Kyprolis’s dominance illustrated in clinical pathways.
By Brandon Goode, Analyst
17 May 2016
As new drugs to treat multiple myeloma become available, oncology clinical pathways are expected to have an increasing influence on utilization management in the US. Oncology clinical pathways can be developed by either third-party companies (largely physician-led) or payers, are mostly considered to be decision-support management tools, and recommend one or more treatments as a preferred choice for a particular patient population based on published clinical evidence. The choice of preferred treatment is initially based on efficacy, followed by safety and cost. If a treatment demonstrates a clear advantage in terms of efficacy or safety over another treatment, it will be the treatment of choice, regardless of its pricing compared to competitors. Around 80% of patients are expected to be treated consistently with pathway recommendations and payers tend utilize physician incentives to encourage on-pathway use of drugs.
The Kyprolis, Revlimid, and dexamethasone (KRD) regimen lies in the second line of Anthem’s multiple myeloma pathway and is indicated in the National Comprehensive Cancer Network’s (NCCN) Evidence Blocks as the most effective regimen in relapsed disease. While the NCCN rates the evidence bases of KRD and the Empliciti, Revlimid, and dexamethasone regimen as equal in this setting, KRD is clearly the preferred regimen with much higher efficacy ratings – echoed by the placement of the drugs in Anthem’s pathway.
Multiple myeloma clinical pathways used by Anthem’s Cancer Care Quality Program
|Line of therapy||SCT candidates||Non-SCT candidates|
|First or salvage therapy||Velcade, Revlimid, and DMVelcade, DOX, and DMVelcade, DM, and CTX||Revlimid and DMVelcade and DM|
|Second and subsequent (ECOG PS: 0, 1, 2)||Kyprolis, Revlimid, and DMVelcade and DM|
|Third and subsequent (ECOG PS: 0, 1, 2)||DarzalexEmpliciti, Revlimid, and DM|
|CTX = cyclophosphamide; DM = dexamethasone; DOX = doxorubicin; ECOG PS = Eastern Cooperative Oncology Group Performance Status; SCT = stem cell transplant|
|Source: AIM Specialty Health, 2016|
Datamonitor Healthcare considers the positioning of treatments in NCCN guidelines and Evidence Blocks to be indicative of a drug’s position in the majority of available oncology pathway tools as they are based on the same evidence and are built on similar methodologies. Kyprolis will continue to dominate the recurrent setting on oncology pathways, potentially becoming more common in the first line with an efficacy backing equal to that of Velcade in the NCCN Evidence Blocks. A lack of differentiation from Velcade will hinder the inclusion of Empliciti and Ninlaro in earlier lines, particularly when generic bortezomib becomes available in 2017. Following the release of Phase III results, Darzalex has great promise for pathway inclusion at earlier lines with an alternative and effective mechanism of action, impressive safety, and a wide-ranging application.
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