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«Clinical Commissioning policy: Amifampridine phosphate for the treatment of LambertEaston Myasthenic Syndrome Reference: NHS England: 16009/P ...»

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Clinical

Commissioning

policy: Amifampridine

phosphate for the

treatment of LambertEaston Myasthenic

Syndrome

Reference: NHS England: 16009/P

OFFICIAL

NHS England INFORMATION READER BOX

Directorate

Medical Operations and Information Specialised Commissioning

Nursing Trans. & Corp. Ops. Commissioning Strategy

Finance

Publications Gateway Reference: 05527s

Document Purpose Policy

Document Name Clinical Commissioning Policy 16009/P Author Specialised Commissioning Team Publication Date 13 July 2016 Target Audience CCG Clinical Leaders, Care Trust CEs, Foundation Trust CEs, Medical Directors, Directors of PH, Directors of Nursing, NHS England Regional Directors, NHS England Directors of Commissioning Operations, Directors of Finance, NHS Trust CEs Additional Circulation #VALUE!

List Description Not Routinely Commissioned - NHS England will not routinely commission this specialised treatment in accordance with the criteria described in this policy.

Cross Reference This document is part of a suite of policies with Gateway Reference 05527s.

Superseded Docs N/A (if applicable) Action Required N/A Timing / Deadlines N/A (if applicable) Contact Details for england.specialisedcommissioning@nhs.net further information 0 Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet.

OFFICIAL

Standard Operating Procedure:

Clinical Commissioning Policy:

Amifampridine phosphate for the treatment of Lambert-Easton Myasthenic Syndrome First published: July 2016 Prepared by NHS England Specialised Services Clinical Reference Group for Neurosciences Published by NHS England, in electronic format only.

OFFICIAL Contents 1 Introduction

2 Definitions

3 Aims and Objectives

4 Epidemiology and Needs Assessment

5 Evidence Base

6 Documents which have informed this Policy

7 Date of Review

References

OFFICIAL

Policy Statement NHS England will not routinely commission amifampridine phosphate for LambertEaston Myasthenic syndrome in accordance with the criteria outlined in this document. In creating this policy NHS England has reviewed this clinical condition and the options for its treatment. It has considered the place of this treatment in current clinical practice, whether scientific research has shown the treatment to be of benefit to patients, (including how any benefit is balanced against possible risks) and whether its use represents the best use of NHS resources. This policy document outlines the arrangements for funding of this treatment for the population in England.

Equality Statement Promoting equality and addressing health inequalities are at the heart of NHS England’s values. Throughout the development of the policies and processes cited in

this document, we have:

 Given due regard to the need to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited under the Equality Act 2010) and those who do not share it; and  Given regard to the need to reduce inequalities between patients in access to, and outcomes from healthcare services and to ensure services are provided in an integrated way where this might reduce health inequalities Plain Language Summary About Lambert-Eaton myasthenic syndrome (LEMS) Lambert-Eaton myasthenic syndrome (LEMS) is a rare disorder caused by a problem with how the patient's nerves send signals to their muscles.

 LEMS occurs because the immune system attacks the nerve endings by mistake.

 This weakens the signals from the nerves to the muscles – preventing the muscles contracting (tightening) properly.

LEMS results in muscle weakness and sometimes a dry mouth, constipation and being unable to get or maintain an erection (impotence).

OFFICIAL

There are two main groups of patients with LEMS:

 In about 50%, the disease is caused by an underlying lung cancer, usually the type linked to smoking. These people usually develop the disease in middle age or later.

 In the other 50%, there is no obvious trigger to the disease and patients do not have cancer. This form of the disease may start at any age.

About the new treatment Amifampridine phosphate (Firdapse®) is the only treatment licensed in the United Kingdom (UK) for the treatment of symptoms linked to LEMS. The medicine works by increasing the release of a chemical which aids nerve signal transmission.

What have we decided NHS England has carefully reviewed the evidence to treat Lambert-Eaton myasthenic syndrom e with amifampridine phospate (Firdapse®). We have concluded that there is not enough evidence to make the treatment available at this time.

–  –  –

1 Introduction This document describes the evidence that has been considered by NHS England in formulating a proposal to not routinely commission amifampridine phospate (Firdapse®) for patients with Lambert-Eaton myasthenic syndrome.





Lambert-Eaton myasthenic syndrome (LEMS) is a rare disorder caused by a problem with the transmission of nerve signals to the muscles. The immune system mistakenly attacks the nerve endings, which causes an insufficient release of a chemical neuro transmitter called acetylcholine resulting in impaired nerve signal transmission. This weakens the nerve impulses from the nerves to the muscles and prevents the muscles contracting properly. Thus LEMS results in muscle weakness and sometimes dryness of the mouth, constipation and impotence.

In about 50% of people with LEMS, the disease is triggered by an underlying lung cancer. These people usually develop the disease in middle age or later. There is no obvious trigger in the other 50% of patients with LEMS who do not have cancer, and this form of the disease may start at any age.

If there is no cancer, LEMS does not shorten life but may have a considerable impact on quality of life. People with small cell lung cancer will have a shorter life expectancy because of the aggressive nature of the cancer. They can develop complications such as difficulty breathing, difficulty swallowing and pneumonia.

Amifampridine increases the release of acetylcholine from nerve cells. It is an inhibitor of voltage-dependent potassium channels and prolongs the depolarisation of the pre-synaptic cell membrane, allowing for enhanced calcium influx into the neuron which facilitates the release of acetylcholine, thereby improving neuromuscular transmission.

Amifampridine is the international non-proprietary name (INN) for 3,4-diaminopyridine (3,4-DAP). There are no licensed preparations of amifampridine available in the UK.

Amifampridine phosphate (Firdapse®) (3,4-DAP phosphate) is the phosphate salt of amifampridine and is a stable formulation that does not require refrigeration.

OFFICIAL

Amifampridine phosphate is the only treatment licensed for the symptomatic treatment of patients with Lambert-Eaton myasthenic syndrome (LEMS).

Amifampridine phosphate (Firdapse®) was designated an orphan medicine by the European Medicines Agency in 2002, and was awarded a marketing authorisation under exceptional circumstances in 2009.

2 Definitions Lambert-Eaton myasthenic syndrome (LEMS) is a chronic progressive debilitating condition of presynaptic neuromuscular transmission. It is caused by insufficient release of a chemical neurotransmitter called acetylcholine from the synaptic vesicles resulting in impaired nerve signal transmission.

Amifampridine (3,4-DAP) increases the release of acetylcholine from nerve cells. It inhibits the voltage-dependent potassium channels and prolongs the depolarisation of the pre-synaptic cell membrane, allowing for enhanced calcium influx into the neuron which facilitates the release of acetylcholine, thereby improving neuromuscular transmission.

Amifampridine phosphate (Firdapse®) is the phosphate salt of amifampridine.

3 Aims and Objectives This policy aims to define NHS England's commissioning position on amifampridine phosphate (Firdapse®) as part of the treatment pathway for adult patients with Lambert-Eaton myasthenic syndrome.

The objective is to ensure evidence based commissioning in the use of amifampridine phosphate for the treatment of adults with Lambert-Eaton myasthenic syndrome.

–  –  –

4 Epidemiology and Needs Assessment Lambert-Eaton myasthenic syndrome (LEMS) is a rare condition with prevalence estimated at 5 per 2 million. It is therefore estimated that there are 150 patients with LEMS in the UK (NHS England, 2013).

LEMS is strongly associated with cancer, especially small-cell lung cancer (SCLC). It is estimated that about 3% of patients with SCLC have LEMS, and 40 to 60% of patients with LEMS have SCLC; 5% have other cancers. Where LEMS occurs in the absence of cancer it is often associated with an autoimmune disorder (NHS England, 2013).

In 75- 95% of cases the patient's immune system attacks their nerve endings. The aetiology can be traced to auto-antibodies that are directed against voltage gated calcium channels (NHS England, 2013).

5 Evidence Base NHS England has concluded that there is not sufficient evidence to support a proposal for the routine commissioning of amifampridine phosphate (Firdapse®) for the treatment of Lambert-Eaton myasthenic syndrome.

Amifampridine is the international non-proprietary name (INN) for 3,4 diaminopyridine (3,4-DAP). There are no licensed preparations of amifampridine available in the UK. Amifampridine phosphate (Firdapse®) (3,4-DAP phosphate) is the phosphate salt of amifampridine and is a stable formulation that does not require refrigeration. Amifampridine phosphate is the only treatment licensed for the symptomatic treatment of patients with Lambert-Eaton myasthenic syndrome (LEMS).

The evidence review sought to answer the following questions:

1) Is amifampridine phosphate clinically effective in adult patients with confirmed Lambert-Eaton myasthenic syndrome (LEMS)?

2) Is amifampridine phosphate cost effective in adult patients with confirmed Lambert-Eaton Myasthenic Syndrome?

OFFICIAL

The clinical evidence supporting the use of amifampridine phosphate in LEMS originates from studies of unlicensed amifampridine. The evidence is consistent in demonstrating some improvement in muscle strength from treatment with amifampridine without clear demonstration of actual clinical benefit to the patients.

1) Is amifampridine phosphate clinically effective in adult patients with confirmed Lambert-Eaton myasthenic syndrome?

The literature search could not identify any studies of the clinical efficacy of amifampridine phosphate. This evidence review was therefore limited to the use of amifampridine base in LEMS.

There are only a few high quality studies of amifampridine in LEMS. The most recent Cochrane Review of amifampridine (3, 4-DAP) in patients with Lambert-Eaton myasthenic syndrome (Keogh et al., 2011) is a well-conducted systematic review and meta-analysis that summarises best available current evidence. This includes the four RCTs reporting on the efficacy of 3, 4-DAP treatment in LEMS (McEvoy, 1989;

Oh, 2009; Sanders, 2000; Wirtz, 2009). This review was graded as "limited but moderate to high quality evidence at low risk of bias” by the authors. The 4 RCTs demonstrate the efficacy of 3, 4-DAP in LEMS, with all reporting improvement in muscle strength score or myometric limb measurements. Meta-analysis of the efficacy endpoints showed 1) Quantitative Myasthenia Gravis (QMG) muscle score improvement of 2.44 points (mean) with a 95% confidence interval ranging from 3.6 to 1.22; and 2) Compound Muscle Action Potential (CMAP) amplitude improvement of 1.36 mV (mean) with a 95% confidence interval ranging from 0.99 to 1.72.

The authors also note that the improvement produced by 3, 4-DAP treatment of LEMS may not be regarded as clinically significant based on the accepted QMG improvement to actual clinical benefit cut off being pegged at 2.6 points (Barohn et al., 1998). The key limitations remain the small trial sizes and the relatively short time periods of the trials reviewed. A further review of the use of aminopyridines in neuromuscular disorders (Sedehizadeh et al., 2012), also focussed on the four trials covered in the Cochrane review, reaching similar conclusions.

OFFICIAL

Amifampridine is contraindicated in patients who have epilepsy, uncontrolled asthma or congenital QT syndromes. Given very few studies on safety of amifampridine in LEMS, a large case series (n=669) report on the use of amifampridine at the French treatment centre was included in this review although majority of patients multiple sclerosis and only three had LEMS (Flet et al., 2010). At a mean treatment dose of 30 mg daily (which is lower than what is usually prescribed for LEMS), 16% of all patients discontinued treatment due to an adverse drug reaction out of which 8% could be directly linked to amifampridine. Most side effects were mild to moderate with paraesthesias as the most common complaint. 6 patients had serious adverse events including seizures, cardiovascular and hepatic disorders. These findings indicate that amifampridine is generally well tolerated but should be prescribed after thorough investigation for seizure history and with provisions of continued monitoring of liver and cardiac function during treatment especially for patients on high dosage.

Sedehizadeh et al., 2012 recommend that the daily dose of the drug should not exceed 80 mg/day on the basis of the finding that 3 patients on dosage 100mg/ day developed seizures.

In conclusion, the current evidence is consistent in demonstrating some improvement in muscle strength from treatment with amifampridine but ambiguous on the actual clinical impact of this improvement. Amifampridine is generally well tolerated at lower doses with adverse effects generally correlated with daily prescribed dose.



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