CENTER FOR DRUG EVALUATION AND RESEARCH APPLICATION NUMBER: 022567Orig1s000 MEDICAL REVIEW(S) CLINICAL REVIEW Application Type NDA Application Number(s) 022567 Related IND 054613 Priority or Standard Standard Submit Date(s) March 22, 2010 Received Date(s) March 22, 2010 PDUFA Goal Date January 22, 2011 Division / Office DPP/ODE1 Reviewer Name(s) Cheri Lindberg, MD Review Completion Date January 19, 2011 Established Name Vilazodone HCl (Proposed) Trade Name Viibryd Therapeutic Class Antidepressant Applicant PGxHealth, LLC Formulation(s) 10, 20, 40 mg tablet Dosing Regimen Once daily – oral Indication(s) Major Depressive Disorder Intended Population(s) Adult Reference ID: 2893768 Template Version: March 6, 2009 Reference ID: 2893768 Clinical Review Cheri Lindberg, M.D. NDA 022567 Vilazodone Table of Contents 1 RECOMMENDATIONS/RISK BENEFIT ASSESSMENT ......................................... 5 1.1 Recommendation on Regulatory Action ............................................................. 5 1.2 Risk Benefit Assessment.................................................................................... 5 1.3 Recommendations for Postmarket Risk Evaluation and Mitigation Strategies ... 6 2 INTRODUCTION AND REGULATORY BACKGROUND ........................................ 7 2.1 Product Information ............................................................................................ 7 2.2 Tables of Currently Available Treatments for Proposed Indications ................... 8 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 ............ 9 2.6 Other Relevant Background Information .......................................................... 10 3 ETHICS AND GOOD CLINICAL PRACTICES....................................................... 11 3.1 Submission Quality and Integrity ...................................................................... 11 3.2 Compliance with Good Clinical Practices ......................................................... 11 3.3 Financial Disclosures........................................................................................ 12 4 SIGNIFICANT EFFICACY/SAFETY ISSUES RELATED TO OTHER REVIEW DISCIPLINES ......................................................................................................... 12 4.1 Chemistry Manufacturing and Controls ............................................................ 12 4.2 Clinical Microbiology......................................................................................... 13 4.3 Preclinical Pharmacology/Toxicology ............................................................... 13 4.4 Clinical Pharmacology...................................................................................... 13 4.4.1 Mechanism of Action.................................................................................. 13 4.4.2 Pharmacodynamics.................................................................................... 14 4.4.3 Pharmacokinetics....................................................................................... 14 5 SOURCES OF CLINICAL DATA............................................................................ 15 5.1 Tables of Studies/Clinical Trials ....................................................................... 15 5.2 Review Strategy ............................................................................................... 20 5.3 Discussion of Individual Studies/Clinical Trials................................................. 20 6 REVIEW OF EFFICACY......................................................................................... 39 Efficacy Summary...................................................................................................... 39 6.1 Indication – Major Depressive Disorder............................................................ 39 6.1.1 Methods ..................................................................................................... 39 6.1.2 Subject Disposition..................................................................................... 43 6.1.2 Demographics............................................................................................ 45 6.1.4 Analysis of Primary Endpoint(s) ................................................................. 48 6.1.5 Analysis of Secondary Endpoints(s) .......................................................... 49 6.2.0 Efficacy Conclusions......................................................................................... 64 Reference ID: 2893768 3 Clinical Review Cheri Lindberg, M.D. NDA 022567 Vilazodone 7 REVIEW OF SAFETY............................................................................................. 64 Safety Summary ........................................................................................................ 64 7.1 Methods............................................................................................................ 65 7.1.1 Studies/Clinical Trials Used to Evaluate Safety ......................................... 65 7.1.2 Categorization of Adverse Events.............................................................. 66 7.1.3 Pooling of Data across Studies/Clinical Trials to Estimate and Compare Incidence.................................................................................................... 66 7.2 Adequacy of Safety Assessments .................................................................... 67 7.2.1 Overall Exposure at Appropriate Doses/Durations and Demographics of Target Populations..................................................................................... 67 7.2.2 Explorations for Dose Response................................................................ 69 7.2.3 Special Animal and/or In Vitro Testing ....................................................... 70 7.2.4 Routine Clinical Testing ............................................................................. 70 7.2.5 Metabolic, Clearance, and Interaction Workup .......................................... 71 7.2.6 Evaluation for Potential Adverse Events for Similar Drugs in Drug Class .. 71 7.3 Major Safety Results ........................................................................................ 73 7.3.1 Deaths........................................................................................................ 73 7.3.2 Nonfatal Serious Adverse Events .............................................................. 73 7.3.3 Dropouts and/or Discontinuations .............................................................. 87 7.4 Supportive Safety Results ............................................................................ 93 7.4.1 Common Adverse Events .......................................................................... 93 7.4.2 Laboratory Findings ................................................................................... 97 7.4.3 Vital Signs ................................................................................................ 103 7.4.4 Electrocardiograms (ECGs) ..................................................................... 106 7.4.5 Special Safety Studies/Clinical Trials....................................................... 111 7.5 Other Safety Explorations............................................................................... 116 7.5.3 Drug-Demographic Interactions ............................................................... 118 7.5.4 Drug-Disease Interactions........................................................................ 119 7.5.5 Drug-Drug Interactions............................................................................. 119 7.6 Additional Safety Evaluations ......................................................................... 119 7.6.1 Human Carcinogenicity............................................................................ 123 7.6.2 Human Reproduction and Pregnancy Data.............................................. 123 7.6.3 Pediatrics and Assessment of Effects on Growth .................................... 124 7.6.4 Overdose, Drug Abuse Potential, Withdrawal and Rebound.................... 124 8 POSTMARKET EXPERIENCE............................................................................. 125 9 APPENDICES ...................................................................................................... 126 9.2 Labeling Recommendations ........................................................................... 126 9.3 Advisory Committee Meeting.......................................................................... 126 Reference ID: 2893768 4 Clinical Review Cheri Lindberg, M.D. NDA 022567 Vilazodone 1 Recommendations/Risk Benefit Assessment 1.1 Recommendation on Regulatory Action From a clinical perspective, approval is recommended (with revisions to the proposed label) of NDA 022567 Viibryd (vilazodone) for the treatment of Major Depressive Disorder in adult patients. 1.2 Risk Benefit Assessment The efficacy of vilazodone was demonstrated in two (2) of seven (7) controlled trials designed to evaluate vilazodone as a treatment for Major Depressive Disorder in adult outpatients. Review of the safety data submitted by the applicant reveals a safety profile that is similar to other serotonin reuptake inhibitors; with the exception of ophthalmologic abnormalities, there were no