While a transplant can be life-altering for a patient as a permanent cure for their underlying condition, it can also profoundly affect their immune system, according to Dr. Matthew Cheng, assistant professor in transplant infectious diseases and medical mycology at McGill University, speaking during a panel discussion at Benefits Canada’s Face to Face Drug Plan Management Forum in Toronto in December.
In the session, which was supported by Bristol Myers Squibb, Novo Nordisk Canada and Takeda Canada, Dr. Cheng said transplant physicians must engage in a delicate dance between suppressing the patient’s immune system enough to make sure there isn’t an issue with the transplant, while avoiding suppressing it too much that the patient becomes vulnerable to an infection.
Despite best efforts to tackle these infections, patients often can’t tolerate existing medications or the infection becomes resistant to treatments, he said, noting one of the most common post-transplant problems is a virus called cytomegalovirus. While the virus doesn’t affect a healthy, functioning immune system, it can cause a major problem when the immune system becomes suppressed, such as after a transplant.
Sometimes, despite doctors using everything available to treat the infection, it still becomes resistant and there are no other options, noted Dr. Cheng. “This is a problem because, unless we treat this virus aggressively, quickly and completely, it can cause damage to almost every single tissue in the body.”
That’s why the infectious disease community is incredibly excited to have access to a new drug for the treatment of resistant CMV after transplantation, he said. “It works, it’s safe and it’s going to protect patients when they are most vulnerable.”
In the past, transplant patients had to stay in the hospital for weeks or months post-surgery so they could receive an intravenously administered medication, added Dr. Cheng, noting the new treatment can be given orally, which means patients can get out of the hospital and back to their families, work and society.
While some private payers may suggest the existing standard of care is tried and true and limit access to new innovative therapies, “in the case of CMV post-transplant, the tried and true doesn’t work well,” he said. “This is not a matter of wanting to save a few dollars. This is a life-saving treatment that transplant patients need. Imagine going through a marathon of a transplant with all the side-effects and all the complications only to have a life-saving treatment at the end withheld.”
Also speaking on the panel, Dr. Amer Johri, professor in the department of medicine at Queen’s University, said one of the scariest parts of hypertrophic cardiomyopathy it that it’s one of the most common causes of sudden cardiac arrest.
When a patient has hypertrophic cardiomyopathy, their heart muscle becomes thickened and can’t pump blood properly to supply the rest of the body. Since oxygen isn’t going to the rest of the body or the brain, people might experience palpitations and shortness of breath, feel lightheaded and tired and have chest pain. Patients can have significant life-altering symptoms, which can affect their daily activities, their ability to earn a livelihood and even their mental health.
Unfortunately, “we do not have good treatments,” said Dr. Johri. “We give these patients some medications to try to prevent the complications, including heart failure, rhythm problems and stroke, but we’re not able to prevent some of these ultimate complications.”
Currently, no disease-specific therapies are available to address the underlying mechanism of this condition, he said. However, there’s a surgical procedure to cut out the thickening in the heart where traditional medications don’t work, he added, but it can be invasive and isn’t available to patients in remote or under-resourced communities.
A new treatment option that targets the underlying pathophysiology of hypertrophic cardiomyopathy has shown good effects in clinical trials and improves patient’s functional abilities and quality of life, said Dr. Johri. Physicians will continue to treat with existing medications and, if they aren’t working, will add the new medication. “It’s adding to our armamentarium in the condition for which we had limited options that worked before.”
In 2015, the Canadian Medical Association recognized obesity as a chronic disease and encouraged physicians to provide appropriate treatment, said Dr. Arash Pakseresht, associate medical director of medical affairs for Canada at Novo Nordisk Canada, also speaking on the panel.
The disease is associated with multiple comorbid conditions and increased mortality, he said, citing complications such as type 2 diabetes, fatty liver, osteoarthritis and mental-health conditions like anxiety or depression. Indeed, a patient living with a body mass index between 40 and 50 has a 50 per cent chance of reaching age 70.
A range of treatment and interventions are available for weight management, said Dr. Pakseresht, as well as comprehensive clinical practice guidelines for treating obesity in Canada. The most recent update offered a pharmacotherapy decision tool, he added, because it’s very typical to add on anti-obesity medications as an adjoint to the lifestyle interventions for those with a high body mass index.
However, he noted current treatments can’t offer more than eight per cent to 10 per cent weight loss and lifestyle intervention alone aren’t sustainable. There’s a physiological reaction in the body after weight loss that promotes weight regain, explained Dr. Pakseresht, and it’s very difficult to keep weight off solely with lifestyle intervention.
Bariatric surgery is very effective in terms of the magnitude of the weight loss, but it’s an invasive intervention. As well, some patients don’t qualify for the surgery and there can be two- to three-year wait times in Canada.
Dr. Pakseresht described a new drug that’s been approved for weight management, which reduces appetite and food intake. The dosing schedule is gradual stepwise over time and it offers a 15 per cent sustained weight loss compared to 2.4 per cent from lifestyle intervention alone.
A weight loss as small as five per cent can improve some obesity-related complications, but for many a 10 per cent weight loss is required to improve or reverse other complications, such as fatty liver, cardiovascular disease or type 2 diabetes remission, he said. In the new drug’s clinical trials, half of patients achieved 15 per cent weight loss and the treatment had a positive impact on quality of life and improved physical functioning.
Read more coverage of the 2022 Face to Face Drug Plan Management Forum.