Development of medicine use in the primary Danish health sector – 1st quarter 2009

The Danish Medicines Agency's quarterly monitoring of medicine use focuses on the active substances or groups of medicines, for which the sale and consumption in the primary health sector has changed markedly compared to the same quarter of the previous year.

Active substances or groups of medicines with a significant increase in turnover

Active substances or groups of medicines with a significant drop in turnover

Active substances or groups of medicines with a significant increase in turnover

The following active substances or groups of medicines are characterised by the largest increase in turnover from Q1 2008 to Q1 2009:

• Human papillomavirus types 6, 11, 16 and 18
• Methylphenidate
• Penicillins
• Quetiapine
• Insulins and analogues for injection, long-acting
• Insulin aspart
• Tiotropium bromide
• Formoterol and other products for obstructive respiratory tract disorders
• Antithrombotic agents
• Pregabalin

The table below shows the development of the turnover and the quantity consumed of these active substances and groups of medicines. If the word “New” is added after the active substance or group of medicines, it means that the particular medicine was not included in the previous quarterly report.

You can find additional information on the development of each active substance or group of medicines by clicking on the links in the table.

Table 1. Active substances or groups of medicines with a significant increase in turnover from Q1 2008 to Q1 2009

1) ATC: Anatomical Therapeutic Chemical Classification System
2) Vaccines do not have a fixed DDD value and thus the quantity consumed cannot be calculated.

In total, the turnover of the groups of medicines shown in table 1 has increased by DKK 146 million. In contrast, the total sale of all medicines has only increased by DKK 8 million from Q1 2008 to Q1 2009, as the turnover has fallen for a large number of medicines.

Human papillomavirus vaccine types 6, 11, 16 and 18

The vaccine is included in the Danish childhood immunisation programme from 1 January 2009, and it is offered to girls aged 12-15. The start-up programme was launched in October 2008, where the vaccine was also offered to girls born in 1993-1995. The vaccine is to offer protection against infections with the human papillomavirus, types 6, 11, 16 and 18, that increase the risk of cervical cancer. The increase in turnover of DKK 71.3 million (see figure 1) is due to an increased number of new users.

Figure 1. Development of the turnover of human papillomavirus types 6, 11, 18 and 18

Methylphenidate
The active substance methylphenidate is a psychostimulant indicated for ADHD (attention deficit hyperactivity disorder). The increased turnover of DKK 15 million is partly due to the marketing of Concerta in Q2 2008. Previously, the prescription of Concerta required a special compassionate use permit, and the product was therefore not included in the Register of Medicinal Product Statistics. In Q1 2009, the quantity of Concerta sold amounted to DKK 9.8 million. The remaining part of the increased turnover (DKK 5.2 million) is due to an increased quantity consumed, partly because of an increased number of users and partly because of an increased consumption per person.   

Figure 2. Development of the turnover and consumption of methylphenidate

Penicillins
Penicillin is used for fighting bacterial infections. The increase in sales of DKK 10.8 million compared to Q1 2008 is evenly distributed on the different types of penicillins. The increase is partly due to an increase in the number of users (4 %) and partly to increased prices for several products in the group.

Figure 3. Development of the turnover and consumption of penicillins

Quetiapine
Quetiapine is a second-generation antipsychotic. The number of users has risen by 20 % from 12,961 to 15,545 users. This accounts for an increase in the turnover of DKK 8.5 million (see figure 4) of this antipsychotic, which costs DKK 56 per DDD. The increase in turnover is seen for Seroquel® as a prolonged-release tablet (Seroquel® Prolong marketed in Q2 2008) by DKK 9.7 million, while Seroquel® as an ordinary tablet has fallen by DKK 0.4 million, and the synonymous product Alzen (marketed in Q1 2008) has fallen by DKK 0.9 million. In the last quarter in 2008, the indication for Quetiapine was extended to include “treatment of severe depression by bipolar affective disorder”.

Figure 4. Development of the turnover and consumption of quetiapine

Insulins and analogues for injection, long-acting
An increased number of users (43 %) is the primary cause for the increased turnover of DKK 8.2 million (see figure 5). The increasing turnover applies to both subgroups, insulin glargine (Lantus solo star®) by DKK 4.3 million and insulin detemir (Levemir®) by DKK 5.1 million.

Figure 5. Development of the turnover and consumption of insulins and analogues for injection, long-acting

Insulin aspart
An increased number of users (47 %) is the primary cause for the increased turnover of DKK 7.7 million. The increased turnover is primarily due to an increased sale of NovoMix 30 FlexPen of DKK 7.3 million.

Figure 6. Development of the turnover and consumption of insulin aspart

Tiotropium bromide
Tiotropium bromide (Spiriva®) is a long-acting anticholinergic indicated for treatment of chronic obstructive pulmonary disease (COPD). The increased turnover of DKK 6.7 million (figure 7) is due to the marketing of Spiriva® Respimat® in Q4 2007. It is a new type of inhaler, in which a pump supplies the medicine, and therefore it does not require the same lung capacity. The turnover of this product in isolation has increased by DKK 8.1 million, which is due to an increased number of new users.

Figure 7. Development of the turnover and consumption of tiotropium bromide

Formoterol and other products for obstructive respiratory tract disorders
These medicines are combination products consisting of formoterol, which has a bronchodilating effect, and synthetic glucocorticoids. The products are indicated for the treatment of both asthma and COPD. The increase in turnover of DKK 6.6 million (see figure 8) is due to an increased number of new users (9 %).

Figure 8. Development of the turnover and consumption of formoterol and other products for obstructive respiratory tract disorders

Antithrombotic agents
The turnover of antithrombotic agents has risen by DKK 5.6 million (6 %) (see figure 9) since the same quarter of the previous year. The increased turnover is partly due to an increased number of new users (3 %).

Figure 9. Development of the turnover and consumption of antithrombotic agents

Pregabalin
Pregabalin (Lyrica®) is a product for epilepsy and it is part of the group “other antiepileptics”.The increase in turnover of DKK 5.4 million is primarily due to an increased number of new users (38 %). Since Q1 2006, the indication for pregabalin has been extended. Apart from nerve pain and epilepsy, the product is also indicated for generalised anxiety disorder.

Figure 10. Development of the turnover and consumption of pregabalin

Active substances or groups of medicines with a significant drop in turnover

The following active substances or groups of medicines are characterised by the largest drop in turnover from Q1 2008 to Q1 2009:

• Venlafaxine
• Amlodipine
• Simvastatin
• Pneumococcal vaccine
• Beta blocking agents without combination

The table below shows the development of the turnover and the quantity consumed of these active substances and groups of medicines. If the word “New” is added after the active substance or group of medicines, it means that the particular medicine was not included in the previous quarterly report.
You can find additional information on the development of each active substance or group of medicines by clicking on the links in the table.

Table 2. Active substances or groups of medicines with a significant drop in turnover or other marked changes to the quantity consumed

3) Vaccines do not have a fixed DDD value and thus the quantity consumed cannot be calculated.

Venlafaxine
Venlafaxine is an antidepressant used for treating severe depression and anxiety. The fall in turnover of DKK 44.3 million since the last quarter – a drop of 82 % – is caused by the expiry of the patent in December 2008. This caused the DDD price to plunge from DKK 14.25 to DKK 2.42.

Figure 11. Development of the turnover and consumption of venlafaxine

Amlodipine
Amlodipine is a calcium channel blocker that has a vasodilative effect on arteries and veins, and thereby it reduces blood pressure. The turnover of this active substance has dropped by DKK 29.4 million (figure 12). The falling turnover is the aftermath of a sudden massive price increase of the frequently sold product in the last quarter of 2007. Sales peaked in Q1 2008 (DKK 1.74 per DDD) but have subsequently fallen to the level prior to Q4 2007 (DKK 0.39 per DDD).
In Q1 2009, 171,853 persons bought this active substance, which constitutes an increase of 16 % since the same quarter in 2008.

Figure 12. Development of the turnover and consumption of amlodipine

Simvastatin
Simvastatin is a lipid-regulating substance that is part of the group HMG C0A reductase inhibitors. The drop in turnover of DKK 22.8 million (figure 13) is due to a continuing fall in the average treatment price. In Q1 2009, the price per DDD was DKK 0.31. Since Q2 2007, where the price of simvastatin suddenly skyrocketed by 800 % (read more in the Danish Competition Authority’s investigation on the price increase of simvastatin – in Danish only) to DKK 2.50 per DDD, the price per DDD has fallen continuously.

Figure 13. Development of the turnover and consumption of simvastatin

Pneumococcal vaccine
The pneumococcal vaccine was included in the childhood immunisation programme in October 2007. The vaccine protects against disease caused by the pneumococcal bacteria, which may cause blood poisoning (sepsis) and meningitis. It can be especially dangerous in children under the age of 2. The vaccine must be administered three times, when children are 3, 5 and 12 months old.
The turnover for this vaccine has fallen by DKK 19.1 million compared to the same quarter of the previous year (see figure 14). The fall may be caused by the fact that a start-up programme was carried out under which children aged 4-17 months were also offered the vaccine.

Figure 14. Development of the turnover of the pneumococcal vaccine

For further information, please contact Bine Kjøller Bjerregaard, tel.: +45 4488 9104.

Danish Medicines Agency, 17 August 2009