Onasemnogene abeparvovec

Onasemnogene abeparvovec
Gene therapy
Target geneSMN1
VectorAdeno-associated virus serotype 9
Names
Trade namesZolgensma
Other namesAVXS-101, onasemnogene abeparvovec-xioi
Clinical data
Drug classGene therapy[1]
Main usesSpinal muscular atrophy (SMA)[2]
Side effectsVomiting, liver failure, low platelets[1]
Pregnancy
category
    Routes of
    use    		Intravascular
    External links
    AHFS/Drugs.comProfessional Drug Facts
    Legal
    License data
    Legal status
    • AU: S4 (Prescription only) [3][4]
    • CA: Rx-only / Schedule D [5]
    • UK: POM (Prescription only) [6]
    • US: ℞-only [1][7]
    • EU: Rx-only [2]
    • In general: ℞ (Prescription only)

    Onasemnogene abeparvovec, sold under the brand name Zolgensma, is a medication used to treat certain types of spinal muscular atrophy (SMA).[2][1] It is used as a one-time gradual injection into a vein with at least 2 months of corticosteroids.[1] It is used in children less than two years old.[1]

    Common side effects include vomiting and increased liver enzymes.[1] Serious side effects may include liver failure and low platelets.[1] There is also evidence of damage to the heart; however, this is of unclear significance.[1] Onasemnogene abeparvovec is a type of gene therapy and works by providing a new copy of the gene that makes the human SMN protein.[1]

    Onasemnogene abeparvovec was approved for medical use in the United States in 2019.[1] In 2020 it was approved in Japan, Brazil, Europe, and Canada.[8][9][2][10][11] At launch, it cost about US$ 2.125 million per treatment in the United States, making it one of the most expensive medications.[12]

    Medical uses

    Onasemnogene abeparvovec has been developed to treat spinal muscular atrophy, a disease linked to a mutation in the SMN1 gene on chromosome 5q[7] and diagnosed predominantly in young children that causes progressive loss of muscle function and frequently death.

    In a study of 22 babies, 20 (90%) did not need a ventilator at 14 months, as compared to a typical rate of 25% not needing a ventilator at that age.[2] 64% of babies were also able to sit for more than 30 seconds without help at 18 months, which is not seen in those not treated.[2]

    The treatment is approved in the United States and certain other countries for use in children with spinal muscular atrophy up to the age of two, including at the presymptomatic stage of the disease.[13] In the European Union and Canada, it is indicated forpinal muscular atrophy who either have a diagnosis of spinal muscular atrophy type 1 or have up to three copies of the SMN2 gene.[2][14]

    The medication is administered as an intravenous infusion.[15] The medication is used with corticosteroids in an effort to protect the liver.[1]

    Side effects

    Common side effects may include nausea and elevated liver enzymes.[1] Serious side effects may include liver problems and low platelets.[1] Transient elevated levels of cardiac troponin‑I were observed in trials; the importance of which is not known.[1] However, cardiac toxicity was seen in studies of other animals.[1]

    As the medication may reduce the platelet count, platelets may need to be checked before the medication is started, then weekly for the first month and every two weeks for the next two months until the level is back to baseline.[1] Liver function should be monitored for three months after administration.[16]

    Mechanism of action

    After intravenous administration of onasemnogene abeparvovec, the SMN transgene is maintained as a non‐integrating episome in the nuclei of target cells

    SMA is a neuromuscular disorder caused by a mutation in the SMN1 gene, which leads to a decrease in SMN protein, a protein necessary for survival of motor neurons. Onasemnogene abeparvovec is a biologic drug consisting of AAV9 virus capsids that contains a SMN1 transgene along with synthetic promoters.[6]

    Upon administration, the AAV9 viral vector delivers the SMN1 transgene to the affected motor neurons, where it leads to an increase in SMN protein.

    History

    Onasemnogene abeparvovec was developed by the US biotechnology startup AveXis, which was acquired by Novartis in 2018,[17] based on the work at the Institut de Myologie in France.[18]

    The U.S. Food and Drug Administration (FDA) granted the application for onasemnogene abeparvovec-xioi fast track, breakthrough therapy, priority review, and orphan drug designations.[13] The FDA also awarded the manufacturer a rare pediatric disease priority review voucher, and granted the approval of Zolgensma to AveXis Inc.[13]

    In June 2015, the European Commission granted orphan designation for the drug.[19] In July 2019, the drug was removed from the Committee for Medicinal Products for Human Use (CHMP) accelerated assessment program.[20]

    In May 2019, onasemnogene abeparvovec received US FDA approval as a treatment for children less than two years old.[13] Since 2019, the treatment has been reimbursed in Israel[21] and Qatar.[22] In March 2020, onasemnogene abeparvovec was granted regulatory approval in Japan with the label identical to the US one.[8] Also in March 2020, the European Medicines Agency recommended a conditional marketing authorization for use in people with SMA type 1 or with any SMA type and having no more than three copies of the SMN2 gene.[23][2] In May 2020, Onasemnogene abeparvovec was conditionally approved in Europe.[2][24]

    In August 2020, onasemnogene abeparvovec was granted regulatory approval in Brazil by the Brazilian Health Regulatory Agency (ANVISA).[25]

    In December 2020, onasemnogene abeparvovec was approved for medical use in Canada.[26][27]

    Onasemnogene abeparvovec was approved for medical use in Australia in February 2021.[3][4][28]

    An official approval in Russia was granted in December 2021.[29]

    Society and culture

    Economics

    The drug carries a list price of US$2.125 million per treatment, making it the most expensive medication in the world as of 2019.[30] In its first full quarter of sales US$160 million of medication was sold.[31]

    In Japan, the drug was made available through the public health care system on 20 May 2020, making it the most expensive drug covered by the Japanese public health care system.[32] The Central Social Insurance Medical Council, responsible for approving the universal drug fee schedule in Japan, has negotiated the price down to ¥167,077,222 (approx. USD 1,530,000) per patient.[33][34]

    Controversy

    In the months leading up to the medication's approval by the US Food and Drug Administration (FDA), a whistleblower informed Novartis that certain studies of the medication had been subject to data manipulation.[35] Novartis fired two AveXis executives it determined responsible for the alleged data manipulation but informed the FDA of the data integrity issue only in June 2019, a month after the drug's approval.[35] The delay drew strong condemnation from the FDA.[36] In October 2019, the company admitted to not having informed the FDA and the European Medicines Agency (EMA) for seven months about toxic effects of the intravenous formulation observed in laboratory animals.[37] Due to data manipulation issue, the EMA withdrew their decision to allow an accelerated assessment of the medication.[38]

    In December 2019, Novartis announced that it would donate 100 doses of onasemnogene abeparvovec per year to children outside the US through a global lottery. The decision, which has been claimed by Novartis to be based on a recommendation by unnamed bioethicists,[39] was received with much criticism by the European Commission,[40] some European healthcare regulators[41] and patient groups who see it as emotionally burdening, suboptimal, and ethically questionable.[42] Novartis did not consult with families or doctors before announcing the scheme.[43][44]

    Names

    Onasemnogene abeparvovec is the international nonproprietary name (INN)[45] and the United States Adopted Name (USAN).[46]

    References

    1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 "Zolgensma- onasemnogene abeparvovec-xioi kit full prescribing information". DailyMed. 24 May 2019. Archived from the original on 19 November 2019. Retrieved 18 November 2019.
    2. 1 2 3 4 5 6 7 8 9 "Zolgensma EPAR". European Medicines Agency (EMA). 24 March 2020. Archived from the original on 17 July 2020. Retrieved 30 July 2020. Text was copied from this source which is © European Medicines Agency. Reproduction is authorized provided the source is acknowledged.
    3. 1 2 3 "Zolgensma". Therapeutic Goods Administration (TGA). 10 March 2021. Archived from the original on 9 September 2021. Retrieved 8 September 2021.
    4. 1 2 3 "AusPAR: Onasemnogene abeparvovec". Therapeutic Goods Administration (TGA). 22 April 2021. Archived from the original on 9 September 2021. Retrieved 8 September 2021.
    5. ↑ "Summary Basis of Decision (SBD) for Zolgensma". Health Canada. 23 October 2014. Archived from the original on 30 May 2022. Retrieved 29 May 2022.
    6. 1 2 "Zolgensma 2 x 1013 vector genomes/mL solution for infusion - Summary of Product Characteristics (SmPC)". (emc). 30 June 2020. Archived from the original on 28 October 2020. Retrieved 30 July 2020.
    7. 1 2 "Zolgensma". U.S. Food and Drug Administration (FDA). 6 August 2019. STN: 125694. Archived from the original on 19 November 2019. Retrieved 1 November 2019. Public Domain This article incorporates text from this source, which is in the public domain.
    8. 1 2 "Novartis receives approval from Japanese Ministry of Health, Labour and Welfare for Zolgensma the only gene therapy for patients with spinal muscular atrophy (SMA)". Novartis (Press release). Archived from the original on 21 January 2023. Retrieved 29 March 2020.
    9. ↑ Mueller, Casimir Jones SC-Lisa L. (September 2020). "First Gene Therapy Products Approved in Brazil". Lexology. Archived from the original on 2 June 2021. Retrieved 1 June 2021.
    10. ↑ "Health Canada approves $2.8M treatment for spinal muscular atrophy | Globalnews.ca". Global News. Archived from the original on 23 May 2022. Retrieved 31 January 2023.
    11. ↑ "onasemnogene abeparvovec". CADTH.ca. 26 May 2020. Archived from the original on 2 June 2021. Retrieved 1 June 2021.
    12. ↑ "At $2.1 Million, New Gene Therapy Is The Most Expensive Drug Ever". NPR. 24 March 2019. Archived from the original on 18 January 2023. Retrieved 31 January 2023.
    13. 1 2 3 4 "FDA approves innovative gene therapy to treat pediatric patients with spinal muscular atrophy, a rare disease and leading genetic cause of infant mortality". U.S. Food and Drug Administration (FDA). 24 May 2019. Archived from the original on 1 September 2019. Retrieved 18 November 2019. Public Domain This article incorporates text from this source, which is in the public domain.
    14. ↑ "Health Canada approves Zolgensma, the one-time gene therapy for pediatric patients with spinal muscular atrophy (SMA)". Newswire Canada. Cision. 16 December 2020. Archived from the original on 3 June 2021. Retrieved 2 July 2021.
    15. ↑ "Onasemnogene Abeparvovec". LiverTox: Clinical and Research Information on Drug-Induced Liver Injury. NCBI Bookshelf. 20 August 2020. PMID 33242238. Bookshelf ID: NBK564658. Archived from the original on 14 August 2022. Retrieved 13 August 2022.
    16. ↑ "FDA approves innovative gene therapy to treat pediatric patients with spinal muscular atrophy, a rare disease and leading genetic cause of infant mortality". U.S. Food and Drug Administration (FDA) (Press release). 11 September 2019. Archived from the original on 1 September 2019. Retrieved 18 November 2019. Public Domain This article incorporates text from this source, which is in the public domain.
    17. ↑ "Novartis successfully completes acquisition of AveXis, Inc" (Press release). Novartis. Archived from the original on 9 September 2019. Retrieved 6 October 2018.
    18. ↑ "AveXis receives FDA approval for Zolgensma, the first and only gene therapy for pediatric patients with spinal muscular atrophy (SMA)". Novartis (Press release). 24 May 2019. Retrieved 13 August 2022.
    19. ↑ "EU/3/15/1509". European Medicines Agency. 17 September 2018. Archived from the original on 19 November 2019. Retrieved 19 November 2019.
    20. ↑ "Novartis' Zolgensma Joins Growing List of Medicines to Lose Accelerated Assessment Status in EU". RAPS. Archived from the original on 19 November 2019. Retrieved 19 November 2019.
    21. ↑ Julian HL. "In First, World's Most Expensive Medicine Used to Treat Israeli Toddler". Archived from the original on 29 March 2020. Retrieved 29 March 2020.
    22. ↑ "HMC implements innovative gene therapy to treat congenital spinal muscular atrophy". The Peninsula. 20 November 2019. Archived from the original on 29 March 2020. Retrieved 29 March 2020.
    23. ↑ "New gene therapy to treat spinal muscular atrophy". European Medicines Agency (Press release). 27 March 2020. Archived from the original on 29 March 2020. Retrieved 29 March 2020.
    24. ↑ "Global Novartis News Archive". Novartis (Press release). Archived from the original on 29 May 2020. Retrieved 20 May 2020.
    25. ↑ "Medicamento conhecido como mais caro do mundo recebe registro da Anvisa". G1 (in português do Brasil). Archived from the original on 31 August 2020. Retrieved 18 August 2020.
    26. ↑ "Health Canada approves Zolgensma, the one-time gene therapy for pediatric patients with spinal muscular atrophy (SMA)" (Press release). Novartis Pharmaceuticals Canada. 16 December 2020. Archived from the original on 3 June 2021. Retrieved 27 May 2021 – via Cision.
    27. ↑ "PRODUCT MONOGRAPH INCLUDING PATIENT MEDICATION INFORMATION : ZOLGENSMA" (PDF). Pdf.hres.ca. Archived (PDF) from the original on 14 June 2021. Retrieved 24 March 2022.
    28. ↑ "TGA eBS - Product and Consumer Medicine Information Licence". Ebs.tga.gov.au. Archived from the original on 9 September 2021. Retrieved 24 March 2022.
    29. ↑ "Минздрав зарегистрировал препарат для лечения СМА «Золгенсма»". Ведомости (in русский). Archived from the original on 10 December 2021. Retrieved 2022-07-08.
    30. ↑ "$2.1m Novartis gene therapy to become world's most expensive drug". The Guardian. London. Reuters. 25 May 2019. Archived from the original on 7 November 2020. Retrieved 25 May 2019.
    31. ↑ Miller, John (30 October 2019). "Novartis' Zolgensma study halted by FDA amid safety questions". Reuters. Archived from the original on 30 October 2019. Retrieved 30 October 2019.
    32. ↑ 初の「億超え新薬」ゾルゲンスマの薬価はどう決まったか Archived 15 August 2020 at the Wayback Machine (Japanese). AnswersNews.
    33. ↑ 厚生労働省告示第二百十四号 Archived 31 October 2020 at the Wayback Machine (Japanese). Ministry of Health, Labour and Welfare, Japan.
    34. ↑ 脊髄性筋萎縮症に対する遺伝子治療用製品「ゾルゲンスマ®点滴静注」薬価基準収載のお知らせ Archived 28 October 2020 at the Wayback Machine (Japanese). Novartis Pharma.
    35. 1 2 Erman M (24 September 2019). "Novartis blames former AveXis executives for Zolgensma data manipulation". Reuters. Archived from the original on 26 September 2019. Retrieved 26 September 2019.
    36. ↑ "Statement on data accuracy issues with recently approved gene therapy". U.S. Food and Drug Administration (FDA) (Press release). 19 November 2019. Archived from the original on 19 November 2019. Retrieved 1 December 2019. Public Domain This article incorporates text from this source, which is in the public domain.
    37. ↑ "Novartis says delayed telling FDA of Zolgensma concern due to 'mistake'". Reuters. 1 November 2019. Archived from the original on 11 November 2019. Retrieved 11 November 2019.
    38. ↑ "Zolgensma°: the drug of extremes". April 2020. p. 107. Archived from the original on 29 October 2020. Retrieved 22 May 2020.
    39. ↑ "Novartis in talks with patients upset about lottery-like gene therapy giveaway". Reuters. 20 December 2019. Archived from the original on 1 June 2021. Retrieved 29 May 2021.
    40. ↑ Kyriakides S (19 February 2020). "Answer given by Ms Kyriakides on behalf of the European Commission". European Parliament. Archived from the original on 28 October 2020. Retrieved 21 April 2020.
    41. ↑ "No "lottery for life" - Statement by Beneluxa Health Ministers addressing the global managed access program designed by Novartis and Avexis". Beneluxa. 30 January 2020. Archived from the original on 22 May 2020. Retrieved 21 April 2020.
    42. ↑ "AVXS-101 (Zolgensma) to be made available globally through a controversial programme". SMA Europe. 26 December 2019. Archived from the original on 13 March 2020. Retrieved 21 April 2020.
    43. ↑ "Dismay at lottery for $2.1m drug to treat children with muscle-wasting disease". The Guardian. 20 December 2019. Archived from the original on 21 December 2019. Retrieved 21 December 2019.
    44. ↑ "Novartis to Offer World's Most Expensive Drug for Free Via Lottery". The Wall Street Journal. 19 December 2019. Archived from the original on 21 December 2019. Retrieved 21 December 2019.
    45. ↑ World Health Organization (2018). "International nonproprietary names for pharmaceutical substances (INN): recommended INN: list 79". WHO Drug Information. 32 (1): 95–6. hdl:10665/330941.
    46. ↑ "Onasemnogene abeparvovec (USAN/INN)". PubChem. Archived from the original on 9 September 2021. Retrieved 9 September 2021.
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