This is the text extract for Annual Review 2007 - Part 3, browse documents here.

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18

HIV/AIDS

Improving New Zealanders’ access to HIV treatments was a major theme in 2006-07. Five new treatments were added to the Pharmaceutical Schedule, including the first of a new type of HIV medicine, a fusion inhibitor. The five new treatments are: Atazanavir (Reyataz) – a more convenient once-a-day protease inhibitor with fewer metabolic side effects. Enfuvirtide (Fuzeon) – the first fusion inhibitor, a new class of medicines, used to treat people with the most advanced stages of HIV/AIDS. Tenofovir (Viread) – another nucleotide reverse transcriptase inhibitor. Emtricitabine (Emtriva) – used in combination with Tenofovir. Kivexa -- a combination of abacavir and lamivudine. About 980 people are treated with subsidised HIV medicines, with expenditure in the region of $9 million per year.

HIV/AIDS

Cost (millions) $14.0 Prescriptions 9,000 8,000 7,000 $10.0 6,000 $8.0 5,000 4,000 3,000 $4.0 2,000 $2.0 1,000 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Ending 30 June Cost HIV/AIDS Prescriptions HIV/AIDS

$12.0

$6.0

$0.0

Asthma

During 2006-07 there were major changes in the range and availability of asthma inhalers. Most significantly, combination inhalers were made available to many more people with asthma. Combination inhalers include two types of asthma medicine (longacting beta agonists with inhaled corticosteroids) and are mainly used by people with moderate to severe asthma. Key decisions during the year were: access was widened to long-acting beta agonist inhalers (Serevent Accuhaler, Oxis Turbuhaler and Foradil); the Seretide combination inhaler was subsidised; and there is wider access to combination corticosteroid and LABA inhalers (Seretide and Symbicort). The changes represent a significant step forward in the treatment of asthma, including the addition of a combination aerosol inhaler (Seretide) to the available types of dry powder combination inhalers. About 42,000 New Zealanders use LABAs either on their own, or in combination forms, and the widening of access will lead to significant growth in the number using combination inhalers. This growth is reflected in the prescribing data for 2006-07, which show long-acting beta-agonists becoming increasingly popular. Meanwhile, prescription numbers for other types of asthma inhalers flattened.

Asthma

Cost (millions) $50.0 $45.0 $40.0

$35.0

Prescriptions 1,000,000 900,000 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0

$30.0 $25.0 $20.0 $15.0 $10.0 $5.0 $0.0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Ending 30 June Cost long-acting beta agonists Cost inhaled corticosteroids Cost Symptom relievers

Prescriptions long-acting beta agonists Prescriptions inhaled corticosteroids Prescriptions Symptom relievers

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19

“I just said to myself ‘man, just get up and do it”

Heart disease

PHARMAC’s flagship cardiovascular disease campaign, One Heart Many Lives, continued to develop. It is an optimal use campaign aimed at men at risk of developing heart disease, New Zealand’s biggest killer. The campaign has a particular focus on Māori and Pacific men, who on average die earlier than other New Zealand men, and under-use available medicines. PHARMAC’s partnership with the Hawke’s Bay DHB has built on the successful start to the campaign in the 2005-06 year, and the campaign has now expanded into Northland, where there is a 14 year mortality gap between Māori men and the New Zealand average. We also continued to follow the progress of Hastings man Tamati Davis (above), who has changed his life and lost more than 100kg. The Northland campaign was developed in partnership with the local DHB, iwi and health providers with a community launch in Kaitaia in April 2007, featuring free heart checks, and a performance by the pop group Ardijah (Ardijah’s frontman Ryan Monga is a role model for the campaign locally, having successfully lost and kept off weight through changes to his diet and lifestyle). Medicine funding changes for heart disease included listing clopidogrel (Plavix), to help prevent blood clots developing in people who have had heart surgery. It’s an investment of about $7 million per year, benefiting 7000 people in the first year. Access was also widened to the beta blocker carvedilol , to benefit more people with heart failure.

Cholesterol management

Cost (millions) $70.0 Prescriptions 1,400,000

$60.0

1,200,000

$50.0

1,000,000

$40.0

800,000

$30.0

600,000

$20.0

400,000

$10.0

200,000

$0.0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Ending 30 June

Cost Statins Cost Fibrates Cost Cholesterol absorption inhibitors Prescriptions Fibrates Prescriptions Statins

0

Prescriptions Cholesterol absorption inhibitors

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0

Diabetes

PHARMAC worked with BPACNZ and Diabetes NZ to develop resources to help people manage their diabetes. Lifestyle choices are emphasised as part of the One Heart Many Lives cardiovascular campaign because, in addition to reducing people’s cardiovascular risk, reducing weight and lifestyle changes can reduce the risks of developing Type 2 diabetes. About 30,000 New Zealanders use insulin, either on its own or in combination with other diabetes treatments. In late 2006 PHARMAC funded insulin glargine (Lantus), a long-acting insulin for people with the most difficulty controlling their blood sugar levels. About 10% will qualify for insulin glargine funding, an investment of $5 million over the next five years. Approximately 100,000 New Zealanders are thought to have Type 2 diabetes, with the number increasing by up to 10% each year. PHARMAC widened access to pioglitazone (Actos) for people with Type 2 diabetes so it can now be prescribed by GPs as well as specialists, which will make it easier for Māori and Pacific people to access it. The use of pioglitazone is anticipated to double within four years as a result of the changes.

Osteoporosis and HRT

The gradual decline in prescribing of hormone replacement therapy (HRT) continued in 2006-07. Prescribing had declined steeply when two major studies published in 2002 and 2003 raised concerns about the impact of HRT on heart disease and breast cancer, and this declining trend is now flattening out. With 122,000 prescriptions for HRT written in 2006-07, prescribing is now at 30% of the peak prescribing recorded in 2001. Prescription numbers for bisphosphonates, used to treat osteoporosis, continued an upward trend in the past year. This reflects both underlying growth and a major access widening decision by PHARMAC in 2005-06, the full impact of which was seen for the first time in the last financial year. The growth was mainly driven by an increase in prescribing of alendronate (Fosamax), with prescription numbers growing to 206,000. This in turn drove spending (before rebates) to over $13 million. Hormone Replacement Therapy and Osteoporosis

Cost (millions) $14.0 Prescriptions 450,000 400,000 350,000 $10.0 300,000 $8.0 250,000 200,000 150,000 $4.0 100,000 $2.0 50,000 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Ending 30 June Cost HRT Cost Bisphosphonates Prescriptions HRT Prescriptions Bisphosphonates

$12.0

$6.0

$0.0

Diabetes

Cost (millions) $30.0 Prescriptions 800,000 700,000 600,000 $20.0 500,000 400,000 300,000 200,000 $5.0 100,000 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

$25.0

$15.0

$10.0

$0.0

Year Ending 30 June Cost Diabetes Cost Diabetes Management Prescriptions Diabetes Prescriptions Diabetes Management

Approximately 100,000 New Zealanders are thought to have Type diabetes and this number is growing by up to 10% each year.

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1

Mental Health

Prices of antidepressants continued to fall, with a generic version of paroxetine leading to increased competition and a subsequent price reduction. This is estimated to mean savings of $45 million over the next three years, a further example of the impact competition can have on prices when medicines come off-patent. PHARMAC worked with BPACNZ and health professional organisations to help health professionals and patients adjust to the brand change. Paroxetine continues to be one of the most widely-used antidepressants, which overall continued a pattern of strong prescribing growth in 2006-07. Prescription numbers for newer antidepressants (particularly SSRIs) went up by about 90,000 to some 720,000 nationally. Prescriptions for all antidepressants (older agents and newer agents) surpassed 1 million for the first time. This may in part be due to access policy changes meaning that many prescriptions previously paid for by patients, are now being subsidised by the Government. Antidepressants

Cost (millions) $35.0 $30.0 $25.0 $20.0 400,000 $15.0 300,000 $10.0 $5.0 $0.0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Ending 30 June Cost New Antidepressants Cost Old Antidepressants Prescriptions New Antidepressants Prescriptions Old Antidepressants 200,000 100,000 0 Prescriptions 800,000 700,000 600,000 500,000

Geraldine MacGibbon Therapeutic Group Manager Geraldine MacGibbon considered studying music at Auckland University, before opting for science. She graduated with a PhD in Neuropharmacology, having a particular interest in pharmaceuticals and how the brain works. But she hasn’t abandoned music – she’s a mezzo soprano in the NBR New Zealand Opera chorus (most recently in the Wellington production of Turandot), studying under Margaret Medlyn. She’s also a keen member of PharmAce, the in-house tennis team that plays fortnightly at Wellington’s Renouf Centre. Geraldine joined PHARMAC about 18 months ago; her job involves so many things, she finds it almost impossible to describe. She’s a Therapeutic Group Manager (TGM), responsible for the areas of ‘pain and brain’: mental health, analgesics, anaesthetics and neurology. TGMs are responsible for processing funding applications, writing the briefing papers for PTAC and attending their meetings, organising the analysis, negotiating with the pharmaceutical companies, writing the Board papers, liaising with Access and Optimal Use team over implementation, working with contract managers and dealing with queries from the public. PHARMAC has six TGMs, and it’s long been the organisation’s pivotal role. “Yes, it’s hard work, sometimes with great frustrations, but I love my job! I can’t believe how lucky I am. It has such variety, and everything has a tangible and visible effect on New Zealanders. “PHARMAC’s management and Board really listen to us, and show they have confidence. The only downside is that it’s hard to imagine where I’d go from here. “Living in Wellington is great too; I’d give it 8/10. That’s something from an ex-Aucklander!”

ADHD treatments

Cost (millions) $2.5 Prescriptions 80,000 70,000 $2.0 60,000 50,000 40,000 $1.0 30,000 20,000 $0.5 10,000 $0.0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Ending (June) Cost Methylphenidate Hydrochloride - 10 mg Cost Methylphenidate Hydrochloride - 20 mg Prescriptions Methylphenidate Hydrochloride - 10 mg Prescriptions Methylphenidate Hydrochloride - 20 mg Total scripts adjusted for introduction of Slow Release 0

$1.5

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Funding of trastuzumab (Herceptin) for breast cancer was one of the year’s most significant pharmaceutical issues.

PHARMAC and District Health Boards closely examined funding the 12-month sequential, post-chemotherapy option (supported by most breast cancer campaigners), which would have cost around $25 million and seriously hindered the ability to fund other healthcare. After looking across all the evidence, DHBs and PHARMAC decided not to fund the 12-month course of Herceptin, but to keep it under active review. PHARMAC sought further advice from its expert clinical committees on a treatment regimen tested in an independent Finnish trial (FinHer, using Herceptin for nine weeks in combination with a taxane drug). The evidence showed this concurrent approach to be effective, with its effectiveness comparable to longer duration treatments. After further analysis, DHBs accepted PHARMAC’s recommendation to fund the concurrent nine-week option.

Cancers and transplant drugs

Access was widened to the taxane drug paclitaxel (Taxol) for breast cancer and it’s expected up to 550 women will be treated with paclitaxel each year for node positive early breast cancer. PHARMAC estimates the investment will cost an additional $12.5 million over five years. Taxanes are hospital-administered chemotherapeutic drugs that are funded for a number of cancers, including ovarian, fallopian and metastatic breast cancer. Expenditure on cancer medicines continues to grow strongly, as new medicines are added to the Schedule and their use grows. This is likely to be a continuing pattern for future years, with a number of new agents becoming available to treat a range of cancers, and which can be taken as a tablet which avoids patients having to be treated in hospitals. In addition, these treatments tend to be quite high cost. PHARMAC is also moving towards managing hospital spending on cancer medicines, so this continues to be an area of high interest for PHARMAC. Cancer and transplant treatments

Cost (millions) $30.0 Prescriptions 90,000 80,000 $25.0 70,000 $20.0 60,000 50,000 $15.0 40,000 $10.0 30,000 20,000 $5.0 10,000 $0.0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Ending 30 June

Cost Chemotherapeutic Agents Cost Endocrine Therapy Cost Immunosuppressants Prescriptions Chemotherapeutic Agents Prescriptions Endocrine Therapy Prescriptions Immunosuppressants

The concurrent option was chosen because: It shows comparable clinical benefits to longer courses of Herceptin; The shorter duration makes it cost-effective; At $6 million per annum, it is affordable to DHBs; and It requires fewer infusions and can be delivered by DHBs.

The concurrent nine-week regimen is now fully funded for all women, but an important research question remains. While both short and long duration concurrent regimens demonstrate effectiveness, no trials have been done to demonstrate if one method is superior. PHARMAC has now committed $3.2 million to the international ‘SOLD’ trial, which will address this question. The trial, which is likely to involve New Zealand women, will begin recruiting patients in 2007-08.

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