Comprehensive cost analysis of 4th line + therapies for relapsed/refractory multiple myeloma in Germany: Drug, co-medication, and office-based treatment perspective Free

Introduction: The therapeutic landscape of RRMM is undergoing remarkable changes. In recent years, numerous innovative drugs have been approved in Europe, broadening treatment options significantly. Germany is one of the fasted adapting markets due to its unique reimbursement model. In addition to hospital/ambulatory treatment, German patients can also be treated in an office-based setting. Since most RRMM patients are over 70 years and have several comorbidities, treatment in later lines is not only impacted by previous treatments but also considers the social situation (transportation to treatment, time for treatment, side effects etc.) and needs of the patients. For every patient an individual treatment decision is required. We assume, that total treatment costs differ, not only by different drug costs for the myeloma treatment but also show a wide range in costs for co-medications and fees for physician services, number of visits and time at the haematological office. In addition, costs for medications associated with treatment of side effects are considered of high impact.

Objectives: While patients treated in line 1-3 usually get their treatment within hospital setting, patients in later lines are more often treated in office-based setting. Therefore, we wanted to analyse costs for established and novel 4^th line (and onwards) reimbursed treatments for relapsed refractory multiple myeloma together with co-medications and incorporating also costs arising from an office-based setting in Germany.

Method: Desktop research using German databases (Lauer Taxe, EbM-uniformed physicians remuneration catalogue, Onkologievereinbarung-specialized oncology remuneration agreement) was conducted. Whilst there is no official myeloma registry in Germany, treatments we considered were reimbursable combination therapies frequently used in the 4^th line treatment of RRMM in Germany in 2023, containing: carfilzomib, daratumumab, elotuzumab, melflufen, selinexor, talquetamab and teclistamab, and newly approved therapeutic options like elranatamab, along with evidence-based recommendations regarding premedication, comedication, and mandatory prophylaxis of treatment-related adverse events, as outlined in the Summary of Product Characteristics (SmPC) and published literature. Cost basis is price to public on an annual basis. CAR-T treatment was excluded because it is currently only available in the hospital setting.

Results: Costs for myeloma drugs and combinations show a broad variation, from 88.863€ for Elotuzumab/Revlimid/Dexamethasone (ERd), to 178.850€ for talquetamab treatment. The second lowest in terms of annual costs was melflufen with 106.839€, followed by Elotuzumab/Pomalidomide/Dexamethasone (EPd):119.301€, teclistamab: 124.626€, Selinexor/Dexamethasone (Sd): 129.976€, elranatamab: 146.706€ and Daratumumab/Pomalidomide/Dexamethasone (DPd) with 164.578€. Physicians' fees are paid according to federal oncology remuneration agreements and differ between oral and i.v. treatments, with i.v. treatments being the highest, of 853,28€-1096,12€ per year. Costs for concomitant medication also show a wide variability due to patient-individual use, different treatment options, extent of side effects and frequency. Our research identified the concomitant medication for treatment with selinexor-containing regimens as the highest cost driver, with 54.417€ per year for romiplostim mostly, followed by concomitant use of i.v. immunoglobulins for bi-specific antibody-containing regimens, resulting in costs of 18.431,92€-45.302,12€ per year. There are also treatments like DPd with low costs of 2.229€ per year or melflufen with 3.531€ per year.

Conclusions: The costs for treating patients with RRMM in 4^th line+ vary in all 3 categories: drug costs, physicians fees and concomitant medication. While calculating annual costs for the different myeloma treatments is relatively straightforward, showing costs between 88.863€ and 178.850€ per year, calculating costs for concomitant treatments is associated with a high uncertainty because of individual differences and frequency. The next step in our research will be to investigate the use of concomitant medications, based on RWE for Germany. Although treatment patterns for RRMM in other European countries comply with international guidelines, costs will certainly vary here as well. We will compare the costs of treating patients with RRMM in the major European countries in future analyses.