As with many other aspects of clinical practice, the impact of COVID-19 on prescribing patterns appears to have accelerated pre-existing trends rather than radically shifting them in a new direction.
The particular trend in question has been a marked tendency towards community-based prescribing, with drug regimes that need to be administered intravenously declining in popularity during peaks of the pandemic as outpatient clinics were closed or scaled back.
So what does this mean for pharmaceutical companies looking ahead to 2021?
For this article, we’ll look at three key disease areas in particular: COPD (chronic obstructive pulmonary disease), rheumatoid arthritis and multiple sclerosis. In each case, we’ve sought to understand which drug types have been the winners and losers in terms of usage over the last nine months – and crucially whether the trends tell us anything significant about more lasting shifts in prescribing habits across these different care pathways.
COPD: a stabilising mission
It is well-established that during the first wave of COVID cases COPD patients were actively discouraged from attending hospital-based clinics and almost exclusively managed in primary care.
Some patients used existing medications and bronchodilators under GP supervision; others were switched onto treatment plans that could be safely administered through primary care alone.
We see this echoed in prescribing data, with figures for hospital prescribing going down marginally in the spring, before reverting to normal over the summer as clinics reopened.
In some respects, the story here is unremarkable, given the starting position of the vast majority – 98% – of prescriptions already being administered in primary care. As such, the net effect of the pandemic was marginal.
There is a slight wrinkle in that the early trend for a slight dip in hospital-based prescribing was not matched by an associated rise in the number of prescriptions administered in primary care. That may suggest a small care gap opening up at the outset of the pandemic, but it is difficult to assess the scale and impact of this given the relatively small numbers involved.
What it underlines for COPD is that the pre-eminent model for prescribing remains primary care-led, with the response during the first wave being focused on stabilising the individual in a COVID-safe way. Both national policy steers towards community-based care and the clinical guidelines around insulating this particular patient group from hospital-acquired COVID infection mean that this is unlikely to change heading into 2021.
Rheumatoid arthritis: the triumph of generics
Rheumatoid arthritis offers a more interesting picture. Here we see a significant rise in prescribing rates for biosimilars. From March 2019, use of on-patent etanercept, adalimumab and rituximab went down and, at the same time, the adalimumab biosimilar went up and so did etanercept and rituximab biosimilars.
The pattern is obvious: as these generic biologics get approved, then branded biologics go down and the benefit is that the arthritis pathway has become cheaper to run.
A challenge for pharma now is how to capitalise on this knowledge in the new integrated healthcare systems. Some ICSs (integrated care systems) may not have a particular rheumatoid arthritis pathway and may have a workstream to look at all older patients, many of whom will have rheumatoid arthritis.
The key commercial question heading into 2021 will be discovering who best to talk to about the treatment of rheumatoid arthritis and the impact of biosimilars within their patient communities.
In theory, the system should have more money to spend as there should be cost savings and this may open up opportunities to invest elsewhere in the rheumatology pathway, or maybe elsewhere in the older people workstream. So where is the opportunity and how could your offer fill that gap?
Multiple sclerosis: resolving the mystery
Finally, multiple sclerosis presents a more challenging story for pharma. Between May 2019 and May 2020, there has been a reduction in several key treatments: Lemtrada, Tysabri and Gilenya.
Lemtrada is a monoclonal antibody (MAB) given by infusion. Tysabri, or natalizumab, is also an infusion injection. For both of these treatments, the prescribing figures are down.
So why are these two going down? Almost certainly it is because the way they are administered. They would not have been able to be given to multiple sclerosis patients during the initial phase of the pandemic, which is reflected in the patterns across our data.
The mystery though is what happened to these MS patients in the meantime? How are they being managed and what have they been switched to, if anything? Our initial instinct was that the orally administered Gilenya had picked up the slack, but we found that this also down -0.6% during this time frame.
Yet, Gilenya aside, we find the medications that are trending upward were orally administered, which demonstrates that there is market leverage in having an oral alternative to biologics and biosimilars.
An important driver for this is surely the NICE (National Institute for Health and Care Excellence) rapid response guidelines, which made it clear that vulnerable patients should be switched to oral or subcutaneous or homecare-based medications where possible. The question is how much, if at all, we see the re-emergence of intravenous treatment as the pandemic subsides.
More pertinently, we also need to confront the possibility that some MS patients may have experienced poorer clinical outcomes as a result of being shifted away from established drugs during the peak of the first wave.
Conclusion
Applying the spotlight to these three specific disease areas is obviously selective, but it does start to build a more universal message about the importance of looking into the nuances of prescribing patterns going into 2021.
The fuller research we’re conducting – which will feed into a detailed white paper in the new year – suggest that pharmaceutical companies need to be very sensitive to the issue of pandemic-led changes to care pathways potentially leaving patients facing sub optimal treatment plans.
Yet there is also the prospect that wholesale shifts in prescribing, notably from branded to generic medicines, could open up significant cost savings – and with this may come potential opportunities for new investment in novel treatments elsewhere in a care pathway.
And in this environment, pharma companies need to think strategically about where else could be further openings as more financial headroom opens up for fund-holding bodies. Are there ways in which your products could improve the overall service for patients in that pathway or even in that wider health system, because the money can be spent on something else? Or at the very sharp end, if you have an on-patent drug on your books and you experience a sustained drop in sales, are there conversations to be had about whether patent biologic medicine could be used on other patient cohorts within the same pathway?
Here’s one final reflection: while the pandemic has clearly left its mark on prescribing patterns, it is worth noting that not all of these trends are driven wholly or even partially by the health emergency we experienced in 2020.
Many of these patterns and nuances will persist into 2021 and beyond, and only serve to underline the importance of understanding the perspective of purchasers in new integrated system. Companies that understand the new NHS landscape and can engage in holistic conversations with the new systems about how their product range can improve outcomes across a whole pathway – or even at population level – will stand the best chance of success.
Oli Hudson is content director at Wilmington Healthcare
