111 Using a scenario approach to assess for the current and future demand of immunoglobulins would impact demand as neurology is the highest consuming specialty). Interestingly, from both interviews and the literature, limitations of these treatments or therapies were found: certain treatments (e.g., FcRn, Rituximab) held a ‘double edge’ in being a possible alternative for patients, and yet also causing immunosuppression (as described previously), which could still warrant Ig, albeit reduced. Further, while gene-correcting options are available for PIDs,65 it is only suitable for a minority: “Only 10 to 15% of patients have a monogenetic cause of the diseases, and that means that only that percentage would be suitable to undergo these procedures. That’s one. Second, there’s no gene therapy for CVID or XLA.” (Expert 12). Overall, while experts acknowledged the possibilities of alternative therapies and its impact on decreasing Ig demand, many expressed they see no real competition that would displace Ig within the next 3–10 years. Additionally, the expense of Ig was an important economic factor with many ramifications1,66–70 which could potentially force economies to curb their demand: “If the cost is higher, the consumption can decline because countries cannot afford it” (Expert 3). One clinician particularly tied evidence, economic and legal aspects together by advocating for a strict evidence-based approach to prescribing Ig, which would dampen demand: “I think we should strive for more evidence-baseness of using the IVIG, I think the present situation is still a little bit wild and uncontrolled… there will be a stop on that, it will be more strictly regulated…If IVIG would not be reimbursed for specific indications because the evidence is meagre or shallow, then of course, that will influence prescription.” (Expert 10) Literature provides examples of how some hospitals have initiated various stewardship programs to monitor and curb demand.59,71,72 More social, ecological, political, legal factors were found from the interviews. Particular for the Netherlands, experts shared how an important healthcare change was to occur in 2021, called the overheveling, or the Transfer Act, motioned by the Ministry of Health in 2017 to curb Ig demand by narrowing Ig prescription and distribution to the hospitals only. This act would eradicate the local pharmacy scheme, a ‘black box’ where reimbursement occurs regardless of the indication. Those patients and their treatment costs would be transferred to the hospital budget instead. Experts hypothesized of the upcoming effects, with some perceiving advantages such as providing insights into patient care and usage, “to give a bigger opportunity to actually cut down on cost” (Expert 13). However, they seemed quite wary of the disadvantages, such as patients being referred from hospital-to-hospital or patients having limited product options.
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