The Pharmaceutical Journal Vol 264 No 7081 p184
January 29, Letters

Clozapine

Reduce the price

From Mr S. R. Bazire, MRPharmS

SIR,—As a trust chief pharmacist, I read the recent Novartis promotional supplement on clozapine distributed with The Pharmaceutical Journal with interest, tinged with sadness to think that a respected member of the pharmaceutical industry should spend money on such a document.
Let us examine some facts. Clozapine is not expensive. In fact, it is extremely cheap. One Novartis brand 100mg clozapine tablet is £1.09 in France, 31p in Spain and 26p in Greece. Generic brands are even cheaper, eg, less than 25p per 100mg tablet in the Netherlands. Unlike most other atypical antipsychotics, clozapine is long off patent and there are no research and development costs to recover. At the moment, however, one Clozaril 100mg tablet costs £1.78 (British National Formulary) in the UK. The UK is the only country in the world where only one source of clozapine is available. Novartis is the sole UK supplier and it runs the CPMS (Clozaril Patient Monitoring Service).
The price of Clozaril in the UK includes the cost of the comprehensive Novartis CPMS service. While the safety of the CPMS is beyond doubt, the current Clozaril price can only in part be explained by the inclusion of the CPMS costs. Patient safety has, of course, to be a major consideration but this must be put into some sort of perspective. We must not lose sight of the fact that schizophrenia itself is a life-threatening condition. Up to 10 per cent of schizophrenics die by suicide, particularly in chronic relapsing illness,¹ and clozapine may reduce this high suicide rate, perhaps by up to a 10th.² Since 2 per cent of schizophrenics would die from unmonitored clozapine, it might actually be safer overall to treat all schizophrenics with clozapine and forget the blood monitoring entirely! While I am not seriously suggesting this as a course of action - remember that for a chronic schizophrenic there is a risk to being on clozapine - but there is also a risk in not being on clozapine.
From recent audits, it is clear that there is rationing of the use of clozapine in the UK on price grounds. My own trust has 175 patients on clozapine, with a clozapine expenditure of around £450,000 per annum, and rising. Were clozapine to be the same price in the UK as in, eg, the Netherlands, my trust (and many others) could afford to treat many more schizophrenics, and save significant sums. I understand there are now approaching 100,000 people in the US currently taking clozapine, around 0.03 per cent of the population. In the UK, there are around 12,000 people currently on clozapine, 0.02 per cent of the population. The US figure is 50 per cent higher than that of the UK. There are cheaper generics available in the US, although Novartis in the US reduced the branded clozapine price to just above that of a new generic at the same time that the generic became available. Will it take the appearance of a generic clozapine in the UK to force reconsideration of the current pricing structure?
Any alternative clozapine supplier(s) in the UK would, of course, have adequately to overcome the problem of tracking patients across the country to ensure no re-exposure to clozapine after a clozapine-induced blood dyscrasia. This would not be simple nor cheap, but could be implemented in the UK. For example, in the US, there is a parallel system that combines the advantages of local control with a national tracking scheme. It should be noted that few other countries have any form of national tracking system.
Rather than commission articles on how to put a business case to cash-strapped health authorities for more money for expensive drugs, perhaps Novartis should consider reducing the price of Clozaril, thus making these actions unnecessary, and allowing more patients to receive this invaluable and life saving drug.

Stephen Bazire
Pharmacy Services Director, Norfolk Mental Health Care NHS Trust

Declaration of financial interest I have never received any consultancy fees or honoraria from, nor taken part in funded research nor written sponsored articles for, Novartis, manufacturers of Clozaril, nor from any other company wishing to provide an alternate source of clozapine in the UK, nor do I intend to do so in the future.

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