Paying More For Less — The Challenge of Novel Drugs in Africans
I happened upon a pharmacy benefit manager in an African country that was helping Novartis push their new heart failure drug Entresto. In the article I saw, the theme was of Entresto being superior to Enalapril and that patients should have better access to it. Samples of the drug were seemingly being given to cardiologists who replaced Enalapril with Entresto in their patients.
The cardiologists would go on to inquire how their patient could afford the drug once the samples had finished. A credit agreement would then be offered to allow patients to pay in instalments for the drug. Amazing! finally, Africans now have access to blockbusting new drugs you’re wont to think. There is however one missing but vital question. Is Entresto instead of Enalapril actually cost-effective and the appropriate clinical thing to do?
Here’s a quick back of the napkin math and extra simplified analysis that suggests perhaps not.
Entresto costs about $30 for a month’s supply while Enalapril costs about $2 for the same duration. That’s a massive difference of $336 a year! Enalapril, the drug Entresto is looking to replace, reduces the risk of death and hospitalizations in patients with heart failure. To prevent 1 of the aforementioned events, 11 people would have to take the drug over 3–4 years. Entresto, on the other hand, has a superior value as shown in the trial published in the prestigious New England Journal of Medicine. The demonstration of this superior efficacy has won it top recommendation by several professional bodies. It’s now been given a prime position in newly issued guidelines.
Digging deeper, however, it may seem that the numbers aren’t as representative of Africans as they are of Caucasians, the primary study population. In the Enalapril study, around 15% of the participants were black, not a great proportion. Entresto was even worse, only 5% were black. Read black as African American, a group that is not even as genetically diverse as native Africans. So based on this alone, Enalapril’s efficacy is essentially more applicable to blacks than Entresto’s. Even more interesting is the forest plot for Entresto. When broken down by race, their own numbers show that this drug is simply not efficacious for blacks.
The highlighted row shows that Entresto crosses the hazard ratio line in blacks. This means that it cannot be said to be more efficacious than Enalapril in this population.
So imagine being saddled with $336 of debt for a treatment that’s not efficacious for you. This is essentially what is being promoted to African patients. With Enalapril on the other hand, the data for its efficacy is more representative and the treatment is dirt cheap.
Africans are overlooked in much of medical research. Newsweek recently covered this in a feature with a Nigerian born American medical researcher. His work has brought to light the value of looking at African DNA for new clues in the fight against cancer among other opportunities. We need regulators and professional bodies making calls that promote more inclusive drug testing and scientific research. Drug companies must be made to demonstrate specific benefit to Africans or do local African trials that show benefit before they are allowed a license for a drug. That a drug works for Caucasians does not mean it will work for Africans. Africans need to be able to trust that when a drug is recommended for an extra $336, there isn’t a better alternative that costs just $2.
First published on August 2018 at Health news Nigeria
Since this piece was published, a new startup, 54 gene, was founded with the purpose of providing African genetic material for pharmaceutical research.
Also Drugviu, a startup that provides medication Info, Reviews &
Discounts for Communities of Color in the U.S was selected into the 2019 Techstars impact accelerator class, highlighting once more the importance of this problem. Check them out.
