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AMA

I'm a Health Economist (I submit new medicines to NICE for use on the NHS) AMA

45 replies

QALY · 14/11/2018 00:01

I work in the pharmaceutical industry and quantify the long term medical outcomes and economic case to NICE and other Health Technology Assessment bodies in Scotland (SMC) and Wales (AWMSG) with the aim of getting a positive recommendation and reimbursement for the new medicine for use within the NHS. I have worked on a number of cancer drugs as well as drugs for other non-cancer medical conditions.

Ask me anything and i'll do my best to answer your questions.

OP posts:
QALY · 15/11/2018 21:14

Faintly

I can't see them listed on that site, but I know they've been very transparent and vocal about all pharma being so for many, many years. They have reported all of their trials on clinicaltrials.gov since the early 2000s and also similar EU-based registers.

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IndigoHen · 15/11/2018 21:21

What are your views on CBD oil? My mother claims that it works for cancer too but because pharma won't profit from that, they won't investigate further. Is there even an ounce of truth in that?

IndigoHen · 15/11/2018 21:21

Have you come across any cure at all for endometriosis?

QALY · 15/11/2018 22:04

Indigo

I have no knowledge of CBD oil except the recent news about confiscating it at customs from the poor children with epilepsy or endometriosis treatments. The company I work for doesn't conduct research in these areas.

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QALY · 15/11/2018 22:07

Faintly

I followed your link to alltrials and then looked at the BMJ series of unreported trials and their database. Pleased to report that all trial results have been reported. Two were reported late. blogs.bmj.com/bmj/2018/03/29/it-is-time-to-fix-the-problem-of-unreported-clinical-trials/

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PerkingFaintly · 15/11/2018 22:39

QALY, that's really encouraging to hear.

RosieStarr · 16/11/2018 12:13

Do you get frustrated when you hear about people pushing ‘alternative medicine’ (eg. Homeopathy) for use on the NHS?

TakeAChanseyOnMe · 16/11/2018 12:39

How do you see the future of affordability with the increasingly complex and therefore more expensive drugs coming to the market? What comes to mind is antisense nucleotide treatment for SMA1 which has been declined by NICE as it’s £500k for the first year for the drug alone.

Immunotherapy has revolutionised cancer treatment (especially melanoma) but also at great cost. What’s your experience with this?

The increasing production of biosimilars for monoclonal antibodies is looking good, big savings as they’re used in multiple specialties. Increasing indications seems to bring the price down too as rituximab is “only” about £3k a course now I believe? (So obviously there’s now a humanised version that’s many times the price).

The people who say “oh the drug companies won’t look at this because they can’t make money for it” - they’d find a way! Often it’s a combination with another drug (see cardiac and blood pressure treatments) or a new device (inhalers - the drugs might be out of patent but the device isn’t).

QALY · 16/11/2018 20:03

Rosie

Actually I see a few sides to this issue! On a purely health economic perspective, I used to get really wound up about homeopathy specifically being funded on the NHS because of the lack of evidence and the fact that because its use is established it doesn't face the same scrutiny in terms of clinical and cost-effectiveness as conventional/new medicines.

From additional perspectives, I think the actual cost of homeopathy is a fraction of NHS costs and there is probably a lot more waste of resources elsewhere in the NHS and probably has a decent placebo effect if nothing else.

And it's generally considered safe, if not actually effective beyond placebo effect . I know of someone who uses a homeopathic anti-malaria remedy instead of conventional antimalarials and I think he's bonkers In this clinical situation I'd want to be relying on a randomised clinical trial that demonstrates clinical efficacy. It's one thing taking homeopathic remedies for self care of self-limiting minor symptoms but another altogether relying on it to prevent a potentially life-threatening condition.

But, the NHS has limited funding, so I feel that treatments with more robust evidence should take priority, because for every £ we spend on something that money isn't there for something else. There is always an opportunity cost so to be responsible for society as a whole, in terms of getting the best patient health outcomes within the budget, we should be choosing to invest in the treatments that have the most robust evidence and are also cost-effective.

And then again, I know there are many potential treatments that don't have or can't have the gold standard in terms of evidence base. E.g. very rare diseases, old medicines off patent being used in new clinical areas but without the backing of pharma to fund new studies, etc.

And I also think that western medicine is catching up with Eastern medicine and while we dismiss stuff as not being evidence based, it may simply be that we don't yet have the science to understand it or no one has bothered to do the science yet. I think the ancient wisdom of Chinese and ayurverdic was based on observation and there's a lot to be said for that. But these days, it's dismissed as anecdotal and society demands more robust evidence. I recall seeing a fascinating programme a few years ago about acupuncture being tested in a functional MRI machine, which showed that it was effective for pain relief, but only if the needles were inserted in the right place, at the right angle and depth according to standard practice. It would be easy to poo-poo it without this scientific evidence of efficacy. I'm sure it was only n=1, but that allows a hypothesis to be tested and an evidence base developed with time and funding.

So, I guess what I'm saying is that I feel a tad conflicted!

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QALY · 16/11/2018 20:42

Chansey

How do you see the future of affordability with the increasingly complex and therefore more expensive drugs coming to the market?

NICE recently introduced the budget impact test to help address the affordability issue. This was a real issue for the new treatments for Hep C that were cost-effective but not affordable without significant impact on existing services. This allows the NHS to implement new treatments in a more sustainable way.

Immunotherapy has revolutionised cancer treatment (especially melanoma) but also at great cost. What’s your experience with this?

I agree that immunology and new targeted treatments have revolutionised treatment. Many conventional chemotherapy drugs are only effective in a small proportion of patients and there is no way of knowing which patients will respond to the drug so it's given to everyone and priced accordingly. Once you get drugs that are more effective and can be targeted to fewer patients with a better response rate, naturally the price will go up as it will still have cost as much to on average develop the drug and so the costs need to be recouped from fewer patients.

The increasing production of biosimilars for monoclonal antibodies is looking good, big savings as they’re used in multiple specialties. Increasing indications seems to bring the price down too as rituximab is “only” about £3k a course now I believe? (So obviously there’s now a humanised version that’s many times the price).The people who say “oh the drug companies won’t look at this because they can’t make money for it” - they’d find a way! Often it’s a combination with another drug (see cardiac and blood pressure treatments) or a new device (inhalers - the drugs might be out of patent but the device isn’t).

The patent issue is hugely complex and these scenarios are downstream of this. I always find it bizarre that a songwriter will get royalties for life on a song they've written. But a new drug is patented from discovery and by the time it gets to market it will have cost billions to develop and '000s of other drugs will have fallen by the wayside so there are often less that 10 years for the pharma company to recoup the development costs for their whole pipeline, not just the one successful drug that makes it. So creative patent extensions become commercially necessary to generate the profits needed to invest in the future pipeline. No wonder Governments don't fund the majority of drug research!

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pitterpatterrain · 16/11/2018 20:52

What do you think about the increasing push/trend for EMA to approve drugs with phase 1/2 data?

QALY · 16/11/2018 21:04

Rain

It brings a lot more uncertainty in terms of clinical efficacy (wider confidence intervals) and cost-effectiveness for starters, but also more risk as there will typically be fewer patients and less chance to observe adverse events.

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ToteBags · 10/12/2018 11:18

How much do you earn?

ViragoKnows · 14/12/2018 11:14

.

ClaryFray · 14/12/2018 16:51

Why was essure passed when it's caused so many women long term health problems?

QALY · 15/12/2018 21:57

Clary
Sorry I don't know anything about Essure, but NICE's role is to look at the cost-effectiveness of medicines that have been approved by the MHRA. The MHRA determines the benefits & safety to grant a licence.

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QALY · 15/12/2018 22:01

Totebags

Salaries vary depending on experience and employer. Starting around £40k entry level in the public sector. Pharma can be much more depending on experience & role.

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TakeAChanseyOnMe · 16/12/2018 17:29

On a more light hearted note, how much does the media’s portrayal of new drugs annoy you? Like talking about some breakthrough like it’s new but it’s been widely known about for years. The sodium valproate and pregnancy articles come to mind as a recent thing.

QALY · 16/12/2018 20:18

Chansey

On a serious note, the sodium valproate and pregnancy articles have been prompted by yet another MHRA safety update published in April 2018: www.gov.uk/drug-safety-update/valproate-medicines-epilim-depakote-contraindicated-in-women-and-girls-of-childbearing-potential-unless-conditions-of-pregnancy-prevention-programme-are-met

Yes, it's been known of for decades, but still being prescribed to women of child-bearing age without adequate counselling and pregnancy prevention in place to avoid totally avoidable teratogenic side effects.

On a lighter note, the media simply regurgitate the PR issued by pharma or academia. Rarely is new clinical trial data critiqued adequately by journalists.

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TitsalinaBumSquash · 16/12/2018 20:42

Interesting job OP, thanks for starting this thread.

Have you heard about the VERTEX/NHSE Orkambi / pipeline deal saga currently going on for CF patients?
Whats you're take on it?
Also how do you feel about people saying that for targeted, precision medications, NICE's assessment process isn't fit for purpose?

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