Translarna

Translarna 125 mg granules for oral suspension

Translarna 250 mg granules for oral suspension

Translarna 1000 mg granules for oral suspension

Translarna 125 mg granules for oral suspension

Each sachet contains 125 mg ataluren.

Translarna 250 mg granules for oral suspension

Each sachet contains 250 mg ataluren.

Translarna 1000 mg granules for oral suspension

Each sachet contains 1000 mg ataluren.

Granules for oral suspension.

White to off-white granules.

Translarna is indicated for the treatment of Duchenne muscular dystrophy resulting from a nonsense mutation in the dystrophin gene, in ambulatory patients aged 5 years and older. Efficacy has not been demonstrated in non-ambulatory patients.

The presence of a nonsense mutation in the dystrophin gene should be determined by genetic testing.

Treatment with Translarna should only be initiated by specialist physicians with experience in the management of Duchenne/Becker muscular dystrophy.

Posology

Ataluren should be administered orally every day in 3 doses.

The first dose should be taken in the morning, the second at midday, and the third in the evening. Recommended dosing intervals are 6 hours between morning and midday doses, 6 hours between midday and evening doses, and 12 hours between the evening dose and the first dose on the next day.

The recommended dose is 10 mg/kg body weight in the morning, 10 mg/kg body weight at midday, and 20 mg/kg body weight in the evening (for a total daily dose of 40 mg/kg body weight).

Translarna is available in sachets of 125 mg, 250 mg or 1000 mg. The table below provides information on which sachet strength(s) to use in the preparation of the recommended dose by body weight range.

Delayed or missed dose

If there is a delay in the administration of ataluren of less than 3 hours after the morning or midday doses or less than 6 hours after the evening dose, the dose should be taken with no changes to the subsequent dose schedules. If there is a delay of more than 3 hours after the morning or midday doses or more than 6 hours after the evening dose, the dose should not be taken, and patients should resume their usual dosing schedule. Patients should not take a double or extra dose if a dose is missed. It is important to administer the correct dose. Increasing the dose above the recommended dose may be associated with reduced effectiveness.

Special populations

Elderly

The safety and efficacy of ataluren in patients aged 65 and older have not yet been established.

Renal impairment

Safety and efficacy of ataluren in patients with renal impairment has not been established.

Hepatic impairment

No dosage adjustment is required for patients with mild, moderate or severe hepatic impairment.

Paediatric population

The safety and efficacy of Translarna in children aged 6 months to 5 years have not yet been established. No data are available.

Method of administration

Translarna should be administered orally after mixing it to a suspension in liquid or in semi-solid food. Sachets should only be opened at the time of dose preparation. The full contents of each sachet should be mixed with, at least 30 ml of liquid (water, milk, fruit juice) or 3 tablespoons of semi-solid food (yoghurt or apple sauce). The prepared dose should be mixed well before administration. The amount of the liquid or semi-solid food can be increased based on patient preference. Patients should take the entire dose.

Concomitant use of intravenous aminoglycosides.

Patients who do not have a nonsense mutation

Patients must have a nonsense mutation in the dystrophin gene as part of their underlying disease state, as determined by genetic testing. Patients who do not have a nonsense mutation should not receive ataluren.

Renal impairment

Patients with renal impairment should be closely monitored.

Changes in lipid profile

Because changes in lipid profile (increased triglycerides and cholesterol) were reported for some patients in clinical trials, it is recommended that total cholesterol, LDL, HDL, and triglycerides be monitored on an annual basis in nonsense mutation Duchenne muscular dystrophy (nmDMD) patients receiving ataluren, or more frequently as needed based on the patient's clinical status.

Hypertension with use of concomitant systemic corticosteroids

Because hypertension with use of concomitant systemic corticosteroids was reported for some patients in clinical trials, it is recommended that resting systolic and diastolic blood pressure be monitored every 6 months in nmDMD patients receiving ataluren concomitantly with corticosteroids, or more frequently as needed based on the patient's clinical status.

Renal function monitoring

Because small increases in mean serum creatinine, blood urea nitrogen (BUN), and cystatin C were observed in the controlled studies of nmDMD, it is recommended that serum creatinine, BUN, and cystatin C be monitored every 6 to 12 months in nmDMD patients receiving ataluren, or more frequently as needed based on the patient's clinical status.

Potential interactions with other medicinal products

Caution should be exercised when ataluren is co-administered with medicinal products that are inducers of UGT1A9, or substrates of OAT1, OAT3, or OATP1B3.

Aminoglycosides

Aminoglycosides have been shown to reduce the readthrough activity of ataluren in vitro. In addition, ataluren was found to increase nephrotoxicity of intravenous aminoglycosides. The co-administration of these medicinal products with ataluren should be avoided. Since the mechanism by which ataluren increases nephrotoxicity of intravenous aminoglycosides is not known, concomitant use of other nephrotoxic medicinal products with ataluren is not recommended. If this is unavoidable (e.g. vancomycin to treat MRSA) careful monitoring of renal function is advised.

Aminoglycosides

Ataluren should not be co-administered with intravenous aminoglycosides, based on cases of decreased renal function observed in a clinical trial in patients with nmCF.

Elevations of serum creatinine occurred in several nmCF patients treated with ataluren and intravenous aminoglycosides together with other antibiotics for cystic fibrosis exacerbations. The serum creatinine elevations resolved in all cases, with discontinuation of the intravenous aminoglycoside, and either continuation or interruption of Translarna. These findings suggested that co-administration of Translarna and intravenous aminoglycosides may potentiate the nephrotoxic effect of the aminoglycosides. Therefore, if treatment with intravenous aminoglycosides is necessary the treatment with Translarna should be stopped and can be resumed 2 days after administration of the aminoglycoside has ended. The effect of co-administration of ataluren with other nephrotoxic medicinal products is unknown.

Dehydration may be a contributing factor in some of these cases. Patients should maintain adequate hydration while taking ataluren.

Effect of other medicinal products on ataluren pharmacokinetics

Based on in vitro studies, ataluren is a substrate of UGT1A9. Co-administration of rifampicin, a strong inducer of metabolic enzymes including UGT1A9, decreased ataluren exposure by 29%. The significance of these findings for humans is unknown. Caution should be exercised when ataluren is co-administered with medicinal products that are inducers of UGT1A9 (e.g. rifampicin).

Effect of ataluren on pharmacokinetics of other medicinal products

Based on in vitro studies, ataluren has the potential to inhibit UGT1A9, organic anion transporter 1 (OAT1), organic anion transporter 3 (OAT3) and organic anion transporting polypeptide 1B3 (OATP1B3). Co-administration of ataluren with mycophenolate mofetil in healthy subjects did not affect the exposure of its active metabolite, mycophenolic acid (a substrate of UGT1A9). No dose adjustment is required when ataluren is co-administered with medicinal products that are substrates of UGT1A9. Caution should be exercised when ataluren is co-administered with medicinal products that are substrates of OAT1 or OATP1B3 because of the risk of increased concentration of these medicinal products (eg, oseltamivir, aciclovir, captopril, furosemide, bumetanide, valsartan, pravastatin, rosuvastatin, atorvastatin, pitavastatin). Caution should also be exercised when ataluren is co-administered with OAT3 substrates (eg, ciprofloxacin), especially those OAT3 substrates with a narrow therapeutic window. In a clinical study, the extent of exposure for ciprofloxacin was 32% higher in the presence of ataluren. In a separate clinical study, the extent of exposure for adefovir was 60% higher in the presence of ataluren. Caution should be exercised when ataluren is co-administered with adefovir.

Based on the in vitro studies, ataluren is not expected to be an inhibitor of neither p-gp mediated transport nor of cytochrome P450 mediated metabolism. Similarly, ataluren is not expected in vivo to be an inducer of cytochrome P450 isoenzymes.

Coadministration of corticosteroids (deflazacort, prednisone, or prednisolone) with ataluren did not affect the plasma concentrations of ataluren. No clinically relevant change in the plasma concentrations of corticosteroids was seen with co-administration of ataluren. These data indicate no apparent drug-drug interaction between corticosteroids and ataluren, and no dose adjustments are required.

Medicinal products that affect the p-glycoprotein transporter

In vitro, ataluren is not a substrate for the p-glycoprotein transporter. The pharmacokinetics of ataluren are unlikely to be affected by medicinal products that inhibit the p-glycoprotein transporter.

Pregnancy

There are no adequate data from the use of ataluren in pregnant women. Studies in animals have shown reproductive toxicity only at doses that resulted in maternal toxicity.

As a precautionary measure, it is recommended to avoid the use of ataluren during pregnancy.

Breastfeeding

It is unknown whether ataluren/metabolites are excreted in human milk. Available pharmacodynamic/toxicological data in animals have shown excretion of ataluren/metabolites in milk. A risk to the breastfed new-borns/infants cannot be excluded.

Breast-feeding should be discontinued during treatment with ataluren.

Fertility

Non-clinical data revealed no hazard for humans based on a standard male and female fertility study in rats.

The effect of ataluren on driving, on cycling, or on using machines has not been tested. Patients who experience dizziness should use caution when driving, cycling or using machines.

Summary of the safety profile

The safety profile of ataluren is based on pooled data from two randomised, double-blind, 48-week placebo-controlled studies conducted in a total of 232 male patients with Duchenne muscular dystrophy (nmDMD) caused by a nonsense mutation treated at the recommended dose of 40 mg/kg/day (10, 10, 20 mg/kg; n=172) or at a dose of 80 mg/kg/day (20, 20, 40 mg/kg; n=60), as compared to placebo-treated patients (n=172).

The most common adverse reactions in the 2 placebo-controlled studies were vomiting, diarrhoea, nausea, headache, upper abdominal pain, and flatulence, all occurring in >5% of all ataluren-treated patients. In both studies, 1/232 (0.43%) patients treated with ataluren discontinued due to an adverse reaction of constipation and 1/172 (0.58%) placebo patients discontinued treatment due to an adverse reaction of disease progression (loss of ambulation).

Adverse reactions were generally mild or moderate in severity, and no treatment-related serious adverse events were reported among ataluren-treated patients in these 2 studies.

Tabulated list of adverse reactions

The adverse reactions reported in patients with nmDMD treated with the recommended daily dose of 40 mg/kg/day ataluren in the 2 placebo-controlled studies are presented in Table 1. Adverse reactions reported in >1 patient in the 40 mg/kg/day group at a frequency greater than that of the placebo group are presented by MedDRA System Organ Class, Preferred Term, and frequency. Frequency groupings are defined to the following convention: very common (> 1/10) and common (> 1/100 to < 1/10).

Table 1. Adverse reactions reported in >1 ataluren-treated patients with nmDMD at a frequency greater than placebo in the 2 placebo-controlled studies (pooled analysis)

In a 48-week open-label extension study in patients with nmDMD patients who were ambulant or non-ambulant demonstrated a similar safety profile. Long term safety data is not available.

Description of selected adverse reactions (laboratory abnormalities)

Serum lipids

During the randomised, placebo-controlled studies of nmDMD, mean total cholesterol and triglycerides were normal at baseline and increased, reaching borderline high or high values. Lipid levels shifted from normal at baseline to high (above the upper limit of normal) at Week 48 in slightly higher percentages of patients receiving ataluren compared to those receiving placebo (total cholesterol 15.1% vs. 6.1%, triglycerides 21.1% vs. 13.4%, respectively). The values tended to stabilize early in the study and did not increase further with continued treatment.

Renal function tests

During the randomised, placebo-controlled studies, small increases in mean serum creatinine, BUN, and cystatin C were observed. The values tended to stabilize early in the study and did not increase further with continued treatment.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via:

Ireland

HPRA Pharmacovigilance

Earlsfort Terrace

IRL - Dublin 2

Tel: +353 1 6764971

Fax: +353 1 6762517

Website: www.hpra.ie

e-mail: medsafety@hpra.ie

United Kingdom

Yellow Card Scheme

Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store

Healthy volunteers receiving a single oral dose of 200 mg/kg of ataluren experienced transient, low-grade symptoms of headache, nausea, vomiting, and diarrhoea. No serious adverse reactions were observed in these subjects. In the event of a suspected overdose, supportive medical care should be provided including consulting with a healthcare professional and close observation of the clinical status of the patient.

Pharmacotherapeutic group:Other drugs for disorders of the musculo-skeletal system, ATC code: M09AX03

Mechanism of action

A nonsense mutation in DNA results in a premature stop codon within an mRNA. This premature stop codon in the mRNA causes disease by terminating translation before a full-length protein is generated. Ataluren enables ribosomal readthrough of mRNA containing such a premature stop codon, resulting in production of a full-length protein.

Pharmacodynamic effects

Nonclinical in vitro experiments in nonsense mutation cellular assays and fish larvae cultured in an ataluren solution have shown that ataluren enabled ribosomal readthroughwith a bell-shaped (inverted-U shaped) concentration-response relationship. It is hypothetised that the in vivo dose response relationship may also be bell-shaped, but in vivo data were too limited to confirm this hypothesis in a mouse model for nmDMD and in humans.

Nonclinical in vitro studies suggest that continuous exposure to ataluren may be important for maximizing activity and that effects of the active substance on ribosomal read-through of premature stop codons reverse shortly after withdrawal of ataluren.

Clinical efficacy and safety

The efficacy and safety of Translarna were assessed in 2 randomised, double-blind, placebo-controlled, trials in nmDMD. The primary efficacy endpoint in both trials was change in 6 Minute Walk Distance (6MWD) at Week 48. Other endpoints included in both trials were time to persistent 10% worsening in 6MWD, change in time to run/walk 10 meters at Week 48, change in time to climb 4 stairs at Week 48, and change in time to descend 4 stairs at Week 48. Patients were required to have documented confirmation of the presence of a nonsense mutation in the dystrophin gene as determined by gene sequencing.

Study 1 evaluated 174 male patients, ages 5 to 20 years. All patients were required to be able to walk >75 meters without the need for assistive devices during a screening 6-Minute Walk Test (6MWT). The majority of patients in all treatment groups were Caucasian (90%). Patients were randomised in a 1:1:1 ratio and received ataluren or placebo 3 times per day (morning, midday, and evening), with 57 receiving ataluren 40 mg/kg/day (10, 10, 20 mg/kg), 60 receiving ataluren 80 mg/kg/day (20, 20, 40 mg/kg), and 57 receiving placebo.

In Study 1, a post hoc analysis of the primary endpoint showed that from baseline to Week 48, patients receiving ataluren 40 mg/kg/day had a 12.9 meters mean decline in 6MWD, and patients receiving placebo had a 44.1-meter mean decline in 6MWD (Figure 1). Thus, the mean change in observed 6MWD from baseline to Week 48 was 31.3 meters better in the ataluren 40 mg/kg/day arm than in the placebo arm (p=0.056). In a statistical based model the estimated mean difference was 31.7 meters (adjusted p=0.0367). There was no difference between ataluren 80 mg/kg/day and placebo.

These results indicate that ataluren 40 mg/kg/day slows the loss of walking ability in nmDMD patients.

Figure 1. Mean Change in 6-Minute Walk Distance (Study 1)

A post-hoc analysis of time to persistent 10% worsening in 6MWD showed that 26% of patients in the ataluren 40 mg/kg/day arm had progressed at Week 48 compared to 44% in the placebo group (p=0.0652) (Figure 2). There was no difference between ataluren 80 mg/kg/day and placebo. These results indicate that fewer patients receiving ataluren 40 mg/kg/day worsened in 6MWD over 48 weeks.

Figure 2. Kaplan-Meier Curve of Time to Persistent 10% 6MWD Worsening (Study 1)

In timed function tests (TFTs), tests of time to run/walk 10 meters, time to climb 4 stairs, and time to descend 4 stairs, ataluren-treated patients demonstrated smaller increases in the time it takes to run/walk 10 meters, climb 4 stairs, and descend 4 steps, indicating slowing of nmDMD progression relative to placebo.

The mean change in timed function tests from baseline to Week 48 was better in the ataluren 40 mg/kg/day arm than placebo in time to run/walk 10 meters (better by 1.5 seconds), time to climb 4 stairs (better by 2.4 seconds), and time to descend 4 stairs (better by 1.6 seconds), Figure 3.

Figure 3. Mean Change in Timed Function Tests (Study 1)

6MWD Results in Patients with a Baseline 6MWD < 350 meters.

In patients with a baseline 6MWD <350 meters, the mean change in observed 6MWD from baseline to Week 48 was 68 meters better in the ataluren 40 mg/kg/day arm than in the placebo arm (p=0.0053).

In these patients, the mean change in timed function tests from baseline to Week 48 was better in the ataluren 40 mg/kg/day arm than placebo in time to run/walk 10 meters (better by 3.5 seconds), time to climb 4 stairs (better by 6.4 seconds), and time to descend 4 stairs (better by 5.0 seconds).

Study 2 evaluated 230 male patients, ages 7 to 14 years. All patients were required to be able to walk >150 meters and less than 80% predicted without the need for assistive devices during a screening 6MWT. The majority of patients in both treatment groups were Caucasian (76%). Patients were randomised in a 1:1 ratio and received ataluren 40 mg/kg/day (n=115) or placebo (n=115) 3 times per day (morning, midday, and evening).

Ataluren-treated patients experienced clinical benefit as measured by numerically favorable differences versus placebo across the primary and secondary efficacy endpoints. As the primary endpoint (change in 6MWD from baseline to Week 48) did not reach statistical significance (p≤0.05), all other p-values should be considered nominal.

In the ITT population, the difference between the ataluren and placebo arms in mean change in observed 6MWD from baseline to Week 48 was 15.4 meters better in the ataluren 40 mg/kg/day arm than in the placebo arm. In a statistical based model the estimated mean difference was 13.0 meters (p=0.213), Figure 4. Separation between ataluren and placebo was maintained from Week 16 through the end of the study.

Figure 4. Mean Change in 6-Minute Walk Distance (Study 2)

Over 48 weeks, ataluren-treated patients showed less decline in muscle function, as evidenced by smaller increases in the time to run/walk 10 meters, climb 4 steps, and descend 4 steps in the ataluren-treated group relative to placebo. The differences favoring ataluren versus placebo in mean changes in timed function tests at Week 48 in the ITT population reached the threshold for a clinically meaningful difference (changes ~1 to 1.5 seconds).

The mean change in timed function tests from baseline to Week 48 was better in the ataluren 40 mg/kg/day arm than placebo in observed time to run/walk 10 meters (better by 1.2 seconds, p=0.117), time to climb 4 stairs (better by 1.8 seconds, p=0.058), and time to descend 4 stairs (better by 1.8 seconds, p=0.012), Figure 5.

Figure 5. Mean Change in Timed Function Tests (Study 2)

Time to 10% worsening in 6MWD was defined as the last time that 6MWD was not 10% worse than baseline. In the ITT population, the hazard ratio for ataluren versus placebo was 0.75 (p=0.160), representing a 25% reduction in the risk of 10% 6MWD worsening.

Paediatric population

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This medicinal product has been authorised under a so-called 'conditional approval' scheme. This means that further evidence on this medicinal product is awaited.European Medicines Agency will review new information on this medicinal product at least every year and this SmPC will be updated as necessary.

Administration of ataluren on a body weight-adjusted basis (mg/kg) resulted in similar steady-state exposures (AUC) among children and adolescents with nmDMD over a broad range of body weights. Although ataluren is practically insoluble in water, ataluren is readily absorbed after oral administration as a suspension.

General characteristics of ataluren after administration

Absorption

Peak plasma levels of ataluren are attained approximately 1.5 hours after dosing in subjects who received medicinal product within 30 minutes of a meal. Based on the urinary recovery of radioactivity in a single-dose study of radiolabeled ataluren, the oral bioavailability of ataluren is estimated to be > 55%. Ataluren plasma concentrations at steady state increase proportionally with increasing dose. Steady-state plasma concentrations are dose-proportional for ataluren doses between 10 and 50 mg/kg, and no accumulation is observed after repeated dosing.

Distribution

In vitro, ataluren is 99.6% bound to human plasma proteins and the binding is independent of plasma concentration. Ataluren does not distribute into red blood cells.

Biotransformation

Ataluren is metabolized by conjugation via uridine diphosphate glucuronosyltransferase (UGT) enzymes, predominantly UGT1A9 in liver and intestine.

In vivo, the only metabolite detected in plasma after oral administration of radio-labelled ataluren was the ataluren-O-1β-acyl glucuronide; exposure to this metabolite in humans was approximately 8% of the plasma AUC of ataluren.

Elimination

Ataluren plasma half-life ranges from 2-6 hours and is unaffected either by dose or repeated administration. The elimination of ataluren is likely dependent on hepatic and intestinal glucuronidation of ataluren followed by renal excretion of the resulting glucuronide metabolite.

After a single oral dose of radiolabeled ataluren, approximately half of the administered radioactive dose is recovered in the faeces and the remainder was recovered in the urine. In the urine, unchanged ataluren and the acyl glucuronide metabolite account for <1% and 49%, respectively, of the administered dose.

Linearity/non-linearity

Steady-state plasma concentrations are dose-proportional for ataluren doses between 10 and 50 mg/kg, and no accumulation is observed after repeated dosing. Based on data in healthy volunteers, the relative bioavailability of ataluren is approximately 40% lower at steady-state than after the initial dose. The onset of reduction in relative bioavailability is estimated to occur approximately 60 hours after the first dose. The steady-state is established after approximately two weeks of thrice daily dosing.

Characteristic in specific groups of subjects or patients

Age

Based on data from subjects ranging in age from 5 years to 57 years, there is no apparent effect of age on ataluren plasma exposure. Age-adjusted dosing is not required.

Gender

Females were not studied in nmDMD clinical trials. However there were no apparent effects of gender on ataluren plasma exposure in other populations.

Race

It is unlikely that the pharmacokinetics of ataluren are significantly affected by UGT1A9 polymorphisms in a Caucasian population. Due to the low number of other races included in the clinical studies, no conclusions can be drawn on the effect of UGT1A9 in other ethnic groups.

Renal impairment

No studies have been conducted with Translarna in patients with renal impairment. Patients with renal impairment should be monitored closely.

Hepatic impairment

Based on a pharmacokinetic assessment conducted in groups with either mild, moderate or severe hepatic impairment versus a control group of healthy subjects, no dose adjustment is required for patients with any degree of hepatic impairment. No apparent differences of the total ataluren exposure in the control, mild, and severe hepatic impairment groups were observed. An approximately 40% decrease of mean total ataluren exposure in the moderate hepatic impairment group versus the control group was noted probably due to the small sample size and variability.

Non-ambulatory

There were no apparent differences in either steady-state relative bioavailability or apparent clearance due to loss of ambulation. No dosing adjustment is needed for patients who are becoming nonambulatory.

Polydextrose (E1200)

Macrogol

Poloxamer

Mannitol (E421)

Crospovidone

Hydroxyethyl cellulose

Artificial vanilla flavour: maltodextrin, artificial flavours and propylene glycol.

Silica, colloidal anhydrous (E551)

Magnesium stearate

Adverse reactions possible when combined with:

• Benzodiazepines

• CNS depressants

• Antidepressants

• MAO inhibitors

4 years

Each prepared dose is best administered immediately after preparation. The prepared dose should be discarded if not consumed within 24 hours of preparation if kept refrigerated (2 - 8 °C), or within 3 hours at room temperature (15 - 30 °C).

• Storage temperature: up to 30°C

• Keep out of reach of children

Heat-sealed laminated aluminium foil sachet: polyethylene terephthalate (child resistance), polyethylene (coloring and polyester/foil bond), aluminum foil (moisture barrier), adhesive (polyurethane class), copolymer of ethylene and methacrylic acid (sealant resin for packaging integrity).

Pack of 30 sachets.

Sachets should only be opened at the time of dose preparation. The full contents of each sachet should be mixed with at least 30 ml of liquid (water, milk, fruit juice), or 3 tablespoons of semi-solid food (yoghurt or apple sauce). The prepared dose should be mixed well before administration. The amount of the liquid or semi-solid food can be increased based on patient preference.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.

PTC Therapeutics International Limited

5th Floor

3 Grand Canal Plaza

Grand Canal Street Upper

Dublin 4

D04 EE70

Ireland

Translarna 125 mg granules for oral suspension

EU/1/13/902/001

Translarna 250 mg granules for oral suspension

EU/1/13/902/002

Translarna 1000 mg granules for oral suspension

EU/1/13/902/003

Date of first authorisation: 31 July 2014

Date of latest renewal: 16 June 2017

23 March 2018