British Columbia Moves Into Third Phase of Mandatory Switching

The first of the Canadian provinces to implement a mandatory biosimilar switching policy, British Columbia (BC), has initiated a new phase of the program this month. Residents enrolled in the PharmaCare prescription coverage plan who are receiving the reference version of rituximab (Rituxan) will be switched to 1 of 3 biosimilar versions (Truxima, Riximyo, Ruxience).

On the cusp of the transition, officials in the BC public health system touted the success of their biosimilars switching program thus far, saying it had saved millions of dollars that were plowed back into other health initiatives that have improved access for many patients of the Pacific Coast district, which has roughly 5 million residents.

“We have seen great successes with our Biosimilars Initiative, with thousands of patients transitioning to safe and equally effective biosimilar drugs,” said Adrian Dix, minister of health.

Mandatory switching programs in Canada have not met with unanimous support, as many residents and patient advocates have expressed concerns about what switching may mean for the stability of their managed conditions. Health officials in Canada, however, say they remain confident in the medical science that supports biosimilars as equivalent in safety and efficacy to their reference products. The BC PharmaCare system does allow for exceptions to mandatory switching.

“We take great care here in British Columbia to examine the evidence thoroughly,” Dix said.

Phase by Phase

In the first phase of the program, which began in May 2019, patients were switched from etanercept, infliximab, and insulin glargine reference products to biosimilars. These switches occurred only for patients receiving treatment for ankylosing spondylitis, rheumatoid arthritis, psoriatic arthritis, plaque psoriasis, and diabetes (type 1 and type 2).

In the second phase, which began in September 2019, patients with Crohn disease and ulcerative colitis were switched from reference infliximab to biosimilar versions.

The current switch to rituximab biosimilars, which constitutes the third phase, affects patients undergoing treatment for granulomatosis with polyangiitis, microscopic polyangiitis, relapsing-remitting multiple sclerosis, and rheumatoid arthritis.

Dix said that biosimilars cost 25% to 50% less than biologics, which account for the largest slice of the health-spending pie, so the 15-month-old switch to biosimilars in BC is already paying off with huge savings. In 2018, BC spent $84.2 million on reference infliximab, so the incentive to switch to biosimilars was very strong.

“This work is allowing us to put another $30.7 million over the next 3 years, in addition to the $96.6 million from earlier phases of the Biosimilars Initiative, back into BC’s health care system,” Dix said.

On the whole, biosimilars have barely penetrated the health care system in Canada, where they have an 8% use rate. Dix noted that countries that are furthest ahead with biosimilars enjoy usage rates from 50% to 95%.

Switching by the Numbers

Nevertheless, in BC, the switching rates achieved through the Biosimilars Initiative are impressive. Among PharmaCare patients who were taking etanercept reference product, 85% have switched to Brenzys or Erelzi. For patients taking Remicade for nongastrointestinal and gastrointestinal issues, 84% and 78% have switched, respectively; and 71% of patients have been transitioned from Lantus to Basalgar for their diabetes conditions.

In the United States, by contrast, biosimilars account for just 2.3% of spending in the biologics marketplace, according to a recent presentation by Juliana Reed, MS, a vice president and Global Corporate Affairs lead for Pfizer; and biosimilar infliximab accounts for just 8.5% of the infliximab market, according to Wayne Winegarden of the Pacific Research Institute. Filgrastim biosimilar sales in the United States are highly advanced, relative to other biosimilar products. They amount to 50.4% of expenditures for infliximab.

The May 2019 phase 1 transition involved 20,700 British Columbians and allowed them 6 months to work with their health care advisors to transition from originator products. Phase 2 involved 2000 patients, who were given the same transition time. The current, rituximab changeover also involves a 6-month deadline—until February 2021—and roughly 1600 patients.

The savings have not only made care more affordable, but also broadened access to care in BC, Dix said. “The savings have allowed expanded coverage of treatments for chronic obstructive pulmonary disease and attention deficit hyperactivity disorder in adults, and treatments that mitigate the risk of heart attack or stroke.”