11 min read

The Role of Real-World Evidence in the Adoption of Biosimilars

As the US biosimilar market expands rapidly, discover why real-world evidence can unlock your market access.

We are more than halfway through the year that Humira® lost exclusivity. By all counts, as many as 10 adalimumab biosimilars are expected to be available in the US by the end of 20231. The biggest-selling drug of all time is now facing a lot of biosimilar competition. But there’s more to it.

Beyond adalimumab, the industry is waiting and watching as we potentially approach a turning point for biosimilar adoption in the U.S. Sponsors see cost savings during research and development phases, in clinical studies, and during production, so biosimilars can be offered at lower cost, ideally allowing for cost savings and broader access. While this has been true in Europe, the U.S. has yet to realize anything close to the 40% cost savings projected by the Congressional Budget Office2. Even though biosimilars have been in the U.S. market since 2015 with the launch of Zarxio® (filgrastim-sndz)2, uptake has been slow compared with Europe, which saw its first biosimilar almost a decade earlier. By the numbers, as of May 2023, the US has approved 40 biosimilars3, and the EU has approved 93 biosimilars4.

Adoption in the U.S. is dependent on a complicated landscape that includes the current regulatory environment, clinical evidence, patient and provider preferences, and economic incentives. Patient and provider education gaps and formulary preferences for higher-cost originator biologics (thanks to incentives and rebates) are currently the most prominent challenges hindering widespread adoption. Further complicating matters, the landscape is slightly different depending on the therapeutic area. For example, oncologists are comfortable with biosimilars, likely due to the Centers for Medicare and Medicaid Service’s Oncology Care Model5, a value-based care initiative where physicians assume greater financial risk in delivering healthcare6. But Rheumatologists are more reluctant. This reluctance is the result of questions around efficacy (noted as a “top concern”) and cost savings for patients6.

The perception that biosimilars lack efficacy is likely due, at least in part, to the fact that approval is based mainly on analytical studies that demonstrate high molecular similarity and low impurity levels to the originator biologic. This means that biosimilars may not need to be tested in all indicated patient populations. So, providers and patients may have concerns about efficacy, safety, and immunogenicity, including switching from one biologic to another.

Another wrinkle is that, unlike generics, pharmacists cannot determine if a biosimilar can be given in place of an originator biologic that has been prescribed by a physician. However, the U.S. Food and Drug Administration (FDA) can determine if a biosimilar is interchangeable, which allows pharmacist substitution. Interchangeability has been shown to increase biosimilar use when uptake has been slow7. However, to receive an interchangeable designation, manufacturers must sponsor clinical trials during which patients switch back and forth from the originator to the biosimilar at least three times without diminished efficacy or any additional safety concerns8, increasing the cost to sponsors.

Might the U.S. learn from Europe, where the biosimilars market is very mature?

Europe developed a framework for approving biosimilars in 2005, wherein biosimilars can be marketed through an abridged application9. Similarly, in the U.S. in 2010, the Biologics Price Competition and Innovation Act (BPCIA) created the 351(k) Biologics License Applications (BLA) pathway for biosimilars. The BCPIA promotes innovation by providing a period of exclusivity for originator biologics10 and promotes competition by enabling a quicker, less expensive pathway for approval of biosimilar and interchangeable products once the exclusivity period has lapsed9. Specifically, the BCPIA allows follow-on sponsors to partly rely on the FDA’s determination of safety and efficacy for the originator biologic.

In Europe, the real-world setting has been instrumental in addressing the concerns and needs of patients, providers, and payers. In an appraisal of both regulatory and post-marketing activities in second-generation biosimilars (including monoclonal antibodies), post-marketing pharmacovigilance (PV) programs aimed at confirming efficacy and safety have been described as “crucial”11. Study authors concluded that limited information on the safety, efficacy, and immunogenicity of biosimilars at the time of regulatory approval needs to be addressed with long-term patient safety and outcomes research.

The FDA has also stated interest in the use of RWE to analyze biosimilar utilization and outcomes, in both the 2018 Biosimilars Action Plan12 and the 2021 Biosimilar User Fee Act (BsUFA) Commitment Letter 2023-202713. Furthermore, the FDA is working to maximize scientific and regulatory clarity for biosimilar product development, including efforts to “leverage real-world data to support regulatory decision-making related to biosimilars, when possible”14. Finally, through the BsUFA Research Pilot Program, FDA announced intent to develop guidance on how RWE can be leveraged to earn an interchangeability designation15.

How can sponsors leverage real-world evidence?

Sponsors should plan an integrated evidence generation strategy early in product development and regularly revisit and revise the strategy based on internal goals and the external landscape. Identified gaps should be addressed in a way that will satisfy multiple stakeholders, including regulators, payers, providers, and patients. Sponsors must consider what is most important – efficacy, safety, immunogenicity, switch data – when designing evidence generation strategies. Study types may include:

  1. Real-world, post-marketing surveillance studies (including registries) that address long-term safety and effectiveness
  2. Switch studies that demonstrate safety and efficacy
  3. Analysis of diverse patient populations (e.g., patients with comorbidities, patients in different age groups, etc.), either prospectively (if it’s early post-launch) or retrospectively
  4. Patient-reported outcomes (PROs), questionnaires
  5. Health economics studies
  6. Patient preference studies
  7. Indirect treatment comparisons (ITCs), matching or external control studies to account for issues like missing data or differences in baseline characteristics

Are you ready to plan your integrated evidence generation strategy?

Identification of evidence gaps through a systematic review of external stakeholder requirements, the current clinical and scientific landscape, and internal strategic initiatives is a good first step. Utilizing existing infrastructure, leveraging efforts already in place, and information already being collected in a real-world setting are other practical solutions. Finally, well-designed studies that leverage modernized technology and data acquisition approaches, including decentralized study design, may reduce burden on providers and patients, and help lower certain barriers to care for patients and/or caregivers or care teams. Having partners well-versed in such study approaches can help reduce the time to plan and operationalize studies by bringing experience and expertise needed to best support study design, operational aspects, recruitment and retention, and the technology and infrastructure needed.

Patient communities, advocacy groups, regulators, coverage bodies, and manufacturers are on the verge of a turning point in biosimilar adoption in the U.S. Having an organization that understands the intersection of these equally important agendas and data requirements to ensure successful outcomes, in concert with the safe and appropriate use of the drug, combined with the need to ensure reasonableness and outcomes of the therapy is a new ground – UBC is ready.

To find out more about how UBC can help plan your RWE strategy, get in touch with our team here.

About the Author

Judy Lytle, PhD, MBEE, PMP, is the Executive Director of Real-World Evidence Study Solutions at UBC. She utilizes her extensive expertise to help biopharma develop evidence generation strategies, powered by rigorous science, that are designed to demonstrate value.


  1. Jeremias S. (2022). “Part 1: Biosimilars to Bring a Bumper Crop of Adalimumab Options.” AJMC Center for Biosimilars. https://www.centerforbiosimilars.com/view/part-1-biosimilars-to-bring-a-bumper-crop-of-adalimumab-options. Accessed 06/29/2023.
  2. Yazdany J. Failure to Launch: Biosimilar Sales Continue to Fall Flat in the United States. Arthritis Rheumatol. 2020 Jun;72(6):870-873. doi: 10.1002/art.41203. Epub 2020 Apr 23. PMID: 31922346; PMCID: PMC7255927. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7255927/
  3. GaBI Online. “Biosimilars approved in the US.” https://www.gabionline.net/biosimilars/general/biosimilars-approved-in-the-us. Accessed 07/03/2023.
  4. GaBI Online. “Biosimilars approved in Europe.” https://www.gabionline.net/biosimilars/general/biosimilars-approved-in-europe. Accessed 07/03/2023.
  5. Center for Medicare & Medicaid Services. “Oncology Care Model.” https://innovation.cms.gov/innovation-models/oncology-care. Accessed 06/29/2023.
  6. Oskouel S, Feinberg B, Lam G, Holekamp N, Rarely C, Baldetti J, Hunder H. (2022). 2022 Biosimilars Report: The U.S. Journey and Path Ahead.” https://www.cardinalhealth.com/content/dam/corp/web/documents/Report/cardinal-health-2022-biosimilars-report.pdf. Accessed 07/03/2023.
  7. Aitken M, Kleinrock M, Pritchett J. (2023). Biosimilars in the United States 2023-2027: Competition, Savings and Sustainability. IQVIA Institute for Human Data Science. https://www.iqvia.com/insights/the-iqvia-institute/reports/biosimilars-in-the-united-states-2023-2027. Accessed 06/29/2023.
  8. US FDA. 2019. “Considerations in Demonstrating Interchangeability with a Reference Product Guidance for Industry.” https://www.fda.gov/media/124907/download. Accessed 07/03/2023.
  9. Minghetti P, Rocco P, Cilurzo F, Vecchio LD, Locatelli F. (2012). The regulatory framework of biosimilars in the European Union, Drug Discov. Today. 63–70, http://dx.doi.org/10.1016/j.drudis.2011.08.001.
  10. US FDA. “Biological Product Innovation and Competition.” https://www.fda.gov/drugs/biosimilars/biological-product-innovation-and-competition. Accessed 07/03/2023.
  11. Blandizzi C, Galeazzi M, Valesini G. (2018). Transitioning from first- to second-generation biosimilars: An appraisal of regulatory and post-marketing challenges. Pharmacol Res. 128:306-314.
  12. US FDA. 2018. Biosimilars Action Plan: Balancing Innovation and Competition. https://www.fda.gov/media/114574/download. Accessed 07/03/2023.
  13. US FDA. 2021. Biosimilar Biological Product Reauthorization Performance Goals and Procedures Fiscal Years 2023 through 2027. https://www.fda.gov/media/152279/download. Accessed 07/03/2023.
  14. US FDA. “Biological Product Innovation and Competition.” https://www.fda.gov/drugs/biosimilars/biological-product-innovation-and-competition. Accessed 07/03/2023.
  15. US FDA. “BsUFA III Regulatory Research Pilot Program: Research Roadmap. https://www.fda.gov/media/164751/download. Accessed 07/03/2023.

Other Recent Posts

5 min read

UBC and Thread Expand SitePlus Offering and Active Studies with BioPharma Sponsors to Optimize Evidence Generation

This augments the central site model with additional research services and tech to widen recruitment and improves site and patient experience.
3 min read

UBC Appoints Anthony Luttenberger Chief Commercial Officer

Biopharma services industry veteran brings decades of experience spanning late-stage, clinical trials, & post-approval commercial support.
1 min read

UBC Listed as a Citeline Awards Finalist for Excellence in RWE

UBC is once again a finalist for the Citeline Awards, with our 2024 nomination coming in the Excellence in RWE category.

Thank You for Connecting with UBC

Lorem ipsum dolor sit amet consectetur. Mi proin enim ipsum nascetur. Venenatis odio scelerisque non netus ac et pellentesque.

What You Can Expect Next

Lorem ipsum dolor sit amet consectetur. Cras aliquam erat eget magna sollicitudin.

Get Ready to Change Your Business

Lorem ipsum dolor sit amet consectetur. Mi proin enim ipsum nascetur. Venenatis odio scelerisque non netus ac et pellentesque.

Service Request

Bekki Bracken Brown

President & Chief Executive Officer

Bekki Bracken Brown serves as the President and CEO of UBC, guiding the company’s mission and values, including the improvement of access for patients to receive better outcomes. She oversees all aspects of UBC, such as operations, business growth strategy, sales and marketing, and acquisition support.

With over 20 years of industry experience, Ms. Brown brings knowledge from a successful career in senior management from her tenure at Quintiles, INC Research, and, most recently, with Syneos Health. She’s been a member of the North Carolina BIO Board of Directors since 2019. She is also a member of the Healthcare Businesswomen’s Association — Southeast Chapter and CHIEF, an organization that supports women executive leaders. Ms. Brown earned her bachelor’s degree at Duke University.