全球首个口服戈谢病药Cerdelga获美国FDA批准上市，用作特定1型戈谢病（Gaucher disease）成人患者唯一的一线口服疗法 8月19日，美国FDA批准 Cerdelga(eliglustat)用于1型戈谢病成人患者长期治疗，戈谢病是一种罕见的遗传性疾病。戈谢病发生于不能产生足够葡糖脑苷脂酶的人当中。这种酶的缺乏可引起脂肪物质在脾脏、肝脏及骨髓聚积。戈谢病的主要特征包括肝脏及脾脏肿大，红细胞计数降低（贫血），血小板计数降低及骨问题。 Cerdelga是一种含有Eliglustat的硬胶囊剂产品，以口服给药。在1型戈谢病患者中，这款药物通过抑制脂肪形成的代谢过程而减少脂肪物质的产生。据估计，1型戈谢病在美国影响大约6000人。 “今天的批准为1型戈谢病患者提供了另一种重要的治疗选择，”FDA药品评价与研究中心药物评价III办公室副主任、医学博士、公共卫生学硕士Egan表示称。“此外，Cerdelga还获得FDA孤儿药资格，这反映了FDA关注并致力于罕见疾病治疗药物的发展。” Cerdelga 的安全性及有效性在两项由199名1型戈谢病受试者参与的临床试验中得到评价。在一项随机、双盲、安慰剂对照、多中心临床试验中，Cerdelga的安全性及有效性在40名之前未接受过酶替代治疗的1型戈谢病受试者中得到评价。受试者以初始剂量42mg接受治疗，每天用药两次，治疗4周之后，服用最大剂量84mg，每天用药两次。 与安慰剂相比，Cerdelga治疗可使脾脏体积从初始治疗到研究结束时（第 39 周）有更大程度的降低，达到了试验的主要终点。与安慰剂相比，Cerdelga 还使肝脏体积、血小板计数及红细胞（血红蛋白）水平得到更大地改善。 另一项研究试图在159名之前有过治疗及用酶替代疗法稳定的1型戈谢病受试者中确定Cerdelga与酶替代疗法相比的安全性及有效性。试验中受试者接受酶替代治疗药物伊米苷酶或Cerdelga治疗。试验证明，在稳定血红蛋白水平，改善血小板计数及脾脏和肝脏体积方面Cerdelga治疗与伊米苷酶有类似效果。 在Cerdelga临床试验中观察到的最常见副作用有疲劳、头痛、恶心、腹泻、背部疼痛、四肢疼痛和上腹部疼痛。Cerdelga由马萨诸塞州剑桥市的健赞公司生产。 HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use CERDELGA™ safely and effectively. See full prescribing information for CERDELGA. CERDELGA™ (eliglustat) capsules, for oral use Initial U.S. Approval: 2014 INDICATIONS AND USAGE CERDELGA is a glucosylceramide synthase inhibitor indicated for the long-term treatment of adult patients with Gaucher disease type 1 who are CYP2D6 extensive metabolizers (EMs), intermediate metabolizers (IMs), or poor metabolizers (PMs) as detected by an FDA-cleared test. (1) Limitations of Use: CYP2D6 ultra-rapid metabolizers may not achieve adequate concentrations of CERDELGA to achieve a therapeutic effect (1) A specific dosage cannot be recommended for CYP2D6 indeterminate metabolizers (1) DOSAGE AND ADMINISTRATION Select patients using an FDA-cleared test for determining CYP2D6 genotype (2.1) CYP2D6 EMs or IMs: 84 mg orally twice daily (2.2) CYP2D6 PMs: 84 mg orally once daily (2.2) Swallow capsules whole, do not crush, dissolve or open capsules (2.3) Avoid eating grapefruit or drinking grapefruit juice (2.3) DOSAGE FORMS AND STRENGTHS 84 mg capsules (3) CONTRAINDICATIONS CYP2D6 EMs and IMs taking a strong or moderate CYP2D6 inhibitor with a strong or moderate CYP3A inhibitor (4, 5.1, 7.1, 12.2) CYP2D6 IMs and PMs taking a strong CYP3A inhibitor (4, 5.1, 7.1, 12.2) WARNINGS AND PRECAUTIONS ECG Changes and Potential for Cardiac Arrhythmias: Not recommended in patients with pre-existing cardiac disease, long QT syndrome, and concomitant use of Class IA and Class III antiarrhythmics (5.2) ADVERSE REACTIONS The most common adverse reactions (≥10%) are: fatigue, headache, nausea, diarrhea, back pain, pain in extremities, and upper abdominal pain (6.1) To report SUSPECTED ADVERSE REACTIONS, contact Genzyme Corporation at 1-800-745-4447 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch DRUG INTERACTIONS Eliglustat is a CYP2D6 and CYP3A substrate. Co-administration of CERDELGA with drugs that inhibit CYP2D6 and CYP3A may significantly increase the exposure to eliglustat and result in prolongation of the PR, QTc, and/or QRS cardiac interval, which could result in cardiac arrhythmias. Consider potential drug interactions prior to and during therapy (5.1, 7.1) CYP2D6 IMs and PMs taking moderate CYP3A inhibitors: not recommended (7.1) CYP2D6 PMs taking weak CYP3A inhibitors: not recommended (7.1) CYP2D6 EMs and IMs taking strong or moderate CYP2D6 inhibitors and CYP2D6 EMs taking strong or moderate CYP3A inhibitors: reduce the dosage to 84 mg once daily (2.2, 7.1) Eliglustat is an inhibitor of P-gp and CYP2D6. Co-administration with drugs that are substrates for P-gp or CYP2D6 may result in increased concentrations of the other drug (7.2) See Full Prescribing Information for a list of clinically significant drug interactions (7.1, 7.2) USE IN SPECIFIC POPULATIONS Pregnancy: Only administer if the potential benefit justifies the potential risk. Based on animal data, may cause fetal harm (8.1) Nursing mothers: Discontinue drug or nursing based on importance of drug to mother (8.3) Renal impairment: Not recommended in moderate to severe impairment (8.6) Hepatic impairment: Not recommended (8.7) See 17 for PATIENT COUNSELING INFORMATION and Medication Guide. Revised: 8/2014 FULL PRESCRIBING INFORMATION: CONTENTS* 1 INDICATIONS AND USAGE CERDELGA is indicated for the long-term treatment of adult patients with Gaucher disease type 1 (GD1) who are CYP2D6 extensive metabolizers (EMs), intermediate metabolizers (IMs), or poor metabolizers (PMs) as detected by an FDA-cleared test [see Dosage and Administration (2.1)]. Limitations of Use: Patients who are CYP2D6 ultra-rapid metabolizers (URMs) may not achieve adequate concentrations of CERDELGA to achieve a therapeutic effect [see Clinical Studies (14)]. A specific dosage cannot be recommended for those patients whose CYP2D6 genotype cannot be determined (indeterminate metabolizers) [see Clinical Studies (14)]. 2 DOSAGE AND ADMINISTRATION 2.1 Patient Selection Select patients with Gaucher disease type 1 based on their CYP2D6 metabolizer status. It is recommended patient genotypes be established using an FDA-cleared test for determining CYP2D6 genotype [see Indications and Usage (1)]. 2.2 Recommended Adult Dosage The recommended dosage of CERDELGA is 84 mg twice daily in CYP2D6 EMs and IMs. The recommended dosage in CYP2D6 PMs is 84 mg once daily; appropriate adverse event monitoring is recommended [see Adverse Reactions (6.1)]. The predicted exposures with 84 mg once daily in patients who are CYP2D6 PMs are expected to be similar to exposures observed with 84 mg twice daily in CYP2D6 IMs [see Clinical Pharmacology (12.3)]. Some inhibitors of CYP2D6 and CYP3A are contraindicated with CERDELGA depending on the patient's metabolizer status [see Contraindications (4)]. Co-administration of CERDELGA with other CYP2D6 and CYP3A inhibitors may require dosage adjustment depending on the patient's CYP2D6 metabolizer status to reduce the risk of potentially significant adverse reactions [see Table 3 and Table 4 in Drug Interactions (7.1)]. Reduce the dosage of CERDELGA to 84 mg once daily for: CYP2D6 EMs and IMs taking strong or moderate CYP2D6 inhibitors CYP2D6 EMs taking strong or moderate CYP3A inhibitors 2.3 Important Administration Instructions Swallow capsules whole, preferably with water, and do not crush, dissolve, or open the capsules. CERDELGA can be taken with or without food. Avoid the consumption of grapefruit or grapefruit juice with CERDELGA because grapefruit is a strong CYP3A inhibitor [see Drug Interactions (7.1)]. If a dose of CERDELGA is missed, take the prescribed dose at the next scheduled time; do not double the next dose. For patients currently treated with imiglucerase, velaglucerase alfa, or taliglucerase alfa, CERDELGA may be administered 24 hours after the last dose of the previous enzyme replacement therapy (ERT). 3 DOSAGE FORMS AND STRENGTHS CERDELGA is supplied as 84 mg hard gelatin capsules, with a pearl blue-green opaque cap and pearl white opaque body imprinted with "GZ02" in black. Each capsule contains 100 mg eliglustat tartrate, which is equivalent to 84 mg of eliglustat. 4 CONTRAINDICATIONS CERDELGA is contraindicated in the following patients due to the risk of significantly increased eliglustat plasma concentrations which may result in prolongation of the PR, QTc, and/or QRS cardiac intervals that could result in cardiac arrhythmias. See Table 3 and Table 4 for examples of drugs in each of the categories described [see Drug Interactions (7.1)]: EMs or IMs taking a strong or moderate CYP2D6 inhibitor concomitantly with a strong or moderate CYP3A inhibitor. IMs or PMs taking a strong CYP3A inhibitor. 5 WARNINGS AND PRECAUTIONS 5.1 Drug-Drug Interactions Eliglustat is a CYP2D6 and CYP3A substrate. Drugs that inhibit CYP2D6 and CYP3A metabolism pathways may significantly increase the exposure to eliglustat and result in prolongation of the PR, QTc, and/or QRS cardiac intervals that could result in cardiac arrhythmias [see Clinical Pharmacology (12.2)]. Some drugs that are inhibitors of CYP2D6 and CYP3A are contraindicated with CERDELGA depending on the patient's CYP2D6 metabolizer status [see Contraindications (4)]. See Table 3 and Table 4 for other potentially significant drug interactions [see Drug Interactions (7.1)]. 5.2 ECG Changes and Potential for Cardiac Arrhythmias Use of CERDELGA in patients with pre-existing cardiac conditions has not been studied during clinical trials. Because CERDELGA is predicted to cause increases in ECG intervals (PR, QTc, and QRS) at substantially elevated eliglustat plasma concentrations, use of CERDELGA is not recommended in patients with pre-existing cardiac disease (congestive heart failure, recent acute myocardial infarction, bradycardia, heart block, ventricular arrhythmia), long QT syndrome, and in combination with Class IA (e.g., quinidine, procainamide) and Class III (e.g., amiodarone, sotalol) antiarrhythmic medications [see Clinical Pharmacology (12.2)]. 6 ADVERSE REACTIONS 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The most common adverse reactions to CERDELGA (occurring in ≥10% of the 126 GD1 patients treated with CERDELGA across Trials 1 and 2) were fatigue, headache, nausea, diarrhea, back pain, pain in extremities, and upper abdominal pain. The adverse reaction profile of CERDELGA is based on two controlled studies, Trials 1 and 2. Table 1 presents the profile from the 9-month double-blind, randomized, placebo-controlled trial of 40 treatment-naïve patients (Trial 1). Patients were between the ages of 16 and 63 on the date of the first dose of study drug, and included 20 males and 20 females. Table 1: Adverse Reactions Occurring in ≥10% of Treatment-Naïve GD1 Patients and More Frequently than Placebo (Trial 1) CERDELGA (N=20) Placebo (N=20) Adverse Reaction Patients n (%) Patients n (%)   Arthralgia 9 ( 45) 2 ( 10)   Headache 8 ( 40) 6 ( 30)   Migraine 2 ( 10) 0 ( 0)   Flatulence 2 ( 10) 1 ( 5)   Nausea 2 ( 10) 1 ( 5)   Oropharyngeal pain 2 ( 10) 1 ( 5) Table 2 presents the profile from the 12-month open-label, randomized, imiglucerase-controlled trial of 159 treated patients switching from enzyme replacement therapy (ERT) (Trial 2). Patients were between the ages of 18 and 69 on the date of the first dose of CERDELGA, and included 87 females and 72 males. Table 2: Adverse Reactions Occurring in ≥5% of GD1 Patients Switching from Enzyme Replacement Therapy to CERDELGA and More Frequently than Imiglucerase (Trial 2)* CERDELGA (N=106) Imiglucerase (N=53) Adverse Reaction Patients n (%) Patients n (%) Fatigue 15 ( 14) 1 ( 2) Headache 14 ( 13) 1 ( 2) Nausea 13 ( 12) 0 ( 0) Diarrhea 13 ( 12) 2 ( 4) Back pain 13 ( 12) 3 ( 6) Pain in extremity 12 ( 11) 1 ( 2) Upper abdominal pain 11 ( 10) 0 ( 0) Dizziness 9 ( 8) 0 ( 0) Asthenia 9 ( 8) 0 ( 0) Cough 7 ( 7) 2 ( 4) Dyspepsia 7 ( 7) 1 ( 2) Gastroesophageal reflux disease 7 ( 7) 0 ( 0) Constipation 5 ( 5) 0 ( 0) Palpitations 5 ( 5) 0 ( 0) Rash 5 ( 5) 0 ( 0) Trial 2 was not designed to support comparative claims for CERDELGA for the adverse reactions reported in this table. In an uncontrolled study, with up to 4 years of treatment, in 26 patients, the types and incidences of adverse reactions were similar to Trials 1 and 2. 7 DRUG INTERACTIONS 7.1 Potential for Other Drugs to Affect CERDELGA Eliglustat is a CYP2D6 and CYP3A substrate. CYP2D6 and CYP3A Inhibitors Drugs that inhibit CYP2D6 and CYP3A pathways may significantly increase the exposure to eliglustat and result in prolongation of the PR, QTc, and/or QRS cardiac interval which could result in cardiac arrhythmias: Some inhibitors of CYP2D6 and CYP3A are contraindicated with CERDELGA depending on the patient's CYP2D6 metabolizer status [see Contraindications (4)]. Co-administration of CERDELGA with other CYP2D6 and CYP3A inhibitors may require dosage adjustment depending on the patient's CYP2D6 metabolizer status to reduce the risk of potential significant adverse reactions (see Table 3 and Table 4). Table 3: Established and Other Potentially Significant Drug Interactions: Alteration in CERDELGA Dosage May Be Recommended Based on Drug Interaction Studies or on Predicted Interaction in EMs and IMs Recommended CERDELGA Dosage, by CYP2D6 Metabolizer Status CYP450 Inhibitors EM IM Strong or Moderate CYP2D6 inhibitors concomitantly with Strong or Moderate CYP3A inhibitors Contraindicated Contraindicated Strong CYP2D6 inhibitors e.g., paroxetine 84 mg once daily 84 mg once daily Moderate CYP2D6 inhibitors e.g., terbinafine 84 mg once daily 84 mg once daily Strong CYP3A inhibitors e.g., ketoconazole 84 mg once daily Contraindicated Moderate CYP3A inhibitors e.g., fluconazole 84 mg once daily Not recommended Table 4: Established and Other Potentially Significant Drug Interactions: Alteration in CERDELGA Dosage May Be Recommended Based on Predicted Interaction in PMs CYP450 Inhibitors Recommended CERDELGA Dosage for PMs Strong CYP3A inhibitors e.g., ketoconazole Contraindicated Moderate CYP3A inhibitors e.g., fluconazole Not recommended Weak CYP3A inhibitors e.g., ranitidine Not recommended CYP3A Inducers Co-administration of CERDELGA with strong CYP3A inducers significantly decreases eliglustat exposure. Use of CERDELGA with strong CYP3A inducers (e.g., rifampin, carbamazepine, phenobarbital, phenytoin, and St. John's Wort) is not recommended in EMs, IMs, and PMs. 7.2 Potential for CERDELGA to Affect Other Drugs Eliglustat is an inhibitor of P-gp and CYP2D6. Co-administration of CERDELGA with drugs that are substrates for P-gp or CYP2D6 may result in increased concentrations of the concomitant drug as shown in Table 5. Table 5: Drug Interactions that Result in Increased Concentrations of the Concomitant Drug Drug Class or Drug Name Clinical Recommendations Digoxin (P-gp substrate) Measure serum digoxin concentrations before initiating CERDELGA. Reduce digoxin dose by 30% and continue monitoring. Other P-gp substrates (e.g., phenytoin, colchicine, dabigatran etexilate) Monitor therapeutic drug concentrations, as indicated, or consider reducing the dosage of the concomitant drug and titrate to clinical effect. CYP2D6 substrates Metoprolol; tricyclic antidepressants (e.g., nortriptyline, amitriptyline, imipramine); phenothiazines (e.g., perphenazine, chloropromazine). 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Pregnancy Category C Risk Summary There are no adequate or well-controlled studies with CERDELGA in pregnant women. However, animal reproduction studies have been conducted for eliglustat. In these animal studies, a spectrum of anomalies at doses 6 times the recommended human dose were observed in orally dosed rats. No fetal harm was observed with oral administration of eliglustat to pregnant rabbits at dose levels 10 times the recommended human dose. CERDELGA should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Clinical Considerations Disease-associated maternal and embryo-fetal risk Women with Gaucher disease type 1 have an increased risk of spontaneous abortion, especially if disease symptoms are not treated and controlled pre-conception and during a pregnancy. Pregnancy may exacerbate existing Gaucher disease type 1 symptoms or result in new disease manifestations. Gaucher disease type 1 manifestations may lead to adverse pregnancy outcomes including, hepatosplenomegaly which can interfere with the normal growth of a pregnancy and thrombocytopenia which can lead to increased bleeding and possible hemorrhage. Animal Data Reproduction studies have been performed in pregnant rats at oral doses up to 120 mg/kg/day (about 6 times the recommended human dose based on body surface area) and in pregnant rabbits at oral doses up to 100 mg/kg/day (about 10 times the recommended human dose based on body surface area). In rats, at 120 mg/kg/day (about 6 times the recommended human dose based on body surface area), eliglustat increased the number of late resorptions, dead fetuses and post implantation loss, reduced fetal body weight, and caused fetal cerebral variations (dilated cerebral ventricles), fetal skeletal variations (poor bone ossification) and fetal skeletal malformations (abnormal number of ribs or lumbar vertebra). Eliglustat did not cause fetal harm in rabbits at oral doses up to 100 mg/kg/day (about 10 times the recommended human dose based on body surface area). In a pre and postnatal development study in rats, eliglustat did not show any significant adverse effects on pre and postnatal development at doses up to 100 mg/kg/day (about 5 times the recommended human dose based on body surface area). 8.3 Nursing Mothers It is not known whether CERDELGA is present in human milk. Because many drugs are present in human milk, and because of the potential for serious adverse reactions in nursing infants from CERDELGA, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the lactating woman. 8.4 Pediatric Use Safety and effectiveness in pediatric patients have not been established. 8.5 Geriatric Use Clinical studies of CERDELGA did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Clinical experience has not identified differences in responses between the elderly and younger patients. 8.6 Renal Impairment There is no dosage adjustment required for patients with mild renal impairment. CERDELGA has not been studied in patients with moderate to severe renal impairment or end-stage renal disease (ESRD). Use of CERDELGA in these patients is not recommended. 8.7 Hepatic Impairment CERDELGA has not been studied in patients with hepatic impairment. Use of CERDELGA is not recommended in all stages of hepatic impairment or cirrhosis. 8.8 Poor Metabolizers Dosing of CERDELGA 84 mg once daily has not been studied in PMs, however the predicted systemic exposures in these patients are within the range of those observed in clinical studies. Appropriate adverse event monitoring is recommended [see Adverse Reactions (6.1) and Clinical Studies (14)]. 10 OVERDOSAGE The highest eliglustat plasma concentration experienced to date occurred in a single-dose, dose escalation study in healthy subjects, in a subject taking a dose equivalent to approximately 21 times the recommended dose for GD1 patients. At the time of the highest plasma concentration (59-fold higher than normal therapeutic conditions), the subject experienced dizziness marked by disequilibrium, hypotension, bradycardia, nausea, and vomiting. In the event of acute overdose, the patient should be carefully observed and given symptomatic and supportive treatment. Hemodialysis is unlikely to be beneficial given that eliglustat has a large volume of distribution [see Clinical Pharmacology (12.3)]. 11 DESCRIPTION CERDELGA (eliglustat) capsules contain eliglustat tartrate, which is a small molecule inhibitor of glucosylceramide synthase that resembles the ceramide substrate for the enzyme, with the chemical name N-((1R,2R)-1-(2,3-dihydrobenzo[b][1,4]dioxin-6-yl)-1-hydroxy-3-(pyrrolidin-1-yl)propan-2-yl)octanamide (2R,3R)-2,3-dihydroxysuccinate. Its molecular weight is 479.59, and the empirical formula is C23H36N2O4+½(C4H6O6) with the following chemical structure: Each capsule of CERDELGA for oral use contains 84 mg of eliglustat, equivalent to 100 mg of eliglustat tartrate (hemitartrate salt). The inactive ingredients are microcrystalline cellulose, lactose monohydrate, hypromellose and glyceryl behenate, gelatin, candurin silver fine, yellow iron oxide, and FD&C blue 2. 12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action Gaucher disease is caused by a deficiency of the lysosomal enzyme acid β-glucosidase. Acid β-glucosidase catalyzes the conversion of the sphingolipid glucocerebroside into glucose and ceramide. The enzymatic deficiency causes an accumulation of glucosylceramide (GL-1) primarily in the lysosomal compartment of macrophages, giving rise to foam cells or "Gaucher cells". CERDELGA is a specific inhibitor of glucosylceramide synthase (IC50 = 10 ng/mL), and acts as a substrate reduction therapy for GD1. In clinical trials CERDELGA reduced spleen and liver size, and improved anemia and thrombocytopenia. In this lysosomal storage disorder (LSD), clinical features are reflective of the accumulation of Gaucher cells in the liver, spleen, bone marrow, and other organs. The accumulation of Gaucher cells in the liver, spleen, and bone marrow leads to organomegaly and skeletal disease. Presence of Gaucher cells in the bone marrow and spleen lead to clinically significant anemia and thrombocytopenia. 12.2 Pharmacodynamics Electrocardiographic Evaluation QTc interval prolongation was studied in a double-blind, single dose, placebo- and positive-controlled crossover study in 42 healthy subjects. Concentration-related increases were observed for the placebo-corrected change from baseline in the PR, QRS, and QTc intervals. Based on PK/PD modeling, eliglustat plasma concentrations of 500 ng/mL are predicted to cause mean (upper bound of the 95% one-sided confidence interval) increases in the PR, QRS, and QTcF intervals of 22 (26), 7 (10), and 13 (19) msec, respectively. At the highest geometric mean concentrations of 237 ng/mL following a single supratherapeutic dose tested in the thorough QT study, CERDELGA did not prolong the QT/QTc interval to any clinically relevant extent. 12.3 Pharmacokinetics At a given dose, the systemic exposure (Cmax and AUC) depends on the CYP2D6 phenotype. In CYP2D6 EMs and IMs, the eliglustat pharmacokinetics is time-dependent and the systemic exposure increases in a more than dose proportional manner. After multiple oral doses of 84 mg twice daily in EMs, eliglustat systemic exposure (AUC0-12) increased up to about 2-fold at steady state compared to after the first dose (AUC0-∞). The pharmacokinetics of eliglustat in CYP2D6 PMs is expected to be linear and time-independent. Compared to EMs, the systemic exposure following 84 mg twice daily at steady state is 7- to 9-fold higher in PMs. Absorption In CYP2D6 EMs, median time to reach maximum plasma concentrations (tmax) occurs at 1.5 to 2 hours following multiple doses of CERDELGA 84 mg twice daily. The corresponding mean Cmax values range from 12.1 to 25.0 ng/mL in EMs. The mean AUCtau values range from 76.3 to 143 hr*ng/mL in EMs. The Cmax and AUCtau in one IM subject receiving multiple doses of CERDELGA 84 mg two time daily was 44.6 ng/mL and 306 hr*ng/mL, respectively. The oral bioavailability is low in EMs (<5%) following single dose of CERDELGA 84 mg due to significant first-pass metabolism. In PMs, median tmax occurs at 3 hours following multiple doses of CERDELGA 84 mg twice daily. The corresponding mean Cmax and AUCtau values range from 113 to 137 ng/mL and 922 to 1057 hr*ng/mL, respectively. Oral dosing of CERDELGA 84 mg once daily has not been studied in PMs. The predicted Cmax and AUC0-24hr in PMs using physiologically-based pharmacokinetic (PBPK) model with 84 mg once daily are 75 ng/mL and 956 hr*ng/mL, respectively. Administration of CERDELGA with a high fat meal resulted in a 15% decrease in Cmax but no change in AUC. Food does not have a clinically relevant effect on eliglustat pharmacokinetics. Distribution Eliglustat is moderately bound to human plasma proteins (76 to 83%). In the blood, it is mainly distributed in plasma and not red blood cells. After intravenous (IV) administration, the volume of distribution of eliglustat was 835 L in CYP2D6 EMs, suggesting wide distribution to tissues (CERDELGA is only for oral use). Metabolism and Elimination CERDELGA is extensively metabolized with high clearance, mainly by CYP2D6 and to a lesser extent CYP3A4. Primary metabolic pathways of eliglustat involve sequential oxidation of the octanoyl moiety followed by oxidation of the 2,3-dihydro-1,4-benzodioxane moiety, or a combination of the two pathways, resulting in multiple oxidative metabolites. No active metabolites have been identified. After oral administration of 84 mg [14C]-eliglustat, the majority of the administered dose is excreted in urine (41.8%) and feces (51.4%), mainly as metabolites. After 42 mg IV administration in healthy volunteers, mean (CV%) of eliglustat total body clearance was 88 L/h (8.8%) in CYP2D6 EMs (CERDELGA is only for oral use). Following multiple oral doses of CERDELGA 84 mg twice daily, eliglustat terminal elimination half-life (T1/2) was approximately 6.5 hours in EMs and 8.9 hours in PMs. Specific Populations Based on population PK analysis, there was no effect of mild renal impairment on eliglustat PK. Furthermore, gender, body weight, age, and race had no clinically relevant impact on the pharmacokinetics of eliglustat. Drug Interactions - Effect of Other Drugs on CERDELGA In vitro, eliglustat is metabolized primarily by CYP2D6 and to a lesser extent by CYP3A4. Eliglustat is also a substrate of P-glycoprotein (P-gp). Co-administration of CERDELGA with CYP2D6 Inhibitors Systemic exposure (Cmax and AUCtau) of eliglustat increased 7.0-fold and 8.4-fold, respectively, following co-administration of CERDELGA 84 mg twice daily with paroxetine (a strong CYP2D6 inhibitor) 30 mg once daily in EMs (N=30), respectively. Simulations using PBPK models suggested that paroxetine may increase the Cmax and AUCtau of eliglustat 2.1- and 2.3-fold in IMs, respectively. Compared to paroxetine, the effects of terbinafine (a moderate inhibitor of CYP2D6) on the exposure of eliglustat in EMs or IMs were predicted to be smaller. Simulations using PBPK models suggested that terbinafine may increase the Cmax and AUCtau of eliglustat 3.8- and 4.5-fold in EMs, respectively. Both Cmax and AUCtau increased 1.6-fold in IMs. Co-administration of CERDELGA with CYP3A Inhibitors CYP2D6 EMs and IMs: Following co-administration of CERDELGA 84 mg twice daily with ketoconazole (a strong CYP3A inhibitor) 400 mg once daily, the systemic exposure (Cmax and AUCtau) of eliglustat increased 4.0-fold and 4.4-fold in EMs (N=31). Simulations using PBPK models suggested that ketoconazole may increase the Cmax and AUCtau of eliglustat 4.4- and 5.4-fold in IMs, respectively. Compared to ketoconazole, the effects of fluconazole (a moderate inhibitor of CYP3A) on the exposure of eliglustat in EMs or IMs were predicted to be smaller. Simulations using PBPK models suggested that fluconazole may increase the Cmax and AUCtau of eliglustat 2.8- and 3.2-fold in EMs, respectively, and 2.5- to 2.9-fold in IMs, respectively. CYP2D6 PMs: The effect of CYP3A inhibitors on the systemic exposure of eliglustat in PMs has not been evaluated in clinical studies. Simulations using PBPK models suggest that ketoconazole may increase the Cmax and AUC0-24h of eliglustat 4.3- and 6.2-fold when co-administered with CERDELGA 84 mg once daily in PMs. Simulations using PBPK models suggested that fluconazole may increase the Cmax and AUC0-24h of eliglustat 2.4- and 3.0-fold, respectively, when co-administered with CERDELGA 84 mg once daily. Co-administration of CERDELGA with CYP2D6 and CYP3A inhibitors Simulations using PBPK models suggested that concomitant use of CERDELGA 84 mg twice daily with paroxetine and ketoconazole may increase the Cmax and AUCtau of eliglustat 16.7- and 24.2-fold in EMs, respectively. The predicted Cmax and AUCtau of eliglustat increased 7.5- to 9.8-fold in IMs, respectively. Simulations using PBPK models suggested that concomitant use of CERDELGA 84 mg twice daily with terbinafine and fluconazole may increase the Cmax and AUCtau of eliglustat 10.2- and 13.6-fold in EMs. The predicted Cmax and AUCtau of eliglustat increased 4.2- to 5.0-fold in IMs, respectively. Effect of CYP3A inducers on Eliglustat PK Systemic exposures (Cmax and AUCtau) of eliglustat decreased by approximately 90% in EMs and IMs, following co-administration of CERDELGA 127 mg twice daily with rifampin (a strong CYP3A inducer) 600 mg PO once daily. The only approved dose of CERDELGA is 84 mg. Systemic exposures of eliglustat decreased by approximately 95% following co-administration of CERDELGA 84 mg twice daily with rifampin 600 mg PO once daily in PMs. Effect of OATP (organic anion transporting polypeptide) Inhibitors on Eliglustat PK Systemic exposures of eliglustat were similar with or without co-administration of single 600 mg IV dose of rifampin (a potent OATP inhibitor) regardless of subjects' CYP2D6 phenotypes. Effect of P-gp Inhibitors on Eliglustat PK The effect of P-gp inhibitors on the systemic exposure of eliglustat has not been studied clinically. Effect of Gastric pH-Modifying Agents on Eliglustat PK Gastric pH-modifying agents (Maalox®, Tums®, Protonix®) did not have a clinically relevant effect on eliglustat exposure. Drug Interactions - Effect of CERDELGA on the PK of Other Drugs Eliglustat is an inhibitor of P-gp and CYP2D6. Following multiple doses of CERDELGA 127 mg twice daily, systemic exposures (Cmax and AUC) to metoprolol (a CYP2D6 substrate) increased compared to metoprolol administration alone. Mean Cmax and AUC increased by 1.7- and 2.3-fold, respectively, in EMs and by 1.2- and 1.6-fold, respectively in IMs. The only approved dose of CERDELGA is 84 mg. Following multiple doses of CERDELGA 127 mg twice daily in EMs and IMs or 84 mg twice daily in PMs, systemic exposures (Cmax and AUC) to digoxin (a P-gp substrate, with narrow therapeutic index) increased compared to digoxin administration alone. Mean Cmax and AUC increased by 1.7- and 1.5-fold, respectively. The only approved dose of CERDELGA is 84 mg. In vitro, eliglustat is a weak inhibitor of CYP3A. Repeated doses of CERDELGA 84 mg twice daily did not change the exposures to norethindrone (1.0 mg) and ethinyl estradiol (0.035 mg). Therefore, CERDELGA is not expected to impact the efficacy or safety of oral contraceptives containing norethindrone and ethinyl estradiol. 13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenesis Carcinogenic potential of CERDELGA was assessed in 2-year carcinogenicity studies in rats and mice. In Sprague-Dawley rats, eliglustat was administered by oral gavage at doses up to 75 mg/kg/day in males (about 3.6 times the recommended human daily dose of 84 mg twice daily, based on body surface area) and 50 mg/kg/day in females (about 2.4 times the recommended human daily dose based on body surface area). In CD-1 mice, eliglustat was administered to males and females at up to 75 mg/kg/day (about 1.8 times the recommended human daily dose based on body surface area) via dietary admixture. Eliglustat did not produce any treatment-related neoplasms in rats or mice. Mutagenesis Eliglustat was negative in the Ames test, chromosome aberration test in human peripheral blood lymphocytes, mouse lymphoma gene mutation assay and in vivo oral mouse micronucleus test. Impairment of Fertility In a fertility and early embryonic development study in rats, eliglustat increased pre-implantation loss at 30 (about 1.5 times the recommended human oral dose based on body surface area) and 100 mg/kg/day (about 5 times the recommended human oral dose based on body surface area). In mature male rats, eliglustat showed reversible adverse effects on sperm morphology, testes (germ cell necrosis), and sloughed cells in the epididymis at 200 mg/kg/day (about 10 times the recommended human oral dose based on body surface area). Similar effects on sperm were not seen in mature Cynomolgus monkeys at 72 mg/kg/day (about 7 times the recommended human oral dose based on body surface area). 14 CLINICAL STUDIES The efficacy of CERDELGA was evaluated in three clinical trials in patients with Gaucher disease type 1. 14.1 CERDELGA in Treatment-Naïve GD1 Patients – Trial 1 Trial 1 was a randomized, double-blind, placebo-controlled, multicenter clinical study evaluating the efficacy and safety of CERDELGA in 40 treatment-naïve GD1 patients 16 years of age or older (median age 30.4 years) with pre-existing splenomegaly and hematological abnormalities. Patients were required to have received no treatment with substrate reduction therapy within 6 months or ERT within 9 months prior to randomization; all but 5 patients in the study had no prior therapy. Patients were stratified according to baseline spleen volume (≤ 20 or > 20 multiples of normal [MN]) and randomized in a 1:1 ratio to receive CERDELGA or placebo for the duration of the 9-month blinded primary analysis period. The CERDELGA treatment group was comprised of IM (5%), EM (90%) and URM (5%) patients. Patients randomized to CERDELGA treatment received a starting dose of 42 mg twice daily, with a dose increase to 84 mg twice daily possible at Week 4 based on the plasma trough concentration at Week 2. The majority of patients (17 [85%]) received a dose escalation to 84 mg twice daily at Week 4, and 3 (15%) continued to receive 42 mg twice daily for the duration of the 9-month blinded primary analysis period. The primary endpoint was the percentage change in spleen volume (in MN) from baseline to 9 months as compared to placebo. Secondary endpoints were absolute change in hemoglobin level, percentage change in liver volume (in MN), and percentage change in platelet count from baseline to 9 months compared to placebo. At baseline, mean spleen volumes were 12.5 and 13.9 MN in the placebo and CERDELGA groups, respectively, and mean liver volumes were 1.4 MN for both groups. Mean hemoglobin levels were 12.8 and 12.1 g/dL, and platelet counts were 78.5 and 75.1 x 109/L, respectively. During the 9-month primary analysis period, CERDELGA demonstrated statistically significant improvements in all primary and secondary endpoints compared to placebo, as shown in Table 6. Table 6: Change from Baseline to Month 9 in Treatment-Naïve Patients with GD1 Receiving Treatment with CERDELGA in Trial 1 Placebo (n=20) CERDELGA (n=20) Difference (CERDELGA – Placebo) [95% CI] p value* MN = Multiples of Normal, CI = confidence interval, NA = Not applicable Percentage Change in Spleen Volume MN (%) 2.3 -27.8 -30.0 [-36.8, -23.2] <0.0001 Absolute Change in Spleen Volume (MN) 0.3 -3.7 -4.1 [-5.3, -2.9] NA Absolute Change in Hemoglobin Level (g/dL) -0.5 0.7 1.2 [0.6, 1.9] 0.0006 Percentage Change in Liver Volume MN (%) 1.4 -5.2 -6.6 [-11.4, -1.9] 0.0072 Absolute Change in Liver Volume (MN) 0.0 -0.1 -0.1 [-0.2, 0.0] NA Percentage Change in Platelet Count (%) -9.1 32.0 41.1 [24.0, 58.2] <0.0001 Absolute Change in Platelet Count (x 109/L) -7.2 24.1 31.3 [18.8, 43.8] NA Estimates and p-value are based on ANCOVA model that includes treatment group, baseline spleen severity group (≤20MN, >20MN) and baseline parameter value.  In an uncontrolled study of treatment naïve GD1 patients, improvements in spleen and liver volume, hemoglobin level, and platelet count continued through the 4 year treatment period. 14.2 Patients Switching from Enzyme Replacement Therapy to CERDELGA – Trial 2 Trial 2 was a randomized, open-label, active-controlled, non-inferiority, multicenter clinical study evaluating the efficacy and safety of CERDELGA compared with imiglucerase in 159 treated GD1 patients (median age 37.4 years) previously treated with enzyme replacement therapy (≥3 years of enzyme replacement therapy, dosed at 30-130 U/kg/month in at least 6 of the prior 9 months) who met pre-specified therapeutic goals at baseline. Pre-specified baseline therapeutic goals included: no bone crisis and free of symptomatic bone disease within the last year; mean hemoglobin level of ≥ 11 g/dL in females and ≥ 12 g/dL in males; mean platelet count ≥ 100,000/mm3; spleen volume < 10 times normal and liver volume < 1.5 times normal. Patients were randomized 2:1 to receive CERDELGA or imiglucerase for the duration of the 12-month primary analysis period. Seventy-five percent of patients randomized to CERDELGA were previously treated with imiglucerase; 21% with velaglucerase alfa and 4% were unreported. Patients randomized to CERDELGA treatment received a starting dose of 42 mg twice daily, with dose increases to 84 mg twice daily and 127 mg twice daily possible at Weeks 4 and 8 based on plasma trough concentrations of CERDELGA at Weeks 2 and 6, respectively. The percentage of patients receiving the 3 possible CERDELGA doses was: 42 mg twice daily (20%), 84 mg twice daily (32%) and 127 mg twice daily (48%). The CERDELGA treatment group was comprised of PM (4%), IM (10%), EM (80%) and URM (4%) patients. At baseline, mean spleen volumes were 2.6 and 3.2 MN in the imiglucerase and CERDELGA groups, respectively, and liver volumes were 0.9 MN in both groups. Mean hemoglobin levels were 13.8 and 13.6 g/dL, and platelet counts were 192 and 207 x 109/L, respectively. The primary composite endpoint required stability in all four component domains (hemoglobin level, platelet count, liver volume, and spleen volume) based on changes between baseline and 12 months. Stability was defined by the following pre-specified thresholds of change: hemoglobin level <1.5 g/dL decrease, platelet count < 25% decrease, liver volume <20% increase and spleen volume <25% increase. The percentages of patients meeting the criteria for stability in the individual components of the composite endpoint were assessed as secondary efficacy endpoints. CERDELGA met the criteria to be declared non-inferior to imiglucerase in maintaining patient stability. After 12 months of treatment, the percentage of patients meeting the primary composite endpoint was 84.8% for the CERDELGA group compared to 93.6% for the imiglucerase group. The lower bound of the 95% CI of the 8.8% difference, -17.6%, was within the pre-specified non-inferiority margin of -25%. At Month 12, the percentages of CERDELGA and imiglucerase patients respectively, who met stability criteria for the individual components of the composite endpoint were: hemoglobin level, 94.9% and 100%; platelet count, 92.9% and 100%; spleen volume, 95.8% and 100%; and liver volume, 96.0% and 93.6%. Of the patients who did not meet stability criteria for the individual components, 12 of 15 CERDELGA patients and 3 of 3 imiglucerase patients remained within therapeutic goals for GD1. Mean changes from baseline in the hematological and visceral parameters through 12 months of treatment are shown in Table 7. There were no clinically meaningful differences between groups for any of the four parameters. Table 7: Mean Changes from Baseline to Month 12 in Patients with GD1 Switching to CERDELGA in Trial 2 Imiglucerase (N=47) Mean [95% CI] CERDELGA (N=99) Mean [95% CI] MN = Multiples of Normal, CI = confidence interval   Percentage Change in Spleen Volume MN (%)* -3.0 [-6.4, 0.4] -6.2 [-9.5, -2.8] Absolute Change in Spleen Volume (MN)* -0.1 [-0.2, 0.0] -0.2 [-0.3, -0.1] Absolute Change in Hemoglobin Level (g/dL) 0.0 [-0.2, 0.2] -0.2 [-0.4, -0.1] Percentage Change in Liver Volume MN (%) 3.6 [0.6, 6.6] 1.8 [-0.2, 3.7] Absolute Change in Liver Volume (MN) 0.0 [0.0, 0.1] 0.0 [0.0, 0.0] Percentage Change in Platelet Count (%) 2.9 [-0.6, 6.4] 3.8 [0.0, 7.6] Absolute Change in Platelet Count (x 109/L) 6.0 [-0.9, 13.0] 9.5 [1.4, 17.6] Patients Stable for 52 Weeks, n (%) (Composite Primary Endpoint) 44 (93.6) 84 (84.8) Excludes patients with a total splenectomy 16 HOW SUPPLIED/STORAGE AND HANDLING CERDELGA is supplied as 84 mg hard gelatin capsules, with a pearl blue-green opaque cap and pearl white opaque body imprinted with "GZ02" in black. CERDELGA 84 mg capsules are supplied as: NDC-58468-0220-1 – Carton containing 4 packs of capsules (56 capsules total). Each pack is composed of 1 blister card of 14 capsules and a cardboard wallet. NDC-58468-0220-2 – Carton containing 1 pack of capsules (14 capsules total). Each pack is comprised of 1 blister card of 14 capsules and a cardboard wallet. Store at 68 °F - 77 °F (20 °C - 25 °C) with excursions permitted between 59 °F and 86 °F (15 °C to 30 °C) [see USP Controlled Room Temperature]. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=819f828a-b888-4e46-83fc-94d774a28a83 赛诺菲口服戈谢病药物Cerdelga获欧盟批准 赛诺菲(Sanofi)颠覆性口服戈谢病药物Cerdelga(eliglustat)近日如愿获得欧盟批准，用作特定1型戈谢病(Gaucher disease)成人患者的一线口服疗法。在美国，Cerdelga于2014年8月获得FDA批准。 Cerdelga不适用于经基因检测(CYP2D6)证实对Cerdelga代谢更快或代谢速度不确定的少数患者。赛诺菲计划从2015年开始陆续将Cerdelga推向欧盟成员国市场。 目前，酶替代疗法(ERT)是戈谢病的标准治疗方案，患者需终身定期(每2周注射一次)接受静脉输注。业界预测，Cerdelga作为首个口服治疗药物，将完全颠覆当前依赖注射型药物的戈谢病市场格局，成为1型戈谢病群体的一个重要新治疗选择。 赛诺菲花了足足15年时间，终于研制成功首个口服戈谢病药物Cerdelga，该药的临床项目，是有史以来在戈谢病群体中开展的最大规模临床项目，涉及29个国家约400例患者。III期项目中，Cerdelga在2个试验中均成功稳定了病情：其中一项安慰剂对照研究在初治患者中开展，另一项研究则证明了Cerdelga对酶替代疗法Cerezyme的非劣效性。 Cerezyme(注射用伊米苷酶，imiglucerase)是赛诺菲旗下罕见病单元健赞(Genzyme)在20多年前推出的全球首个戈谢病治疗药物，也曾一度是全球最昂贵的药物，治疗成本高达30万美元/年。过去多年，Cerezyme一直统治戈谢病市场。业界预测，口服药物Cerdelga将大肆瓜分Cerezyme的市场份额，同时将与另2种注射药物——夏尔(Shire)的Vpriv和辉瑞(Pfizer)的Elelyso展开竞争。 Cerdelga是一种强效、高度特异性神经酰胺类似物抑制剂，靶向葡萄糖神经酰胺合成酶(glucosylceramide synthase, GCS)，能够降低葡萄糖神经酰胺的产生。Cerdelga适用于肝脏药物代谢酶细胞色素P450 2D6(CYP2D6)代谢基因型为弱代谢(poor metabolizers，PMs)、中等代谢(intermediate metabolizers，IMs)、快代谢(extensive metabolizers，EMs)的1型戈谢病成人患者的长期治疗，但不适用于超速代谢者(ultrarapid metabolizers，UMs)。 Cerdelga的获批，对戈谢病群体是一个大好消息，无论从科学和临床角度来看，该药作为一种一线口服药物，已被证明具有积极的风险/利益属性。酶替代疗法(ERT)能够降解沉积在细胞中的脂肪沉积物并会引起各种症状，而Cerdelga则能够直接抑制脂肪沉积物在细胞中的积累。 戈谢病(Gaucher Disease)是一种常染色体隐性遗传所造成的葡糖脑苷脂沉积症，主要是因编码葡萄糖脑苷酯酶(glucocerebrosidase) 的结构基因突变，导致该酶缺乏，致使巨噬细胞内的葡萄糖脑苷脂不能被进一步水解而堆积在溶酶体中，导致细胞失去原有的功能。这些病理性细胞在人体器官中的浸润会造成骨骼、骨髓、脾脏、肝脏和肺部的病变。目前，全球仅有1万名戈谢病患者，美国患者总数约为6000人。