Australian Public Assessment Report for Aminolevulinic acid HCl Proprietary Product Name: Gliolan Sponsor: Specialised Therapeutics Australia Pty Ltd March 2014 Therapeutic Goods Administration About the Therapeutic Goods Administration (TGA) · The Therapeutic Goods Administration (TGA) is part of the Australian Government Department of Health, and is responsible for regulating medicines and medical devices. · The TGA administers the Therapeutic Goods Act 1989 (the Act), applying a risk management approach designed to ensure therapeutic goods supplied in Australia meet acceptable standards of quality, safety and efficacy (performance), when necessary. · The work of the TGA is based on applying scientific and clinical expertise to decision- making, to ensure that the benefits to consumers outweigh any risks associated with the use of medicines and medical devices. · The TGA relies on the public, healthcare professionals and industry to report problems with medicines or medical devices. TGA investigates reports received by it to determine any necessary regulatory action. · To report a problem with a medicine or medical device, please see the information on the TGA website < http://www.tga.gov.au>. About AusPARs · An Australian Public Assessment Record (AusPAR) provides information about the evaluation of a prescription medicine and the considerations that led the TGA to approve or not approve a prescription medicine submission. · AusPARs are prepared and published by the TGA. · An AusPAR is prepared for submissions that relate to new chemical entities, generic medicines, major variations, and extensions of indications. · An AusPAR is a static document, in that it will provide information that relates to a submission at a particular point in time. · A new AusPAR will be developed to reflect changes to indications and/or major variations to a prescription medicine subject to evaluation by the TGA. Copyright © Commonwealth of Australia 2014 This work is copyright. You may reproduce the whole or part of this work in unaltered form for your own personal use or, if you are part of an organisation, for internal use within your organisation, but only if you or your organisation do not use the reproduction for any commercial purpose and retain this copyright notice and all disclaimer notices as part of that reproduction. Apart from rights to use as permitted by the Copyright Act 1968 or allowed by this copyright notice, all other rights are reserved and you are not allowed to reproduce the whole or any part of this work in any way (electronic or otherwise) without first being given specific written permission from the Commonwealth to do so. Requests and inquiries concerning reproduction and rights are to be sent to the TGA Copyright Officer, Therapeutic Goods Administration, PO Box 100, Woden ACT 2606 or emailed to <[email protected]>. AusPAR Gliolan Aminolevulinic acid HCl Specialised Therapeutics AustraliaPty Ltd Page 2 of 62 PM-2012-03095-1-2 Date of Finalisation 3 March 2014 Therapeutic Goods Administration Contents I. Introduction to product submission _____________________________________ 4 Submission details ____________________________________________________________________ 4 Product background __________________________________________________________________ 4 Regulatory status _____________________________________________________________________ 5 Product Information__________________________________________________________________ 5 II. Quality findings _____________________________________________________________ 5 Introduction ___________________________________________________________________________ 5 III. Nonclinical findings _______________________________________________________ 7 Introduction ___________________________________________________________________________ 7 Pharmacology _________________________________________________________________________ 7 Pharmacokinetics ____________________________________________________________________ 16 Toxicology ____________________________________________________________________________ 17 Nonclinical summary and conclusions _____________________________________________ 26 IV. Clinical findings __________________________________________________________ 29 Introduction __________________________________________________________________________ 29 Pharmacokinetics ____________________________________________________________________ 32 Pharmacodynamics__________________________________________________________________ 33 Dosage selection for the pivotal studies ___________________________________________ 34 Efficacy _______________________________________________________________________________ 34 Safety _________________________________________________________________________________ 35 V. Pharmacovigilance findings ____________________________________________ 41 Risk management plan ______________________________________________________________ 41 Summary of recommendations _____________________________________________________ 43 Summary and recommendation ____________________________________________________ 46 VI. Overall conclusion and risk/benefit assessment __________________ 46 Introduction __________________________________________________________________________ 46 Quality ________________________________________________________________________________ 47 Nonclinical ___________________________________________________________________________ 47 Clinical ________________________________________________________________________________ 48 Risk management plan ______________________________________________________________ 57 Risk benefit analysis _________________________________________________________________ 58 Outcome ______________________________________________________________________________ 60 Attachment 1. Product Information ____________________________________ 61 Attachment 2. Extract from the Clinical Evaluation Report __________ 61 AusPAR Gliolan Aminolevulinic acid HCl Specialised Therapeutics Australia Pty Ltd Page 3 of 62 PM-2012-03095-1-2 March 2014 Date of Finalisation 3 March 2014 Therapeutic Goods Administration I. Introduction to product submission Submission details Type of Submission: New Chemical Entity Decision: Approved Date of Decision: 31 October 2013 Active ingredient: Aminolevulinic acid HCl Product Name: Gliolan Sponsor’s Name and Address: Specialised Therapeutics Australia Pty Ltd Level I, 711 High Street East Kew Victoria 3102 Dose form: Powder for Oral Solution Strength: 30 mg/mL Container: Vial Pack size: Single Approved Therapeutic use: Gliolan is indicated in adult patients for visualisation of malignant tissue during surgery for malignant gliomas that are glioblastoma multiforme (GBM) on preoperative imaging, and who are intended for resection of the tumour. Route of administration: Oral Dosage (abbreviated): 20 mg aminolevulinic acid hydrochloride per kilogram body weight. The solution should be administered orally three hours (range 2 to 4 hours) before anaesthesia. ARTG Number: 202549 Product background Aminolevulinic acid (5-aminolevulinic acid HCl; 5-ALA or ALA) is a naturally occurring, endogenous substance, which belongs to the group of sensitizers used in photodynamic/radiation therapy. It has been previously developed and approved for local (topical) treatment of some kinds of skin cancer and pre cancerous conditions. It is a pro- drug that is metabolised intracellularly to form the fluorescent molecule, protoporphyrin (PPIX). The exogenous application of 5-ALA leads to a highly selective accumulation of PPIX in tumour cells and epithelial tissues. AusPAR Gliolan Aminolevulinic acid HCl Specialised Therapeutics Australia Pty Ltd Page 4 of 62 PM-2012-03095-1-2 March 2014 Date of Finalisation 3 March 2014 Therapeutic Goods Administration Tumour tissue at the transition zone between tumour and normal tissue is visualized intra Following excitation with blue in the malignant tissue,operatively emits with a strong light redfrom PpIX a xenon fluorescence arc lamp (the [λ = peak 375 tois 440at 635 nm]. nm). PpIX is photolabile and fluorescencelight (λ=400 decreases to 410 over nm), the the course PPIX, whichof light has exposure. accumulated Gliolan selectively is contraindicated in acute or chronic types of porphyria. Specialised Therapeutics Australia Pty Ltd (STA) has applied to register Gliolan (aminolevulinic acid hydrochloride; 5-ALA) as a diagnostic agent for visualisation of malignant tissue during surgery of malignant glioma (brain tumours WHO grade III and IV) by means of photodynamic diagnosis. During surgery, tumour resection is improved as malignant tissue is differentiated more easily from normal brain tissue, due to a colour reaction to light. GBM is otherwise fatal following rapid deterioration of the patient. 5-ALA is an endogenous heme precursor. Gliolan was approved in the EU in 2007 and has been used under the TGA Special Access Scheme in Australia, by qualified and accredited neurosurgeons This AusPAR describes the application by the sponsor to register Gliolan for the following indication: ‘Gliolan is indicated in adult patients for visualisation of malignant tissue during surgery for malignant gliomas that are glioblastoma multiforme (GBM), and intended for gross macroscopic resection of all visible tumour.’ During the evaluation process and prior to registration the proposed indication was altered to: ‘Gliolan is indicated in adult patients for visualisation of malignant tissue during surgery