Zimberelimab

2024年医保谈判，比往年提前了一点，赶在了最冷的时节到来之前。全国人大会议中心的门口反而没有像往年那样人头攒动。 场外陪同的企业人士格外的少，谈判代表进场后，他们站在商务车附近，分散在全国人大中心街道上和附近的胡同里，随时准备接应从会场出来的谈判代表。今年谈判代表依然三缄其口，从现场出来后三两步走到车上，扬长而去。 除了谈判企业，还有前来了解风向的其他投资方和企业方人士。一位药企人士在场外驻足一会，本想跟同行聊一聊，但来的时间不巧，没遇到熟人。他今年没参与谈判，是为了明年做准备，“今年预示明年，如果今年严峻，明年只会更严峻。” 01 没有灵魂砍价，但依然艰巨的谈判 从谈判企业来看，第一天谈判品种主要是代谢、心血管、镇痛等，第二天主要是降糖药和肿瘤药，第三天以肿瘤药和中药为主，最后一天多为非独家竞价品种。 从场外很难看出总体风向，无法用温和或者严峻的词汇一概而论，所有情况都因品种而论。 PD-1格局或许有变，目录外的PD-1中，誉衡生物的赛帕利单抗、正大天晴/康方生物的派安普利单抗去年放弃谈判资格，今年是首次参与。恒瑞、君实和百济神州也要进行新增适应症谈判。 糖尿病药物和肺癌药物依然竞争激烈。糖尿病药物品种多，专家过评率较高，主打一个混战。今年诺和诺德公司的依柯胰岛素周制剂，海思科的DPP-4抑制剂考格列汀片，信立泰的DPP-4抑制剂福格列汀、恒瑞的（SGLT2）抑制剂脯氨酸加格列净片、复方制剂恒格列净二甲双胍缓释片、武汉久安药物研究院的盐酸二甲双胍缓释片均前来谈判。 肺癌领域按照靶点分成不同赛场。三代EGFR迎来新的搅局者，今年上市的圣和药业的瑞厄替尼片、倍而达的瑞齐替尼现身。MET抑制剂中三个特泊替尼（默克）、卡马替尼（诺华）、伯瑞替尼（鞍石生物）都出现在初审名单中。ROS1抑制剂方面，今年获批的瑞普替尼（再鼎医药）、安奈克替尼（正大天晴）在初审名单中，即将冲击两款进口药克唑替尼（辉瑞）、恩曲替尼（罗氏）的市场地位。 大多数领域内资和外资已经在正面交锋，自免领域目前还是外资的主场，涉及的自免药物包括赛诺菲的度普利尤单抗、GSK的IL-5生物制剂美泊利珠单抗、诺华的司库奇尤单抗、辉瑞的JAK抑制剂阿布昔替尼。 有的品种谈判时间不到半小时，康方生物的两款双抗产品和阿斯利康的DS-8201都在第二天上午进行谈判，他们结束得尤其的晚，康方生物董事长夏瑜下午一点才走出会场，比她更晚的还有阿斯利康中国区副总裁黄彬。 一周前的预谈判会有更多拉锯。在专家评审阶段结束后，国家医保局会通过申报系统向相关企业反馈评审结果，包括经专家评审确定的谈判/竞价参照药品、谈判主规格和医保支付范围等内容。在预谈判阶段，药企可以了解到参照药品的选择。如果对参照药品的选择不满意，还有机会进行申诉的。药企对正式谈判的预期反而是比较明确的。 但偶尔会出现意外插曲，现场因素也有可能对结果产生影响。 一位企业代表听说同品种竞品已经完成续约，顿时紧张起来，该竞品是他们的参照药品，他担心竞品再次降价后，压缩了自己谈判的空间。 不管客观情况如此，药企的主要任务就是证明自己值得被最大的支付方医保买单。业内人士对于谈判产品的最终成功率倒是有比较乐观的期待。“经过多年的谈判经验后，谈判双方更有默契，对于降价幅度、信封底价也有把握。” 值得关注的是，今年很少看到对灵魂砍价的宣传，在国家医保局官方公众号的评论区，精选留言中许多关于对创新药进医保的呼声。 图片来源：深蓝观 02 什么是有价值的创新？ 今年医保谈判的特点之一，在于谈判品种较少，前期评审时的过评率较低。2023年国家医保谈判，121个品种谈判成功；而今年，通过形式审查的目录外药品249种，最终参加谈判或竞价的只有117种。 一名医保研究者说到：“国谈现在主要是医保资金池子有限。降幅和通过率也都降低了不少。”根据医保局在谈判开始前发布的一系列文件，本次国谈以“加快创新药的临床应用”为重点，将主要关注创新护城河高的产品，对于普通品种的药物较往年而言筛选更严格。 业内流传，今年医保局的一个重要任务是：支持创新药。 国家医保局已经建立起一套在流程上科学、系统的医保准入程序，包括准备阶段、申报阶段、专家评审、谈判/竞价与结果公布，其中专家评审是实现“价值定价”的核心，包含综合评审与药品价格测算两大关键价值评估环节。 从去年开始,医保部门在药物评审中新引入了药品分类方法,基于临床价值分为突破性疗法、改良型新药、药效相当、不及性药物4种。不及性药物指的是那些疗效不显著优于现有药物、毒副作用不更低、患者依从性不更佳的药物，这类药品在医保评审中不被视为优先考虑的对象。 医保局格外强调对创新药的鼓励，但对于创新药的分类和出价，药企或许会有不同意见。 这一偏差体现在医保局对参照药品的选择上，比如用一代药作为二代药的参照，用不同适应症的同类药作为参照。药企如果不满意参照药品的选择，可以进行申诉，但有说服力的理由不应该只是技术的迭代，而是真正的临床价值。 从这个角度来看，今年有很多有讨论空间的品种。 比如恒瑞的复方制剂恒格列净二甲双胍缓释片，是首个SGLT2抑制剂联合二甲双胍的固定复方缓释制剂，在疗效上提供了血糖控制和额外的心血管保护效果，最终能在价格上可能高于普通二甲双胍。 康方的两款PD-1双抗，是相对于PD-1单抗的升级。目前医保目录内的四款PD-1单抗年治疗费用已经很低，按照用药时间12个月测算，恒瑞医药卡瑞利珠单抗年治疗费用约4.6万元、百济神州替雷利珠单抗年治疗费用约4.5万元、君实生物特瑞普利单抗年治疗费用约4.4万元. 康方生物在谈判前将卡度尼利单价从13220元/125mg/瓶降至6166元/125mg/瓶，降幅为53.4%，年治疗费用控制在20万元以下。依沃西单抗保持49.7万的年治疗费用。 HER2 ADC方面，阿斯利康的三代ADC德曲妥珠单抗的HER2阳性乳腺癌二线治疗、HER2低表达乳腺癌二线预计本次谈判，由之前的8860元/支降为6912元/支，并同步取消慈善赠药，年治疗费用依然在30万以上。 其参照药是同为HER-2靶点的ADC药物注射用恩美曲单抗，罗氏的二代ADC恩美曲妥珠单抗目前共获批HER2阳性乳腺癌二线和辅助治疗2个适应症，已在医保目录中，预计今年到期续约。恩美曲妥珠单抗年用药费用为13.44万元，两者中间还有十多万的价格gap。 医保局对这些升级换代药物的价值评定，要等到谈判结果出来之后才能揭晓。 03 最关键的一年 从2015年开始，中国创新药行业经历了10年的研发阶段，现在正迎来自主创新药的收获阶段，走完第一个产业周期。 药企到了关键时期，如果销售额无法覆盖研发投入，看不到商业化的希望，药企会早早将临床早期的管线以几千万美元的首付款授权给海外药企。近两年，海外BD“不得已的活跃”，成为药企的生存手段。能BD出海的管线，一定是存在国际竞争力的。这些管线在临床早期就被海外药企锁定，可能会减少国内企业从这些研发投入中获得的回报。 由此会给整个产业链带来一个难题：前期投入的社会融资、政府引导基金、政府补贴就会代为补偿。这样损失的不仅是在第一个产业周期的投入，还有对下一个产业周期的预期。 近几年里，今年尤为关键。 从营收环境来看，今年转好希望有限。根据各企业中报，2024年上半年，医药板块的营业收入为1.3万亿元，较去年同期略有下降，降幅为0.44%。从投资规模来看，上半年医疗健康领域一级市场共发生630起投融资事件，同比下降27.8%，融资金额总计421.6亿人民币，同比下降1.1%。 在生物制药融资寒冬之际，如果中国生物技术公司因为资金不足，将有潜力的药物授权给跨国药企来继续开发，那么这些药物最终由跨国公司上市，这会使医保谈判更难，因为跨国公司对药品价格的要求通常更高。 在外界环境掣肘的条件下，此次产品是否能够进入医保目录，将影响着药企在未来一段时间的走向。但上述医保研究者也提到，这种“指望”本身是不平衡、不健康的，尤其在定价方面，医保方和企业方的逻辑是不同的。 “从研发，立项，临床，投资融资，等等环节，把创新药的未来市场预期和企业估值拉到一个脱离市场的水平。然后遇到了一个目前筹资只有一年3万亿左右不到的医保，中国药品行业市场营销就是不到一万亿的市场规模。之前有个专家做过统计，医保基金3万亿，换算成美元，仅仅跟全球最大的两家药企年营收持平。”上述研究者分析到。” 在我国医疗支付端结构以单一的医保基金支付为主的现状下，医保基金任务艰巨。 在这种情况下，想要把投资方、产品方、支付方的期待拉平，一方面要对医保基金进行结构性调整。 数据显示，2022年，医保对新药的支出从2019年的59.49亿元增长到481.89亿元，增长了7.1倍。浙商证券计算，2022年创新药占医保基金比例仅为1.96%。1.96%的占比说明医保基金对创新药支付的提升空间仍然很大，应该是医药板块少有的医保支出金额具有较大上行空间的行业（2017年美国医药市场创新药占比77%，中国创新药占比仍较低）。腾笼换鸟，涉及利益博弈，需要魄力和时间。 另一方面要依靠市场上更多参与方的加入和稀释。这也是国家医保部门在谈判之外正在积极谋划的事务——构建多层次的保障体系。 近期，上海医保局率先开始了多元支付的试点行动，参与方包括两家商保公司，12家公立医院，以及上海医保局、上海金融监管局、上海保交所等官方部门。患者在就诊后，可以即时享受“商保+医保”的一次性结算。 同时，今年9月，国务院印发《关于加强监管防范风险推动保险业高质量发展的若干意见》，其中提到：推动商业健康保险与健康管理深度融合。鼓励面向老年人、慢病患者等群体提供保险产品。 “医保是保基本的前提下支持创新。其他资本可以在鼓励创新前提下兼顾基本。”上述医保研究者说到。 在他看来，无论每年的谈判降幅如何浮动，最终落入的价格区间必定是在医保视野下的合理价格，为基本保障的目的而设置，只能兼顾鼓励创新。因此，讨论降幅变化的意义不大，只有将以鼓励创新为主要目的的市场化支付逻辑重新整合，中国创新药企业才能真正找到一条长久稳定的道路。 来源 | 深蓝观（药智网获取授权转载） 撰稿 | 吴妮 李昀 责任编辑 | 八角 声明：本文系药智网转载内容，图片、文字版权归原作者所有，转载目的在于传递更多信息，并不代表本平台观点。如涉及作品内容、版权和其它问题，请在本平台留言，我们将在第一时间删除。 商务合作 | 王存星 19922864877（同微信）  阅读原文，是受欢迎的文章哦

iStock/ Marcin Klapczynski After several high-pro including BMS’ $1.5B breakup with Agenus, anti-TIGIT therapies are generating cautious optimism. TIGIT therapeutics have the potential to extend the benefits of checkpoint inhibitors to patients who can’t yet benefit from the anti-PD-1 and anti-PD-L1 therapeutics that have revolutionized cancer treatment. While the modality has seen a spate of high-pro recent mid-stage data from an anti-TIGIT therapy developed by iTeos Therapeutics shines a light on the continued interest and movement in this space. Last month at the 2024 European Society for Medical Oncology (ESMO) Congress, iTeos and GSK revealed Phase II results showing that iTeos’ anti-TIGIT candidate belrestotug plus GSK’s anti-PD-1 therapeutic Jemperli elicited promising response rates in patients with non-small cell lung cancer (NSCLC). The data had been highly anticipated, with the prime ESMO presentation spot alone propelling a rise in iTeos’ shares, according to STAT News . TIGIT, short for T cell immunoreceptor with Ig and immunoreceptor tyrosine-based inhibitory motif domains, is an inhibitory receptor that is expressed on the surface of the T cells and natural killer (NK) cells, as well as other immune cells, explained Hua Wang, an assistant professor at the University of Illinois Urbana-Champagne. “Anti-TIGIT therapies . . . aim to reactivate the T and NK cells,” he told BioSpace . But while much excitement has surrounded this class of cancer therapy, companies in the space have suffered numerous setbacks, most recently in August when Bristol Myers Squibb canceled a $1.5 billion TIGIT deal and returned the asset to Agenus. Earlier in the summer, Roche and Merck each announced that recent Phase II/III studies comparing anti-TIGIT therapeutics alone or in combination, against either Keytruda or Keytruda plus chemotherapy, failed to meet the primary endpoints. Despite the challenges, the anti-TIGIT space has remained active. Roche and Merck are both continuing TIGIT studies, for example. “We believe TIGIT is a valid target, based on data and clear activity observed in some tumor types,” a Roche spokesperson told BioSpace in an email. Readouts for Roche’s Phase III trials of tiragolumab are expected this year in NSCLC, and for esophageal cancer and liver cancer in 2025. Meanwhile, Merck is conducting several Phase III studies evaluating a fixed-dose combination of its anti-TIGIT drug vibostolimab and Keytruda in NSCLC, including KeyVibe-003 , KeyVibe-006 and KeyVibe-007 . Other companies in the TIGIT space include BeiGene and AstraZeneca , as well as partners Gilead and Arcus Biosciences. The latter two companies are moving anti-TIGIT therapy domvanalimab and anti-PD-1 antibody zimberelimab plus chemotherapy into Phase III studies for lung and gastrointestinal cancers after positive Phase II data presented in the spring, as GSK and iTeos take their combo into Phase III in first-line NSCLC. Trial Design Matters The recent difficulties in the TIGIT space show how trial design affects outcomes, Michel Detheux, president and CEO of iTeos, told BioSpace by email. “Roche, Merck, and Arcus (with Gilead) each evaluated their TIGIT therapeutics combined with a PD-1 and chemotherapy in first-line NSCLC despite no pattern of care having been established to indicate that chemotherapy enhanced efficacy in that setting.” For example, in 2023, Roche’s SKY-01 Phase III trial “compared its TIGIT+PD-L1 [tiragolumab + atezolizumab] against its own PD-L1 [atezolizumab] instead of the standard of care [Keytruda, a PD-1 inhibitor], which created confusion about the performance of its TIGIT + PD-L1 and PD-L1,” Detheux said. More recently, he continued, Merck’s Keyvive-008 evaluated vibostolimab plus Keytruda in small cell lung cancer (SCLC). “Merck was attempting to beat a newly established standard of care with its TIGIT+PD-1 therapeutic, despite SCLC being an indication where TIGIT had failed previously, and where [Keytruda] also had failed.” Merck discontinued the Keyvive-008 trial. What the failed trials show is that “the immune checkpoint axis is perhaps more complicated than we thought,” Michael Gibson, an associate professor of medicine at Vanderbilt University, told BioSpace by email. “More components are involved in the tumor microenvironment than just the drug-target interaction.” Setbacks should be expected, though, Gibson added. “The nature of clinical investigation teaches us that setbacks are more common than progress. We learn a great deal from so-called negative trials.” The question of whether setbacks related to TIGIT therapeutics may be overcome “is both scientifically interesting and clinically challenging,” Gibson commented. He speculated that in the face of setbacks, this class may add therapeutic benefits as a combination therapy. While checkpoint inhibitors are the current companions of choice, there may be other possibilities. “Some insight may lie, for example, in drug mechanisms such as bispecifics and antibody-drug conjugates, combinations of inhibitors, modulation of the tumor microenvironment and even, perhaps, by affecting the patient’s microbiome,” Gibson said. Notably, “Roche found a correlation between the response to anti-TIGIT therapy and the expression level of CD-155 on the surface of the tumor cell. That’s very positive,” Wang said. “It suggests that patients who are not responding to anti-PD-1 or anti PDL-1 therapies who have a high expression level of CD-155 may respond to anti-TIGIT therapeutics.” Bright Lights Based on recent results from iTeos and GSK, as well as Gilead and Arcus, it appears the tide may be beginning to turn. At ESMO, iTeos and GSK reported that after at least 5.6 months of follow-up, 60% of patients given the belrestotug/Jemperli combo had an objective response, compared to about 30% of those given Jemperli alone. What sets belrestotug apart from most other TIGITs is that it has a mutli-faceted mechanism of action and appears effective at low doses, Detheux noted. TIGIT therapeutics by BeiGene, Roche and Merck required either “very high doses” or were ineffective, he said. Belrestotug is also the only TIGIT program that has had to comply with the FDA’s Project Optimus, with a dose-ranging exercise required to understand the efficacy and safety pro its TIGIT+PD-1 doublet, Detheux said. “We believe this will allow GSK and iTeos to succeed in selecting the optimal dose, whereas others have struggled and launched Phase III trials without conducting a more in-depth review of the dose selection.” Meanwhile, at the 2024 American Society of Clinical Oncology conference, Gilead and Arcus presented Phase II data from a combination of domvanalimab and zimberelimab plus chemotherapy in upper GI cancers. It showed that nearly 60% of patients achieved progression-free survival at 12 months. “By binding to TIGIT with Fc-silent properties, domvanalimab is believed to work by freeing up immune-activating pathways and activate immune cells to attack and kill cancer cells without depleting critical immune cells,” a Gilead spokesperson told BioSpace by email. Currently, fewer than 40% of cancer patients respond to immunotherapy . “Therefore, we need more new technology and immunotherapies and we have to keep testing. Hopefully, patients will respond,” Wang said. But, he added, whether future therapeutic options will include anti-TIGIT therapeutics remains to be seen. “I would be cautious about [speculating] whether anti-TIGIT therapeutics will be successful, but there’s some hope.”