P48 The puppet prescriber or custodian of the NHS purse: are patients really at the centre of what we do?
Authors: Smith Liz , Rangaraj Satyapal , Deepak Samundeeswari , Camina Nicola 
Published: October 2019

Abstract

Background
Biologic therapies have revolutionised the management of patients with rheumatological conditions; with considerable cost to the NHS. The switch of originators to biosimilar products was challenging. We aim to share our experience of adalimumab biosimilar switch and believe this is reflective of the challenges experienced in some other centres.
The development of biosimilar aims to challenge the excesses of pharma profits by encouraging competition in the market place. Previous switches to intravenous biosimilar products had been uneventful. We were informed that the trust was implementing switch of biologics to biosimilar and later told biosimilar A was the biosimilar version allocated to us. This was a decision beyond the Trust, with NHS England deciding on the allocation. For our Trust, biosimilar A was allocated for patients weighing 30kg requiring a 40mg dose and biosimilar B allocated for patients weighing less than 30kg requiring a 20mg dose (NB: no 20mg preparation available for biosimilar A). Patients commenced on biosimilar B 20mg preparation can remain on biosimilar B and move on to its 40mg preparation once they weigh 30kg. Biosimilar A, the cheaper of the two preparations, contains preservative, citrate. Both biosimilars are double the volume of the originator biologic.

Case
a biologic-naïve 16 year-old patient was the first to be treated with the chosen biosimilar A, and, upon self-administrating; the patient clearly expressed a high level of pain. Following the experience with the patient the team felt that this was not an appropriate option.

Methods
With the feedback from the patient, rheumatology team highlighted the issues and focussed on high quality patient centred care not just focussing on the short term cost saving option but understanding that the patient engagement and compliance is cost saving in the long run. The team enquired with other specialities and regional paediatric rheumatology centres regarding their biosimilar switch.

Results
Liaising with the High cost pharmacy team, we successfully obtained authorisation to prescribe biosimilar B. We promptly switched the patient to biosimilar B and prescribe this now for all suitable to switch and new patients. So far there have been no negative comments or issues from the switch to the citrate free product.

Conclusion
It is vital that we provide an evidence based cost saving medication to treat children with long term conditions. However when new medications are being introduced, there needs to be greater consideration for the paediatric population which currently seems lacking. Collaborative working with the high cost pharmacy team, regular communications with other specialities, adult colleagues and involving the national nurse specialists group greatly benefitted us in managing this situation. More studies are required to identify patient factors involved in these scenarios.

Conflicts of Interest
The authors declare no conflicts of interest.