Pemetrexed maintenance treatment for non-squamous non-small-cell lung cancer after pemetrexed and cisplatin

Pemetrexed (Alimta, Eli Lilly and Company) is a multi-targeted anticancer antifolate agent that disrupts crucial folate-dependent metabolic processes essential for cell replication.

Pemetrexed has a marketing authorisation as 'monotherapy for the maintenance treatment of locally advanced or metastatic non-small-cell lung cancer (NSCLC) other than predominantly squamous cell histology in patients whose disease has not progressed immediately following platinum-based chemotherapy'.

The most common adverse reactions of pemetrexed are bone marrow suppression; anaemia, neutropenia, leukopenia, thrombocytopenia, and gastrointestinal toxicities; anorexia, nausea, vomiting, diarrhoea, constipation, pharyngitis, mucositis, and stomatitis. For full details of adverse reactions and contraindications, see the summary of product characteristics.

The recommended dose of pemetrexed is 500 mg/m² of body surface area; it is administered as an intravenous infusion over 10 minutes on the first day of each 21‑day cycle. To reduce toxicity, patients should also receive folic acid and vitamin B12 supplements. To reduce the incidence and severity of skin reactions, premedication with a corticosteroid is recommended.

The list price for pemetrexed is £160 for a 100‑mg vial and £800 for a 500‑mg vial (excluding VAT; BNF, January 2014). Using the company's estimated average body surface area of 1.79 m², the drug cost for each treatment cycle is £1,440. Because treatment continues until disease progression or toxicity, the number of cycles varies; in the clinical trial the mean number of cycles for maintenance treatment was 7.86. Therefore, assuming 8 cycles of treatment, the average total treatment cost is approximately £11,520. The company has agreed a commercial access agreement with NHS England that makes pemetrexed available at a reduced cost for continuation maintenance treatment (that is, pemetrexed maintenance after pemetrexed and cisplatin induction therapy). The financial terms of the agreement are commercial in confidence.