Drug of the Month – Infliximab (Remicade) from Centocor, Inc.
Home Infusion Therapy has long been centered on certain core therapies. Antibiotic and analgesic therapies and parenteral and enteral nutrition have long been mainstays of the industry, but not many drugs have been added to the armamentarium lately. One drug that does lend itself to home infusion therapy is infliximab.
What is infliximab?
Infliximab is monoclonal antibody that specifically binds to human tumor necrosis factor alpha, which inhibits its binding to its receptor. TNF a is found in elevated concentrations in the fluids and tissues affected by a number of inflammatory conditions, including rheumatoid arthritis, Crohn’s disease, ulcerative colitis, ankylosing spondylitis, psoriatic arthritis and plaque psoriasis. Infliximab is indicated for all of these conditions
How is infliximab provided and prepared?
Infliximab is provided as a lyophilized white powder in vials of 100 mg. It is reconstituted with 10ml of Sterile Water for Injection. The vials contain no preservative and the entire content must be administered or discarded right away. The manufacturer recommends that the infusion must begin within 3 hours of reconstitution. The patient’s dose should be finally diluted in 250 ml of 0.9% Sodium Chloride Injection, which should be administered over not less than 2 hours.
Is infliximab associated with adverse reactions during the infusion?
Yes. When infliximab was first marketed, home infusion was strongly discouraged because hypersensitivity was believed to be too great a risk. These reactions have included hypotension, urticaria, and dyspnea. The manufacturer recommends that any time infliximab is to be infused, epinephrine, corticosteroids and antihistamines must be readily available.
How is infliximab administered at home?
Typically, the nurse reconstitutes the dose in the home and then dilutes it in the final container. The drug is typically administered via a rate control device to ensure the two hour infusion time, with the nurse in attendance throughout. The nurse records vital signs frequently and regularly, before and during the infusion. The infusion is interrupted immediately at the first sign of adverse reaction.
Who prescribes infliximab?
Rheumatologists prescribe infliximab for rheumatoid arthritis and ankylosing spondylitis. Gastroenterologists, and some surgeons do the bulk of prescribing for Crohn’s Disease and ulcerative colitis. Dermatologists prescribe the drug for plaque psoriasis and for psoriatic arthritis.
How can we sell infliximab?
The physician can obtain substantial reimbursement for office-based administration of infliximab. Physicians who are entrepreneurial enough to create office-based infusion suites are unlikely to refer these patients to home infusion providers. Investigate the likely specialists in your area to determine which ones do office infusion and concentrate your efforts on those who have not. Inquire as to whether your local hospital has an ambulatory infusion center and determine whether significant infliximab is being administered there. Many such hospital-based centers do a poor job of collecting for such infusions and they might see your willingness to take these patients as an attractive method of cost-avoidance.
Who pays for infliximab?
Virtually all third-party payers pay for this drug, but many third-party payers consider it to be a “specialty” drug, and therefore restrict payment for it to either a single provider or to a small panel. Since the drug is so expensive, you should never admit a case unless or until you know you will be paid for it at an acceptable rate.
How is infliximab coded?
The S-code for infliximab is S9359. That code description is: “HOME INFUSTION THERAPY, ANTI-TUMOR NECROSIS FACTOR INTRAVENOUS THERAPY; (E.G.INFLIXIMAB); ADMINISTRATIVE SERVICE”
What is the financial impact of infliximab?
The AWP of infliximab is nearly $692 per 100 mg vial, so for the average patient, receiving 2.5 to 5 mg per kg, the typical dose is 2 to 4 vials per dose. The dosing cycle depends on the disease, but is usually one infusion every 4, 6, or 8 weeks. If the patient is responsive, the drug is given for very long terms of therapy.
What special considerations pertain to infliximab?
Infliximab predisposes the patient to infection, including bacterial sepsis, tuberculosis, invasive fungal and other opportunistic infections. It is an absolute requirement that latent tuberculosis be ruled out before commencing therapy, because infliximab administration can reactivate and disseminate dormant disease. Infliximab co-administered with 6-mercaptopurine or azathioprine has also been implicated in a rare form of T-cell lymphoma, particularly in adolescent and young adult patients.