Background:The advent of biosimilars has heralded a new era for cost effective biologic prescribing in the NHS. As patents expire for originator biologics, less expensive versions are now widely available as biosimilars. Non-medical switches (for reasons unrelated to a patient’s health) ensure prescribing of best value medicines, and cost savings can be redirected to patient care.1This practice resonates with recommendations from Lord Carter’s 2016 report regarding reducing unwarranted variation in the NHS and adopting cost saving opportunities.2In 2018/19, following loss of patent exclusivity for the expensive adalimumab originator biologic, UHCW worked in accordance with national directives to drive forward one of the largest non-medical biosimilar switches.Objectives:This qualitative review aims to explore the success of the adalimumab biosimilar switch and key themes associated with switch backs/refusals across the Rheumatology (R), Gastroenterology (G) and Dermatology (D) specialities at UHCW.Methods:The switch plan occurred between April-December 2019. 403 patients (R;189, G;176, D; 38) were eligible for switch. Patients were informed of the plan in advance via a patient information leaflet/hospital clinic visits. Switch refusals, withheld treatments and cancellations were documented and patients were advised to contact the hospital pharmacy/clinical teams if they encountered any concerns, adverse effects or lack of efficacy post switch. The clinician would then advise on subsequent management.Results:During April-December 2019, 264/403 patients had been successfully switched (R;122, G;109, D;33). 33/403 patients switched back to the originator biologic (R;22, G;10; D;1). Of the 22 rheumatology switch back patients; 6 patients reported injection site pain and variably headache, fatigue, disease relapse, gastrointestinal (GI) upset, erythema; 10=reported lack of efficacy and variably influenza-type symptoms, relapse in associated psoriasis, difficulty in walking/sleeping, hair loss, excessive perspiration, facial cellulitis, foot drop and GI upset; 1=blepharitis;1=latex allergy before injection; 3=later declined switch; 1=damaged two devices and did not wish to continue biosimilar. Of the 10 gastroenterology switch back patients; 1=injection site pain; 2=lack of efficacy; 1=developed needle phobia; 1=latex allergy before injection; 1=switch detrimental to health; 2=unstable disease; 1=insomnia; 1=pregnancy. The 1 dermatology switch back patient reported injection site pain and bleeding.38/403 patients refused the switch and remained on the originator biologic (R;11, G;27, D;0). 29/403 patients had treatment cancellations and were switched to an alternative biologic (R;17, G;9, D;3). 32/403 patients stopped treatment (R;13, G;19, D;0). Treatment was withheld for 7/403 patients (R;4, G;2, D;1).Conclusion:The UHCW adalimumab biosimilar switch plan succeeded in switching a total of 66% of patients; thus an annual cost saving of £73,020. Injection site pain, most likely due to the biosimilar citrate content, and lack of efficacy according to patient perception and subsequent clinical review, were the most predominant causative themes for switch backs. Gastroenterology patients accounted for 71% (27/38) of the total switch refusals. Additional data regarding patient refusals, identifies future opportunities to improve patient counselling and drive further cost savings.References:[1]Azevedo V, et al. Biosimilars: considerations for clinical practice. Considerations in Medicine. 2017;1(1):13–8[2]Lord Carter of Coles. (2016) Operational productivity and performance in English NHS Acute Hospitals: Unwarranted variations [Online]Acknowledgments:Mark Easter, Chief Pharmacist, Hardeep Bagga, Deputy Chief Pharmacist, UHCW Pharmacy Homecare Team, UHCW Specialist Clinical Teams.Disclosure of Interests:None declared
Background:The adalimumab biosimilar switch plan, actioned 2018-19 was one of the most complex of all biologic switches across several specialties. Non-medical switches are considered to ensure the best value medicines are prescribed for patients in line with NICE Technology Appraisals.Objectives:This 2 year follow up review explores the value of the switch for Rheumatology (R) patients in comparison to two other major specialisms; Dermatology (R) and Gastroenterology (G).Methods:403 homecare (HC) patients had been identified as eligible for switch to a citrate containing biosimilar (R;189, G;176, D;38) between April-December 2019. 35 hospital FP10 patients receiving the citrate-free originator biologic were also identified for switch to the citrate containing biosimilar and prescription processing via HC (R; 24, G; 9, D;2). Biosimilar switch information was communicated via patient letters/clinic reviews. FP10 patients also received remote pharmacist telephone support, as part of a PDSA (Plan, Do, Study, Act) quality improvement pilot. Data in regard to switch refusal, treatment cessation, withheld treatment and patient satisfaction ratings for pharmacist phonecalls (1 = unsatisfactory, 5=very satisfied) was documented.Results:235/403 HC patients successfully switched (R;99, G;107, D;29). 64/403 HC patients switched back to the originator (R;47, G;12; D;5). Of the 64 switch back HC patients; 52% = reported lack of efficacy; 27% = injection site pain and 21% = various other factors such as blepharitis, insomnia and hair loss. 38/403 HC patients refused the switch and remained on the originator biologic (R;11, G;27, D;0). 31/403 HC patients switched to an alternative biologic (R;19, G;9, D;3). 32/403 HC patients stopped treatment (R;13, G;19, D;0). Treatment was withheld for 3/403 HC patients (R;0, G;2, D;1). 100% of FP10 patients switched to HC. 31/35 FP10 patients switched to the biosimilar (R; 22, G; 7, D; 2). 3/31 patients switched back to the originator due to lack of efficacy or side effects. 4 patients refused the switch to biosimilar (R;3, G;1, D;0). 89% of patients were very satisfied with the pharmacist telephone support.Conclusion:In summary, 58% of all eligible HC patients switched in comparison to 89% of FP10 patients who received pharmacist telephone support; total cost saving following HC and FP10 switch = £270,000. Rheumatology demonstrated the least success in HC switching (52%) and the highest HC switch back figure (25%). Injection site pain and subjective lack of efficacy appear to be the main reasons for ongoing switch backs. The PDSA project demonstrates that a thorough pharmacist assessment of patient concerns in rationalising the use of a biologic agent versus biosimilar can be valuable for patients. Further cost effective adalimumab biosimilars have recently been launched. This seminal review emphasises the ongoing need for robust critical appraisals of biosimilars, with consideration for both clinical and cost effective parameters, before establishing their placement in treatment pathways.Acknowledgements:Mark Easter, UHCW and Interim Integrated Care System Chief Pharmacist, Hardeep Bagga, Deputy Chief Pharmacist, UHCW Pharmacy Homecare Team and UHCW Specialist Rheumatology, Gastroenterology and Dermatology Clinical Teams.Disclosure of Interests:None declared
Background:The Pharmacy High Cost Drug (HCD) and Homecare (HC) team, based at a large acute teaching hospital consists of a range of skilled pharmacists, technicians and administrative staff. The team act as a HCD liaison between the hospital and commissioners, working closely with an expanding variety of specialist clinical teams to manage prescription processing for the following patient groups; HC: 2238; Hospital FP10: 1060; Outsourced Subsidiary Pharmacy Model: 41. HCD management, particularly immunosuppressive biologic therapies for complex rheumatology conditions such as rheumatoid arthritis, has been challenging during the Covid-19 pandemic. The inelasticity in demand for better care closer to home and a functional Integrated Care Records system has intensified, as many patients are now shielding/self-isolating at home.1 Frugal innovations have been key during this time – achieving value and simplicity in service re-design to deliver better patient care.Objectives:This review explores the support provided by the Pharmacy HCD and HC team to the rheumatology service since March 2020 to aid in service improvements during the pandemic.Methods:The Pharmacy HCD and HC team reviewed existing practice to better respond to the service changes required during the pandemic in regard to the following areas; identifying patients for Covid-19 shielding; responding to changes in HC service provision; communication with commissioners; remote staff working; reviewing HCD formulations and administration routes; changes in commissioning arrangements.Results:i) Rapid development of patient datasets following identification of 1,623 immunosuppressive drug entries in line with BSR Covid-19 guidance (first published in March 2020), thus enabling social distancing/shielding guidance to be issued to patients via letters/virtual platforms.2 ii) Swift re-routing of urgent new biologic HC registrants to a new hospital pharmacy home delivery provision when certain HC providers temporarily imposed restrictions on intake of new registrants. This hospital initiative was further enhanced to a hub and spoke model enabling patients to have easy access to their medications from their nominated local community pharmacy branch. iii) Providing assurance to commissioners that clinical follow up reviews could continue virtually, blood samples could be taken at an external hub and blueteq documentation would be completed covering NICE technology appraisal (TA) criteria. iv) A successful pilot utilising the lean PDSA (Plan, Do, Study, Act) quality improvement methodology, to enable remote working pharmacists and technicians to process HC prescriptions remotely in the absence of an electronic prescribing and medicines administration system. v) Reviewing potential plans to switch certain hospital day-case intravenous biosimilar infusions such as infliximab to subcutaneous administration via HC. vi) Business contingency development plans to protect fragile medication supply chains. vii) Clarifying implications for changes in contracting and payment arrangements announced by NHS England and NHS Improvement due to the pandemic.3Conclusion:In summary, the role of the HCD Pharmacists during the pandemic in supporting rheumatology patients and the multidisciplinary team has been fundamental; ensuring signed prescriptions are securely processed to safely deliver medication to those in need.References:[1]NHS. The NHS long term plan. 2019. [Online].[2]British Society for Rheumatology (2020) Covid-19 - Identifying patients for shielding in England. [Online].[3]NHS. Revised arrangements for NHS contracting and payment during the COVID-19 pandemic. 2020. [Online].Acknowledgements:Mark Easter, UHCW and Interim Integrated Care System Chief Pharmacist, Hardeep Bagga, Deputy Chief Pharmacist, UHCW Pharmacy Homecare Team and UHCW Specialist Rheumatology Clinical Team.Disclosure of Interests:None declared
Descriptive weighted analyses were used to examine the trends in opioid prescribing practices for RA. Multivariable logistic regression was used to examine the factors associated with receiving opioid prescriptions among RA visits. Results: Overall, there were 4.45 (95% CI, 2.30-6.60) million adult outpatient visits annually with a primary diagnosis of RA. About one in five visits (21.53%) resulted in opioid prescriptions. The number of RA visits involving opioid prescriptions increased from 1.26
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