I strongly recommend the blog of Richard Lehman at the BMJ. Each week he surveys the major general medical journals, and provides insightful commentary (e.g. on mesothelioma explained), which is always perceptive, and often bitingly funny and critical. His hilarious comments about naming of antibody based medications, from this weeks issue, and recent comments about the successors to statins (he has claimed copyright to naming them ‘fatins’) are typical. This week he starts off:

Last week, dear friends, we kicked off with alirocumab and evolocumab. This week it’s the turn of nivolumab, ipilimumab, and pembrolizumab. It’s driving me mab.

I wanted to discuss today another issue that he has written about:

When penicillin was first produced in Oxford in 1940, it was life-saving and literally priceless. But soon Norman Heatley invented a way of producing a few grams of it using bedpans and milk bottles, and in 1941 he travelled to the USA to persuade Merck to mass-produce it. There was no question of a patent. Within a few years, penicillin had become one of the cheapest yet most valuable drugs. Now when monoclonal antibodies first appeared in the 1990s, they were rare and expensive. Hundreds have since been patented, and they remain eye-wateringly expensive—£75,000 is the UK cost of a course of ipilumab, for example. The ones we have been discussing this week are last-ditch treatments for aggressive disseminated cancers. Are we to believe that there have been no production advances which could have brought down costs for all these izumabs and ilumabs and olumabs? That £10K per month of postponed death will forever be the fixed price that manufacturers can reasonably demand? I’d be for calling their bluff. There should be an international production facility for producing monoclonal antibodies at cost for use in cancers and for carrying out independent, rigorously conducted trials. The present system is a blot on medicine.

I think we need to go much further than this, for the problem is not just with monoclonal antibodies, but with all new molecules coming to market. Pharmaceutical companies in general price new medicines, not according to some reasonable calculus of cost of production, recuperation of development cost, and a profit margin, but by asking “what is the highest price we can possibly get away with?”

Which means that new medications are all horrendously expensive, even if relatively cheap to produce, and even if the initial R&D costs were funded publicly (as for example inhaled NO and AZT for AIDS). In neonatology we have been a bit sheltered from some of the worst excesses, because our patients use small volumes of any drug. Molecules developed specifically for newborn infants, however, can often be very pricey, such as surfactants, inhaled NO, and intravenous ibuprofen.

I have great fears that any new molecule (lactoferrin? IGF?) specifically developed for preterm babies will end up being ‘eye-wateringly’ expensive also, and that we will have to make choices about what other things we will cut from our budgets (breast-feeding support? Assistance to families?) in order to pay for them.