The FDA has approved the pegfilgrastim biosimilar LA-EP2006 (pegfilgrastim-bmez; Ziextenzo) as a treatment to decrease the incidence of infection, exhibited from febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anti-cancer therapy that is associated with a clinically significant incidence of febrile neutropenia.
The FDA has approved the pegfilgrastim (Neulasta) biosimilar LA-EP2006 (pegfilgrastim-bmez; Ziextenzo) as a treatment to decrease the incidence of infection, exhibited from febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anti-cancer therapy that is associated with a clinically significant incidence of febrile neutropenia.1
The approval is based on analytical, preclinical, and clinical studies, including data from the pivotal three-way pharmacokinetics (PK) and pharmacodynamics (PD) LA-EP06-104 trial comparing Sandoz's pegfilgrastim biosimilar with US-sourced reference pegfilgrastim; the pegfilgrastim biosimilar with European Union—sourced reference pegfilgrastim; and US- with EU-sourced reference pegfilgrastim.2 Results showed that PK and PD similarity were demonstrated in all three comparisons, and there were no clinically meaningful differences observed in safety and immunogenicity among the groups.
"When a cancer patient with febrile neutropenia gets an infection, it can have serious consequences such as delays or dose reductions of chemotherapy," Carol Lynch, president of Sandoz Inc., the developer of the biosimilar, stated in a press release. "The approval of Ziextenzo expands our oncology portfolio, providing physicians with a long-acting supportive oncology biosimilar option. It builds on the foundation of trust and experience we developed with our short-acting filgrastim Zarxio—the leading filgrastim by market share in the US—including consistent product supply and reliable patient services."
Pegfilgrastim is a long-acting version of filgrastim (Neupogen), which is indicated for select patients with cancer undergoing chemotherapy to enhance the production of infection-fighting white blood cells. The indication is specific to those receiving myelosuppressive anticancer drugs associated with a clinically significance incidence of febrile neutropenia.
In April 2019, Sandoz resubmitted a biologics license application to then FDA for LA-EP2006 to decrease the incidence of infection from febrile neutropenia in patients with nonmyeloid malignancies receiving myelosuppressive anticancer therapy.3 The resubmission addressed a complete response letter issued by the FDA in June 2016.
The resubmitted application included updated data from the LA-EP06-104 study, methodology of which was presented at the 2018 ESMO Congress. The study was sufficiently powered (90%) to achieve confidence intervals within margins 0.8 to 1.25 in co-primary endpoints pairwise comparisons. The investigators noted that due to historically known high intra- and inter-subject variabilities with reference biologic in area under the serum concentration-time curve (AUC)0-inf, the study, in healthy volunteers, is appropriate and establishes the scientific bridge to demonstrate similarity of PK/PD, safety, and immunogenicity between LA-EP2006, EU reference pegfilgrastim, and US reference pegfilgrastim. As of October 2018, the trial was ongoing in in 5 US and 1 Dutch study sites.
The European Commission approved LA-EP2006, known as Ziextenzo, as a treatment to reduce the duration of neutropenia and incidence of febrile neutropenia that is associated with anticancer chemotherapy in November 2018. With that approval, the biosimilar became indicated for use in the same proposed indications as reference pegfilgrastim, which is to prevent febrile neutropenia in patients receiving myelosuppressive chemotherapy, those with acute myeloid leukemia receiving induction or consolidation chemotherapy, patients with cancer undergoing bone marrow transplantation, those undergoing autologous peripheral blood progenitor cell collection and therapy, and those with severe chronic neutropenia.
The European approval was based on comprehensive analytical, preclinical and clinical data demonstrating the similarity between Ziextenzo and pegfilgrastim regarding safety, efficacy, and quality. Part of the submitted data was from a single-dose, double-blind, randomized, two-way crossover, phase I study, in which the biosimilar demonstrated similar PD, PK, immunogenicity, and safety as reference pegfilgrastim.4
The study consisted of 2 treatment periods separated by an 8-week washout period. A total 169 patients between the ages of 18 and 45 years were randomized to either the biosimilar or pegfilgrastim. Each treatment was administered at a 6-mg subcutaneous dose on day 1 of each treatment period.
PK/PD similarity was claimed if 90% PK and 95% PD confidence intervals (CIs) for geometric mean ratios of AUC from time of dosing and extrapolated to infinity (AUC0-inf), or to the last measurable concentration (AUC0-last), maximum observed serum concentration (Cmax), absolute neutrophil count (ANC) area under the effect curve from the time of dosing to the last measurable concentration (AUEC0-last), and ANC maximum effect attributable to the therapy under investigation (Emax) were completely contained within the predefined margin (0.8-1.25).
Results showed that similar PK/PD data were demonstrated: 90% CIs of geometric mean ratio of proposed biosimilar/reference for PK: AUC0-inf (1.0559-1.2244), AUC0-last (1.0607-1.2328), Cmax (1.0312-1.1909) and 95% CIs for PD (ANC): AUEC0-last (0.9948-1.0366), Emax (0.9737-1.0169) were contained within the predefined margin.
Moreover, the biosimilar and reference pegfilgrastim demonstrated similar safety profiles and were well tolerated, and there was no detection of neutralizing or clinically relevant antibodies.
In November 2018, the FDA approved the first pegfilgrastim biosimilar CHS-1701 (pegfilgrastim-cbqv; Udenyca) for patients with cancer receiving myelosuppressive chemotherapy.
In June 2018, the FDA granted approval to pegfilgrastim-jmdb (Fulphila), another pegfilgrastim biosimilar, to decrease the incidence of infection by febrile neutropenia in patients with nonmyeloid malignancies receiving myelosuppressive chemotherapy.