FDA ap­proves drug for rare con­di­tion that trig­gers in­tense pain from light ex­po­sure

Five years af­ter EU reg­u­la­tors ap­proved a ther­a­py to treat a rare in­her­it­ed meta­bol­ic con­di­tion that caus­es ex­treme sen­si­tiv­i­ty to light, the FDA has en­dorsed the treat­ment — mark­ing the first-ever ap­proval for pa­tients with ery­thro­poi­et­ic pro­to­por­phyr­ia (EPP) in the Unit­ed States.

The ther­a­py, which is ad­min­is­tered via an im­plant in­sert­ed sub­cu­ta­neous­ly, was de­vel­oped by Aus­tralian drug mak­er Clin­u­v­el Phar­ma­ceu­ti­cals and is sold as Sce­nesse.

In pa­tients with EPP, the ac­tiv­i­ty of fer­rochelatase — an en­zyme in­volved in the pro­duc­tion of a key com­po­nent in he­mo­glo­bin — is com­pro­mised. Re­duced fer­rochelatase ac­tiv­i­ty caus­es the ac­cu­mu­la­tion of pro­to­por­phyrin IX (PPIX) — and light ex­po­sure on the skin can re­act with PPIX, spark­ing in­tense pain, red­ness and thick­en­ing.

Sce­nesse, known chem­i­cal­ly as afame­lan­otide, binds with the melanocortin-1 re­cep­tor on the sur­face of melanocyte cells found in the epi­der­mis of the skin. This trig­gers a cas­cade of re­ac­tions that re­sult in the melanocyte fa­vor­ing the pro­duc­tion of eu­me­lanin (black/brown) over pheome­lanin (red/yel­low). The pro­duc­tion of eu­me­lanin in the skin in­de­pen­dent of ex­po­sure to sun­light or ar­ti­fi­cial light sources of­fers the pa­tient the abil­i­ty to cope with the mol­e­c­u­lar dam­age caused by light.

In Jan­u­ary, STAT pro­filed a Con­necti­cut woman who com­pared the pain she felt from light ex­po­sure to the ex­pe­ri­ence of hav­ing boil­ing oil poured on her hands and knees. On­ly around 600 Amer­i­cans suf­fer from EPP. Switzer­land and Italy had Clin­u­v­el agree to pay 80% of the drug’s cost be­fore al­low­ing it, ac­cord­ing to STAT.

“We are de­ter­min­ing our pric­ing strat­e­gy (in the Unit­ed States) but our ap­proach is go­ing to be far more trans­par­ent and fair than many of our peers. For this we re­fer you to our ap­proach to pric­ing in Eu­rope,” a Clin­u­v­el spokesper­son told End­points News.

Sce­nesse is priced in Eu­rope at €14,101 per in­jectable im­plant, or €56,404 per pa­tient based on four in­jectable im­plants per an­num (ex­clud­ing lo­cal tax­es), the spokesper­son added.

The US ap­proval for Sce­nesse was based on twin place­bo-con­trolled clin­i­cal tri­als. In the first 93-pa­tient tri­al, 48 sub­jects were giv­en Sce­nesse, while the rest were on place­bo.  Af­ter 180 days of ex­po­sure to di­rect sun­light be­tween 10 am and 6 pm, pa­tients on the ther­a­py were pain-free for a me­di­an 64 hours, ver­sus 41 hours for those in the place­bo arm.

In the oth­er 74-pa­tient study, 38 re­ceived Sce­nesse, while the rest got place­bo. Pa­tients were fol­lowed for 270 days which they spent out­doors be­tween 10 am and 3 pm and were as­sessed for pain lev­els — al­though the analy­sis did not in­clude sun ex­po­sure on days pa­tients re­port­ed spend­ing time in a com­bi­na­tion of both di­rect sun­light and shade. The me­di­an to­tal num­ber of hours un­der these con­di­tions in which pa­tients felt ‘no pain’ was six hours for pa­tients re­ceiv­ing Sce­nesse and 0.75 hours for pa­tients re­ceiv­ing place­bo.

Clin­u­v­el formed in 1987 af­ter re­searchers start­ed work­ing on the idea of syn­the­siz­ing hu­man hor­mones to pro­tect the skin.

Secretary of health and human services Alex Azar speaking in the Rose Garden at the White House (Photo: AFP)

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In a new memorandum issued Tuesday last week, the HHS chief stripped the FDA and other health agencies under his purview of their rule making ability, asserting all such power “is reserved to the Secretary.” Sheila Kaplan of the New York Times first obtained and reported the details of the September 15 bulletin.

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Comparing KEYNOTE-590 and CheckMate-649, of course, comes with the usual caveats. But a side-by-side look at the overall survival numbers also offer some perspective on a new frontier for the reigning checkpoint rivals, both of whom are claiming to have achieved a first.

President Donald Trump (via AP Images)

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In podcasts, public forums, social media and medical journals, a growing number of prominent health leaders say they fear that Trump — who has repeatedly signaled his desire for the swift approval of a vaccine and his displeasure with perceived delays at the FDA — will take matters into his own hands, running roughshod over the usual regulatory process.

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Moving into earlier and earlier treatment lines, Bristol Myers Squibb is reporting that adjuvant treatment with Opdivo has doubled the time that esophageal or gastroesophageal junction cancer patients stay free of disease.

With the CheckMate-577 data at ESMO, CMO Samit Hirawat said, the company believes it can change the treatment paradigm.

While a quarter to 30% of patients typically achieve a complete response following chemoradiation therapy and surgery, the rest do not, said Ronan Kelly of Baylor University Medical Center. The recurrence rate is also high within the first year, Hirawat added.

Clay Siegall (Life Science Washington via YouTube)

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Jonathan Rigby, Immune Regulation group CEO

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Eli Lilly CSO Dan Skovronsky (file photo)

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Greg Friberg (File photo)

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