Clinical Review Amol Purandare, MD NDA 021572 Cubicin (Daptomycin for injection) CLINICAL REVIEW Application Type NDA supplement Application Number(s) 21572 Priority or Standard Priority Submit Date(s) June 30, 2016 Received Date(s) June 30, 2016 PDUFA Goal Date March 30, 2017 (Major amendment) Division / Office DAIP/OAP Reviewer Name(s) Amol Purandare, MD Review Completion Date March 23, 2017 Established Name Daptomycin (Proposed) Trade Name Cubicin Therapeutic Class Cyclic Lipopeptide Applicant Cubist Pharmaceuticals Formulation(s) Injection Dosing Regimen 5 mg/kg (12-<18 years), 7 mg/kg (7-11 years), 9 mg/kg (2-6 years), and 10 mg/kg (1-< 2 years) Indication(s) Complicated Skin and Skin Structure Infections 1 Reference ID: 4075320 Clinical Review Amol Purandare, MD NDA 021572 Cubicin (Daptomycin for injection) Intended Population(s) Ages 1 year to <18 years Table of Contents 1 RECOMMENDATIONS/RISK BENEFIT ASSESSMENT..........................................6 1.1 Recommendation on Regulatory Action ..............................................................6 1.2 Risk Benefit Assessment .....................................................................................6 1.3 Recommendations for Postmarket Risk Evaluation and Mitigation Strategies ....6 1.4 Recommendations for Postmarket Requirements and Commitments.................7 2 INTRODUCTION AND REGULATORY BACKGROUND .........................................7 2.1 Product Information .............................................................................................7 2.2 Tables of Currently Available Treatments for Proposed Indications....................7 2.3 Availability of Proposed Active Ingredient in the United States ...........................8 2.4 Important Safety Issues With Consideration to Related Drugs............................8 2.5 Summary of Presubmission Regulatory Activity Related to Submission .............8 2.6 Other Relevant Background Information .............................................................8 3 ETHICS AND GOOD CLINICAL PRACTICES..........................................................8 3.1 Submission Quality and Integrity .........................................................................8 3.2 Compliance with Good Clinical Practices ............................................................9 3.3 Financial Disclosures...........................................................................................9 4 SIGNIFICANT EFFICACY/SAFETY ISSUES RELATED TO OTHER REVIEW DISCIPLINES.............................................................................................................9 4.1 Chemistry Manufacturing and Controls ...............................................................9 4.2 Clinical Microbiology ............................................................................................9 4.3 Preclinical Pharmacology/Toxicology ..................................................................9 4.4 Clinical Pharmacology .........................................................................................9 4.4.1 Mechanism of Action...................................................................................10 4.4.2 Pharmacodynamics.....................................................................................10 4.4.3 Pharmacokinetics ........................................................................................10 5 SOURCES OF CLINICAL DATA.............................................................................10 5.1 Tables of Studies/Clinical Trials.........................................................................10 5.2 Review Strategy.................................................................................................12 6 REVIEW OF EFFICACY ..........................................................................................12 Efficacy Summary .......................................................................................................12 6.1 Indication ...........................................................................................................12 2 Reference ID: 4075320 Clinical Review Amol Purandare, MD NDA 021572 Cubicin (Daptomycin for injection) 6.1.1 Methods.......................................................................................................12 6.1.2 Demographics .............................................................................................13 6.1.3 Subject Disposition......................................................................................15 6.1.4 Analysis of Primary Endpoint(s) ..................................................................16 6.1.5 Analysis of Secondary Endpoints(s)............................................................16 6.1.6 Other Endpoints ..........................................................................................19 6.1.7 Subpopulations............................................................................................19 6.1.8 Analysis of Clinical Information Relevant to Dosing Recommendations.....19 6.1.9 Discussion of Persistence of Efficacy and/or Tolerance Effects .................19 6.1.10 Additional Efficacy Issues/Analyses............................................................19 7 REVIEW OF SAFETY..............................................................................................19 Safety Summary..........................................................................................................19 7.1 Methods .............................................................................................................20 7.1.1 Studies/Clinical Trials Used to Evaluate Safety ..........................................21 7.1.2 Categorization of Adverse Events...............................................................21 7.1.3 Pooling of Data Across Studies/Clinical Trials to Estimate and Compare Incidence.....................................................................................................23 7.2 Adequacy of Safety Assessments .....................................................................23 7.2.1 Overall Exposure at Appropriate Doses/Durations and Demographics of Target Populations ......................................................................................23 7.2.2 Explorations for Dose Response.................................................................24 7.2.3 Special Animal and/or In Vitro Testing ........................................................24 7.2.4 Routine Clinical Testing...............................................................................24 7.2.5 Metabolic, Clearance, and Interaction Workup ...........................................24 7.2.6 Evaluation for Potential Adverse Events for Similar Drugs in Drug Class...25 7.3 Major Safety Results..........................................................................................25 7.3.1 Deaths .........................................................................................................25 7.3.2 Nonfatal Serious Adverse Events................................................................25 7.3.3 Dropouts and/or Discontinuations ...............................................................26 7.3.4 Significant Adverse Events..........................................................................26 7.3.5 Submission Specific Primary Safety Concerns ...........................................26 7.4 Supportive Safety Results .................................................................................27 7.4.1 Common Adverse Events............................................................................27 7.4.2 Laboratory Findings.....................................................................................31 7.4.3 Vital Signs ...................................................................................................32 7.4.4 Electrocardiograms (ECGs) ........................................................................33 7.4.5 Special Safety Studies/Clinical Trials..........................................................33 7.4.6 Immunogenicity ...........................................................................................33 7.5 Other Safety Explorations..................................................................................33 8 POSTMARKET EXPERIENCE................................................................................33 9 APPENDICES..........................................................................................................34 3 Reference ID: 4075320 Clinical Review Amol Purandare, MD NDA 021572 Cubicin (Daptomycin for injection) 9.1 Literature Review/References ...........................................................................34 9.2 Labeling Recommendations ..............................................................................34 9.3 Advisory Committee Meeting.............................................................................34 9.4 Clinical Investigator Financial Disclosure Review..............................................34 4 Reference ID: 4075320 Clinical Review Amol Purandare, MD NDA 021572 Cubicin (Daptomycin for injection) Table of Tables Table 1: FDA Treatment for cSSSI caused by Gram positive pathogens ........................9 Table 2 : Studies.............................................................................................................12 Table 3: Demographic Characteristics of Safety Analysis Set .......................................16