Go or no go? A delayed decision on Evrenzo

A three-month delay to a US FDA verdict on Biogen’s aducanumab means that March will be decidedly quieter than expected on the approvals front. However, there are two valuable decisions still to come concerning Evrenzo, the anaemia pill from Astrazeneca/Fibrogen, and Bristol/Bluebird’s multiple myeloma project ide-cel, both of which carry big sellside forecasts.

The Pdufa date is also approaching for Keytruda’s perioperative use in triple-negative breast cancer, though a negative advisory panel makes approval unlikely. And, over a decade since its clinical development started, Pfizer/Lilly’s troubled pain project tanezumab will be up for discussion.

Delayed verdict

Astrazeneca/Fibrogen’s Evrenzo, which contains the active ingredient roxadustat, has 2026 forecasts of $2.4bn, making the decision on its approvability, due by March 20, the biggest of the month in terms of potential sales. The verdict was supposed to have come at the end of last year, but the FDA requested further clinical data analyses.

Analysts believe that Evrenzo, which is already on the market in Japan and China, will get US backing in dialysis-dependent and independent chronic kidney disease, although the calibre of the label will be important. A black box warning is likely, Leerink analysts believe, possibly encompassing the risk of overcorrecting haemoglobin or more worrying issues including infection, malignancy, or cardiovascular events.

If the label does warn of increased risk of cardiovascular events the impact would likely be modest in dialysis-dependent patients, Leerink states. In this group Evrenzo is intended to replace erythropoiesis-stimulating agents (ESAs), which already have a cardiovascular warning. That said, if the safety of Evrenzo and ESAs is considered similar, doctors could favour the older, cheaper drugs.

In non-dialysis-dependent patients a cardiovascular black box would be more of a problem. Less than 15% of these patients receive ESAs precisely because of this risk, so use of Evrenzo would be limited too.

Competition

The second most potentially valuable decision will be that for Bristol Myers Squibb's and Bluebird’s BCMA-targeting Car-T project ide-cel in late-line multiple myeloma. The filing was based on the phase II Karmma study, which showed an 82% overall remission rate at the highest dose tested.

Glaxosmithkline’s Blenrep became the first anti-BCMA therapy approved for relapsed or refractory multiple myeloma last year, despite underwhelming efficacy and severe ocular toxicity. Blenrep, an antibody-drug conjugate, can only be used in patients who have received at least four prior therapies, and approval came with a black box warning and requirement for a REMS programme.

Ide-cel's real competition could come from J&J and Legend Biotech’s cilta-cel, another BCMA-directed Car-T therapy whose rolling submission started at the end of last year. In terms of efficacy cilta-cel looks unbeatable, having shown a 97% overall remission rate, though neurotoxicity has been an issue.

Safety concerns

After 13 years and 39 clinical trials Pfizer and Lilly’s pain project tanezumab is up before an FDA panel next month as the companies seek approval of a 2.5mg dose in moderate to severe osteoarthritis.

Safety will be big on the agenda: the anti-nerve growth factor’s past has been blighted by incidences of rapidly progressive osteoarthritis that led to a partial clinical hold. Dosing in studies had to be lowered, leading to lower efficacy (New tanezumab pain for Pfizer and Lilly, October 24, 2018).

The balancing act for regulators will be whether doctors desperate for non-opioid options for pain relief can overcome their concerns over toxicity. If tanezumab does get approved a boxed warning looks likely.

The result of the panel will also have read across to Regeneron’s similarly-acting fasinumab. Data from that project's long-term phase III safety study are due in the first half of this year.

The tables below list first-time and supplementary US approvals and advisory meetings due, with consensus forecasts from EvaluatePharma.