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NDA 208341 Supplement 14 Clinical Review, Cross Discipline Team Leader and Division Director Summary Memorandum

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NDA 208341 Supplement 14 Clinical Review, Cross Discipline Team Leader and Division Director Summary Memorandum NDA 208341 Supplement 14 Clinical Review, Cross Discipline Team Leader and Division Director Summary Memorandum Table of Contents 1. Executive Summary..........................................................................................5 1.1. Summary of Regulatory Action ...................................................................5 1.2. Benefit-Risk Assessment ............................................................................6 1.3. Patient Experience Data .............................................................................9 2. Background ....................................................................................................10 2.1. Product Information...................................................................................11 2.2. Summary of Regulatory Activity Related to Submission ...........................12 2.3. Summary of Study Protocol ......................................................................12 2.3.1. Protocol Amendments ........................................................................14 2.4. Product Quality..........................................................................................16 3. Nonclinical Pharmacology/Toxicology ............................................................16 4. Clinical Pharmacology ....................................................................................16 5. Clinical Microbiology.......................................................................................16 6. Clinical/Statistical: Efficacy .............................................................................16 6.1. Cohort 1: 12- to <18-Year-Old Subjects....................................................17 6.1.1. Disposition of Subjects .......................................................................17 6.1.2. Demographic and Baseline Characteristics........................................18 6.1.3. Efficacy Results SVR 12 (12- to <18-Year-Old Subjects)...................18 6.2. Cohort 2: 6- to <12-Year-Old Subjects......................................................19 6.2.1. Disposition of Subjects .......................................................................19 6.2.2. Demographics and Baseline Characteristics of Subjects ...................20 6.2.3. Efficacy Week 12 After Discontinuation of Treatment (6- to <12-Year-Old Subjects) 21 6.3. Overall Efficacy Summary (6- to <18-Year-Old Subjects).........................22 7. Safety .............................................................................................................22 7.1. Safety Data Subjects 12 to <18 Years ......................................................22 7.2. Safety Data Group 2: Ages 6 to <12 Years...............................................24 2 Reference ID: 4577692 NDA 208341 Supplement 14 Clinical Review, Cross Discipline Team Leader and Division Director Summary Memorandum 7.3. Other Adverse Events ...............................................................................27 7.4. Weight-Based Exposure and Safety Issues..............................................27 7.5. Drug Interactions.......................................................................................28 7.6. Use in Pregnancy and Lactation ...............................................................28 8. Advisory Committee Meeting..........................................................................28 9. Pediatrics........................................................................................................28 10.Other Relevant Regulatory Issues..................................................................29 10.1. Submission Quality and Integrity ........................................................29 10.2. Compliance With Good Clinical Practices ..........................................29 10.3. Financial Disclosures..........................................................................29 11.Labeling ..........................................................................................................30 11.1. Highlights of Prescribing Information ..................................................30 12.Postmarketing Recommendations..................................................................36 12.1. Risk Evaluation and Management Strategies (REMS) .......................36 12.2. Postmarketing Requirements (PMRs) and Commitments (PMCs) .....36 13.References .....................................................................................................36 14.Appendix: Clinical Investigator Financial Disclosure Review .........................38 3 Reference ID: 4577692 NDA 208341 Supplement 14 Clinical Review, Cross Discipline Team Leader and Division Director Summary Memorandum Table of Tables Table 1. Demographics and Baseline Characteristics for Subjects Ages 12 to <18 Years 18 Table 2. ALT Normalization in Subjects 12 to <18 Years of Age.........................19 Table 3. Demographics and Baseline Characteristics for Subjects Ages 6 to <12 Years 21 Table 4. ALT Normalization in Subjects 6 Years to <12 Years of Age.................22 Table 5. Overall Summary of Adverse Events 12 to <18 Years Old, Cohort 1 ....23 Table 6. ADRs >1 Subjects Ages 12 to <18 Years Old .......................................23 Table 7. Common AEs (≥5%) in Subjects Ages 12 to <18 Years Without Regard to Relatedness 24 Table 8. Overall Summary of AEs and ADRs Ages 6 to <12 Years.....................25 Table 9. ADRs Subjects Ages 6 to <12 Years .....................................................25 Table 10. Common AEs (≥5%) Subjects Ages 6 to <12 Years............................26 Table 11. SOF/VEL Weight Band Doses Utilized in Study 1143 .........................28 Table 12. PK of Sofosbuvir and Velpatasvir in Infected Pediatric Patients 6 Years and Older 34 4 Reference ID: 4577692 NDA 208341 Supplement 14 Clinical Review, Cross Discipline Team Leader and Division Director Summary Memorandum 1. Executive Summary 1.1. Summary of Regulatory Action This supplemental new drug application (NDA) is intended to expand the indicated population for Epclusa® (sofosbuvir and velpatasvir; SOF/VEL) FDC (Fixed Drug Combination) to include subjects 6 years old and older or weighing at least 17 kg. This submission also serves as a Prior Approval Supplement to support the addition of a new tablet strength 200 mg/50 mg tablets. The NDA was reviewed by the multi-disciplinary team and each discipline recommended approval for the NDA. I, the signatory authority for this application, concur with the recommendations from the review team. SOF/VEL will be approved for children six years of age and older or weighing at least 17 kg with HCV genotype 1, 2, 3, 4, 5, or 6 infection. • Without cirrhosis or with compensated cirrhosis • With decompensated cirrhosis for use in combination with ribavirin The Applicant submitted a multicenter, open-label, non-comparative trial (1143) in which 175 children (102 children 12 to <18 years old, 73 children 6 to <12 years old) were enrolled, treated for 12 weeks and followed for 24 weeks after discontinuation of study treatment. The trial design comprised two phases: a PK lead-in phase and a treatment phase in which the safety and efficacy of the SOF/VEL were evaluated. The SOF/VEL dose was based on the child’s age. Adolescents received the current adult dosage of 400 mg/100 mg (SOF/VEL) tablet once daily. Children 6 to <12 years of age received the 200 mg/50 mg (SOF/VEL) daily tablet. The Applicant was interested in weight-band dosing with adult dosage administered for subjects weighing ≥ 35 kg. Exposures of SOF, GS-331007 and VEL in adolescents were compared to historical data in adults collected in SOF/VEL clinical studies. GS-331007 AUCtau and Cmax and VEL AUCtau and Ctau were within the predefined equivalence boundary of 70% to 200%. The SOF AUCtau and Cmax and VEL Cmax in subjects 12 to <18 years of age were higher than observed in the adult population. 5 Reference ID: 4577692 NDA 208341 Supplement 14 Clinical Review, Cross Discipline Team Leader and Division Director Summary Memorandum Exposures of SOF, GS-331007 and VEL in children 6 to <12 years of age were compared to historical data in adults collected in SOF/VEL clinical studies. Sofosbuvir Cmax, VEL Cmax and VEL Ctau were not fully contained within the predefined equivalence boundary of 70% to 200 %. Specifically the SOF Cmax value exceeded the equivalence boundary and the VELtau was too low. The Applicant summary analysis documented SOF exposures were higher and VEL Ctau were lower. They conducted analyses to see if lower weight band (e.g., ≥30 kg) for adult dose would improve VEL Ctau. With the >30 kg weight band, VEL Ctau exposures increased; however, further increases in SOF exposures were noted. The safety of the higher SOF exposures was supported by data from 6 children who were <35 kg and received the adult dose for because the dosages were age rather than weight driven. The efficacy outcomes, as measured by SVR 12 were 95% for adolescents and 93% for children 6 to <12 years of age. One child in the 12 to <18 year old group became pregnant, discontinued and relapsed. One child in the 6 to <12 year old group experienced virologic failure. The Safety data indicated that Epclusa® is safe and well tolerated, no deaths, SAEs or related Grade 3 or 4 events, two D/Cs, The commonly observed AEs in children were similar to those seen in adults and were mild in severity. Overall the benefit risk assessment is favorable. 1.2. Benefit-Risk Assessment Benefit-Risk
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