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42 Plasma KCE Reports 120 Table 18: Plasma derivatives and recombinant factors reimbursed by the NIHDI in euros Increase (%) from % of 2004 to total Plasma derivative 2004 2005 2006 2006 (2006) PPSB CAF 3.085.617 3.460.927 3.538.650 +15% 3% Fact VIII 40.985.245 49.261.250 55.007.814 +34% 49% Fact VIII-human CAF 3.641.669 3.346.896 1.529.897 ‐58% 1% Fact VIII-recombinant 37.343.576 45.914.354 53.477.916 +43% 48% FEIBA 44.564 141.977 578.834 +1199% 1% Factor IX-human 1.300.125 804.461 541.869 ‐58% 0% Factor IX-human CAF 1.220.440 671.533 378.548 ‐69% 0% Factor IX-human not-CAF 79.685 132.928 163.321 +105% 0% Factor IX-recombinant 1.482.492 2.866.969 3.639.488 +145% 3% Fact VII-human CAF 47.712 52.041 11.280 ‐76% 0% Factor VIIa-recombinant 4.606.335 3.262.395 1.565.229 ‐66% 1% von Willebrand +/- Fact VIII 838.996 1.246.384 1.335.818 +59% 1% von Willebrand +/- Fact VIII CAF 651.254 531.557 439.080 ‐33% von Willebrand +/- Fact VIII not-CAF 187.741 714.826 896.738 +378% Factor XIII-human 3.941 4.751 4.034 +2% 0% Alb & SSPP 13.578.166 14.248.444 12.200.319 ‐10% 11% Alb & SSPP CAF 13.061.558 10.499.273 7.416.617 ‐43% 7% Alb & SSPP not-CAF 516.470 3.749.154 4.783.694 +826% 4% Other plasma protein fractions 138 17 8 ‐94% 0% SC Immunoglobulins polyvalent 0 5.231 165.310 ‐ 0% IV Immunoglobulins polyvalent 30.448.581 31.498.645 33.450.863 +10% 30% IV Immunoglobulins polyvalent CAF 14.137.200 14.262.430 16.485.695 +17% 15% IV Immunoglobulins polyv. not-CAF 16.311.381 17.236.216 16.965.168 +4% 15% Antithrombine III 446.735 566.246 377.277 ‐16% 0% Total all products 96.868.647 107.419.738 112.416.793 +5% 100% Total human derivatives 53,436,244 55,376,020 53,734,159 +1% 48% Total recombinant factors 43,432,403 52,043,718 58,682,633 +35% 52% 3.1.3 The case of immunoglobulins The remaining of this chapter focuses on polyvalent immunoglobulins (IG). Demand in immunoglobulins is the highest among all derivatives when considering the amount of plasma required to produce it. Its use continues to grow as the number of clinical indications for IG keeps increasing. This increased demand resulted in severe product shortages in the late 1990’s in the US and a number of other countries, impacting IG supply in Belgium. In addition, IG is important in terms of amounts involved and budget impact in Belgium, representing 62% of expenses in human plasma derivatives in 2006. In this chapter, IG is used to describe pooled polyvalent human immunoglobulin, that can be administered intravenously or subcutaneously; IG does not cover hyperimmune or specific immunoglobulins. Polyvalent IG are used to treat a wide range of diseases due to three major therapeutic properties: IG can replace or supplement antibodies in immunodeficiency diseases, in order to restore normal humoral immune function; IG has an immunomodulatory action in various autoimmune conditions and inflammatory diseases; and IG may be used as prophylaxis or therapeutic adjunct against some infectious agents in patients with normal immune humoral function. After IG was shown to be effective in the treatment of auto-immune and inflammatory disorders, the list of disease for which it is used has grown rapidly.
KCE Reports 120 Plasma 43 3.2 INDICATIONS FOR IMMUNOGLOBULINS This section aims at identifying the diseases requiring significant amounts of immunoglobulins, to enable interpretation of IG amounts consumed or calculation of amounts required. We describe and compare the recommendations for IG use in Belgium and in five other industrialized countries. Based on the indications that are included in at least one country (29 indications), we present a review of the scientific evidence on IG effectiveness to date. Warning: In this document, the term indication is used to refer to a disease or syndrome for which immunoglobulin (IG) is used or considered to be used. It does not stand for “authorized indication” or “licensed indication”, which refers to the indications proposed by the manufacturer and authorized by the drug regulatory authority. 3.2.1 Recommendations for the use of immunoglobulins The recommendations on which diseases can be treated with polyvalent 3.2.1.1 immunoglobulins vary per country, as well as the status of the recommendations. A few countries have developed full evidence-based guidelines, such as Canada and the United Kingdom (UK), extending recommendations beyond the labelled indications; other countries, such as Belgium, did not develop guidelines yet but have legally defined a list of reimbursed indications; for others countries, such as the Netherlands, a list of “labelled” indications is presented (i.e. indications approved by the regulatory drug agency). As a consequence, the legal status of these recommendations differs per country. Recommendations in Belgium In Belgium, official recommendations for IG use have not been yet published, but guidelines for IG use are currently under development by the Health Council (CSS/HGR). The only sources for guidance on IG use are the list of indications that are authorized in Belgium for each IG brand product (labelled indications) and the list of reimbursed indications and criteria for reimbursement for each indication, stated in the law (Table 19): • The authorized indications vary per brand product and over time. • The indications and criteria for which IG are reimbursed by the INAMI/RIZIV are described in the Royal Decree from 21 December 2001, with last modification stated in the Ministerial Decree from 15 July 2008. d Intravenous immunoglobulins In Belgium, several brands or pharmaceutical specialities of intravenous immunoglobulins (IVIG) are registered. Though reimbursed indications vary per brand product, the following pathologies are considered in the decree and summarized in Table 19: 1. Haematological indications • Primary immune deficiency conditions: agammaglobulinemia; hypogammaglobulinemia with specific criteria; congenital deficiency in antipolysaccharidic antibodies (providing specific criteria are met) • Secondary immune deficiency: o Multiple myeloma and chronic lymphocytic leukaemia with severe hypogammaglobulinemia and recurrent infections o Prevention of infections in patients having an allogenic bone marrow transplant o Paediatric AIDS o Treatment of septicaemia in preterm infants and neonates d Arrêté ministériel du 18 juillet 2008 modifiant la liste jointe à l'arrêté royal du 21 décembre 2001 fixant les procédures, délais et conditions en matière d'intervention de l'assurance obligatoire soins de santé et indemnités dans le coût des spécialités pharmaceutiques (MB 18 JUILLET 2008 DEUXIEME EDITION).
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