2 The technology
2.1 Eltrombopag (Revolade, GlaxoSmithKline) increases platelet production by activating the thrombopoietin receptor, thereby stimulating platelet production and reducing bleeding. Eltrombopag has a UK marketing authorisation for the treatment of 'chronic immune (idiopathic) thrombocytopenic purpura (ITP) patients aged 1 year and above who are refractory to other treatments (e.g. corticosteroids, immunoglobulins)'.
2.2 Eltrombopag is taken orally. The summary of product characteristics states that the recommended starting dose is 50 mg once daily but that patients of East Asian ancestry should start eltrombopag at a reduced dose of 25 mg once daily. It recommends that patients should take eltrombopag at least 4 hours before or after antacids, dairy products (or other calcium-containing food products) or mineral supplements containing polyvalent cations (for example, iron, calcium, magnesium, aluminium, selenium and zinc). If, after initial therapy, platelet counts are below the target level (50×109 per litre), the dosage may be increased to a maximum of 75 mg once daily. Treatment should be stopped if the platelet count does not increase sufficiently to avoid clinically significant bleeding after 4 weeks of therapy at a dosage of 75 mg once daily. The summary of product characteristics stipulates that eltrombopag treatment should remain under the supervision of a physician who is experienced in the treatment of haematological diseases. For full details of dosage and administration, see the summary of product characteristics.
2.3 The summary of product characteristics lists the following adverse reactions for eltrombopag as being common (1 or more patient in every 100 and fewer than 1 patient in every 10) or very common (1 or more patient in every 10): psychiatric disorders (insomnia), nervous system disorders (headache and paraesthesia), eye disorders (cataract and dry eye), gastrointestinal disorders (nausea, diarrhoea, constipation and upper abdominal pain), hepatobiliary disorders (increased alanine aminotransferase, increased aspartate aminotransferase, increased blood bilirubin and hyperbilirubinaemia, and abnormal hepatic function), skin and subcutaneous tissue disorders (rash, pruritus and alopecia), musculoskeletal and connective tissue disorders (arthralgia, myalgia, muscle spasm and bone pain), and general disorders (fatigue and peripheral oedema). For full details of adverse reactions and contraindications, see the summary of product characteristics.
2.4 The 'British national formulary' (BNF; edition 64) states that the net price of a 28‑tablet pack of 25 mg eltrombopag is £770 (a single 25 mg dose costs £27.50). The net price of a 28‑tablet pack of 50 mg eltrombopag is £1540 (a single 50 mg dose costs £55). The cost per patient will vary with dose adjustment and treatment duration. The manufacturer indicated that the average daily cost of eltrombopag (based on the mean dose of eltrombopag in the EXTEND study of 51.3 mg per day) is £56.43. The manufacturer of eltrombopag (GlaxoSmithKline) has agreed a patient access scheme with the Department of Health that makes eltrombopag available with a discount. The size of the discount is commercial in confidence. The Department of Health considered that this patient access scheme does not constitute an excessive administrative burden on the NHS.