首个口服戈谢病药物Cerdelga（eliglustat 中文译名：依利格鲁司特硬胶囊）获欧美批准上市
近日，颠覆性口服戈谢病药物Cerdelga (eliglustat) 已如愿获批上市，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。
批准日期：2014年8月19日[美国] 2015年1月22日[欧盟] 2015年4月2日[日本]；公司：Genzyme Corporation
CERDELGA™(eliglustat)胶囊，为口服使用
初次批准：2014
作用机制
戈谢病是溶酶体酶酸性β-葡萄糖苷酶缺乏所致。酸性β-葡萄糖苷酶催化神经鞘脂类葡糖脑苷脂转化为葡萄糖和神经酰胺。酶的缺乏致葡糖苷酯酰鞘氨醇(GL-1)的蓄积主要地在巨噬细胞的溶酶体隔室, 产生泡沫细胞或"戈谢[Gaucher]细胞"。CERDELGA是一种特异性葡萄糖神经酰胺合酶抑制剂(IC50 = 10 ng/mL)，和作用如同对GD1底物减低治疗。在临床试验 CERDELGA减小脾和肝大小，和改善贫血和血小板减少。
在这个溶酶体贮存疾病(LSD)，临床特点是戈谢[Gucher]胞在肝脏，脾，骨髓，和其他器官积蓄的反映。戈谢细胞在肝，脾，和骨髓的积蓄导致器官肿大和骨骼疾病。在骨髓和脾中存在戈谢细胞导致临床上显著贫血和血小板减少。
适应证和用途
CERDELGA是一种葡萄糖神经酰胺合酶抑制剂长期治疗有戈谢病1型成年病人是被FDA-批准的试验的CYP2D6快代谢型(EMs)，中间代谢型(IMs)，或慢代谢型(PMs)。
使用限制:
⑴ CYP2D6超快速代谢者可能不实现CERDELGA适当治疗作用浓度。
⑵ 对CYP2D6不确定代谢者不能推荐一个特异性剂量
剂量和给药方法
⑴用FDA-批准的试验测定CYP2D6基因型选择病人。
⑵ CYP2D6 EMs或IMs：84 mg口服每天2次。
⑶ CYP2D6 PMs：84 mg口服每天1次。
⑷ 整吞胶囊，不要粉碎，溶解或打开胶囊。
⑸ 避免吃柚子或饮柚子汁。
剂型和规格
84 mg胶囊
禁忌证
⑴ CYP2D6 EMs和IMs服用强或中度CYP2D6抑制剂与强或中度CYP3A抑制剂
⑵ CYP2D6 IMs和PMs服用强CYP3A抑制剂。
警告和注意事项
⑴ ECG变化和对心律失常潜能：不推荐在有预先存在心脏病病人，长QT综合征，和类别IA和类别III抗心律失常药同时使用。
不良反应
最常见不良反应(≥10%)是：疲乏，头痛，恶心, 腹泻，背痛，四肢痛，和上腹痛
药物相互作用
⑴ Eliglustat是一种CYP2D6和CYP3A底物。CERDELGA与抑制CYP2D6和CYP3A  药物的共同给药可能显著增加对eliglustat暴露和导致延长PR，QTc，和/或QRS心脏间隔，可能导致心律失常。治疗前和期间考虑潜在药物相互作用。
⑵ CYP2D6 IMs和PMs服用中度CYP3A抑制剂：不推荐使用。
⑶ CYP2D6 PMs服用弱CYP3A抑制剂：不推荐使用。
⑷ CYP2D6 EMs和IMs服用强或中度CYP2D6抑制剂和CYP2D6 EMs服用强或中度CYP3A抑制剂：减低剂量至84 mg每天1次。
⑸ Eliglustat是一种P-gp和CYP2D6抑制剂。与P-gp或CYP2D6底物药物共同给药可能导致增加其他药物浓度。
⑹ 临床上显著药物相互作用清单见完整处方资料。
特殊人群中使用
⑴ 妊娠：只有如潜在获益胜过潜在风险才给予。根据动物数据，可能致胎儿危害。
⑵ 哺乳母亲：终止药物或哺乳考虑药物对母亲重要性。
⑶ 肾受损：在中度至严重受损不推荐。
⑷ 肝受损：不推荐

Cerdelga 84 mg capsules, hard
Genzyme Therapeutics
1. Name of the medicinal product
Cerdelga 84 mg capsules, hard
2. Qualitative and quantitative composition
Each capsule contains 84.4 mg of eliglustat (as tartrate).
Excipient(s) with known effect:
Each capsule contains 106 mg lactose (as monohydrate).
For the full list of excipients, see section 6.1.
3. Pharmaceutical form
Capsule, hard.
Capsule with pearl blue-green opaque cap and pearl white opaque body with “GZ02” printed in black on the body of the capsule. The size of the capsule is 'size 2' (dimensions 18.0 x 6.4 mm).
4. Clinical particulars
4.1 Therapeutic indications
Cerdelga is indicated for the long-term treatment of adult patients with Gaucher disease type 1 (GD1), who are CYP2D6 poor metabolisers (PMs), intermediate metabolisers (IMs) or extensive metabolisers (EMs).
4.2 Posology and method of administration
Therapy with Cerdelga should be initiated and supervised by a physician knowledgeable in the management of Gaucher disease.
Posology
The recommended dose is 84 mg eliglustat twice daily in CYP2D6 intermediate metabolisers (IMs) and extensive metabolisers (EMs). The recommended dose is 84 mg eliglustat once daily in CYP2D6 poor metabolisers (PMs). If a dose is missed, the prescribed dose should be taken at the next scheduled time; the next dose should not be doubled.
The capsules may be taken with or without food. Consumption of grapefruit or its juice should be avoided (see section 4.5).
Special populations
CYP2D6 ultra-rapid metabolisers (URMs) and indeterminate metabolisers
Cerdelga should not be used in patients who are CYP2D6 ultra-rapid metabolisers (URMs) or indeterminate metabolisers (see section 4.4).
Patients with hepatic impairment
Cerdelga has not been studied in patients with hepatic impairment. Therefore, no dose recommendations can be made.
Patients with renal impairment
Cerdelga has not been studied in patients with renal impairment. Therefore, no dose recommendations can be made.
Elderly patients (≥65 years)
A limited number of patients aged 65 and over were enrolled in clinical trials. No significant differences were found in the efficacy and safety profiles of elderly patients and younger patients.
Paediatric population
The safety and efficacy of Cerdelga in children and adolescents under the age of 18 years has not been established. No data are available.
Method of administration
Cerdelga is to be taken orally. The capsules should be swallowed whole, preferably with water, and should not be crushed, dissolved, or opened.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
Patients who are CYP2D6 intermediate metabolisers (IMs) or extensive metabolisers (EMs) taking a strong or moderate CYP2D6 inhibitor concomitantly with a strong or moderate CYP3A inhibitor, and patients who are CYP2D6 poor metabolisers (PMs) taking a strong CYP3A inhibitor. Use of Cerdelga under these conditions results in substantially elevated eliglustat plasma concentrations (see section 4.4 and 4.5).
4.4 Special warnings and precautions for use
Initiation of therapy: CYP2D6 genotyping
Before initiation of treatment with Cerdelga, patients should be genotyped for CYP2D6 to determine the CYP2D6 metaboliser status (see section 4.2, Special populations).
Drug-drug interactions
Cerdelga is contraindicated in patients who are CYP2D6 intermediate metabolisers (IMs) or extensive metabolisers (EMs) taking a strong (e.g. paroxetine, fluoxetine, quinidine) or moderate (e.g. duloxetine, terbinafine) CYP2D6 inhibitor concomitantly with a strong (e.g. clarithromycin, itraconazole) or moderate (e.g. erythromycin, fluconazole) CYP3A inhibitor, and in patients who are CYP2D6 poor metabolisers (PMs) taking a strong CYP3A inhibitor. Under these conditions both major metabolic pathways for eliglustat metabolism are impaired, with predicted substantially elevated eliglustat plasma concentrations (see section 4.5). Although no significant QTc increases were seen in a thorough QT study in healthy volunteers, based on PK/PD modelling, eliglustat plasma concentrations 11-fold the predicted human Cmax are predicted to cause mild increases in the PR, QRS, and QTc intervals (see section 5.1, Electrocardiographic evaluation).
For use of Cerdelga with one strong or moderate inhibitor of CYP2D6 or CYP3A, see section 4.5.
Use of Cerdelga with strong CYP3A inducers substantially decreases the exposure to eliglustat, which may reduce the therapeutic effectiveness of eliglustat; therefore concomitant administration is not recommended (see section 4.5).
Patients with pre-existing cardiac conditions
Use of Cerdelga in patients with pre-existing cardiac conditions has not been studied during clinical trials. Because eliglustat is predicted to cause mild increases in ECG intervals at substantially elevated plasma concentrations, use of Cerdelga should be avoided in patients with 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) and Class III (e.g. amiodarone, sotalol) antiarrhythmic medicinal products.
Monitoring of clinical response
Some treatment-naïve patients showed less than 20% spleen volume reduction (sub-optimal results) after 9 months of treatment (see section 5.1). For these patients, monitoring for further improvement or an alternative treatment modality should be considered.
For patients with stable disease who switch from enzyme replacement therapy to eliglustat, monitoring for disease progression (e.g. after 6 months with regular monitoring thereafter) should be performed for all disease domains to evaluate disease stability. Reinstitution of enzyme replacement therapy or an alternative treatment modality should be considered in individual patients who have a sub-optimal response.
Lactose
Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.
4.5 Interaction with other medicinal products and other forms of interaction
Eliglustat is metabolised primarily by CYP2D6 and to a lesser extent by CYP3A4. Concomitant administration of substances affecting CYP2D6 or CYP3A4 activity may alter eliglustat plasma concentrations. Eliglustat is an inhibitor of P-gp and CYP2D6 in vitro; concomitant administration of eliglustat with P-gp or CYP2D6 substrate substances may increase the plasma concentration of those substances.
The list of substances in section 4.5 is not an inclusive list and the prescriber is advised to consult the SmPC of all other prescribed medicinal products for potential drug-drug interactions with eliglustat.
Agents that may increase eliglustat exposure
Cerdelga is contraindicated in patients who are CYP2D6 intermediate metabolisers (IMs) or extensive metabolisers (EMs) taking a strong or moderate CYP2D6 inhibitor concomitantly with a strong or moderate CYP3A inhibitor , and in patients who are CYP2D6 poor metabolisers (PMs) taking a strong CYP3A inhibitor (see section 4.3). Use of Cerdelga under these conditions results in substantially elevated eliglustat plasma concentrations.
CYP2D6 inhibitors
In intermediate (IMs) and extensive metabolisers (EMs):
After repeated 84 mg twice daily doses of eliglustat in non-PMs, concomitant administration with repeated 30 mg once daily doses of paroxetine, a strong inhibitor of CYP2D6, resulted in a 7.3- and 8.9-fold increase in eliglustat Cmax and AUC0-12, respectively. A dose of eliglustat 84 mg once daily should be considered when a strong CYP2D6 inhibitor (e.g. paroxetine, fluoxetine, quinidine, bupropion) is used concomitantly in IMs and EMs.
At 84 mg twice daily dosing with eliglustat in non-PMs, it is predicted that concomitant use of moderate CYP2D6 inhibitors (e.g. duloxetine, terbinafine, moclobemide, mirabegron, cinacalcet, dronedarone) would increase eliglustat exposure approximately up to 4-fold. Caution should be used with moderate CYP2D6 inhibitors in IMs and EMs.
CYP3A inhibitors
In intermediate (IMs) and extensive metabolisers (EMs):
After repeated 84 mg twice daily doses of eliglustat in non-PMs, concomitant administration with repeated 400 mg once daily doses of ketoconazole, a strong inhibitor of CYP3A, resulted in a 3.8 and 4.3-fold increase in eliglustat Cmax and AUC0-12, respectively; similar effects would be expected for other strong inhibitors of CYP3A (e.g. clarithromycin, ketoconazole, itraconazole, cobicistat, indinavir, lopinavir, ritonavir, saquinavir, telaprevir, tipranavir, posaconazole, voriconazole, telithromycin, conivaptan, bocerevir). Caution should be used with strong CYP3A inhibitors in IMs and EMs.
At 84 mg twice daily dosing with eliglustat in non-PMs, it is predicted that concomitant use of moderate CYP3A inhibitors (e.g. erythromycin, ciprofloxacin, fluconazole, diltiazem, verapamil, aprepitant, atazanavir, darunavir, fosamprenavir, imatinib, cimetidine) would increase eliglustat exposure approximately up to 3-fold. Caution should be used with moderate CYP3A inhibitors in IMs and EMs.
In poor metabolisers (PMs):
At 84 mg once daily dosing with eliglustat in PMs, it is predicted that concomitant use of strong CYP3A inhibitors (e.g. ketoconazole, clarithromycin, itraconazole, cobicistat, indinavir, lopinavir, ritonavir, saquinavir, telaprevir, tipranavir, posaconazole, voriconazole, telithromycin, conivaptan, boceprevir) would increase the Cmax and AUC0-24 of eliglustat 4.3- and 6.2-fold. The use of strong CYP3A inhibitors is contraindicated in PMs.
At 84 mg once daily dosing with eliglustat in PMs, it is predicted that concomitant use of moderate CYP3A inhibitors (e.g. erythromycin, ciprofloxacin, fluconazole, diltiazem, verapamil, aprepitant, atazanavir, darunavir, fosamprenavir, imatinib, cimetidine) would increase the Cmax and AUC0-24 of eliglustat 2.4- and 3.0-fold, respectively. Use of a moderate CYP3A inhibitor with eliglustat is not recommended in PMs.
Caution should be used with weak CYP3A inhibitors (e.g. amlodipine, cilostazol, fluvoxamine, goldenseal, isoniazid, ranitidine, ranolazine) in PMs.
CYP2D6 inhibitors used simultaneously with CYP3A inhibitors
In intermediate (IMs) and extensive metabolisers (EMs):
At 84 mg twice daily dosing with eliglustat in non-PMs, it is predicted that the concomitant use of strong or moderate CYP2D6 inhibitors and strong or moderate CYP3A inhibitors would increase Cmax and AUC0-12 up to 17- and 25-fold, respectively. The use of a strong or moderate CYP2D6 inhibitor concomitantly with a strong or moderate CYP3A inhibitor is contraindicated in IMs and EMs.
Grapefruit products contain one or more components that inhibit CYP3A and can increase plasma concentrations of eliglustat. Consumption of grapefruit or its juice should be avoided.
Agents that may decrease eliglustat exposure
Strong CYP3A inducers
After repeated 127 mg twice daily doses of eliglustat in non-PMs, concomitant administration of repeated 600 mg once daily doses of rifampicin (a strong inducer of CYP3A as well as the efflux transporter P-gp) resulted in an approximately 85% decrease in eliglustat exposure. After repeated 84 mg twice daily doses of eliglustat in PMs, concomitant administration of repeated 600 mg once daily doses of rifampicin resulted in an approximately 95% decrease in eliglustat exposure. Use of a strong CYP3A inducer (e.g. rifampicin, carbamazepine, phenobarbital, phenytoin, rifabutin and St. John's wort) with eliglustat is not recommended in IMs, EMs and PMs.
Agents whose exposure may be increased by eliglustat
P-gp substrates
After a single 0.25 mg dose of digoxin, a P-gp substrate, concomitant administration of 127 mg twice daily doses of eliglustat resulted in a 1.7- and 1.5-fold increase in digoxin Cmax and AUClast, respectively. Lower doses of substances which are P-gp substrates (e.g. digoxin, colchicine, dabigatran, phenytoin, pravastatin) may be required.
CYP2D6 substrates
After a single 50 mg dose of metoprolol, a CYP2D6 substrate, concomitant administration of repeated 127 mg twice daily doses of eliglustat resulted in a 1.5- and 2.1-fold increase in metoprolol Cmax and AUC, respectively. Lower doses of medicinal products that are CYP2D6 substrates may be required. These include certain antidepressants (tricyclic antidepressants, e.g. nortriptyline, amitriptyline, imipramine, and desipramine), phenothiazines, dextromethorphan and atomoxetine).
4.6 Fertility, pregnancy and lactation
Pregnancy
There are no or limited amount of data from the use of eliglustat in pregnant women. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity (see section 5.3). As a precautionary measure, it is recommended to avoid the use of Cerdelga during pregnancy.
Breast-feeding
It is unknown whether eliglustat or its metabolites are excreted in human milk. Available pharmacodynamic/toxicological data in animals have shown excretion of eliglustat in milk (see section 5.3). A risk to the newborns/infants cannot be excluded. A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from Cerdelga therapy taking into account the benefit of breast-feeding for the child and the benefit of therapy for the woman.
Fertility
Effects on testes and reversible inhibition of spermatogenesis were observed in rats (see section 5.3). The relevance of these findings for humans is not known.
4.7 Effects on ability to drive and use machines
Cerdelga has no or negligible influence on the ability to drive and use machines.
4.8 Undesirable effects
Summary of the safety profile
The majority of adverse reactions are mild and transient. The most frequently reported adverse reaction with Cerdelga is dyspepsia, in approximately 6% of the patients. About 2% of patients receiving Cerdelga in clinical trials permanently discontinued treatment due to any adverse reaction.
The most frequently reported serious adverse reaction in clinical studies was syncope (0.8%). All events were associated with predisposing risk factors and appeared to be vasovagal in nature. None of these events led to discontinuation from the study.
Tabulated list of adverse reactions
The overall adverse reaction profile of Cerdelga is based on 1400 patient-years of treatment exposure and pooled results from the primary analysis periods and extension periods of two pivotal Phase 3 studies (ENGAGE and ENCORE), one 8-year, long term Phase 2 study (Study 304) and one supporting Phase 3b study (EDGE). In these four studies a total of 393 patients between the ages of 16-75 years received eliglustat for a median duration of 3.5 years (up to 9.3 years).
Adverse reactions are ranked by system organ class and frequency ([very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000)]). All adverse reactions reported in >2% of the patients are presented in Table 1.Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.
Table 1: Tabulated list of adverse reactions

System Organ Class	Common
Nervous system disorders	Headache*, dizziness*
Cardiac disorders	Palpitations
Gastrointestinal disorders	Dyspepsia, abdominal pain upper*, diarrhoea*, nausea, constipation, abdominal pain*, gastrooesophageal reflux disease, abdominal distension*, gastritis,
Musculoskeletal and connective tissue disorders	Arthralgia
General disorders and administration site conditions	Fatigue

A cut-off of >2% was applied
The incidence of the adverse reaction was the same or higher with placebo than with Cerdelga in the placebo-controlled pivotal study.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the national reporting system listed below:
United Kingdom
Yellow Card Scheme
Website: www.mhra.gov.uk/yellowcard
Ireland
HPRA Pharmacovigilance
Earlsfort Terrace
IRL - Dublin 2
Tel: +353 1 6764971
Fax: +353 1 6762517
Website: www.hpra.ie
e-mail: medsafety@hpra.ie
4.9 Overdose
The highest eliglustat plasma concentration observed to date occurred in a Phase 1 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 treatment and supportive care.
5. Pharmacological properties
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Other alimentary tract and metabolism products, Various alimentary tract and metabolism products, ATC code: A16AX10.
Mechanism of action
Eliglustat is a potent and specific inhibitor of glucosylceramide synthase, and acts as a substrate reduction therapy (SRT) for GD1. SRT aims to reduce the rate of synthesis of the major substrate glucosylceramide (GL-1) to match its impaired rate of catabolism in patients with GD1, thereby preventing glucosylceramide accumulation and alleviating clinical manifestations.
Pharmacodynamic effects
In clinical trials in treatment-naïve GD1 patients, plasma GL-1 levels were elevated in the majority of these patients and decreased upon Cerdelga treatment. Additionally, in a clinical trial in GD1 patients stabilised on enzyme replacement therapy (ERT) (i.e. having already achieved therapeutic goals on ERT prior to initiating Cerdelga treatment), plasma GL-1 levels were normal in most patients and decreased upon Cerdelga treatment.
Clinical efficacy and safety
The recommended dosing regimens (see section 4.2) are based on modelling, either of PK/PD data from the dose-titration regimens applied in the clinical studies for IMs and EMs, or physiologically-based PK data for PMs.
Pivotal study of Cerdelga in treatment-naïve GD1 patients – study 02507(ENGAGE)
Study 02507 was a randomized, double-blind, placebo-controlled, multicenter clinical study in 40 patients with GD1. In the Cerdelga group 3 (15%) patients received a starting dose of 42 mg eliglustat twice daily during the 9-month primary analysis period and 17 (85%) patients received a dose escalation to 84 mg twice daily based on plasma trough concentration.
Table 2: Change from baseline to Month 9 (primary analysis period) in treatment-naïve patients with GD1 receiving treatment with Cerdelga in study 02507

Placebo* (n=20) a	Cerdelga (n=20) a	Difference (Cerdelga – Placebo) [95% CI]	p valueb
Percentage Change in Spleen Volume MN (%) (primary endpoint)	2.26	-27.77	-30.0 [-36.8, -23.2]	<0.0001
Absolute Change in Haemoglobin Level (g/dL) (secondary endpoint)	-0.54	0.69	1.22 [0.57, 1.88]	0.0006
Percentage Change in Liver Volume MN (%) (secondary endpoint)	1.44	-5.20	-6.64 [-11.37, -1.91]	0.0072
Percentage Change in Platelet Count (%) (secondary endpoint)	-9.06	32.00	41.06 [23.95, 58.17]	<0.0001

MN = Multiples of Normal, CI = confidence interval
a 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 haemoglobin levels were 12.8 and 12.1 g/dL, and platelet counts were 78.5 and 75.1 x 109/L, respectively.
b Estimates and p-values are based on an ANCOVA model
All patients transitioned to Cerdelga treatment after Month 9.
During the open-label long term treatment period with Cerdelga (extension phase), all patients with complete data who continued to receive Cerdelga showed further improvements throughout the extension phase. Results (change from baseline) after 18 months, 30 months and 4.5 years of exposure to Cerdelga on the following endpoints were: absolute change in haemoglobin level (g/dL) 1.1 (1.03) [n=39], 1.4 (0.93) [n=35], and 1.4 (1.31) [n=12]; mean increase in platelet count (mm3) 58. 5% (40.57%) [n=39], 74.6% (49.57%) [n=35], and 86.8% (54.20%) [n=12]; mean reduction in spleen volume (MN) 46.5% (9.75%) [n=38], 54.2% (9.51%) [n=32], and 65.6% (7.43%) [n=13]; and mean reduction in liver volume (MN) 13.7% (10.65%) [n=38], 18.5% (11.22%) [n=32], and 23.4% (10.59%) [n=13].
Long-term clinical outcomes in treatment-naïve GD1 patients – study 304
Study 304 was a single-arm, open-label, multicenter study of Cerdelga in 26 patients. Nineteen patients completed 4 years of treatment. Fifteen (79%) of these patients received a dose escalation to 84 mg eliglustat twice daily; 4 (21%) patients continued to receive 42 mg twice daily.
Eighteen patients completed 8 years of treatment. One patient (6%) received a further dose escalation to 127 mg twice daily. Fourteen (78%) continued on 84 mg Cerdelga twice daily. Three (17%) patients continued to receive 42 mg twice daily. Sixteen patients had an efficacy endpoint assessment at year 8.
Cerdelga showed sustained improvements in organ volume and haematological parameters over the 8 year treatment period (see Table 3).
Table 3: Change from baseline to year 8 in study 304

N	Baseline Value (Mean)	Change from Baseline (Mean)	Standard Deviation
Spleen Volume (MN)	15	17.34	-67.9%	17.11
Haemoglobin Level (g/dL)	16	11.33	2.08	1.75
Liver Volume (MN)	15	1.60	-31.0%	13.51
Platelet Count (x109/L)	16	67.53	109.8%	114.73

MN = Multiples of Normal
Pivotal study of Cerdelga in GD1 patients switching from ERT– Study 02607 (ENCORE)
Study 02607 was a randomized, open-label, active-controlled, non-inferiority, multicenter clinical study in 159 patients previously stabilised with ERT. In the Cerdelga group 34 (32%) patients received a dose escalation to 84 mg eliglustat twice daily and 51 (48%) to 127 mg twice daily during the 12-month primary analysis period , and 21 (20%) patients continued to receive 42 mg twice daily.
Based on the aggregate data from all doses tested in this study, Cerdelga met the criteria set in this study to be declared non-inferior to Cerezyme (imiglucerase) in maintaining patient stability. After 12 months of treatment, the percentage of patients meeting the primary composite endpoint (composed of all four components mentioned in Table 4) was 84.8% [95% confidence interval 76.2% - 91.3%] for the Cerdelga group compared to 93.6% [95% confidence interval 82.5% - 98.7 %] for the Cerezyme group. Of the patients who did not meet stability criteria for the individual components, 12 of 15 Cerdelga patients and 3 of 3 Cerezyme patients remained within therapeutic goals for GD1.
There were no clinically meaningful differences between groups for any of the four individual disease parameters (see Table 4).
Table 4: Changes from baseline to Month 12 (primary analysis period) in patients with GD1 switching to Cerdelga in study 02607

Cerezyme (N=47)** Mean [95% CI]		Cerdelga (N=99) Mean [95% CI]
Spleen Volume
Percentage of Patients with stable spleen volume*a		100%		95.8%
Percentage Change in Spleen Volume MN (%)*		-3.01 [-6.41, 0.40]		-6.17 [-9.54, -2.79]
Haemoglobin Level
Percentage of Patients with stable haemoglobin levela		100%		94.9%
Absolute Change in Haemoglobin Level (g/dL)		0.038 [-0.16, 0.23]		-0.21 [-0.35, -0.07]
Liver Volume
Percentage of Patients with stable liver volumea		93.6%		96.0%
Percentage Change in Liver Volume MN (%)		3.57 [0.57, 6.58]		1.78 [-0.15, 3.71]
Platelet Count
Percentage of Patients with stable platelet counta		100%		92.9%
Percentage Change in Platelet Count (%)		2.93 [-0.56, 6.42]		3.79 [0.01, 7.57]

MN = Multiples of Normal, CI = confidence interval
Excludes patients with a total splenectomy.
All patients transitioned to Cerdelga treatment after 52 weeks
a The stability criteria based on changes between baseline and 12 months: haemoglobin level ≤1.5 g/dL decrease, platelet count ≤25% decrease, liver volume ≤20% increase, and spleen volume ≤25% increase.
All patient number (N)= Per Protocol Population
During the open-label long term treatment period with Cerdelga (extension phase) the percentage of patients with complete data meeting the composite stability endpoint was maintained at 84.6% (n=136) after 2 years, 84.4% (n=109) after 3 years and 91.1% (n=45) after 4 years. The majority of extension phase discontinuations were due to transition to commercial product from year 3 onwards. Individual disease parameters of spleen volume, liver volume, haemoglobin levels and platelet count remained stable through 4 years (see Table 5).
Table 5: Changes from Month 12 (primary analysis period) to Month 48 in patients with GD1 in the Long Term Treatment Period on Cerdelga in study 02607

Year 2		Year 3		Year 4
	Cerezyme /Cerdelgaa Mean [95% CI]	Cerdelgab   Mean [95% CI])	Cerezyme /Cerdelgaa Mean [95% CI]	Cerdelgab   Mean [95% CI]	Cerezyme /Cerdelgaa Mean [95% CI]	Cerdelgab   Mean [95% CI]
Patients at start of year (N)	51	101	46	98	42	96
Patients at end of year (N)	46	98	42	96	21	44
Patients with available data (N)	39	97	16	93	3	42
Spleen Volume
Patients with stable spleen volume (%)*	31/33 (93.9) [0.798, 0.993]	69/72 (95.8) [0.883, 0.991]	12/12 (100.0) [0.735, 1.000]	65/68 (95.6) [0.876, 0.991]	2/2 (100.0) [0.158, 1.000]	28/30 (93.3) [0.779, 0.992]
Change in Spleen Volume MN (%)*	-3.946[-8.80, 0.91]	-6.814[-10.61, -3.02]	-10.267[-20.12, -0.42]	-7.126[-11.70, -2.55]	-27.530[-89.28, 34.22]	-13.945[-20.61, -7.28]
Haemoglobin Level
Patients with stable haemoglobin level (%)	38/39 (97.4) [0.865, 0.999]	95/97 (97.9) [0.927, 0.997]	16/16 (100.0) [0.794, 1.000]	90/93 (96.8) [0.909, 0.993]	3/3 (100.0) (0.292, 1.000]	42/42 (100.0) [0.916, 1.000]
Change from baseline in Haemoglobin Level (g/dL)	0.034[-0.31, 0.38]	-0.112[-0.26, 0.04]	0.363[-0.01, 0.74]	-0.103[-0.27, 0.07]	0.383[-1.62, 2.39]	0.290[0.06, 0.53]
Liver Volume
Patients with stable liver volume (%)	38/39 (97.4) (0.865, 0.999)	94/97 (96.9) (0.912, 0.994)	15/16 (93.8) [0.698, 0.998]	87/93 (93.5) (0.865, 0.976)	3/3 (100.0) [0.292, 1.000]	40/42 (95.2) [0.838, 0.994]
Change from baseline in Liver Volume MN (%)	0.080[-3.02, 3.18]	2.486[0.50, 4.47]	-4.908[-11.53, 1.71]	3.018[0.52, 5.52]	-14.410[-61.25, 32.43]	-1.503[-5.27, 2.26]
Platelet Count
Patients with stable platelet count (%)	33/39 (84.6) [0.695, 0.941]	92/97 (94.8) [0.884, 0.983]	13/16 (81.3) [0.544, 0.960]	87/93 (93.5) [0.865, 0.976]	3/3 (100.0) [0.292, 1.000]	40/42 (95.2) [0.838, 0.994]
Change in Platelet Count (%)	-0.363[-6.60, 5.88]	2.216[-1.31, 5.74]	0.719[-8.20, 9.63]	5.403[1.28, 9.52]	-0.163[-35.97, 35.64]	7.501[1.01, 13.99]
Composite Stability Endpoint
Patients who are Stable on Cerdelga (%)	30/39 (76.9) [0.607, 0.889]	85/97 (87.6) [0.794, 0.934]	12/16 (75.0) [0.476, 0.927]	80/93 (86.0) [0.773, 0.923]	3/3 (100.0) [0.292, 1.000]	38/42 (90.5) [0.774, 0.973]

MN = Multiples of Normal, CI = confidence interval
Excludes patients with a total splenectomy.
a Cerezyme/Cerdelga - Originally Randomized to Cerezyme
b Cerdelga - Originally Randomized to Cerdelga
Clinical experience in CYP2D6 poor metabolisers (PMs) and ultra-rapid metabolisers (URMs)
There is limited experience with Cerdelga treatment of patients who are PMs or URMs. In the primary analysis periods of the three clinical studies, a total of 5 PMs and 5 URMs were treated with Cerdelga. All PMs received 42 mg eliglustat twice daily, and four of these (80%) had an adequate clinical response. The majority of URMs (80%) received a dose escalation to 127 mg eliglustat twice daily, all of which had adequate clinical responses. The one URM who received 84 mg twice daily did not have an adequate response.
The predicted exposures with 84 mg eliglustat once daily in patients who are PMs are expected to be similar to exposures observed with 84 mg eliglustat twice daily in CYP2D6 intermediate metabolisers (IMs). Patients who are URMs may not achieve adequate concentrations to achieve a therapeutic effect. No dosing recommendation for URMs can be given.
Effects on skeletal pathology
After 9 months of treatment, in Study 02507, bone marrow infiltration by Gaucher cells, as determined by the total Bone Marrow Burden (BMB) score (assessed by MRI in lumbar spine and femur) decreased by a mean of 1.1 points in Cerdelga treated patients (n=19) compared to no change in patients receiving placebo (n=20). Five Cerdelga-treated patients (26%) achieved a reduction of at least 2 points in the BMB score.
After 18 and 30 months of treatment, BMB score had decreased by a mean 2.2 points (n=18) and 2.7 (n=15), respectively for the patients originally randomised to Cerdelga, compared to a mean decrease of 1 point (n=20) and 0.8 (n=16) in those originally randomised to placebo.
After 18 months of Cerdelga treatment in the open-label extension phase, the mean (SD) lumbar spine Bone Mineral Density T-score increased from -1.14 (1.0118) at Baseline (n=34) to -0.918 (1.1601) (n=33) in the normal range. After 30 months and 4.5 years of treatment, the T-score further increased to -0.722 (1.1250) (n=27) and -0.533 (0.8031) (n=9), respectively.
Results of study 304 indicate that skeletal improvements are maintained or continue to improve during at least 8 years of treatment with Cerdelga.
In study 02607, lumbar spine and femur BMD T- and Z-scores were maintained within the normal range in patients treated with Cerdelga for up to 4 years.
Electrocardiographic evaluation
No clinically significant QTc prolonging effect of eliglustat was observed for single doses up to 675 mg.
Heart-rate corrected QT interval using Fridericia's correction (QTcF) was evaluated in a randomized, placebo and active (moxifloxacin 400 mg) controlled cross-over, single-dose study in 47 healthy subjects. In this trial with demonstrated ability to detect small effects, the upper bound of the one-sided 95% confidence interval for the largest placebo-adjusted, baseline-corrected QTcF was below 10 msec, the threshold for regulatory concern. While there was no apparent effect on heart rate, concentration-related increases were observed for the placebo corrected change from baseline in the PR, QRS, and QTc intervals. Based on PK/PD modelling, eliglustat plasma concentrations 11-fold the predicted human Cmax are expected to cause mean (upper bound of the 95% confidence interval) increases in the PR, QRS, and QTcF intervals of 18.8 (20.4), 6.2 (7.1), and 12.3 (14.2) msec, respectively.
Paediatric population
The European Medicines Agency has waived the obligation to submit the results of studies with Cerdelga in all subsets of the paediatric population in Gaucher disease Type 2 (see section 4.2 for information on paediatric use).
The European Medicines Agency has deferred the obligation to submit the results of studies with Cerdelga in the subsets of the paediatric population from 24 months to less than 18 years in Gaucher disease Type 1 and Type 3 (see section 4.2 for information on paediatric use).
5.2 Pharmacokinetic properties
Absorption
Median time to reach maximum plasma concentrations occurs between 1.5 to 3 hours after dosing, with low oral bioavailability (<5%) due to significant first-pass metabolism. Eliglustat is a substrate of the efflux transporter P-gp. Food does not have a clinically relevant effect on eliglustat pharmacokinetics. Following repeated dosing of eliglustat 84 mg twice daily, steady state was reached by 4 days, with an accumulation ratio of 3-fold or less. Oral dosing of 84 mg eliglustat once daily has not been studied in CYP2D6 poor metabolisers (PMs).
Distribution
Eliglustat is moderately bound to human plasma proteins (76 to 83%) and is mainly distributed in plasma. After intravenous administration, the volume of distribution was 816 L, suggesting wide distribution to tissues in humans. Nonclinical studies demonstrated a wide distribution of eliglustat to tissues, including bone marrow.
Biotransformation
Eliglustat 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.
Elimination
After oral administration, the majority of the administered dose is excreted in urine (41.8%) and faeces (51.4%), mainly as metabolites. After intravenous administration, eliglustat total body clearance was 86 L/h. After repeated oral doses of 84 mg eliglustat twice daily, eliglustat elimination half-life is approximately 4-7 hours in non-PMs and 9 hours in PMs.
Characteristics in specific groups
CYP2D6 phenotype
Population pharmacokinetic analysis shows that the CYP2D6 predicted phenotype based on genotype is the most important factor affecting pharmacokinetic variability. Individuals with a CYP2D6 poor metaboliser predicted phenotype (approximately 5 to 10% of the population) exhibit higher eliglustat concentrations than intermediate or extensive CYP2D6 metabolisers.
Gender, body weight, age, and race
Based on the population pharmacokinetic analysis, gender, body weight, age, and race had limited or no impact on the pharmacokinetics of eliglustat.
5.3 Preclinical safety data
The principal target organs for eliglustat in toxicology studies are the GI tract, lymphoid organs, the liver in rat only and, in the male rat only, the reproductive system. Effects of eliglustat in toxicology studies were reversible and exhibited no evidence of delayed or recurring toxicity. Safety margins for the chronic rat and dog studies ranged between 8-fold and 15-fold using total plasma exposure and 1- to 2-fold using unbound (free fraction) plasma exposures.
Eliglustat did not have effects on CNS or respiratory functions. Concentration-dependent cardiac effects were observed in nonclinical studies: inhibition of human cardiac ion channels, including potassium, sodium, and calcium, at concentrations ≥ 7-fold of predicted human Cmax; sodium ion channel-mediated effects in an ex-vivo electrophysiology study in dog Purkinje fibres (2-fold of predicted human unbound plasma Cmax); and increases in QRS and PR intervals in dog telemetry and cardiac conduction studies in anaesthesised dogs, with effects seen at concentrations 14-fold of predicted human total plasma Cmax, or 2-fold of predicted human unbound plasma Cmax.
Eliglustat was not mutagenic in a standard battery of genotoxicity tests and did not show any carcinogenic potential in standard lifetime bioassays in mice and rats. Exposures in the carcinogenicity studies were approximately 4-fold and 3-fold greater in mice and rats, respectively, than the mean predicted human eliglustat total plasma exposure, or less than 1-fold using unbound plasma exposure.
In mature male rats, no effects on sperm parameters were observed at systemically non-toxic doses. Reversible inhibition of spermatogenesis was observed in the rat at 10-fold of predicted human exposure based on AUC, a systemically toxic dose. In rat repeated dose toxicity studies, seminiferous epithelial degeneration and segmental hypoplasia of the testes was seen at 10-fold of predicted human exposure based on AUC.
Placental transfer of eliglustat and its metabolites was shown in the rat. At 2 and 24 hours post-dose, 0.034 % and 0.013 % of labelled dose was detected in foetal tissue, respectively.
At maternal toxic doses in rats, foetuses showed a higher incidence of dilated cerebral ventricles, abnormal number of ribs or lumbar vertebrae, and many bones showed poor ossification. Embryofoetal development in rats and rabbits was not affected up to clinically relevant exposure (based on AUC).
A lactation study in the rat showed that 0.23% of labelled dose was transferred to pups during 24 hours post-dose, indicating milk excretion of eliglustat and/or its related materials.
6. Pharmaceutical particulars
6.1 List of excipients
Capsule contents:
Microcrystalline cellulose
Lactose monohydrate
Hypromellose
Glycerol dibehenate
Capsule shell:
Gelatin
Potassium aluminium silicate (E555)
Titanium dioxide (E171)
Yellow iron oxide (E172)
Indigotine (E132)
Printing ink:
Shellac glaze
Black iron oxide (E172)
Propylene glycol
Ammonium hydroxide 28%
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
3 years
6.4 Special precautions for storage
This medicinal product does not require any special storage conditions.
6.5 Nature and contents of container
PETG/COC.PETG/PCTFE-aluminium blister
Each blister wallets contains 14 hard capsules.
Each pack contains 14, 56 or 196 hard capsules.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal and other handling
Any unused product or waste material should be disposed of in accordance with local requirements.
7. Marketing authorisation holder
Genzyme Europe B.V., Gooimeer 10, 1411DD, Naarden, The Netherlands
8. Marketing authorisation number(s)
EU/1/14/974/001 56 capsules
EU/1/14/974/002 196 capsules
EU/1/14/974/003 14 capsules
9. Date of first authorisation/renewal of the authorisation
Date of first authorisation: 19 January 2015
10. Date of revision of the text
01/09/2017
Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu.
首个口服戈谢病药物Cerdelga（eliglustat）获欧盟批准
近日,颠覆性口服戈谢病药物Cerdelga（eliglustat）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。
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。
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。
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上市国家: 荷兰
原产地英文商品名:
Cerdelga 84mg/caps 14caps/box
原产地英文药品名:
eliglustat
中文参考商品译名:
Cerdelga硬胶囊 100毫克/胶囊 14胶囊/盒
中文参考药品译名:
依利格鲁司特
生产厂家英文名:
Genzyme Europe B.V.
-----------------------------------------------
上市国家: 荷兰
原产地英文商品名:
Cerdelga 84mg/caps 56caps/box
原产地英文药品名:
eliglustat
中文参考商品译名:
Cerdelga硬胶囊 84毫克/胶囊 56胶囊/盒
中文参考药品译名:
依利格鲁司特
生产厂家英文名:
Genzyme Europe B.V.
-----------------------------------------------
上市国家: 荷兰
原产地英文商品名:
Cerdelga 84mg/caps 196caps/box
原产地英文药品名:
eliglustat
中文参考商品译名:
Cerdelga硬胶囊 84毫克/胶囊 196胶囊/盒
中文参考药品译名:
依利格鲁司特
生产厂家英文名:
Genzyme Europe B.V.