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Azelaic Acid Azelaic Acid (FINACEA) Topical Foam 15% National Drug Monograph August 2016 VA Pharmacy Benefits Management Services, Medical Advisory Panel, and VISN Pharmacist Executives The purpose of VA PBM Services drug monographs is to provide a focused drug review for making formulary decisions. Updates will be made when new clinical data warrant additional formulary discussion. Documents will be placed in the Archive section when the information is deemed to be no longer current. FDA Approval Information Description/Mechanism of Azelaic acid is a naturally occurring C9-dicarboxylic acid that is found in plants Action (such as whole grain cereals), animals and humans. Azelaic acid has antiinflammatory, antioxidative and antikeratinizing effects. In rosacea skin, azelaic acid decreases cathelicidin levels and kallikrein 5 (KLK5) activity and possibly inhibits toll-like receptor 2 (TLR2) expression.1 A 15% gel formulation has been marketed for rosacea, and 20% cream has been available for acne vulgaris. The newer foam formulation consists of an oil- in-water emulsion and was designed to have a higher lipid content than the gel for dry and sensitive skin. Indication(s) Under Review Topical treatment of inflammatory papules and pustules of mild to moderate in This Document rosacea. Dosage Form(s) Under Foam, 15% Review REMS REMS No REMS Postmarketing Requirements See Other Considerations for additional REMS information Pregnancy Rating Category B Executive Summary Efficacy There have been no head-to-head trials comparing the foam and gel formulations of azelaic acid in terms of safety, tolerability and efficacy in the treatment of papulopustular (PP) rosacea.. In two major randomized clinical trials, azelaic acid foam produced small benefits over vehicle foam in achieving Investigator’s Global Assessment (IGA) treatment success (NNTs of 9.2 and 11.5) and in reducing inflammatory lesion counts. Azelaic acid foam reduced inflammatory erythema but was ineffective in improving telangiectasias. Safety Contraindications: None Warnings / Precautions: Hypopigmentation, eye irritation, flammable propellant. Common Adverse Reactions: Application site pain, pruritus, dryness, erythema. Application site adverse events were generally mild to moderate, occurred early in treatment and were transient, with most events in the azelaic acid foam group lasting no longer than 1 hour. Other Considerations The two major efficacy-safety trials included patients with moderate to severe PP rosacea (with the majority [86.8%–90.0%] having moderate disease); however, the FDA approved azelaic acid foam for treatment of mild to moderate PP rosacea. The foam and gel formulations of azelaic acid have not been compared in a clinical study. A generic azelaic acid gel (15%) product is tentatively approved and is not yet marketed. Storage and Handling. WARNING: Flammable. Need to avoid fire, flame, or smoking during and immediately following application. Contents under pressure. Must not puncture or incinerate. Must not expose to heat or store at temperatures above 120°F (49°C). Projected Place in Therapy Azelaic acid topical foam would provide benefit for reducing inflammatory lesions in patients with mainly moderate PP rosacea and may be used as an alternative to azelaic acid gel 15%, with consideration given to relative product costs and patient preference. Azelaic acid is considered to be first-line therapy and may be useful in combination with either other topical agents or oral agents. Background Purpose for Review FDA approval of new formulation with supportive randomized clinical trials (RCTs) Issues to be determined: Does azelaic acid foam offer efficacy advantages over available alternatives? Does azelaic acid foam offer safety advantages over available alternatives? Are there subgroup response predictors for safety or efficacy of this product? Other Therapeutic Options Alternative topical treatments at approximately the same step in therapy for mild to moderate papulopustular (PP) rosacea are listed in the table below (source, UpToDate2). Formulary Alternatives Dose and Effects Other Considerations FDA-approved for Mild–Moderate PP Rosacea Benzoyl Peroxide Topical Dose: Initially once daily; Limited efficacy data. Gel 5%, 10%; Lotion 5%, gradually increase to two Bleaches towels and 10% to three times daily if clothing. needed. Metronidazole Topical Dose: Twice daily for Approved for treatment Cream or Gel 0.75%, 1% 0.75% products. of inflammatory lesions Once daily for 1% and erythema of rosacea. products. Ineffective for facial Onset: 2–4 wks telangiectasias. Max Effects: 8–9 wks Relapse is common following discontinuation. Pregnancy category B. Sulfacetamide Sodium- Dose: One to three times Approved as an aid in the Sulfur Topical Lotion 10% / daily. treatment of “acne 5% rosacea.” Mechanism unknown. Limited efficacy data. May cause allergic reactions; avoid in patients with sulfa allergies. Has an unpleasant odor. Used Off-label for PP Rosacea Benzoyl Peroxide / Clinical Study Dose: Bleaches towels and Clindamycin Topical Gel Once daily for 12 wks. clothing. Combination 5% / 1% may be more effective than clindamycin alone. Clindamycin Phosphate Clinical Study Dose: Efficacy data are limited Topical Lotion, Topical Once or twice daily for 12 and pertain to a lotion Solution / Topical Swab (all wks. product. Concerns about 1%) antibiotic resistance. Erythromycin Topical Gel Dose: Twice daily. Limited data suggest 2%, Solution 2% benefit. Concerns about antibiotic resistance. Permethrin Topical Cream Clinical Study Doses: Limited efficacy data. 5% (Rx) Once daily for 7 wks or Mechanism may be twice daily for 8–15 wks. related to anti- ectoparasitic effects against Demodex folliculorum mite. Long- term safety is unknown. Tretinoin Cream 0.025% Dose: Once daily at night. Has antiinflammatory effects and repairs extracellular matrix. Variable efficacy results. May worsen underlying vascular disease and produce skin irritation. Retinoids and High-dose Vitamin A (Highly Teratogenic), Criteria for Use limit indication to acne vulgaris. Nonformulary Alternatives Dose and Effects Other Considerations FDA-approved for Mild–Moderate PP Rosacea Azelaic Acid (FINACEA, by Dose: Twice daily; For treatment of the Bayer HealthCare) Topical however, once daily may inflammatory papules and Gel 15% be as effective as twice pustules of rosacea. May daily.3 cause some reduction of Onset: 2–4 wks erythema4; however, has Max effects: 12–15 wks not been evaluated for rosacea erythema in the absence of papules and pustules. Ineffective for facial telangiectasias. A generic gel product by Glenmark Pharms is tentatively approved and not yet marketed. Shown to be superior to metronidazole 0.75% gel5 and similar to metronidazole 1% gel in reducing inflammatory lesion counts and erythema.6 Ivermectin Topical Cream Dose: Once daily Approved for treatment 1% of inflammatory lesions of rosacea in adult patients. Antiinflammatory and possibly antiparasitic (anti-Demodex) effects. Superior to metronidazole 0.75% cream in reducing inflammatory lesions7 and maintaining remission8 in moderate to severe PP rosacea. Criteria for Use. Metronidazole Lotion 0.75% Dose: Twice daily. See metronidazole above. Onset and Max Effects: See above. Sulfacetamide Sodium- Dose: One to three times See sulfacetamide-sulfur Sulfur Topical Suspension, daily for all products lotion above. E-green Cleanser, Cream, E-Green except one to two times emollient cream contains Emollient Cream, Emulsion, daily for cleansing a color corrector. Low Foam, Liquid, Suspension, products. sulfur content reduces Cleansing Pads in various odor. concentrations, most commonly 10% / 5%; low sulfur (LS) products contain 2% sulfur. Used Off-label for PP Rosacea Adapalene Gel 0.1% Dose: Once daily for up See tretinoin above. to 12 wks. Adapalene is generally better tolerated than other retinoids. Azelaic Acid (AZELEX, by Dose: Twice daily FDA-approved for Allergan) Topical Cream Onset: 2–4 wks treatment of mild to 20% Max effects: 12–15 wks moderate inflammatory acne vulgaris. Shown to be effective in reducing inflammatory lesions and erythema of PP rosacea,9 and similar or superior to metronidazole 0.75% cream in reducing inflammatory lesions,10,11 erythema10,11 and skin dryness.10 Clindamycin Topical Gel See clindamycin above. 1% Efficacy (FDA Approved Indications) Literature Search Summary A literature search was performed on PubMed/Medline (1966 to 9 Jun 2016) and the Cochrane Central Register of Controlled Trials (issue 5 of 12, May 2016) using the search terms azelaic acid and foam. The search was limited to studies performed in humans. Reference lists of review articles were searched for relevant clinical trials. Clinical trial data were also obtained from the manufacturer’s AMCP dossier12 and the FDA Medical Review(s).13 All relevant RCTs, comparative observational studies and long-term ( 1 year) studies were included. Review of Efficacy The literature search found no studies that directly compared azelaic acid foam 15% with either other azelaic acid formulations (e.g., 15% gel, 20% cream) or other rosacea treatments. The FDA approval of azelaic acid foam was based mainly on two (one phase II and one phase III) double-blind placebo-controlled trials (Table 1). Table 1 Overview of Clinical Trials Trial Purpose / Interventions Population Design (Status) 1401841 Determine the irritation potential of azelaic 40 healthy volunteers Phase I DB VC (15853) acid foam using the 21-day cumulative IIC RCT irritancy test 1401842
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