Highlights

• So, the majority of patients are started on a biosimilar TNF inhibitor, and until recently that would have been Benepali, so the biosimilar of etanercept, and that was pretty much all across the board unless there was a reason to use a different TNF inhibitor, such as if they had comorbid psoriasis, or uveitis, or inflammatory bowel disease, or something like that. However, since Humira came off patent in October, we have been using biosimilar adalimumab as well. So, I would say about half of our patients have gone on to biosimilar etanercept now, and half of them go on to biosimilar adalimumab.
• We do not really use small molecules neither first, nor second, or even third line because the price differential is so great. If we were to use a small molecule, it might be either baricitinib, or tofacitinib; those are the two JAKs available to us. Again, they are more than double the price of the biosimilars, and unless there is a very good reason for us to use it, like the patient really cannot tolerate injections, or cannot give it for themselves, or perhaps there is a past history of malignancy where we might choose a small molecule off license rather than a biologic therapy, then the majority of our patients would go onto injected biosimilar TNF, or rituximab.
• [A major unmet need] is the 30% of patients who do not respond to their first biologic therapy, so we are not particularly good at identifying patients in terms of which mechanism of action, or class they are going to respond to. It is all a bit hit and miss at the moment, so we need a much more stratified medicine approach, via biomarkers to precision medicine.