25 November 2021

Black Friday decision making, Covid and rituximab: is anyone buying?

Comment COVID-19 Medications

In Australia, despite our fierce independence, we seem to love following US trends, especially of late.

It doesn’t just stop with music, television shows, reasons for vaccine hesitancy. Despite their lack of relevance to us, an increasing trend seems to be celebrating American holidays such as Halloween and Thanksgiving, and accordingly that great exercise in marketing, online sales on Black Friday.

Black Friday is an excellent example of trading off hope. For the uninitiated, let me break down how a standard Black Friday interaction should go, if it’s done right:

  1. In the lead-up to the day, sellers promise that ‘something great’ is on the way, and to be ready (because you wouldn’t want to miss it).
  2. You, the consumer, get excited. Maybe you can finally get that lampshade you’ve always wanted, at a not outrageous cost, to match all your pillow covers?
  3. The much-promised, highly awaited Big Day arrives. You open your inbox in excitement.
  4. The sale has heavy caveats: in the discount selection, lampshades are limited only to medium size. What good is that for your outsized lamp?
  5. After weighing up the pros and cons, you ponder if this dastardly sale could ever even help you.
  6. Optional: you end up buying more pillow covers, not on sale.

It’s human nature to get excited about being able to finally get what you always wanted, and to get it at a reasonable price. As in e-commerce, as in medical life – and rituximab, especially as of late, has presented much the same quandary.

Phil Robinson and I recently wrote an editorial, published this week in The Lancet Rheumatology, about what endemic covid means for rituximab. It seems to be getting a bit of press but I wanted to contextualise it for Australia. Do we have our own balance, or are we just going to end up following US trends?

Rituximab can be an exceptionally useful drug. There are times when nothing else will do, and we seem to keep on finding more and more uses for it at every major conference that goes by. For some time, it really seemed that it was only cost that stopped us using it earlier and for more.

With biosimilars driving the price down, and PBS changes on the horizon, I don’t think it’s out of line to say it really could have been a golden era for rituximab. It was acceptable for us to get a little excited.

Of course, it just had to be the case that covid would come, and that rituximab would disadvantage our patients not only in terms of protection against infection, but with poor response to covid vaccination. In the US, where public health restrictions are loose, and so is covid, rituximab-treated patients have been sitting ducks. Deaths from breakthrough covid infections are dominated by rituximab.

It seems that this might be the latest US trend, coming to an Australia near you. We are, as we’re often told, moving into a different stage of covid – one where Covid Zero is gone, vaccination will protect us and this will be a disease of the unvaccinated. What if your immune system leaves you as vulnerable as the unvaccinated, despite your best efforts? Our country will move on, and we’ll figure out you, your ANCA-associated vasculitis and your covid later.

I was so looking forward to buying the discounted rituximab on the Black Friday Big Day. It seems sad to be sitting there on the website, looking at all the caveats.

There are clearly balances that we need to make, between abandoning a good drug which could lead to better outcomes for our patients, versus taking it on and risking (and definitely fearing) a covid-related death. We are expert at weighing up risk-benefit, but it’s understandable that our enthusiasm has cooled.

Now there are caveats and conditions, of which permanent hiding in the basement is not a practical one. Maybe vaccinating patients before they need rituximab and allowing them strong and sustained humoral immunity might be enough to protect them? Maybe we can find the right early treatments, post-exposure prophylaxis, or even pre-exposure prophylaxis. The right strategies backed up by the right research will be needed if we’re to help our patients benefit from rituximab.

Life wasn’t meant to be easy for rheumatologists. We could dream of generic tofacitinib in a few years, up until ORAL Surveillance wore the gloss away. We were just starting to find more uses for tocilizumab, with biosimilars on the horizon, when it became scarce on the ground.

Rituximab is just one of many, but it’s one where alternative solutions are not thick on the ground. It’s natural for us to walk away from Black Friday disappointed, but we owe it to our patients to help them know what’s best to buy and for them to get the bargain they deserve.