ideasIdea
Publicly funded dose-reduction trials of expensive approved drugs
Many approved cancer drugs probably work just as well at half the dose, which would halve their side effects and cost. Companies will not test this, so payers and public funders should.
Payers and public agencies fund randomised non-inferiority trials of reduced doses or less frequent schedules of high-cost approved agents, prioritised by spend and by pharmacological plausibility (saturated target, flat exposure-response, long half-life). Precedents include reduced-dose abiraterone with food and reduced-dose or extended-interval checkpoint inhibitors. Results are used directly in reimbursement.
Hypothesis
At least half of well-chosen dose-reduction trials will demonstrate non-inferiority, and the savings from adopted reductions will exceed the trial costs within two years of read-out.
Rationale
The pharmacology of several blockbuster agents suggests over-dosing; the financial return for payers is immediate and large, and the incentive gap for sponsors is structural.
What would test it
A payer consortium funds five such trials over five years and reports non-inferiority results and realised savings.
Maturity
being tested at scale
Who has to act
payer
Cost to try
Medium ($1M to $50M)
Years to first evidence
4
Bottlenecks it attacks
- Wrong doses · Most drug doses were chosen as the highest a person can tolerate, which is often more than they need.
- Prices and value · New cancer drugs routinely cost over $150,000 a year, often for months of benefit. Systems cannot afford them and patients go bankrupt.
- Incentives reward me-too drugs and marginal gains · The system pays the same for a drug that adds two months as for a cure, so companies race to copy rather than to cure.