Australians seem to have greater pharmaceutical options for rheumatic disease than Kiwis – but maybe that’s not always a good thing.
Sometimes I look over the ditch with envious eyes.
Rheumatologists in Australia seem to have free and easy access to a vast range of biologic and targeted DMARDs – the stuff of dreams for this Kiwi rheumatologist.
That’s what comes with spending twice as much per head of capita on pharmaceuticals. Australia spends about 1.4% of gross domestic product (GDP) on pharmaceuticals – close to the OECD mean of 1.5% – while New Zealand spends 1% of GPD on medicines.
You get what you pay for, and in New Zealand that means people with rheumatic disease can access a more limited range of biologics and there are no government subsidies for Janus kinase inhibitors – and therefore virtually none are prescribed.
On the flipside, through the Pharmaceutical Management Agency, or PHARMAC, national-level purchasing means the New Zealand government gets “the best health outcomes for New Zealand’s investments in medicines”. I think that’s government-speak for “we get the medicines at a very good price”.
We don’t have any national-level data describing outcomes for our patients, so the impact of differences in access to modern therapeutics remains unclear. Logical thinking would conclude that there will be patients with immune-inflammatory conditions in New Zealand that have unmet treatment need, or have adequate disease control but have to contend with medication adverse effects that they would avoid if they could.
One thing patients in rheumatology clinics in New Zealand do not have to contend with is the shock of hearing that your wonder drug, the oral targeted medication that you tolerated so well, has suddenly been slapped with a black box warning. And there’s nothing that scares a patient more than the lolly scramble of familiar and sinister adverse outcomes of “heart attack and stroke, cancer, blood clots” with the ultimate adverse outcome of “death” offered almost as an afterthought.
While grappling with limited access to therapeutics for my patients, I have often recalled the aphorism offered by the clinical pharmacologist who taught me as a medical student: “When a new drug class comes to market, don’t prescribe it to your patients for a year, but don’t let your family have it for five years.” Given that the first Janus kinase inhibitor was registered for use in Australia by the PBS in October 2015, the five-year window seems a fairly accurate time frame.
Rheumatologists from both sides of the Tasman Sea share a college and its training programme, and face many similar patients in day-to-day clinical practice. What we don’t have in common are therapeutic options.
I’ve no doubt that eventually many more medication classes will be funded in New Zealand. By then we will have an increased understanding of the benefits and risks. Sometimes waiting has its advantages.
