9 November 2017 EMA/CHMP/490007/2017 Committee for Medicinal Products for Human Use (CHMP) Assessment report PREVYMIS International non-proprietary name: letermovir Procedure No. EMEA/H/C/004536/0000 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 .............................................. 5 1.1. Submission of the dossier ..................................................................................... 5 1.2. Steps taken for the assessment of the product ........................................................ 6 2. Scientific discussion ................................................................................ 8 2.1. Problem statement ............................................................................................... 8 2.2. Quality aspects .................................................................................................... 9 2.2.1. Introduction...................................................................................................... 9 2.2.2. Active Substance ............................................................................................... 9 2.2.3. Finished Medicinal Product ................................................................................ 12 2.2.4. Discussion on chemical, pharmaceutical and biological aspects.............................. 17 2.2.5. Conclusions on the chemical, pharmaceutical and biological aspects ...................... 17 2.2.6. Recommendation(s) for future quality development ............................................. 17 2.3. Non-clinical aspects ............................................................................................ 18 2.3.1. Introduction.................................................................................................... 18 2.3.2. Pharmacology ................................................................................................. 18 2.3.3. Pharmacokinetics ............................................................................................ 20 2.3.4. Toxicology ...................................................................................................... 22 2.3.5. Ecotoxicity/environmental risk assessment ......................................................... 29 2.3.6. Discussion on non-clinical aspects ..................................................................... 31 2.3.7. Conclusion on the non-clinical aspects ............................................................... 33 2.4. Clinical aspects .................................................................................................. 34 2.4.1. Introduction.................................................................................................... 34 2.4.2. Pharmacokinetics ............................................................................................ 37 2.4.3. Pharmacodynamics .......................................................................................... 52 2.4.4. Discussion on clinical pharmacology ................................................................... 57 2.4.5. Conclusions on clinical pharmacology ................................................................. 63 2.5. Clinical efficacy .................................................................................................. 64 2.5.1. Dose response studies ..................................................................................... 64 2.5.2. Main study ..................................................................................................... 66 2.5.3. Discussion on clinical efficacy ............................................................................ 95 2.5.4. Conclusions on the clinical efficacy .................................................................... 97 2.6. Clinical safety .................................................................................................... 97 2.6.1. Discussion on clinical safety ............................................................................ 114 2.6.2. Conclusions on the clinical safety .................................................................... 115 2.7. Risk Management Plan ...................................................................................... 115 2.8. Pharmacovigilance ........................................................................................... 116 2.9. New Active Substance ...................................................................................... 116 2.10. Product information ........................................................................................ 117 2.10.1. User consultation ......................................................................................... 117 2.10.2. Labelling exemptions ................................................................................... 117 Assessment report EMA/CHMP/490007/2017 Page 2/124 2.10.3. Additional monitoring ................................................................................... 117 3. Benefit-Risk Balance ........................................................................... 118 3.1. Therapeutic Context ......................................................................................... 118 3.1.1. Disease or condition ...................................................................................... 118 3.1.2. Available therapies and unmet medical need ..................................................... 118 3.1.3. Main clinical studies ....................................................................................... 118 3.2. Favourable effects ............................................................................................ 119 3.3. Uncertainties and limitations about favourable effects ........................................... 119 3.4. Unfavourable effects ......................................................................................... 120 3.5. Uncertainties and limitations about unfavourable effects ....................................... 121 3.6. Effects Table .................................................................................................... 122 3.7. Benefit-risk assessment and discussion ............................................................... 122 3.7.1. Importance of favourable and unfavourable effects ............................................ 122 3.7.2. Balance of benefits and risks .......................................................................... 123 3.8. Conclusions ..................................................................................................... 123 4. Recommendations ............................................................................... 123 Assessment report EMA/CHMP/490007/2017 Page 3/124 List of abbreviations ALT Alanine transaminase AST Aspartate transaminase AUC Area under the concentration-time curve AUCtau Area under the concentration-time curve to the end of the dosing period AUCτ,ss Area under the concentration-time curve steady state CMV Cytomegalovirus DAO Data-As-Observed DILI Drug-Induced Liver Injury ECI Event of clinical interest eGFR Estimated glomerular filtration rate FAS Full Analysis Set FSH Follicle-stimulating hormone GAP Genotypic Analysis Population GCCA Global Clinical Compliance Assurance GCV Ganciclovir GV Genotypic variant GVHD Graft-versus-host disease HSCT Hematopoietic stem cell transplant HSV Herpes simplex virus LLoQ Lower limit of quantification LOTTR Last observed time point MDRD Modification of diet in renal disease PET Pre-emptive therapy QTcF Fridericia correction of the QT interval VGCV Valganciclovir VZV Varicella Zoster Virus Assessment report EMA/CHMP/490007/2017 Page 4/124 1. Background information on the procedure 1.1. Submission of the dossier The applicant Merck Sharp & Dohme Limited submitted on 31 March 2017 an application for marketing authorisation to the European Medicines Agency (EMA) for PREVYMIS, through the centralised procedure falling within the Article 3(1) and point 4 of Annex of Regulation (EC) No 726/2004. The eligibility to the centralised procedure was agreed upon by the EMA/CHMP on 23 June 2016. PREVYMIS was designated as an orphan medicinal product EU/3/11/849 on 15 April 2011 in the following condition: Prevention of cytomegalovirus disease in patients with impaired cell-mediated immunity deemed at risk. The applicant applied for the following indication: for prophylaxis of cytomegalovirus (CMV) reactivation and disease in adult CMV-seropositive recipients [R+] of an allogeneic haematopoietic stem cell transplant (HSCT). Following the CHMP positive opinion on this marketing authorisation, the Committee for Orphan Medicinal Products (COMP) reviewed the designation of Prevymis as an orphan medicinal product in the approved indication. More information on the COMP’s review can be found in the Orphan maintenance assessment report published under the ‘Assessment history’ tab on the Agency’s website: ema.europa.eu/Find medicine/Human medicines/European public assessment reports. The legal basis for this application refers to: Article 8.3