Filgotinib for Moderate to Severe Rheumatoid Arthritis: An Evidence Review Group Perspective of a NICE Single Technology Appraisal
Authors: Sabine E. Grimm, Ben Wijnen, Rob Riemsma, Debra Fayter, Nigel Armstrong, Charlotte Ahmadu, Lloyd Brandts, Kate Misso, John R. Kirwan, Jos Kleijnen & Manuela A. Joore
The National Institute for Health and Care Excellence (NICE) invited the manufacturer (Gilead) of filgotinib (Jyseleca™), as part of the single technology appraisal process, to submit evidence for its clinical and cost effectiveness for the treatment of patients with moderate to severe rheumatoid arthritis (RA). Kleijnen Systematic Reviews Ltd, in collaboration with Maastricht University Medical Centre, was commissioned to act as the independent Evidence Review Group (ERG). This paper summarises the company submission (CS), presents the ERG’s critical review of the clinical- and cost-effectiveness evidence in the CS, highlights the key methodological considerations, and describes the development of the NICE guidance by the NICE Appraisal Committee. The evidence for filgotinib was based on two good-quality international randomised controlled trials. In FINCH 1, filgotinib was compared with placebo, and in FINCH 2, filgotinib was compared with adalimumab and placebo. As there was no head-to-head evidence with most active comparators, the company performed two separate network meta-analyses (NMAs), one for the conventional disease-modifying antirheumatic drugs–inadequate response population and one for the biological disease-modifying antirheumatic drugs–inadequate response population. The outcomes analysed were American College of Rheumatology response criteria at weeks 12 and 24, and European League Against Rheumatism response criteria at 24 weeks. The statistical methods used to perform the NMAs were valid and were in line with previous NICE appraisals. Results of the NMAs are confidential and cannot be reported here, but they were uncertain due to heterogeneity of the included studies. The economic analysis of the patient population with moderate RA suffered from limited evidence on the progression from moderate to severe health states. For the moderate RA population, the final analyses comparing filgotinib, with or without methotrexate, against standard of care resulted in incremental cost-effectiveness ratios of around £20,000 per quality-adjusted life-year gained in the company’s and ERG’s base-case and scenario analyses. NICE recommended filgotinib in combination with methotrexate or as monotherapy when methotrexate is contraindicated, or if people cannot tolerate it, for patients with moderate RA whose disease had responded inadequately to two or more conventional disease-modifying antirheumatic drugs (DMARDs). For the severe RA population, in view of the higher or similar net health benefits that filgotinib provided versus its comparators, NICE recommended filgotinib with or without methotrexate for patients whose disease had responded inadequately to two or more conventional DMARDs, who had been treated with one or more biological DMARDs, if rituximab was not an option, or after treatment with rituximab.
Key Points for Decision Makers
Filgotinib is the first biological disease-modifying antirheumatic drug (DMARD) that has been recommended for use in patients with moderate rheumatoid arthritis (RA) in the England and Wales National Health Service.
The incremental cost-effectiveness ratios of filgotinib versus its comparators were around £20,000 per quality-adjusted life-year gained in the moderate population; in the severe population, filgotinib provided similar or higher net health benefits compared with its comparators.
Evidence for rates of progression from moderate to severe RA and subsequent treatment sequences was not readily available but remains crucial for the modelling of cost-effectiveness of biological DMARDs for the treatment of moderate RA.
RA appraisals and other appraisals with a large number of comparators and potential treatment sequences would benefit from methodological guidance on how to incorporate these in economic models.