Peter's Quasi-Daily Blah-g

A drug that treats a variety of white blood cell cancers typically costs about $148,000 a year, and doctors can customize and quickly adjust doses by adjusting how many small-dose pills of it patients should take each day—generally up to four pills. At least, that was the case until now.

Last year, doctors presented results from a small pilot trial hinting that smaller doses could work just as well as the larger dose—dropping patients down from three pills a day to just one. Taking just one pill a day could dramatically reduce costs to around $50,000 a year. And it could lessen unpleasant side-effects, such as diarrhea, muscle and bone pain, and tiredness. But just as doctors were gearing up for more trials on the lower dosages, the makers of the drug revealed plans that torpedoed the doctors’ efforts: they were tripling the price of the drug and changing pill dosages.

The drug, ibrutinib (brand name Imbruvica), typically came in 140 mg capsules, of which patients took doses from 140 mg per day to 560 mg per day depending on their cancer and individual medical situation. (There were also 70 mg capsules for patients taking certain treatment combinations or having liver complications.) The pills treat a variety of cancers involving a type of white blood cell called B cells. The cancers include mantle cell lymphoma, which was approved for treatment with four 140 mg pills per day, and chronic lymphocytic leukemia, approved to be treated with three 140 mg pills per day. Each 140 mg pill costs somewhere around $133—for now.

Imbruvica’s makers, Janssen and Pharmacyclics, have now gotten approval to sell four different tablets of varying strengths: 140 mg, 280 mg, 420 mg, and 560 mg. But the new pills will all be the same price—around $400 each—even the 140 mg dose pill. The makers will stop selling the old, cheaper 140 mg pill within three months, according to a report by the Washington Post.

The plan nixes any chance to lower costs with lower dosages. Even if patients can drop down to just 140 mg a day, they’ll pay three-times what they pay now for each 140 mg pill.

“Kind of pissed off”

In a statement to the Post, Janssen and Pharmacyclics explained the move saying the new line-up is “a new innovation to provide patients with a convenient one pill, once-a-day dosing regimen and improved packaging, with the intent to improve adherence to this important therapy.” They noted that those taking 560 mg a day will save money with the new pricing.

But doctors balked at what they saw as an underhanded move. In an interview with the Post, oncologist Mark Ratain of the University of Chicago Medicine, put things bluntly: “That got us kind of pissed off.”

Ratain and colleagues wrote a commentary in the weekly newsletter Cancer Letters this month, decrying the price hike and new pill series, calling it “highly unusual.” In addition to thwarting efforts to help lower treatment costs, the doctors pointed out that the new dosage line-up will make it harder to nimbly adjust patients’ doses by simply advising them to take different numbers of pills each day. Switching a patient from a 280 mg or 420 mg per day dose down to 140 mg will require paper work, filling a new prescription, and having patients return unused pills—a process that can drag out for weeks. And upping a patient’s dose would either be just as lengthy of a process or risk multiplying their treatment costs even further by doubling or tripling the pills each day.

In their commentary, titled in part “Sales Revenues at the Potential Expense of Patient Safety,” the doctors lay out examples of when quick dosage changes would be necessary. Those include when a patient needs to drop down while they’re on a short course of antibiotics or to adjust for new combination-cancer treatments. “Any putative convenience advantage of taking one pill a day is negated by the marked inconvenience to the patient of having to return pills every time there is a need for a dosage change,” they write.

Ratain and colleagues end with a call to the Food and Drug Administration to look into the matter, “given that it creates a barrier to optimal prescribing for some patients,” they write. “We further urge the FDA to recognize that the combination of the high price per pill and the flat pricing scheme are specific impediments to safe administration, and that ignoring the marketing approach for ibrutinib is antithetical to fostering optimally safe dosing and administration.”

Amazon just released a new way for Alexa users to customize their experience with the virtual assistant. New Alexa Skill Blueprints allow users to create their own personalized Alexa skills, even if they don’t know how to code. These “blueprints” act as templates for making questions, responses, trivia games, narrative stories, and other skills with customizable answers unique to each user. Amazon already has a number of resources for developers to make the new skills they want, but until now, users have had to work within the confines of pre-made Alexa skills.

Currently, more than 20 templates are available on the new Alexa Skill Blueprints website, all ready for Alexa users to personalize with their own content. Let’s say you want to make a personalized trivia game for your family and friends: choosing the Trivia blueprint brings up more information about how this particular blueprint works, including audio examples and instructions on how to fill out the template. Click “Make Your Own” to then write your own trivia questions, possible answers, and choose which answer is correct for each question. You can even add sound effects like applause to make the game feel more real. After naming your trivia game, it will be accessible within minutes on all of the Alexa devices associated with your Amazon account.

Blueprints range in complexity and usefulness—some are just for fun, like the various types of trivia games you can customize. Others, like the Houseguest and Flashcards blueprints, could end up being quite useful. Houseguest lets Alexa answer questions about your home, such as “How do you turn on the TV?” or “Where’s the extra toilet paper” and could be helpful if you rent your space on AirBnb, or simply have a friend staying over when you’re out of town. Flashcards let Alexa quiz students on any topic’s terms and definitions using review and test modes. The most ambiguous and easiest to play around with is the custom Q&A blueprint, which lets you program Alexa to provide a specific answer to a custom question.