autoinjector and PFS design considerations. Use of a UTW cannula may enable more rapid LVAI injections with minimal tissue effects, especially for higher viscosity formulations.
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Affiliation(s)
- Bruce C Roberts
- Translational and Clinical Sciences Center of Excellence, BD Technologies and Innovation, Research Triangle Park, NC, USA
| | - Christopher Rini
- Translational and Clinical Sciences Center of Excellence, BD Technologies and Innovation, Research Triangle Park, NC, USA
| | - Rick Klug
- Translational and Clinical Sciences Center of Excellence, BD Technologies and Innovation, Research Triangle Park, NC, USA
| | - Douglas B Sherman
- Translational and Clinical Sciences Center of Excellence, BD Technologies and Innovation, Research Triangle Park, NC, USA
| | | | - Ronald J Pettis
- Translational and Clinical Sciences Center of Excellence, BD Technologies and Innovation, Research Triangle Park, NC, USA
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13
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Guayboon T, Chinthammitr Y, Sukpanichnant S, Horthongkham N, Angkasekwinai N. Human herpesvirus 8-associated multicentric Castleman disease in a patient with advanced HIV infection: A case report. Medicine (Baltimore) 2021; 100:e28077. [PMID: 34889256 PMCID: PMC8663817 DOI: 10.1097/md.0000000000028077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/15/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONAL Multicentric Castleman disease (MCD) is a nonclonal lymphoproliferative disorder that is rarely reported from Southeast Asian countries. Here, we report a case of human herpesvirus 8 (HHV-8)-associated MCD in a patient with advanced human immunodeficiency virus (HIV) infection who presented with prolonged intermittent fever, urticarial rash, hepatosplenomegaly, and generalized lymphadenopathy. PATIENT CONCERNS A 34-year-old man with advanced HIV infection who was in good compliance with his antiretroviral treatment regimen presented with intermittent fever, weight loss, marked hepatosplenomegaly, and generalized lymphadenopathy. Recurrent symptoms of high-grade fever, abdominal discomfort, pancytopenia, and high C-reactive protein level occurred for 16 months. DIAGNOSES Histopathological findings of left inguinal lymph node revealed diffuse effacement of lymph node architecture with coexpression of HHV-8 latency-associated nuclear antigen 1 from immunohistochemical staining. The HHV-8 viral load was 335,391 copies/mL. INTERVENTIONS The patient was treated initially with one dose of intravenous rituximab (375 mg/m2) followed by subcutaneous rituximab (1400 mg) weekly for 5 weeks. OUTCOMES The patient's recurrent systemic symptoms subsided dramatically, and he has now been in remission for almost two years. LESSONS HHV8-associated MCD remains a diagnostic challenge in advanced HIV disease and should be suspected in those with recurrent flares of systemic inflammatory symptoms. Lymph node histopathology is essential for diagnosis and for excluding clonal malignancy. HHV-8 viral load is also useful for diagnosis and for monitoring disease activity.
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Affiliation(s)
- Theerajet Guayboon
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yingyong Chinthammitr
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sanya Sukpanichnant
- Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Navin Horthongkham
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nasikarn Angkasekwinai
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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14
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Polatuzumab vedotin plus obinutuzumab and lenalidomide in patients with relapsed or refractory follicular lymphoma: a cohort of a multicentre, single-arm, phase 1b/2 study. THE LANCET HAEMATOLOGY 2021; 8:e891-e901. [DOI: 10.1016/s2352-3026(21)00311-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 12/29/2022]
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15
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Epstein RS. Payer Perspectives on Intravenous versus Subcutaneous Administration of Drugs. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:801-807. [PMID: 34531668 PMCID: PMC8439384 DOI: 10.2147/ceor.s317687] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/03/2021] [Indexed: 11/23/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has brought increased attention to vulnerable populations such as older or immunocompromised patients and heightened the focus on alternatives to intravenous (IV) formulations, particularly those that may be administered in a non-clinical setting. Among these alternative formulations are subcutaneous (SC) injections, which comprise an increasing share of commercialized and pipeline therapies. While much has been published about the benefits and limitations of IV versus SC administration to patients and health systems, less attention has been given to payer considerations regarding these routes of administration. Accordingly, this article provides payer perspectives on some of the key differences between IV and SC administration as they relate to management and billing, cost, treatment adherence and safety, and patient preference and quality of life. The benefits and limitations of these drug administration routes to key healthcare stakeholders—namely patients, physicians, and payers—are also discussed. Considerations of relevance are highlighted, including the potential for misalignment of stakeholder interests and countervailing factors that may impact decision-making about IV and SC formulations.
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16
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Woodley WD, Morel DR, Sutter DE, Pettis RJ, Bolick NG. Clinical Evaluation of Large Volume Subcutaneous Injection Tissue Effects, Pain, and Acceptability in Healthy Adults. Clin Transl Sci 2021; 15:92-104. [PMID: 34268888 PMCID: PMC8742644 DOI: 10.1111/cts.13109] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/14/2021] [Accepted: 06/16/2021] [Indexed: 11/30/2022] Open
Abstract
Determining feasibility and tolerability of large volume viscous subcutaneous injection may enable optimized, intuitive delivery system design. A translational early feasibility clinical study examined large volume subcutaneous injection viability, tolerability, acceptability, tissue effects and depot location for ~1, 8, and 20 cP injections at volumes up to 10 ml in the abdomen and 5 ml in the thigh in 32 healthy adult subjects. A commercial syringe pump system delivered 192 randomized, constant rate (20 µl/s) injections (6/subject) with in‐line injection pressure captured versus time. Deposition location was qualified via ultrasound. Tissue effects and pain tolerability were monitored through 2 hours post‐injection with corresponding Likert acceptability questionnaires administered through 72 hours. All injection conditions were feasible and well‐tolerated with ≥79.3% favorable subject responses for injection site appearance and sensation immediately post‐injection, increasing to ≥96.8% at 24 hours. Mean subject pain measured via 100 mm visual analog scale increased at needle insertion (6.9 mm, SD 10.8), peaked during injection (26.9 mm, SD 21.7) and diminished within 10 minutes post‐removal (1.9 mm, SD 4.2). Immediate injection site wheal (90.9%) and erythema (92.6%) formation was observed with progressive although incomplete resolution through 2 hours (44.6% and 11.4% remaining, respectively). Wheal resolution occurred more rapidly at lower viscosities. Most subjects (64.5%) had no preference between abdomen and thigh. Correlations between tissue effects, injection pressure and pain were weak (Pearson’s rho ± 0–0.4). The large volume injections tested, 1–20 cP viscosities up to 10 ml in the abdomen and 5 ml in the thigh, are feasible with good subject acceptability and rapid resolution of tissue effects and pain.
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Affiliation(s)
- Wendy D Woodley
- BD Technologies & Innovation, Research Triangle Park, NC, USA
| | - Didier R Morel
- BD Medical- Pharmaceutical Systems, Le Pont de Claix, France
| | - Diane E Sutter
- BD Technologies & Innovation, Research Triangle Park, NC, USA
| | - Ronald J Pettis
- BD Technologies & Innovation, Research Triangle Park, NC, USA
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17
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Rule S, Barreto WG, Briones J, Carella AM, Casasnovas O, Pocock C, Wendtner CM, Zaja F, Robson S, MacGregor L, Tschopp RR, Nick S, Dreyling M. Efficacy and safety assessment of prolonged maintenance with subcutaneous rituximab in patients with relapsed or refractory indolent non-Hodgkin lymphoma: results of the Phase III MabCute study. Haematologica 2021; 107:500-509. [PMID: 34134469 PMCID: PMC8804572 DOI: 10.3324/haematol.2020.274803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Indexed: 11/29/2022] Open
Abstract
Rituximab plus chemotherapy induction followed by rituximab maintenance for up to 2 years confers a long-term benefit in terms of progression-free survival in patients with indolent non-Hodgkin lymphoma. It is not known whether further prolonged maintenance with rituximab provides additional benefit. The phase III MabCute study enrolled 692 patients with relapsed or refractory indolent non-Hodgkin lymphoma. Patients who responded to induction with rituximab plus chemotherapy and were still responding after up to 2 years’ initial maintenance with subcutaneous rituximab were randomized to extended maintenance with subcutaneous rituximab (n=138) or observation only (n=138). The primary endpoint of investigator-assessed progression-free survival in the randomized population was un-addressed by the end of study because of an insufficient number of events (129 events were needed for 80% power at 5% significance if approximately 330 patients were randomized). In total, there were 46 progression-free survival events, 19 and 27 in the rituximab and observation arms, respectively (P=0.410 by stratified log-rank test; hazard ratio 0.76 [95% confidence interval: 0.37– 1.53]). The median progression-free survival was not reached in either randomized arm. There were no new safety signals; however, adverse events were seen slightly more frequently with rituximab than with observation during extended maintenance. Maintenance for up to 2 years with rituximab after response to initial induction therefore remains the standard of care in patients with relapsed or refractory indolent non- Hodgkin lymphoma. (Clinicaltrials.gov identifier: NCT01461928)
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Affiliation(s)
- Simon Rule
- Derriford Hospital and Plymouth University Medical School, Plymouth, United Kingdom
| | | | | | | | | | - Chris Pocock
- Kent and Canterbury Hospital, Canterbury, United Kingdom
| | - Clemens-Martin Wendtner
- Munich Clinic Schwabing, Academic Teaching Hospital, Ludwig-Maximilians University, Munich, Germany
| | | | | | | | | | - Sonja Nick
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
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18
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Opportunities in an Evolving Pharmaceutical Development Landscape: Product Differentiation of Biopharmaceutical Drug Products. Pharm Res 2021; 38:739-757. [PMID: 33903976 DOI: 10.1007/s11095-021-03037-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
The current perspective reviews the biopharmaceutical market until end of 2020 and highlights the transforming biopharmaceutical landscape during the recent decade. In particular, the rise of biosimilars and the development of new therapeutic modalities through recent advancement in molecular biology research sustainably change the product scenery. The present manuscript describes opportunities for pharmaceutical technical development, highlighting concepts such as product differentiation to succeed in a competitive product landscape. Product differentiation offers the opportunity for numerous life-cycle options and market exclusivity through incremental improvements in standard of care treatment. In particular, different formulation options and formulation-device combinations are described, focusing on systemic delivery of monoclonal antibody products and patient-centered development. The concept of product differentiation is exemplified in a case study about HER2+ breast cancer therapy, underlining pharmaceutical technical solutions and major improvements for the patient.
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19
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Abad-Sazatornil MR, Arenaza A, Bayo J, García Mata J, Guinea De Castro JM, León J, Letellez J, Reguero V, Martínez Chamorro C, Salar A. Impact of the subcutaneous formulations of trastuzumab and rituximab on efficiency and resource optimization in Spanish hospitals: H-Excelencia study. BMC Health Serv Res 2021; 21:320. [PMID: 33832464 PMCID: PMC8034176 DOI: 10.1186/s12913-021-06277-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 03/15/2021] [Indexed: 11/20/2022] Open
Abstract
Background Subcutaneous (SC) versus intravenous (IV) administration is advantageous in terms of patient convenience and hospital efficiency. This study aimed to compare the effect of optimizing the processes involved in SC versus IV administration of rituximab and trastuzumab on hospital capacity and service quality. Methods This cross-sectional resource utilization study interviewed oncologists, hematologists, nurses, and pharmacists from 10 hospitals in Spain to estimate changes in processes associated with conversion from IV to SC rituximab and trastuzumab, based on clinical experience and healthcare use from administrative databases. Results Efficient use of SC formulations increased the monthly capacity for parenteral administration by 3.35% (potentially increasable by 5.75% with maximum possible conversion according to the product label). The weekly capacity for hospital pharmacy treatment preparation increased by 7.13% due to conversion to SC formulation and by 9.33% due to transferring SC preparation to the cancer treatment unit (potentially increasable by 12.16 and 14.10%, respectively). Monthly hospital time decreased by 33% with trastuzumab and 47% with rituximab. In a hypothetical hospital, in which all processes for efficient use of SC rituximab and/or trastuzumab were implemented and all eligible patients received SC formulations, the estimated monthly capacity for preparation and administration increased by 23.1% and estimated hospital times were reduced by 60–66%. Conclusions Conversion of trastuzumab and rituximab to SC administration could improve the efficiency of hospitals and optimize internal resource management processes, potentially increasing care capacity and improving the quality of care by reducing time spent by patients at hospitals. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06277-8.
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Affiliation(s)
| | - Ainhoa Arenaza
- Hospital Pharmacy, Hospital Clínico San Carlos, Madrid, Spain
| | - Juan Bayo
- Oncology Unit, Hospital Juan Ramón Jiménez, Huelva, Spain
| | - Jesus García Mata
- Medical Oncology Unit, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | | | - Josefa León
- Hospital Pharmacy, Hospital Morales Meseguer, Murcia, Spain
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20
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Badkar AV, Gandhi RB, Davis SP, LaBarre MJ. Subcutaneous Delivery of High-Dose/Volume Biologics: Current Status and Prospect for Future Advancements. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:159-170. [PMID: 33469268 PMCID: PMC7812053 DOI: 10.2147/dddt.s287323] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/15/2020] [Indexed: 12/15/2022]
Abstract
Subcutaneous (SC) delivery of biologics has traditionally been limited to fluid volumes of 1-2 mL, with recent increases to volumes of about 3 mL. This injection volume limitation poses challenges for high-dose biologics, as these formulations may also require increased solution concentration in many cases, resulting in high viscosities which can affect the stability, manufacturability, and delivery/administration of therapeutic drugs. Currently, there are technologies that can help to overcome these challenges and facilitate the delivery of larger amounts of drug through the SC route. This can be achieved either by enabling biologic molecules to be formulated or delivered as high-concentration injectables (>100 mg/mL for antibodies) or through facilitating the delivery of larger volumes of fluid (>3 mL). The SC Drug Delivery and Development Consortium, which was established in 2018, aims to identify and address critical gaps and issues in the SC delivery of high-dose/volume products to help expand this delivery landscape. Identified as a high priority out of the Consortium's eight problem statements, it highlights the need to shift perceptions of the capabilities of technologies that enable the SC delivery of large-volume (>3 mL) and/or high-dose biologics. The Consortium emphasizes a patient-focused approach towards the adoption of SC delivery of large-volume/high-concentration dosing products to facilitate the continued expansion of the capabilities of novel SC technologies. To raise awareness of the critical issues and gaps in high-dose/volume SC drug development, this review article provides a generalized overview of currently available and emerging technologies and devices that could facilitate SC delivery of high-dose/volume drug formulations. In addition, it discusses the challenges, gaps, and future outlook in high-dose/volume SC delivery as well as potential solutions to exploit the full value of the SC route of administration.
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Affiliation(s)
- Advait V Badkar
- Pharmaceutical Research & Development, Pfizer Inc., Andover, MA, USA
| | - Rajesh B Gandhi
- Drug Product Science & Technology, Bristol-Myers Squibb, Co., New Brunswick, NJ, USA
| | - Shawn P Davis
- BioPharmaceuticals Development, Research & Development, AstraZeneca, Cambridge, MA, UK
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21
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Budget Impact Analysis of the Introduction of Rituximab and Trastuzumab Intravenous Biosimilars to EU-5 Markets. BioDrugs 2020; 35:89-101. [PMID: 33368051 PMCID: PMC7803676 DOI: 10.1007/s40259-020-00461-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 12/14/2022]
Abstract
Background Biologic treatments impose a large financial burden on healthcare payers. Subcutaneous formulations of trastuzumab and rituximab offer administration cost savings relative to the intravenous products through reduced preparation and infusion times. However, intravenous biosimilars have the potential to offset administration costs through lower drug costs. Objective The objective was to develop a budget impact model (BIM) from a payer’s perspective for the EU-5 countries (UK, France, Germany, Spain, Italy) to demonstrate the economic impact of using intravenous trastuzumab and rituximab biosimilars. Methods An incidence-based BIM was developed to estimate the net budget impact utilising epidemiology data from the literature, market research data on the use of relevant treatments in all approved indications, and corresponding costs. The budget impact was estimated for 5 years following introduction of the biosimilars. Results Analysis using the base-case results indicated that adoption of the biosimilars trastuzumab and rituximab would result in net cost savings. At year 5, the net budget saving ranged from €4.05 million to 303.86 million for rituximab and from €19 million to 172 million for trastuzumab. The cost saving could potentially extend treatment to 291–15,671 more patients with rituximab and 622–3688 more patients with trastuzumab. Conclusion This budget impact analysis emphasised that increased use of intravenous rituximab and trastuzumab biosimilars may result in cost savings from the payer’s perspective across the EU-5 countries. Supplementary Information The online version contains supplementary material available at 10.1007/s40259-020-00461-8.
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22
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Woodley WD, Yue W, Morel DR, Lainesse A, Pettis RJ, Bolick NG. Clinical Evaluation of an Investigational 5 mL Wearable Injector in Healthy Human Subjects. Clin Transl Sci 2020; 14:859-869. [PMID: 33278331 PMCID: PMC8212760 DOI: 10.1111/cts.12946] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 11/09/2020] [Indexed: 11/26/2022] Open
Abstract
An investigational wearable injector (WI), the BD Libertas Wearable Injector (BD Libertas is a trademark of Becton, Dickinson and Company), was evaluated in an early feasibility clinical study for functional performance, tissue effects, subject tolerability, and acceptability of 5 mL, non‐Newtonian ~ 8 cP subcutaneous placebo injections in 52 healthy adult subjects of 2 age groups (18–64 years and ≥ 65 years). Randomized WI subcutaneous injections (n = 208, 4/subject) were delivered to the right and left abdomen and thigh of each subject, 50% (1 thigh and 1 abdomen) with a defined movement sequence during injection. Injector functional performance was documented. Deposition was qualified and quantified with ultrasound. Tissue effects and tolerability (pain) were monitored through 24 hours with corresponding acceptability questionnaires administered through 72 hours. WI (n = 205) automatically inserted the needle, delivered 5 mL ± 5% in 5.42 minutes (SD 0.74) and retracted. Depots were entirely (93.2%) or predominantly (5.4%) localized within the target subcutaneous tissue. Slight to moderate wheals (63.9%) and erythema (75.1%) were observed with ≥ 50% resolution within 30–60 minutes. Subject pain (100 mm Visual Analog Scale) peaked mid‐injection (mean 9.1 mm, SD 13.4) and rapidly resolved within 30 minutes (mean 0.4 mm, SD 2.6). Subjects’ peak pain (≥ 90.2%), injection site appearance (≥ 92.2%) and injector wear, size, and removal (≥ 92.1%) were acceptable (Likert responses) with 100% likely to use the injector if prescribed. Injection site preference was divided between none (46%), abdomen (25%), or thigh (26.9%). The investigational WI successfully delivered 5 mL viscous subcutaneous injections. Tissue effects and pain were transient, well‐tolerated and acceptable. Neither injection site, movement or subject age affected injector functional performance or subject pain and acceptability.
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Affiliation(s)
- Wendy D Woodley
- BD Technologies & Innovation, Research Triangle Park, North Carolina, USA
| | - Wen Yue
- BD, Franklin Lakes, New Jersey, USA
| | | | | | - Ronald J Pettis
- BD Technologies & Innovation, Research Triangle Park, North Carolina, USA
| | - Natasha G Bolick
- BD Technologies & Innovation, Research Triangle Park, North Carolina, USA
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23
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Klein C, Jamois C, Nielsen T. Anti-CD20 treatment for B-cell malignancies: current status and future directions. Expert Opin Biol Ther 2020; 21:161-181. [PMID: 32933335 DOI: 10.1080/14712598.2020.1822318] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The introduction of anti-CD20 monoclonal antibody therapy with rituximab in the 1990s greatly improved outcomes for patients with B-cell malignancies. Disease resistance or relapse after successful initial therapy and declining efficacy of subsequent rounds of treatment were the basis for the development of alternative anti-CD20-based antibody therapies. AREAS COVERED The novel anti-CD20 antibodies of atumumab, ublituximab, and obinutuzumab were developed to be differentiated via structural and mechanistic features over rituximab. We provide an overview of preclinical and clinical data, and demonstrate ways in which the pharmacodynamic properties of these novel agents translate into clinical benefit for patients. EXPERT OPINION Of the novel anti-CD20 antibodies, only obinutuzumab has shown consistently improved efficacy over rituximab in randomized pivotal trials in indolent non-Hodgkin lymphoma and chronic lymphocytic leukemia. The Phase 3 GALLIUM trial demonstrated significant improvements in progression-free survival with obinutuzumab-based immunochemotherapy over rituximab-based immunochemotherapy. Novel combinations of obinutuzumab, including with chemotherapy-free options are being explored, such as with the newly approved combinations of obinutuzumab with venetoclax, ibrutinib, or acalabrutinib. The biggest unmet need remains in the treatment of diffuse large B-cell lymphoma; emerging options in this field include the use of CAR-T cells and T-cell bispecific antibodies.
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Affiliation(s)
- Christian Klein
- Roche Pharma Research & Early Development, Roche Innovation Center Zurich , Schlieren, Switzerland
| | - Candice Jamois
- Clinical Pharmacology, Pharmaceutical Sciences, Roche Pharma Research and Early Development, Roche Innovation Center Basel , Basel, Switzerland
| | - Tina Nielsen
- Product Development Oncology, F. Hoffmann-La Roche Ltd , Basel, Switzerland
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Erasmus JH, Archer J, Fuerte-Stone J, Khandhar AP, Voigt E, Granger B, Bombardi RG, Govero J, Tan Q, Durnell LA, Coler RN, Diamond MS, Crowe JE, Reed SG, Thackray LB, Carnahan RH, Van Hoeven N. Intramuscular Delivery of Replicon RNA Encoding ZIKV-117 Human Monoclonal Antibody Protects against Zika Virus Infection. Mol Ther Methods Clin Dev 2020; 18:402-414. [PMID: 32695842 PMCID: PMC7363633 DOI: 10.1016/j.omtm.2020.06.011] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 05/15/2020] [Indexed: 12/31/2022]
Abstract
Monoclonal antibody (mAb) therapeutics are an effective modality for the treatment of infectious, autoimmune, and cancer-related diseases. However, the discovery, development, and manufacturing processes are complex, resource-consuming activities that preclude the rapid deployment of mAbs in outbreaks of emerging infectious diseases. Given recent advances in nucleic acid delivery technology, it is now possible to deliver exogenous mRNA encoding mAbs for in situ expression following intravenous (i.v.) infusion of lipid nanoparticle-encapsulated mRNA. However, the requirement for i.v. administration limits the application to settings where infusion is an option, increasing the cost of treatment. As an alternative strategy, and to enable intramuscular (IM) administration of mRNA-encoded mAbs, we describe a nanostructured lipid carrier for delivery of an alphavirus replicon encoding a previously described highly neutralizing human mAb, ZIKV-117. Using a lethal Zika virus challenge model in mice, our studies show robust protection following alphavirus-driven expression of ZIKV-117 mRNA when given by IM administration as pre-exposure prophylaxis or post-exposure therapy.
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Affiliation(s)
- Jesse H. Erasmus
- Pre-Clinical Vaccine Development, Infectious Disease Research Institute, Seattle, WA, USA
- HDT Biocorp, Seattle, WA, USA
- Department of Microbiology, University of Washington, Seattle, WA, USA
| | - Jacob Archer
- Pre-Clinical Vaccine Development, Infectious Disease Research Institute, Seattle, WA, USA
- HDT Biocorp, Seattle, WA, USA
- Department of Microbiology, University of Washington, Seattle, WA, USA
| | - Jasmine Fuerte-Stone
- Pre-Clinical Vaccine Development, Infectious Disease Research Institute, Seattle, WA, USA
| | - Amit P. Khandhar
- Pre-Clinical Vaccine Development, Infectious Disease Research Institute, Seattle, WA, USA
- HDT Biocorp, Seattle, WA, USA
| | - Emily Voigt
- Pre-Clinical Vaccine Development, Infectious Disease Research Institute, Seattle, WA, USA
| | - Brian Granger
- Pre-Clinical Vaccine Development, Infectious Disease Research Institute, Seattle, WA, USA
| | - Robin G. Bombardi
- The Vanderbilt Vaccine Center, Vanderbilt University Medical Center, Nashville, TN 27232, USA
| | - Jennifer Govero
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Qing Tan
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Lorellin A. Durnell
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Rhea N. Coler
- Pre-Clinical Vaccine Development, Infectious Disease Research Institute, Seattle, WA, USA
| | - Michael S. Diamond
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - James E. Crowe
- The Vanderbilt Vaccine Center, Vanderbilt University Medical Center, Nashville, TN 27232, USA
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 27232, USA
- Department of Pathology Microbiology & Immunology, Vanderbilt University Medical Center, Nashville, TN 27232, USA
| | - Steven G. Reed
- Pre-Clinical Vaccine Development, Infectious Disease Research Institute, Seattle, WA, USA
- HDT Biocorp, Seattle, WA, USA
| | - Larissa B. Thackray
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Robert H. Carnahan
- The Vanderbilt Vaccine Center, Vanderbilt University Medical Center, Nashville, TN 27232, USA
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 27232, USA
| | - Neal Van Hoeven
- Pre-Clinical Vaccine Development, Infectious Disease Research Institute, Seattle, WA, USA
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Stewart D, Aucoin JS, Crosbie T, Forman M, Lye E, Christofides A, Mitha A. Update on the subcutaneous administration of rituximab in Canadian cancer centres. ACTA ACUST UNITED AC 2020; 27:113-116. [PMID: 32489254 DOI: 10.3747/co.27.6041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Results of studies comparing subcutaneous (sc) with intravenous (iv) rituximab indicate that the two formulations are comparable in efficacy, but most patients and health care professionals prefer the sc route, commonly because of shorter chair time and reduced risk of infusion-related reactions. Recent Canadian data, including those from the scuba study reported here, support the results of earlier international studies showing a reduction in preparation and administration time with the sc formulation, lower cost of administration, and reduced drug wastage because of the fixed sc dosing. Given the significant time and cost savings of the sc formulation, that formulation is generally preferred over the iv formulation for the treatment of follicular lymphoma, diffuse large B cell lymphoma, and chronic lymphocytic leukemia.
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Affiliation(s)
- D Stewart
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB
| | - J S Aucoin
- Centre hospitalier régional de Trois-Rivières, Université de Montréal, Trois-Rivières, QC
| | | | | | - E Lye
- Lymphoma Canada, Mississauga, ON
| | | | - A Mitha
- Hoffmann-La Roche, Mississauga, ON
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Accelerating the development of novel technologies and tools for the subcutaneous delivery of biotherapeutics. J Control Release 2020; 321:475-482. [DOI: 10.1016/j.jconrel.2020.02.036] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 02/21/2020] [Accepted: 02/23/2020] [Indexed: 01/04/2023]
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Delgado Sánchez O, Gutiérrez A, do Pazo F, Ginés J, Martorell C, Boyeras B, Bento L, Garcia-Recio M, Sampol A. Comparative Cost Analysis Of Intravenous And Subcutaneous Administration Of Rituximab In Lymphoma Patients. CLINICOECONOMICS AND OUTCOMES RESEARCH 2019; 11:695-701. [PMID: 31819561 PMCID: PMC6874115 DOI: 10.2147/ceor.s212257] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 10/31/2019] [Indexed: 12/24/2022] Open
Abstract
Purpose The availability of different routes of administration of rituximab, with different dosing and times of infusion in the day care unit, raises the question of which formulation would be the best in terms of direct cost, particularly with the approval of new intravenous (IV) rituximab biosimilars. We aim to retrospectively compare the direct costs of IV and subcutaneous (SC) rituximab in lymphoma, considering drug cost, pharmacy handling and occupation in day care unit in Son Espases University Hospital during 2017, now that the IV biosimilar is available. Patients and methods The data were collected from Oncosafety®-AVIDA for doses and SAP® for economic data. The costs of occupation are published by the Local Health Service. Results In 2017, 527 cycles were prescribed for 103 patients with lymphoma: 141 IV and 386 SC. Median doses were 690 mg and 1400 mg with a median cost of the drug of 1458.45€ and 1334.77€ for IV and SC routes, respectively. The nurse handling costs were 4.49€ and 2.24€, respectively. The cost of the day care unit occupation was 493€ and 123€, respectively. Overall, the median total cost per cycle was 1955.94€ for the IV, 1460.01€ for the SC and 1729€ for the biosimilar (p<0.001). The sensitivity analysis showed that it would be necessary for the cost of the IV biosimilar to be 34% lower than the price of SC rituximab to make a difference. Conclusion This study shows a reduction in the cost with the administration of SC rituximab in real life compared with using the IV original rituximab and the biosimilar. This information is relevant for healthcare managers and administrations and applies only in the case of drugs with SC original presentations still not available in their correspondent biosimilars.
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Affiliation(s)
| | - Antonio Gutiérrez
- Lymphoma Unit of Hematology Department, Son Espases University Hospital, IdISBa, Palma, Spain
| | - Fernando do Pazo
- Pharmacy Department, Son Espases University Hospital, IdISBa, Palma, Spain
| | - Jordi Ginés
- Pharmacy Department, Son Espases University Hospital, IdISBa, Palma, Spain
| | - Clara Martorell
- Pharmacy Department, Son Espases University Hospital, IdISBa, Palma, Spain
| | - Bàrbara Boyeras
- Pharmacy Department, Son Espases University Hospital, IdISBa, Palma, Spain
| | - Leyre Bento
- Lymphoma Unit of Hematology Department, Son Espases University Hospital, IdISBa, Palma, Spain
| | - Marta Garcia-Recio
- Lymphoma Unit of Hematology Department, Son Espases University Hospital, IdISBa, Palma, Spain
| | - Antonia Sampol
- Lymphoma Unit of Hematology Department, Son Espases University Hospital, IdISBa, Palma, Spain
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Brief Report: Integration of PrEP Services Into Routine Antenatal and Postnatal Care: Experiences From an Implementation Program in Western Kenya. J Acquir Immune Defic Syndr 2019; 79:590-595. [PMID: 30204720 DOI: 10.1097/qai.0000000000001850] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Programmatic approaches for delivering pre-exposure prophylaxis (PrEP) to pregnant and postpartum women in settings with high HIV burden are undefined. The PrEP Implementation for Young Women and Adolescents (PrIYA) Program developed approaches for delivering PrEP in maternal child health (MCH) clinics. METHODS Under the PrIYA Program, nurse-led teams worked with MCH staff at 16 public, faith-based, and private facilities in Kisumu, Kenya, to determine optimal clinic flow for PrEP integration into antenatal care (ANC) and postnatal care (PNC). A program-dedicated nurse facilitated integration. HIV-uninfected women were screened for behavioral risk factors; same-day PrEP was provided to interested and medically eligible women. PrEP and MCH services were evaluated using standardized flow mapping and time-and-motion surveys. RESULTS Clinics developed 2 approaches for integrating PrEP delivery within ANC/PNC: (1) co-delivery: ANC/PNC and PrEP services delivered by same MCH nurse or (2) sequential services: PrEP services after ANC/PNC by a PrEP-specialized nurse. Three clinics selected co-delivery and 13 sequential services, based on patient volume and space availability. Overall, 86 ANC/PNC visits were observed. Clients who initiated PrEP took a median of 18 minutes (interquartile range 15-26) for PrEP-related activities (risk assessment, PrEP counseling, creatinine testing, dispensation, and documentation) in addition to other routine ANC/PNC activities. For clients who declined PrEP, an additional 13 minutes (interquartile range 7-15) was spent on PrEP-related risk assessment and counseling. CONCLUSIONS PrEP delivery within MCH used co-delivery or sequential approaches. The moderate additional time burden for PrEP initiation in MCH would likely decline with community awareness and innovations such as group/peer counseling or expedited dispensing.
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Anderson KC, Landgren O, Arend RC, Chou J, Jacobs IA. Humanistic and economic impact of subcutaneous versus intravenous administration of oncology biologics. Future Oncol 2019; 15:3267-3281. [DOI: 10.2217/fon-2019-0368] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
More oncology biologics are becoming available for subcutaneous (sc.) administration and are expected to provide useful therapeutic options. We evaluated evidence published in the past 5 years to assess the humanistic and economic impact of sc. versus intravenous administration of approved cancer therapies and identify outcomes favoring either administration route. These publications focused predominantly on healthcare resource utilization and economic outcomes, demonstrating resource and cost savings with sc. administration. Patients reported a better health-related quality of life and preference for sc. formulations. Time-and-motion study analyses confirmed the convenience of sc. administration. These findings suggest that future availability of sc. oncology biologics, especially anti-PD-1/PD-ligand 1 antibodies due to their increased utility in various malignancies, may be beneficial for patients, healthcare providers and payers.
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Affiliation(s)
- Kenneth C Anderson
- Division of Hematologic Neoplasia, Harvard Medical School, Dana-Farber Cancer Institute, Boston, MA 02215, USA
| | - Ola Landgren
- Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Rebecca C Arend
- University of Alabama at Birmingham, Comprehensive Cancer Center, Experimental Therapeutics Program, Birmingham, AL 35294, USA
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Pintye J, Drake AL, Begnel E, Kinuthia J, Abuna F, Lagat H, Dettinger J, Wagner AD, Thirumurthy H, Mugwanya K, Baeten JM, John-Stewart G. Acceptability and outcomes of distributing HIV self-tests for male partner testing in Kenyan maternal and child health and family planning clinics. AIDS 2019; 33:1369-1378. [PMID: 30932954 PMCID: PMC6546533 DOI: 10.1097/qad.0000000000002211] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Providing HIV self-tests to women for distribution to male partners may provide a unique opportunity to increase male partner and couples testing among women in HIV high-burden settings. METHODS Between November 2017 and June 2018, we offered self-tests for at-home couples or partner HIV testing to HIV-uninfected women seeking routine maternal and child health and family planning services at eight facilities in Kisumu, Kenya. Women accepting self-tests were offered at least two self-tests (OraQuick) to take to their partner(s) with instructions on use. HIV self-testing (HIVST) outcomes were evaluated using available programmatic data. RESULTS Overall, 3620 women were offered self-tests for at-home male partner HIV testing. The median age was 24 years (interquartile range 21-28) and 81% were in monogamous marriages. Overall, 1422 (39%) women reported having a partner of unknown HIV status, of whom 755 (53%) accepted self-tests. Among women with partners of unknown HIV status who declined self-tests (n = 667), 49% reported needing to consult their partner. Pregnant women were more likely to accept HIVST than nonpregnant women (prevalence ratio = 1.2, 95% confidence interval 1.0-1.4, P = 0.013). Self-testing outcomes were ascertained for 389 (44%) women who accepted self-tests. Among these women, 93% offered HIVSTs to their male partner; of these, 95% reported their male partners used the self-test and 99% used a self-test with their partner. CONCLUSION Among women attending routine maternal and child health and family planning services who had male partners of unknown HIV status, over half accepted self-tests for partner testing. Most women with outcomes ascertained reported that male partners accepted and used self-tests and that couples testing occurred.
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Affiliation(s)
- Jillian Pintye
- Department of Global Health, University of Washington, Seattle, Washington
| | - Alison L Drake
- Department of Global Health, University of Washington, Seattle, Washington
| | - Emily Begnel
- Department of Global Health, University of Washington, Seattle, Washington
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Obstetrics/Gynecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Felix Abuna
- University of Washington—Kenya, Nairobi, Kenya
| | | | - Julia Dettinger
- Department of Global Health, University of Washington, Seattle, Washington
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, Washington
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kenneth Mugwanya
- Department of Global Health, University of Washington, Seattle, Washington
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Pediatric, University of Washington, Seattle, Washington
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Potential cost savings owing to the route of administration of oncology drugs: a microcosting study of intravenous and subcutaneous administration of trastuzumab and rituximab in the Netherlands. Anticancer Drugs 2019; 29:791-801. [PMID: 29846248 DOI: 10.1097/cad.0000000000000648] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
There is little evidence on the costs associated with the route of administration of oncology drugs. We investigated time and resource use for hospitals and patients and compared healthcare and societal costs for intravenous (IV) and subcutaneous (SC) administration of trastuzumab and rituximab. Data for the preparation and administration of both drugs were collected at the hospital pharmacy and at the oncology day care unit. Patients completed a questionnaire for obtaining information on societal costs (productivity losses, informal care and traveling expenses). A total of 126 patients were recruited in six hospitals; 82 received trastuzumab (37 IV and 45 SC) and 44 received rituximab (23 IV and 21 SC). The costs per administration (including societal cost but excluding drug costs) were &OV0556;167 and &OV0556;264 for IV and &OV0556;76 and &OV0556;146 for SC trastuzumab and rituximab, respectively. The costs for SC administration were lower in all categories. The largest cost component was related to time spent at the day care unit (overhead costs). This resulted in savings of &OV0556;47 for SC trastuzumab and &OV0556;69 for SC rituximab. The costs related to time of healthcare professionals was &OV0556;9 lower for both drugs. The costs for consumables resulted in another &OV0556;12 savings. Societal costs were &OV0556;22 lower for SC trastuzumab and &OV0556;28 lower for SC rituximab. Although administration costs are relatively a small part of the total costs, important savings can be generated by switching to an SC route of administration especially because a large number of patients receive oncology drugs and patients receive more than one administration.
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Lee C, Guo H, Klinngam W, Janga SR, Yarber F, Peddi S, Edman MC, Tiwari N, Liu S, Louie SG, Hamm-Alvarez SF, MacKay JA. Berunda Polypeptides: Biheaded Rapamycin Carriers for Subcutaneous Treatment of Autoimmune Dry Eye Disease. Mol Pharm 2019; 16:3024-3039. [PMID: 31095909 DOI: 10.1021/acs.molpharmaceut.9b00263] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The USFDA-approved immunosuppressive drug rapamycin (Rapa), despite its potency, is limited by poor bioavailability and a narrow therapeutic index. In this study, we sought to improve bioavailability of Rapa with subcutaneous (SC) administration and to test its therapeutic feasibility and practicality in a murine model of Sjögren's syndrome (SS), a systemic autoimmune disease with no approved therapies. To improve its therapeutic index, we formulated Rapa with a carrier termed FAF, a fusion of the human cytosolic FK506-binding protein 12 (FKBP12) and an elastin-like polypeptide (ELP). The resulting 97 kDa FAF (i) has minimal burst release, (ii) is "humanized", (iii) is biodegradable, (iv) solubilizes two Rapa per FAF, and (v) avoids organic solvents or amphiphilic carriers. Demonstrating high stability, FAF remained soluble and monodisperse with a hydrodynamic radius of 8 nm at physiological temperature. A complete pharmacokinetic (PK) analysis of FAF revealed that the bioavailability of SC FAF was 60%, with significantly higher blood concentration during the elimination phase compared to IV FAF. The plasma concentration of Rapa delivered by FAF was 8-fold higher with a significantly increased plasma-to-whole blood ratio relative to free Rapa, 24 h after injection. To evaluate therapeutic effects, FAF-Rapa was administered SC every other day for 2 weeks to male non-obese diabetic (NOD) mice, which develop an SS-like autoimmune-mediated lacrimal gland (LG) inflammation and other characteristic features of SS. Both FAF-Rapa and free Rapa exhibited immunomodulatory effects by significantly suppressing lymphocytic infiltration, gene expression of IFN-γ, MHC II, type I collagen and IL-12a, and cathepsin S (CTSS) activity in LG compared to controls. Serum chemistry and histopathological analyses in major organs revealed no apparent toxicity of FAF-Rapa. Given its improved PK and equipotent therapeutic efficacy compared to free Rapa, FAF-Rapa is of further interest for systemic treatments for autoimmune diseases like SS.
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Affiliation(s)
- Changrim Lee
- Department of Pharmacology and Pharmaceutical Sciences, School of Pharmacy , University of Southern California , Los Angeles , California 90089 , United States
| | - Hao Guo
- Department of Pharmacology and Pharmaceutical Sciences, School of Pharmacy , University of Southern California , Los Angeles , California 90089 , United States
| | - Wannita Klinngam
- Department of Pharmacology and Pharmaceutical Sciences, School of Pharmacy , University of Southern California , Los Angeles , California 90089 , United States
| | - Srikanth R Janga
- Department of Ophthalmology, USC Roski Eye Institute, Keck School of Medicine , University of Southern California , Los Angeles , California 90089 , United States
| | - Frances Yarber
- Department of Ophthalmology, USC Roski Eye Institute, Keck School of Medicine , University of Southern California , Los Angeles , California 90089 , United States
| | - Santosh Peddi
- Department of Pharmacology and Pharmaceutical Sciences, School of Pharmacy , University of Southern California , Los Angeles , California 90089 , United States
| | - Maria C Edman
- Department of Ophthalmology, USC Roski Eye Institute, Keck School of Medicine , University of Southern California , Los Angeles , California 90089 , United States
| | - Nishant Tiwari
- Department of Pathology, Keck School of Medicine , University of Southern California , Los Angeles , California 90089 , United States
| | - Siyu Liu
- Department of Pharmacology and Pharmaceutical Sciences, School of Pharmacy , University of Southern California , Los Angeles , California 90089 , United States
| | - Stan G Louie
- Department of Pharmacology and Pharmaceutical Sciences, School of Pharmacy , University of Southern California , Los Angeles , California 90089 , United States
| | - Sarah F Hamm-Alvarez
- Department of Pharmacology and Pharmaceutical Sciences, School of Pharmacy , University of Southern California , Los Angeles , California 90089 , United States.,Department of Ophthalmology, USC Roski Eye Institute, Keck School of Medicine , University of Southern California , Los Angeles , California 90089 , United States
| | - J Andrew MacKay
- Department of Pharmacology and Pharmaceutical Sciences, School of Pharmacy , University of Southern California , Los Angeles , California 90089 , United States.,Department of Ophthalmology, USC Roski Eye Institute, Keck School of Medicine , University of Southern California , Los Angeles , California 90089 , United States.,Department of Biomedical Engineering, Viterbi School of Engineering , University of Southern California , Los Angeles , California 90089 , United States
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Locke KW, Maneval DC, LaBarre MJ. ENHANZE ® drug delivery technology: a novel approach to subcutaneous administration using recombinant human hyaluronidase PH20. Drug Deliv 2019; 26:98-106. [PMID: 30744432 PMCID: PMC6394283 DOI: 10.1080/10717544.2018.1551442] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
ENHANZE® drug delivery technology is based on the proprietary recombinant human hyaluronidase PH20 enzyme (rHuPH20; Halozyme Therapeutics, Inc.) that facilitates the subcutaneous (SC) delivery of co‐administered therapeutics. rHuPH20 works by degrading the glycosaminoglycan hyaluronan (HA), which plays a role in resistance to bulk fluid flow in the SC space, limiting large volume SC drug delivery, dispersion, and absorption. Co-administration of rHuPH20 with partner therapies can overcome administration time and volume barriers associated with existing SC therapeutic formulations, and has been shown to reduce the burden on patients and healthcare providers compared with intravenous formulations. rHuPH20 (as HYLENEX® recombinant) is currently FDA-approved for subcutaneous fluid administration for achieving hydration, to increase the dispersion and absorption of other injected drugs, and in subcutaneous urography for improving resorption of radiopaque agents. rHuPH20 is also co-formulated with two anticancer therapies, trastuzumab (i.e. Herceptin® SC) and rituximab (i.e. RITUXAN HYCELA®/RITUXAN® SC/MabThera® SC) and dosed sequentially with human immunoglobin to treat primary immunodeficiency (i.e. HyQvia®/HYQVIA®). This article reviews pharmaceutical properties of rHuPH20, its current applications with approved therapeutics, and the potential for future developments.
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Stewart DA, Boudreault JS, Maturi B, Boras D, Foley R. Evaluation of subcutaneous rituximab administration on Canadian systemic therapy suites. ACTA ACUST UNITED AC 2018; 25:300-306. [PMID: 30464679 DOI: 10.3747/co.25.4231] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Non-Hodgkin lymphoma (nhl) is the most common hematologic malignancy. Diffuse large B-cell lymphoma (dlbcl) and follicular lymphoma (fl) constitute 55% of new nhl cases and are initially treated with rituximab-based chemoimmunotherapy. Relative to intravenous (IV) rituximab, a subcutaneous (sc) formulation approved in 2016 has comparable pharmacokinetics, efficacy, and safety, and a greatly reduced administration time; it is also preferred by patients. The objective of the present study was to estimate the effect (on systemic therapy suite time and on the costs of drug acquisition and administration) of implementing sc rituximab in the initial chemoimmunotherapy for fl and dlbcl over 3 years in the Canadian market. Methods An Excel (Microsoft Corporation, Redmond, WA, U.S.A.)-based model was created with a population size based on epidemiologic data and current rituximab use, duration of use considering initial therapy, time savings for sc rituximab administration from published studies, costs from standard Canadian sources, and assumed uptake in implementing provinces of 65%, 75%, and 80% over 3 years. Key parameters and sensitivity analysis values were validated by clinical experts located in various Canadian jurisdictions. Costs are reported in 2017 Canadian dollars from the perspective of the health care system. Results More than 3 years after implementation of sc rituximab, we estimated that 5762 Canadians would be receiving sc rituximab, resulting in savings of 128,715 hours in systemic therapy suite time and approximately $40 million in drug and administration costs. Sensitivity analyses suggest that the model is most sensitive to sc market uptake, number of induction therapy cycles, and eligible patients. Conclusions Subcutaneous administration of rituximab can significantly reduce systemic therapy suite time and achieve substantial savings in drug and administration costs.
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Affiliation(s)
- D A Stewart
- Tom Baker Cancer Centre and University of Calgary, Calgary, AB
| | | | - B Maturi
- Hoffmann-La Roche Limited, Mississauga, ON
| | - D Boras
- Hoffmann-La Roche Limited, Mississauga, ON
| | - R Foley
- Juravinski Hospital and Cancer Centre, Hamilton, ON
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Bittner B, Richter W, Schmidt J. Subcutaneous Administration of Biotherapeutics: An Overview of Current Challenges and Opportunities. BioDrugs 2018; 32:425-440. [PMID: 30043229 PMCID: PMC6182494 DOI: 10.1007/s40259-018-0295-0] [Citation(s) in RCA: 235] [Impact Index Per Article: 39.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Subcutaneous delivery of biotherapeutics has become a valuable alternative to intravenous administration across many disease areas. Although the pharmacokinetic profiles of subcutaneous and intravenous formulations differ, subcutaneous administration has proven effective, safe, well-tolerated, generally preferred by patients and healthcare providers and to result in reduced drug delivery-related healthcare costs and resource use. The aim of this article is to discuss the differences between subcutaneous and intravenous dosing from both health-economic and scientific perspectives. The article covers different indications, treatment settings, administration volumes, and injection devices. We focus on biotherapeutics in rheumatoid arthritis (RA), immunoglobulin-replacement therapy in primary immunodeficiency (PI), beta interferons in multiple sclerosis (MS), and monoclonal antibodies (mAbs) in oncology. While most subcutaneous biotherapeutics in RA, PI, and MS are self-administered at home, mAbs for oncology are still only approved for administration in a healthcare setting. Beside concerns around the safety of biotherapeutics in oncology, a key challenge for self-administration in this area is that doses and dosing volumes can be comparatively large; however, this difficulty has recently been overcome to some extent by the development of high-concentration solutions, the use of infusion pumps, and the coadministration of the dispersion enhancer hyaluronidase. Furthermore, given the increasing number of biotherapeutics being considered for combination therapy and the high dosing complexity associated with these, especially when administered intravenously, subcutaneous delivery of fixed-dose combinations might be an alternative that will diminish these burdens on healthcare systems.
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Affiliation(s)
- Beate Bittner
- Product Optimization, Global Product Strategy, F. Hoffmann-La Roche Ltd, Grenzacher Strasse 124, 4070, Basel, Switzerland.
| | - Wolfgang Richter
- Roche Pharmaceutical Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, Grenzacher Strasse 124, 4070, Basel, Switzerland
| | - Johannes Schmidt
- Product Optimization, Global Product Strategy, F. Hoffmann-La Roche Ltd, Grenzacher Strasse 124, 4070, Basel, Switzerland
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Turner MR, Balu-Iyer SV. Challenges and Opportunities for the Subcutaneous Delivery of Therapeutic Proteins. J Pharm Sci 2018; 107:1247-1260. [PMID: 29336981 PMCID: PMC5915922 DOI: 10.1016/j.xphs.2018.01.007] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/21/2017] [Accepted: 01/03/2018] [Indexed: 12/22/2022]
Abstract
Biotherapeutics is a rapidly growing drug class, and over 200 biotherapeutics have already obtained approval, with about 50 of these being approved in 2015 and 2016 alone. Several hundred protein therapeutic products are still in the pipeline, including interesting new approaches to treatment. Owing to patients' convenience of at home administration and reduced number of hospital visits as well as the reduction in treatment costs, subcutaneous (SC) administration of biologics is of increasing interest. Although several avenues for treatment using biotherapeutics are being explored, there is still a sufficient gap in knowledge regarding the interplay of formulation conditions, immunogenicity, and pharmacokinetics (PK) of the absorption of these compounds when they are given SC. This review seeks to highlight the major concerns and important factors governing this route of administration and suggest a holistic approach for effective SC delivery.
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Affiliation(s)
- Michael R Turner
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, New York 14214
| | - Sathy V Balu-Iyer
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, New York 14214.
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Hill SL, Davies A. Subcutaneous rituximab with recombinant human hyaluronidase in the treatment of non-Hodgkin lymphoma and chronic lymphocytic leukemia. Future Oncol 2018; 14:1691-1699. [PMID: 29405071 DOI: 10.2217/fon-2017-0574] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The anti-CD20 monoclonal antibody rituximab (MabThera®/Rituxan®) has been proven to improve outcomes in a range of B-cell malignancies. Initially developed as a formulation for intravenous infusion, administration times for rituximab can be prolonged and associated with infusion-related reactions, prompting a combined clinical development program investigating subcutaneous delivery in combination with recombinant human hyaluronidase. As this program comes to fruition, this article reviews the evidence demonstrating subcutaneous rituximab to have noninferior pharmacokinetics when delivered at a fixed-dose as well as equivalent clinical outcomes in the treatment of follicular lymphoma, chronic lymphocytic leukemia and diffuse large B-cell lymphoma. This mode of delivery is more preferable to patients and healthcare professionals and is associated with time and cost savings.
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Affiliation(s)
| | - Andrew Davies
- Cancer Research UK Centre, Cancer Sciences Division, University of Southampton, Southampton, UK
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Olsen J, Jensen KF, Olesen DS, Knoop A. Costs of subcutaneous and intravenous administration of trastuzumab for patients with HER2-positive breast cancer. J Comp Eff Res 2017; 7:411-419. [PMID: 29199854 DOI: 10.2217/cer-2017-0048] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Trastuzumab is available in an intravenous (iv.) and a subcutaneous (sc.) formulation. The objective of this study was to estimate the costs of administration of iv. and sc. trastuzumab treatment. MATERIALS & METHODS Via interviews, we identified all the activities associated with iv. and sc. administration. The outcome was time estimates. To estimate the administration costs, the time estimates were valued by average gross wages. RESULTS The iv. administration takes longer time as infusion time is longer (25 or 85 min). The iv. administration is associated with higher cost for 17 cycles; €971 (€1858 vs €887). CONCLUSION sc. administration is associated with lower administration costs. Switching patients from iv. to sc. would make it possible to treat more patients without increasing the personnel resources.
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Affiliation(s)
- Jens Olsen
- Health Economics Department, Incentive, Holte Stationsvej 14, 1st, DK-2840 Holte, Denmark
| | | | - Daniel Sloth Olesen
- Health Economics Department, Incentive, Holte Stationsvej 14, 1st, DK-2840 Holte, Denmark
| | - Ann Knoop
- Department of Oncology, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
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Fargier E, Ranchon F, Huot L, Guerre P, Safar V, Dony A, Hequet N, Bachy E, Savouroux S, Fronteau C, Tomaré P, Tournamille JF, Schwiertz V, Vantard N, Le Gouill S, Gyan E, Salles G, Rioufol C. SMABcare study: subcutaneous monoclonal antibody in cancer care: cost-consequence analysis of subcutaneous rituximab in patients with follicular lymphoma. Ann Hematol 2017; 97:123-131. [DOI: 10.1007/s00277-017-3147-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
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Davies A, Berge C, Boehnke A, Dadabhoy A, Lugtenburg P, Rule S, Rummel M, McIntyre C, Smith R, Badoux X. Subcutaneous Rituximab for the Treatment of B-Cell Hematologic Malignancies: A Review of the Scientific Rationale and Clinical Development. Adv Ther 2017; 34:2210-2231. [PMID: 28983819 PMCID: PMC5656720 DOI: 10.1007/s12325-017-0610-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Indexed: 12/25/2022]
Abstract
Rituximab (MabThera®/Rituxan®), a chimeric murine/human monoclonal antibody that binds specifically to the transmembrane antigen CD20, was the first therapeutic antibody to enter clinical practice for the treatment of cancer. As monotherapy and in combination with chemotherapy, rituximab has been shown to prolong progression-free survival and, in some indications overall survival, in patients with various B-cell malignancies, while having a well-established and manageable safety profile and a wide therapeutic window. As a result, rituximab is considered to have revolutionized treatment practices for patients with B-cell malignancies. A subcutaneous (SC) formulation of rituximab has been developed, comprising the same monoclonal antibody as the originally marketed formulation [rituximab concentrate for solution for intravenous (IV) infusion], and has undergone a detailed, sequential clinical development program. This program demonstrated that, at fixed doses, rituximab SC achieves non-inferior serum trough concentrations in patients with non-Hodgkin lymphoma and chronic lymphocytic leukemia, with comparable efficacy and safety relative to the IV formulation. The added benefit of rituximab SC was demonstrated in dedicated studies showing that rituximab SC allows for simplified and shortened drug preparation and administration times resulting in a reduced treatment burden for patients as well as improved resource utilization (efficiency) at the treatment facility. The improved efficiency of delivering rituximab's benefit to patients may broaden patient access to rituximab therapy in areas with low levels of healthcare resources, including IV-chair capacity constraints. This article is a companion paper to G. Salles, et al., which is also published in this issue. FUNDING F. Hoffmann-La Roche Ltd.
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MESH Headings
- Administration, Intravenous/standards
- Animals
- Antibodies, Monoclonal, Murine-Derived/therapeutic use
- Antineoplastic Agents, Immunological/standards
- Antineoplastic Agents, Immunological/therapeutic use
- B-Lymphocytes/drug effects
- Disease-Free Survival
- Hematologic Neoplasms/drug therapy
- Humans
- Infusions, Intravenous/standards
- Injections, Subcutaneous/standards
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Rituximab/therapeutic use
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Affiliation(s)
- Andrew Davies
- Cancer Research UK Centre, Faculty of Medicine, University of Southampton, Southampton, UK.
| | | | | | | | | | - Simon Rule
- Plymouth University Medical School, Plymouth, UK
| | - Mathias Rummel
- Hospital of the Justus-Liebig-University, Giessen, Germany
| | | | | | - Xavier Badoux
- Department of Haematology, St. George Hospital, Kogarah, Australia
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Assouline S, Buccheri V, Delmer A, Gaidano G, Trneny M, Berthillon N, Brewster M, Catalani O, Li S, McIntyre C, Sayyed P, Badoux X. Pharmacokinetics, safety, and efficacy of subcutaneous versus intravenous rituximab plus chemotherapy as treatment for chronic lymphocytic leukaemia (SAWYER): a phase 1b, open-label, randomised controlled non-inferiority trial. LANCET HAEMATOLOGY 2017; 3:e128-38. [PMID: 26947201 DOI: 10.1016/s2352-3026(16)00004-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/22/2015] [Accepted: 01/04/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Part one of the two-part SAWYER study predicted that subcutaneous rituximab 1600 mg would achieve trough serum concentrations that were non-inferior to those achieved with intravenous rituximab 500 mg/m(2) in patients with chronic lymphocytic leukaemia. In part two of the study, we aimed to confirm the pharmacokinetic non-inferiority of subcutaneous rituximab, and investigate its safety and efficacy. METHODS We did this phase 1b, open-label, randomised controlled non-inferiority study at 68 centres in 19 countries in Europe, North America, South America, and Australasia. Patients aged 18 years or older with untreated chronic lymphocytic leukaemia were randomly assigned, via an interactive voice-response system with a permuted block randomisation scheme (block size of ten), to receive subcutaneous rituximab 1600 mg or intravenous rituximab 500 mg/m(2) plus fludarabine and cyclophosphamide every 4 weeks for up to six cycles. In cycle one, all patients received intravenous rituximab 375 mg/m(2). Randomisation was stratified by Binet stage and fludarabine and cyclophosphamide administration route (oral vs intravenous). Study investigators and patients were not masked to group allocation, but allocation was concealed from the statistician, clinical scientist, and clinical pharmacologist. The primary endpoint was trough serum concentration at cycle five, with a non-inferiority margin of 0·8 for the adjusted geometric mean ratio of the subcutaneous to the intravenous dose. We did the primary analysis in patients in the intention-to-treat population with complete pharmacokinetic data (pharmacokinetic population). This trial is registered with ClinicalTrials.gov, number NCT01292603, and is ongoing, although the treatment stage is now complete. FINDINGS Between Aug 20, 2012, and June 17, 2013, we randomly assigned 176 patients to receive subcutaneous rituximab (n=88) or intravenous rituximab (n=88); 134 (76%) patients comprised the pharmacokinetic population. As of May 7, 2014, median follow-up was 13·9 months (IQR 11·9-16·0) for patients in the subcutaneous group and 14·1 months (11·6-16·5) for patients in the intravenous group. At cycle five, the geometric mean trough serum concentration in patients given subcutaneous rituximab was non-inferior to that in patients given intravenous rituximab (97·5 μg/mL vs 61·5 μg/mL), with an adjusted geometric mean ratio of 1·53 (90% CI 1·27-1·85). In the safety analysis, the proportion of patients reporting adverse events was similar between the subcutaneous and intravenous groups (all grades: 82 [96%] of 85 patients and 81 [91%] of 89 patients; serious adverse events: 25 [29%] and 29 [33%] patients; grade ≥3: 59 [69%] and 63 [71%] patients, respectively). The most common adverse event of grade 3 or higher was neutropenia (48 [56%] patients in the subcutaneous group and 46 [52%] patients in the intravenous group); the most common serious adverse event was febrile neutropenia (n=9 [11%] and n=4 [4%], respectively). We recorded administration-related reactions in 37 (44%) patients given subcutaneous rituximab and 40 (45%) patients given the intravenous dose, with differences between administration routes for injection-site erythema (n=10 [12%] and n=0, respectively) and nausea (n=2 [2%] and n=11 [12%], respectively). More patients reported local cutaneous reactions after subcutaneous rituximab (n=36 [42%]) than after intravenous rituximab (n=2 [2%]); most of these reactions were grade 1 or 2. INTERPRETATION When combined with fludarabine and cyclophosphamide, subcutaneous rituximab 1600 mg achieved trough serum concentrations that were pharmacokinetically non-inferior to those achieved with intravenous rituximab 500 mg/m(2), with a similar safety and efficacy profile between the two groups. Treatment with subcutaneous rituximab should allow patients with chronic lymphocytic leukaemia to receive clinical benefit from the drug via a more convenient delivery method than the intravenous route, and might also be used in combination regimens with approved and emerging oral regimens. FUNDING F Hoffmann-La Roche.
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Affiliation(s)
- Sarit Assouline
- Jewish General Hospital, McGill University, Montréal, QC, Canada.
| | - Valeria Buccheri
- Hematology Division-Clinics Hospital, University of São Paulo, São Paulo, Brazil
| | - Alain Delmer
- Department of Haematology, Hôpital Robert Debré, Reims, France
| | - Gianluca Gaidano
- Division of Haematology, Department of Translational Medicine, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy
| | - Marek Trneny
- Charles University, General Hospital Prague, Prague, Czech Republic
| | | | - Michael Brewster
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center, Welwyn, UK
| | | | - Sai Li
- F Hoffmann-La Roche, Basel, Switzerland
| | - Christine McIntyre
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center, Welwyn, UK
| | | | - Xavier Badoux
- Department of Haematology, St George Hospital, Sydney, NSW, Australia
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Zhang L, Ghielmini M, Cheson BD, Ujjani C. Pros and cons of rituximab maintenance in follicular lymphoma. Cancer Treat Rev 2017. [DOI: 10.1016/j.ctrv.2017.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Farolfi A, Silimbani P, Gallegati D, Petracci E, Schirone A, Altini M, Masini C. Resource utilization and cost saving analysis of subcutaneous versus intravenous trastuzumab in early breast cancer patients. Oncotarget 2017; 8:81343-81349. [PMID: 29113393 PMCID: PMC5655288 DOI: 10.18632/oncotarget.18527] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 06/02/2017] [Indexed: 11/25/2022] Open
Abstract
We conducted an economic evaluation of intravenous (IV) vs subcutaneous (SC) trastuzumab for the treatment of patients with early breast cancer (EBC). Data of patients receiving adjuvant IV trastuzumab at our institute in 2014 were used to study three different treatment scenarios: 1) IV trastuzumab, 2) SC trastuzumab, and 3) IV trastuzumab during chemotherapy followed by SC trastuzumab. Our cohort included 114 patients with a median weight of 63.75 kg. Scenario 2 was the most time-saving treatment, with 71.7% reduction in preparation time and 89.3% reduction in chair time compared to scenario 1. Considering full costs, the mean costs per patient/year were € 14,233 ± 8,698 for scenario 1, € 14,272 ± 8,312 for scenario 2, and € 14,535 ± 8,646 for scenario 3 (p = 0.959). When mean body weight was > 65.2 kg, the mean cost was lower in scenario 2 than in scenario 1. Scenario 2 proved a valuable time-saving and cost-saving option. A shift from IV to SC trastuzumab should be considered, especially in capacity-constrained oncology departments.
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Affiliation(s)
- Alberto Farolfi
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Paolo Silimbani
- Oncology Pharmacy Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Davide Gallegati
- Financial and Management Control, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Elisabetta Petracci
- Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Alessio Schirone
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Mattia Altini
- Healthcare Administration, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Carla Masini
- Oncology Pharmacy Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
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Mihajlović J, Bax P, van Breugel E, Blommestein HM, Hoogendoorn M, Hospes W, Postma MJ. Microcosting Study of Rituximab Subcutaneous Injection Versus Intravenous Infusion. Clin Ther 2017; 39:1221-1232.e4. [PMID: 28579210 DOI: 10.1016/j.clinthera.2017.05.342] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 03/23/2017] [Accepted: 05/09/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE The goal of this study is to identify and compare all direct costs of intravenous and subcutaneous rituximab given to patients with diffuse large B-cell lymphoma in the Netherlands. METHODS Using a prospective, observational, bottom-up microcosting study, we collected primary data on the direct medical costs of the preparation, administration, and acquisition of rituximab. Drug costs and costs of drug wastage, labor costs, material costs, and outpatient costs were identified using standardized forms, structured using prices from official pricelists, and compared for the intravenous and subcutaneous forms of rituximab. FINDINGS Measurements were taken on 53 rituximab administrations (33 intravenous and 20 subcutaneous) and on 13 rituximab preparation (7 intravenous and 6 subcutaneous). The mean total costs were €2176.77 for the intravenous infusion and €1911.09 for the subcutaneous injection. The estimated difference of €265.17 (95% CI, €231.99-`€298.35) per administration was mainly attributable to differences in time spent in the chemotherapy unit, related outpatient costs, drug wastage, and drug costs. IMPLICATIONS Rituximab administered in the form of subcutaneous injection is less costly than its intravenous form. With their equal effectiveness taken into account, subcutaneous rituximab administration can result in significant savings when transferred to the total diffuse large B-cell lymphoma population in the Netherlands.
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Affiliation(s)
- Jovan Mihajlović
- Department of Pharmacotherapy, Epidemiology, and Economics, University of Groningen, Groningen, the Netherlands; Mihajlović Health Analytics, Novi Sad, Serbia.
| | - Pieter Bax
- Department of Pharmacotherapy, Epidemiology, and Economics, University of Groningen, Groningen, the Netherlands
| | - Erwin van Breugel
- Department of Pharmacotherapy, Epidemiology, and Economics, University of Groningen, Groningen, the Netherlands
| | - Hedwig M Blommestein
- Institute of Health Policy & Management, Erasmus University, Rotterdam, the Netherlands
| | - Mels Hoogendoorn
- Department of Haematology, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Wobbe Hospes
- Department of Pharmacy, Isala Clinics, Zwolle, the Netherlands; Department of Pharmacy, Ommelander Zorggroep, Winschoten/Delfzijl, the Netherlands
| | - Maarten J Postma
- Department of Pharmacotherapy, Epidemiology, and Economics, University of Groningen, Groningen, the Netherlands; Institute of Science in Healthy Aging & health caRE, University Medical Center Groningen, Groningen, the Netherlands
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Burrows SH, Akinbobuyi O, Rule S, Crosbie N. Subcutaneous rituximab can be safely administered without pre-medication. Br J Haematol 2017; 181:836-837. [PMID: 28542835 DOI: 10.1111/bjh.14703] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Simon Rule
- Haematology Department, Derriford Hospital, Plymouth, UK
| | - Nicola Crosbie
- Haematology Department, Derriford Hospital, Plymouth, UK
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Carlson J, Cox K, Bedwell K, Ku M. Rituximab for subcutaneous delivery: Clinical management principles from a nursing perspective. Int J Nurs Pract 2016; 21 Suppl 3:1-13. [PMID: 26681664 DOI: 10.1111/ijn.12413] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Nurses play an integral role in administering treatments to patients with non-Hodgkin's lymphomas. Intravenous (IV) rituximab was approved by the Australian Therapeutic Goods Administration in 1998, and a novel subcutaneous (SC) formulation was approved in 2014. Fixed-dose SC rituximab is highly concentrated; co-formulation with a fully human recombinant vorhyaluronidase alfa enzyme helps overcome the physiological barriers of the SC space, facilitating drug dispersion. Despite a different pharmacokinetic profile to the IV preparation, SC rituximab demonstrates a comparable efficacy/safety profile. Most frequently occurring rituximab-related adverse events include neutropenia, nausea and constipation, and administration-related reactions are more frequent with the SC preparation. Compared with IV, SC delivery reduces treatment times and nurse workload, and patients report greater comfort and convenience. This article sets out nursing considerations for optimal administration of SC rituximab, including premedication, drug handling/preparation, injection technique, after-care and management of adverse events, particularly administration-related reactions.
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Affiliation(s)
| | - Keith Cox
- Chris O'Brien Lifehouse, Sydney, Australia.,The University of Sydney, Sydney, Australia
| | - Kylie Bedwell
- Roche Products Pty. Ltd, Dee Why, New South Wales, Australia
| | - Mathew Ku
- Austin Hospital, Heidelberg, Victoria, Australia
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Time Savings with Rituximab Subcutaneous Injection versus Rituximab Intravenous Infusion: A Time and Motion Study in Eight Countries. PLoS One 2016; 11:e0157957. [PMID: 27362533 PMCID: PMC4928781 DOI: 10.1371/journal.pone.0157957] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 06/06/2016] [Indexed: 12/20/2022] Open
Abstract
Background Rituximab is a standard treatment for non-Hodgkin lymphoma. The SABRINA trial (NCT01200758) showed that a subcutaneous (SC) rituximab formulation did not compromise efficacy or safety compared with intravenous (IV) infusion. We aimed to quantify active healthcare professional (HCP) time and patient chair time for rituximab SC and IV, including potential time savings. Methods This non-interventional time and motion study was run in eight countries and 30 day oncology units. Rituximab SC data were collected alongside the MabCute trial (NCT01461928); IV data were collected per routine real-world practice. Trained observers recorded active HCP time for pre-specified tasks (stopwatch) and chair time (time of day). A random intercept model was used to analyze active HCP time (by task and for all tasks combined) in the treatment room and drug preparation area, drug administration duration, chair time and patient treatment room time by country and/or across countries. Active HCP and chair time were extrapolated to a patient’s first year of treatment (11 rituximab sessions). Results Mean active HCP time was 35.0 and 23.7 minutes for IV and SC process, respectively (-32%, p <0.0001). By country, relative reduction in time was 27–58%. Absolute reduction in extrapolated active HCP time (first year of treatment) was 1.1–5.2 hours. Mean chair time was 262.1 minutes for IV, including 180.9 minutes infusion duration, vs. 67.3 minutes for SC, including 8.3 minutes SC injection administration (-74%, p <0.0001). By country, relative reduction was 53–91%. Absolute reduction in extrapolated chair time for the first year of treatment was 3.1–5.5 eight-hour days. Conclusions Compared with rituximab IV, rituximab SC was associated with reduced chair time and active HCP time. The latter could be invested in other activities, whereas the former may lead to more available appointments, reducing waiting lists and increasing the efficiency of day oncology units. Trial Registration ClinicalTrials.gov NCT01200758
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Ponzetti C, Canciani M, Farina M, Era S, Walzer S. Potential resource and cost saving analysis of subcutaneous versus intravenous administration for rituximab in non-Hodgkin's lymphoma and for trastuzumab in breast cancer in 17 Italian hospitals based on a systematic survey. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:227-33. [PMID: 27284260 PMCID: PMC4883807 DOI: 10.2147/ceor.s97319] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Subcutaneous versions of different oncology therapies have been available for patients for a few years, yet patient-relevant and hospital benefits have not been assessed in real life. Methods In order to analyze the impact of subcutaneous administrations for rituximab or trastuzumab in comparison to the respective intravenous mode a primary research in Italy was executed. The study’s primary objectives were to analyze the resource and cost implications from different perspectives (patient, medical staff) in the real world. The route of administration was discussed and aligned with the participating centers in order to capture all relevant therapy parts. After the successful execution of a pilot study 19 centers in six regions in Italy were recruited to participate. Results Significant time savings might be achieved with the subcutaneous mode through significantly lower patient preparation time including less time preparing the actual dosing for each individual patient. The total time difference is 3.3 hours with rituximab in hematology (non-Hodgkin’s lymphoma), which adds up to 23.55 hours for a full course of treatment per patient (overall preparation time: 40.1 hours intravenous [95% confidence interval (CI): ±0.47] vs 16.6 hours subcutaneous [95% CI: ±0.2]). In early breast cancer (trastuzumab), the time saving might be 3.3 hours for the first cycle and the total time saving for patient preparation might be 17.2 hours (overall preparation time: 38.8 hours intravenous [95% CI: ±9.42] vs 21.6 hours subcutaneous [95% CI: ±9.9]). Furthermore, in both settings, the time of medical staff was reduced and could hence be used elsewhere. Finally, in case wastage was experienced with intravenous therapies, there were potential significant reductions in wastage through the subcutaneous administration (93%–100%) with cost savings of €6,057 with rituximab subcutaneous and €28,399 with trastuzumab subcutaneous administration for the full treatment course. Conclusion There are significant resource and cost savings due to subcutaneous administration with rituximab and trastuzumab in Italy based on a systematic survey. With the availability of a subcutaneous use of rituximab and trastuzumab, hospitals, patients and payers in general still have the current standard of care therapies available in the approved indications for a more efficient use of time and resources.
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Affiliation(s)
- Clemente Ponzetti
- Group Policlinic Monza, Alessandria, National Scientific Associazione Nazionale dei Medici delle Direzioni Ospedaliere (National Association of Hospital Physicians), Bologna, Italy
| | | | | | | | - Stefan Walzer
- MArS Market Access and Pricing Strategy GmbH, Weil am Rhein, Loerrach, Germany; Health Care Management, State University Baden-Wuerttemberg, Loerrach, Germany
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Abstract
Rituximab has become a keystone of the treatment of B-cell lymphoproliferation. The standard administration route is intravenous infusion with risks of infusion-related reactions. In order to make administration easier, increase convenience for the patient and improve cost effectiveness, a subcutaneous (sc.) form has recently been developed. Early phase clinical studies in patients with follicular lymphoma have shown that a fixed dose of 1400 mg by sc. route yielded at least non-inferior pharmacokinetics that are at least as good as those of intravenous rituximab, as measured by Ctrough levels. The safety profile was also comparable. Preliminary analyses of clinical efficacy showed at least non-inferior response rates. Although additional information is required, these results suggest that sc. rituximab may become a useful option for treating patients with B-cell non-Hodgkin's lymphoma.
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Affiliation(s)
- Philippe Solal-Celigny
- Institut de Cancérologie de l'Ouest, Saint-Herblain, Bld Jacques Monod 44805 Saint-Herblain Cedex, France
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