Medical Policy: 02.04.71 

Original Effective Date: April 2018 

Reviewed: April 2019 

Revised: April 2019 

 

Notice:

This policy contains information which is clinical in nature. The policy is not medical advice. The information in this policy is used by Wellmark to make determinations whether medical treatment is covered under the terms of a Wellmark member's health benefit plan. Physicians and other health care providers are responsible for medical advice and treatment. If you have specific health care needs, you should consult an appropriate health care professional. If you would like to request an accessible version of this document, please contact customer service at 800-524-9242.

 

Benefit Application:

Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

 

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

 

Description:

DPD stands for dihydropyrimidine dehydrogenase. It is an enzyme made by the liver that helps our body break down thymine and uracil. DPD deficiency happens when we have low or no levels of the DPD enzyme. It is very rare to have no DPD (a complete DPD deficiency) but it is slightly more common to have low or very low levels (a partial deficiency). The Dihydropyrimidine dehydrogenase (DPYD) gene helps to control the production of DPD in our bodies. There are a number of changes (mutations) in the DPYD gene that can cause DPD deficiency. The enzyme has the ability to break down fluoropyrimidines. Fluoropyrimidines include 5-fluorouracil (5-FU, Adrucil®) and capecitabine (Xeloda®).

 

Fluoropyrimidines (5-Fluorouracil (5-FU) and its derivative capecitabine) are widely used antineoplastic chemotherapy drugs. 5-FU has been used for many years to treat solid tumors. Although the benefits of 5-fluoroucil-based therapy is prolonging survival, major side effects are seen in many individuals receiving the drugs. In general, the incidence of grade 3 or 4 toxicity (mainly neutropenia, diarrhea, mucositis, and hand-foot syndrome) increases with higher systemic exposure to 5-FU. Several studies have reported statistically significant positive associations between 5-FU exposure and tumor response. In current practice, however, 5-FU dose is reduced when symptoms of severe toxicity appear, but is seldom increased to promote efficacy. Lab algorithm tests and genetic tests have garnered recent interest in optimizing dosage.

 

So far, research has shown that people with DPD deficiency usually develop severe side effects after the first few doses of fluorouracil or capecitabine. To avoid the risk of severe and potentially fatal reactions, the manufactures of both 5-FU and the oral fluoropyrimidine recommend that the drugs are contraindicated in patients with known DPD deficiency.

 

Variability in systemic exposure to 5-fluorouracil (5-FU) is thought to directly impact 5-FU tolerability and efficacy. The standard approach is dosing according to body surface area. Two alternative approaches have been proposed for modifying use of 5-FU: (1) dosing based on determined area under the curve serum concentration target and (2) genetic testing for variants affecting 5-FU metabolism. For genetic testing, currently available polymerase chain reaction tests assess specific variants in genes encoding dihydropyrimidine reductase (DPYD) and thymidylate synthase (TYMS) in the catabolic and anabolic pathways of 5-FU metabolism. There are several testing options for DPYD genotype, although, at present most test only for the DPYD 2A variant. Approximately 10% of individuals receiving fluoropyrimidines have severe side effects from fluorouracil and capecitabine. But not everyone has a DPD deficiency. The testing to determine the likelihood of intolerance is unreliable at this time. Additional studies are needed before the use of DPD deficiency as a predictive molecular marker for fluoropyrimidines toxicity can be recommended as a standard of care.

 

Patient exposure to 5-FU is most accurately described by estimating the AUC (area under the curve), the total drug exposure over a defined period of time. 5-FU exposure is influenced by method of administration, circadian variation, liver function, and the presence of inherited dihydropyrimidine reductase (DPYD). Catabolism of 5-FU is controlled by the activity of DPYD. Because DPYD is a saturable enzyme, the pharmacokinetics of 5-FU are strongly influenced by the dose and schedule of administration.

 

Pathophysiology

Based on known 5-FU pharmacology, it is possible to determine a sampling scheme for area under the curve (AUC) determination and to optimize an AUC target and dose-adjustment algorithm for a particular 5-FU chemotherapy regimen and patient population. For each AUC value or range, the algorithm defines the dose adjustment during the next chemotherapy cycle most likely to achieve the target AUC without overshooting and causing severe toxicity.

 

Dihydropyrimidine dehydrogenase (DPD) enzyme – encoded by DPYD gene. This enzyme catabolizes >80% of 5-FU into an inactive form that is eliminated in the urine (rate limiting enzyme). Reduced DPD activity can lead to the accumulation of active 5-FU metabolite, increasing the risk for 5-FU toxicity.

 

Thymidylate synthase (TYMS) enzyme – encoded by TYMS gene, this is the primary target for 5-FU. The remaining 5-FU drug is metabolized by different enzymes into an active form that inhibits the synthesis of DNA and RNA by competitive inhibition of TYMS or by direct incorporation of cytotoxic metabolites into nucleic acids. TYMS gene variants result in reduced expression of TYMS and may be associated with higher clinical responsiveness to 5-FU therapy and increased risk of toxicity.

 

Lack of detection of the targeted DPYD and TYMS variants does not rule out risk for 5-FU toxicity or predict degree of responsiveness to 5-FU.

 

National Institute of Health and Care Excellence (NICE)

In 2015, Freeman et al published a health technology assessment (HTA) on the My5-FU assay to guide dose adjustment in patients receiving 5-FU chemotherapy by continuous infusion. The report was conducted on behalf of the National Institute of Health and Care Excellence (NICE). The assessment included a review of studies on the accuracy of the My5-FU assay compared with a reference standard test, high-performance liquid chromatography (HPLC) or liquid chromatography–mass spectrometry (LC-MS). Three studies were included, as well as information provided by the manufacturer. Risk of bias was difficult to assess due to incomplete reporting. In particular, it was unclear whether there was complete reporting of failed samples or outliers, which could result in overly optimistic estimates of accuracy.

 

No RCTs or nonrandomized comparative studies were identified comparing health outcomes in cancer patients who did and did not have 5-FU dose adjustment using the My5-FU assay and who were treated with chemotherapy regimens used in current clinical practice. A systematic review of the available literature found a significantly higher response rate with BSA-based monitoring and no significant difference in toxicity.

 

National Comprehensive Cancer Network Version 1.2019

Universal pretreatment DPYD genotyping remains controversial, however, and the NCCN Panel does not support it at this time. Although current National Comprehensive Cancer Network (NCCN) guidelines acknowledge that the “selection, dosing, and administration of anticancer agents and the management of associated toxicities are complex,” NCCN does not recommend use of area under the curve guidance for 5-fluorouracil (5-FU) dosing or genetic testing for DPYD and/or TYMS variants in patients with colon, rectal, breast, gastric, pancreatic cancer, or head and neck cancers.

 

Prior Approval:

Not applicable

 

Policy:

For more information regarding personalized testing for pharmacotherapy please see policy 02.04.64.

 

My5-FU™ testing or other assays for determining 5-fluorouracil area under the curve in order to adjust 5-fluorouracil (5-FU)dose is considered investigational.

 

Testing for genetic variants in dipyrimidine dehydrogenase (DPYD) or thymidylate synthase (TYMS) genes to guide 5-FU dosing and/or treatment choice is considered investigational.

 

No RCTs or nonrandomized comparative studies were identified comparing health outcomes in cancer patients who did and did not have 5-FU dose adjustment using the My area under the curve assays and who were treated with chemotherapy regimens used in current clinical practice. The genetic testing to predict drug metabolism have not been proven to change health outcomes at this time. The poor predictive value of genetic testing for DPYD/TYMS remains a barrier to recommend for testing.

 

Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes and / or diagnosis codes.

  • 81230 CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, common variant(s) (eg, *2, *22)
  • 81231 CYP3A4 (cytochrome P450 family 3 subfamily A member 5) (eg, drug metabolism), gene analysis, common variant(s) (eg, *2, *3, *4, *5, *6, *7)
  • 81232 DPYD (dihydropyrimidine dehydrogenase)(eg, 5-fluorouracil/5-FU and capecitabine drug metabolism), gene analysis, common variant(s) (eg, *2A, *4, *5, *6)
  • 81346 TYMS (thymidylate synthetase)(eg, 5-fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (eg, tandem repeat variant)
  • S3722 Dose optimization by area under the curve (AUC) analysis, for infusional 5-fluorouracil

 

Selected References:

  • Caudle KE, Thorn CF, Klein TE, Swen JJ, McLeod HL, Diasio RB, Schwab M. Clinical Pharmacogenetics Implementation Consortium guidelines for dihydropyrimidine dehydrogenase genotype and fluoropyrimidine dosing. Clin Pharmacol Ther. 2013; 94(6): 640-5. PubMed
  • Lee S, McLeod HL. Pharmacogenetic tests in cancer chemotherapy: what physicians should know for clinical application. J Pathol. 2011; 223(1): 15-27. PubMed
  • Gamelin EC, Danquechin-Dorval EM, Dumesnil YF, et al. Relationship between 5-fluorouracil (5-FU) dose intensity and therapeutic response in patients with advanced colorectal cancer receiving infusional therapy containing 5-FU. Cancer. Feb 1 1996;77(3):441-451. PMID 8630950
  • Boige V, Vincent M, Alexandre P, et al. DPYD genotyping to predict adverse events following treatment with flourouracil-based adjuvant chemotherapy in patients with stage III colon cancer: a secondary analysis of the PETACC-8 Randomized Clinical Trial. JAMA Oncol. Jan 21 2016. PMID 26794347
  • Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Pharmacogenetic Testing to Predict Serious Toxicity From 5-Fluorouracil (5-FU) for Patients Administered 5-FU-Based Chemotherapy for Cancer. TEC Assessments. 2010;24:Tab 13.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Colon Cancer. Version 1.2019.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Rectal Cancer. Version 1.2019.
  • National Institute for Health and Care Excellence (NICE). Fluorouracil chemotherapy: The My5-FU assay for guiding dose adjustment [DG16]. 2014.
  • Freeman K, Connock M, Cummins E, et al. Fluorouracil plasma monitoring: systematic review and economic evaluation of the My5-FU assay for guiding dose adjustment in patients receiving fluorouracil chemotherapy by continuous infusion. Health Technol Assess. Nov 2015;19(91):1-322. PMID 26542268
  • Ruzzo A, et al. (2014) Genetic markers for toxicity of adjuvant oxaliplatin and fluoropyrimidines in the phase III TOSCA trial in high-risk colon cancer patients. Sci Rep 5: 6828.
  • Lee AM, Shi Q, et al. (2016) Association between DPYD c.1129-5923 C>G/hapB3 and severe toxicity to 5-fluorouracil-based chemotherapy in stage III colon cancer patients: NCCTG N0147(Alliance). Pharmacogenet Genomics 26: 133–137.
  • Amstutz U Henricks LM Offer SM et al.Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for Dihydropyrimidine Dehydrogenase Genotype and Fluoropyrimidine Dosing: 2017 update. Clin Pharmacol Ther. 2018; 103: 210-216
  • Amstutz U, Largiadèr CR. Genotype-guided fluoropyrimidine dosing: ready for implementation. Lancet Oncol. 2018 Nov;19(11):1421-1422. doi: 10.1016/S1470-2045(18)30744-7. Epub 2018 Oct 19
  • Cremolini C, Del Re M, Antoniotti C, Lonardi S, Bergamo F et al. DPYD and UGT1A1 genotyping to predict adverse events during first-line FOLFIRI or FOLFOXIRI plus bevacizumab in metastatic colorectal cancer. Oncotarget. 2017 Dec 21;9(8):7859-7866. doi: 10.18632/oncotarget.23559. eCollection 2018 Jan 30.
  • Toffoli G, Innocenti F, Polesel J, De Mattia E, Sartor F, Dalle Fratte C, Ecca F, et al. The Genotype for DPYD Risk Variants in Patients With Colorectal Cancer and the Related Toxicity Management Costs in Clinical Practice. Clin Pharmacol Ther. 2019 Apr;105(4):994-1002. doi: 10.1002/cpt.1257. Epub 2018 Nov 22.
  • Henricks LM, van Merendonk LN, Meulendijks D, Deenen MJ, Beijnen JH, de Boer A, Cats A, Schellens JHM. Effectiveness and safety of reduced-dose fluoropyrimidine therapy in patients carrying the DPYD*2A variant: A matched pair analysis. Int J Cancer. 2019 May 1;144(9):2347-2354. doi: 10.1002/ijc.32022. Epub 2019 Jan 4
  • Nahid NA, Apu MNH, Islam MR, et al. DPYD*2A and MTHFR C677T predict toxicity and efficacy, respectively, in patients on chemotherapy with 5-fluorouracil for colorectal cancer. Cancer Chemother Pharmacol. Jan 2018;81(1):119-129. PMID 29134491 

 

Policy History:

  • April 2019 - Annual Review, Policy Revised
  • April 2018 - New Policy

Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

 

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