1. How Canadians Access Drugs for Rare Disorders Health Canada and Provincial Drug Plans Durhane Wong-Rieger, PhD President Canadian Organization for Rare Disorders

2. 27 May 2006 Drug Approval Process and Orphan Drugs2 Key Steps to Drug Access Health Canada: Approval to Market Common Drug Review: Cost-Effectiveness Provincial Drug Plans: Impact on Drug Budgets and Comparative Costs What about Orphan Drugs?

3. 27 May 2006 Drug Approval Process and Orphan Drugs3 Health Canada: Must Approve Sale  Manufacturer Must Make Application  Company decides to “sell” drug in Canada; applies for specific indications; pays application fee  If “breakthrough”, can be given “priority review”  Company submits evidence from clinical trials  Is Drug Safe: cause serious harm? Side effect?  Does drug work: reduce symptoms, improve outcomes, cure?  Do benefits outweigh harms: life-threatening disease, no other treatments, evidence?

4. 27 May 2006 Drug Approval Process and Orphan Drugs4 Common Drug Review: Is it Worth the Cost?  Pharmacoeconomics uses economics and clinical science to answer question: Is drug cost-effective?  Effectiveness: what are the benefits of the drugs  Cure the disease  Reduce major symptoms, fewer side effects, significantly easier to use  Gives more years of life  Cost per additional years of life  Are the additional benefits worth the additional costs?  Is it as cost-effective as previous drugs

5. 27 May 2006 Drug Approval Process and Orphan Drugs5  Avodart  Axert  Combigan  Reyataz  Humira  Myfortic  Neulasta  Pegasys RBV  Teveten Plus  Telzir  Vfend  Yasmin  Tarceva  Kivexa  Evra  Iressa (Noc/c)  Viread (Noc/c) ***  Remodulin ***  Fabrazyme  Adderall XR  Replagal (Noc/c)  Zavesca  Forteo  Ciprodex  Gynazole.1  Relpax ***  Sensipar  Amevive  Aldurazyme  Lantus ***  Norprolac ***  Strattera ***  Ebixa *** 42% 58% *** All listed by Quebec 14 19 33 CDR Recommendations as of December 31, 2005

6. 27 May 2006 Drug Approval Process and Orphan Drugs6 Provincial Drug Plan listing status of the 33 New Drug recommendations from CDR May 2004 – December 31 2005 24% 27% 30% 15% 30% 0% 27% 100% 55% 42% Yes 58% No * Quebec does not participate iMAM® Brogan Inc. December 2005 Drug Plan Listing Status of CDR Recommendations

7. 27 May 2006 Drug Approval Process and Orphan Drugs7 CDR Decisions to Date (Aug. 24, 2005) DecisionNo. submissons List in a similar manner as drug plans list other drugs of the same class 8 List with criteria/conditions4 Not to list16 Total decisions28

8. 27 May 2006 Drug Approval Process and Orphan Drugs8 Provincial Response to CDR Decisions BCALSKMBONNBNSPEINL No. listing decisions 15102201301 No. listings156220501 Average time to listing (days) 284349351310328--302--300 Historical time to listing (days) 450406346551494592428744352 Concordance with CDR recommendation 1/15/510/102/2 --11/13--1/1

9. 27 May 2006 Drug Approval Process and Orphan Drugs9 Access to Orphan Drugs in Canada  Unlike USA, UK, Japan, Australia and European Union, Canada does not have an Orphan Drug Policy  In USA, provides incentives for companies to research drugs for orphan conditions, negotiated conditions for priority review for FDA approval  In most other countries, priority reviews and specific criteria for approval (surrogate markers, small patient populations, collapsed Phase 2/3 trials)  Canada can provide priority review and will consider surrogate markers

10. 27 May 2006 Drug Approval Process and Orphan Drugs10 CDR process not suited to orphan disorders  CRD applies standard cost-effectivness review even to orphan indications  Typically, drugs for orphan indications are new treatments based on surrogate markers with no long-term studies  Typically, drugs for orphan indications will be more costly  No specific criteria for treatments that are life-saving or have no other drugs available  Evaluation of cost relative to benefits (cost versus savings over other drugs)  Cost-effectiveness ($ for Quality-adjusted life year gained) approved if less than $50,000  Off-label (use not approved by Health Canada) will not be assessed by CDR (no clinical data)

11. 27 May 2006 Drug Approval Process and Orphan Drugs11 National Pharmaceutical Strategy  Proposed for a national program for access to drugs (funding and post-market surveillance) approved by F/P/T Ministers in 2004  Could include catastrophic drug coverage (those whose drug costs are exorbitant relative to income)  Could include national drug formulary (list and conditions for funding drugs through public drug plans)  Could include “expensive drugs for rare disorders”  10-year NPS with first progress report: June 2006

12. 27 May 2006 Drug Approval Process and Orphan Drugs12 Why Do Advocacy?  Solve an individual problem (specialist appointment, access to treatment & homecare)  Address problem that affects group of consumers {disease-specific & community} (hospital parking, clinic hours, specialist care & emergency; insurance coverage)  Influence a policy or regulation or law (Drug licensing or formulary listing, hospital closures; disease-specific programs, disability assistance, care in rural areas)

13. 27 May 2006 Drug Approval Process and Orphan Drugs13 What is Advocacy?  Appeal for support by writing letters, making phone calls, visiting decision-makers or those with influence.  Engage public support by publicize stories through media, tell stories at meetings, conferences, gatherings & hold press conferences; conduct polls, surveys & publicize findings.  Engage support of influential others or decision-makers; be present at appropriate events, such as committee meetings, conferences and legislative sessions.  Demonstrate at appropriate events in order to make issues public.  Disrupt service delivery, meetings, conferences or legislative sessions to force attention to the problem or issue.

14. 27 May 2006 Drug Approval Process and Orphan Drugs14 Best Outcomes Win-win solution, commitment to change Legitimacy with Decision Makers Credibility Among Consumers (Public)

15. 27 May 2006 Drug Approval Process and Orphan Drugs15 Provide A Solution, Not Just the Problem  Start with the need  Increased burden of not preventing or not treating could escalate healthcare costs  Despite high cost of treatment, cost effective  Give them a solution  Long-term: Co-ordinated strategy of treatment and prevention reduces impact and future infections  Short-term: Investment in diagnosis and early treatment to reduce burden of disease

16. 27 May 2006 Drug Approval Process and Orphan Drugs16 Don’t Forget the Sizzle  Use language to appeal to emotions: compassion, fear, justice  Create a headline: “tainted” blood, “miracle” drug, “silent” killer, “hidden” epidemic, nation of “guinea pigs”  Appeal to the audience’s sense of justice or compassion: “the right thing to do”  Appeal to the audience’s self-interest: “what’s in it for me”  KISS rule still works

17. 27 May 2006 Drug Approval Process and Orphan Drugs17 You Gotta Have Friends  Build A Coalition  Creates stronger case; Optimizes scarce resources  Bring together disparate views  Talk to One Another  Coordinate activities  Share intelligence  Keep others posted on your actions  Row Together (Our Worse Enemies are Ourselves)  Enemies: Different Interests, No Trust  Bed Fellows: Common Interest, No Trust  Competitors: Different Interests, Trust  Allies: Common Interest, Trust

18. 27 May 2006 Drug Approval Process and Orphan Drugs18 Engage the Media  Make media aware of, care about, your cause and/or group  Engage media to promote cause and group to public [Patients with private drug insurance get anemia treatment but those on BC public drug plan do not]  Use media to press decision makers (embarrass, support, threaten, reward) [BC is the only major province in Canada that does not fund treatment for anemia for cancer patients undergoing chemotherapy]  Use media to bring in high profile supporters

19. 27 May 2006 Drug Approval Process and Orphan Drugs19 8 Simple Rules for Meeting Your Legislator  Rule 1: Don’t make your first ask at a fundraiser unless you are a major contributor. You may use the occasion to reinforce a previous request.  Rule 2: Approach the legislator as a human being. Make yourself likeable. You are here to build a relationship  Rule 3: Define the issue simply. Have an answer to “What Can I Do?” Make sure it is do-able.  Rule 4: Listen actively. Confirm points of agreement. Clarify. Stay on topic. It’s your agenda.

20. 27 May 2006 Drug Approval Process and Orphan Drugs20 8 Simple Rules for Meeting Your Legislator (2)  Rule 5: Be prepared with facts and figures but you don’t have to be the expert. Admit if you don’t know. Offer to follow up.  Rule 6: Be early. Don’t stay late.  Rule 7: Leave something behind.  Rule 8: Follow up with a letter of thanks and ask to meet again.

21. 27 May 2006 Drug Approval Process and Orphan Drugs21 You Can Sell Them Anything...If You Know What They Want  Tie in with the government’s agenda  Population health and wellness  Health quality and patient care  Sustainable healthcare system  Programs that are evidence-based are harder to step away from  Listen for political (pre-election) platform and fit into the “context”  Identify the overlapping risk factors (other chronic diseases or issues)  Find ways to sell issues to other sectors  Public Health; Community and Social Services  Crime and Safety  Relate to high-profile health issues that affect the public  Make investments upstream to reduce downstream costs  Give positive feedback