Switching from Atripla to generic-containing regimens can produce large cost savings

Switching from branded Atripla to regimens that include at least one generic drug formulation can achieve big cost savings without compromising virological efficacy, according to research from Brighton presented to the recent conference of the British HIV Association (BHIVA) in Liverpool.

The study involved 86 people who switched from one-pill Atripla to multi-pill combinations that included at least one generic. The annual cost saving associated with the treatment switch was £159,000. The vast majority of that saving resulted from switching to a combination of tenofovir, generic efavirenz and generic lamivudine. All the study participants who switched maintained an undetectable viral load and only one person discontinued their new regimen because of pill burden.

Atripla combines efavirenz, emtricitabine and tenofovir in a single pill taken once daily. Its potency, convenience and relative safety meant that it was, for a long time, the preferred drug for first-line HIV therapy. Although it has now been supplanted by alternative regimens, it continues to be taken by a large number of people.

Efavirenz is now available as a generic, as is lamivudine, which is similar to emtricitabine in its chemical make-up and anti-HIV activity. Given the considerable pressure on the NHS and HIV services to save money, pharmacists and clinicians in Brighton undertook a study to calculate the cost-savings that could be achieved by people switching from branded Atripla to multi-drug regimens incorporating at least one generic drug and to assess the safety and durability of these alternative combinations.

A retrospective review of notes and pharmacy data identified 428 people, who between August 2015 and March 2017, were being prescribed Atripla and had no clinical reason to change this therapy. Of these, 268 had been referred to a pharmacist to discuss switching to one of two generic-containing regimens:

• Efavirenz (generic), lamivudine (generic) and branded tenofovir.

• Efavirenz (generic) with branded emtricitabine and tenofovir (Trudava).

A total of 119 people (44%) agreed to switch, 86 changing to efavirenz/lamivudine/tenofovir and 29 to efavirenz/Truvada.

Wanting to remain on a single-pill regimen was the main reason why people declined to switch (n = 41). Also cited were concerns about travel and work (n = 15) and adherence (n = 7).

Three-quarters of patients remained on their multi-agent regimen. However, a fifth switched treatment because of central-nervous system (CNS) side-effects, most of these individuals reverting to therapy with Atripla. Only one patient cited pill burden as the reason for wanting to change therapy.

All the patients who switched from Atripla maintained virological control (below 40 copies/ml six and twelve months after treatment change).

The estimated annual saving achieved by people switching from branded Atripla to a generic-containing regimen was £159,500. Most of this saving (£154,890.24) was associated with changing to efavirenz/lamivudine/tenofovir.

However, switching to generics was not without its challenges, including supply of medication and patients receiving different brands. Greater than predicted use of generics led to delays in supply of stock. As a result, patients received different brands of medication when prescriptions were refilled. This meant that patients were receiving pills of differing appearance, increasing the potential for confusion about which pills had been taken.

Despite these concerns, the investigators conclude that a regimen consisting of generic efavirenz and lamivudine with tenofovir is a viable cost-saving and well-tolerated switch option. Increased pill burden does not appear to be an issue for patients.

Hardweir V et al. The next generiction update. British HIV Association conference, abstract O6, April, 2017. (Presentation available here).