Hospitals are unable to stock certain drugs due to a diminishing budget for medicines, writes FIONA GARTLAND
A DECISION by the Department of Health to make the cancer drug Ipilimumab available was welcomed last week. But it is just one of many drugs doctors have been unable to prescribe for their patients.
Since January this year, the National Centre for Pharmacoeconomics (NCPE), which measures value for money, has assessed 16 drugs. Most were recommended for further evaluation, two were recommended for release and three were found not to be cost-effective.
Among those deemed not cost-effective was Rivaroxaban. It, and a similar drug, Dabigatran, are used to prevent stroke and embolism. Both are alternatives to Warfarin, which is cheaper and has been on the market for many years.
Dr Joe Galvin, cardiology consultant at the Mater hospital, says Dabigatran had been available until last autumn when it was withdrawn, except for patients already on it.
For most patients Warfarin is effective, Dr Galvin says, though it does require blood tests to control its levels. But for some, it causes bleeding and can be dangerous.
“I’ve had some patients who’ve had major bleeds even though they have been going to the Warfarin clinic [for blood tests],” he says. The drug can be affected by diet, Dr Galvin says, whereas Dabigastran is stable. He understands the financial constraints, but says it would be useful if there was some mechanism to petition the HSE on behalf of individuals who really need the drug.
Noel Horgan, consultant ophthalmic surgeon at the Royal Victoria Eye and Ear Hospital says he can no longer obtain Ranibizumab, used to treat patients with age-related macular degeneration and diabetic eye disease. Though it was available up to the end of last year, most hospitals in the country no longer stock it because of its cost.
“It is proven to be of real benefit in improving or preventing vision loss in diabetic patients,” he says. “There are young diabetic patients who are potentially at a disadvantage because of lack of access to it.”
Hospitals are taking another drug of similar chemical composition, used intravenously to treat cancer and still being purchased, and subdividing it into vials for use as an eye treatment. But it has not been licensed for that purpose.
He says there should be ring-fenced funding to treat people with the condition and better negotiation on pricing.
“At present, the best we can do for patients is offer them an unlicensed treatment,” he says.
Oncologist and Senator Dr John Crown says there are cancer drugs other than Ipilimumab that should be available, including Cabazitaxel, for treating prostate cancer. It was judged not to be cost effective by the NCPE in March this year. He says the model being used to assess cost effectiveness is flawed and simplistic.
“Cancer drugs should not be measured by cost per year of life saved. They should apply that to press secretaries and PR consultants and to Hiqa [Health Information and Quality Authority] before they apply it to cancer drugs,” he says.
Director of NCPE Dr Michael Barry believes we are going to see more and more pressure on the system as more high-cost medications come down the pipeline. “With a diminishing budget the real task is to satisfy patient demand,” he says.
There should be more use of performance-based risk-sharing schemes, he says, in cases where drugs are only effective for a small number of patients. A drugs company could pay part of the cost of treatment and the HSE could pay the remainder.
“If the patient is responding we’ll continue to pay; if not the HSE gets the money back,” he says.
Chief medical officer at the Department of Health Dr Tony Holohan believes prescribing should be reduced. We spend €2 billion a year on drugs, he says, and there is a wide variation in patterns of prescribing by GPs. The level of antibiotic and statin prescription, to reduce cholesterol, is “of concern” he says. And some GPs prescribe expensive brands when cheaper versions are available.
“There is a lot of expenditure that could be redirected to new drugs,” he says. There needs to be a “root and branch look at total expenditure” on drugs, he says, and evidence-based prescribing must be introduced.
We keep adding to the cost base, but no one would want to see services cut to fund drugs, he says.