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Assessment Report 15 November 2018 EMA/CHMP/843546/2018 Committee for Medicinal Products for Human Use (CHMP) Assessment report Fexinidazole Winthrop International non-proprietary name: fexinidazole Procedure No. EMEA/H/W/002320/0000 Note Assessment report as adopted by the CHMP with all information of a commercially confidential nature deleted. 30 Churchill Place ● Canary Wharf ● London E14 5EU ● United Kingdom Telephone +44 (0)20 3660 6000 Facsimile +44 (0)20 3660 5520 Send a question via our website www.ema.europa.eu/contact An agency of the European Union © European Medicines Agency, 2018. Reproduction is authorised provided the source is acknowledged. Table of contents 1. Background information on the procedure ............................................ 11 1.1. Submission of the dossier ................................................................................... 11 1.2. Steps taken for the assessment of the product ...................................................... 12 2. Scientific discussion .............................................................................. 13 2.1. Introduction ...................................................................................................... 13 2.1.1. Disease or condition ........................................................................................ 13 2.1.2. Epidemiology .................................................................................................. 13 2.1.3. Aetiology and pathogenesis .............................................................................. 14 2.1.4. Clinical presentation, diagnosis and stage/prognosis ............................................ 14 2.1.5. Management ................................................................................................... 15 2.1.6. About the product ........................................................................................ 16 2.1.7. Type of Application and aspects on development ................................................. 16 2.2. Quality aspects .................................................................................................. 17 2.2.1. Introduction.................................................................................................... 17 2.2.2. Active Substance ............................................................................................. 17 2.2.3. Finished Medicinal Product ................................................................................ 20 2.2.4. Discussion on chemical, pharmaceutical and biological aspects.............................. 25 2.2.5. Conclusions on the chemical, pharmaceutical and biological aspects ...................... 25 2.2.6. Recommendations for future quality development ............................................... 25 2.3. Non-clinical aspects ............................................................................................ 25 2.3.1. Introduction.................................................................................................... 25 2.3.2. Pharmacology ................................................................................................. 26 2.3.3. Pharmacokinetics ............................................................................................ 28 2.3.4. Toxicology ...................................................................................................... 30 2.3.5. Ecotoxicity/environmental risk assessment ......................................................... 32 2.3.6. Discussion on non-clinical aspects ..................................................................... 33 2.3.7. Conclusion on the non-clinical aspects ............................................................... 34 2.4. Clinical aspects .................................................................................................. 34 2.4.1. Introduction.................................................................................................... 34 2.4.2. Pharmacokinetics ............................................................................................ 45 2.4.3. Pharmacodynamics .......................................................................................... 58 2.4.4. Discussion on clinical pharmacology ................................................................... 62 2.4.5. Conclusions on clinical pharmacology ................................................................. 63 2.5. Clinical efficacy .................................................................................................. 63 2.5.1. Dose response studies ..................................................................................... 64 2.5.2. Main studies ................................................................................................... 65 2.5.3. Discussion on clinical efficacy .......................................................................... 120 2.5.4. Conclusions on the clinical efficacy .................................................................. 127 2.6. Clinical safety .................................................................................................. 128 2.6.1. Discussion on clinical safety ............................................................................ 159 2.6.2. Conclusions on the clinical safety .................................................................... 162 Assessment report EMA/CHMP/843546/2018 Page 2/177 2.7. Risk Management Plan ...................................................................................... 162 2.8. Pharmacovigilance ........................................................................................... 165 2.9. Product information .......................................................................................... 165 2.9.1. User consultation .......................................................................................... 165 3. Benefit-Risk Balance ........................................................................... 166 3.1. Therapeutic Context ......................................................................................... 166 3.1.1. Disease or condition ...................................................................................... 166 3.1.2. Available therapies and unmet medical need ..................................................... 166 3.1.3. Main clinical studies ....................................................................................... 167 3.2. Favourable effects ............................................................................................ 168 3.3. Uncertainties and limitations about favourable effects ........................................... 168 3.4. Unfavourable effects ......................................................................................... 169 3.5. Uncertainties and limitations about unfavourable effects ....................................... 170 3.6. Effects Table .................................................................................................... 171 3.7. Benefit-risk assessment and discussion ............................................................... 173 3.7.1. Importance of favourable and unfavourable effects ............................................ 173 3.7.2. Balance of benefits and risks .......................................................................... 175 3.7.3. Additional considerations on the benefit-risk balance ......................................... 175 3.8. Conclusions ..................................................................................................... 175 4. Recommendations ............................................................................... 175 Assessment report EMA/CHMP/843546/2018 Page 3/177 List of abbreviations (c)GMP (current)Good Manufacturing Practices 3T3 NRU-PT 3T3 neutral red uptake phototoxicity test ADME Absorption, Distribution, Metabolism, and Excretion ADRs Adverse drug reactions AE Adverse events Ae Absolute excretion ALP Alkaline phosphatase Alu Aluminum API Active Product Ingredient AQ Absorption Quotient AQL Acceptable quality limit AR assessment report ASMF Active Substance Master File AST Aspartate aminotransferase AUC Area under time-concentration curve b.i.d. Two times a day BBB Blood-brain barrier BC Buffy-coat BCS Biopharmaceutics Classification System BID Twice a day BMI Body mass index BSA Bovine Serum Albumin BUN Blood urea nitrogen BW Bodyweight CAR Central African Republic CD Chagas disease CFU Colony Forming Unit CHMP Committee for Medicinal Products for Human Use CI Confidence interval Assessment report EMA/CHMP/843546/2018 Page 4/177 Clint Intrinsic clearance Clr Clearance Cmax Maximum observed plasma concentration CMH Cochran Mantel Haenszel CNS Central nervous system CNS Central nervous system Cpk Process capability CQAs Critical Quality Attributes C-R Concentration-Response CRF Case report form CS Clinically significant CSF Cerebrospinal fluid CSR Clinical study report CTAB Cetyl Trimethyl Ammonium Bromide CTC Capillary tube centrifugation CTD Common Technical Document DALA Dependence and drug abuse liability DART Development and reproductive toxicology DBL Database lock DBS Dried blood spot DDI Drug-drug interactions DFMO α-difluoromethylornithine DNA Deoxyribonucleic acid DNDi Drugs for Neglected Diseases initiative DRC Democratic Republic of the Congo DSC Differential scanning calorimetry DSMB Data and Safety Monitoring Board EC European Commission ECG Electrocardiogram eCRF Electronic case report
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