The assessment for disinvestment of intramuscular interferon beta for relapsing-remitting multiple sclerosis in Brazil

In Brazil, inclusion and exclusion of health technologies within the Unified Health System (SUS) is the responsibility of the National Committee for Health Technology Incorporation (CONITEC). A recent Cochrane systematic review demonstrated that intramuscular interferon beta 1a (INFβ-1a-IM) was inferior to the other interferons beta (INFβ) for multiple sclerosis. As a result, CONITEC commissioned an analysis to review possible disinvestment within SUS. The objective of this paper is to describe the disinvestment process for INFβ-1a-IM in Brazil. The first assessment comprised a literature review and mixed treatment comparison meta-analysis. The outcome of interest was the proportion of relapse-free patients in 2 years. This analysis confirmed the inferiority of INFβ-1a-IM. Following this, CONITEC recommended disinvestment, with the decision sent for public consultation. More than 3,000 contributions were made on CONITEC’s webpage, most of them against the preliminary decision. As a result, CONITEC commissioned a study to assess the effectiveness of INFβ-1a-IM among Brazilian patients in routine clinical care. The second assessment involved an eleven-year follow-up of a non-concurrent cohort of 12,154 MS patients developed by deterministic-probabilistic linkage of SUS administrative databases. The real-world assessment further demonstrated that INFβ-1a-IM users had a statistically higher risk of treatment failure, defined as treatment switching or relapse treatment or death, with the assessment showing that INFβ-1a-IM was inferior to the other interferon betas and to glatiramer acetate in both direct and indirect analysis. The drug ranking with 40.000 simulations INFβ-1a-IM was the worst option, with a success rate of only 152 / 40,000. Following this, CONITEC decided to exclude the intramuscular presentation of interferon beta from the current MS treatment guidelines giving patients who are currently on this treatment the option of continuing until treatment failure. In conclusion, we believe this is the first example of this new disinvestment process in action, providing an exemplar for other treatments in Brazil as well as other countries.