Medicines Management Programme Update

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1 Medicines Management Programme Update Sarah Clarke Chief II Pharmacist and Programme Manager Medicines Management Programme (MMP)

2 Millions ( ) The Medicines Management Programme (MMP) The Medicines Management Programme (MMP) was established in January Aim - sustained national leadership relating to Safe Effective Cost effective prescribing

3 Health Act 2013 Interchangeable medicinal products Reference Pricing Establishment of reimbursement list ( Executive may attach conditions to supply of listed items in the interests of one or more of the following: a) Patient safety b) Cost-effectiveness c) Maximise appropriate use of listed item d) Appropriately applying the resources available to the Executive

4 So what is being done? HTA to the patented side of the market % expenditure Reduce INN Generic 5% Branded Generic 7% Brand - off patent 10% expenditure in the off patent side of the market Prior to reimbursement approval For continued reimbursement approval Patent Brand 78% Generic Prescribing Biosimilars Hospital prescribing

5 Statins - SIMVASTATIN PPI - LANSOPRAZOLE ACE inhibitor - RAMIPRIL ARB - CANDESARTAN SSRI - CITALOPRAM SNRI - VENLAFAXINE OAC - WARFARIN (NOAC: APIXABAN) Antimuscarinics - TOLTERODINE SR

6 Most frequently prescribed medicines Acetylsalicylic Acid Atorvastatin Levothyroxine sodium Paracetamol Bisoprolol Calcium combinations Salbutamol (Inhaled) Esomeprazole Amlodipine Rosuvastatin

7 Statins April 2013 Simvastatin is recommended as the statin of first choice Over 310,000 patients receive a statin each month Approx 4.2 million statin prescriptions issued/annum Total expenditure exceeds 50 million/annum The calculated ingredient cost per prescription item for simvastatin remains the lowest in the therapeutic class

8 Proton pump inhibitors (PPIs ) April 2013 Lansoprazole is recommended as the PPI of first choice Over 265,000 patients receive a PPI each month Approx. 3.6 million PPI prescriptions issued/annum Total expenditure exceeds 55 million/annum Esomeprazole is one of the most expensive PPIs and accounts for over 32% of all PPI prescriptions

9 Inhaled medicines for Asthma and COPD There are over 50 licensed inhalers for asthma and over 25 licensed inhalers for COPD Expenditure on inhalers for asthma and COPD is approx. 98 million per annum ( 86 million GMS & 12 million DPS ). It is estimated that COPD accounts for 84% of this expenditure ( 82 million/annum )

10 Salmeterol + fluticasone (Seretide ) [34%] Tiotropium (Spiriva) [19%] Formoterol + budesonide (Symbicort ) [17.5%] Salbutamol [10%]

11 ICS and LABA inhalers for Asthma & COPD 50 million on ICS and LABA combination inhalers 44 million GMS 2.4 million/month Seretide (GMS only) 1.3 million/month Symbicort (GMS only) New products in this group including hybrid ( generic ) inhalers offer opportunity to reduce expenditure The Symbicort equivalent Bufomix (budesonide 320 µg + formoterol 9 µg) is 35% cheaper than Symbicort [ 42% cheaper than Seretide ]

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13 Most expensive medicines What are we doing? Adalimumab Biosimilars, hospital engagement Clinical nutritional products Primary Care review underway Etanercept Biosimilars, e-authorisation Atorvastatin Preferred Drug Initiative Salmeterol + other drugs for OAD Prescribing and Cost Guidance Formoterol + other drugs for OAD Prescribing and Cost Guidance Tiotropium Prescribing and Cost Guidance Esomeprazole Preferred Drug Initiative Pregabalin Review underway post HTA

14 Non-Vitamin K oral anticoagulants (NOACs) Oral Methotrexate Preferred antibiotics in Primary Care Valproate project underway Available on:

15 Non Vitamin K Oral Anti-Coagulants (NOAC s) Apixaban (Eliquis ) Rivaroxaban (Xarelto ) Edoxaban (Lixiana ) Dabigatran (Pradaxa )

16 Patients 40,000 35,000 Total number of patients on anticoagulants under the GMS & DP schemes from January January ,722 30,000 25,000 Warfarin: 26,296 Dabigatran Rivaroxaban Warfarin Apixaban Edoxaban 20,000 15,000 10,000 5,000 0 Rivaroxaban Apixaban Dabigatran Edoxaban

17 1,200,000 Total expenditure on anticoagulants under the GMS & DP Schemes from January November ,000, , , ,000 Dabigatran Rivaroxaban Warfarin Apixaban Edoxaban 200,000 0

18 0% 0% 9% 4% Dabigatran Rivaroxaban Warfarin Apixaban 87% Edoxaban Proportion of patients on anticoagulation January % 0% 9% 26% Dabigatran Rivaroxaban Warfarin 49% Apixaban Edoxaban Proportion of patients on anticoagulation January 2016

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22 Eculizumab (Soliris ) Paroxysmal Nocternal Haemoglobinuria(PNH) Atypical Haemolytic Uraemic Syndrome (ahus) 430,000+/patient/year Clinical review of applications for centralised reimbursement and outcome follow-up Ongoing follow up for clinical information

23 Jan-12 Mar-12 May-12 Jul-12 Sep-12 Nov-12 Jan-13 Mar-13 May-13 Jul-13 Sep-13 Nov-13 Jan-14 Mar-14 May-14 Jul-14 Sep-14 Nov-14 Jan-15 Mar-15 May-15 Jul-15 Sep-15 Nov-15 Versatis 5% Patch monitored by MMP 3,000,000 2,500,000 2,000,000 1,500,000 Total Expenditure on VERSATIS, GMS and DP NCPE HTA review Cost-effectiveness was not demonstrated 1,000, ,000 0 Price reduction was agreed MMP Prescribing Tips and Tools

24 Collaborations Rheumatology Diabetes Epilepsy/ Neurology HCAI/AMR Mental health

25 Blood Glucose Test Strips Total expenditure in 2014: 46.8million 26 individual test strips reimbursed International evidence suggests limited clinical benefit for type 2 patients not on insulin NCPD published new guidelines in 2015 MMP recommendations went live April 2016

26 Medicines Management Roadshow since 2014 GP and Nursing meetings

27 2016 and beyond Measurement of health outcomes in the clinical setting Use of fampridine for multiple sclerosis Use of eculizumab for PNH and ahus Failure of any technology to deliver satisfactory health outcomes should prompt a discussion around price reduction/disinvestment Oral nutritional supplements in the community setting Use of drugs such as pregabalin, versatis patch Supporting the use of biosimilars e.g. Adalimumab & Etanercept Hospital prescribing High Tech medicines e-authorisation processes (PAH, MS)

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