Technologies: Medicines whose active ingredient is somatropin registered in Brazil.
Indication: Hypopituitarism and Turner syndrome.
Technologies characterization: Somatropin is human growth hormone produced by recombinant DNA technique.
Question: What brand of recombinant human somatropin, currently incorporated by the Unified Health System (4 and 12 IU) and the general market (15, 16, 18, 24, 30, 36, 45 and 60 IU), presents itself more economically advantageous considering the indication, stability and the cost?
Methods: The registered medicines in Brazil were obtained from the electronic database of the National Health Surveillance Agency (ANVISA). The stability of drugs and indications were obtained from the package inserts. The average body weight of patients with active process for somatropin was obtained in the Information System of the Pharmaceutical Assistance Management (SiGAF) and was used to calculate the consumption. To calculate the consumption and the wastage we considered the minimum and maximum dose recommended in Clinical Protocols and Therapeutic Guidelines of the Brazilian Ministry of Health. For the estimated cost of treatment analysis we considered the consumption and the Maximum Price of Sale to the Government with 0% tax obtained from the Drug Market Regulation Chamber on 11/20/2014.
Results: Seven brands with 17 different presentations of human recombinant somatropin are currently available in the market. The medicines Eutropin® 4 IU and Saizen® 4 IU should be used right after reconstituted, Biomatrop® is stable 7 days and Hormotrop® 14 days. All others medicines have stability of 28 days. Hormotrop® is indicated only for hypopituitarism in children, but its formulation is similar to that of medicines indicated for hypopituitarism in adults and Turner syndrome. Comparing all medicines, those incorporated by the SUS showed higher prices per IU (exception: Norditropin® that showed the highest price). For children with hypopituitarism, the estimated average monthly somatropin wastage was 2.05 to 2.28 IU (4 IU stability of 7 and 14 days); 5.84 to 7.54 IU (IU 12); and 6.32 to 10.07 IU for presentations from 15 to 18 IU. For presentations of 24 IU or more the monthly average wastage was estimated to be 13.42 to 63.75 IU. Considering all registered medicines, those incorporated by SUS emerged from the fifth position of lower estimated average cost. For adults with hypopituitarism, the estimated average monthly somatropin wastage was 1.00 to 5.00 IU (4 IU – 7 and 14 days); 6.00 to 21.00 IU (12 IU); and from 0.00 to 21.00 IU for presentations from 15 to 18 IU. For presentations of 30 IU or more the monthly average wastage was estimated to be 30.00 to 105.00 IU. Considering all registered medicines, those incorporated by SUS appeared from the first position of lower average estimated cost for the minimum dose, and from the fifth position for the maximum dose. For patients with Turner syndrome the estimated average monthly somatropin wastage was 2.08 to 2.65 IU (4 UI – 7 and 14 days); 6.08 to 6.86 IU (12 IU); and from 7.18 to 10.18 IU for presentations 15-18 IU. For presentations of 30 IU or more the monthly average wastage was estimated to be 14.29 to 30.08 IU. In a ranking with 17 placements, the medicines incorporated by SUS appeared from the ninth place of lower estimated average cost. The medicines Eutropin® and Saizen® 4 IU showed the highest wastage and the highest cost estimates for both diseases.
Recommendations: Strictly speaking the use of Hormotrop® for hypopituitarism in adults and Turner Syndrome is off label. We emphasize the similarity between the formulation of this medicine and that of the others, and the fact that the indication update process stars with a requested by the registry holder, and not only on the existence of scientific evidence. With the results obtained for hypopituitarism and Turner syndrome we know that: (i) IU prices of medicines incorporated by SUS were the highest among all registered medicines (except for Norditropin®); (ii) less wastage with presentations incorporated by SUS did not translate into better results of estimated mean treatment cost (presentations 15, 16 and 18 IU had lower or similar cost); and that (iii) the stability of Eutropin® and Saizen® 4 IU was responsible for it worst results of treatment cost and wastage. Thus, in order to obtain the medicine with lower cost and wastage, we recommend that the purchase of somatotropin be made considering price per IU, and to allow the participation of presentations of up to 18 IU. We also recommend the inclusion of technical criteria for the purchase somatropin, such as stability of 7 to 28 days.
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