Food and Drug Administration
Center for Drug Evaluation and Research
SUMMARY MINUTES OF THE CDER
PERIPHERAL AND CENTRAL NERVOUS
SYSTEM
DRUGS ADVISORY COMMITTEE
Members Present
(Voting)
Karl Kieburtz, M.D., M.P.H (Acting Chair)
Michael Hughes, Ph.D.
Carol Koski, M.D.
Ralph Sacco, M.D., M.S.
FDA Participants
Robert Temple, M.D.
Russell Katz, M.D.
Eric Bastings, M.D.
Mary Ross
Southworth, M.D.
Executive Secretary
Anuja M.
Patel, M.P.H.
Consultants to the Peripheral and Central Nervous System Drugs Advisory
Committee (Voting)
Lily Jung, M.D., M.M.M. (Consumer Representative)
Larry Goldstein, M.D.
Marc Lenaerts, M.D.
Kenneth Welch, M.B., Ch.B., F.R.C.P
Sheila Weiss Smith, Ph.D., F.I.S.P.E.
Mark Green, M.D.
Federal
Government Employee Consultant (Voting)
Dilip Jeste, M.D.
Peripheral and Central Nervous System Drugs Advisory Committee Industry
Representative (Non-voting)
Roger Porter, M.D.
These summary minutes for the
I certify that I attended the
______//S//_________ __________//S//__________
Anuja Patel, M.P.H. Karl Kieburtz, M.D.
Executive Secretary Acting Chair
Prior to the meeting, the members
and the invited consultants had been provided the background material from the
FDA and from the sponsors. The meeting
was called to order by Karl Kieburtz, (Acting Committee Chair); the conflict of
interest statement was read into the record by Mary Ann Killian (Program
Integrity Advisor, Ethics and Integrity Staff).
There were approximately 120 persons in attendance. There was one speaker for the Open Public
Hearing session.
Open Public Hearing Speaker:
Cynthia McCormick, M.D.
Issue:
Discussions
on new drug application (NDA) 21-645, proposed trade name MT100 (naproxen
sodium and metoclopramide hydrochloride) Tablets, Pozen, Inc., for the proposed
indication of acute treatment of migraine headache with or without aura.
FDA Presentation
·
Opening Remarks Russell
Katz, M.D.
Overview of Issues Director, Division of Neurology Products, FDA
Sponsor Presentation
POZEN Incorporated
·
Introduction and Summary Marshall E. Reese, Ph.D.
Executive Vice President, Product
Development
Pozen Incorporated
·
Overview of Tardive Dyskinesia A.H.V. (Tony) Schapira, M.D.
Professor of Neurology,
Royal Free
·
Review of MT100 Efficacy William James Alexander, M.D., M.P.H., F.A.C.P
Senior
Vice President, Clinical Development
Chief
Medical Officer
Pozen
Incorporated
·
Potential Role of MT100 in Migraine David B. Matchar, M.D., F.A.C.P.
Therapy:
Balancing Benefits and Risks Director,
Professor
of Medicine
Duke University School of Medicine
·
Clinical Considerations on Migraine Stephen D. Silberstein, M.D.
Treatment Director,
FDA Presentation
·
FDA Risk/Benefit Considerations Eric Bastings, M.D.
Clinical Team Leader, DNP, FDA
·
Overview of Tardive Dyskinesia Hyder A. Jinnah, M.D., Ph.D.
The
·
Post-marketing Review of Movement Mary Ross Southworth, Pharm.D.
Disorders and
Neuroleptic Malignant Safety
Evaluator, Division of Drug
Syndrome
Associated with Risk
Evaluation, Office of Drug Safety, FDA
Metoclopramide
Questions for
Advisory Committee
1. Pozen
estimated an annual incidence of tardive dyskinesia (TD) of up to 0.038% for
metoclopramide at a daily dose of 30-40 mg/day for 72 days/year (which
corresponds to up to 380 cases of TD per million patients per year).
Ø
Do you think that this is a reasonable estimate?
Yes = 1 No
= 11 Abstain = 0 Total = 12
Seven of the 11 members who voted “No” said that they did not know what
the recommended estimate should be. Three of the 11 members who voted “No” said
that they think the estimate should be higher. The Chair voted “Yes” and
suggested that a reasonable estimate could be between 0 and 1. The Committee
also suggested ways of obtaining a better estimate.
Please see transcript for details.
Ø
If MT100 were to carry the same risk, would such
a risk level be acceptable if the only contribution of metoclopramide is a
5-10% improvement on sustained headache relief (with no effect on 2-h
endpoints)?
Yes = 2 No
= 10 Abstain = 0 Total = 12
The Chair summarized that the majority of the Committee felt that the
2-h endpoints were critical and most significant. The amount of benefit
demonstrated thus far, without stating its significance or not, was not sufficient
given the perceived risk and the absence of benefit at 2 hr endpoints.
Please see transcript for details.
Ø
Is any risk of tardive dyskinesia acceptable for
a migraine population?
Yes = 12 No
= 0 Abstain = 0 Total = 12
Please see transcript for details.
2.
Is there sufficient evidence that the
chronic-intermittent administration of metoclopramide does not carry a risk of
tardive dyskinesia?
Yes = 0 No
= 12 Abstain = 0 Total = 12
Ø
Is it possible to define a maximum recommended
number of monthly doses of MT100 to avoid the risk of tardive dyskinesia?
Yes = 0 No
= 12 Abstain = 0 Total = 12
The Chair summarized that the Committee felt that there was not enough
evidence that there was no risk of tardive dyskinesia with chronic intermittent
administration; nor could the Committee identify a dose that would be below the
risk or no risk.
Please see transcript for details.
3. Do you
believe that, based on the existing data on medication-overuse headache, there
is evidence that a proportion of patients prescribed MT100 will likely take a
number of monthly doses higher than recommended?
Yes = 12 No
= 0 Abstain = 0 Total = 12
The Committee felt that it was likely that no matter how the drug was
labeled and approved that individuals would take the medication more than the
recommended dosage if there was a limitation on the number of dosages.
Please see transcript for details.
4. All
currently approved acute treatments of migraine are indicated without
restriction regarding the presence or absence of nausea at baseline.
Ø
Given that patients may have nausea at some
attacks and no nausea at others, does an indication
limited to the subpopulation of migraine patients with no nausea at baseline
represent a clinically meaningful and acceptable indication?
Yes = 0 No
= 9 Abstain = 3 Total = 12
The Committee was not in support of individuals without nausea at
baseline being an identifiable group of a clinically meaningful acceptable
indication. The Committee felt that there was an uncertainty whether the nausea
or no nausea populations that have been demonstrated and that the Sponsor
should not mislead itself by a sub group analysis post hoc that may lead them
down the wrong path.
Please see transcript for details.
5. If Pozen
shows prospectively in a new clinical study in migraine patients with no nausea
at baseline:
§
a significant contribution of metoclopramide on
sustained headache pain relief of 5-10%
§
no contribution of metoclopramide at 2-hours
§
no contribution of metoclopramide on relapse rate
or rescue medication use in the 2-24 hour period,
Ø
Would the demonstrated benefit outweigh the
risks related to tardive dyskinesia?
Yes = 0 No
= 12 Abstain = 0 Total = 12
Ø
If not, what additional data (or desired primary
outcome, or desired effect on sustained relief) could provide evidence of
safety and efficacy?
The Committee felt that additional safety
data was needed, and that the 2 h endpoint was important. In addition, the
Committee was concerned with the ways subjects may access the medication
through specific failure of other intervention prior to the exposure of this
intervention.
Please see transcript for details.
Following
completion of discussion of the questions, the committee adjourned at
approximately