Asset Publisher

ph-91177

print Print

Tarpeyo Prior Authorization with Quantity Limit Program Summary

Policy Number: PH-91177

This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies. 

POLICY REVIEW CYCLE

Effective Date

Date of Origin   

07-01-2024           

05-19-2022

FDA LABELED INDICATIONS AND DOSAGE

Agent(s)

FDA Indication(s)

Notes

Ref#

Tarpeyo®

(budesonide)

Delayed release capsule

Reduce the loss of kidney function in adults with primary immunoglobulin A nephropathy (IgAN) who are at risk for disease progression

1

See package insert for FDA prescribing information:  https://dailymed.nlm.nih.gov/dailymed/index.cfm

CLINICAL RATIONALE

IgAN

Immunoglobulin A nephropathy (IgAN), also known as Berger’s disease, is a kidney disease that occurs when IgA deposits build up in the kidneys, causing inflammation that damages the glomeruli, in turn causing the kidneys to leak blood and protein into the urine. The damage may lead to scarring of the nephrons that progresses slowly over may years. Eventually, IgAN can lead to end-stage renal disease (ESRD).(3)

Kidney biopsy is required to confirm the diagnosis of IgAN as there are no validated diagnostic serum or urine biomarkers for IgAN. Biopsy is indicated when a patient has signs of a severe or progressive disease, such as sustained proteinuria of at least 0.5 g/d or an elevated serum creatinine concentration. After a diagnosis has been established, guidelines recommend that all patients with IgAN be assessed for secondary causes (e.g., liver cirrhosis, HIV, hepatitis, inflammatory bowel disease).(3,4)

The primary focus of IgAN management should be optimized supportive care [e.g., blood pressure management, maximally tolerated angiotensin-converting-enzyme inhibitor (ACEI) or angiotensin II blocker (ARB), lifestyle modification, address cardiovascular risk]. Guidelines recommend that all patients with proteinuria greater than 0.5 g/d be treated with an ACEI or ARB irrespective of whether they have hypertension.(3)

Guidelines define high risk of progression in IgAN as proteinuria greater than 0.75–1 g/d despite at least 90 days of optimized supportive care. It is suggested that patients who remain at high risk despite maximal supportive care be considered for a 6 month course of glucocorticoid therapy. They stress the importance of discussing treatment-emergent toxicity, particularly those who have an estimated glomerular filtration rate (eGFR) less than 50 mL/min/1.73 m^2. It is further noted that glucocorticoids should be given with extreme caution or avoided entirely in the following situations:(3)

  • eGFR less than 30 mL/min/1.73 m^2
  • Diabetes
  • Obesity (BMI greater than 30 kg/m^2)
  • Latent infections (e.g., viral hepatitis, tuberculosis)
  • Secondary disease (e.g., cirrhosis)
  • Active peptic ulceration
  • Uncontrolled psychiatric illness
  • Severe osteoporosis

The goal of treatment for these patients that remain at high risk for progressive disease is a reduction of proteinuria to less than 1 g/d.(3)

Efficacy

The effect of Tarpeyo on proteinuria and kidney function was assessed in a randomized, double-blind, phase 3, 2-part, multicenter study (NefIgArd, NCT: 03643965) in adult patients (n=364) with biopsy-proven IgAN, eGFR ≥35 mL/min/1.73 m^2 , and proteinuria (defined as either ≥1 g/day or urine protein to creatinine ratio (UPCR) ≥0.8 g/g) who were on a stable dose of maximally-tolerated renin-angiotensin-system (RAS) inhibitor therapy. Patients with other glomerulopathies, nephrotic syndrome, or those who had been treated with systemic immunosuppressive medications were excluded. Patients were randomized 1:1 to either Tarpeyo 16 mg once daily or placebo and treated for 9 months followed by a 2-week taper of either Tarpeyo 8 mg once daily or placebo. Patients were then observed for 15 months, during which no study drug was administered. At baseline, the mean eGFR was approximately 58 mL/min/1.73 m^2 and the mean UPCR was 1.5 g/g. The median age was 43 years (range from 20-73 years). At baseline, 98% of patients were treated with an ACEI or ARB.(1,2)

The primary outcome for Part A of the study was the ratio (reduction) of UPCR (based on 24-hour urine collections) at 9 months compared to baseline. An interim analysis was based on the first 199 randomized patients who completed the Month 9 visit. A 31% reduction in UPCR was seen in patients treated with Tarpeyo 16mg daily compared to a 5% reduction in the placebo group (95% CI: 16% to 42% reduction; p=0.0001). The final analysis of all 364 patients was consistent with the results of the interim analysis.(1,2)

The primary outcome for Part B of the study was a time-weighted average of the log ratio of eGFR at each time point over 2 years relative to baseline to assess the effect of Tarpeyo on long-term kidney function. After 2 years there was a 5.9 mL/min/1.73 m^2 difference in mean change from baseline in eGFR (95% CI: 3.3 to 8.5 mL/min/1.73 m^2; p<0.0001). This treatment effect at 2 years was consistent across key subgroups, including baseline disease characteristics (e.g., baseline proteinuria).(1)

Safety

Tarpeyo carries no boxed warnings. Tarpeyo is contraindicated in patients with hypersensitivity to budesonide or any of the ingredients of Tarpeyo. Serious hypersensitivity reactions, including anaphylaxis have occurred with other budesonide formulations.(1)

 

REFERENCES

Number

Reference

1

Tarpeyo prescribing information. Calliditas Therapeutics AB. December 2023.

2

Barratt J, Lafayette RA, Kristensen JK, et al. Results from part A of the multi-center, double-blind, randomized, placebo-controlled NefIgArd trial, which evaluated targeted-release formulation of budesonide for the treatment of primary immunoglobulin A nephropathy. Kidney International. 2023;103(2):391-402. doi:10.1016/j.kint.2022.09.017

3

Rovin BH, Adler SG, Barratt J, et al. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney International. 2021;100(4):S1-S276. doi:10.1016/j.kint.2021.05.021

4

Cheung CK, Barratt J, et al. IgA nephropathy: Clinical features and diagnosis. UpToDate. Last updated January 2024. Literature review current through December 2023.

POLICY AGENT SUMMARY PRIOR AUTHORIZATION

Target Brand Agent(s)

Target Generic Agent(s)

Strength

Targeted MSC

Available MSC

Final Age Limit

Preferred Status

Tarpeyo

budesonide delayed release cap

4 MG

M ; N ; O ; Y

N

POLICY AGENT SUMMARY QUANTITY LIMIT

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

QL Amount

Dose Form

Day Supply

Duration

Addtl QL Info

Allowed Exceptions

Targeted NDCs When Exclusions Exist

Tarpeyo

Budesonide Delayed Release Cap

4 MG

120

Capsules

30

DAYS

CLIENT SUMMARY – PRIOR AUTHORIZATION

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Client Formulary

Tarpeyo

budesonide delayed release cap

4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

CLIENT SUMMARY – QUANTITY LIMITS

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Client Formulary

Tarpeyo

Budesonide Delayed Release Cap

4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

PRIOR AUTHORIZATION CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

PA

Target Agent(s) will be approved when ALL of the following are met:

  1. The patient has a diagnosis of primary immunoglobulin A nephropathy (IgAN) confirmed by kidney biopsy AND
  2. The requested agent will be used to reduce the loss of kidney function in a patient at risk for disease progression AND
  3. ONE of the following:
    1. The patient has a urine protein-to-creatinine ratio (UPCR) greater than or equal to 0.8 g/g OR
    2. The patient has proteinuria greater than or equal to 1 g/day AND
  4. The patient’s eGFR is greater than or equal to 30 mL/min/1.73 m^2 AND
  5. If the patient has an FDA approved indication, then ONE of the following:
    1. The patient’s age is within FDA labeling for the requested indication for the requested agent OR
    2. There is support for using the requested agent for the patient’s age for the requested indication AND
  6. ONE of the following:
    1. BOTH of the following:
      1. The patient has tried and had an inadequate response after at least 3 months of therapy with maximally tolerated ACEI or ARB (e.g., benazepril, lisinopril, losartan), or a combination medication containing an ACEI or ARB AND
      2. The patient will be using an ACEI or ARB or a combination medication containing an ACEI or ARB in combination with the requested agent OR
    2. The patient has an intolerance or hypersensitivity to an ACEI or ARB, or a combination medication containing an ACE or ARB OR
    3. The patient has an FDA labeled contraindication to ALL ACEI or ARB AND
  7. ONE of the following:
    1. The patient has an intolerance or hypersensitivity to oral generic budesonide that is not expected to occur with the requested agent OR
    2. The patient has an FDA labeled contraindication to oral generic budesonide that is not expected to occur with the requested agent AND
  8. ONE of the following:
    1. The patient has not previously been treated with a course of therapy (9 months) with the requested agent OR
    2. The patient has previously been treated with a course of therapy with the requested agent, AND there is support for an additional course of therapy with the requested agent AND
  9. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., nephrologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
  10. The patient does NOT have any FDA labeled contraindications to the requested agent

Length of Approval: 10 months

NOTE: If Quantity Limit applies, please refer to Quantity Limit criteria.

*Step therapy requirement may not apply if a prior health plan paid for the medication - documentation of a paid claim may be required.

QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

QL with PA

Quantity limit for the Target Agent(s) will be approved when ONE of the following is met:

  1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  2. ALL of the following:
    1. The requested quantity (dose) exceeds the program quantity limit AND
    2. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
    3. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit

Length of Approval: up to 10 months

This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.

ALBP _  Commercial _ CSReg _ Tarpeyo__PAQL _ProgSum_ 07-01-2024  _  © Copyright Prime Therapeutics LLC. May 2024 All Rights Reserved