Elranatamab for treating relapsed and refractory multiple myeloma after 3 or more treatments

Recommendation

NICE has recommended elranatamab with managed access as an option for treating relapsed and refractory multiple myeloma in adults, only after 3 or more lines of treatment (including an immunomodulatory drug, a proteasome inhibitor and an anti‑CD38 antibody) when the multiple myeloma has progressed on the last treatment. It is only recommended if the conditions in the managed access agreement for elranatamab are followed.

Eligible population for elranatamab

The Multiple myeloma: patient outcomes in real-world practice study estimates that 15% of people with multiple myeloma are expected to receive fourth-line treatment.

Table 1 shows the population who are eligible for fourth-line treatment and the number of people who are expected to have elranatamab in each of the next 5 years. These figures include the impact of the predicted population growth.

The market share for elranatamab is based on consultant haematologist opinion. It can be amended to reflect local practice in the resource impact template.

Treatment options for the eligible population

The treatment most commonly used for relapsed and refractory multiple myeloma after 3 lines of treatment (including an immunomodulatory agent, a proteasome inhibitor and an anti‑CD38 antibody) is pomalidomide plus dexamethasone.

Teclistamab is another treatment option included in the resource impact template. It was recently recommended for use in routine commissioning in the NHS in NICE's technology appraisal guidance on teclistamab for treating relapsed and refractory multiple myeloma after 3 or more treatments.

If the myeloma is refractory to 5 or more treatments, selinexor plus dexamethasone can be used. The resource impact of this is considered in the resource impact template and report for NICE's technology appraisal guidance on selinexor with dexamethasone for treating relapsed or refractory multiple myeloma after 4 or more treatments.

A consultant haematologist highlighted that there might be a group of people with the condition (approximately 10%) currently having panobinostat, bortezomib and dexamethasone at fourth line.

For more information about the treatments, such as dose and average treatment duration, see the resource impact template.

Financial resource impact (cash items)

The company has a commercial arrangement. This makes elranatamab available to the NHS with a discount. The size of the discount is commercial in confidence.

The confidential price of elranatamab can be put into the resource impact template and other variables may be amended.

The payment mechanism for the technology is determined by the responsible commissioner and depends on the technology being classified as high cost.

Further analysis is provided in the resource impact template, and the financial impact of cash items can be calculated.

Capacity impact

The median treatment duration for elranatamab is assumed to be 5.6 months. This is based on the MagnetisMM‑3 trial.

Treatment with elranatamab and teclistamab needs the person to be hospitalised during the step-up dosing protocol to mitigate the risks of cytokine release syndrome (CRS) and neurotoxicity. Based on consultant haematologist opinion this is assumed to be for 5 days.

Elranatamab and teclistamab are administered by a subcutaneous injection. Whereas the main comparator, pomalidomide with dexamethasone, is delivered orally. So, there are more administration appointments needed for treatment with elranatamab. The resource impact template allows commissioners to assess the resource impact of any additional attendances at provider services.

Adverse events relating to CRS or neurotoxicity may result in administrations of tocilizumab and additional critical care episodes.

Adverse events relating to hypogammaglobulinaemia may result in administrations of intravenous immunoglobulin therapy.

There is uncertainty over the number of patients who may need additional medications for adverse events and the treatment duration for these.

The adverse-event rates and associated costs can be amended in the resource impact template to reflect local assumptions.

Table 2 shows the impact on capacity activity across the eligible population in each of the next 5 years. This is based on market share increases for both elranatamab and teclistamab and includes the impact of the predicted population growth.

Further analysis is provided in the resource impact template. The financial capacity impact, from a commissioner (national) and provider (local) perspective can be calculated.

About this resource impact summary report

This resource impact summary report accompanies the NICE guidance on Elranatamab for treating relapsed and refractory multiple myeloma after 3 or more treatments and should be read with it. See terms and conditions on the NICE website.

ISBN: 978-1-4731-6700-1