Primary Risk Drivers
Below is a snapshot of domains that materially influence the MARA Rating.
Clinical effectiveness
The clinical trial evidence from NeflgArd Nef-301 demonstrated that targeted-release budesonide plus standard care is more effective than standard care alone, particularly in patients with a UPCR of 1.5 g/g or more. The primary outcome showed a significant change in UPCR at 9 months compared to placebo, indicating a clear clinical advantage.
Cost effectiveness
The most likely ICER for targeted-release budesonide was estimated at £4,672 per QALY gained, which is well within NICE’s acceptable range for NHS resources. This indicates a strong cost-effectiveness profile, especially when considering the potential for fewer adverse effects compared to systemic corticosteroids.
Quality of life
Patient experts highlighted that IgAN significantly impacts quality of life, with symptoms affecting daily functioning. The potential of targeted-release budesonide to delay the need for dialysis or transplant is likely to improve HRQoL, although specific validated HRQoL data were not provided.
Supporting Domains
Safety and Adverse Effects
Targeted-release budesonide is expected to have a better safety profile than systemic corticosteroids, with fewer serious side effects. The committee noted that while it shares a similar spectrum of adverse effects, the frequency is anticipated to be lower, supporting its use.
Comparator Selection
The treatment was compared against standard care, which includes ACE inhibitors and ARBs, as well as placebo in the clinical trial. This is appropriate as these are the current standard treatments for IgAN, ensuring relevant and robust comparisons.
Patient Population and Subgroups
The trial population was broadly representative of the UK population with IgAN, particularly those at risk of rapid disease progression. The committee confirmed that the demographic characteristics aligned well with clinical practice, enhancing generalizability.
Care Pathway Integration
Targeted-release budesonide is intended as an add-on to existing standard care, which facilitates its integration into current treatment pathways without requiring significant changes to infrastructure or training.
Resource Use and Cost Implications
The economic model indicated that targeted-release budesonide would not only be cost-effective but could also lead to cost savings by delaying progression to higher CKD stages, which are associated with higher treatment costs.
Evidence Quality and Robustness
The evidence is based on a well-designed Phase III RCT (NeflgArd Nef-301) with a reasonable sample size and robust methodology. However, some uncertainties remain regarding the long-term effects and the impact of retreatment.
Uncertainty, Sensitivity, and Broader Impacts
While there are uncertainties regarding the long-term effects and the implications of retreatment, the overall context of unmet need and the potential benefits of delaying disease progression provide a favorable backdrop for decision-making.
