Seeking approval for the potential use of GATTEX to pediatric patients builds on Shire’s decade-long commitment to addressing needs in GI diseases
Cambridge, Mass. – November 13, 2018 – Shire plc (LSE: SHP, NASDAQ: SHPG) the global leader in rare diseases, announced today the U.S. Food and Drug Administration (FDA) has accepted for filing the supplemental new drug application to extend the indication of GATTEX® (teduglutide [rDNA origin]) for Injection to pediatric patients (aged 1-17 years old) with Short Bowel Syndrome (SBS) who are dependent on parenteral support. GATTEX is a prescription medicine indicated for the treatment of adult patients with SBS who are dependent on parenteral support.1
Shire submitted the supplemental new drug application to the U.S. FDA on September 11, 2018. The U.S. FDA is expected to reach a decision in March 2019.
SBS is a serious, chronic and rare malabsorption disorder resulting from surgical resection. People with SBS are unable to absorb enough nutrients and fluids from what they eat and drink alone. Malabsorption puts people at risk for diarrhea, dehydration, electrolyte disturbances and malnutrition.2,3,4 Children with SBS have had a large portion of the intestine removed by surgery due to congenital or acquired conditions of the newborn or trauma.5
“The filing acceptance of Shire’s supplemental new drug application by the U.S. FDA is an important milestone in our efforts to investigate the use of GATTEX as a potential treatment for children with SBS who are dependent on parenteral support,” said Howard Mayer, M.D., Senior Vice President and Chief Medical Officer, Shire. “Addressing unmet medical needs in rare disease is the focus of Shire’s work, and we are pleased to continue advancing our GI portfolio to help patients living with rare and specialized GI conditions.”
The application included data from two core, completed Phase 3 studies as well as interim data from two ongoing extension studies. The Phase 3 studies included a 24-week, double-blind , multi-center, multi-national trial (TED-C14-006) and a 12-week, open-label, multi-center study (TED-C13-003), both of which evaluated the efficacy, safety, and pharmacodynamics of GATTEX in children with SBS who were stable on their required parenteral nutrition (PN)/ intravenous (IV) support that provided at least 30% of caloric and/or fluid/electrolyte needs for at least three months prior to screening.6
“Many children who develop SBS as infants may remain dependent on parenteral support, which helps to address their nutrition and fluid needs,” said Beth Carter, M.D., Medical Director of Intestinal Rehabilitation and Nutrition Support, Children’s Hospital Los Angeles. “While the goal in SBS management is to ensure patients receive the right amount of nutrients and fluids, we also look for opportunities to reduce, and even help some of these patients wean off of parenteral support. The development of teduglutide for pediatric SBS patients age 1 year and older is important as the data from the Phase 3 studies suggest it might potentially address an unmet medical need in this patient population.”
Fifty-nine patients ages 1 to 17 years enrolled and completed the 24-week, double-blind study, which included children in the U.S., Canada, UK, Germany, Finland, Belgium, and Italy.6 Subjects elected to receive either teduglutide or SOC; patients receiving teduglutide were randomized to receive either the 0.025 mg/kg or 0.05 mg/kg dose (0.025mg/kg, n=24; 0.05 mg/kg, n=26; Standard of Care (SOC), n=9). The study found that 54.2% and 69.2% of patients treated with teduglutide (0.025 mg/kg and 0.05 mg/kg, respectively) vs. 11.1% receiving standard of care achieved a 20% or greater reduction in the volume of parenteral support at 24 weeks compared to baseline, the study’s primary efficacy endpoint.7 In addition, five children on teduglutide (0.025 mg/kg, n=2; 0.05 mg/kg, n=3) were completely weaned off parenteral support at week 24 compared to none in the standard of care arm.7 The most frequent treatment-emergent adverse events (teduglutide 0.025 mg/kg, 0.05 mg/kg, or standard of care, respectively), included: pyrexia (33%, 42%, 44%), vomiting (42%, 31%, 56%), upper respiratory tract infection (29%, 31%, 44%), cough (8%, 38%, 33%), diarrhea (33%, 12%, 11%), nasopharyngitis (17%, 23%, 22%), abdominal pain (17%, 23%, 0%), dehydration (33%, 4%, 0%), increased ALT (29%, 8%, 0%), headache (13%, 19%, 11%), and catheter site erythema (0%, 4%, 22%).7 The findings from this study were recently presented at the 10th International Pediatric Intestinal Failure and Rehabilitation Symposium.
Forty patients ages 1 to 17 years enrolled and completed the 12-week, open-label study (TED-C13-003). Patients either received teduglutide (0.0125 mg/kg, n=8; 0.025 mg/kg, n=14; 0.05 mg/kg, n=15) or standard of care (SOC) (n=5). Between baseline and week 12 of the study, prescribed PN volume and calories changed, respectively, by a median of 41% and 45% in the 0.025 mg/kg/day group, 25% and 52% in the 0.05 mg/kg/day group, and 0% and 6% in the 0.0125 mg/kg/day group. Reductions in PN volume and calories, respectively, of 0% and 1% were seen in the SOC group. On the basis of patient diary data, daily parenteral nutrition infusion time decreased in patients receiving teduglutide 0.025 mg/kg (median decrease of 4.0 hours) and 0.05 mg/kg (median decrease of 3.0 hours) at 12 weeks; no changes in median daily infusion time were observed for teduglutide 0.0125 mg/kg or SOC at 12 weeks. Four patients receiving teduglutide achieved independence from parenteral nutrition: 3 of 15 in the 0.05 mg/kg group (achieved at weeks 4, 8, and 12) and 1 of 14 in the 0.025 mg/kg group (achieved at week 11). At week 16 (4 weeks after teduglutide discontinuation), 2 of these 4 patients had resumed parenteral nutrition and 2 remained independent. All patients experienced ≥1 treatment-emergent adverse event. No serious treatment-related adverse events were deemed to be teduglutide-related. The most commonly reported treatment-emergent side effects included GI-related AEs, upper respiratory tract infection, catheter-related complications, and pyrexia. Severe adverse events were reported in 30% of patients receiving teduglutide and 20% of patients receiving SOC.8
About Short Bowel Syndrome
In adults, SBS occurs after extensive surgical removal of the bowel due to conditions such as Crohn's disease, inadequate blood supply to the small intestines (mesenteric ischemia), trauma, or other conditions.5 In children and adolescents, SBS is commonly caused by either congenital abnormalities (birth defects) or severe intestinal diseases that require surgical removal of the intestines.9,10
SBS is a serious, chronic and rare malabsorption disorder resulting from surgical resection. Children with SBS are unable to absorb enough nutrients and fluids from what they eat and drink alone. Malabsorption puts people at risk for diarrhea, dehydration, electrolyte disturbances and malnutrition.2,3,4
Patients with SBS often require nutritional support, including parenteral nutrition (PN) and/or intravenous (IV) fluids to supplement and stabilize nutritional needs.11
Patients who are dependent on PN/IV are at risk for serious complications, including catheter-related infections, blood clots, or liver damage,4 and often experience disrupted sleeping, frequent urination, and a loss of independence.11
About GATTEX® (teduglutide [rDNA origin]) for Injection
GATTEX® (teduglutide [rDNA origin]) is a recombinant analog of human glucagon-like peptide 2. In the U.S., GATTEX is indicated for the treatment of adult patients with short bowel syndrome who are dependent on parenteral support. The safety and efficacy of GATTEX in pediatric patients have not been established in the U.S.1
IMPORTANT SAFETY INFORMATION for adult SBS patients who are dependent on parental support
WARNINGS AND PRECAUTIONS
Colorectal polyps were identified during clinical trials. There is a risk for acceleration of neoplastic growth. Colonoscopy of the entire colon with removal of polyps should be done within 6 months prior to starting treatment with GATTEX and is recommended after 1 year. Subsequent colonoscopies should be done as needed, but no less frequently than every 5 years. In case of intestinal malignancy (GI tract, hepatobiliary, pancreatic), discontinue GATTEX. The clinical decision to continue GATTEX in patients with non-gastrointestinal malignancy should be made based on risk and benefit considerations.
Intestinal obstruction has been reported in clinical trials. In patients who develop obstruction, GATTEX should be temporarily discontinued pending further clinical evaluation and management.
Biliary and Pancreatic Disease
Cholecystitis, cholangitis, cholelithiasis, and pancreatitis have been reported in clinical trials. Patients should undergo laboratory assessment (bilirubin, alkaline phosphatase, lipase, amylase) before starting GATTEX. Subsequent laboratory tests should be done every 6 months. If clinically meaningful changes are seen, further evaluation is recommended including imaging, and continued treatment with GATTEX should be reassessed.
Fluid overload and congestive heart failure have been observed in clinical trials. There is potential for fluid overload while on GATTEX. If fluid overload occurs, especially in patients with underlying cardiovascular disease, parenteral support should be appropriately adjusted and GATTEX treatment reassessed.
Increased Absorption of Concomitant Oral Medication
Altered mental status in association with GATTEX has been observed in patients on benzodiazepines in clinical trials. Patients on concomitant oral drugs (e.g., benzodiazepines, phenothiazines) requiring titration or with a narrow therapeutic index may require dose adjustment while on GATTEX.
The most common adverse reactions (≥ 10%) across all studies with GATTEX are abdominal pain, injection site reactions, nausea, headaches, abdominal distension, upper respiratory tract infection. In addition, vomiting and fluid overload were reported in the SBS studies (1 and 3) at rates ≥10%.
To report SUSPECTED ADVERSE REACTIONS, contact Shire Medical Information at 1-866-888-0660 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. For U.S. GATTEX Prescribing Information www.shirecontent.com/PI/PDFS/Gattex_USA_ENG.pdf
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1 GATTEX Prescribing Information. 2016. Available at: http://www.shirecontent.com/PI/PDFS/Gattex_USA_ENG.pdf. Accessed October 23, 2018.
2 Seidner DL, Schwartz LK, Winkler MF, Jeejeebhoy K, Boullata JI, Tappenden KA. Increased Intestinal Absorption in the Era of Teduglutide and Its Impact on Management Strategies in Patients With Short Bowel Syndrome Associated Intestinal Failure. JPEN J Parenter Enteral Nutr. 2013;37(2):201-211.
3 O'Keefe SJ, Buchman AL, Fishbein TM, Jeejeebhoy KN, Jeppesen PB, Shaffer J. Short Bowel Syndrome and Intestinal Failure: Consensus Definitions and Overview. Clin Gastroenterol Hepatol. 2006;4(1):6-10.
4 Hofstetter S, Stern L, Willet J. Key Issues in Addressing the Clinical And Humanistic Burden of Short Bowel Syndrome in the U.S. Current Medical Research and Opinion. 2013;29:495-504.
5 Wales PW, Christison-Lagay ER. Short Bowel Syndrome: Epidemiology and Etiology. Semin Pediatr Surg. 2010; 19(1):3-9. doi: 10.1053/j.sempedsurg.2009.11.001.
6 Short Bowel Syndrome Research Study for Children Up To 17 Years of Age on Parenteral Nutrition – Tabular View. ClinicalTrials.gov, U.S. National Library of Medicine. Available at: clinicaltrials.gov/ct2/show/record/NCT02682381?term=TED-C14-006&rank=2&view=record
7 Grimm A, Carter BA, Hill S, et. al. Teduglutide Reduced Parenteral Support in Children With Short Bowel Syndrome Associated-Intestinal Failure (SBS-IF): a Phase 3 Study. Abstract to be presented at the 10th International Pediatric Intestinal Failure and Rehabilitation Symposium. Pittsburgh, PA. September 20-22, 2018.
8 Carter, BA, Cohran VC, Cole CR, et al. Outcomes from a 12-Week, Open-Label, Multicenter Clinical Trial of Teduglutide in Pediatric Short Bowel Syndrome.The Journal of Pediatrics. 2017; 181:102-16
9 Squires RH, Duggan C, Teitelbaum DH, et. al. Natural History of Pediatric Intestinal Failure: Initial Report from the Pediatric Intestinal Failure Consortium. J Pediatr. 2012;161:723-8.e2.
10 Duro D, Kamin D, Duggan C. Overview of Pediatric Short Bowel Syndrome. J Pediatr Gastroenterol Nutr. 2008;47: Suppl 1, S33-6.
11 G Kelly, Darlene et al. Short Bowel Syndrome: Highlights Of Patient Management, Quality Of Life, And Survival. JPEN. Journal Of Parenteral And Enteral Nutrition. 2014 May;38(4):427-37. doi: 10.1177/0148607113512678.