Highlights

• Yes, absolutely, RA has a lot of choices in terms of drug treatment options, and patients prefer subcut, but we as commissioners obviously would also prefer subcut because there is an administration fee for giving an IV, which is charged to us, so yes, on the whole subcut or even if you mentioned oral, it would be the JAK inhibitors these days, and they have taken quite a significant market share already, so yes, subcut over IV, and then potentially oral over subcut.
• Yes, some of them have discounts, they have PAS, not all of them, but yes, we have a PAS for the JAK inhibitors, the newer ones, but obviously the anti-TNFs now are biosimilars, they are reference priced, or tender priced, and for the ILs it is list price.
• I think confidence has grown now, so if you are coming to the market now with a biosimilar, we have reference price, we have national targets around the percentage of patients that should be switched and initiated on biosimilars, and in most areas there is little resistance from clinicians now because we have the clinical experience with them. The only challenge we had was with one of the adalimumab biosimilars that contains citrate, so it meant that it was a more painful injection for patients because Humira originally had citrate, but then they modified the formulation so it was less stingy. However, patients then complained when we gave them a biosimilar that was stingy again because it had the citrate in. So, that has been a challenge, and it was a fair challenge because we ended up switching again to a different biosimilar that did not contain citrate. So, yes, excipients do become important, and that’s probably the only barrier that we recently had, not biosimilars in general, but any differences that the patients may notice between the two molecules, not the two molecules, the two preparations.