# Publicly funded dose-reduction trials of expensive approved drugs

Source: https://onco.cc/ideas/idea-tr1-public-dose-reduction-trials-of-approved-drugs/  
OnCo record `idea-tr1-public-dose-reduction-trials-of-approved-drugs` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Some expensive approved cancer drugs probably work as well at lower doses, as reduced-dose abiraterone with food and extended-interval checkpoint inhibitors suggest. Companies will not test this, so payers should fund randomised non-inferiority trials prioritised by spend and pharmacology, and use the results in reimbursement.

## Summary

Payers and public agencies fund randomised non-inferiority trials of reduced doses or less frequent schedules of high-cost approved agents, prioritised by spend and by pharmacological plausibility (saturated target, flat exposure-response, long half-life). Precedents include reduced-dose abiraterone with food and reduced-dose or extended-interval checkpoint inhibitors. Results are used directly in reimbursement.

## Fields

- Kind: Idea
- Last checked: 2026-09-08
- Hypothesis: At least half of well-chosen dose-reduction trials will demonstrate non-inferiority, and the savings from adopted reductions will exceed the trial costs within two years of read-out.
- Rationale: The pharmacology of several blockbuster agents suggests over-dosing; the financial return for payers is immediate and large, and the incentive gap for sponsors is structural.
- Proposed test: A payer consortium funds five such trials over five years and reports non-inferiority results and realised savings.
- Maturity: being-tested-at-scale
- Actor: payer

## Sources

- The Anticancer Fund: https://www.anticancerfund.org/

## Connected records

- technologies: [Immune checkpoint inhibitors](https://onco.cc/technologies/checkpoint-inhibitor/), [Small-molecule kinase inhibitors](https://onco.cc/technologies/kinase-inhibitors/)
- drugs: [Imatinib](https://onco.cc/drugs/imatinib/), [Nivolumab](https://onco.cc/drugs/nivolumab/), [Pembrolizumab](https://onco.cc/drugs/pembrolizumab/)
- bottlenecks: [Incentives reward me-too drugs and marginal gains](https://onco.cc/bottlenecks/b-incentive-misalignment/), [Prices and value](https://onco.cc/bottlenecks/b-drug-pricing/), [Wrong doses](https://onco.cc/bottlenecks/b-dose-optimisation/)

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