Dermatologists are regularly affected by non-medical switching as they care for complex patients who might require innovative medications if first line therapies are not effective. Payers use non-medical switching as a cost-containment strategy, and push patients towards medications that are more affordable to them via formulary changes, prior authorization, or step-therapy requirements. A study carried out by Patel et al. showed that non-medical switching could reduce costs for the system and the individual [1].

Many patient advocacy groups are in opposition to non-medical switching. Some argue that the potential savings for switching drug treatments could be cancelled out by additional doctor visits or treatment failures, though there is no consistent evidence of this increased cost. Some others worry that the negative patient expectations associated with a medication switch could result in the ‘nocebo effect’, causing their status to deteriorate. Patients with problems of anxiety, depression, or a tendency to somatize may be impacted more. Frank conversations regarding non-medical switching could alleviate some patient concerns and reduce the risk of negative outcomes. 

Non-medical switching should consider two governing principles: 1) the physician–patient relationship must be protected to ensure the best outcomes; and 2) patients stabilized on a biological therapy should not be forced to undergo a non-medical switch [2].

Biological therapies are the newest frontier in medicine, and these treatments have created new hope for patients with complex dermatologic conditions such as psoriasis and alopecia. Nevertheless, the price of these innovative biological medicines is predicted to outpace the health expenditure capacities of most nations. Non-medical switching from biologicals to biosimilars has the potential to improve access to care. Switching patients from four European countries with rheumatoid arthritis from reference infliximab to a biosimilar (30% cheaper) could save over €433 million over five years according to the study. 

Denmark mandated in 2018 all patients with psoriasis switch from adalimumab originator to a biosimilar. This switch was well-tolerated with appreciable cost-savings for the health system and no apparent negative effect on drug retention. A similar switching policy was initiated in Alberta, Canada, where biologicals account for 72% of total drug spending, with the cost increasing by 14% annually. Approximately 60% of Alberta Health patients have been switched to a biosimilar, resulting in cost-savings for the province.

The impact of non-medical switching may vary greatly based on the patient, their presenting condition, and the medications being switched. The decision to switch should be made after evaluation of and discussions with the patient. Non-medical switching can decrease costs for the system and the individual. As cost-containment becomes an increasingly valued measure of healthcare performance, non-medical switching may become increasingly common [1]. 

Conflict of interest
The authors of the research paper [1] declared that there was potential conflict of interest.

For full details of the authors’ conflict of interest, see the research paper [1].

Abstracted by Hannah Dibble, BS, Caitlin G Purvis, MD; Palak V Patel, BA, BS, Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC 27157-1071, USA.

Editor’s Comment
Readers interested to learn more about non-medical switching are invited to visit www.gabi-journal.net to view the following manuscript published in GaBI Journal: 

A critical review of substitution policy for biosimilars in Canada 

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References
1.  Patel PV, Purvis CG, Hamid RN, et al.  Non-medical switching in dermatology: cost-conscious policy or an affront to patient safety? Dermatolog Treat. 2022;1-8.
2.  GaBI Online - Generics and Biosimilars Initiative. 2nd ASBM/GaBI biosimilar webinar on non-medical switching [www.gabionline.net]. Mol, Belgium: Pro Pharma Communications International; [cited 2022 Nov 4]. Available from: www.gabionline.net/conferences/2nd-asbm-gabi-biosimilar-webinar-on-non-medical-switching

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