Drug Class Review. Disease-modifying Drugs for Multiple Sclerosis. Single Drug Addendum: Fingolimod

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1 Drug Class Review Disease-modifying Drugs for Multiple Sclerosis Single Drug Addendum: Fingolimod Final Original Report February 2011 The Agency for Healthcare Research and Quality has not yet seen or approved this report. The purpose of the is to summarize key information contained in the Drug Effectiveness Review Project report Disease-modifying drugs for multiple sclerosis: Single drug addendum: Fingolimod, dated February The full report can be accessed at the following web address: Readers are advised to review the full report. The purpose of reports is to make available information regarding the comparative clinical effectiveness and harms of different drugs. Reports are not usage guidelines, nor should they be read as an endorsement of or recommendation for any particular drug, use, or approach. They are not intended to provide any legal or business advice. Oregon Health & Science University does not recommend or endorse any guideline or recommendation developed by users of these reports. Marian McDonagh, PharmD Marian McDonagh, PharmD, Principal Investigator Oregon Evidence-based Practice Center Mark Helfand, MD, MPH, Director Copyright 2011 by Oregon Health & Science University Portland, Oregon All rights reserved.

2 INTRODUCTION In the Report on Disease-modifying Drugs for Multiple Sclerosis, 5 injectable drugs were reviewed in comparison with each other (most recent update, August 2010). Since that time, an oral medication, fingolimod (Gilenya ) was approved in the United States and Canada for patients with relapsing forms of multiple sclerosis to reduce the frequency of clinical exacerbations and to delay the accumulation of physical disability. Fingolimod is a sphingosine 1-phosphate receptor modulator and is reported to work at least in part though reducing lymphocyte migration into the central nervous system. It is thought to result in redistribution of autoaggressive lymphocytes (T cells and B cells) to the lymph nodes and away from the central nervous system. The purpose of this addendum to the larger report on drugs to treat multiple sclerosis is to review the evidence on the comparative effectiveness and harms of fingolimod compared to the other 5 drugs previously reviewed. Scope and Key Questions The goal of this report is to compare the effectiveness and harms profile of fingolimod to the other disease-modifying drugs in the treatment of multiple sclerosis. Included drugs are shown in Table 1. Table 1. Included drugs Agent Fingolimod Gilenya (a) Glatiramer Acetate Copaxone Interferon beta-1a Avonex, Avonex PS Interferon beta-1a Rebif Dosage and administration Indication Mechanism of action Patients with relapsing forms of multiple sclerosis to reduce the 0.5 mg orally frequency of clinical exacerbations once daily and to delay the accumulation of physical disability nervous system 20 mg Subcutaneously once daily 30 mcg Intramuscularly once weekly 22 or 44 mcg Subcutaneously three times weekly Reduce frequency of relapses in patients with RRMS including patients who experienced a first clinical episode and have MRI features consistent with MS Treatment of patients with relapsing forms of MS to slow accumulation of physical disability and decrease frequency of clinical exacerbations. Effective in patients who experienced first clinical episode and have MRI features consistent with MS Treatment of relapsing forms of MS to decrease the frequency of clinical exacerbations and delay the accumulation of physical disability A sphingosine 1-phosphate receptor modulator and is reported to work at least in part though reducing lymphocyte migration into the central May interfere with antigen presentation by mimicking and competing with MBP, a self-antigen, for binding to the MHC on the APC. The glatiramer-mhc competes with the MBP-MHC for binding to the TCR on T helper cells, which downregulates Th1 activity and promotes a Th2 cell response, leading to increased anti-inflammatory cytokine production Modulates the immune system by reducing T cell migration from the periphery into the CNS by decreasing the production of adhesion molecules and increasing the production of metalloproteases on the vascular endothelium that constitutes the blood brain barrier. These agents may also inhibit the generation of pro-inflammatory cytokines from Th1 cells (TNFα, IFNγ, IL-12). MS drugs addendum: fingolimod 2 of 9

3 Agent Interferon beta-1b Betaseron Interferon beta-1b Extavia Mitoxantrone Novantrone b Natalizumab Tysabri c Dosage and administration Indication Mechanism of action Treatment of relapsing forms of MS to reduce the frequency of 0.25 mg clinical exacerbations. Effective in Subcutaneously patients who experienced first Every other day clinical episode and have MRI features consistent with MS 0.25 mg Subcutaneously every other day 12 mg/m 2 Intravenously Every 3 months (Maximum cumulative dose is 140 mg/m 2 ) 300 mg Intravenously every 4 weeks Treatment of relapsing forms of MS to reduce frequency of clinical exacerbations. Effective in patients who experienced a first clinical episode and have MRI features consistent with MS Reduce neurologic disability and/or the frequency of clinical relapses in SPMS, PRMS or worsening RRMS Treatment of relapsing forms of multiple sclerosis to delay the accumulation of physical disability and reduce frequency of clinical exacerbations Inhibits cell division and impairs the proliferation of T cells, B cells and macrophages by intercalating and crosslinking DNA, thus inhibiting DNA replication and RNA synthesis of these cells. Impairs antigen presentation by causing apoptosis of APCs and other cells that associate with APCs. Binds to α 4 integrins expressed on leukocytes, which prevents binding to adhesion cells VCAM-1 and MAdCAM-1 on the vascular endothelium and prevents migration of leukocytes from the periphery into the CNS. Abbreviations: APC, antigen-presenting cell; CIS, clinically isolated syndrome; CNS, central nervous system; DNA, deoxyribonucleic acid; IL, interleukin; MAdCAM-1, mucosal vascular addressin cell adhesion molecule-1; MBP, myelin basic protein; MHC, major histocompatibility complex; MRI, magnetic resonance imaging; MS, multiple sclerosis; RNA, ribonucleic acid; PRMS, progressive relapsing multiple sclerosis; PS, prefilled syringes; RRMS, relapsing-remitting multiple sclerosis; SPMS, secondary progressive multiple sclerosis; TCR, T cell receptor; Th, T- helper; TNF, Tumor Necrosis Factor; VCAM-1, vascular cell adhesion molecule-1. a Not available in Canada. b Generic products available in Canada. c Recommended for patients who have had an inadequate response to or are unable to tolerate an alternate multiple sclerosis therapy. The key questions for this addendum are based on those in the complete report. There may be questions below that are not relevant to this addendum; these are noted by brackets [ ]. The participating organizations of the approved the following key questions to guide the review for this report: 1. What is the comparative effectiveness of fingolimod and other disease-modifying treatments for multiple sclerosis, including use of differing routes and schedules of administration? 2. [Do disease-modifying treatments for multiple sclerosis in effects on the development or recurrence of interferon beta neutralizing antibodies?] 3. [What is the evidence that interferon beta neutralizing antibody status has an impact on clinical outcomes (relapse and disease progression) in patients with multiple sclerosis?] MS drugs addendum: fingolimod 3 of 9

4 4. What is the effectiveness of fingolimod and other disease-modifying treatments for patients with a clinically isolated syndrome? 5. Do fingolimod and other disease-modifying treatments for multiple sclerosis differ in harms? 6. Are there subgroups of patients based on demographics (age, racial or ethnic groups, and gender), socioeconomic status, other medications, severity of disease, or co-morbidities for which fingolimod is more effective or associated with fewer adverse events than other disease-modifying treatment? METHODS Literature Search We searched Ovid MEDLINE (1996-week 4 December 2010), Ovid MEDLINE In-Process & Other Non-Indexed Citations (November 08, 2010), the Cochrane Database of Systematic Reviews (4th Quarter, 2010), the Cochrane Central Register of Controlled Trials (4th Quarter, 2010), and Database of Abstracts of Reviews of Effects (DARE) using included drugs, indications, and study designs as search terms. We attempted to identify additional studies through hand searches of reference lists of included studies and reviews. In addition, we searched the US Food and Drug Administration Center for Drug Evaluation and Research website for medical and statistical reviews of individual drug products. Finally, we requested dossiers of published and unpublished information from the pharmaceutical manufacturer of fingolimod. The dossier received was screened for studies or data not found through other searches. Validity Assessment We assessed the internal validity (quality) of included studies as good, fair, or poor based on predefined criteria. Trials that had a fatal flaw were rated poor quality; trials that met all criteria were rated good quality; the remainder were rated fair quality. The results of some fair-quality studies are likely to be valid, while others are only possibly valid. A poor-quality trial is not valid; the results are at least as likely to reflect flaws in the study design as a true difference between the compared drugs. We graded the overall strength of a body of evidence pertaining to a particular key question or outcome based on an approach devised by the GRADE working group. This approach reflects the risk of bias of the studies (based on quality and study designs), consistency of results, directness of evidence, and precision of pooled estimates resulting from the set of studies relevant to the question. Strength of evidence was graded as High, Moderate, Low, or insufficient. MS drugs addendum: fingolimod 4 of 9

5 RESULTS Overview Electronic literature searches identified 76 citations. We received a dossier from the pharmaceutical manufacturer, which supplied additional data on studies in the form of posters and slide sets from presentations at conferences. We reviewed the US Food and Drug Administration Medical and Statistical reviewer reports regarding the New Drug Application for fingolimod. By applying the eligibility criteria, we ultimately included 4 unique studies enrolling a combined 2845 patients: 1 head-to-head comparison trial, 2 placebo-controlled trials, and 1 randomized extension study of 1 placebo-controlled trial. The US Food and Drug Administration documents included some data on these studies. Two posters relating to an additional extension study of the head-to-head comparison trial submitted for consideration by the manufacturer were not included due to inadequate information provided to conduct a full quality assessment. All included studies enrolled patients with relapsing-remitting multiple sclerosis. The US Food and Drug Administration approved dose of fingolimod is 0.5 mg daily. The comparative evidence regarding a higher dose (1.25 mg per day) is included for completeness and to highlight the relative effects increasing the dose above the dose approved by the US Food and Drug Administration. Key Question 1 Summary of findings There was moderate-strength evidence that fingolimod 0.5 mg once daily and 1.25 mg once daily resulted in lower annualized relapse rates than interferon beta-1a (0.16, 0.20, and 0.33 respectively; P< 0.001). Fingolimod 0.5 mg once daily and 1.25 mg once daily resulted in more patients having no confirmed relapse at 1 year compared with interferon beta-1a (82.5%, 80.5%, and 70.1% respectively; numbers needed to treat, 8.3 for fingolimod 0.5 mg once daily and 10 for 1.25 mg once daily); differences between the lower dose of fingolimod and the higher dose were not statistically significant. The rate of confirmed disability progression over 12 months was low in both groups and not statistically significant between groups, although the change in ratings on 2 scales measuring disability and function showed slightly better results with fingolimod than interferon beta-1a. It is unlikely however, that progression differences would have been identified in a 1 year time frame. Key Question 2 Not relevant to this drug. Key Question 3 Not relevant to this drug. MS drugs addendum: fingolimod 5 of 9

6 Key Question 4 No evidence found. Key Question 5 Summary of findings There was moderate-strength evidence that there are differences in adverse events between fingolimod 0.5 mg once daily and interferon beta-1a for some specific adverse events. Higher rates of pyrexia (relative risk, 4.26; 95% CI, 2.62 to 6.97), influenza-like illness (relative risk, 10.55; 95% CI, 6.39 to 17.57), and myalgia (relative risk, 3.13; 95% CI, 1.76 to 5.59) were found with interferon beta-1a; a higher rate of increased alanine aminotransferase (relative risk, 3.52; 95% CI, 1.66 to 7.50) was found with fingolimod. No deaths occurred in the interferon or fingolimod 0.5 mg groups and there was no difference in rate of herpes zoster infections between fingolimod 0.5 mg once daily and interferon beta-1a. After the first dose of fingolimod, dose-dependent bradycardia and atrioventricular block occurred in the first 6 to 8 hours however none persisted or occurred later in treatment. Across all 3 trials, bradycardia occurred in 1.2% of patients taking 1.25 mg fingolimod, 0.6% taking 0.5 mg fingolimod, 0.2% taking placebo, and 0% taking interferon, and second-degree atrioventricular blockade occurred in 0.4% of patients taking 1.25 mg fingolimod, 0.1% taking 0.5 mg fingolimod, and 0% taking placebo or interferon. Discontinuations due to adverse events and serious adverse events occurred more frequently with fingolimod 1.25 mg than with fingolimod 0.5 mg or interferon beta-1a. The increased risk of discontinuing drug due to an adverse event with fingolimod 1.25 mg once daily compared with 0.5 mg was relative risk, 1.79 (95% CI, 1.11 to 2.89) and compared with interferon beta-1a was relative risk, 2.69 (95% CI, 1.55 to 4.69), with numbers needed to harm of 23 and 16, respectively. Fingolimod 1.25 mg was associated with higher risk of herpes virus infections than fingolimod 0.5 mg (relative risk, 2.61; 95% CI, 1.75 to 5.49; number needed to harm, 30) or interferon beta-1a (relative risk, 1.97; 95% CI, 1.01 to 3.86; number needed to harm, 37). Over 12 months, 8 of 10 cases of localized skin cancer and 2 cases of breast cancer were diagnosed during the trial in patients taking fingolimod, macular edema occurred in 4 patients in the 1.25 mg fingolimod group (1%), 2 in the 0.5 mg group (0.5%), and none in the interferon group, and pulmonary function was reduced in fingolimod patients (2% to 3% reduction FEV1). Two deaths (0.48%) occurred with fingolimod 1.25 mg, both due to viral infections (each case had additional confounding factors). Key Question 6 Very limited evidence is currently available on fingolimod in patient subgroups. An analysis of change in depression scale scores relative to placebo has been presented at a conference, but a full publication is not available at this time. The US Food and Drug Administration Clinical Reviewer document reported on their pooled analyses of data from the 2 most recent trials. Both used 1.25 mg and 0.5 mg of fingolimod, with comparisons to either placebo or interferon beta- 1a. They found no clear difference in effect of fingolimod by gender or age, but noted that a MS drugs addendum: fingolimod 6 of 9

7 higher overall ARR was seen in the subgroup of patients that were younger, which is consistent with published data on the natural history of MS. A similar analysis by US Food and Drug Administration reviewers found no difference in the effect of fingolimod based on baseline disability score, but noted that patients with worse disability at baseline have higher annualized relapse rates than those with lower scores, as would be expected. SUMMARY The main findings of this review are summarized in Table 2. The applicability of the results were limited by the scope of the Key Questions and inclusion criteria and by the generalizability of the studies included. The trials included narrowly defined populations of patients who met strict criteria for case definition, had few or no comorbidities, and used few or no concomitant medications. Minorities, older patients, and the most seriously ill patients were underrepresented. The evidence was largely applicable to patients with relapsing-remitting multiple sclerosis of moderate severity. The comparative evidence was limited to treatment for 1 year and did not reflect changes beyond that time. Outcomes related to disability progression may require 2 or more years to evaluate. The conclusions about benefit or harm relative to other disease-modifying drugs were limited only to interferon beta-1a (30 mcg given intramuscularly once weekly). MS drugs addendum: fingolimod 7 of 9

8 Table 2. Summary of the evidence by key question Key question Key Question 1. What is the comparative effectiveness of disease-modifying treatments for multiple sclerosis, including use of differing routes and schedules of administration? Key Question 5. Do disease-modifying treatments for multiple sclerosis differ in harms? Key Question 6. Are there subgroups of patients based on demographics (age, racial or ethnic groups, and gender), socioeconomic status, other medications, severity of disease, or co-morbidities for which one diseasemodifying treatment is more effective or associated with fewer adverse events? Strength of evidence Fingolimod 1.25 mg or 0.5 mg once daily vs. interferon beta-1a: Moderate All others: Insufficient Fingolimod 1.25 mg or 0.5 mg once daily vs. interferon beta-1a: Moderate All others: Insufficient Age, gender, baseline disability score: Moderate All others: Insufficient Conclusion Fingolimod 0.5 mg once daily and 1.25 mg once daily resulted in lower annualized relapse rates than interferon beta-1a (0.16, 0.20, 0.33 respectively; P< 0.001). Fingolimod 0.5 mg once daily and 1.25 mg once daily resulted in more patients having no confirmed relapse at 1 year compared with interferon beta-1a (82.5%, 80.5%, and 70.1% respectively); NNT, 8.3 for fingolimod 0.5 mg and 10 for 1.25 mg daily. Differences were not found between the lower dose of fingolimod and the higher dose. Rates of confirmed disability progression were low, and similar between groups. Higher rates of pyrexia (RR, 4.26 ( ), Influenzalike illness (RR, ( )), and myalgia (RR, 3.13 ( )) were found with interferon beta-1a, while a higher rate of increased alanine aminotransferase (RR, 3.52 ( )) was found with fingolimod. The rate of herpes zoster infections was similar between fingolimod 0.5 mg once daily and interferon beta- 1a. Fingolimod 1.25 mg was associated with higher risk of herpes virus infections than fingolimod 0.5 mg (RR, 2.61; 95% CI, 1.75 to 5.49; NNH, 30) or interferon beta-1a (RR, 1.97; 95% CI, 1.01 to 3.86; NNH, 37). Macular edema occurred in 4 patients in the 1.25 mg fingolimod group (1%), 2 in the 0.5 mg group (0.5%), and none in the interferon group. After the first dose of fingolimod, 1.2% of patients taking 1.25 mg fingolimod, 0.6% taking 0.5 mg fingolimod, 0.2% taking placebo, and 0% taking interferon experienced bradycardia. The risk of discontinuing drug due to an adverse event increased with fingolimod 1.25 mg once daily compared with fingolimod 0.5 mg once daily (RR, 1.79 (1.11 to 2.89); NNH, 23) and with interferon beta-1a (RR, 2.69 (1.55 to 4.69); NNH,16). Differences in efficacy based on age, gender, or baseline disability score were not found with fingolimod. Abbreviations: NNH, number needed to harm; NNT, number needed to treat; RR, relative risk. MS drugs addendum: fingolimod 8 of 9

9 CONCLUSIONS In patients with relapsing-remitting multiple sclerosis, fingolimod 0.5 mg and 1.25 mg once daily was superior to interferon beta-1a in improving relapse-related outcomes, including annualized relapse rates and proportion without relapse, over a 1 year period. Progression of disability was not different between the treatments. The higher dose (1.25 mg once daily) of fingolimod resulted in higher numbers and more severe adverse events, including herpes zoster infections and symptomatic bradycardia after the first dose, as well as more patients discontinuing treatment. Differences in adverse events between 0.5 mg fingolimod and interferon beta-1a were limited to more patients with pyrexia, myalgia, and flu-like symptoms with interferon and more with elevated liver enzymes with fingolimod. Ongoing concerns with the safety of fingolimod include the risk of macular edema, the effect of lung function, cancers, and serious viral infections. Further studies are underway to better determine these risks with fingolimod. MS drugs addendum: fingolimod 9 of 9

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