COMMENTARY

Why Can't UK Immunocompromised Patients Get Evusheld?

David J. Kerr, CBE, MD, DSc

Disclosures

September 29, 2022

This transcript has been edited for clarity.

I'm David Kerr, professor of cancer medicine at Oxford. As I'm gearing up to have my autumnal COVID-19 booster vaccine, there's a small controversy raging in the United Kingdom about access to a medicine called Evusheld.

This was developed by AstraZeneca. It's a combination of two relatively long-acting antibodies (tixagevimab and cilgavimab) that bind to the spike protein on the outside of the SARS-CoV-2 virus, the virus that causes COVID-19. The antibody binds to the spike protein and prevents it from binding to and infecting or damaging cells, so it's what's called preexposure prophylaxis.

Although vaccination is still the best approach to protecting against and, one would hope, conferring a degree of herd protection to our population as a whole, there are some people who cannot mount an appropriate immune response and we have to take care of these folks. Because the vaccines don't work very well for them, the vaccine itself is not sufficient to protect them.

Evusheld, in trials that have been done hitherto, can protect people who can't mount an immune response from being infected. Between 75% and 80% of patients treated with Evusheld didn't get COVID-19. The duration of effect seemed to be at least for 6 months, possibly longer, so it's a really good result. This caused our medicines regulatory authority in the United Kingdom to approve the drug in March of this year. Although the drug has been approved, it's not yet funded and not yet available for vulnerable patients.

These are patients who, for reasons of inborn genetic diseases, cannot mount an immune response; patients who are pharmacologically immune depleted; patients who have had transplants and are on immunosuppressive drugs; and some of our cancer patients, particularly those with blood or hematologic malignancies, who can receive very heavy treatment that can pound the immune system to bits.

These are, in the population as a whole, relatively small numbers, but an important number of people who are still vulnerable to developing COVID-19 despite vaccination.

Why isn't the drug available? We have a two-stage process in the UK. We have the scientists and regulatory authorities looking at the evidence and data and saying, "Yes, it stacks up. This drug is effective and safe to some extent."

The second phase is a health technology assessment undertaken by NICE, our National Institute for Health and Care Excellence — something that I've talked about a number of times before and the sometimes seemingly arbitrary decisions that they make. NICE hasn't evaluated the drug yet, and the British government has held out because they are arguing that we don't have enough data.

The trials with Evusheld were done before the Omicron variant dominated, as it does now; therefore, they are looking to try to work with AstraZeneca to generate more real-world data to show that Evusheld would prevent infection from the Omicron variant of the virus. Equally as important, how long does that protection last? Is it as protective against Omicron, and what's the duration of that protection? Those bits of work are going on now.

Some real-world data are starting to emerge, showing that Evusheld will offer some degree of protection against Omicron, but there are still question marks about duration and the proportion of the population that would benefit.

NICE aren't due to report on this — although the drug was approved in March of this year — until next year some time. That's what's caused a degree of consternation in the community of patients that we serve. Some of my clinical colleagues are beating the drum, saying, "We must have this drug now." We're still waiting on NICE to announce.

One obvious way to go around this is the government, which has bent over backwards in the UK to do as much as it can to protect the population from COVID-19. There was fantastic vaccine rollout and an extraordinary economic package to support individuals during lockdown to maintain the workforce, to support families and people at home. They've done a fantastic job.

Wanting to damp down this controversy, perhaps the sensible thing would be to ask NICE to evaluate the data that they have just now, to allow AstraZeneca to present whatever real-world evidence they have, and although it may not be perfect, it may be sufficient — we don't know — to pass the NICE health technology assessment.

Watch this space. Let's see what happens. If I were government, that's what I would do. I would ask NICE to bring their appraisal forward. I would ask them to work with AstraZeneca to go over every ounce and iota of data that they have to see if this drug will be sufficiently effective and sufficiently cost-effective to be used before winter comes. I think the whole world is holding its breath, expecting another COVID-19 winter surge. Now would be the time to act.

What do you think? Here we are in the UK discussing yet another quasi–"health-rationing" problem. It's not. This is about collecting more data and being as rational as possible. Can we accelerate that process? Perhaps.

Thanks for listening. I'd be very grateful for any comments that you might choose to make.

For the time being, Medscapers, ahoy. Thank you.

David J. Kerr, CBE, MD, DSc, is a professor of cancer medicine at the University of Oxford. He is recognized internationally for his work in the research and treatment of colorectal cancer and has founded three university spin-out companies: COBRA Therapeutics, Celleron Therapeutics, and Oxford Cancer Biomarkers. In 2002, he was appointed Commander of the British Empire by Queen Elizabeth II.

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