Rivaroxaban for the treatment of deep vein thrombosis and ...

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3.1.1 EINSTEIN-DVT Population Whilst the main inclusion criteria match the population as defined by NICE, the exclusion criteria mean that a number of small subgroups of patients are excluded from the evidence base. 3.1.1.1 Excluded on basis of comorbidities or patient characteristics These include (taken from Table 10, page 40 of the MS) 1 : Additional indications for a vitamin K antagonist Creatinine clearance 3x upper limit of normal Contraindication to anticoagulation Bacterial endocarditis Active bleeding or a high risk of bleeding Systolic blood pressure >180 mmHg or diastolic blood pressure >110 mmHg Childbearing potential without proper contraceptive measures Pregnancy or breastfeeding Concomitant use of strong cytochrome P-450 3A4 inhibitors (e.g. human immunodeficiency virus, protease inhibitors or systemic ketoconazole) or inducers (e.g. rifampicin, carbamazepine or phenytoin) Participation in another clinical trial within 30 days prior to screening Life expectancy of less than 3 months Pre-randomisation therapeutic doses of LMWH, fondaparinux or UH for more than 36 hours >1 single dose of vitamin K antagonist pre-randomisation Thrombectomy, insertion of a vena cava filter or fibrinolytic agent for current episode of thrombosis Contraindication to enoxaparin, warfarin or acenocoumarol Some of these exclusions are in line with the licensing of the drug (i.e. creatinine clearance
contraindications for the drug (as listed in the SmPC) 19,20 , and would therefore appear eligible for treatment, are not included in the trial evidence. These include: Additional indications for a vitamin K antagonist Creatinine clearance 180 mmHg or diastolic blood pressure >110 mmHg Of particular note is the exclusion of patients with high risk of bleeding. This group is specifically Superseded – mentioned in the NICE scope as a potential subgroup analysis. Whilst it could be argued that these groups required additional resources to treat or different treatment regimes and would therefore have presented practical challenges within the trial, this does not alter the fact that there is no evidence about the action of rivaroxaban in these groups. The manufacturer does not report having sought See Erratum clinical opinion to explore this. 3.1.1.2 Excluded on basis of index event It would also appear that only patients with proximal DVT were included in the trial. This is not apparent from the MS, 1 but is stated in the EINSTEIN-DVT study protocol 22 on page 6. The ERG attempted to clarify this point in with the manufacturer by asking for the proportion of patients with distal, provoked and spontaneous DVTs, but the question was not interpreted by the manufacturer as the ERG had intended (the question was intended to related to baseline proportions, but was answered with outcome proportions). 17 This focus on patients with proximal DVTs would appear to be in line with the expectations of the clinical advisors to the ERG, who felt that this appraisal should focus on proximal DVT patients. However, this distinction is not stated in the NICE scope, 3 nor in the SmPC, 19,20 and the ERG remains unclear on this point. As evidence is not available for the subgroup discussed above, it is unclear whether the available evidence from different populations is applicable to these subgroups. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxx. 20 Copyright 2012 Queen's Printer and Controller of HMSO. All rights reserved.
Page 1 and 2: Rivaroxaban for the treatment of de
Page 3 and 4: TABLE OF CONTENTS List of Abbreviat
Page 5 and 6: Table 12 Time to therapeutic INR (I
Page 7 and 8: identified in the model). Table 40
Page 9 and 10: Figures Figure 1 Flow diagram for i
Page 11 and 12: Figure 23 Exploratory analysis in c
Page 13 and 14: MS Manufacturer’s submission NE S
Page 15 and 16: The dose of LMWH used reflects Amer
Page 17 and 18: xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Page 19 and 20: The exploratory analysis in cancer
Page 21 and 22: intended treatment duration of 12 m
Page 23 and 24: VTE therefore has a substantial bur
Page 25 and 26: indefinite treatment. VTE LMWH, low
Page 27 and 28: 3 Critique of manufacturer’s defi
Page 29: Subgroups to be considered Special
Page 33 and 34: 3.1.3 MTC populations The populatio
Page 35 and 36: 3.2.2 Length of treatment As discus
Page 37 and 38: “No preventative therapy” is th
Page 39 and 40: It could be argued that poor TTR ma
Page 41 and 42: 3.4.2 Outcomes recommended by EMA r
Page 43 and 44: 4 CLINICAL EFFECTIVENESS 4.1 Critiq
Page 45 and 46: competitor products were excluded f
Page 47 and 48: Figure 1 Flow diagram for identifyi
Page 49 and 50: Table 7: Table showing list of rele
Page 51 and 52: The approach taken to quality asses
Page 53 and 54: o EINSTEIN-DVT dose-ranging study 3
Page 55 and 56: Trial name References, study type E
Page 57 and 58: 4.2.1 Critique of pivotal EINSTEIN-
Page 59 and 60: However, the study design did not i
Page 61 and 62: Table 10: Summary of outcomes for E
Page 63 and 64: Chi-square analyses were undertaken
Page 65 and 66: clarification on this matter, the m
Page 67 and 68: Both of these factors are likely to
Page 69 and 70: It remains unclear why these patien
Page 71 and 72: leeding may be less suited to longe
Page 73 and 74: may account for the apparent differ
Page 75 and 76: Table 13: Criteria used to define a
Page 77 and 78: DVT and/or PE xxxxxxxxx xxxxxxxxxxx
Page 79 and 80: There is some doubt about the appro
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Subgroup analyses - EINSTEIN-Ext Su
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o It is clear that bleed events wer
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is likely to be small as the outcom
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depends on the specific parameteris
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4.4.3 Between study standard deviat
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Table 19.2: VTE recurrence (dichoto
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Table 22 Uncertainties in clinical
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The ERG are of the understanding th
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For the primary analysis, the rates
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In the economic model, the manufact
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Finally, in cancer patients, the ma
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Our experts believed that patients
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Similarly, the manufacturer used da
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Table 25: baseline risk of events f
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y intended treatment duration given
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eflect the current long term risk o
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survival of 70% in the 148 non-surg
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Monitoring xxxxxxxxxxxxxxxxxxxxxxxx
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The ERG acknowledges that the monit
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For patients managed in the inpatie
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The searches identified 2,811 poten
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The health state utility value for
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xxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxx
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few occasions for both VTEs and ble
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2) the values used in the PSA for t
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5.2.1 Results included in the manuf
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Figure 8: Tornado plot - Net Moneta
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5.2.2.1.2. Results for patients for
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Figure 12: Cost-effectiveness plane
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Figure 14: Tornado plot - Net Monet
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5.2.2.2 Subgroup analysis - cancer
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Figure 17: Tornado plot - Net Monet
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5.2.3 Comment on validity of result
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Table 36: Summary of uncertainties
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Summary of uncertainties Has the im
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Superseded - See Erratum 6. ADDITIO
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Superseded - See Erratum Table 37 S
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Superseded - See Erratum Table 38:
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Superseded - See Erratum Figure 21:
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Superseded - See Erratum 6.3. Proba
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6.5. Exploratory analysis in cancer
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Figure 23: Exploratory analysis in
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Table 60: Deterministic base case a
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The ERG also examined the impact of
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days after stopping treatment.(Bull
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Both Phase II studies performed ana
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Appendix 2 Correction of Tables 29
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Appendix 3 Definition of `sufficien
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A bullet on page 42 states that `53
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Both numbers refer to the placebo a
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9. REFERENCES 1. Bayer PLC. Rivarox
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http://www.dh.gov.uk/en/Publication
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51. Department of Health. NHS Refer
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77. NICE Guidance. Atrial fibrillat
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