Disclaimer : This is my best availaible knwoledge on this subject. Don’t take a treatment decision or judge by this post alone. Do your own enquiry and talk to your doctor before taking a treatment decision. Remember these are complex diseases. This is just a general guide as I see many patients dont take these drugs because of costs. But as you will see, costs can be managed for many in the long run. Also, if you are healthy, you can probably earn better.
Most doctors do not loot patients (yes its true). Its impossible for busy rheumatologists to explain this much in detail in a clinic. They hence ending up prescribing one biologic over another. Also I have seen, when I discuss so much about costs to patients, they feel I am marketing for these companies and they dont’t return back (It hurts when they don't return, specially when I put an hour to give them most cost effective option in 500 rupees, besides treating them too :)
You should always make decision with your rheumatologist. I believe in giving information to patients, better information empowers patients to make better decisions. Don’t misuse this information with half understanding to blame or fight with your doctor.
Biologic drugs have radically changed the way rheumatology or autoimmunediseases can be treated in India.
Psoriasis, Psoriatic arthritis and Ankylosing spondylitis are autoimmuneconditions that can be treated by same three biologic drugs -
Infliximab , etanercept and adalimumab.
These three drugs work the same way. They are called anti TNF drugs as they block TNF which is increased in these conditions.
There is no difference in how they work.
Chosing between them depends on cost involved, doctor prefernce or experience. Some feel that etanercept may be slight weaker than other two, but in most cases all three work equally. However despite similar way of action, they are different molecules. One might work and other might not.
But usually all three work quite similarly.
All these drugs were originally invented around 20 years ago. The biologic drugs are very complex drugs. Initially due to patent law, there was only one brand worldwide for each molecule. Now as their patents have expired new copies of these drugs by Indian companies have come into the market. They are known as biosimilars.
What is the difference between invented molecular (original biologic) and biosimilar. Doesn’t biosimilar mean generic drug?
Biologic drugs are complex drugs. You can’t really make an exact similar copy of it. Simple drugs like paracetamol are very easy to replicate and hence their copies are known as generic drugs which are exactly same as original drug.
Biologic drugs are very difficult to replicate and hence their copies are known as biosimilar drugs, meaning they are similar, but not exactly same.
Also, since biological drugs were originally invented molecules, they usually have very large companies and solid data behind them. Many biosimilar drugs in India might not have rigorous safety data.
But in real life the effect of both appears to be very similar. Since biosimilar drugs required copying rather than inventing something new, they can afford to be much less costly.
2. Which biologic drug to use for above diseases in India ?
All 3 types currently available in India might be used. They have similar results.
When one doesn’t work, other can be tried.
I try to choose the biologic in most cost-effective manner possible for patients, as there is no difference in how they work.
3. Why I have to be careful of costs of biological drugs in India ? I have adequate insurance, it should cover it.
Biological drugs are expensive and usually required long term. The insurance coverage might not be enough to cover you, you might exhaust family insurance.Most insurance companies exclude arthritis in their diseases covered. Only group insurance (if you work in a company) might cover arthritis.
4. Why my insurance company doesnt reimburse my biologic drug costs for my arthritis treatment in India?
Arthritis are chronic diseases, its very costly for insurance company to cover them.
Insurance coverage in India is quite low, companies cannot afford to cover chronic diseases. Most insurance companies have MBBS, BAMS doctors screening claims request who themselves don’t know what biologics are.
Awareness of arthritis and rheumatology in India is very poor. So cancer, diabetes, kidney diseases being chronic diseases are covered, but many a times arthritis or autoimmune diseases are not.
Also arthritis will be usually there lifelong. It occurs many a times in young people. These diseases usually don't decrease life expectancy of a person (fortunately for patients, but unfortunate for insurance companies ).
So insurance company will have to pay lifelong costs for patient, they simply cannot afford this, because insurance coverage is very low in India with high number of claims. Cancer, diabetes, kidney disease occur in older people, with much less likelihood of repeated claims in very long run.
24 hour admission criteria
Most biologics might not require infusion or admission. Hence insurance company which usually cover costs only after admission, will reject claim of biologic drugs. Also it is poor awareness. They might cover cancer chemotherapy or cancer biologics if its less than 24 hours admission, because of footage cancer awareness gets. But they won't cover arthritis biologics because of poor laws and attention of it.
Below is summary of bilogical drugs, their brand names and their approxmate costs as of this date.
I have given costs per month, per year. Remember that these injection doses can be decreased in the long run in many patients. If that becomes the case the costs do come down. I have also given down the costs if dose is reduced. I have also given cost advantages and disdavantages of each drug. I am repeating no drug is better than other, the cost and technique of recieving injections can help you to discuss with your doctor and choose one accordingly.
Infliximab
Etanercept
Adalimumab
3. It is confusing. In short how to choose a biologic drug for my disease in cost effective way ?
To make it short following points can help you choose a biologic for your disease
1) If patient weight is less than 60-70 kg and biologic is required for long run Infliximab (any brand) might become the cheapest.
2) If patient has insurance cover, which covers only admission, infliximab might be preferred again (as it needs to be given after admission).
3) If somebody is not sure about biologics, wants to start with low costs and likely to not require biologic long term, etanercept (any brand) might become preferable cost wise. Also Etanercept has same dose in any weight. Etanercept might be slightly less effective for Psoriatic arthritis patients.
4) If long term biologic drug therapy is required, with ease of taking injections at home and also if patient is higher weight, adalimumab (exemptia) might become preferable cost wise (explanation given above in cost advantage table of adalimumab)
4. What if you cannot afford or fail biologics for ankylosing spondylitis ?
This article might help
Do watch for further article about autoimmune conditions and arthritis
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