FDA ex­perts of­fer a big thumbs up for J&J’s flawed ap­pli­ca­tion for ke­t­a­mine-based de­pres­sion drug — but tri­al fail­ures, safe­ty ques­tions spur con­cerns

J&J may have a deeply flawed ap­pli­ca­tion for its new/old drug to treat ma­jor de­pres­sion, but the re­searchers who turned out to present the case for es­ke­t­a­mine en­coun­tered a re­cep­tive au­di­ence of FDA ex­perts on Tues­day. 

By a wide mar­gin — 14 yes, 2 no and 1 ab­sten­tion — the pan­el con­clud­ed that J&J had of­fered “sub­stan­tial ev­i­dence of the ef­fec­tive­ness of es­ke­t­a­mine,” an in­tranasal ver­sion of a pow­er­ful anes­thet­ic called ke­t­a­mine, bet­ter known in par­ty cir­cles as ‘Spe­cial K.’

The key safe­ty is­sue is the known link be­tween the long­time use of ke­t­a­mine and neu­ro­tox­i­c­i­ty. The re­searchers re­lied on pre­clin­i­cal dog and rat stud­ies to make their case — hard­ly the gold stan­dard on safe­ty da­ta. But the pan­el seemed con­tent that a long-term safe­ty study on a post­mar­ket­ing ba­sis would be enough to war­rant an OK now, with 15 vot­ing that J&J had suc­cess­ful­ly out­lined the safe­ty pro­file for an ini­tial ap­proval. And at least one of the au­thor­i­ties not­ed that cur­rent­ly used de­pres­sion drugs al­so have safe­ty is­sues with long­time use.

The mon­ey ques­tion:

Do the ben­e­fits out­weigh the risks? Yes: 14. No: 2. Ab­stain: 1.

J&J calls es­ke­t­a­mine — which they plan to mar­ket as Spra­va­to — the first drug with a new mech­a­nism of ac­tion in de­pres­sion for some 30 years. Of course, ke­t­a­mine has al­so been used off-la­bel for de­pres­sion for years. It’s an NM­DA drug, with ri­vals in the clin­ic from var­i­ous bio­phar­ma com­pa­nies, in­clud­ing Al­ler­gan.

“Ke­t­a­mine is a nasty drug,” not­ed pan­el mem­ber Steven Meisel, sys­tem di­rec­tor of med­ica­tion safe­ty at Fairview Health Ser­vices/Health­east Care Sys­tem. “It’s been around for 50 years….But ob­vi­ous­ly we’re us­ing low­er dos­es.” Meisel, though, was im­pressed by a sur­vey re­searchers com­plet­ed that high­light­ed just how much these pa­tients need­ed a new ther­a­py.

“You don’t take that pa­tient’s voice as of­ten as you should in this space.”

“The vast ma­jor­i­ty of these pa­tients will take the risks,” he added. “I think that’s very im­por­tant….”

Two of the stud­ies failed to meet the pri­ma­ry out­come, and that raised con­cerns. 

“What prece­dent is set when 2 of 3 short­er ef­fi­ca­cy stud­ies didn’t meet the pri­ma­ry end­point?” Meisel asked. “That’s some­thing the agency has to wres­tle with. “Do we set a prece­dent that may be hard to step back from.”

If the FDA goes ahead and of­fers a for­mal ap­proval, which looks in­creas­ing­ly like­ly in view of the neu­tral in­ter­nal re­view, they’ll be once again over­look­ing the agency’s gold stan­dard on 2 pos­i­tive, well con­trolled stud­ies. But that’s in­creas­ing­ly com­mon, es­pe­cial­ly un­der com­mis­sion­er Scott Got­tlieb.

J&J ex­pe­ri­enced sig­nif­i­cant fail­ures with this pro­gram, and has promis­ing da­ta from one late-stage study and a with­draw­al study, which the ex­perts and in­sid­ers seemed will­ing to ac­cept in lieu of a sec­ond well-con­trolled tri­al.

Es­ke­t­a­mine is one of J&J’s top late-stage drugs, which the phar­ma gi­ant be­lieves has block­buster mar­ket po­ten­tial. By all ap­pear­ances, they’ll soon be able to ex­plore just how big this drug can be.

Donald and Melania Trump watch the smoke of fireworks from the South Lawn of the White House on July 4, 2020 (via Getty)

Which drug de­vel­op­ers of­fer Trump a quick, game-chang­ing ‘so­lu­tion’ as the pan­dem­ic roars back? Eli Lil­ly and Ab­Cellera look to break out of the pack

We are unleashing our nation’s scientific brilliance and will likely have a therapeutic and/or vaccine solution long before the end of the year.

— Donald Trump, July 4

Next week administration officials plan to promote a new study they say shows promising results on therapeutics, the officials said. They wouldn’t describe the study in any further detail because, they said, its disclosure would be “market-moving.”

— NBC News, July 3

Something’s cooking. And it’s not just July 4 leftovers involving stale buns and uneaten hot dogs.

Over the long weekend observers picked up signs that the focus in the Trump administration may swiftly shift from the bright spotlight on vaccines being promised this fall, around the time of the election, to include drugs that could possibly keep patients out of the hospital and take the political sting out of the soaring Covid-19 numbers causing embarrassment in states that swiftly reopened — as Trump cheered along.

So far, Gilead has been the chief beneficiary of the drive on drugs, swiftly offering enough early data to get remdesivir an emergency authorization and into the hands of the US government. But their drug, while helpful in cutting stays, is known for a limited, modest effect. And that won’t tamp down on the hurricane of criticism that’s been tearing at the White House, and buffeting the president’s most stalwart core defenders as the economy suffers.

We’ve had positive early-stage vaccine data, most recently from Pfizer and BioNTech, playing catchup on an mRNA race led by Moderna — where every little sign of potential trouble is magnified into a lethal threat, just as every advance excites a frenzy of support. But that race still has months to play out, with more Phase I data due ahead of the mid-stage numbers looming ahead. A vaccine may not be available in large enough quantities until well into 2021, which is still wildly ambitious.

So what about a drug solution?

Trump’s initial support for a panacea focused on hydroxychloroquine. But that fizzled in the face of data underscoring its ineffectiveness — killing trials that aren’t likely to be restarted because of a recent population-based study offering some support. And there are a number of existing drugs being repurposed to see how they help hospitalized patients.

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Shoshanna Shendelman, Applied Therapeutics CEO (Applied Therapeutics)

A lit­tle biotech slaps back at a 'crim­i­nal' short at­tack, vow­ing to pur­sue a pros­e­cu­tion of their case

As short attacks go, Biotech Research Partners’ assault on Applied Therapeutics’ “cherry picked” data and a variety of so-called red flags didn’t cause a whole lot of damage. Ahead of the July 4 holiday, its shares $APLT were dinged and showed signs of quick recovery.

But that didn’t stop an incendiary response, as the biotech swung into action bright and early Monday morning.

Applied Therapeutics accused the authors of the short report of manipulating graphs and figures, misrepresenting data and included factual misrepresentations — all of which added up, in their view, to fraud.

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Cel­lec­tis slammed af­ter pa­tient dies and FDA slaps a hold on their tri­al for an off-the-shelf CAR-T for mul­ti­ple myelo­ma

Cellectis was slammed after the market close on Monday as the biotech reported that the FDA demanded it hit the brakes on their MELANI-01 trial for their off-the-shelf cell therapy UCARTCS1A after one of the patients in the study died of treatment-related cardiac arrest.

The multiple myeloma patient had previously been treated unsuccessfully with various therapies, noted the biotech, and had been given dose level two (DL2) of their allogeneic CAR-T.

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UP­DAT­ED: Im­munomedics spells out PFS ben­e­fit of Trodelvy in mTNBC, hunt­ing a full OK just weeks af­ter ac­cel­er­at­ed ap­proval

By the time the FDA finally granted an accelerated OK for Immunomedics’ Trodelvy, we already got a very strong hint that their confirmatory Phase III study in metastatic triple-negative breast cancer was a success.

That’s because the independent data safety monitoring committee recommended that the trial be stopped early. But just what pointed them to the conclusion was still unclear.

“We do not know the totality of their decision other than it’s pretty evident that the primary endpoint was met; otherwise they could not request to halt the study,” Behzad Aghazadeh, the executive chairman, told Endpoints News at the time.

Bill Haney, Dragonfly CEO (Dave Pedley/Getty Images for SXSW)

A boom­ing Drag­on­fly is tak­ing its TriN­KETs to Copen­hagen as the lat­est Bris­tol My­ers pact spurs ex­pan­sion plans — out­side the US

Bristol Myers Squibb is making a habit out of collaborating with the crew at Dragonfly, adding their 3rd deal in a series that now will take them into newly charted R&D territory. And the fast-growing team at the Cambridge-based biotech is adding a facility in Copenhagen for its next growth spurt, where the government is making it easy to recruit scientists internationally as the U.S. throttles back.

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Covid-19 roundup: Teamed up with NIH, Re­gen­eron launch­es PhI­II pre­ven­tion tri­al for an­ti­body cock­tail

As Regeneron moves its antibody cocktail into Phase II/III trials testing REGN-COV2 as a treatment for both hospitalized and non-hospitalized patients with Covid-19, the biotech is also starting a Phase III in the prevention setting.

The National Institute of Allergy and Infectious Diseases — which orchestrated the large, randomized study for remdesivir that produced positive results — will jointly run the study.

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Douglas Love, Annexon CEO (Annexon)

IPO bound? Ac­tu­al­ly, An­nex­on was al­ready prepped and primed to toss its S-1 to Wall Street as in­vestors ral­lied

The Wall Street IPO shuffle generally calls for a little distance between the crossover ante and the Wall Street double, but with the window on the street wide open and biotech sizzling hot, who’s waiting?

The crew at Annexon didn’t leave anyone in suspense for long about their IPO plans. A day after the Bay Area biotech with clinical plans to target neurodegeneration quietly unveiled a $100 million raise, they were back with an S-1 outlining a pitch to double that — or more.

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Jean-Paul Clozel, Idorsia CEO (Patrick Straub/Keystone via AP Images)

Sec­ond PhI­II study for Idor­si­a's sleep drug re­turns pos­i­tive re­sults, but al­so rais­es new ques­tions

Following a successful Phase III study in April showcasing the safety and potential of its new sleep drug, Idorsia posted some mixed news in the second Phase III study, but that won’t stop a planned filing aimed at regulatory approval.

The drug, a dual orexin receptor antagonist (DORA) called daridorexant, was found to significantly improve sleep maintenance and subjective total sleep time in 25 mg doses, replicating results from the first Phase III study. However, improvements in sleep onset and daytime functioning narrowly missed statistical significance, despite numerical consistency with the April study.

Elias Zerhouni (Photo by Vincent Isore/IP3/Getty Images)

Elias Zer­houni dis­cuss­es ‘am­a­teur hour’ in DC, the de­struc­tion of in­fec­tious dis­ease R&D and how we need to prep for the next time

Elias Zerhouni favors blunt talk, and in a recent discussion with NPR, the ex-Sanofi R&D and ex-NIH chief had some tough points to make regarding the pandemic response.

Rather than interpret them, I thought it would be best to provide snippets straight from the interview.

On the Trump administration response:

It was basically amateur hour. There is no central concept of operations for preparedness, for pandemics, period. This administration doesn’t want to or has no concept of what it takes to protect the American people and the world because it is codependent. You can’t close your borders and say, “OK, we’re going to be safe.” You’re not going to be able to do that in this world. So it’s a lack of vision, basically just a lack of understanding, of what it takes to protect the American people.

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