Comment by cnewey | Hacker News Reader

Comment by cnewey | Hacker News Reader

It's interesting that the article states that Infliximab is more expensive than Adalimumab.

> anti-TNF drugs, such as adalimumab, work similarly to infliximab and are significantly cheaper, more research is needed to establish whether they’re clinically effective

Adalimumab has been extensively tested and has been prescribed in the UK for at least 9 years - as that's how long I've been on it. The NHS wouldn't be prescribing it if it wasn't clinically effective.

Both medications are monoclonal antibodies for TNF-alpha, but are slightly different in formulation. Infliximab is a chimeric monoclonal antibody derived from a mouse/human cell lineage, whereas Adalimumab is derived solely from human sources.

My understanding (from the consultants at the research hospital where I am a Crohn's patient) is that Adalimumab is a) more expensive than Infliximab and b) less likely to trigger the patient to develop an immune response after a long prescription period, as the chimeric cell lineage can be recognised by the immune system as "foreign" after a while. I'm not a clinician so I can't really speak to the correctness of this statement, but anecdotally that's what I have been told by my consultant.

I am not sure that Infliximab is more expensive either. From what I understood at the time of my prescription, Adalimumab (Humira) was the more expensive drug, although prices have dropped significantly since then.

We got a generic Adalimumab formulation on the market in the UK about 3-4 years ago - until then, we were using AbbVie's Humira which I believe cost the NHS about £400/pen at the time. As I understand it, Infliximab is cheaper than this - although the generic Adalimumabs are also cheaper (~£80/pen IIRC).

> trigger the patient to develop an immune response after a long prescription period

My doctor put me on low-dose MTX for this exact reason—here's hoping I never start to develop infliximab antibodies...

Regarding the price, I would also have to assume they're comparing generic v generic (even though generic adalimumab wasn't available in the US until this year!), so I wonder if the reason they're saying infliximab is more expensive is because of the associated nursing labor/infusion clinic/IV supply costs. I only paid five bucks for my meds at the last infusion, but had to pay $160 for them to infuse it in me!

Also, side note, the fact that a name-brand Humira pen "only" cost the NHS £400 in the UK (and likely cost even less for patients) is blowing my mind. They retail for about $3500 a pop here :(

The pricing on Humira in the US feels like a scam, although I'm not totally clear on who--the insurance companies? My insurance covers some % of the astronomical price, I put the rest on a credit card, and AbbVie deposits that money right back into my bank account, minus $5. After about two or three iterations of this, my out-of-pocket maximum has been reached for the year, and I've paid $10-15, minus credit card cash back. I guess having Crohn's has an upside.

The U.S. essentially subsidizes drug development for the rest of the world. It’s f’d up.

What's extra crazy is that Humira in particular was (partly) discovered thanks to British tax dollars. But you're not at all wrong!

It costs nothing in the UK as it's covered under the National Health Service. Well - I say "nothing". All British citizens pay "national insurance", but it's effectively a regressive tax that's not based on the individual's health (as insurance would be), so some folks are effectively subsidising others. To give you an idea of cost, my NI contributions are about ~5.5% of my salary, but that also goes towards the state pension.

All that said, it's not a massive cheap free-for-all on medication - in the UK we've still got hospital/NHS trust budgets which have been iteratively slashed by a decade of successively worse Conservative governments, so generally the inclination is for the NHS to prescribe the (much) cheaper generics.

US health insurance is not based on patients health, either.

There's also a prescription charge, so it's not completely free.

I've been getting a biosimilar to Infliximab for several years to treat Crohns. I go in for an infusion every 8 weeks; about 6 times per year. I can only tell you the cost on the invoice from US providers, but it's about $10k for each infusion. $60k per year.

That said, our healthcare providers get very creative with pricing, so I don't know how Adalimumab compares. It's never been suggested to me.

I’ve been on infliximab for a while. My insurance (in USA) pays about $1800 for the drug + the 2 hours of time in the infusion center. It’s even cheaper (for the insurance company) to do an at home infusion.

Adalimumab (Humira) is available in the USA, and has been for some time.

I think maybe what the article is saying is that they didn't test giving Adalimumab early, so they don't know if that is as clinically effective as the Infliximab that they did test early.

I can tell you that Adalimumab is going to be at least as effective as Infliximab, and probably marginally better, at a minimum. This will obviously vary by patients, but Adalimumb is simply a superior design (it has comparable-to-somewhat-superior epitope conformation/selectivity, and has a humanized Fc part which has a much more favourable immunologic profile), and tends to statistically outperform.

They both have roughly the same target, but Adalimumab is a more recent, technologically superior in every way, design. I'm frankly not 100% sure why any doctor would want to start someone on Infliximab in 2024 if Adalimumab was also available. I think the kind of doctor who does this is the kind of doctor who hasn't caught wind of the fact that early treatment with the best biologics leads to better patient outcomes (this is not the first paper that suggests this, it's a trend in clinical research that dates back at least 15 years). More traditionally, Infliximab was given first, and patients who failed that treatment were then "ramped up" to the equivalent but superior Adalimumab.

Nowadays the state of the art is to start with Adalimumab right off the bat, or even better, one of the newer biologics: either an integrin targeting one like Natalizumab or Vedolizumab (I admit to not being as up to date on this therapeutic avenue as I am on the others), or an IL23/IL12 targeting one like Ustekinumab (although the latter has already been obsoleted by the more p19-selective Risankizumab).

> I'm frankly not 100% sure why any doctor would want to start someone on Infliximab in 2024 if Adalimumab was also available.

My gastro says he simply sees better results on infliximab than he does on adalimumab across all his patients, so he tends to start people on the former first. I think the fact that it's an infusion versus a shot does make a difference. AFAIK very few of his patients end up failing infliximab and switching to adalimumab, other than the ones who don't respond to TNFis period.

(Worth noting here that I actually was on twice-monthly adalimumab prior to getting a Crohn's DX, so I'm definitely one of those people for whom infliximab is a better choice. The adalimumab helped with spondylitis pain to an extent, but GI imaging at the time still came back definitively Crohn-y!)

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