|
2012年12月14日，美国食品药品监督管理局(FDA)批准Iclusig (ponatinib)治疗有慢性粒性白血病(CML)和Philadelphia染色体阳性急性淋巴母细胞白血病(Ph+ ALL)，两种罕见血和骨髓疾病的成年。
Iclusig正在被批准比处方药用户收费的目标日期2013年3月27日提前超过三个月审评，这个日期监督管理局计划完成药物申请。在监督管理局的优先审评程序下FDA审评Iclusig药物申请，这个程序为当没有满意另外治疗存在，或比上市产品提供显着改善的产品可能提供安全和有效治疗提供提前6个月审评。
Iclusig阻断促进癌细胞发展某些蛋白。药物每天服用1次治疗有CML和Ph+ ALL的慢性，加速，和母细胞相患者其白血病是对一类被称为酪氨酸激酶抑制剂(TKIs)耐药或不能耐受。Iclusig靶向CML细胞有一种特殊突变，被称为T315I，它使这些细胞对当前批准的TKIs耐药。
FDA的药物评价和研究中心血液和肿瘤产品室主任Richard Pazdur，M.D.说：“Iclusig的批准是重要的因为对其他药物不反应的CML患者提供治疗选择，尤其是有T315I 突变很少治疗选择的患者”“Iclusig 是今年底被批准治疗CML的第三个药物和治疗ALL的第二个药物，证实FDA承诺为罕见疾病患者批准安全和有效药物。”
Iclusig在监管局加速批准程序下，该程序提供患者较早得到有前途新药而公司进行另外研究确证药物的获益和安全使用。治疗被赋予孤儿药物指定因为意向治疗一种罕见病或情况。
在449例有各种CML和Ph+ ALL相患者一项单组临床试验评价Iclusig的安全性和有效性。所有参加者用Iclusig治疗。
通过在大多数CML患者发现的表达Philadelphia染色体遗传突变细胞百分率减低，重大细胞遗传学反应(MCyR)证实药物的有效性。所有患者的54%和70%患者有T315I 突变实现MCyR。在分析时尚未达到MCyR的中位时间。
在CML和Ph+ ALL加速和母细胞相，通过经历白细胞计数正常化或无白血病证据(重大血液学反应或MaHR)患者数确定Iclusig的有效性。
结果显示：
●有CML加速相患者52% 经历MaHR中位时间9.5个月；
●有母细胞相CML患者31%实现MaHR中位时间4.7个月； 和
●有Ph+ ALL患者41%实现MaHR中位时间3.2个月。
Iclusig正在被批准有一个黑框警告警告患者和卫生保健专业人员药物可能致血液凝固和肝脏毒性。临床试验期间最常报道副作用包括高血压，皮疹，腹痛，疲乏，头痛，干皮肤，便秘，发热，关节痛，和恶心。
Iclusig是由在麻省剑桥的ARIAD药业上市， Bosulif是由位于纽约城的Pfizer上市，和Synribo是由位于滨州的Frazer， Teva药业上市。Marqibo是由加州旧金山的Talon Therapeutics公司上市。
批准日期：2012年12月14日；改善：Ariad Pharmaceuticals，Inc.
ICLUSIG® (ponatinib)片为口服使用
美国初次批准：2012
适应证和用途
Iclusig是一种激酶抑制剂适用于为治疗对既往酪氨酸激酶抑制剂治疗耐药或不能耐受的有慢性相，加速相，或母细胞相慢性粒性白血病(CML)成年患者或对既往酪氨酸激酶抑制剂治疗耐药或不能耐受的Philadelphia染色体阳性急性淋巴母细胞白血病(Ph+ALL)。这个适应证是根据反应率。没有用Iclusig的试验证明改善疾病相关症状或增加生存。
剂量和给药方法
● 45 mg有或无食物口服每天1次。
● 对血液学和非-血液学毒性调整剂量或中断给药。
剂型和规格
片：15mg和45mg
禁忌证
无。
警告和注意事项
● 充血性心衰：监视患者充血性心衰的体征和症状和临床有指针时治疗。
● 高血压：监视高血压和临床有指针时治疗。
● 胰腺炎：每月监视血清酯酶； 中断或终止。
● 出血：对严重出血中断Iclusig.
● 液体潴留：监视患者for 液体潴留； 中断，reduce，or 终止Iclusig。
● 心律失常：监视心律失常的症状。
● 骨髓抑制：血小板减少，中性粒细胞减少，和贫血可能需要中断或减低剂量。每两周监视全细胞计数共3个月和然后每月和当临床上指示。对ANC < 1000/mm3或血小板减少 < 50,000/ mm3中断Iclusig。
● 肿瘤溶解综合征：开始用Iclusig治疗前确保水化和纠正高尿酸水平.
● 伤口愈合受到损害和胃肠道穿孔：在接受大型手术患者中短暂中断治疗。
● 胚胎-胎儿毒性：可能致胎儿危害。劝告妇女对胎儿的潜在风险。
不良反应
最常见非-血液学不良反应(≥ 20%)是高血压，皮疹，腹痛，疲乏，头痛，干皮肤，便秘，关节痛，恶心，和发热。血液学不良反应包括血小板减少，贫血，中性粒细胞减少，淋巴细胞减少，和白细胞减少。
为报告怀疑不良反应，联系ARIAD Pharmaceuticals，Inc. 电话(1-855-55-ARIAD)或FDA电话1-800-FDA-1088或www.fda.gov/medwatch
药物相互作用
强CYP3A抑制剂：如果共同给药不能避免减低 Iclusig剂量
特殊人群中使用
未曾在小于18岁患者中试验Iclusig的安全性和疗效。
FDA approves Iclusig to treat two rare types of leukemia
Drug approved 3 months ahead of schedule
The U.S. Food and Drug Administration today approved Iclusig (ponatinib) to treat adults with chronic myeloid leukemia (CML) and Philadelphia chromosome positive acute lymphoblastic leukemia (Ph+ ALL), two rare blood and bone marrow diseases.
Iclusig is being approved more than three months ahead of the product’s prescription user fee goal date of March 27, 2013, the date the agency was scheduled to complete review of the drug application. The FDA reviewed the Iclusig drug application under the agency’s priority review program, which provides for an expedited six-month review for drugs that may provide safe and effective therapy when no satisfactory alternative therapy exists, or offer significant improvement compared to marketed products.
Iclusig blocks certain proteins that promote the development of cancerous cells. The drug is taken once a day to treat patients with chronic, accelerated, and blast phases of CML and Ph+ ALL whose leukemia is resistant or intolerant to a class of drugs called tyrosine kinase inhibitors (TKIs). Iclusig targets CML cells that have a particular mutation, known as T315I, which makes these cells resistant to currently approved TKIs.
“The approval of Iclusig is important because it provides a treatment option to patients with CML who are not responding to other drugs, particularly those with the T315I mutation who have had few therapeutic options,” said Richard Pazdur, M.D., director of the Office of Hematology and Oncology Products in FDA’s Center for Drug Evaluation and Research. “Iclusig is the third drug approved to treat CML and the second drug approved to treat ALL this year, demonstrating FDA’s commitment to approving safe and effective drugs for patients with rare diseases.”
The FDA approved Bosulif (bosutinib) in September 2012 and Synribo (omacetaxine mepesuccinate) in October 2012 to treat various phases of CML. Marqibo (vincristine sulfate liposome injection) was approved in August 2012 to treat Philadelphia chromosome negative ALL.
Iclusig is being approved under the agency’s accelerated approval program, which provides patients earlier access to promising new drugs while the company conducts additional studies to confirm the drug’s clinical benefit and safe use. The therapy was granted an orphan product designation because it is intended to treat a rare disease or condition.
Iclusig’s safety and effectiveness were evaluated in a single clinical trial of 449 patients with various phases of CML and Ph+ ALL. All participants were treated with Iclusig.
The drug’s effectiveness was demonstrated by a reduction in the percentage of cells expressing the Philadelphia chromosome genetic mutation found in most CML patients, major cytogenetic response (MCyR). Fifty-four percent of all patients and 70 percent of patients with the T315I mutation achieved MCyR. The median duration of MCyR had not yet been reached at the time of analysis.
In accelerated and blast phase CML and Ph+ ALL, Iclusig’s effectiveness was determined by the number of patients who experienced a normalization of white blood cell counts or had no evidence of leukemia (major hematologic response or MaHR). Results showed:
52 percent of patients with accelerated phase CML experienced MaHR for a median duration of 9.5 months;
31 percent of patients with blast phase CML achieved MaHR for a median duration of 4.7 months; and
41 percent of patients with Ph+ ALL achieved MaHR for a median duration of 3.2 months.
Iclusig is being approved with a Boxed Warning alerting patients and health care professionals that the drug can cause blood clots and liver toxicity. The most common side effects reported during clinical trials include high blood pressure, rash, abdominal pain, fatigue, headache, dry skin, constipation, fever, joint pain, and nausea.
欧盟更新帕纳替尼Ponatinib的使用建议
帕纳替尼（Ponatinib）是一种抗癌药物。用于治疗成人慢性粒细胞白血病（(CML）、“费城染色体阳性”（Ph+）急性淋巴细胞白血病（ALL）。主要用于治疗对达沙替尼或尼洛替尼治疗无效的患者，或不能耐受达沙替尼或尼洛替尼的患者，以及不适合伊马替尼后续治疗的患者。也可用于治疗具有基因突变（“T315I突变”）的患者，该基因突变使患者对伊马替尼、达沙替尼或尼洛替尼产生耐药。帕纳替尼于2013年7月在欧盟通过集中审批程序获得批准。
2013年11月22日，欧洲药品管理局（EMA）发布消息，由于帕纳替尼有引起致命性血凝块和严重血管狭窄的风险，人用药品委员会（CHMP）提出更新帕纳替尼的使用建议，以帮助患者最小化血凝块阻塞动脉或静脉的风险。
上述建议是在对临床研究数据进行评估后提出的，包括两项正在进行的研究（一项I期剂量探索研究和一项关键性II期研究）。研究结果表明，接受帕纳替尼治疗的患者动脉与静脉血栓事件的发生率比上市批准时观察到的发生率更高。在I期研究中，2013年9月随访数据的初步分析显示，严重闭塞性血管事件的发生率为22%（81名患者中有18名患者发生），而II期研究数据的初步分析显示发生率为13.8%（449名患者中有62名患者发生）。I期研究的中位治疗持续时间为2.7年，而II期研究为1.3年。另外，在最近中止的一项III期研究（比较帕纳替尼与伊马替尼，中位治疗持续时间为3个月）中，帕纳替尼组报告的闭塞性血管事件例数更多。研究中报告的事件包括心血管、脑血管、周围血管和静脉血栓事件。无论有无风险因素，患者均出现了这些事件，且老年患者与有缺血（如心脏病发作）和卒中、高血压、糖尿病或血脂异常病史的患者更常见。
根据评估结果，CHMP建议，除非经评估其获益大于风险，既往存在心脏病发作或卒中的患者不能使用帕纳替尼。另外，应评估所有患者的心血管风险，并在帕纳替尼治疗前和治疗期间采取降低风险的措施。高血压患者应控制其血压，若出现血凝块阻塞动脉或静脉的体征，应立即停止使用帕纳替尼。
CHMP在评估帕纳替尼临床试验的更新数据后发现，使用帕纳替尼后血凝块的发生率比药物最初获批时观察到的发生率更高。血凝块相关疾病（如心脏病发作和卒中）已经确认为帕纳替尼的不良反应，并建议更新到欧盟范围内的帕纳替尼产品信息中。CHMP计划对帕纳替尼的获益和风险相关数据进行进一步深入评估，并会就该药物的使用是否应该进一步更新提出建议。
给患者的建议
1、帕纳替尼仍可作为白血病的治疗药物。然而，将采取新措施，以减少血凝块（如心脏病发作、卒中和深静脉血栓形成）相关疾病的风险。
2、医生将会对心脏或循环系统疾病的发生风险进行评估，并会在帕纳替尼治疗前和治疗期间采取措施减少这些风险。
3、如果有高血压病史，医生会提出降低血压的建议，如果血压仍保持较高水平则会考虑中断治疗。
4、如果既往有心脏病发作或卒中病史，医生会慎重考虑帕纳替尼治疗的可行性。
5、如果医生已开具帕纳替尼处方，应警惕血凝块的症状和体征，包括腿部剧烈疼痛或肿胀、突然不明原因的气短、呼吸急促或咳嗽、胸痛、面部、手臂或腿部无力或麻木。如果发现任何相关体征和症状，应立即就医。
6、如果对治疗有任何问题，请咨询医生或药剂师。
给医疗专业人士的建议
1、除非经评估其治疗获益大于风险，有心脏病发作或卒中病史的患者不能使用帕纳替尼。
2、应评估患者的心血管状态，并在开始帕纳替尼治疗前积极处理心血管风险因素。治疗期间继续监测并优化心血管状态。
3、帕纳替尼治疗期间应控制高血压，如果高血压未得到控制，则应考虑中断帕纳替尼治疗。
4、应密切监测患者发生血管闭塞或血栓栓塞的症状和体征，如果在治疗过程中出现相关症状和体征，应立即中断治疗。
美国FDA对帕纳替尼的相关风险控制措施
帕纳替尼于2012年12月在美国获得上市许可。2013年10月11日，美国食品药品监管局（FDA）发布警示信息，提示帕纳替尼致严重及致死性血凝块和严重血管狭窄相关报告明显增加。提醒医疗专业人士使用帕纳替尼时应慎重考虑每个患者的治疗获益是否可能大于风险。
2013年10月31日，FDA要求帕纳替尼生产企业ARIAD公司主动暂停帕纳替尼的上市许可，并停止销售使用。ARIAD公司同意FDA的建议，并表示在暂停期间继续研究帕纳替尼的安全性，同时患者和医疗专业人士应根据FDA的新建议使用帕纳替尼。
2013年11月5日，FDA针对10月31日的声明发布了后续消息，为目前正在服用帕纳替尼和服用帕纳替尼获益大于风险的病人及医疗专业人士提供了详细的帕纳替尼使用说明和注意事项。
2013年12月20日，FDA针对帕纳替尼的使用提出了多项安全控制措施，以重点警示其致死性血凝块和严重血管狭窄风险。一旦这些新的措施得以有效实施，帕纳替尼有望在美国针对合适的患者恢复上市许可。医疗专业人士在使用帕纳替尼时，应该实施这些附加的安全性措施并慎重评估每个患者的治疗风险和获益。
ARIAD Announces Accelerated Approval by FDA of Iclusig (Ponatinib) for Patients with CML and Ph+ ALL Resistant or Intolerant to Prior Tyrosine Kinase Inhibitor Therapy
“For patients with CML and Philadelphia-positive ALL who become resistant or intolerant to TKI treatments, the approval of Iclusig is very positive news,” said Rosalie Canosa, program division director at CancerCare. “The addition of Iclusig to the arsenal of anti-leukemia medicines is a significant development and one that offers hope for patients coping with CML and Philadelphia-positive ALL.”
The FDA approval of Iclusig was based on results from the pivotal Phase 2 PACE (Ponatinib Ph+ ALL and CML Evaluation) trial in patients with CML or Ph+ ALL who were resistant or intolerant to prior TKI therapy, or who had the T315I mutation of BCR-ABL. Iclusig had robust anti-leukemic activity, with 54 percent of chronic-phase CML patients, including 70 percent of patients with the T315I mutation, achieving a major cytogenetic response (MCyR) – the primary endpoint of the PACE trial for chronic-phase patients.
In patients with advanced disease, 52 percent of accelerated-phase CML patients, 31 percent of blast-phase CML patients and 41 percent of Ph+ ALL patients achieved a major hematologic response (MaHR) to Iclusig. MaHR was the primary endpoint in the trial for patients with advanced disease.
About Iclusig (ponatinib)
Iclusig is a kinase inhibitor. The primary target for Iclusig is BCR-ABL, an abnormal tyrosine kinase that is expressed in chronic myeloid leukemia (CML) and Philadelphia-chromosome positive acute lymphoblastic leukemia (Ph+ ALL). Iclusig was designed using ARIAD’s computational and structure-based drug design platform specifically to inhibit the activity of BCR-ABL. Iclusig targets not only native BCR-ABL but also its isoforms that carry mutations that confer resistance to treatment, including the T315I mutation, which is the most common mutation among resistant patients. Iclusig is the only TKI that is effective in CML and Ph+ ALL patients with this mutation.
Please see important safety information below, and the full prescribing information for Iclusig at www.ariad.com or www.iclusig.com.
Indication, Usage and Dosing
Iclusig is indicated for the treatment of adult patients with chronic phase, accelerated phase, or blast phase chronic myeloid leukemia (CML) that is resistant or intolerant to prior tyrosine kinase inhibitor (TKI) therapy or Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) that is resistant or intolerant to prior TKI therapy.
This indication is based upon response rate. There are no trials verifying an improvement in disease-related symptoms or increased survival with Iclusig.
The recommended dose of Iclusig is a 45 mg tablet taken once-daily with or without food.
Important Safety Information
Cardiovascular, cerebrovascular, and peripheral vascular thrombosis, including fatal myocardial infarction and stroke have occurred in Iclusig-treated patients. Serious arterial thrombosis occurred in 8% of Iclusig-treated patients. Interrupt and consider discontinuation of Iclusig in patients who develop arterial thrombotic events.
Hepatotoxicity, liver failure and death have occurred in Iclusig-treated patients. Monitor hepatic function prior to and during treatment. Interrupt and then reduce or discontinue Iclusig for hepatotoxicity.
Warnings and Precautions
Twenty patients treated with Iclusig (4%) experienced serious congestive heart failure (CHF) or left ventricular dysfunction, with 4 fatalities. Monitor patients for signs or symptoms consistent with CHF and treat as clinically indicated, including interruption of Iclusig. Consider discontinuation of Iclusig in patients who develop serious CHF.
Eight patients treated with Iclusig (2%) experienced treatment-emergent symptomatic hypertension as a serious adverse reaction, including hypertensive crisis. Treatment-emergent hypertension occurred in 67% of patients. Monitor and manage blood pressure elevations.
Clinical pancreatitis occurred in 6% of patients (5% Grade 3) treated with Iclusig. The incidence of treatment emergent lipase elevation was 41%. Check serum lipase every 2 weeks for the first 2 months and then monthly thereafter or as clinically indicated. Dose interruption or reduction may be required. In cases where lipase elevations are accompanied by abdominal symptoms, interrupt treatment with Iclusig and evaluate patients for pancreatitis.
Serious bleeding events occurred in 5% of patients treated with Iclusig, including fatalities. The incidence was higher in patients with AP-CML, BP-CML, and Ph+ ALL. Most events occurred in patients with grade 4 thrombocytopenia. Interrupt Iclusig for serious or severe hemorrhage.
Serious fluid retention events occurred in 3% of patients treated with Iclusig. One instance of brain edema was fatal. Monitor patients for fluid retention and manage patients as clinically indicated. Interrupt, reduce, or discontinue Iclusig as clinically indicated.
Symptomatic bradyarrhythmias that led to a requirement for pacemaker implantation occurred in 3 (1%) Iclusig-treated patients. Advise patients to report signs and symptoms suggestive of slow heart rate (fainting, dizziness, or chest pain).
Supraventricular tachyarrhythmias occurred in 5% of Iclusig-treated patients. Atrial fibrillation was the most common supraventricular tachyarrhythmia. Advise patients to report signs and symptoms of rapid heart rate (palpitations, dizziness).
Severe (Grade 3 or 4) myelosuppression occurred in 48% of patients treated with Iclusig. Obtain complete blood counts every 2 weeks for the first 3 months and then monthly or as clinically indicated, and adjust the dose as recommended.
Two patients (<1%) treated with Iclusig developed serious tumor lysis syndrome. Hyperuricemia occurred in 7% of patients. Ensure adequate hydration and treat high uric acid levels prior to initiating therapy with Iclusig.
Since Iclusig may compromise wound healing, interrupt Iclusig for at least 1 week prior to major surgery. Serious gastrointestinal perforation (fistula) occurred in one patient 38 days post-cholecystectomy.
Iclusig can cause fetal harm. Advise women to avoid pregnancy while taking Iclusig.
Adverse Reactions
The most common non-hematologic adverse reactions (≥20%) were hypertension, rash, abdominal pain, fatigue, headache, dry skin, constipation, arthralgia, nausea, and pyrexia. Hematologic adverse reactions included thrombocytopenia, anemia, neutropenia, lymphopenia, and leukopenia. Please see the full Prescribing Information for Iclusig, including the Boxed Warning.
About CML and Ph+ ALL
CML is characterized by an excessive and unregulated production of white blood cells by the bone marrow due to a genetic abnormality that produces the BCR-ABL protein. After a chronic phase of production of too many white blood cells, CML typically evolves to the more aggressive phases referred to as accelerated phase and blast crisis. Ph+ ALL is a subtype of acute lymphoblastic leukemia that carries the Ph+ chromosome that produces BCR-ABL. It has a more aggressive course than CML and is often treated with a combination of chemotherapy and tyrosine kinase inhibitors. The BCR-ABL protein is expressed in both of these diseases.
|
