AusPAR Attachment 2 Extract from the Clinical Evaluation Report for catridecacog (rys) Proprietary Product Name: NovoThirteen Sponsor: Novo Nordisk Pharmaceuticals Pty Ltd Date of CER: January 2013 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 the Extract from the Clinical Evaluation Report • This document provides a more detailed evaluation of the clinical findings, extracted from the Clinical Evaluation Report (CER) prepared by the TGA. This extract does not include sections from the CER regarding product documentation or post market activities. • The words [Information redacted] indicate confidential information has been deleted. • For the most recent Product Information (PI), please refer to the TGA website <http://www.tga.gov.au/hp/information-medicines-pi.htm>. Copyright © Commonwealth of Australia 2014 This work is copyright. 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Submission PM-2012-02713-3-4 Extract from the Clinical Evaluation Report for NovoThirteen Page 2 of 80 Therapeutic Goods Administration Contents List of abbreviations __________________________________________________________ 5 1. Clinical rationale _________________________________________________________ 7 2. Contents of the clinical dossier ________________________________________ 8 2.1. Scope of the clinical dossier _________________________________________________ 8 2.2. Paediatric data _______________________________________________________________ 9 2.3. Good clinical practice ________________________________________________________ 9 3. Pharmacokinetics ________________________________________________________ 9 3.1. Studies providing pharmacokinetic data __________________________________ 9 3.2. Summary of pharmacokinetics ___________________________________________ 11 3.3. Evaluator’s overall conclusions on pharmacokinetics __________________ 17 4. Pharmacodynamics ____________________________________________________ 19 4.1. General comment __________________________________________________________ 19 4.2. Study F13CD-1725 (pivotal Phase III study): clot solubility ___________ 20 5. Dosage selection for the pivotal studies ___________________________ 20 6. Clinical efficacy _________________________________________________________ 21 6.1. Pivotal efficacy study (F13CD-1725): congenital FXIII deficiency _____ 21 6.2. Extension (F13CD-3720) to the pivotal study (F13CD-1725) _________ 31 6.3. Evaluator’s overall conclusions on efficacy ______________________________ 37 7. Clinical safety ___________________________________________________________ 39 7.1. Studies providing evaluable safety data _________________________________ 39 7.2. Exposure ___________________________________________________________________ 39 7.3. Safety: pivotal (F13CD-1725) and extension (F13CD-3720) studies __ 39 7.4. Other studies _______________________________________________________________ 45 7.5. Post-marketing experience _______________________________________________ 49 7.6. Safety issues with potential for major regulatory impact ______________ 49 7.7. Evaluator’s overall conclusions on clinical safety _______________________ 50 8. First round benefit-risk assessment ________________________________ 52 8.1. First round assessment of benefits _______________________________________ 52 8.2. First round assessment of risks __________________________________________ 53 8.3. First round assessment of benefit-risk balance _________________________ 54 9. First round recommendation regarding authorisation _________ 54 10. Clinical questions ____________________________________________________ 54 10.1. General issue _______________________________________________________________ 54 10.2. Pharmacokinetics __________________________________________________________ 54 Submission PM-2012-02713-3-4 Extract from the Clinical Evaluation Report for NovoThirteen Page 3 of 80 Therapeutic Goods Administration 10.3. Pharmacodynamics ________________________________________________________ 54 10.4. Efficacy _____________________________________________________________________ 54 10.5. Safety _______________________________________________________________________ 56 11. Second round evaluation of clinical data submitted in response to questions ______________________________________________________________________ 56 11.1. General issue _______________________________________________________________ 57 11.2. Pharmacokinetics __________________________________________________________ 68 11.3. Efficacy _____________________________________________________________________ 68 11.4. Safety _______________________________________________________________________ 74 12. Second round benefit-risk assessment __________________________ 76 12.1. Second round assessment of benefits ____________________________________ 76 12.2. Second round assessment of risk _________________________________________ 77 12.3. Second round assessment of benefit-risk balance ______________________ 78 13. Second round recommendation regarding authorisation ____ 79 Submission PM-2012-02713-3-4 Extract from the Clinical Evaluation Report for NovoThirteen Page 4 of 80 Therapeutic Goods Administration List of abbreviations Abbreviation Meaning AE adverse event APTT activated partial thromboplastin time AST aspartate aminotransferase ALT alanine aminotransferase AT anti-thrombin AUC area under the curve BMI body mass index bw body weight C30 plasma activity/concentration at 30 minutes post dose CD congenital FXIII deficiency CI confidence interval CL clearance CRF case report form CV coefficient of variation ECG electrocardiogram ELISA enzyme-linked immunosorbent assay EMA European Medicines Agency EOT end-of-text F1+2 prothrombin fragment 1+2 FAS full analysis set FFP fresh frozen plasma FXIII coagulation factor XIII GCP good clinical practice GLP good laboratory practice Submission PM-2012-02713-3-4 Extract from the Clinical Evaluation Report for NovoThirteen Page 5 of 80 Therapeutic Goods Administration Abbreviation Meaning ICH International Conference on Harmonisation IEC Independent Ethics Committee INR international normalised ratio IRB Institutional Review Board IU international units i.v. intravenous MedDRA medical dictionary for regulatory activities NN Novo Nordisk PD pharmacodynamics pdFXIII plasma derived coagulation factor XIII PK pharmacokinetics PP per-protocol PT prothrombin time rFXIII recombinant human coagulation factor XIII SAE serious adverse event SD standard deviation SOC system organ class t1/2 terminal half-life TAT thrombin anti-thrombin Vss volume of distribution, steady state Submission PM-2012-02713-3-4 Extract from the Clinical Evaluation Report for NovoThirteen Page 6 of 80 Therapeutic Goods Administration 1. Clinical rationale Congenital factor XIII (FXIII) is a rare autosomal recessive bleeding disorder with an estimated 1 prevalence of 1 patient per 2 to 5 million people.0F The Australian Bleeding Disorders Registry (ABDR) Annual Report 2010-2011 indicates that there were 17 people in Australia with FXIII deficiency at 30 June 2011, and 7 of these individuals had received FXIII-containing product in 2 the 2010-2011 financial year.1F The Clinical Overview included an acceptable clinical rationale for the development of NovoThirteen, and much of the following information has been taken from that overview. FXIII is a pro-enzyme (pro-transglutaminase) and is the terminal enzyme in the coagulation cascade. In plasma, FXIII circulates as an inactive zymogen heterotetramer [A2B2] held together by strong non-covalent interactions. Intra-cellular FXIII is a homodimer of two A-subunits [A2] and is found in circulating platelets and monocytes. The A subunits are synthesized