CENTER FOR DRUG EVALUATION AND RESEARCH APPLICATION NUMBER: 214231Orig1s000 SUMMARY REVIEW Dasiglucagon NDA 214231 Summary Basis for Regulatory Action Date electronic stamp NDA # NDA 214231 Applicant Zealand Pharma Date of Submission March 27, 2020 PDUFA Goal Date March 27, 2021 Proprietary Name ZEGALOGUE Established or Proper Name Dasiglucagon injection Dosage Form(s) Subcutaneous injection Applicant Proposed Treatment of severe hypoglycemia in patients Indication(s)/Population(s) with diabetes ages six years and above Applicant Proposed Dosing Regimen(s) 0.6 mg/0.6 mL Recommendation on Regulatory Action Approval Treatment of severe hypoglycemia in pediatric Recommended Indication(s)/Population(s) and adult patients with diabetes ages six years and above Recommended Dosing Regimen(s) 0.6 mg/0.6 mL Office of New Drugs (OND) Action Package Names of discipline reviewers; Material Reviewed/Consulted: Dates of review Clinical Reviewer Kristen Pluchino 3/10/21 Biostatistics Yoonhee Kim 11/09/20 Center for Device and Radiologic Health David Wolloscheck/Rumi Young 2/2/21 Pharmacology Toxicology Patricia Brundage 12/18/20; 11/23/20 Office of Pharmaceutical Quality Technical Lead: Muthukumar Ramaswamy 11/27/20, 2/5/21, and 2/23/21 Clinical Pharmacology and Pharmacometrics SJ Lau/Manoj Khurana 12/10/21 and 3/4/21 Interdisciplinary Review Team for Cardiac Girish Bende 2/13/20 and 7/28/20 Safety Studies Clinical Cardiology, Division of Cardiology Preston Dunnmon 10/29/20 and Nephrology Office of Biotechnology Products­ Faruk Sheikh 12/04/20 immunogenicity review Office of Scientific Investigations Cynthia Kleppinger 11/23/20 Division of Medication Error Prevention and Colleen Little/Lolita White 2/24/21; 2/9/21; Analysis-human factors and labeling review 1/25/21; 12/11/20 Division of Risk Management Mei-Yean Chen 1/11/21 Division of Medication Error Prevention and Ariane Conrad 4/29/20 Analysis-proprietary name review Division of Pediatrics and Maternal Health Christos Mastroyannis 11/16/20 Office of Prescription Drug Promotion Samantha Bryant 2/24/21; 1/15/21 Division of Medical Policy Programs-patient Sharon Williams 1/21/21 labeling review 1 Reference ID: 4766024 Dasiglucagon NDA 214231 Table of Contents 1. Benefit-Risk Assessment .........................................................................................................5 2. Background............................................................................................................................13 3. Product Quality......................................................................................................................15 4. Nonclinical Pharmacology/Toxicology .................................................................................18 5. Clinical Pharmacology...........................................................................................................20 6. Clinical/Statistical-Efficacy...................................................................................................27 7. Safety .....................................................................................................................................34 8. Advisory Committee Meeting ...............................................................................................40 9. Pediatrics................................................................................................................................41 10. Other Relevant Regulatory Issues .....................................................................................41 Labeling .........................................................................................................................................43 11. Postmarketing Recommendations .....................................................................................43 Appendix 1.....................................................................................................................................45 2 Reference ID: 4766024 Dasiglucagon NDA 214231 Table of Tables Table 1: US-Approved Glucagon Products for Treatment of Severe Hypoglycemia ...................14 Table 2: Key Pharmacological and Pharmacokinetic Properties of Dasiglucagon .......................21 Table 3: Summary statistics of plasma glucose PD parameters as arithmetic mean (standard deviation) and median (range) for tmax, TPG≥70mg/dL, and TPG increase≥20mg/dL...............23 Table 4: Subject Disposition in Efficacy Studies ..........................................................................30 Table 5: Time to Plasma Glucose Recovery – Studies 16137, 17145, 17086...............................31 Table 6: Time to Plasma Glucose Recovery by Age Group- Study 17086 ...................................32 Table 7: Time to Plasma Glucose Recovery by Subgroups – Adult Placebo-Controlled Pool.....32 Table 8: Time to Plasma Glucose Recovery for Batch A vs. Batch B- Study 17084 ...................34 Table 9: AEs by System Organ Class Occurring at a Frequency of ≥2% and more than Placebo within 12 Hours of Dosing, Preferred Term - Placebo Controlled-Pool .......................................36 Table 10: AEs by System Organ Class Occurring within 12 Hours of Dosing ≥2% and more than Placebo, Preferred Term, Age Group - Study 17086.....................................................................37 3 Reference ID: 4766024 Dasiglucagon NDA 214231 Table of Figures Figure 1: Chemical Structure of Dasiglucagon .............................................................................15 Figure 2: Prefilled Syringe Components .......................................................................................17 Figure 3: Pre-Filled Syringe Components .....................................................................................17 Figure 4: Dasiglucagon Autoinjector Components .......................................................................17 Figure 5: Mean Dasiglucagon and GlucaGen plasma concentration profiles by dose - Study 15126 .............................................................................................................................................22 Figure 6: Mean plasma glucose concentration following single doses of Dasiglucagon and GlucaGen - Study 15126 ...............................................................................................................23 Figure 7: Effect of covariates on dasiglucagon exposure- Population pharmacokinetic Modeling .......................................................................................................................................................24 Figure 8 : Plasma glucose change from baseline - Studies 16137 and 17145...............................26 Figure 9: Mean (with standard error of mean) plasma glucose concentration profiles following single SC doses of dasiglucagon, GlucaGen, and placebo ............................................................27 Figure 10: Study 16137- K-M Plot of Cumulative Proportions of Subjects with Recovery.........31 Figure 11: Leukocytes over Screening, Dosing, and Follow Up – Placebo-Controlled Pool .......38 4 Reference ID: 4766024 Dasiglucagon NDA 214231 1. Benefit-Risk Assessment Benefit-Risk Assessment Framework Benefit-Risk Integrated Assessment Severe hypoglycemia is a serious medical condition that is most commonly the result of exogenous insulin therapy in patients with diabetes mellitus. Severe hypoglycemia is defined as hypoglycemia requiring assistance from another person because the affected individual is confused or unconscious secondary to neuroglycopenia and cannot take carbohydrates orally. Seizures and coma are not uncommon consequences of severe hypoglycemia. Left untreated, severe hypoglycemia may result in permanent neurologic sequelae or death. Severe hypoglycemia is more common in patients with type 1 diabetes mellitus (T1DM) than type 2 diabetes mellitus (T2DM), but T2DM patients treated with insulin or sulfonylureas are at greater risk than those treated with other antidiabetic agents. Treatment options include intravenous dextrose, but this option requires administration by a healthcare professional in a hospital or emergency medical setting. Injectable glucagon products are the mainstay of ambulatory treatment of severe hypoglycemia. For many years only glucagon products that required reconstitution by the caregiver before injection were available (although Gvoke which does not require reconstitution and Baqsimi, which is administered intranasally, were both very recently approved for the treatment of severe hypoglycemia). Dasiglucagon is a glucagon analog that acts at the glucagon receptor to increase plasma glucose, but unlike native glucagon, dasiglucagon is stable in aqueous solution, and through its development, the sponsor aimed to provide a ready-to-use treatment option. It is important to note that for these products the goal is not to treat symptoms; symptomatic hypoglycemia without neurologic compromise should be treated with oral intake of a fast-acting source of carbohydrate such as fruit juice. Instead, the objective is to increase blood glucose concentrations rapidly, resolve neuroglycopenia, and prevent the serious complications of neurologic damage and death. Three adequate and well-controlled clinical studies have established the effectiveness of a single injection of dasiglucagon 0.6 mg for the treatment of severe hypoglycemia in patients with diabetes age 6 and above. Time to plasma glucose recovery, defined as the initial increase in plasma glucose