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Page 1 of 51
Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
Given that:
The professional groups highlighted that allopurinol intolerance is often
wrongly diagnosed in clinical practice, without appropriate titration of
dosage or any attempt of desensitisation.
Patients in the trial population described in the manufacturers
submission either couldnt have allopurinol because it was
contraindicated or their uric acid levels had not normalised despite 3 or
more months of treatment with the maximum medically appropriate dose
determined by the treating clinician.
The ERG stated that it was not clear from the manufacturers submission
whether desensitisation to allopurinol hypersensitivity had been
attempted before trial entry.
Does the Committee consider that the results of these trials can be
generalised to clinical practice in the NHS in England and Wales?
Clinical effectiveness evidence in the manufacturers submission was
based predominantly on the findings from simple pooled analyses of
primary and secondary efficacy data from 2 phase III trials. The
manufacturer stated that because these trials were replicates, a metaanalysis of the combined estimate of effects would not be appropriate. But
the ERG pointed out that simple pooling of data may yield counterintuitive
results. Does the Committee consider simple pooling of outcome data
acceptable?
The manufacturers submission stated that that there were no unexpected
imbalances in drop-outs between groups in the trials. But the ERG
highlighted that in the 2 key trials a higher proportion of patients in the
pegloticase every 2 weeks arms had dropped out at the end of the study
(30% in trial C0405 and 28% in trial C0406) than in the placebo arms (5%
in trial C0405 and 13% in trial C0406). The ERG stated that the
manufacturer did not explain or adjust for the imbalances in these the dropout rates, particularly in the patients who dropped out because of adverse
Page 2 of 51
Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
events in both trials. Does the Committee think that this dropout may have
biased the results?
According to the manufacturers submission, one of the inclusion criteria
used to define chronic refractory gout in the phase III trials was gouty
arthritis, while in the published results from the trials (Sundy et al., 2011),
it was referred to as gouty arthropathy . At clarification stage the
manufacturer stated that gouty arthritis was used as an eligibility criterion,
but that the term gouty arthritis was not defined. It was left to the clinical
judgement of the investigator to decide whether or not the patient had this
condition. The ERG stated that it was unclear how gouty arthritis was
defined and applied as one of the inclusion criteria in the key clinical trials.
The marketing authorisation for pegloticase is for the treatment of severe
debilitating chronic tophaceous gout in adult patients who may also have
erosive joint involvement. Does the Committee consider that these terms
(gouty arthritis, gouty arthropathy or erosive joint involvement) refer to the
same condition?
In one treatment arm of the phase III trials patients were given pegloticase
8 mg every 2 weeks. The ERG stated that the impact of repeated courses
of pegloticase on uric acid levels, secondary outcomes, immunogenicity
and adverse events was not clear from the clinical effectiveness evidence
in the manufacturers submission. What is the Committees view on the
possible loss of efficacy and increased risk of adverse events because of
pegloticases potential immunogenicity?
Cost-effectiveness
In the manufacturers economic model, patients receiving pegloticase are
separated into responder, non-responder and non-completer groups.
The manufacturers submission stated that the primary reason for patients
becoming non-completers was adverse events and in clinical practice this
would occur within the first month of treatment. Data from the trials on the
proportion of non-completers who had withdrawn from pegloticase
National Institute for Health and Clinical Excellence
Page 3 of 51
Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
treatment by one month and the time to treatment cessation for noncompleters were unavailable. The ERG stated that it was uncertain how
patients in the non-completer groups would be identified in clinical
practice. What is the Committees view on this group in light of UK clinical
practice?
In the manufacturers health economic model it is assumed that the
maximum duration of pegloticase treatment would be 6 months. But data
from an open-label extension study of the patients included in the phase III
trials suggest average treatment duration of ************** in pegloticase
responders. Does the Committee accept that pegloticase would not be
used for more than 6 months in UK clinical practice?
The economic model presented in the manufacturers submission assumes
that the benefits of pegloticase treatment to responders during the 6-month
treatment period can be maintained in the long-term by allopurinol or
febuxostat treatment. The manufacturer did not provide direct clinical
evidence to support a maintained treatment effect using these treatments.
The ERG considered that this was an area of substantial uncertainty
because there was no direct evidence about effectiveness of maintenance
treatment. What is the Committees view on this uncertainty?
In the manufacturers model, persistence with maintenance treatment
(allopurinol or febuxostat) after pegloticase treatment in responders was
extrapolated based on indirect evidence. The ERG noted that 34% of the
incremental quality-adjusted life year (QALY) gains were accrued more
than 10 years after pegloticase treatment and the incremental costeffectiveness ratio (ICER) was sensitive to the discontinuation rate of
maintenance treatment. Does the Committee think the assumption about
persistence with maintenance treatment in the model is justifiable?
The ERG noted that treatment effectiveness is captured in the model by
patient-related outcomes including serum uric acid, frequency of gouty
flares and tophi resolution. Does the Committee think that a lower serum
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
uric acid level could result in additional utility benefits over and above that
associated with reduced gout flares and tophi resolution?
The manufacturers model made assumptions about rheumatology visits,
accident and emergency visits and hospital admissions associated with
higher levels of serum uric acid. Does the Committee consider that
resource use would be higher with higher serum uric acid levels over and
above that associated with gout flares?
The manufacturers model captured treatment effectiveness by changes in
4 patient-related outcomes: serum uric acid, quality of life, frequency of
flares and tophi resolution. The ERG noted that the clinical continuation
rule in the manufacturers model differed from the definition of response
applied in the phase III trials, and that additional analyses were performed
on the trial data to inform its health economic model. Also, primary end
points in the trials were based on plasma uric acid level but while in the
manufacturers health economic model the end points were based on
serum uric acid level. What is the committees view on the data used in the
manufacturers modelling?
1
1.1
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
composed entirely or partly of uric acid crystals. Severe gout with
recurrent flares and tophi has a significant impact on the patient
leading to pain, fatigue, progressive loss of mobility and function
and a worsening of quality of life.
1.2
1.3
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
British Society for Rheumatology and the British Health
Professionals in Rheumatology guideline for the management of
gout (BSR guideline) recommends a stricter target of
300 micromol/litre.
1.4
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
2
2.1
The technology
Pegloticase (Krystexxa, Savient), is a polyethylene glycol
conjugate of recombinant uricase (urate oxidase). It catalyses the
oxidation of uric acid to allantoin, which is water soluble and can
be excreted in urine resulting lowered serum uric acid.
2.2
2.3
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
2.4
2.5
3
3.1
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
Population
3.2
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
Intervention
3.3
Pegloticase
The manufacturer submission stated that, while the phase III trials
were 6 months long, the optimal treatment course has not been
established. It stated that treatment duration should be based on
a maintained response (serum uric acid below 360 micromol/litre)
and clinical judgement. The manufacturer estimated that the
average length of a course of pegloticase treatment for patients
whose condition responded to treatment (and who maintain serum
uric acid levels below 360 micromol/litre was 6 months. The
treatment duration for patients whose condition did not respond to
pegloticase treatment was estimated as 2 months. The average
duration of treatment across all patients receiving pegloticase was
estimated by the manufacturer to be 4 months. The manufacturer
also reported that no information was available about the
anticipated number of repeat courses and treatments that may be
needed by patients receiving pegloticase and that the intervals
between treatments would be patient dependent. Further details
received at clarification stage on time to treatment stopping
across all pegloticase trials suggests average treatment duration
of around ******* in pegloticase responders.
Comparators
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
3.4
Outcomes
Tophus resolution
gout flares
Pain
reduction in tophus
pain
Physical function
physical function
3.5
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
laboratories. The manufacturer tested the observed plasma and
serum uric acid for agreement using the kappa coefficient and
obtained a value of 0.74 (p<0.001), on a scale of 0 to 1 (0
indicating no agreement and 1 indicating complete agreement
between methods).
3.6
4
4.1
Clinical-effectiveness evidence
The systematic review conducted by the manufacturer identified a
single published journal article and 6 conference abstracts. The
Page 13 of 51
Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
published article (Sundy et al. 2011) presented the results of
2 phase III trials of pegloticase: C0405 and C0406. The abstracts
presented data on some aspects of these trials and an open-label
extension study C0407. Data from the abstracts were not included
in the submission. The clinical data presented in the submission
were from the published article, an internal report on the
integrated summary of efficacy of these trials as well as an
unpublished clinical study report of open-label extension safety
study (C0407).
4.2
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
continued throughout the trial. Patients also received prophylaxis
against infusion reactions with oral fexofenadine 60 mg the
evening before each infusion, 60 mg oral fexofenadine and 1 g
oral paracetamol the morning of the infusion and intravenous
hydrocortisone 200 mg immediately before each infusion.
Although the trials included 2 pegloticase dosing regimens (8 mg
every 2 weeks or every 4 weeks) only the results of the patients
receiving the anticipated licensed dose (pegloticase 8 mg every
2 weeks) were included for the estimate of efficacy in the
submission.
4.3
4.4
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
4.5
4.6
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
4.7
4.8
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
4.9
4.10
4.11
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
4.12
4.13
Placebo (n=29)
2/27 (7.4)
23/43 (53.5)
29/43 (67.4)
43
1.2 (1.62)
43
1.3 (1.49)
43
3.9 (22.71)
43
Page 19 of 51
Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
Change from
**************
baseline to final
visit. Mean (SD)
HAQ disability index
N
**
Change from
*************
baseline to final
visit. Mean (SD)
SF36 physical component summary
N
**
Change from
***********
baseline to final
visit. Mean (SD)
4.14
*************
1.37 (30.04)
**
*************
43
0.02 (0.408)
**
***********
43
0.30 (8.97)
4.15
4.16
Page 20 of 51
Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
effects of pegloticase in patients who continued to receive active
treatment from the phase III trials and in those originally
randomised to placebo, and the duration of benefit. Outcomes
included the plasma and serum uric acid response, tophus
response, incidence and frequency of gout flares, swollen joint
count (SJC), tender joint count (TJC), SF-36, HAQ and Clinical
global assessment of disease activity.
4.17
4.18
4.19
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
responders to pegloticase treatment group. Infusion reactions
were the second most commonly reported adverse events,
occurring in 34.6% of patients. Infusion reactions were less
frequent in pegloticase responders. There were 4 deaths in the
open-label extension study, 1 (from sepsis) while receiving
pegloticase, 3 (from cellulitis/sepsis, pneumonia, worsening of
myelodysplastic disorder) at various times after the last dose of
pegloticase.
4.20
4.21
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
***************************************************************************
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**.
4.22
4.23
The ERG was satisfied that all available phase III trials were
included in the submission but noted that in the two phase III trials
a higher proportion of patients in the pegloticase every 2 weeks
arms had dropped out at the end of the study (30% in C0405 and
28% in C0406) than in the placebo arms (5% in C0405 and 13%
in C0406). The ERG stated that the manufacturer did not explain
Page 23 of 51
Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
or adjust for the imbalances in these the drop-out rates,
particularly in the patients who dropped out because of adverse
events in both trials.
4.24
4.25
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
4.26
4.27
4.28
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
manufacturers submission. It stated that limited evidence from
the small scale re-exposure trial (C0409) suggested that there
***************************************************************************
****************************************************************. The
ERG also stated that it was not clear whether the benefits of
pegloticase would be maintained after pegloticase treatment
stopped or whether maintenance treatment with other uratelowering drugs would be successful in maintaining low uric acid
levels and other benefits in the long-term.
5
5.1
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
5.2
5.3
5.4
5.5
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
highlighted concerns about the reported incidence of infusion
reactions (2637.5%) which led to up to 10% of patients stopping
pegloticase, and delayed hypersensitivity reactions despite
corticosteroid or antihistamine prophylaxis. The patient groups
further highlighted a high incidence of gout flare, lack of clarity
about the optimal duration of treatment and the development of
anti-pegloticase antibodies, leading to loss of efficacy. Additionally
they said there is a potential risk of cardiovascular adverse
effects, particularly in a population at increased risk of
cardiovascular disease because of the association between gout
and the metabolic syndrome.
5.6
6
6.1
Cost-effectiveness evidence
The manufacturer identified 1 economic evaluation of pegloticase
in patients with refractory chronic gout performed from a US
healthcare perspective (Wang et al. 2012) but did not consider it
relevant for this appraisal. The manufacturer therefore submitted
a de novo model comparing pegloticase with best supportive care
in patients with chronic gout refractory to xanthine oxidase
inhibitors. Each branch of the decision tree structure (see figure 1)
is coupled with a Markov model for extrapolation to the 20-year
base-case time horizon. There are 4 health states in the Markov
model based on patients serum uric acid levels:
below 360 micromol/litre
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
360 or higher but below 480 micromol/litre
480 or higher but below 600 micromol/litre
600 micromol/litre or higher.
Death is also included as a Markov state in the model.
Figure 1 Decision analytical structure
6.2
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
The non-responders are defined as those who discontinue
pegloticase treatment because serum uric acid levels exceed the
limit set out in the summary of product characteristics: increase
to above 360 micromole/litre on 2 consecutive observations. In
the base-case analysis, patients were assumed to be identified
as non-responders after 2 months of pegloticase treatment.
These patients, estimated to be 27.2% of original cohort, were
switched to best supportive care. Based on the clinical trial data,
it is assumed that some clinical benefit was still obtained in this
patient group.
The non-completer group was defined in the manufacturers
submission as patients who are non-persistent to pegloticase
treatment, but subsequently the manufacturer clarified that this
included patients who failed to complete the full 6 month
treatment course for any reasons, primarily due to adverse
events, but could also include other reasons such as patient
dislike of intravenous administration. These patients are
assumed to not gain any clinical benefit from pegloticase
treatment although pegloticase treatment costs are incurred. In
the base-case analysis, it was assumed that a non-completer
could be identified by 1 month of pegloticase treatment. In the
manufacturers model 32.0% of patients do not complete
pegloticase treatment and are switched to best supportive care
after 1 month.
6.3
6.4
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
CONFIDENTIAL
maintenance treatment was modelled with data derived from an
observational study of allopurinol (Annemans et al. 2008) and
from a randomised trial of febuxostat (EXCEL). Patients who
discontinued maintenance treatment (non-persistent patients)
were switched to best supportive care. It was assumed that
maintenance treatment was effective in maintaining the serum
uric acid levels achieved by pegloticase treatment, and that with
non-persistence with maintenance treatment serum uric acid
levels returned to baseline levels. The probability of becoming
non-persistent on maintenance treatment, and therefore
progressing to best supportive care, was modelled using a
constant hazard for febuxostat, and a decreasing hazard for
allopurinol. The rate of discontinuation for febuxostat was derived
by taking the average proportion (434/590=26%) who were nonpersistent at the end of the 2-year EXCEL trial across the 2 doses
(80 mg/day and 120 mg/day) and assuming a constant hazard
(exponential survival curve) to convert this proportion to a monthly
rate of 1.3%, which is equivalent to an annual rate of 14%. The
rate of discontinuation for allopurinol was derived by fitting a
Weibull survival curve to retrospective 2-year observational data
from 7443 UK patients with chronic gout, of whom 89% were
receiving allopurinol. In the economic model, the manufacturer
stated that a Weibull curve was fitted to the second year of data
from the trial to reflect long-term persistence (as opposed to
persistence from the start of treatment).
6.5
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
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6.6
6.7
6.8
6.9
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
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patients became non-persistent with maintenance treatment,
serum uric acid levels were based on trial data from the
pegloticase non-responder group for months 6 to 12 of the model
and on the baseline level for the whole trial cohort for the
remainder of the model. Serum uric acid levels in non-responders
were based on data from non-responders in the pegloticase arm
of the trials for 2 months and then on data from the placebo arms
of the 2 phase III trials for the remaining 4 months once the
patients have progressed to best supportive care. Serum uric acid
levels in non-completers were based on data from the placebo
arms of the 2 phase III trials for the full 6 months. The baseline
serum uric acid level was modelled beyond 6 months for nonresponder and non-completer patients.
6.10
6.11
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
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model. For non-completers and patients in the best supportive
care arm of the model tophi resolution achieved at 6 months in the
pooled analysis of the placebo arms of the trials was modelled
and maintained for entire time horizon of the model.
6.12
6.13
6.14
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
Issue date: November 2012
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reactions, adverse event costs, refractory chronic gout
management, treatment for acute flares, and tophus surgery.
Resource use for the management of severe debilitating
refractory chronic gout according to serum uric acid level was
estimated by clinical expert survey and the in-depth clinician
interview. Drug cost incurred for prophylaxis for acute gout flares
and infusion reactions, adverse event costs, refractory chronic
gout management, acute flares treatment were based on costs in
the British National Formulary (BNF) 63 All other resource use
cost was estimated using NHS reference costs and Health
Related Groups for 201011. The resource use for 2 adverse
drug effects (infusion reactions and vomiting) was modelled for
the pegloticase arm and assumed 0 for best supportive care,
which was assumed to consist of standard medical care with
NSAIDS, colchicine and corticosteroids but no urate-lowering
treatment. However, a cost for drug treatment associated with the
best supportive care comparator was not included in the
economic model in the original submission. The cost used in the
model of managing an episode of acute flare was 295 based on
a Scottish Medicines Consortium guidance (637/10) on
febuxostat.
6.15
6.16
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
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was particularly sensitive to changes in baseline levels of serum
uric acid, the disutility associated with higher serum uric acid
levels and patients age. The sensitivity analyses also show that
the disutility associated with higher serum uric acid levels is a
significant driver of cost effectiveness, which is important given
the significant uncertainty about this assumption. The costeffectiveness results were also fairly sensitive to changes in the
utility value for patients with serum uric acid level under the target
value and the baseline utility value. The cost-effectiveness results
were also moderately sensitive to the parameter values for
treatment efficacy and persistence with pegloticase treatment.
6.17
6.18
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
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manufacturer responded with a revised model in which 10% of the
responders were assumed to switch to best supportive care,
instead of maintenance treatment with xanthine oxidase inhibitors,
after pegloticase treatment. The revised model also included drug
costs for best supportive care. Best supportive care treatment was
considered to consist of an NSAID (for instance naproxen 500 mg
per day) in about 90% of patients, colchicine (for instance
1000 mg per day) in about 10% of patients and corticosteroids (for
instance prednisolone 1015 mg per day) in about 75% of
patients. The deterministic results for this revised base-case
analysis (referred to as the revised model) showed an incremental
cost of 9452 and incremental QALY of 0.305, compared with
best supportive care resulting in an ICER of 31,027 per QALY
gained. A probabilistic sensitivity analysis (after correcting for an
error identified in the computer program used to run the
probabilistic sensitivity analysis) of 10,000 samples using the
revised assumptions yielded a mean ICER of 31,031 per QALY
gained (incremental cost of 9491 and a QALY gain of 0.306).
6.19
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
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life had already been captured in the 4 serum uric acid health
states
assuming no correlation between serum uric acid levels and
utility
different mortality rates.
The revised ICERs were particularly sensitive to assumptions that
tophi resolution influences utility and that serum uric acid levels are
correlated with utility. The ICER increased to 43,614 per QALY
gained when no extra decrease in utility was assumed in patients
with tophi, and to 38,535 when serum uric acid levels were
assumed not to be correlated with utility.
6.20
6.21
6.22
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
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without having intervening maintenance treatment was assumed
to be 10% but the proportion of trial patients who were eligible to
participate because of intolerance or contraindication to
allopurinol was ***** in trial C0406 and ***** in trial C0405.
6.23
6.24
The ERG was concerned that that the length of time on treatment
in clinical practice could be greater than the 6 months assumed in
the model. It noted that the draft summary of product
characteristics did not limit treatment to 6 months but also
acknowledged the lack of data to support long-term treatment.
The combined data from the 2 key trials (C0405 and C0406) and
the open-label extension study (C0407) showed that the mean
number of treatments received by responders was ****
(median=**, SD=*****). A Kaplan-Meier plot of the time to stopping
treatment for responders to pegloticase all 3 trials showed that the
proportion continuing to receive pegloticase treatment was fairly
high at over *** until around *******, with
*****************************************. The ERG also noted that in
the open-label extension study patients were allowed to continue
pegloticase treatment for up to a maximum of 30 months
(2.5 years).
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
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6.25
6.26
The ERG also had concerns about the survival model used to
extrapolate persistence with allopurinol, and noted that in the
scenario analysis the ICER was sensitive to the rate of
discontinuation of allopurinol. The ERG noted that an alternative
approach to modelling allopurinol persistence could be a Weibull
fit for all the 2-year data available from the UK observational study
(Annemans et al. 2008) as opposed to the Weibull fit for only the
second year data, as in the original model. The ERG noted that a
sensitivity analysis conducted by the manufacturer at the
clarification stage using this approach increased the ICER to
37,981 per QALY gained from the revised base-case ICER of
31,027 per QALY gained.
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
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6.27
The ERG noted that published data from modified intention-totreat analysis of the trials (see section 4.5) were not used to
calculate the clinical effectiveness in the model, and that there
was additional analysis of the trial data to inform the health
economic model. Primary end points in the trials were based on
plasma uric acid level while in the economic model the end points
were based on serum uric acid. However, the ERG noted that
plasma and serum uric acid levels had a degree of correlation and
that serum uric acid levels would likely be used in clinical practice.
The ERG agreed that long-term maintenance of serum uric acid
below 360 micromol/litre could be expected to result in clinically
meaningful changes in patient-related outcomes, although it noted
that the BSR guideline recommended maintaining serum uric acid
levels below 300 micromol/litre.
6.28
The ERG noted that the effectiveness of tophi resolution (in terms
of proportion of patients with resolved tophi) was applied to all
patients in the model and not only to the subgroup with tophi at
baseline. The ERG considered that the model might have
overestimated the treatment benefit of tophi resolution and
therefore biased the analysis in favour of the pegloticase arm. The
ERG also commented that the proportion of patients receiving
pegloticase in clinical practice who have tophi at baseline may be
higher than what was observed in the trials because of the
wording of the draft license indication, which includes the term
tophaceous gout.
6.29
The ERG had concerns that the method for calculating utility from
a combination of serum uric acid level, frequency of flares and
tophi resolution may result in quality of life improvements being
double counted because all 3 are likely to be correlated in an
individual. For example, tophi resolution is likely to be correlated
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with low serum uric acid levels, but the model assumes that the
probability of having tophi resolution is the same irrespective of
the serum uric acid level, and applies a utility benefit for both tophi
resolution and low serum uric acid levels.
6.30
The ERG stated there was a similar risk of double counting when
capturing both the benefits of reduced flares and lower serum uric
acid level, because the frequency of flares is assumed to be
related to the serum uric acid level but in the model both are
treated as independent factors in determining utility. This type of
double counting was more problematic because both utility gains
were applied to all patients from 6 months and to patients in the
pegloticase arm of the model who receive best supportive care
before 6 months. The ERG suggested the potential for double
counting benefits in this manner may have been avoided if the
data on the relationship between serum uric acid and utility had
been properly adjusted to take into account the frequency of flares
as a confounding factor, providing an estimate of the disutility per
serum uric acid state in the absence of flares.
6.31
The ERG was concerned about the assumption that the resource
use would be greater in patients with a higher serum uric acid
level over and above the difference determined by gout flares. It
therefore conducted an analysis in which the resource use for
patients with a serum uric acid over 360 micromol/litre was set to
the same value as for those under 360 micromol/litre. It also
assumed that the number of rheumatology visits associated with
pegloticase treatment would be reduced to 3 (from 5 in the
manufacturers model) in year 1 and none thereafter but assumed
that 2 visits would be needed even in patients classified as nonresponders or non-completers, giving a net reduction in the cost
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of rheumatology visits associated with pegloticase (see section
6.33).
6.32
The ERG also noted that limited details were available about the
methods used to derive the relationship between serum uric acid
level and utility in the model beyond 6 months, which were based
on data from guidance on febuxostat for hyperuricaemia in gout
(NICE technology appraisal guidance 164). The ERG noted that
the relationship between serum uric acid level and underlying
utility was considered uncertain by NICEs Appraisal Committee
during appraisal of TA164.
6.33
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making alternative assumptions about resource used as outlined
in section 6.31
applying the proportion of patients unable to take xanthine
oxidase inhibitors based on the trial population (**** as
mentioned in section 6.22
assuming that utility benefits are driven solely by the frequency
of flares and the resolution of tophi and not directly by the serum
uric acid level to minimise double counting of clinical benefits
(see section 6.296.30)
assuming that utility is based solely on flares
assumed that only 71% of patients have tophi at baseline
because the manufacturers base case implicitly assumes that
100% have tophi at baseline (see section 6.28)
a combined analysis of alternative assumptions about resource
use and utility benefits based only on the frequency of flares and
the tophi resolution (assuming a disutility linked to serum uric
acid level of 0).
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Table 2 Deterministic sensitivity analysis varying some structural
assumptions (from tables 3041of the ERG report)
Incremental cost
(pegloticase best
supportive care)
Incremental
QALY
(pegloticase
best supportive
care)
ICER
(/QALY)
9,452
0.305
31,027
Pegloticase
persistence (100%)
and response rate
(42%)
10,748
0.331
32,492
5% of pegloticase
responders receive
febuxostat
8,955
0.314
28,535
9,624
0.285
33,793
9,580
0.305
31,449
9,606
0.305
31,534
9,345
0.305
30,678
Assumptions about
resource use
12,492
0.305
41,008
Applying the
proportion unable to
take xanthine oxidase
inhibitors in the trial
population to the
modelled population
*******
*****
9,452
0.230
41,118
9,452
0.018
529,771
9,489
0.226
42,000
12,492
0.230
ERGs
scenario 2
*******
Alternative
assumptions about
utility gains
When combining
alternative
assumptions about
utility gains with
alternative
assumptions about
resource use
(scenario 2 plus 3)
ERGs
scenario 1
54,345
ERGs
scenario 3
ERGs
scenario 4
(ERGs
preferred
scenario)
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6.34
6.35
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Table 3 Deterministic sensitivity analysis of ERGs base case varying some
structural assumption (from table 44 of the ERG report)
Incremental cost
(pegloticase best
supportive care)
ERGs preferred
scenario
12,492
12,634
6.36
54,345
ERGs
scenario 4
0.228
55,529
ERGs
scenario 8
Assuming 3 months
treatment in those
who are noncompleter with
pegloticase
Maintenance therapy
unable to maintain
low serum uric acid
levels
0.230
ICER
(/QALY)
ERGs
scenario 7
Assuming lower
persistence on
allopurinol based on 2
year data from
(Annemans et al.)
Incremental QALY
(pegloticase best
supportive care)
15,084
0.226
66,696
ERGs
scenario 9
Substantial
increase
Marginal increase
Increased
ERGs
scenario 10
Increased
Decreased
Increased
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Incremental QALY
(pegloticase best
supportive care)
ICER
(/QALY)
9,452
0.305
31,027
12,235
0.201
60,793
9,142
ERGs
scenario 1
Table 42 of
ERG report
Table 43 of
ERG report
0.316
28,922
0.230
54,345
7
7.1
12,492
ERGs
scenario 4
ERGs
scenario 5
12,698
0.202
62,961
ERGs
scenario 6
12,496
0.233
53,517
Equalities issues
During the scope development some consultees pointed out that
pegloticase is contraindicated in people with glucose-6-phosphate
dehydrogenase (G6PD) deficiency, which is more common
among people with African or Mediterranean ancestry. This was
discussed at the scoping workshop. The attendees at the scoping
workshop agreed that it did not seem to be an equalities issue
that needs addressing in the appraisal, given that people with
G6PD deficiency would not be considered for treatment with
pegloticase because of the specific contraindication.
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8
8.1
Innovation
The manufacturer stated that currently best supportive care is the
only treatment option available for patients for whom pegloticase
would be indicated. The manufacturer stated that pegloticase is
an effective treatment option that reduces uric acid levels and
provides significant disease-modifying benefits including tophus
resolution, reduction in flares (after 3 months of treatment) and
improvements in patients quality of life.
Authors
Anwar Jilani
Technical Lead
Dr Pall Jonsson
Technical Adviser
with input from the Lead Team (Henry Marsh, Katherine Payne and Judith
Wardle).
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Premeeting briefing Pegloticase for treating severe debilitating chronic tophaceous gout
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