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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-J2000-65

Original Effective Date: 09/15/16

Reviewed: 07/12/17

Revised: 08/15/17

Subject: Obeticholic Acid (Ocaliva®) Tablet

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Dosage/ Administration Position Statement Billing/Coding Reimbursement Program Exceptions Definitions
           
Related Guidelines Other References Updates    
           

DESCRIPTION:

Obeticholic acid (Ocaliva) is a semi-synthetic bile acid analogue and farnesoid X receptor (FXR) agonist. FXR is expressed in the liver and intestine, and is responsible for regulating bile acid, inflammatory, fibrotic, and metabolic pathways. When obeticholic acid activates FXR, bile acid synthesis by the liver is suppressed and transport of bile acids out of hepatocytes is increased, thereby decreasing intracellular bile acid concentrations in hepatocytes. Obeticholic acid was approved by the FDA in May 2016 for the treatment of primary biliary cholangitis (PBC) in combination with ursodeoxycholic acid (UDCA) in adults with an inadequate response to UDCA, or as monotherapy in adults unable to tolerate UDCA. Obeticholic acid was previously granted orphan drug designation by the FDA for the treatment of PBC in April 2008.

Primary biliary cholangitis (PBC), previously referred to as primary biliary cirrhosis, is a chronic, progressive autoimmune cholestatic liver disease that slowly destroys the intrahepatic bile ducts within the liver. This causes bile to accumulate in the liver resulting in gradual injury to liver cells and ultimately cirrhosis. Women account for about 90% of PBC cases. It is most commonly diagnosed in patients between the age of 35 and 60. Since cirrhosis occurs only in the late stage, the name primary biliary cirrhosis is now considered a misnomer for patients in the earlier stages of disease. Patients are often initially asymptomatic, and the first sign of disease is often abnormal liver tests [e.g., alkaline phosphatase (ALP), alanine aminotransferase (ALT), and aspartate aminotransferase (AST)]. Fatigue, pruritus, and dry eyes/mouth are the most common symptoms of PBC if symptoms are present prior to the onset of cirrhosis. Once symptoms develop, the mediation duration of survival is 5 to 8 years. The serological hallmark of PBC is the presence of anti-mitochondrial antibody (AMA), a highly disease-specific antibody identified in about 95% of patients with PBC. There is no cure for PBC; however, the use of ursodiol (a.k.a., ursodeoxycholic acid, UDCA) can help improve liver function and may help slow disease progression/onset of cirrhosis. However, up to 30 to 40% of UDCA-treated patients have an inadequate biochemical response, which is associated with significantly worse transplant-free survival rates than UDCA-responsive patients. Prior to the approval of obeticholic acid, UDCA was the only FDA-approved treatment for PBC.

The safety and efficacy of obeticholic acid leading to FDA approval for PBC assessed in a randomized, double-blind, placebo-controlled, 12-month trial (PBC OCA International Study of Efficacy or POISE) of 216 patients with PBC who were taking UDCA for at least 12 months (on a stable dosage for at least 3 months), or who were unable to tolerate UDCA and did not receive UDCA for at least 3 months. Patients were included in the trial if the ALP was 1.67-times upper limit of normal (ULN) or greater and/or if total bilirubin was greater than 1-times ULN but less than 2-times ULN. Patients were excluded from the trial if they had other liver disease, presence of clinically significant hepatic decompensation events, severe pruritus, or Model for End Stage Liver Disease (MELD) score of 15 or greater. Patients were randomized (1:1:1) to receive either obeticholic acid 10 mg once daily for the entire 12 months of the trial, (n=73); obeticholic acid titration (5 mg once daily for the initial 6 months, with the option to increase to 10 mg once daily for the last 6 months if the patient was tolerating but had ALP 1.67-times ULN or greater, and/or total bilirubin greater than ULN, or less than 15% ALP reduction) (n=70); or placebo (n=73). Obeticholic acid or placebo was given in combination with UDCA in 93% of patients and as monotherapy in 7% of patients who were unable to tolerate UDCA. The primary endpoint was response at month 12. Response was defined as a composite of three criteria: ALP less than 1.67-times the ULN, total bilirubin less than or equal to ULN, and an ALP decrease of at least 15%.

The study population was 91% female and 94% white. The mean age was 56 years (range 29 to 86 years). The mean baseline ALP concentration was 323.2 U/L, corresponding to 2.74-times ULN. Approximately 29% of the patients had ALP concentration levels greater than 3-times the ULN. The mean baseline total bilirubin concentration was 0.65 mg/dL, and was less than or equal to the ULN in 92% of the enrolled patients. The primary efficacy results at month 12 can be seen in the table below. Changes in noninvasive measures of liver fibrosis (e.g., elastography and enhanced liver fibrosis scores) did not differ significantly between either treatment group and the placebo group at 12 months. Pruritus was more common with obeticholic acid than with placebo (56% of patients in the 5-10-mg group and 68% of those in the 10-mg group vs. 38% in the placebo group). The rate of serious adverse events was 16% in the 5-10-mg group, 11% in the 10-mg group, and 4% in the placebo group. A multi-year study to assess the effects of obeticholic acid on clinical outcomes in patients with PBC who have more advanced liver disease [Clinical Outcomes with Obeticholic Acid in Liver Treatment (COBALT)] is being conducted with an expected completion date of late 2024 or early 2025.

Table 1: Results of POISE trial at Month 12

 

Obeticholic acid 10 mg

(n=73)

Obeticholic acid titration

(n=70)

Placebo

(n=73)

Primary composite endpoint

 

Responder rate

47%

46%

10%

Components of primary endpoint

     

ALP <1.67-times ULN

55%

47%

16%

Decrease in ALP of at least 15%

77%

77%

29%

Total bilirubin ≤ULN

82%

89%

78%

POSITION STATEMENT:

The Food and Drug Administration has deemed the drug(s) or biological product(s) in this coverage policy to be appropriate for self-administration or administration by a caregiver (i.e., not a healthcare professional). Therefore, coverage (i.e., administration) in a provider-administered setting such as an outpatient hospital, ambulatory surgical suite, physician office, or emergency facility is not considered medically necessary.

Initiation of obeticholic acid (Ocaliva) meets the definition of medical necessity for members meeting ALL of the following criteria:

1. Obeticholic acid is prescribed by a gastroenterologist or hepatologist

2. The member has a diagnosis of primary biliary cholangitis (PBC, a.k.a., primary biliary cirrhosis) confirmed by at least TWO of the following:

a. History of an increased alkaline phosphatase (ALP) level for at least 6 months

b. Presence of anti-mitochondrial antibodies (AMA) [titer of at least 1:40], OR, if-AMA negative or in low titer (1:80 or less), PBC-specific antibodies (anti-GP210 and/or anti-SP100 and/or antibodies against the major M2 components (PDC-E2, 2-oxo-glutaric acid dehydrogenase complex) - laboratory documentation must be submitted

c. Liver biopsy showing histologic evidence consistent with PBC (i.e., non-suppurative destructive cholangitis and destruction of interlobular bile ducts) – biopsy results must be submitted

3. The member does NOT have complete biliary obstruction

4. A baseline ALP level (i.e., within 90 day before treatment initiation) greater than or equal to 1.67-times the upper limit of normal (ULN) – laboratory documentation must be submitted

5. EITHER of the following (“a” or “b”):

a. BOTH of the following (“i” and “ii”):

i. The member has not achieved an adequate biochemical response to ursodiol after at least 1 year of continuous treatment at the maximally tolerated dosage (as assessed by claims history when possible)

• For dosages of ursodiol less than 13 mg/kg/day - a reason must be submitted as to why a higher dosage was not utilized

• An inadequate biochemical response is defined as an ALP level greater than or equal to 1.67-times ULN – laboratory documentation must be submitted

ii. Obeticholic acid will be used in combination with ursodiol treatment

b. The member has experienced persistent and intolerable adverse effects with the use of ursodiol, despite dosage reduction and other management interventions, that necessitates the complete discontinuation of ursodiol treatment - the specific adverse effect leading to discontinuation must be provided

6. The dosage does not exceed 10 mg once daily - the dose must be achieved using the fewest number of tablets possible

Duration of approval: 6 months

Continuation of obeticholic acid (Ocaliva®) meets the definition of medical necessity for members meeting ALL of the following criteria:

1. Authorization or reauthorization for obeticholic acid has been previously approved by Florida Blue or another health plan in the past year for the treatment of PBC, OR the member previously met ALL indication-specific initiation criteria (with the exception of the baseline ALP requirement).

2. The member has had a positive biochemical response to treatment as documented by a reduction in ALP level as compared to baseline (i.e., pre-obeticholic acid treatment) – laboratory documentation must be submitted

3. Member is taking obeticholic acid in combination with ursodiol treatment (as assessed by claims history when possible), unless obeticholic acid was initiated as monotherapy due to prior intolerance to ursodiol

4. The member does NOT have complete biliary obstruction

5. The dosage does not exceed 10 mg once daily - the dose must be achieved using the fewest number of tablets possible

Duration of approval: 1 year

Obeticholic acid is considered experimental or investigational for the treatment of nonalcoholic steatohepatitis (NASH), nonalcoholic fatty liver disease (NAFLD), and all other off-label indications. There is insufficient evidence in the peer-reviewed medical literature to support safety, efficacy, and net health outcomes.

DOSAGE/ADMINISTRATION:

THIS INFORMATION IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND SHOULD NOT BE USED AS A SOURCE FOR MAKING PRESCRIBING OR OTHER MEDICAL DETERMINATIONS. PROVIDERS SHOULD REFER TO THE MANUFACTURER’S FULL PRESCRIBING INFORMATION FOR DOSAGE GUIDELINES AND OTHER INFORMATION RELATED TO THIS MEDICATION BEFORE MAKING ANY CLINICAL DECISIONS REGARDING ITS USAGE.

FDA-approved

• The treatment of primary biliary cholangitis (PBC) in combination with ursodeoxycholic acid (UDCA) in adults with an inadequate response to UDCA, or as monotherapy in adults unable to tolerate UDCA.

• The recommended starting dosage is 5 mg orally once daily. If adequate reduction in ALP and/or total bilirubin has not been achieved after 3 months of 5 mg once daily and the patient is tolerating treatment, the dosage can be increased to 10 mg once daily.

• Take with or without food. For patients taking bile acid binding resins, take obeticholic acid at least 4 hours before or 4 hours after taking a bile acid binding resin, or at as great an interval as possible.

Dose Adjustments

• Intolerable Pruritus: consider one or more of the following:

• Add an antihistamine or bile acid binding resin

• Reduce the dosage to 5 mg every other day, for patients intolerant to 5 mg once daily, or 5 mg once daily, for patients intolerant to 10 mg once daily.

• Temporarily interrupt dosing for up to 2 weeks followed by restarting at a reduced dosage. Increase the dosage to 10 mg once daily, as tolerated, to achieve optimal response.

• Hepatic Impairment:

• Mild impairment (Child-Pugh A): No adjustment necessary

• Moderate (Child-Pugh B) to severe (Child-Pugh C) impairment: Initiate therapy at 5 mg orally once weekly

• Moderate (Child-Pugh B) to severe (Child-Pugh C) impairment, titration: If alkaline phosphatase or total bilirubin have not been adequately reduced after 3 months, increase to 5 mg twice weekly (at least 3 days apart); if needed, may further increase to 10 mg twice weekly (at least 3 days apart)

• Renal Impairment: Obeticholic acid has not been studied in patients with moderate and severe renal impairment; dosage adjustment is likely not needed

Drug Availability

• 5 and 10 mg tablets

PRECAUTIONS:

Boxed Warning

• None

Contraindications

• Patients with complete biliary obstruction

Precautions/Warnings

Liver-Related Adverse Reactions: The member should be monitored for elevations in liver biochemical tests and development of liver-related adverse reaction. Weigh the potential risk against the benefits of continuing treatment in patients who have experienced clinically significant liver-related adverse reactions. Do not exceed 10 mg once daily. Adjust the dosage for patients with moderate or severe hepatic impairment. Discontinue in patients who develop complete biliary obstruction.

Severe Pruritus: In the major clinical trial, severe pruritus was reported in 23% of patients in the obeticholic acid10 mg arm, 19% of patients in the titration arm, and 7% of patients in the placebo arm. Management strategies include the addition of bile acid binding resins or antihistamines, and dosage reduction and/or temporary dosing interruption of obeticholic acid.

Reduction in HDL-C: Monitor for changes in serum lipid levels during treatment. For patients with minimal or no response and who experience a reduction in HDL-C, weigh the potential risks against the benefits of continuing treatment.

Drug Interactions:

o Warfarin: Potential for decreased INR; monitor INR and adjust the dosage of warfarin, as needed, to maintain the target INR range

o CYP1A2 Substrates with Narrow Therapeutic Index (e.g., theophylline and tizanidine): Potential for increased exposure to CYP1A2 substrates; monitor drug concentrations of CYP1A2 substrates with narrow therapeutic index.

Pregnancy: The limited available human data on the use of obeticholic acid during pregnancy are not sufficient to inform a drug-associated risk. In animal reproduction studies, no developmental abnormalities or fetal harm was observed when pregnant rats or rabbits were administered obeticholic acid during the period of organogenesis.

BILLING/CODING INFORMATION:

The following codes may be used to describe:

HCPCS Coding

J8499

Prescription drug, oral, non-chemotherapeutic, Not Otherwise Specified

ICD-10 Diagnoses Codes That Support Medical Necessity

K74.3

Primary biliary cirrhosis

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Part D: BCBSF has delegated to Prime Therapeutics authority to make coverage determinations for the Medicare Part D services referenced in this guideline.

Medicare Advantage: No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of guideline creation.

DEFINITIONS:

None

RELATED GUIDELINES:

None

OTHER:

None

REFERENCES:

  1. Carey EJ, Ali AH, Lindor KD. Primary biliary cirrhosis. Lancet. 2015 Oct 17;386(10003):1565-75.
  2. Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of non-alcoholic fatty liver disease: practice Guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Hepatology. 2012 Jun;55(6):2005-23.
  3. Clinical Pharmacology [Internet]. Tampa (FL): Gold Standard, Inc.; 2017 [cited 2017 Jun 15]. Available from: http://www.clinicalpharmacology.com/.
  4. DRUGDEX® System [Internet]. Greenwood Village (CO): Thomson Micromedex; Updated periodically [cited 2017 Jun 15]. Available from: http://www.thomsonhc.com/.
  5. European Association for the study of the liver. EASL Clinical Practice Guidelines: The diagnosis and management of patients with primary biliary cholangitis. J Hepatol. 2017 Apr 18. doi: 10.1016/j.jhep.2017.03.022 [Epub ahead of print].
  6. Floreani A, Sun Y, Zou ZS, et al. Proposed therapies in primary biliary cholangitis. Expert Rev Gastroenterol Hepatol. 2016;10(3):371-82.
  7. Hirshfield G, Mason A , Luketic V , et al: Efficacy of obeticholic acid in patients with primary biliary cirrhosis and inadequate response to ursodeoxycholic acid.. Gastroenterology 2015; 148(4):751-761.
  8. Hossain N, Kanwar P, Mohanty SR. A Comprehensive Updated Review of Pharmaceutical and Nonpharmaceutical Treatment for NAFLD. Gastroenterol Res Pract. 2016;2016:7109270.
  9. Lindor KD, Gershwin ME, Poupon R, Kaplan M, Bergasa NV, Heathcote EJ; American Association for Study of Liver Diseases. Primary biliary cirrhosis. Hepatology. 2009 Jul;50(1):291-308.
  10. Lombardi R, Onali S, Thorburn D, et al. Pharmacological interventions for non-alcohol related fatty liver disease (NAFLD): an attempted network meta-analysis. Cochrane Database Syst Rev. 2017 Mar 30;3:CD011640.
  11. Neuschwander-Tetri BA, Loomba R, et al. Farnesoid X nuclear receptor ligand obeticholic acid for non-cirrhotic, non-alcoholic steatohepatitis (FLINT): a multicentre, randomised, placebo-controlled trial. Lancet. 2015 Mar 14;385(9972):956-65.
  12. Nevens F, Andreone P, Mazzella G, et al. for the POISE study group. A placebo-controlled trial of obeticholic acid in primary biliary cholangitis. N Engl J Med 2016; 375: 631-43.
  13. Ocaliva (obeticholic acid) [package insert]. Intercept Pharmaceuticals, Inc.. New York, NY. May 2016.
  14. Orphan Drug Designations and Approval [Internet]. Silver Spring (MD): US Food and Drug Administration; 2017 [cited 2017 Jun 15]. Available from: http://www.accessdata.fda.gov/scripts/opdlisting/oopd/index.cfm/.
  15. Purohit T and Cappell MS. Primary biliary cirrhosis: Pathophysiology, clinical presentation and therapy. World J Hepatol. 2015 May 8;7(7):926-41.
  16. Randomized Global Phase 3 Study to Evaluate the Impact on NASH With Fibrosis of Obeticholic Acid Treatment (REGENERATE). ClinicalTrials.gov Identifier: NCT02548351. ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). Accessed June 25, 2017 at: https://www.clinicaltrials.gov/ct2/show/NCT02548351?term=NCT02548351&rank=1
  17. Rudic JS, Poropat G, Krstic MN, et al. Ursodeoxycholic acid for primary biliary cirrhosis. Cochrane Database Syst Rev. 2012 Dec 12;12:CD000551.
  18. Saffioti F, Gurusamy KS, Eusebi LH, et al. Pharmacological interventions for primary biliary cholangitis: an attempted network meta-analysis. Cochrane Database Syst Rev. 2017 Mar 28;3:CD011648.
  19. Urso 250 (ursodiol tablet) and Urso Forte (ursodiol tablet) [package insert]. Aptalis Pharma US, Inc. Bridgewater, NJ. June 2013.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Pharmacy Policy Committee on 07/12/17.

GUIDELINE UPDATE INFORMATION:

09/15/16

New Medical Coverage Guideline.

08/15/17

Review and revision to guideline consisting of updating the description section, position statement, and references.

Date Printed: August 21, 2017: 07:50 PM