Biologic drugs have revolutionised the management of many inflammatory conditions. Patent expirations have stimulated development of highly similar but non-identical molecules, the biosimilars. Extrapolation of indications is a key concept in the development of biosimilars. However, this has been met with concerns around mechanisms of action, equivalence in efficacy and immunogenicity, which are reviewed in this article.
Narrative overview composed from literature search and the authors' experience. Literature search included Pubmed, Web of Science, and online document archives of the Food and Drug Administration and European Medicines Agency.
The concepts of biosimilarity and extrapolation of indications are revisited. Concerns around extrapolation are exemplified using the biosimilar infliximab, CT-P13, focusing on mechanisms of action, immunogenicity and trial design. The opportunities and cautions for using biologics and biosimilars in unlicensed inflammatory conditions are reviewed.
Biosimilars offer many potential opportunities in improving treatment access and increasing treatment options. The high cost associated with marketing approval means that many bio-originators may never become licenced for rarer inflammatory conditions, despite clinical efficacy. Biosimilars, with lower acquisition cost, may improve access for off-label use of biologics in the management of these patients. They may also provide opportunities to explore off-label treatment of conditions where biologic therapy is less established. However, this potential advantage must be balanced with the awareness that off-label prescribing can potentially expose patients to risky and ineffective treatments. Post-marketing surveillance is critical to developing long-term evidence to provide assurances on efficacy as well as safety.