Management of chronic myeloid leukemia in 2023 – common ground and common sense

Great article. Thanks for posting.

One terribly depressing observation I have of this is that while dose modification is entirely sensible, there is absolutely zero incentive for a pharmaceutical company to play along with this.

It even gets down to the point that while ponatinib is indicated with a starting dose of 45mg, everyone knows 15mg is really the place to start. But Takeda can’t say it, they can only “nudge, nudge, wink, wink” to suggest it. I think even legally that they can’t suggest starting below the approved indicated dose, and the sensible doctors prescribing 15mg are doing to “off label”.

If BMS argues that 50mg of dasatinib was actually better all round than 100mg, they are leaving money on the table because charges are milligram based not amount of doses based.

I don’t have a neat answer, but drug development needs to be incentivised to the best outcome for the patient not just how much they can sell. Maybe a manufacturer should be paid just as much for a patient in MMR who takes 20mg as for one who takes 140mg. I am sure this isn’t the answer, but you know where I am getting at.

I have long held the opinion that dose optimisation is more important than TFR because there is a much much bigger cohort of patients who could benefit.

David.

The pricing of drugs is a dark art as many of us have experienced. But in my discussions with pharma companies (at the business level), drugs (TKI's, etc.) are not priced by the 'milligram'. The cost of a 100 mg subscription vs a 50 mg subscription is the same in so far as there is a recognition that buying 100 mg enables someone to get "two 50 mg" out of it, so a patient is better off getting the 100 mg prescription and getting twice the amount for a 50 mg use. This is what pharmaco's are concerned about. So in a way, David's point is very valid. This is also why pharma company's price these drugs such that the incentive to buy 100 mg for a 50 mg prescription costs more. It disincentivizes purchasers from doing this.

By the way, manufacturing cost for our TKI's is pennies per pill. The cost difference to manufacture 50 mg vs 100 mg is near zero. The cost to the pharma company is in the research discovery, translational chemistry, development and clinical trials (safety & efficacy) of the drug. The cost of manufacture in comparison is very low.

Whether a patient is prescribed 100 mg., 50 mg 20 mg of a drug doesn't really matter to the pharmaco. All they care about is that the prescription follows clinical trial protocol so they are not held liable.