Utah Medicaid Dur Report January 2019 Vesicular Monoamine Transporter 2 Inhibitors for Huntington's Disease and Tardive Dyskin

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Utah Medicaid Dur Report January 2019 Vesicular Monoamine Transporter 2 Inhibitors for Huntington's Disease and Tardive Dyskin UTAH MEDICAID DUR REPORT JANUARY 2019 VESICULAR MONOAMINE TRANSPORTER 2 INHIBITORS FOR HUNTINGTON’S DISEASE AND TARDIVE DYSKINESIA Deutetrabenazine (Austedo) Tetrabenazine (Xenazine, generic) Valbenazine (Ingrezza) Report finalized: December 2018 Drug Regimen Review Center Elena Martinez Alonso, B.Pharm., MSc MTSI, Medical Writer Valerie Gonzales, Pharm.D., Clinical Pharmacist Lauren Heath, Pharm.D., MS, BCACP, Assistant Professor (Clinical) Vicki Frydrych, B.Pharm., Pharm.D., Clinical Pharmacist Jacob Crook, MStat, Data and Statistical Analyst Joanne LaFleur, PharmD, MSPH, Associate Professor University of Utah College of Pharmacy, Drug Regimen Review Center Copyright © 2018 by University of Utah College of Pharmacy Salt Lake City, Utah. All rights reserved 1 Contents Background ................................................................................................................................................... 3 Methods ........................................................................................................................................................ 3 Disease Overview and Guideline Recommendations ................................................................................... 4 Huntington’s Disease ............................................................................................................................... 4 Table 1. Clinical Practice Guideline Recommendations for the Treatment of Chorea in Huntington’s Disease ................................................................................................................................................. 5 Tardive Dyskinesia .................................................................................................................................... 6 Table 2. Description of Selected Tardive Syndromes ........................................................................... 6 Table 3. Agents That Can Cause Tardive Syndromes ........................................................................... 7 Table 4. Clinical Practice Guideline Recommendations for Tardive Syndromes .................................. 9 Vesicular Monoamine Transporter 2 Inhibitors .......................................................................................... 11 Table 5. FDA-Approved Vesicular Monoamine Transporter 2 Inhibitors ........................................... 11 Mechanism of Action ......................................................................................................................... 12 Pharmacokinetics ............................................................................................................................... 12 Off-label Use of Tetrabenazine .......................................................................................................... 12 Safety .................................................................................................................................................. 13 Table 6. Adverse Events and Warnings for Vesicular Monoamine Transporter 2 Inhibitors ............. 15 Systematic Review Evidence ....................................................................................................................... 16 Table 7. Strength of Recommendations for Agents in Treating Tardive Syndromes ......................... 17 Table 8. Clinical Practice Algorithm for the Management of Tardive Dyskinesia .............................. 18 Expert Opinion Evidence ............................................................................................................................. 19 Clinical Trial Evidence .................................................................................................................................. 19 Table 9. Results from Placebo-Controlled Trials Including Deutetrabenazine or Valbenazine for Tardive Dyskinesia .............................................................................................................................. 23 Utah Medicaid Utilization Data ................................................................................................................... 24 Table 10. Total ACO Pharmacy Data for VMAT-2 Inhibitors (2016-2018) .......................................... 24 Table 11. Total FFS Pharmacy Data for VMAT-2 Inhibitors (2016-2018) ........................................... 24 Table 12. Total FFS Patients with Diagnosis Codes Submitted for HD and TD (2016-2018) .............. 24 Discussion Topics and Potential Prior Authorization Criteria for VMAT-2 Inhibitors ................................. 25 Summary ..................................................................................................................................................... 28 References .................................................................................................................................................. 30 Appendix A: Literature Search Strategies ................................................................................................... 34 Appendix B: Relevant Diagnosis Codes ....................................................................................................... 35 Appendix C: Key Findings in Cochrane Reviews and Other Systematic Reviews for Tardive Dyskinesia ... 36 Appendix D: Key Findings in Cochrane Reviews for Huntington’s Disease ................................................. 38 Appendix E: Key Findings in Published Placebo-Controlled Trials .............................................................. 39 2 Background Movement disorders are neurological conditions characterized by abnormal voluntary and involuntary movements.1 These disorders can affect activities of daily living and quality of life of patients and their caregivers. Movement disorders include several conditions such as Huntington’s disease, tardive dyskinesia, parkinsonism, Parkinson’s disease, Wilson’s disease, tics, essential tremor, dystonia, and Tourette syndrome, among others.1-3 Three vesicular monoamine transporter type 2 (VMAT-2) inhibitors are currently approved by the U.S. Food and Drug Administration (FDA) for the treatment of chorea associated with Huntington’s disease (HD) and tardive dyskinesia (TD): deutetrabenazine (Austedo), tetrabenazine (Xenazine), and valbenazine (Ingrezza).4-6 Deutetrabenazine and tetrabenazine are approved orphan drugs for the treatment of chorea associated with HD.4,5 Deutetrabenazine and valbenazine are the first drugs to be approved for the treatment of TD in adult patients.4,6 Tetrabenazine has an additional orphan drug designation for the treatment of moderate/severe tardive dyskinesia;7 however it is not yet FDA- approved for that indication. In addition, the 3 VMAT-2 inhibitor agents have orphan drug designations for the treatment of Tourette syndrome in pediatric patients;7 however, no FDA approval is granted for such indication. Each of the VMAT-2 inhibitors is available as an oral formulation.4-6 Dosing should be individualized to each patient and gradually up-titrated based on a reduction of symptoms and tolerability.4-6 There are no current prior authorization criteria in place for VMAT-2 inhibitors. The purpose of this review is to provide evidence that can assist the Medicaid Drug Utilization Review (DUR) Board in assuring appropriate use of the VMAT-2 inhibitors in patient populations most likely to benefit. Methods A literature search for systematic reviews addressing the efficacy and safety of the 3 VMAT-2 inhibitors was conducted in the Cochrane Library and Ovid Medline. References of relevant search results were screened. Search strategies are provided in Appendix A. In addition, searches in The National Institute for Health and Care Excellence (NICE) website were performed. Information concerning product labeling and FDA clinical review documents were searched in the FDA website. Additional information was found in Micromedex, Lexicomp, and Up To Date. Treatment guidelines for the management of Huntington’s disease and tardive dyskinesia were identified by searching in The American Academy of Neurology (AAN) website and checking the reference lists of relevant systematic reviews. Relevant information from the Utah Medicaid Pharmacy and Therapeutics Committee Drug Class Review: Vesicular Monoamine Transporter 2 Inhibitors and Anticholinergic Agents for Movement Disorders (March 2018) was incorporated into this report. Reimbursement documents, health plan documents including prior authorization documents, and any relevant diagnosis coding documents were reviewed for information regarding billing to inform data extraction (claims data). Appendix B includes the International Classification of Diseases (ICD)-9 and ICD- 10 codes for HD and TD. 3 Disease Overview and Guideline Recommendations Movement disorders are neurological conditions caused by basal ganglia dysfunction.1 Basal ganglia are a group of subcortical gray matter nuclei, located in the brain, and principally responsible for motor control.1 The etiology of movement disorders includes certain drugs (eg, antipsychotics), genetic factors, injuries, stroke, infections, and unknown origins.1,3,8,9 Examples of movement disorders include tremor, dystonia, athetosis, chorea, myoclonus, tics, tardive dyskinesia, and Parkinson’s disease.1,3 1. Huntington’s Disease Huntington’s disease, formerly known as Huntington’s chorea,3 is a fatal, progressive, autosomal dominant neurodegenerative disorder caused by a mutation (a CAG segment repetition ≥36) in the
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