A US Food and Drug Administration advisory committee meeting on Biogen, Inc.’s Alzheimer’s drug aducanumab will offer some insight into the amount of flexibility the agency and its external experts are willing to exercise for neurodegenerative diseases with high unmet need, particularly in the wake of a December 2019 guidance document on the quantum and type of data capable of satisfying the “substantial evidence” standard.
On 6 November, the Peripheral and Central Nervous System Drugs Advisory Committee will consider the benefit/risk profile of aducanumab, an anti-amyloid-beta antibody infusion intended for treatment of Alzheimer’s, according to a notice due to publish in the Federal Register on 29 September. The meeting will be held virtually due to the COVID-19 pandemic. (Also see “Virtual Advisory Committees: US FDA Clears A Big Test With OxyContin Meeting” -Pink Sheet, 17 Sep, 2020.)
Biogen submitted the biologics license application in July. (Also see “Keeping Track: Biogen’s Aducanumab Headlines Midsummer Submission Round-Up” – Pink Sheet, 8 Jul, 2020.) The application is undergoing a priority review with a 7 March 2021 goal date, but Biogen said the FDA intends to act even earlier on the application. (Also see “Adu-CAN-umab? Reading The Tea Leaves For Biogen’s US Filing For Alzheimer’s Drug” – Pink Sheet, 10 Aug, 2020.)
The FDA’s decision to accept the BLA for filing, rather than issuing a refuse-to-file letter, surprised some agency observers given questions about the adequacy and robustness of the data package and whether it can satisfy the efficacy standard.
The aducanumab review could have implications for many other development programs and disease categories, as it could signal how far the agency is willing to bend when it comes to demonstrating substantial evidence of efficacy under a December 2019 draft guidance.
“Maybe this action on Biogen’s Alzheimer’s drug is a signal that the FDA is going to start treating neurological disorders with that same degree of flexibility that FDA shows to oncology.” – Hyman, Phelps and McNamara’s Frank Sasinowski
For example, Alzheimer’s is far from a rare disease, with more than 5 million Americans ages 65 and older living with Alzheimer’s dementia in 2020, according to the Alzheimer’s Association, but the aducanumab review could lay the groundwork for changes to development of treatments of rare neurodegenerative diseases.
“Maybe this action on Biogen’s Alzheimer’s drug is a signal that the FDA is going to start treating neurological disorders with that same degree of flexibility that FDA shows to oncology,” said Frank Sasinowski, director at Hyman, Phelps and McNamara, who works with sponsors and patient advocates on rare disease drug development.
SUCCESS DECLARED AFTER TRIALS TERMINATED
If approved, aducanumab would become the first disease-modifying treatment aimed at slowing or stopping the progression of Alzheimer’s.
Whether the drug is actually approvable, however, has been the burning question since October 2019, when Biogen announced plans to submit a BLA based on data from trials the company previously had said were not successful.
In March 2019, Biogen and partner Eisai Co., Ltd. said they would discontinue the Phase III EMERGE and ENGAGE trials in patients with mild cognitive impairment due to Alzheimer’s disease and in patients with mild Alzheimer’s disease dementia. The decision to stop the trials was based on a futility analysis conducted by an independent data monitoring committee, which found the studies were unlikely to meet their primary endpoint. (Also see “Why Biogen/Eisai’s Aducanumab Failure Is Not The End Of Amyloid Hypothesis” – Scrip, 21 Mar, 2019.)
However, in a surprise announcement just seven months later, the development partners said they planned to pursue regulatory approval based on a new analysis, conducted by Biogen in consultation with the FDA, of a larger dataset from the Phase III studies, including additional data that became available after the prespecified futility analysis. (Also see “An About Face As Biogen Says It Will File Aducanumab In Alzheimer’s” – Scrip, 22 Oct, 2019.)
In this new analysis, EMERGE met its primary endpoint showing a significant reduction in clinical decline with high-dose aducanumab. Furthermore, results from a subset of patients in ENGAGE who received sufficient exposure to high-dose aducanumab support the findings from EMERGE, even though ENGAGE did not meet its primary endpoint, Biogen said.
In EMERGE, high-dose aducanumab was associated with a 22% improvement in CDR-SB (Clinical Dementia Rating-Sum of Boxes) scores relative to placebo, with a p-value of 0.01, according to data presented at the Clinical Trials on Alzheimer’s Disease annual meeting in December. Key secondary endpoints also were statistically significantly positive in EMERGE in the high-dose group.
In contrast, in ENGAGE low-dose aducanumab was numerically, but not statistically significantly, better relative to placebo on the primary endpoint; high-dose aducanumab was numerically worse than placebo. However, in a post hoc analysis, data from a subset of patients exposed to high-dose aducanumab showed favorable trends that supported the EMERGE findings, Biogen said.
Inconsistent or mixed efficacy data are not unusual in neurologic diseases, where endpoints are often composites or scales that attempt to quantify patient-reported and functional parameters. In cases of unmet medical need, the agency has a record of
