Drug expenditures in the US grew by 7.7% in 2021 compared to the previous year, as per a recent report published by the American Society of Health-System Pharmacists. The increase was driven by a 4.8% increase in utilization or volume, a 1.9% rise in drug prices, and the rest due to new drug introductions. Unsurprisingly, AbbVie’s blockbuster drug Humira (adalimumab) was the top drug in terms of overall expenditures, followed by the blood thinner Eliquis (apixaban), manufactured by the pharma giants Bristol Myers Squibb and Pfizer, and Eli Lilly’s type 2 diabetes injectable Trulicity (dulaglutide).

The analysis relied on the IQVIA National Sales Perspectives database that records drug purchase data involving several groups including hospitals, retail pharmacies, clinics, home health facilities, and more.

“The drug spending whiplash that clinics and hospitals experienced in the first year of the pandemic did not end with 2021,” said the report’s lead author, Eric Tichy. “Due to the uncertainty of the pandemic, it is unclear how Covid-19 vaccines and treatments with an emergency use authorization (EUA) may influence drug expenditures after FDA approval in 2022, ” he told Pharmaceutical Technology.

He said one aspect of drug spending that stood out was the continued use of Gilead Sciences’ antiviral Veklury (remdesivir), one of the first drugs to receive an EUA to treat Covid-19 in 2020. “[Clinicians are] not able to use other monoclonal antibody therapies because of the resistance issues, so we’re still using Veklury a fair amount, even in the outpatient setting.”

Nonfederal hospitals spent $3.1 billion on Veklury, which was more than the next three drugs combined, as per the report. Once the FDA approved Veklury in October 2020, there was a 167.7% expenditure increase for the antiviral in clinics in 2021. “It’s still a commonly utilized drug and is the only one that has switched over to commercial distribution where the federal government is not paying for it. If it keeps getting used, that will drive up drug utilization costs this year too,” said Tichy, who is also the division chair for supply chain management at the Mayo Clinic in Minnesota.

Swiss pharma Roche’s Actemra (tocilizumab) was another Covid-19 drug that showed a marked increase in expenditure since the pandemic began. There was a 107.9% rise in Actemra expenditures in nonfederal hospitals in 2021 compared to the previous year. Tichy said had it not been for drug shortages that necessitated rationing, this figure could have been even higher.

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Actemra was one of several drugs repurposed to treat Covid-19, but not all have been subsequently found to be effective. The report’s analysis provided a snapshot of how much the controversial drug ivermectin—which has now been found to provide no substantial benefit in several randomized studies—was used in 2021. Ivermectin expenditures experienced a singular 228.0% increase in growth compared to the previous year.

Drug spending increases overall

In 2021, drug expenditures across all sectors grew, with a marked rise in spending by mail-order pharmacies and home healthcare. For the analysis, the report included licensed mail-service pharmacies—both private and federal. Home healthcare meant licensed home health organizations and visiting nurse entities.

The increase in drug spending was a product of several factors. For example, the 7.7% change in drug spending from 2020 attributed to clinics—which include physician offices and outpatient clinics, specialty clinics covering oncology, dialysis, and more—was a combination of an 8.2% increase in volume, a 0.8% increase from new products, and -1.3% negative change from price shifts. As per the report, the pattern of negative pressure due to price reductions was more significant for generic products.

Another trend noted by the report’s authors was an increase in biosimilar use. For example, biosimilars for Avastin, a drug used to treat several types of cancers, had a market share of 62.9%—compared to 35.6% in 2020—in clinics. Similarly, Herceptin biosimilars now hold a 63.2% market share, up from 35.7% the preceding year.

“Clinicians are becoming more comfortable with biosimilars and that has increased their uptake,” Tichy said. Patient litigation has held up several biosimilars, but several, including those for Humira, are expected to hit the market in 2023. Humira is used mostly in the outpatient setting and is covered under “pharmacy benefits” as opposed to “medical benefit” for insurance. Once the Humira biosimilars are launched, they’ll be the first high-cost biosimilars in that retail setting, Tichy said. Last year also marked the FDA granting interchangeability designations to two biosimilars, which means that they can be prescribed in place of a reference therapeutic without additional paperwork.

Amid all these spending increases, however, the controversial Alzheimer’s disease drug Aduhelm was associated with only $2 million in expenditure for clinics and hospitals. Reimbursement issues, monitoring requirements, and questions on clinical evidence backing its efficacy seem to have significantly limited its use in 2021.