2 The technology
2.1 Ramucirumab (Cyramza, Eli Lilly and Company) has a UK marketing authorisation for the following indications:
Ramucirumab in combination with paclitaxel is indicated for 'the treatment of adult patients with advanced gastric cancer or gastro–oesophageal junction adenocarcinoma with disease progression after prior platinum and fluoropyrimidine chemotherapy'.
Ramucirumab monotherapy is indicated for 'the treatment of adult patients with advanced gastric cancer or gastro–oesophageal junction adenocarcinoma with disease progression after prior platinum or fluoropyrimidine chemotherapy, for whom treatment in combination with paclitaxel is not appropriate'.
2.2 Ramucirumab is given as an intravenous infusion over about 60 minutes. Ramucirumab is a human receptor‑targeted monoclonal antibody that specifically binds vascular endothelial growth factor (VEGF) receptor‑2. This interaction prevents VEGF receptor‑2 from binding with activating ligands (VEGF‑A, VEGF‑C and VEGF‑D). Upregulation of VEGF‑A, VEGF‑C and VEGF‑D ligands in gastric cancer is associated with poorer prognosis for people with resected or metastatic disease.
2.3 The summary of product characteristics lists the following adverse reactions: fatigue or asthenia (weakness), neutropenia, leukopenia, diarrhoea, epistaxis (nosebleeds) and hypertension. For full details of adverse reactions and contraindications, see the summary of product characteristics.
2.4 The acquisition cost of ramucirumab is £500 per 10‑ml (100 mg) vial and £2500 per 50‑ml (500 mg) vial (excluding VAT; British national formulary [BNF] edition 69). The recommended dose of ramucirumab with paclitaxel is 8 mg/kg on days 1 and 15 of a 28‑day cycle and the recommended dose for ramucirumab monotherapy is 8 mg/kg every 2 weeks. So, assuming the company's estimated mean body weight of 63.33 kg, the drug cost for each treatment cycle is £6000 for combination therapy (2 × 50‑ml vials and 2 × 10‑ml vials per cycle), or £3000 for monotherapy (1 × 50‑ml vials and 1 × 10‑ml vials per cycle). The company estimated that a person having treatment with ramucirumab combination therapy would have 6 cycles (rounded down from a mean of 6.17 cycles). It estimated a person having treatment with ramucirumab monotherapy would have an average of 7 cycles (rounded up from a mean of 6.94 cycles). So the average costs of a course of ramucirumab combination therapy and monotherapy are £36,000 and £21,000 per person respectively (excluding VAT). Costs may vary in different settings because of negotiated procurement discounts.