Changing medicine trends and its likely impact on the SA healthcare industry committed to excellence

Top therapeutic groups by expenditure Top therapeutic groups by prevalence Top 50 medicines Chronic conditions and medicine adherence/compliance Compliance and persistence Compliance - the Mediscor experience 2 Content Presented by: Dr. Elsabé Hammann (Medical Affairs: Mediscor PBM)

3 Top therapeutic groups by expenditure 3 Therapeutic group% Expenditure% Prevalence Anti-hypertensives Hipolipidaemic agents Anti-depressants Acid reducers Cytostatics3.90.7

4 Top therapeutic groups by prevalence Therapeutic group% Prevalence% Expenditure Combination analgesics513.1 Cough & cold preparations Beta-lactam antibiotics453.4 NSAIDs323.4 Anti-histamines231.6

Top 50 medicines

66 Top 50 medicines by value % of total expenditure 14% of total volume 4 NCE on top 50 list 12 generics on top 50 list 9 new additions to list, including a biological NCE = New chemical entity, products registered after 2003

7 Top 50 medicines - top 5 cost drivers 4.5% of total expenditure 2.4% of total volume 1. Cipralex  (1.1%) 2. Lipitor  10mg (1%) 3. Nexiam  40mg (0.8%) 4. Prexum  4mg (0.8%) 5. Celebrex  200mg (0.8%) 7

8 Top 50 medicines - New chemical entities 8 Cipralex  Cymbalta  Crestor  Prexige 

9 New chemical entities - 1 st story Cipralex  Newer generation anti-depressant Prevalence of 1.9% and 1.1% of total spent Launched during 2004 Moved from position 7 in 2005 to 3 in 2006 Number 1 product in 2007 Lesson - power of marketing - perception that newer is better

10 New chemical entities – 2 nd story Prexige  COXIB Prevalence of 2.2% and 0.4% of total spent in 2007 Launched during 2006 Moved from position 330 in 2006 to 25 in 2007 Cases reported with liver related adverse effects Various countries withdrew product 18 January 2008 – withdrawn from the SA market Lesson: - clinical trials do not represent real world - neither safety in general population, nor long-term safety has been established before launch of product.

11 Top 50 medicines - generics 11 Prexum  Prexum Plus  Adco-Simvastatin  Aspen Lamzid  Adco-Zolpidem  Coxflam  Amloc  Cilift  Lansoloc  Altosec  Flomist 

12 Top 50 medicines – new listings 12 Crestor  - position 24 Prexige  - position 25 Amloc  - position 33 Arimidex  - position 40 Altosec  - position 41 Singulair  - position 42 Lantus  - position 44 Lentogesic  - position 47 Enbrel  - position 50

Chronic conditions and medicine adherence/compliance

14 Chronic conditions and medicine adherence 14 Compliance = the extent to which a patient acts in accordance with the prescribed interval and dose of a medicine dosing regimen Persistence = the duration of time from initiation to discontinuation of therapy

15 Non-compliance - causes 15 Poor compliance can be caused by: Forgetfulness Lack of knowledge by patient A perceived lack of effect Real or perceived side-effects Unclear instructions for administration Physical difficulty in complying with instructions Unattractive formulation Complicated regimen Cost of medicines

16 Compliance - importance 16 Good adherence to medicine therapy is associated with positive health outcomes. Improved compliance may have the following outcomes: Economic: increased medicine expenditure, with associated decrease in overall healthcare costs. Clinical: better control of the disease. Humanistic: improved patient and physician satisfaction.

17 Compliance – measuring Compliance can be measured as follows: Patient self reports Clinical assessment and – estimation Pill counts Pharmacy refill data Biological and chemical markers Electronic event monitoring systems

18 Compliance – the Mediscor experience Criteria: Patient population - all registered CDL PMB patients for 2007 Measured the number of months in which medicine for CDL was claimed Compliance defined as 10 or more months of treatment in 12 months

19 Compliance - the Mediscor experience

20 Compliance - the Mediscor experience 20

21 In summary Five therapeutic groups are responsible for 31% of total medicine expenditure in 2007 Top 50 products are responsible for 23% of expenditure  Four NCEs on the top 50 list  Cipralex , a NCE, is the number one product  12 generics on the top 50 list  9 “new” products 50% of patients claimed at least once for a combination analgesic and a cough & cold preparation 64% patients with a registered CDL PMB condition is compliant with their treatment Compliance  Measures to enhance compliance should be implemented  Increased compliance will increase medicine expenditure, but  Overall healthcare costs will decrease.

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