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Lasmiditan (Reyvow™) New Drug Update

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Lasmiditan (Reyvow™) New Drug Update Lasmiditan (Reyvow™) New Drug Update November 2019 Nonproprietary Name lasmiditan Brand Name Reyvow Manufacturer Eli Lilly and Company Form Tablets Strength 50 mg, 100 mg FDA Approval October 11, 2019 Market Availability Anticipated within 90 days of approval, following Drug Enforcement Agency (DEA) review FDA Approval Classification Standard Review FDB Classification- Specific TBD Therapeutic Class (HIC3) INDICATION1 Lasmiditan (Reyvow) is a serotonin 5-HT1F receptor agonist indicated for the acute treatment of migraine with or without aura in adults. Limitation of Use: Lasmiditan is not indicated for preventive treatment of migraine. PHARMACOKINETICS After oral administration of lasmiditan, the median time to maximum serum concentration (Tmax) is 1.8 hours. Food, age, gender, race, ethnicity, body weight, or renal function do not have a clinically significant effect on the pharmacokinetics of lasmiditan. The agent is 55% to 60% plasma protein bound. Lasmiditan is primarily metabolized via hepatic and extrahepatic metabolism, primarily by non- cytochrome P450 enzymes (e.g., ketone reduction) and has no pharmacologically active metabolites. Its mean terminal half-life is 5.7 hours. CONTRAINDICATIONS/WARNINGS Lasmiditan does not have any contraindications. Lasmiditan has been associated with significant impairment in the ability to drive or operate machinery following a single dose. Patients should be advised not take lasmiditan unless they are able to avoid driving or operating machinery for at least 8 hours after each lasmiditan dose. Prescribers should be aware that the patient’s ability to determine their own mental alertness may also be affected and should discuss this with the patient. Proprietary Information. Restricted Access – Do not disseminate or copy without approval. © 2019 Magellan Rx Management. All Rights Reserved. Central nervous system (CNS) depression may occur with use of lasmiditan, including sedation and dizziness. Use with alcohol or other CNS depressants may potentiate this affect. In clinical trials, use of lasmiditan was associated with symptoms consistent with serotonin syndrome, which may occur with or without coadministration of other serotonergic drugs. If symptoms associated with serotonin syndrome occur, lasmiditan should be discontinued. Lasmiditan labeling contains a warning about the overuse of acute migraine agents, which may lead to medication overuse headache. Medication overuse headache may present as migraine-like daily headaches or as a significant increase in frequency of attacks. Withdrawal of the offending agent(s) and treatment of symptoms may be necessary. DRUG INTERACTIONS Due to the propensity to cause CNS-related adverse effects, including sedation, lasmiditan should be used cautiously in combination with alcohol or other CNS depressants. Use of lasmiditan with medications that increase serotonin may increase the risk of serotonin syndrome; therefore, caution is advised with use of lasmiditan in patients taking other serotonergic agents. Lasmiditan has been associated with a heart rate decrease. Use of heart rate lowering drugs with lasmiditan may result in further heart rate lowering. Concomitant use of lasmiditan with p-glycoprotein (p-gp) or Breast Cancer Resistant Protein (BCRP) substrates should be avoided. COMMON ADVERSE EFFECTS The most common adverse reactions reported in clinical trials (incidence ≥ 5% and greater than placebo) with lasmiditan (reported as incidence with 50 mg, 100 mg, and 200 mg versus placebo, respectively) were dizziness (9%, 15%, and 17% versus 3%), fatigue (4%, 5%, and 6% versus 1%), paresthesia (3%, 7%, and 9% versus 2%), and sedation (6%, 6%, and 7% versus 2%). SPECIAL POPULATIONS Pregnancy Based on data from animal studies lasmiditan can cause embryofetal harm when administered to a pregnant woman. There are no adequate data on the risks associated with use in pregnant women. Pediatrics The safety and efficacy of lasmiditan have not been established in the pediatric population. Geriatrics In clinical trials, dizziness occurred more often in patients ≥ 65 years of age compared to younger adults (16% versus 14%, respectively). Patients ≥ 65 years of age experienced a larger increase in systolic blood pressure compared to younger patients. Clinical trials did not include an adequate number of patients ≥ 65 years of age to inform of differences in efficacy of lasmiditan compared to younger patients. Reyvow New Drug Update – November 2019 Page 2 | Proprietary Information. Restricted Access – Do not disseminate or copy without approval. © 2019 Magellan Rx Management. All Rights Reserved. Hepatic Impairment Lasmiditan has not been studied in patients with severe hepatic impairment (Child-Pugh C); therefore, use in this patient population is not recommended. A dose adjustment is not required for patients with mild or moderate hepatic impairment (Child-Pugh A or B). Renal Impairment No dose adjustment is required based on renal function. DOSAGES The recommended dose is 50 mg, 100 mg, or 200 mg orally as needed, with or without food, for the treatment of migraine with no more than 1 dose taken in any 24 hour period. Patients should not take lasmiditan unless they are able to avoid driving or operating machinery for at least 8 hours after each lasmiditan dose. The safety of treating an average of more than 4 migraines per 30 days with lasmiditan has not been established. CLINICAL TRIALS2,3,4 A literature search was performed using “lasmiditan” and “migraine.” Two multicenter, randomized, double-blind, placebo-controlled clinical trials evaluated the efficacy and safety of lasmiditan for the acute treatment of migraine. The SAMURAI trial (A Study of Two Doses of LAsMiditan Compared to Placebo in the AcUte Treatment of MigRAIne) compared lasmiditan 100 mg and 200 mg to placebo, while the SPARTAN trial (A Study of Three Doses of Lasmiditan Compared to Placebo in the Acute TReaTment of MigrAiNe) compared lasmiditan 50 mg, 100 mg, and 200 mg to placebo. Both SAMURAI and SPARTAN enrolled adult patients ≥ 18 years of age with a diagnosis of migraine with or without aura as defined by the International Headache Society (IHS) diagnostic criteria. Patients were eligible for inclusion if they had a diagnosis of disabling migraine for ≥ 1 year, a Migraine Disability Assessment Score of ≥11, a migraine onset before 50 years of age and 3 to 8 migraine attacks per month (< 15 headache days per month). Patients were excluded from the trials if they met any of the following criteria: ≥ 15 headache days per month; initiation or change in previous migraine treatment within 3 months; or increased seizure risk. Patients with coronary artery disease, arrhythmias, or uncontrolled hypertension were excluded from the SAMURAI trial, but not the SPARTAN trial. Patients enrolled in the SAMURAI trial (n=2,231) were randomized 1:1:1 to receive lasmiditan 200 mg, lasmiditan 100 mg, or placebo for the treatment of their next migraine attack. Patients were instructed to take the study medication within 4 hours of the onset of headache and recorded their responses using an electronic diary. Of the enrolled patients, 1,856 patients received at least the first dose of study drug with 1,805 completing the study and 51 patients discontinuing before study completion. The primary endpoint for the SAMURAI trial was the percent of patients headache pain-free 2 hours after the first dose of study medication (200 mg lasmiditan versus placebo). Secondary endpoints included percent of patients headache pain-free 2 hours after the first dose of study medication (100 mg lasmiditan versus placebo) and the percent of the patients most bothersome symptom (MBS)-free 2 hours after the first dose of study medication (200 mg versus placebo and 100 mg versus placebo). More patients treated with lasmiditan 200 mg were headache pain-free 2 hours after the first dose compared to placebo (32.2% versus 15.3%, respectively; odds ratio [OR], 2.6; 95% confidence interval [CI], 2 to 3.6; p<0.001). Likewise, more patients treated with lasmiditan 100 mg were headache pain-free 2 hours after the first dose Reyvow New Drug Update – November 2019 Page 3 | Proprietary Information. Restricted Access – Do not disseminate or copy without approval. © 2019 Magellan Rx Management. All Rights Reserved. compared to placebo (28.2% versus 15.3%, respectively; OR, 2.2; 95% CI, 1.6 to 3; p<0.001). Additionally, more patients receiving lasmiditan 200 mg compared to placebo were free of their MBS 2 hours after the first dose (40.7% versus 29.5%, respectively; OR, 1.6; 95% CI, 1.3 to 2.1; p<0.001) and lasmiditan 100 mg (40.9%; OR, 1.7; 95% CI, 1.3 to 2.2; p<0.001). Patients enrolled in the SPARTAN trial(n=3,005) were randomized 1:1:1:1 to receive lasmiditan 200 mg, lasmiditan 100 mg, lasmiditan 50 mg, or placebo for the treatment of their next migraine attack. Again, patients recorded their responses using an electronic diary. Of the enrolled patients, 2,583 patients received at least the first dose of the study drug with 2,310 patients providing any post-dose headache assessment. The primary endpoints for the SPARTAN trial were the percentage of patients’ headache pain-free and MBS-free at 2 hours postdose for each treatment arm. A greater percentage of patients treated with lasmiditan were headache pain-free 2 hours after the first dose compared to 21.3% with placebo (lasmiditan 200 mg: 38.8% [OR versus placebo, 2.3; 95% CI, 1.8 to 3.1; p=0.001]; 100 mg: 31.4% [OR versus placebo, 1.7; 95% CI, 1.3 to 2.2; p<0.001]; 50 mg: 28.6%, OR, 1.5; 95% CI, 1.1 to 1.9; p=0.003). Additionally, greater percentage of lasmiditan-treated patients experienced freedom from MBS at 2 hours postdose compared to 33.5% of those treated with placebo (lasmiditan 200 mg: 48.7%, OR, 1.9; 95% CI, 1.4 to 2.4; p<0.001; 100 mg: 44.2%, OR, 1.6; 95% CI, 1.2 to 2.0; p<0.001; 50 mg: 40.8%, OR,1.4; 95% CI, 1.1 to 1.8; p=0.009).
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