By: Dr Neil Thompson, Chief Scientific Officer at Healx, a company member of the Rare Disease Company Coalition
Innovation in the biopharma industry isn’t always about the development of a new therapy for a condition – sometimes it means pioneering an entirely new approach. Right now, we’re witnessing exactly that, as artificial intelligence (AI) promises to re-engineer the entire drug discovery and development process.
Indeed, AI and other new approaches are allowing novel treatments to be designed, developed and delivered more quickly and on a scale never before seen in the industry. This is offering hope to millions of patients in need – particularly those living with a rare condition (95% of which still lack an approved treatment today).
But what are the implications of this technology for policy, patients and treatment pipelines?
How did we get here?
The historical phenotypic-based and target-based approaches of drug discovery have delivered many of the life-saving and life-changing treatments that health systems now have available to them. Yet, despite the successes, the philosophy of ‘one disease, one target, one drug’ has its limitations.
Traditionally, drugs have been developed to target a single biological entity, and it was viewed as undesirable for a drug to interact with multiple targets due to possible adverse side effects. But this approach often fails complex medical conditions, especially many rare diseases which exhibit a broad range of symptoms and causes.
Increasingly, there is evidence that a molecule hitting more than one target, or multiple molecules targeting a single disease, can create a more efficacious profile compared to single-targeted molecules. However, whilst we are seeing a slight increase in the number of multi-target therapies being approved by the FDA (21% of all FDA-approved agents between 2015-2017 were multi-target drugs), the majority of drugs being studied and in line for approval are still addressing a single target.
This poses a problem for rare diseases not only for the biological reasons mentioned above, but also because policy focused on single target therapies continues to steer therapy development towards common diseases – where there are larger patient populations from which to recoup R&D costs – meaning rare conditions remain overlooked.
Policy for progress
Advances in AI in the last decade have helped improve core processes within the drug discovery and development pipeline – from predicting protein structures and discovering new compounds, to monitoring patients during clinical trials and shaping go-to-market strategies.
AI is particularly adept at tackling the conventional challenges of rare disease treatment development. For example, Natural Language Processing (NLP) models can overcome the lack of consolidated knowledge about a rare condition by automatically scanning literature to fill in the gaps with up-to-date data. Machine Learning (ML) algorithms can speed up the drug discovery and development timeline by looking for connections between diseases and the pharmacology of compounds that are already approved for use in another condition, thereby providing valuable insight into targetable mechanisms for diseases that are still poorly understood biologically. And AI can provide the automation and scale needed to provide cost-effective treatments, thereby reducing the cost of R&D for smaller patient populations.
But therapies for rare diseases can only be developed more efficiently and cost-effectively when policy and regulation keeps up with technology. Promisingly, progress is being made in this space.
The Orphan Drug Act of 1983 ushered in a new energy to focus on rare diseases, granting financial and regulatory incentives for the biotech and pharmaceutical industry to develop treatments for them. The 21st Century Cures Act also provided additional incentives and regulatory changes, and policies like the Orphan Drug Tax Credit and the Accelerated Approval Pathway help improve the likelihood of investment in the rare disease space in order to catalyse the therapy development process and increase the likelihood of therapies reaching patients.
Then there are groups like the Rare Disease Company Coalition, who are championing further changes in policy and regulation to support technological advances in rare therapy development.
Just the beginning
What makes AI and other technological advances so fascinating is that as computing power and improvements to data quality are made, they can be rapidly scaled up. The solutions will come faster and faster as biotechs become able to automate more of the process and run more of it in parallel, with expert humans placed along the chain, at decision points where they can provide maximum impact.
It’s not hard to imagine a future where we’re able to discover treatments for whole groups of conditions at once, guided by both technological and human insight. Suddenly, no disease, however rare, need be overlooked, no question about biology left unanswered. But policies and regulations need to be in place to support these advances, so that tech-derived therapies can reach patients more quickly, especially in the rare disease sector.
Pharmacology isn’t just another discipline for AI to be applied to. It could be the most disruptive transformation in the 21st century. It is essential that government policies continue to keep pace with innovation so that novel uses of technology, including AI, can be readily deployed and utilized across treatment discovery and development to better support people with rare diseases.
We are on the cusp of great progress, we can’t afford to be slowed down now.
Bringing over 30 years experience in drug discovery and development, Neil leads Healx’s preclinical work and is deeply passionate about the application of AI to improve rare disease patient access to treatments.
Why a whole-of-society commitment makes economic sense
By: Gina Cioffi, Senior Manager of Public Affairs at Chiesi Global Rare Diseases, a company member of the Rare Disease Company Coalition. This article was written in response to a new report – “The Burden of Rare Diseases: An Economic Evaluation” – authored by experts at IQVIA and Chiesi Global Rare Diseases.
Rare diseases represent a major societal issue with enormous costs and without a clear, concentrated, whole-of-society effort to address the burden on patients, families and caregivers.
At Chiesi Global Rare Diseases, we set out to studycost drivers contributing to the burden of rare diseases to determine the societal benefit of early diagnosis and availability of pharmaceutical treatments. Along with a number of recent publications on the societal and economic burden of rare diseases, our results concur that the magnitude of the cost burden is staggering. The full report – “The Burden of Rare Diseases: An Economic Evaluation” – is available for download.
We know that lack of rare disease data compromises care and adds complexity to the innovation and drug approval process. And, the full extent of the patient, family, and societal burden will remain mostly undocumented. Our study was done through systematic review of the literature as well as expert consultation. We sought to identify new ways to better understand the cost drivers and economic impact that a lack of available treatments poses. This endeavor is critical so that policymakers can understand the benefit of investing in pharmacologic innovation, and it will encourage the development of policies to accelerate the availability of, and access to, rare disease treatments.
Discussions with patient advocacy organizations and physicians led to the selection of 24 rare diseases, each with high unmet needs, across five therapeutic areas including metabolic, neurological, congenital, hematological, and immunological. The selection criteria included the degree of unmet need, relative importance to patient advocacy organizations, interest in the scientific community, prevalence, and apparent burden of disease.
Our assessment consideredthe direct, indirect, and mortality-related costs of the selected 24 rare diseases. Direct costs include treatment, medical procedures, hospitalizations, physician visits, home healthcare, and other medical costs. Indirect costs include patient and caregiver productivity loss, work loss, home changes, and traveling and accommodation for medical visits. Mortality costs are based on value of statistical life (VSL) and the difference between average life expectancy and that for people with a rare disease.
Among our findings:
Although most direct costs are covered by government and commercial insurers, substantial indirect and out of pocket expenses impact patients and their families. We found that cost of rare diseases would be, on average, 21% more expensive PPPY if there was no access to treatment, demonstrating further that therapy access can alleviate government and family burden.
Keep in mind that these overall findings may represent an underestimation. Social costs, including the impact on health-related quality of life, were not part of this analysis.
A major strength of this study is that it presents an economic tool for analysis of the positive impact of rare disease treatments. This data can help justify increased governmental investment to ensure wider patient access to therapies and policy proposals that are reflective of the unique challenges rare disease patients and companies face.
Immediate actions that can accelerate access to treatment include passage of the Newborn Screening Saves Lives Act, providing the Centers for Disease Control and Prevention (CDC) funding to increase its support for State Newborn Screening programs, and full funding of the Food and Drug Administration (FDA) Orphan Products Grant Program. Further focus to ensure legislative efforts prioritize and reflect the unique circumstances and needs of rare disease patients is another imperative.
Incentives for drug development, particularly the Orphan Drug Tax Credit (ODTC), have changed the trajectory for many rare disease patients and likely achieved significant reduction in federal spending and overall burden. Prior to the ODTC, the number of annual deaths from rare diseases was growing at a slightly higher rate than that from other diseases (2.0 percent versus 1.3 percent, respectively). In the 10 years following, the number of annual deaths from rare diseases declined at a rate of 3.1 percent, while the annual number of deaths from other diseases continued to grow at a rate of 1.2 percent. And, prior to the ODTC, only 38 drugs were FDA approved for rare diseases. Today more than 650 rare disease drugs have been approved by the agency.
Despite this success, the ODTC was targeted in the 2017 Tax Cut and Jobs Act when Congress reduced the total amount of the tax credit for qualifying clinical testing expenses from 50 percent to 25 percent. Our industry has yet to see the full impact of that reduction, and yet in the Build Back Better Act we faced another devastating reduction to the tax credit.
Our hope is that policymakers will continue to nurture and sustain innovation based on the positive economic return from rare disease therapies.
The bottom line is that access to therapies for people living with rare diseases generates significant value for society. Now is the time for the Administration and Congress to come together with rare disease stakeholders and implement actions prioritizing the unmet needs of 30 million Americans impacted by rare diseases.
By: Dr. Jason Shafrin of FTI Consulting. This op-ed was written in response to a new white paper published by Alexion, AstraZeneca Rare Disease, a company member of the Rare Disease Company Coalition.
Although individual rare diseases have a low prevalence, one in 10 Americans is affected by one of 7,000 known rare conditions. Approximately 37 percent of rare disease patients have reduced life expectancies due to a lack of treatment options for conditions, and currently, 95 percent of rare diseases have no treatment option.[i]
Legislation, such as the Orphan Drug Act, helped increase the number of rare disease treatment options available; however, the steadily rising costs for these treatments are a cause of concern for lawmakers. As a result, policy experts are calling for a health technology assessment (HTA) framework that would determine whether the value of a pharmaceutical warrants its price.[ii]
Despite intentions to curb rising health care costs, the implementation of an HTA framework could stifle the balance of innovation in and access to orphan drugs. Research from FTI Consulting’s Center for Healthcare Economics and Policy on how orphan drugs would be affected under an HTA framework finds that the HTA framework could negatively impact innovation, development and access to orphan drugs. This is due to a tendency for many HTAs to apply a one-size-fits-all framework to orphan drugs for rare diseases, which inherently have unique needs and are high-risk endeavors.
The research finds that adopting a national HTA body based on the practices of the Institute for Clinical and Economic Review (ICER) could severely curtail access to orphan drugs for rare diseases.[iii] The millions of patients in the United States who already struggle to gain access to treatment for rare conditions cannot afford to lose even more access to treatment. For example, a recently approved therapy for spinal muscular atrophy underwent significant approval delays in the United Kingdom (among other countries) because the UK’s HTA body—known as NICE—determined that the price was too high to justify the treatment gains, despite robust clinical evidence that the drug showing a “substantial benefit.”[iv] Even for those on treatment, rare disease patients can benefit from improved innovations that help enable them to live longer, fulfilling lives.
Many of the value assessments conducted by current HTA bodies fail to account for broader societal benefits orphan drugs provide nor do they take into account how orphan drugs could reduce health disparities. Few HTA bodies value assessments framework incorporate value from allowing patients to return to work or school, or whether new treatment reduce the burden on parents caring for children with rare diseases. Impacts on health disparities are also largely ignored within traditional value assessment and patient advocates are concerned that negative HTA assessments will impact access. Regarding ICER’s negative assessment of new myasthenia gravis treatments, one patient advocate group stated that any barriers to care, such as ICER’s negative evaluation, “… will likely further disproportionately impact Black patients and exacerbate health inequities”.[v]
Looking ahead, applying an HTA framework to orphan drugs for rare diseases could not only hamper access to existing rare disease treatments, but also it could also decrease the likelihood that new orphan drugs will be introduced to the market. Such as the Congressional Budget Office have found that government price controls—whether due to HTA value assessment or other sources—would significantly reduce the number of new treatments that are brought to market.[vi]
As Congress is assessing current health care initiatives and programs for the future, now is an important opportunity to examine how access to rare orphan drugs are impacted through assessment under the national health technology assessment framework.
As the research points out, a one-size-fits-all model has potential negative consequences for access to and development of orphan drugs. Industry leaders, policymakers, and patient advocates can use this research as a starting point for a timely discussion on how to preserve access and innovation for orphan drugs. In order to properly address potential negative outcomes of all frameworks, a discussion is the first step. Now more than ever, it is imperative that we convene all stakeholders to build on this research. Millions of Americans living with rare diseases are depending on it.
The views expressed herein are those of the author(s) and not necessarily the views of FTI Consulting, Inc., its management, its subsidiaries, its affiliates, or its other professionals.
FTI Consulting, Inc., including its subsidiaries and affiliates, is a consulting firm and is not a certified public accounting firm or a law firm.
[i] Stoller, James K. “The Challenge of Rare Diseases.” ScienceDirect, June 2018.
[ii] Lakdawalla, Darius et al., “Health Technology Assessment in the U.S.-A Vision for the Future.” USC Schaeffer. February 9, 2021. https://healthpolicy.usc.edu/research/health-technology-assessment-in-the-u-s-a-vision-for-the-future/
[iii] FTI Consulting, “Challenges in Preserving Access to Orphan Drugs Under an HTA Framework.” December 2, 2021.
[iv] Taylor, Phil. “Shock as NICE Turns Down Biogen’s SMA Therapy.” PMLive, August 14, 2018. http://www.pmlive.com/pharma_news/shock_as_nice_turns_down_biogens_sma_therapy_1248819.
[v] “ICER Myasthenia Gravis Public Comment.” ICER. ICER, April 2, 2021. https://icer.org/wp-content/uploads/2021/03/ICER_Myasthenia-Gravis_Public-Comment-Folio_091021.pdf.
[vi] Congressional Budget Office. CBO’s Simulation Model of New Drug Development. August 2021. https://www.cbo.gov/system/files/2021-08/57010-New-Drug-Development.pdf
By: Aseel Bin Sawad, Pharm D, MSc, MCR, MS, PhD, DBA, Global Reimbursement and Health Economics Lead at Aeglea Biotherapeutics, a company member of the Rare Disease Company Coalition
There are 7,000 to 10,000 rare diseases when looking at all rare diseases in a collective manner.1 Around 25 to 30 million Americans suffer from rare diseases which equates to 1 in every 10 individuals and 50% are children.2-4
Many rare diseases are life-threatening and progressive with substantial morbidity and early mortality.5,6 Unfortunately, only 5 to 7% of rare diseases have FDA-approved treatments, and the majority of these treatments (75%) treat only one rare disease.7
It is imperative to understand the unique challenges of the entire rare disease ecosystem to provide cost-effective and timely access to treatments for people living with rare diseases.
Challenges associated with rare diseases include, but are not limited to, the ability to make an accurate and timely diagnosis; overwhelming clinical burden; lack of adequate real-world data; ability to quantify the economic burden; and pricing and access.
Diagnoses that are Delayed, Undiagnosed and/or Misdiagnosed
It is common for rare diseases to go undiagnosed or misdiagnosed for years, leading to serious complications such as brain damage, intellectual disability, physical disability, among others. Many rare diseases are associated with a poor quality of life due to their progressive nature, extensive utilization of healthcare resources to manage symptoms, and a substantial economic burden on the patients, caregivers and healthcare system.5,6 A recent study shows that diagnostic journeys of patients with rare diseases are lengthy and delay in diagnosis results in advanced, irreversible, and costly complications.8 Despite being born with the condition (i.e., genetic rare disease), one study reports that patients were not accurately diagnosed until an average age of 6.4 years.9
Inherited metabolic disorders are good examples of the unique challenges posed by rare diseases. While affected infants can be diagnosed through newborn screening (NBS), there are limitations. NBS is not available for most rare diseases, and for those that are included in NBS, the availability and reliability may vary from state to state. In some cases, there is lack of consistency in using appropriate analytical cut-off values for disease indicators.10,11 In addition, false negative results can occur because some plasma enzymes may take time to accumulate in newborns.12
Another challenge during the diagnosis of rare diseases is the heterogeneity of the symptoms. You can find two siblings having the same rare disease, but they have different symptoms. Similarly, many rare diseases often share similar symptomatology, leading to a misdiagnosis. Due to the extremely low prevalence of certain rare diseases, even the ‘disease experts’ may only see a handful of cases in their entire career.
Misdiagnosis can also result in a delayed diagnosis, but with extra clinical and economic burden. Patients may experience serious clinical adverse events due to medications prescribed for a disease that they do not have. In addition, further utilization of healthcare resources such as physician visits, emergency room visits, and hospitalizations, leads to extra economic burden (on the patients, caregivers and healthcare system) while patients continue the progression of their underlying, actual disease.
These examples visualize the differences between a patient who was diagnosed with a rare disease at the right time (Case 1), a patient who was not diagnosed (Case 2), a patient whose diagnosis was delayed (Case 3), and a patient who was misdiagnosed (Case 4).
We call on policymakers to make informed decisions when it comes to rare diseases, to support and expand early diagnosis programs like NBS and timely patient access to orphan drugs to enable better health outcomes.
Congress must also preserve and increase incentives to continue attracting, encouraging, and enhancing long-term investments and innovations of rare disease diagnostics and treatments. It is less expensive for the healthcare system to diagnose a patient on time versus risking complications or a massive event where a child, or others, ends up needing long-term care through state aid.
As we move into 2022, we must look at the big picture to ensure that rare disease patients live the quality of life they deserve, and receive the right diagnosis, at the right time, with the right support.
By: Betsy Ricketts, Chair of the Rare Disease Company Coalition, and Vice President of Policy, Government and Public Affairs at Ultragenyx, a company member of the Rare Disease Company Coalition
Originally Published at TheHill.com (December 29, 2021)
Congress’s proposed limits to the Orphan Drug Tax Credit (ODTC) in the Build Back Better Act (H.R. 5376) could severely hurt development of potential treatments for rare diseases that impact 30 million people in the United States, half of whom are children. It is difficult to understand how Congress could agree to the drastic reduction of this proven resource that supports the development of new treatments for 90 percent of the approximately 7,000 known rare diseases that currently do not have an FDA-approved treatment, many of which are life-limiting or fatal.
To understand the significance of the ODTC, it is important to understand the unique challenges — and promises — in taking rare disease drugs from research through development, approval, manufacturing and delivery to patients. Rare diseases have small patient populations, which makes developing drugs to treat them inherently more difficult, costly, and risky than those for common medical conditions. The ODTC incentivizes biotechnology and pharmaceutical companies to invest in the development of treatments that are not otherwise economically viable.
In 1983, recognizing rare diseases historically have attracted minimal attention, Congress established the Orphan Drug Act (ODA), creating the tax credit for advancement of rare disease treatments. At the time, only 38 drugs had been approved by the U.S. Food and Drug Administration (FDA) for rare diseases. Now, thanks to this effective and long-standing public health policy, there are more than 650 drugs approved to treat rare diseases. Most importantly, this has led to a significant and consistent decline in the number of annual deaths from rare diseases.
Congress should not be focused on snatching hope from those living with rare diseases; our representatives should instead support and enhance existing rare disease policy because it is working. Of note, the FDA affirmed the value of the ODA and this incentive in an Office of Inspector General (OIG) report issued in September. Rep. Anna Eshoo (D-Calif.) also recently called for the complete restoration of the ODTC after it was reduced from 50 to 25 percent in 2017.
Continue Reading at The Hill.com
By: Leslie Meltzer, Ph.D., Chief Medical Officer at Orchard Therapeutics, a company member of the Rare Disease Company Coalition
In the first 24 to 48 hours of a baby’s life, a small blood sample is taken to detect serious genetic conditions, some of them deadly, that can be treated if diagnosed early. Thanks to newborn screening (NBS), a critical public health program that screens about 4 million babies a year in the U.S., parents have the opportunity for timely diagnosis, medical guidance, and disease intervention for their babies.
This NBS Awareness Month, advocates in the field, while praising the system for its many accomplishments and lives saved, are also raising red flags about its capacity to handle the coming wave of innovative gene and cell therapies approaching regulatory approval in the U.S. These therapies can bring hope to families facing rare genetic conditions, but for many of these disorders diagnosis as early as possible is often critical to successful intervention – making newborn screening crucial.
The NBS system needs modernization.
In the last 15 years, only six conditions were added to the Federal Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC) Recommended Uniform Screening Panel (RUSP). On average, it takes approximately six years from the time a condition is nominated until it is added to the RUSP, if it is included at all. Even if added to the RUSP, screening in all 50 states can take up to a decade. For example, SCID was added to the RUSP in 2010; however, the condition was included on the first state panel in 2008 but was not added to all state panels until 2018. That means a baby born in one state can have the advantage of diagnosis, medical guidance, and treatment for an addressable genetic condition, while a baby born over the state line may face disability or early death for lack of testing.
More than 60 new gene therapy treatments – many for serious and rare conditions in children – are expected by 2030. This is therefore the right moment to look carefully at NBS capacities and screening implementation timelines with an eye on what is coming in terms of new therapies. An innovation in rare disease therapy almost always requires timely diagnosis and medical guidance in order for patients to benefit from therapy.
Continue reading here.
By: Habib Dable, CEO of Acceleron Pharma, a company member of the Rare Disease Company Coalition
Originally published on MassBio.org (July 20, 2021)
In the biopharmaceutical industry, this refrain is as familiar as it is true. For those of us at companies committed to developing potentially transformative medicines to treat any of the approximately 7,000 recognized rare diseases—93% of which have no FDA-approved treatment—this call to action has never felt more attainable, yet at the same time, more at risk.
As legislators contemplate a range of access and pricing reforms in this era of rising costs and constrained resources, there is a considerable temptation among legislators to paint our industry with a single broad brush. Such one-size-fits-all policy approaches are a very real threat to the innovation that fuels the hopes of the small but needful patient populations we endeavor to serve. Further, such policies fail to recognize or reward the level of risk that smaller, rare-disease-focused companies—historically, the companies best suited to producing true advances in their chosen spaces—incur through much of their existence.
Before becoming CEO of Acceleron, I spent more than 20 years in classic “big pharma” at a multinational corporation with a vast portfolio of marketed drugs to treat prevalent diseases across a breadth of therapeutic areas. Revenues supported nearly 100,000 employees worldwide and funded a robust research pipeline. This is most certainly not the business model my rare disease counterparts and I execute on. Many of us are in the pre-clinical, clinical or early commercial stage, relying almost entirely on investors for funding as we seek meaningful therapeutic advances. Many of us may only have one or two seemingly viable assets, a precarious state in an industry in which failure is far more often the rule rather than the exception.
Continue reading at MassBio.org
By: Emil D. Kakkis is the CEO, president, and founder of Ultragenyx Pharmaceutical, a company member of the Rare Disease Company Coalition
The FDA’s decision to grant accelerated approval to Biogen’s aducanumab (Aduhelm) for the treatment of Alzheimer’s disease was a difficult and bold one that people with the disease, their families, and other drug developers should be applauding.
When it comes to making new therapies for complex, difficult-to-treat diseases, history has shown that progress can’t be made without taking a first — often controversial — step. Without the FDA’s accelerated approval program and novel first treatments based on new and imperfect biomarker endpoints, HIV would not be a controllable disease today, and we might not have such a flourishing clinical research ecosystem in oncology.
Continue reading at STAT News.