Selinexor plus bortezomib and dexamethasone is recommended as an option for treating multiple myeloma in adults, only if:
they have only had 1 previous line of treatment, and their condition is refractory to both daratumumab and lenalidomide, or
they have only had 2 previous lines of treatment and their condition is refractory to lenalidomide.
Selinexor is only recommended if the company provides it according to the commercial arrangement.
This recommendation is not intended to affect treatment with selinexor plus bortezomib and dexamethasone that was started in the NHS before this guidance was published. People having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS healthcare professional consider it appropriate to stop.
Why the committee made these recommendations
For this evaluation, the company asked for selinexor plus bortezomib and dexamethasone (selinexor combination) to be considered only:
after 1 previous line of treatment (second line) for multiple myeloma that is refractory (stops responding) to both daratumumab and lenalidomide, and
after 2 previous lines of treatment (third line).
This does not include everyone who selinexor combination is licensed for.
Carfilzomib plus dexamethasone is the relevant second-line comparator for selinexor combination for treating multiple myeloma that is refractory to daratumumab and lenalidomide. At third line, preferred treatments for multiple myeloma that is still sensitive to lenalidomide include ixazomib plus lenalidomide and dexamethasone (ixazomib combination). For multiple myeloma that is refractory to lenalidomide, the third-line treatment is panobinostat plus bortezomib and dexamethasone (panobinostat combination).
Selinexor combination has only been directly compared in a clinical trial with bortezomib plus dexamethasone, which is not considered a relevant treatment at second or third line. This clinical trial evidence shows that selinexor combination increases how long people have before their condition gets worse compared with bortezomib plus dexamethasone at second line, but not at third line. The trial evidence also shows that selinexor combination does not increase how long people live compared with bortezomib plus dexamethasone either at second or third line.
There have only been indirect comparisons between selinexor combination and carfilzomib plus dexamethasone at second line, or ixazomib combination or panobinostat combination at third line. The results suggest that there are no differences between the treatments on how long people have before their condition gets worse or how long they survive. But these results are highly uncertain.
The cost-effectiveness estimates for selinexor combination compared with carfilzomib plus dexamethasone at second line and with panobinostat combination at third line are within the range that NICE considers an acceptable use of NHS resources. But the cost-effectiveness estimates for selinexor combination compared with ixazomib combination at third line are above what NICE normally considers an acceptable use of NHS resources. So, selinexor combination is only recommended as a second-line treatment for multiple myeloma that is refractory to both daratumumab and lenalidomide, or as a third-line treatment for multiple myeloma that is refractory to lenalidomide.