Donepezil, rivastigmine, galantamine and memantine for ...

The increasing numbers of the very elderly will
increase demands on services. If the drugs are
effective in delaying institutionalisation, there may
be more demand on currently available
community services, where there are currently
resource issues around the numbers of available
professional carers. On the other hand, this may
reduce some of the cost and capacity issues around
service provision in institutions (care homes,
nursing homes). The cost of treatments with these
drugs for a proportion of AD patients needs to be
considered along with the other competing uses of
funds for AD such as support for carers (e.g.
respite care, night-sitters).
Previous NICE guidance 30 projected an expected
annual drug cost for donepezil, rivastigmine and
galantamine (combined) at £42 million,
commenting that this may have been an
overestimate as it did not account for those
patients dropping off therapy, although the
projection was for a ‘steady state’, allowing for
incidence of AD and for patients having an
average treatment period of 36 months. The
Department of Health prescription cost analysis
(PCA) 189 for 2003 reports prescription costs for
these drugs (community prescriptions) at a total of
£31 million (net ingredient costs), excluding a cost
of £636,000 on the prescribing of memantine.
Donepezil prescribing comprised £23.5 million
(76%) of this expenditure. Prescribing of these
products in AD, as reported for 2003, may not
have reached the ‘steady-state’ predictions of the
NICE guidance, but prescribing practice would
have had 2–3 years to develop. Furthermore, the
prescribing data from the PCA is not limited to
AD, and it would be expected that some
prescribing would have been in the non-AD
dementia patient groups, although this may form
a very small proportion of prescribing expenditure
at the present time. Some additional prescribing
costs from non-community-dispensed prescriptions
would also be expected.
Chapter 9
Health Technology Assessment 2006; Vol. 10: No. 1
Factors relevant to NHS policy
© Queen’s Printer and Controller of HMSO 2006. All rights reserved.
Given that memantine has been introduced for
patients with moderately severe to severe AD, it
presents as an additional prescribing cost to the
NHS, at a price of £900 per year (from March
2005) for the 20-mg daily dosage (as used in the
two included RCTs). Following from earlier NICE
guidance and predicting that around 15,000
patients per year may be treated with memantine,
there could be an additional prescribing cost in
the region of £14 million per year, where
memantine was prescribed for moderately severe
to severe AD, although it might take a number of
years before prescription of this product reached
such a large patient group. Where the potential
patient group was predicted to be smaller, with a
limited uptake from physicians, at around 5000
patients per year, additional prescribing costs
would be in the region of £5 million per year.
The industry submission (Lundbeck) to NICE for
memantine predicts a potential treatment group
of 23,448 moderately severe to severe AD patients,
with a mean treatment period of around
6 months, calculating a prescribing cost for
memantine at approximately £10.9 million per
year (with this level of prescribing not being
reached until year 2, following a positive
recommendation/guidance from NICE).
In addition to the prescription cost for products
discussed, there will also be an additional cost
burden on the NHS related to additional
monitoring of patients while on treatment. It is
suggested that this resource use may be limited to
two additional outpatient appointments per year
while on treatment, approximately £216 per year
per patient treated. Any potential cost savings, due
to possible delays in institutionalisation, are likely
to be felt by the PSS sector rather than the NHS.
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