NICE restricts rheumatoid arthritis treatment options
Submitted by THE HEALTH ECONOMICS BLOG
Scrip
Patients with refractory rheumatoid arthritis in the UK who previously had the option of
three treatments will now have the option of just one, a draft appraisal from NICE has
recommended.
Patient groups and charities have reacted strongly to the final appraisal determination,
considering it tantamount to greater suffering for patients, a diminishment of treatment
options and “a lack of interest in patient quality of life”.
Treatment for RA is currently spread across three main anti-tumour necrosis factor (anti-
TNF) products available on the NHS: Wyeth’s Enbrel (etanercept), Abbott’s Humira
(adalimumab) and Schering-Plough’s Remicade (infliximab). These can be used
sequentially to treat RA, replacing initial or second anti-TNF treatment if they are found
to be, or become, ineffective.
However, the NICE draft will limit this to one anti-TNF, with only one additional
treatment, Roche’s B-cell targeting therapy MabThera (rituximab). Rituximab was
previously offered alongside Bristol-Myers Squibb’s Orencia (abatacept) after the initial
three RA treatments proved ineffective. Abatacept was not recommended for NHS use in
April after NICE decided that it was not cost-effective, despite an appeal against the
decision (Scrip Online, April 24th, 2008).
The NICE draft examined data available on clinical effectiveness of the three anti-TNFs,
the nature of rheumatoid arthritis, and the value placed on the benefits of treatments by
people with RA, those who represent them and clinical specialists. It also examined
“effective use” of NHS resources and cost-effectiveness of the drugs, with their cost
estimated in some cases by use of figures in the British National Formulary to reach net
annual totals of £9,295 for adalimumab, £9,295 for etanercept and £8,812 for infliximab
per patient.
In a letter of response to the committee’s decision, The National Rheumatoid Arthritis
Society has argued that successful treatment with anti-TNFs cannot be predicted in
individual patients, resulting in it being “vital” to provide a number of treatment options
for the disease.
Arthritis Care agreed, arguing RA patients were “step by step having their choices
limited and will be missing out on therapies which could have a profound effect on their
quality and length of life.” They also pointed to the continued sequential use of anti-
TNFs in other EU nations, arguing the NICE decision would “[go] against the grain of
policy in Europe”, rendering England the “poor man” of Europe for RA treatment.
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July 27th, 2008 at 9:58 am
No doubt about it, many of the decisions made by NICE are
controversial to say the least. The title is National Institute for
Clinical Excellence, but as far as I can see one its main functions is
to limit government expenditure on expensive drugs. This is done on
the grounds that they are considered (by NICE)to be ineffective in some way, or
not effective enough from the cost point of view. Couple this to the fact that there is a post
code lottery for drugs like anti tnf inhibitors, even when NICE has
approved them, and you get a picture of inconsistency in the supply and
allocation of these drugs in the UK.
Socialised medicine (the NHS) certainly does not mean universally excellent free
medicine and it looks as though NICE is steadily eroding many patient’s access to effective treatment through limiting their clinician’s choice of available drugs.
NICE is wrong and inhuman to prevent those with severe Rheumatoid Arthritis from
having a try at a second anti tnf inhibitor, just because they failed
the first. If these people qualified for the drug in the first place
(after trying all the other dmards) the expense has already been
approved in principle, so it costs no more if they are put on another anti tnf. Nobody can predict in advance how a particular patient will react to a drug and it flies in the face of clinical experience to deny the opportunity of a second try.