Abstract
The UK National Institute for Health and Care Excellence (NICE) considered evidence for voretigene neparvovec (VN; Luxturna®) for the treatment of RPE65-mediated inherited retinal dystrophies (IRD) within its highly specialised technology programme. This paper summarises the evidence provided by the company; the appraisal of the evidence by the Peninsula Technology Appraisal Group, who were commissioned to act as the independent evidence review group (ERG); and the development of the NICE guidance by the appraisal committee. The evidence presented by the company highlighted the significant lifelong burden of IRD for patients and carers. Evidence to support the effectiveness of VN was lacking, but the available evidence showed a modest, sustained improvement across a variety of vision-related outcomes. While patients would remain visually impaired, the committee considered that VN would prevent further deterioration in vision. The modelling approach used by the company had a number of limitations and relied heavily upon a large volume of clinical expert input to produce cost-effectiveness estimates with large uncertainty around long-term effectiveness. The ERG’s main concerns revolved around these long-term outcomes and the plausibility of utility values. The NICE committee were convinced that the clinical benefits of VN were important and an appropriate use of national health service resources within a specialised service. The committee concluded that a high unmet need existed in patients with RPE65-mediated IRD and that VN represents a step change in the management of this condition.
![](http://media.springernature.com/m312/springer-static/image/art%3A10.1007%2Fs40273-020-00953-z/MediaObjects/40273_2020_953_Fig1_HTML.png)
Similar content being viewed by others
References
Daiger SP, Sullivan LS, Bowne SJ. Genes and mutations causing retinitis pigmentosa. Clin Genet. 2013;84(2):132–41.
Hamel CP. Gene discovery and prevalence in inherited retinal dystrophies. C R Biol. 2014;337(3):160–6.
Ripamonti C, et al. Nature of the visual loss in observers with Leber's congenital Amaurosis caused by specific mutations in RPE65. Invest Ophthalmol Vis Sci. 2014;55(10):6817–28.
European Medicines Agency. Luxturna: EPAR—medicine overview. Amsterdam: European Medicines Agency; 2019.
Rakoczy EP, Narfström K. Gene therapy for eye as regenerative medicine? Lessons from RPE65 gene therapy for Leber's congenital Amaurosis. Int J Biochem Cell Biol. 2014;56:153–7.
National Institute for Health and Care Excellence. Voretigene neparvovec for treating inherited retinal dystrophies caused by RPE65 gene mutations Highly specialised technologies guidance [HST11]. 2019. https://www.nice.org.uk/guidance/hst11. Accessed Feb 2020.
National Institute for Health and Care Excellence. Final scope for the evaluation of voretigene neparvovec for treating inherited retinal dystrophies caused by RPE65 gene mutations. 2018. https://www.nice.org.uk/guidance/hst11/history. Accessed Feb 2020.
Chung DC, et al. Novel mobility test to assess functional vision in patients with inherited retinal dystrophies. Clin Exp Ophthalmol. 2018;46(3):247–59.
Mangione CM, et al. Development of the 25-list-item National Eye Institute Visual Function Questionnaire. Arch Ophthalmol. 2001;119(7):1050–8.
Novartis. (Draft) Psychometric evaluation of the modified Visual Function Questionnaire (VFQ-25) using data from AAV2-hRPE65v2-301 (voretigene neparvovec) phase III trial. 2019.
Francis PJ. Genetics of inherited retinal disease. J R Soc Med. 2006;99(4):189–91.
Sonksen PM, Dale N. Visual impairment in infancy: impact on neurodevelopmental and neurobiological processes. Dev Med Child Neurol. 2002;44(11):782–91.
RNIB. Children and young people England: RNIB evidence-based review. London: RNIB; 2016.
Chaumet-Riffaud AE, et al. Impact of retinitis Pigmentosa on quality of life, mental health, and employment among young adults. Am J Ophthalmol. 2017;177:169–74.
Maguire AM, et al. Age-dependent effects of RPE65 gene therapy for Leber's congenital amaurosis: a phase 1 dose-escalation trial. Lancet (London, England). 2009;374(9701):1597–605.
Bennett J, et al. Safety and durability of effect of contralateral-eye administration of AAV2 gene therapy in patients with childhood-onset blindness caused by RPE65 mutations: a follow-on phase 1 trial. Lancet. 2016;388(10045):661–72.
Russell S, et al. Efficacy and safety of voretigene neparvovec (AAV2-hRPE65v2) in patients with RPE65-mediated inherited retinal dystrophy: a randomised, controlled, open-label, phase 3 trial. Lancet (London, England). 2017;390(10097):849–60.
Russell S. Three-year update for the phase 3 voretigene neparvovec study in biallelic RPE65mutation–associated inherited retinal disease. In: Association of research in vision and ophthalmology (ARVO) annual meeting. 2018.
Rondinelli RD. AMA guides to the evaluation of permanent impairment. 6th ed. Chicago: American Medical Association; 2007.
Chung DC, et al. The natural history of inherited retinal dystrophy due to Biallelic mutations in the RPE65 gene. Am J Ophthalmol. 2019;199:58–70.
Christ SL, et al. Longitudinal relationships among visual acuity, daily functional status, and mortality: the Salisbury Eye Evaluation Study. JAMA Ophthalmol. 2014;132(12):1400–6.
National Institute for Health and Care Excellence. TA155: ranibizumab and pegaptanib for the treatment of age-related macular degeneration. London: National Institute for Health and Care Excellence; 2008.
National Institute for Health and Care Excellence. TA229: dexamethasone intravitreal implant for the treatment of macular oedema secondary to retinal vein occlusion. London: National Institute for Health and Care Excellence; 2011.
National Institute for Health and Care Excellence. TA274: ranibizumab for treating diabetic macular oedema. London: National Institute for Health and Care Excellence; 2013.
National Institute for Health and Care Excellence. TA283: ranibizumab for treating visual impairment caused by macular oedema secondary to retinal vein occlusion. London: National Institute for Health and Care Excellence; 2013.
National Institute for Health and Care Excellence. TA294: aflibercept solution for injection for treating wet age-related macular degeneration. Ondon: National Institute for Health and Care Excellence; 2013.
National Institute for Health and Care Excellence. TA297: ocriplasmin for treating vitreomacular traction. London: National Institute for Health and Care Excellence; 2013.
National Institute for Health and Care Excellence. TA298: ranibizumab for treating choroidal neovascularisation associated with pathological myopia. London: National Institute for Health and Care Excellence; 2013.
National Institute for Health and Care Excellence. TA301: fluocinolone acetonide intravitreal implant for treating chronic diabetic macular oedema after an inadequate response to prior therapy. London: National Institute for Health and Care Excellence; 2013.
National Institute for Health and Care Excellence. TA305: aflibercept for treating visual impairment caused by macular oedema secondary to central retinal vein occlusion. London: National Institute for Health and Care Excellence; 2014.
National Institute for Health and Care Excellence. TA346: aflibercept for treating diabetic macular oedema. London: National Institute for Health and Care Excellence; 2015.
National Institute for Health and Care Excellence. TA349: dexamethasone intravitreal implant for treating diabetic macular oedema. London: National Institute for Health and Care Excellence; 2015.
National Institute for Health and Care Excellence. TA369: ciclosporin for treating dry eye disease that has not improved despite treatment with artificial tears. London: National Institute for Health and Care Excellence; 2015.
National Institute for Health and Care Excellence. TA409: aflibercept for treating visual impairment caused by macular oedema after branch retinal vein occlusion. London: National Institute for Health and Care Excellence; 2016.
National Institute for Health and Care Excellence. TA460: adalimumab and dexamethasone for treating non-infectious uveitis. London: National Institute for Health and Care Excellence; 2017.
National Institute for Health and Care Excellence. TA467: holoclar for treating limbal stem cell deficiency after eye burns. London: National Institute for Health and Care Excellence; 2017.
National Institute for Health and Care Excellence. TA486: aflibercept for treating choroidal neovascularisation. London: National Institute for Health and Care Excellence; 2017.
National Institute for Health and Care Excellence. TA532: cenegermin for treating neurotrophic keratitis. London: National Institute for Health and Care Excellence; 2018.
Bainbridge JWB, et al. Long-term effect of gene therapy on Leber’s congenital Amaurosis. N Engl J Med. 2015;372(20):1887–97.
Rentz AM, et al. Development of a preference-based index from the National Eye Institute Visual Function Questionnaire-25. JAMA Ophthalmol. 2014;132(3):310–8.
Oakley J. SHELF-package: tools to support the Sheffield elicitation framework, R package. 2017. https://cran.r-project.org/package=SHELF. Accessed Mar 2020
Hanein S, et al. Leber congenital amaurosis: comprehensive survey of the genetic heterogeneity, refinement of the clinical definition, and genotype-phenotype correlations as a strategy for molecular diagnosis. Hum Mutat. 2004;23(4):306–17.
Acknowledgements
The views expressed in this paper are those of the authors and not necessarily those of the NHS, the NIHR SER programme, or the Department of Health and Social Care. Any errors are the responsibility of the authors. S. Bello, S. Dodman, M. Rezaei Hemami, A. Churchill, and A. Lotery all contributed to the ERG appraisal of VN. A. Churchill and A. Lotery acted as clinical advisors to the evaluation and reviewed the epidemiology and clinical-effectiveness sections of the report.
Author information
Authors and Affiliations
Contributions
All authors commented on the submitted manuscript and have given their approval for the final version to be published. CF, LL, AJH, GJM-T, and LC critiqued the clinical burden and clinical effectiveness methods and evidence; SR critiqued the literature searches conducted by the company; AB, DP, EN, and AJH critiqued the health economic method and evidence and the company’s economic evaluation. LC supervised the appraisal and acted as guarantor. This article was not externally peer reviewed by PharmacoEconomics.
Corresponding author
Ethics declarations
Funding
The appraisal of VN within the NICE HST programme was commissioned by the National Institute for Health Research Systematic Reviews Programme as project number 17/56/05.
Conflict of interest
CF, AB, DP, LL, SR, EN, AJH, GJM-T, and LC have no conflicts of interest that are directly relevant to the content of this article.
Data availability
Documents relevant to this appraisal (including the appraisal scope, CS, ERG report, stakeholder submissions, and NICE guidance issued) can be found on the NICE website at https://www.nice.org.uk/guidance/hst11.
Ethics approval
Not applicable.
Consent
Not applicable.
Rights and permissions
About this article
Cite this article
Farmer, C., Bullement, A., Packman, D. et al. Voretigene Neparvovec for Treating Inherited Retinal Dystrophies Caused by RPE65 Gene Mutations: An Evidence Review Group Perspective of a NICE Highly Specialised Technology Appraisal. PharmacoEconomics 38, 1309–1318 (2020). https://doi.org/10.1007/s40273-020-00953-z
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40273-020-00953-z