Orchard Therapeutics has set a new benchmark in pharmaceutical pricing with Lenmeldy (atidarsagene autotemcel), its recently FDA-approved gene therapy for metachromatic leukodystrophy (MLD). At $4.25 million per treatment, it now stands as the most expensive medicine in the United States.
The one-shot treatment, approved Monday, represents the first FDA-authorized therapy for children with MLD, a devastating rare genetic disorder that causes rapid deterioration in motor and cognitive function. Without treatment, infants born with the most severe form typically don't survive beyond age five, while those with later-onset variants generally don't live past 20.
Understanding Metachromatic Leukodystrophy
MLD is an inherited neurodegenerative disorder caused by a deficiency in the ARSA gene, which codes for the enzyme arylsulfatase-A. This deficiency allows sulphatide compounds to accumulate in the body to toxic levels, destroying the myelin sheath that insulates nerve cells and prevents them from functioning properly.
The resulting symptoms mirror multiple sclerosis, with patients experiencing progressive disability leading to muscle spasticity, seizures, and difficulties with talking, swallowing, and vision. Fewer than 40 children are diagnosed with MLD annually in the United States.
The disease presents in different forms:
- Late infantile MLD (most common and rapidly progressing) begins before 30 months, with affected children typically dying between ages five and eight
- Early juvenile MLD usually starts between 30 months and six years, with life expectancy between 10 and 20 years
Revolutionary Treatment Approach
Lenmeldy employs a groundbreaking approach to treating MLD. The process involves:
- Harvesting stem cells from the patient's bone marrow or blood
- Modifying these cells to replace the defective ARSA gene with a functional version
- Reintroducing the modified cells into the body via a single intravenous infusion
Clinical trial results have been remarkable. In a study of 37 children, all treated patients survived to at least age six, compared to just 58% in historical control groups. Furthermore, 71% of treated children maintained the ability to walk without assistance, and 85% demonstrated normal language and performance IQ scores.
Pricing and Access Considerations
Frank Thomas, Orchard's Chief Operating Officer, defended the $4.25 million price tag, stating it reflects the therapy's "clinical, economic, and societal value" given its potential to halt or slow MLD progression, possibly allowing some children to live normal lives.
The U.S. price exceeds both the European cost of $3.7 million (where it's marketed as Libmeldy) and the $2.3-3.9 million range that the Institute for Clinical and Economic Review (ICER) deemed cost-effective in a 2022 report.
To address access concerns, Orchard is:
- Establishing five specialized treatment centers across the U.S. to minimize travel burden for families
- Offering a personalized support program called Orchard Assist
- Exploring "outcomes-based and other types of innovative reimbursement models" with both private and government payers
Broader Implications for Healthcare Systems
The growing list of high-priced gene therapies for rare diseases has raised concerns about healthcare system sustainability. A study published in Nature last year projected that annual U.S. spending on gene therapies could reach approximately $20.4 billion, with Medicare potentially facing a $5.4 billion bill—less than 1% of its 2018 spending of $597.4 billion.
European Experience with Libmeldy
In Europe, where the therapy was approved in December 2020 as Libmeldy, initial access was limited. NHS England initially rejected the treatment due to its high cost and uncertain long-term benefits. However, a subsequent confidential price reduction led to NHS approval for specific patient groups:
- Children with late infantile or early juvenile MLD without clinical symptoms
- Children with early juvenile MLD who have early symptoms but can still walk independently and show no cognitive decline
The therapy has already been used commercially to treat children in Germany, France, and Italy.
Vivienne Clark, chair of MLD Support Association UK, called NHS approval "a major development in our fight to eradicate MLD" and acknowledged "all the affected children and their families whose lives have been affected by this condition—many of whom selflessly supported our research despite no possibility of benefitting from this treatment."
Future Outlook
As Orchard Therapeutics (recently acquired by Kyowa Kirin) moves forward with the U.S. launch of Lenmeldy, the company faces the challenge of balancing its revolutionary therapeutic value with concerns about affordability and access. The success of this launch may set important precedents for how healthcare systems manage the growing pipeline of high-cost, potentially curative gene therapies for rare diseases.
