Biosimilars and interchangeable biosimilars: facts every prescriber, payor, and patient should know. Insulins perspective

INTRODUCTION

For many of the 537 million adults living now with diabetes, the cost of insulin is becoming prohibitive as the insulin prices have tripled between 2002-2013. Globally, the direct annual cost of healthcare expenditure due to diabetes will soon be US$1 Trillion. Biosimilars provide access to high-quality, affordable biologic therapy that is otherwise inaccessible due to the high costs of original biologics.

AREAS COVERED

A primer to the development of biosimilars shows comparable structural and analytical characterization to the original biologics (e.g. insulins), with no clinically significant or meaningful differences in efficacy and safety. 'Interchangeability' status, a regulatory designation by the US FDA, bestowed to some biosimilars, enables confidence in high-quality, bio-equivalent biosimilar of insulin with key global approvals. This can allow rapid uptake of biosimilars by the prescribers, formulary decision-makers, and payors. Biocon-Viatris's biosimilar Insulin Glargine (Semglee®) is the first interchangeable biosimilar insulin approved by the US FDA.

EXPERT OPINION

The 'interchangeable' status can prompt faster and wider uptake of insulin biosimilars and keep the insulin expenditure under control, especially for patients who otherwise practice non-adherence or rationing of life-saving insulin. Education, support, and awareness can ensure that interchangeable biosimilars gain wider acceptance.

Sodium-glucose co-transporter-2 inhibitors: A cardiovascular outcome trial analysis

Cardiovascular outcome trials (CVOTs) have to be done by sponsors who wish to launch new antidiabetic drugs in the US, since the December 2008 US Food and Drug Administration ruling, which was subsequently accepted by the European Medicines (Evaluation) Agency (EMA) in 2012. However, the medical community asks the question, “So What?” as they are not convinced of the clinical relevance of CVOTs. The patients selected in CVOTs are necessarily high risk, so that they develop major adverse cardiovascular events quickly, but then, the results are extrapolatable to only a certain percentage of patients seen in the clinical practice. Doctors believe that these trials only serve a regulatory need. At the same time, these trials do provide a lot of good data, but it needs to be interpreted well, and extrapolated appropriately to patients in practice as there are differences between what happens in a randomized control trial and in the real world. Hence, the need for this article which serves to dissect the CVOTs of sodium-glucose co-transporter-2 inhibitors, so that doctors are able to better read this evidence. However, the question of which gliflozin is the best cannot be answered by these trials as these are not head to head trials. All the more reason why one needs to look at the data holistically and be empowered to make the right decision for individual patients, hoping to match the best patient for the best drug, rather than determine which drug is better.

Real world evidence (RWE) - Are we (RWE) ready?

Real world evidence is important as it complements data from randomised controlled trials (RCTs). Both have limitations in design, interpretation, and extrapolatability. It is imperative one designs real world studies in the right way, else it can be misleading. An RCT is always considered higher in the evidence ladder and when there is discordance between a real world study and an RCT, it is the latter which is always considered pristine because of the way it is conducted, e.g., randomization, prospective, double-blind, etc. A real world study can also be done prospectively, and propensity score matching can be used to construct comparable cohorts but may not be able to account for certain biases or confounding factors the way an RCT can do. Nevertheless, comparative effectiveness research in the real world is being resorted to, especially for efficiency studies or pharmacoeconomic analyses, and with the advent of machine learning, the electronic healthcare database mining can result in algorithms that help doctors identify clinical characteristics that correlate with optimal response of a patient to a drug/regimen, thus helping him/her select the right patient for the right drug.

Translation and validation of brief patient health questionnaire against DSM IV as a tool to diagnose major depressive disorder in Indian patients

CONTEXT

Depression is frequently encountered in the primary care setting but is often unrecognized and hence untreated. There is a need for a uniform user-friendly screening instrument for depression for primary healthcare personnel in India.

AIMS

Translation and validation of the brief patient health questionnaire (BPHQ) as a screening tool for depression in major Indian languages.

MATERIALS AND METHODS

This was a prospective study conducted at 18 sites, in psychiatric and general clinics. The English version of the BPHQ was translated into 11 Indian languages. The translations were reviewed by experts and volunteers and proofread for the final translated BPHQ. The validation exercise included more than 3000 subjects. A psychiatrist and a psychiatry social worker / coordinator conducted the study under the supervision of the principal investigator. For each language, the presence or absence of major depressive disorder (MDD) as diagnosed with the help of a patient-completed BPHQ and the psychiatrist DSM-IV diagnosis was matched. The kappa coefficient was used as a measure of inter-observer agreement between the two diagnostic methods.

RESULTS

Seven languages failed the primary validation exercise. These translations were reviewed and the updated versions, after proofreading were re-run for validation. The self-administered BPHQ was successfully translated and validated for diagnosis of MDD against DSM-IV diagnosis made by a psychiatrist, in English, Hindi, Marathi oriya, Malayalam, Assamese, Gujarati, Kannada, Telugu, Bengali and Tamil.

CONCLUSIONS

BPHQ is a simple, quick and reliable instrument, which facilitates rapid and accurate diagnosis of depression in the primary care setting in our country.