May 27, 2020: “The Janssen Pharmaceutical Companies of Johnson & Johnson announced that the U.S. FDA has granted approval for a new pediatric formulation of SIRTURO® (bedaquiline).
SIRTURO® is now indicated for use as part of combination therapy in the treatment of adult and pediatric patients (5 years and older and weighing at least 15 kg) with pulmonary multidrug-resistant tuberculosis (MDR‑TB).
In the U.S., the medicine should be reserved for use when an effective treatment regimen cannot otherwise be provided.
This indication received accelerated approval based on time to sputum culture conversion.
Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.
SIRTURO® should not be used for the treatment of latent TB infection, extra-pulmonary or drug-sensitive TB, or for the treatment of infections caused by non-tuberculous mycobacteria.
The safety and efficacy of SIRTURO® in the treatment of HIV-infected patients with MDR-TB have not been established, as clinical data are limited.
Today’s decision marks the first regulatory approval for the pediatric formulation of SIRTURO® and is a key component of Johnson & Johnson’s global pediatric research and development (R&D) program for the medicine.
The new 20 mg tablet can be administered with water for patients who are able to swallow the intact tablet and taken with food.
For patients who have difficulty swallowing intact tablets, the tablet can be dispersed in water and administered. To aid with administration, the dispersed mixture in water can be further mixed with a beverage or soft food.
Alternatively, the tablet can be crushed and mixed with soft food immediately prior to use and administered.
“The first-ever approval of a pediatric formulation of bedaquiline is a significant advancement for children with multidrug-resistant tuberculosis,” said Martin Fitchet, M.D., Global Head, Global Public Health, Johnson & Johnson.
“TB is already an often-overlooked area in global health, and children with the disease are especially vulnerable.
Modernizing pediatric treatment is a critical step toward reducing the suffering of these young patients and ending TB once and for all.”
When SIRTURO® first received accelerated approval from the U.S. FDA for use in eligible adult patients in 2012, it was the first novel TB medicine in more than 40 years.
In 2019, the FDA granted approval for SIRTURO® 100 mg tablets as part of combination therapy in adolescent patients (12 to less than 18 years of age and weighing at least 30 kilograms (66 pounds)) with pulmonary MDR-TB, when an effective treatment regimen cannot otherwise be provided.
Further research is ongoing in children aged two to four, and in infants younger than two years old.
TB is the world’s deadliest infectious disease, claiming approximately 1.5 million lives in 2018 alone – more than HIV and malaria combined.
While TB most often affects adults in their most productive years, in 2018, an estimated 1.1 million children became ill with TB worldwide and more than 200,000 died.
According to the World Health Organization, however, these are likely underestimates of the true burden of the disease in children.
These grim statistics underscore the urgent need for effective pediatric TB treatments.
“In the last 10 years, we have seen great advances in innovation for tuberculosis, especially for the hardest to treat forms,” said Ruxandra Draghia-Akli, M.D., Ph.D., Global Head, Global Public Health R&D, Janssen Research & Development, LLC.
“Johnson & Johnson is proud to be driving this research and development for patients of all ages. This latest accomplishment for our bedaquiline pediatric program will provide a new tool to address MDR-TB in vulnerable populations.”
Today’s FDA approval is supported by evidence from a single-arm, open-label, Phase 2 study that enrolled pediatric patients aged 5 to less than 12 years of age with confirmed or probable pulmonary MDR-TB infection who were treated at half the adult dose with the SIRTURO® 20mg tablet for 24 weeks in combination with a background regimen for the treatment of MDR-TB.
The application for the pediatric formulation obtained priority review from the FDA.
INDICATIONS AND USAGE
SIRTURO® (bedaquiline) is a diarylquinoline antimycobacterial drug indicated as part of combination therapy in the treatment of adult and pediatric patients (5 years and older and weighing at least 15 kg) with pulmonary multi-drug resistant tuberculosis (MDR-TB).
Reserve SIRTURO® for use when an effective treatment regimen cannot otherwise be provided.
This indication is approved under accelerated approval based on time to sputum culture conversion.
Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.
Limitations of Use
Do not use SIRTURO® for the treatment of:
- Latent infection due to Mycobacterium tuberculosis
- Drug-sensitive tuberculosis
- Extra-pulmonary tuberculosis
- Infections caused by non-tuberculous mycobacteria
- The safety and efficacy of SIRTURO® in the treatment of HIV-infected patients with MDR-TB have not been established as clinical data are limited.
IMPORTANT SAFETY INFORMATION
|WARNINGS: INCREASED MORTALITY AND QT PROLONGATIONINCREASED MORTALITY|
An increased risk of death was seen in the SIRTURO® treatment group (9/79, 11.4%) compared to the placebo treatment group (2/81, 2.5%) in one placebo-controlled trial in adults. Only use SIRTURO® in patients 5 years of age and older when an effective treatment regimen cannot otherwise be provided.QT PROLONGATION
QT prolongation can occur with SIRTURO®. Use with drugs that prolong the QT interval may cause additive QT prolongation. Monitor ECGs. Discontinue SIRTURO® if significant ventricular arrhythmia or if QTcF interval prolongation of greater than 500 ms develops.
Warnings and Precautions
Increased Mortality: An increased risk of death was seen in the SIRTURO® treatment group (9/79, 11.4%) compared to the placebo treatment group (2/81, 2.5%) in one placebo-controlled trial in adults (based on the 120 week visit window).
One death occurred during the 24 weeks of administration of SIRTURO®.
The imbalance in deaths is unexplained. No discernible pattern between death and sputum culture conversion, relapse, sensitivity to other drugs used to treat tuberculosis, HIV status, or severity of disease could be observed.
Only use SIRTURO® in patients 5 years of age and older when an effective treatment regimen cannot otherwise be provided.
QT Prolongation: SIRTURO® prolongs the QT interval. Obtain an ECG before initiation of treatment, and at least 2, 12, and 24 weeks after starting treatment with SIRTURO®.
Obtain serum potassium, calcium, and magnesium at baseline and correct if abnormal. Monitor electrolytes if QT prolongation is detected.
SIRTURO® has not been studied in patients with ventricular arrhythmias or recent myocardial infarction.
The following may increase the risk for QT prolongation when patients are receiving SIRTURO®: use with other QT prolonging drugs including fluoroquinolones and macrolide antibacterial drugs and the antimycobacterial drug, clofazimine; a history of Torsade de Pointes; a history of congenital long QT syndrome; a history of or ongoing hypothyroidism; a history of or ongoing bradyarrhythmias; a history of uncompensated heart failure; serum calcium, magnesium, or potassium levels below the lower limits of normal.
If necessary, bedaquiline treatment initiation could be considered in these patients after a favorable benefit risk assessment and with frequent ECG monitoring.
Discontinue SIRTURO® and all other QT prolonging drugs if the patient develops clinically significant ventricular arrhythmia or a QTcF interval of greater than 500 ms (confirmed by repeat ECG).
If syncope occurs, obtain an ECG to detect QT prolongation.
Risk of Development of Resistance to Bedaquiline: A potential for development of resistance to bedaquiline in Mycobacterium tuberculosis exists. Bedaquiline must only be used in an appropriate combination regimen for the treatment of pulmonary MDR-TB to reduce the risk of development of resistance to bedaquiline.
Hepatotoxicity: In clinical trials, more hepatic-related adverse reactions were reported in adults with the use of SIRTURO® plus other drugs to treat tuberculosis compared to other drugs used to treat tuberculosis without the addition of SIRTURO®.
Alcohol and other hepatotoxic drugs should be avoided while on SIRTURO®, especially in patients with impaired hepatic function. Hepatic-related adverse reactions have also been reported in pediatric patients 5 years of age and older.
Monitor symptoms (such as fatigue, anorexia, nausea, jaundice, dark urine, liver tenderness, and hepatomegaly) and laboratory tests (ALT, AST, alkaline phosphatase, and bilirubin) at baseline, monthly while on treatment, and as needed.
Test for viral hepatitis and discontinue other hepatotoxic medications if evidence of new or worsening liver dysfunction occurs. Discontinue SIRTURO® if:
- aminotransferase elevations are accompanied by total bilirubin elevation greater than two times the upper limit of normal
- aminotransferase elevations are greater than eight times the upper limit of normal
- aminotransferase elevations are greater than five times the upper limit of normal and persist beyond two weeks
CYP3A4 Inducers/Inhibitors:Bedaquiline is metabolized by CYP3A4 and its systemic exposure and therapeutic effect may therefore be reduced during co-administration with inducers of CYP3A4.
Avoid co-administration of strong CYP3A4 inducers such as rifamycins (ie, rifampin, rifapentine, and rifabutin) or moderate CYP3A4 inducers such as efavirenz, during treatment with SIRTURO®.
Co-administration of SIRTURO® with strong CYP3A4 inhibitors may increase the systemic exposure to bedaquiline, which could potentially increase the risk of adverse reactions.
Therefore, avoid the use of strong CYP3A4 inhibitors used for more than 14 consecutive days while on SIRTURO®, unless the benefit of treatment with the drug combination outweighs the risk.
Appropriate clinical monitoring for SIRTURO®-related adverse reactions is recommended.
Use in Specific Populations
Risk Summary: Available data from published literature of SIRTURO® use in pregnant women are insufficient to evaluate a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes.
There are risks associated with active tuberculosis during pregnancy. Reproduction studies performed in rats and rabbits have revealed no evidence of harm to the fetus due to oral administration of bedaquiline to pregnant rats and rabbits during organogenesis at exposures up to 6 times the clinical dose based on AUC comparisons.
Clinical Considerations: Disease-associated Maternal and/or Embryo/Fetal Risk Active tuberculosis in pregnancy is associated with adverse maternal and neonatal outcomes including maternal anemia, caesarean delivery, preterm birth, low birth weight, birth asphyxia, and perinatal infant death.
Risk Summary: There is no information regarding the presence of bedaquiline in human milk. Minimal data are available on the effects of the drug on the breastfed infant.
No data are available on the effects of the drug on milk production. Bedaquiline is concentrated in the milk of rats. When a drug is present in animal milk, it is likely that the drug will be present in human milk.
The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for SIRTURO® and any potential adverse effects on the breastfed infant from SIRTURO® or from the underlying maternal condition.
Pediatric Use:The safety, effectiveness and dosage of SIRTURO® in pediatric patients less than 5 years of age and/or weighing less than 15 kg have not been established.
Renal Impairment: SIRTURO® has mainly been studied in adult patients with normal renal function.
Renal excretion of unchanged bedaquiline is not substantial (less than or equal to 0.001%).
No dose adjustment is required in patients with mild or moderate renal impairment. In patients with severe renal impairment or end stage renal disease requiring hemodialysis or peritoneal dialysis, SIRTURO® should be used with caution.
Monitor adult and pediatric patients for adverse reactions of SIRTURO® when administered to patients with severe renal impairment or end stage renal disease requiring hemodialysis or peritoneal dialysis.
Adult: Adverse reactions that occurred more frequently than placebo during treatment with SIRTURO® included: nausea (38% vs 32%), arthralgia (33% vs 22%), headache (28% vs 12%), hemoptysis (18% vs 11%), chest pain (11% vs 7%), anorexia (9% vs 4%), transaminases increased (9% vs 1%), rash (8% vs 4%), and blood amylase increased (3% vs 1%).
The safety assessment of bedaquiline is based on the Week 24 analysis from 30 pediatric patients in an ongoing, single-arm, open-label, multi-cohort trial, (Study 4).
Pediatric Patients (12 years to less than 18 years of age)
The first cohort was designed to enroll patients 12 years to less than 18 years of age (fifteen patients 14 years to less than 18 years of age were enrolled) with confirmed or probable pulmonary MDR-TB infection who received SIRTURO® (400 mg once daily for the first 2 weeks and 200 mg 3 times/week for the following 22 weeks) in combination with a background regimen.
The most common adverse reactions were arthralgia in 6/15 (40%) patients, nausea in 2/15 (13%) patients, and abdominal pain in 2/15 (13%) patients. Among the 15 patients, no deaths occurred during treatment with SIRTURO®.
Observed laboratory abnormalities were comparable to those in adults.
Pediatric Patients (5 years to less than 12 years of age)
The second cohort was designed to enroll patients 5 years to less than 12 years of age (fifteen patients aged 5 years to less than 11 years of age were enrolled) with confirmed or probable pulmonary MDR-TB infection who received SIRTURO® (200 mg once daily for the first 2 weeks and 100 mg 3 times/week for the following 22 weeks) in combination with a background regimen.
The most common adverse reactions were related to elevations in liver enzymes (5/15, 33%), and led to discontinuation of SIRTURO® in three patients.
Elevations in liver enzymes were reversible upon discontinuation of SIRTURO® and some of the background regimen drugs.
Among these 15 pediatric patients, no deaths occurred during treatment with SIRTURO®.”