Novartis: European Commission (EC) approved Revolade® for treatment of pediatric chronic immune thrombocytopenic purpura (ITP) patients

• EU approval of Revolade expands treatment options for pediatric patients aged 1 year and above with chronic ITP who have not responded to other therapies
• Two formulations approved: once-daily tablet and oral suspension formulation designed for younger children who may not be able to swallow tablets
• For about one in four children with ITP, a disorder of low blood platelet count and potential bleeding, the condition becomes chronic[1],[2]

BASEL, 08-Apr-2016 — /EuropaWire/ — Novartis announced today that the European Commission (EC) has approved Revolade^® (eltrombopag) for the treatment of pediatric (aged 1 year and above) chronic immune (idiopathic) thrombocytopenic purpura (ITP) patients who are refractory to other treatments (e.g. corticosteroids, immunoglobulins). The approval includes the use of tablets as well as a new oral suspension formulation of Revolade, which is designed for younger children who may not be able to swallow tablets. Revolade was approved by the EC in 2010 for use in adults with the same condition.

“For the families and caregivers of children affected by a rare disease, having a new treatment option can be game-changing in managing the disease,” said Alessandro Riva, MD, Global Head, Novartis Oncology Development and Medical Affairs.

ITP is a rare blood disorder that affects about five in 100,000 children each year and is characterized by a low platelet count[2],[3]. Because people with ITP have a low number of platelets, they may bruise easily and experience bleeding that is hard to stop[2]. Chronic ITP, defined as ongoing disease more than 12 months after diagnosis[4], occurs in 13-36% of children with ITP[1]. A small number of pediatric patients with chronic ITP may be at risk of significant bleeding[5].

The approval is based on data from two double-blind, randomized, placebo-controlled trials, including the largest Phase III clinical trial in this patient population. In these studies, patients in the treatment and placebo arms were permitted to use some stable maintenance ITP therapies, per local treatment practices. Treatment with Revolade significantly increased and sustained platelet counts among pediatric patients with chronic ITP who were refractory to or had relapsed after prior chronic ITP therapies, and some patients taking concomitant ITP medications were able to reduce or discontinue their use of these medications, primarily corticosteroids.

The EC approval applies to all 28 EU member states, plus Iceland, Norway and Liechtenstein.

Revolade is a once-daily oral thrombopoietin (TPO) receptor agonist that works by inducing stimulation and differentiation of megakaryocytes (large cells, found especially in bone marrow) from bone marrow stem cells to increase platelet production[6]. In August 2015, the US Food and Drug Administration (FDA) approved a new oral suspension formulation, which expanded use of eltrombopag (marketed as Promacta^® in the USA) to include children 1 year of age and older with chronic ITP who have had an insufficient response to corticosteroids, immunoglobulins or splenectomy.

About the PETIT and PETIT2 clinical trials
PETIT is a Phase II, multi-center, three-part study to investigate the efficacy, safety and tolerability of Revolade in pediatric patients (ages 1 to 17 years) with previously treated chronic ITP. The trial included patients living with ITP for six months or longer who had a platelet count <30 Gi/L. Part one was an open label, dose finding study; part two was double-blind and placebo-controlled, and part three was an open-label extension. Patients in the study were permitted to use some stable maintenance ITP therapies, per local treatment practices. The primary efficacy outcome, which was percentage of participants who achieved a platelet count >=50 Gi/L without rescue therapy at least once between weeks one and six, was met by 62% and 32% of patients in the Revolade arm and the control arm, respectively (p=0.011). The secondary efficacy endpoint analyses demonstrated clinically meaningful benefit in terms of decreased need for rescue treatment (13% of patients on Revolade compared to 50% of patients in the control arm). Patients received Revolade for a total of six months during the trial[6],[7].

PETIT2 is a Phase III, multi-center, two-part study to investigate the efficacy, safety and tolerability of Revolade in pediatric patients (ages 1 to 17 years) with previously treated chronic ITP. The trial included patients living with chronic ITP for 12 months or longer who also had a platelet count <30 Gi/L. Part one was randomized, double-blind and placebo-controlled and part two was an open-label extension. Patients in the study were permitted to use some stable maintenance ITP therapies, per local treatment practices. The primary efficacy outcome, which was percentage of participants who achieved a platelet count >=50 Gi/L without rescue therapy for at least six out of eight weeks between weeks five and 12 of part one of the study, was met by 40% of patients treated with Revolade and 3% of patients in the control arm (p<0.001). This result was consistent across the age cohorts. The secondary efficacy endpoint analyses demonstrated clinically meaningful benefit in terms of decreased need for rescue treatment (19% of patients on Revolade compared to 24% of patients in the control arm) during the randomized, double-blind period. Patients were permitted to reduce or discontinue baseline ITP therapy only during the open-label phase of the trial. In the open label eltrombopag-only period, 15 of 87 patients were taking concomitant ITP medications at baseline. Of these 15 patients, eight (53%) had a sustained reduction or permanent discontinuation of at least one baseline ITP medication (seven patients permanently discontinued and one patient had sustained reduction for >=18 weeks). Patients received Revolade for a total of nine months during the trial[6],[8].

In both studies, safety was consistent with the known safety profile of Revolade in chronic ITP in adults and the population under study. No new safety signals were detected. The most common adverse reactions in pediatric chronic ITP patients 1 year and older (greater than or equal to 10% and greater than placebo) were upper respiratory tract infection and nasopharyngitis[6],[7],[8].

About chronic ITP
ITP is a blood disorder characterized by blood that does not clot as it should due to a low number of platelets. People who have ITP often have purple bruises or tiny red or purple dots on the skin. They also may have nosebleeds, bleeding from the gums during dental work, or other bleeding that’s hard to stop. In most cases, an autoimmune response is thought to cause ITP in which a person’s immune system attacks and destroys its own platelets[2].

The two types of ITP are acute (temporary or short-term) and chronic (long-lasting). Acute ITP mainly occurs in children, often after a viral infection, and generally lasts less than six months. The platelet count returns to normal within six to 12 months and treatment may not be needed[2]. Chronic ITP, defined as ongoing disease more than 12 months after diagnosis[4], occurs in 13-36% of children with ITP[1]. A small number of pediatric patients with chronic ITP may be at risk of significant bleeding[5].

The goal of treatment in chronic ITP for children is to maintain a safe platelet count that reduces the risk of bleeding[2]. The most commonly available and used therapies-corticosteroids and intravenous immunoglobulin (IVIG)-are associated with side effects that are often difficult to tolerate in a pediatric setting[5],[9],[10].

About Revolade^® (eltrombopag)
Revolade is approved in more than 100 countries worldwide for the treatment of thrombocytopenia in adult patients with chronic immune (idiopathic) thrombocytopenic purpura (ITP) who have had an inadequate response or are intolerant to other treatments. Eltrombopag (marketed as Promacta^® in the USA), is approved by the US Food and Drug Administration for once-daily use in pediatric patients 1 year and older with chronic ITP who have had an insufficient response to corticosteroids, immunoglobulins or splenectomy. Revolade is also approved in over 45 countries worldwide for the treatment of thrombocytopenia (low blood platelet counts) in patients with chronic hepatitis C to allow them to initiate and maintain interferon-based therapy. In September 2015, the European Commission approved Revolade for the treatment of adults with severe aplastic anemia (SAA) who were either refractory to prior immunosuppressive therapy or heavily pretreated and are unsuitable for hematopoietic stem cell transplant.

Revolade Important Safety Information
Revolade may cause serious side effects, such as liver problems, high platelet counts and a higher chance for blood clots, bleeding after stopping treatment, and bone marrow problems.

Revolade may damage the liver and cause serious, even life threatening, illness. Blood tests to check the liver are needed before taking Revolade and during treatment. When certain antiviral treatments are given together with Revolade for the treatment of thrombocytopenia due to hepatitis C virus (HCV) infections, some liver problems can get worse.

A doctor will order the blood tests and any other tests required. In some cases Revolade treatment may need to be stopped. Patients should tell a doctor right away if they have any of these signs and symptoms of liver problems: yellowing of the skin or the whites of the eyes (jaundice), unusual darkening of the urine, unusual tiredness, right upper stomach area pain.

Patients have a higher chance of getting a blood clot if their platelet count is too high during treatment with Revolade, but blood clots can occur with normal or even low platelet counts. Patients who have cirrhosis of the liver are at risk of a blood clot in a blood vessel that feeds the liver. Patients may have severe complications from some forms of blood clots, such as clots that travel to the lungs or that cause heart attacks or strokes. A doctor will check the patient’s blood platelet counts, and change the dose or stop Revolade if platelet counts get too high. Patients should tell their doctor right away if they have signs and symptoms of a blood clot in the leg, such as swelling or pain/tenderness of one leg.

When patients with chronic ITP stop taking Revolade, their blood platelet count will drop back down to what it was before they started taking Revolade. These effects are most likely to happen within 4 weeks after patients stop taking Revolade. The lower platelet counts may increase risk of bleeding. A doctor will check platelet counts for at least 4 weeks after patients stop taking Revolade. Patients should tell their doctor or pharmacist if they have any bruising or bleeding after they stop taking Revolade.

Patients being treated for the disease may have problems with their bone marrow. Medicines like Revolade could make this problem worse. Signs of bone marrow changes may show up as abnormal results in blood tests. A doctor may also carry out tests to directly check the bone marrow during treatment with Revolade.

The most common side effects of Revolade when used to treat adult patients with chronic ITP include headache, anemia, decreased appetite, insomnia, cough, nausea, diarrhea, alopecia, pruritus, myalgia, pyrexia, fatigue, influenza-like illness, asthenia, chills and peripheral edema.

The most common side effects of Revolade when used to treat pediatric patients with chronic ITP include upper respiratory tract infection, nasopharyngitis, cough, diarrhea, pyrexia, rhinitis, abdominal pain, oropharyngeal pain, toothache, rash, increased AST and rhinorrhea.

The most common side effects of Revolade when used to treat patients with chronic HCV and antiviral agents include headache, anemia, decreased appetite, insomnia, cough, nausea, diarrhea, alopecia, pruritus, myalgia, pyrexia, fatigue, influenza-like illness, asthenia, chills and peripheral edema.

The most common side effects of Revolade when used to treat patients with severe aplastic anemia (SAA) include headache, dizziness, insomnia, cough, dyspnea, oropharyngeal pain, rhinorrhea, nausea, diarrhea, abdominal pain, transaminases increased, ecchymosis, arthralgia, muscle spasms, pain in extremity, fatigue, febrile neutropenia, and pyrexia. Common side effects that may show up in blood tests include increase in some liver enzymes and laboratory tests that may show abnormal changes to the cells in the bone marrow.

Please see full EU Summary of Product Characteristics for Revolade (eltrombopag).

Disclaimer
The foregoing release contains forward-looking statements that can be identified by words such as “can,” “may,” “goal,” “will,” or similar terms, or by express or implied discussions regarding potential new indications or labeling for Revolade (eltrombopag), new formulations of Revolade, or regarding potential future revenues from Revolade. You should not place undue reliance on these statements. Such forward-looking statements are based on the current beliefs and expectations of management regarding future events, and are subject to significant known and unknown risks and uncertainties. Should one or more of these risks or uncertainties materialize, or should underlying assumptions prove incorrect, actual results may vary materially from those set forth in the forward-looking statements. There can be no guarantee that Revolade will be submitted or approved for any additional indications, labeling or formulations in any market, or at any particular time. Nor can there be any guarantee that Revolade will be commercially successful in the future. In particular, management’s expectations regarding Revolade could be affected by, among other things, the uncertainties inherent in research and development, including unexpected clinical trial results and additional analysis of existing clinical data; unexpected regulatory actions or delays or government regulation generally; the company’s ability to obtain or maintain proprietary intellectual property protection; general economic and industry conditions; global trends toward health care cost containment, including ongoing pricing pressures; unexpected safety issues; unexpected quality or manufacturing issues, and other risks and factors referred to in Novartis AG’s current Form 20-F on file with the US Securities and Exchange Commission. Novartis is providing the information in this press release as of this date and does not undertake any obligation to update any forward-looking statements contained in this press release as a result of new information, future events or otherwise.

About Novartis
Novartis provides innovative healthcare solutions that address the evolving needs of patients and societies. Headquartered in Basel, Switzerland, Novartis offers a diversified portfolio to best meet these needs: innovative medicines, eye care and cost-saving generic pharmaceuticals. Novartis is the only global company with leading positions in these areas. In 2015, the Group achieved net sales of USD 49.4 billion, while R&D throughout the Group amounted to approximately USD 8.9 billion (USD 8.7 billion excluding impairment and amortization charges). Novartis Group companies employ approximately 119,000 full-time-equivalent associates. Novartis products are available in more than 180 countries around the world. For more information, please visit http://www.novartis.com.

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References
[1] George JN, Woolf SH, Raskob GE. Idiopathic thrombocytopenic purpura: a practice guideline developed by explicit methods for the American Society of Hematology. Blood. 1996;88(1):3-40.
[2] Immune Thrombocytopenia. US National Institutes of Health website. http://www.nhlbi.nih.gov/book/export/html/4917(link is external). Accessed February 1, 2016.
[3] Fogarty PF, Segal JB. The epidemiology of immune thrombocytopenic purpura. Curr Opin Hematol. 2007;14(5):515-519.
[4] Rodeghiero F, Stasi R, Gernsheimer T, et al. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood. 2009;113(11):2386-2393.
[5] Neunert C, Lim W, Crowther M, et al. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011;117(16):4190-4207.
[6] Revolade Summary of Product Characteristics.
[7] Bussel JB, Garcia de Miguel P, Despotovic JM, et al. Eltrombopag for the treatment of children with persistent and chronic immune thrombocytopenia (PETIT): a randomised, multicentre, placebo-controlled study. Lancet Haematol. 2015; published online July 29, 2015.
[8] Grainger JD, Locatelli F, Chotsampancharoen T, et al. Eltrombopag for children with chronic immune thrombocytopenia (PETIT2): a randomised, multicentre, placebo-controlled trial. Lancet. 2015; published online July 29, 2015.
[9] Provan D, Stasi R, Newland AC, et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010;115(2):168-186.
[10] Cines DB, Blanchette VS. Immune thrombocytopenic purpura. N Engl J Med. 2002;346(13):995-1008.

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