According to a survey by INSIGHT Health, the market for basic therapies for the treatment of rheumatoid arthritis had a sales volume of €739 million in 2008. With average annual growth rates of almost 21 percent, this market has more than doubled since 2004.

> Rheumatoid arthritis (RA) has a prevalence of 0.5–1 percent, with women being affected about twice as often as men. In Germany, approximately 800,000 people are estimated to be affected. Despite its low incidence, RA is of considerable importance due to its chronic course and severity. RA is considered a systemic disease that affects not only the joints but also the heart, lungs, and eyes (see German Rheumatism League Federal Association: Rheumatoid Arthritis - Therapy and Life Perspectives, 2008 (4th ed.), pp. 9 ff.).
In the treatment of RA, early initiation of therapy with basic therapeutic agents, so-called remission inducers or disease-modifying anti-rheumatic drugs (DMARDs), is crucial for the further course of the disease. To take advantage of the "window of opportunity" of an early diagnosis, treatment should be initiated within three months of an RA diagnosis. Diagnosis and treatment as early as possible also makes sense from a health economic perspective: While the direct costs of RA amount to around €4,700, the indirect costs for work absence, early retirement, and other factors are roughly twice as high (cf. German Society for Rheumatology: Economic Implications of RA, p. 12).
The first successes of improved diagnosis and therapy have already been achieved: Between 2001 and 2007, the duration of work incapacity due to inflammatory rheumatic diseases was halved, and the frequency of work incapacity has also decreased significantly (see Hubert: Rheuma-Patienten jetzt besser angebracht, Ärzte Zeitung, March 20/21, 2009, pp. 1f.). On the other hand, sales of basic therapies have increased in recent years. This is due not least to the use of innovative pharmaceuticals.
DMARDs are intended to treat
steer course positively
Drug treatment of early RA is carried out using appropriate basic therapies. In contrast to symptomatic therapy, which can be achieved with nonsteroidal anti-inflammatory drugs (NSAIDs) or so-called coxibs, this group of medications is intended to influence the course of the disease. Continuous DMARD therapy is intended to prevent or delay joint destruction and maintain joint function. The basic therapies listed in the guideline for the treatment of early rheumatoid arthritis form the basis of the following data analyses (see Schneider et al. (2007): DGRh Guideline: Management of Early Rheumatoid Arthritis, p. 13 ff.).
Sales of basic therapies
tika is growing steadily
Analyzing the development of sales of the basic therapeutics presented in the DGRh guideline (2007) based on pharmacy purchasing data, the market volume for 2008 was €739 million based on pharmaceutical company selling prices (ApU) and €962 million based on pharmacy selling prices (AVP). Both sales (based on APU) of immunosuppressants used in therapy (2008: €388 million) and of specific antirheumatics (2008: €351 million) have increased significantly in recent years. Both sales figures more than doubled between 2004 and 2008, with the average annual growth rates for both subgroups amounting to just under 21 percent.
The main drivers of the market are the sales increases of the biotechnologically produced, patent-protected drugs Humira® (adalimumab) and Enbrel® (etanercept), with an average annual growth of 56 percent and 27 percent, respectively, for the years 2004 to 2008 (see Figure 1).
For example, the ApU of the DMARDs etanercept (Enbrel®, 50 mg, 12 pcs, DDD: 7 mg) and adalimumab (Humira®, 40 mg, 6 pcs, DDD: 2.9 mg) is a uniform €4,221.30. This corresponds to a pharmacy retail price (AVP) of €5,271.94. The price of a daily therapeutic dose (DDD) of these two DMARDs is thus over €60. In contrast, generic standard medications containing sulfasalazine or azathioprine, with average DDD costs (according to AVP) of less than €1 and €2, respectively, are a significantly cheaper treatment option.
The differences described have direct implications for the financing of RA patient care: Depending on the chosen treatment approach, the annual direct treatment costs for medications can range from a few hundred to well over ten thousand euros. Furthermore, even small increases in prescriptions for innovative DMARDs can lead to significant increases in revenue and expenditures.

Regional differences in the treatment of rheumatoid arthritis
Regional differences are evident in prescription sales (statutory and private health insurance) for drug therapy with basic therapeutics. Per capita sales vary considerably between the federal states: While in Rhineland-Palatinate, only €6.58 per citizen is sold for basic therapeutics, this figure is €17.35 in Mecklenburg-Western Pomerania. The national average per capita sales in 2008 was €10.15 (see Figure 2).
Incidentally, an average of 60 percent of these sales are attributable to the substances etanercept and adilumimab. While these therapeutics account for only 49 percent of sales in Rhineland-Palatinate, the figure for Mecklenburg-Western Pomerania is 69 percent.
Comparing the data from the individual federal states, with the exception of Bremen and Baden-Württemberg, one can roughly divide the two regions into the southwest and northeast. The northeast is characterized by above-average per capita sales for basic therapeutics, while the southwest is characterized by below-average sales.
However, an analysis of per capita sales of basic therapeutics based on approximately 3,800 regional cells at the place of prescription (ODV: place where the prescription was issued, source: INSIGHT Health) provides a more differentiated picture. A clear regional concentration of prescription sales is evident (see Figure 3).
Annual per capita sales vary regionally between a few cents and nearly €700. The very high per capita sales per inhabitant are predominantly attributable to centers in German cities, i.e., locations where (specialist) medical care tends to be good and where specialized rheumatology practices or experts also attract patients from the (nearby) surrounding areas, who are more likely to prescribe innovative therapies. The top performers here are the centers in the cities of Berlin (€693.49), Freiburg (€663.23), and Mannheim (€567.53). In contrast, in almost 83 percent of the cells shown, DMARDs worth less than €8 per citizen are prescribed. Patients seeking drug therapy in these regions are therefore likely to have less easy access to innovative medications.
by: Christian Bensing /
Dr. André Kleinfeld*