CENTER FOR DRUG EVALUATION AND RESEARCH APPLICATION NUMBER: 205718Orig1s000 PHARMACOLOGY REVIEW(S) Ke Zhang, Ph.D. Pharmacologist Division of Gastroenterology and Inborn Errors Products David B. Joseph, Ph.D. Lead Pharmacologist Division of Gastroenterology and Inborn Errors Products cc: NDA 205,718 DGIEP DGIEP/PM DGIEP/D. Griebel DGIEP/D. Joseph DGIEP/K. Zhang ONDQA/M. Kowblansky ONDQA/R. Frankewich R/D Init.: D. Joseph 9/15/14 2 Reference ID: 3629753 MEMORANDUM DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE FOOD AND DRUG ADMINISTRATION CENTER FOR DRUG EVALUATION AND RESEARCH FROM: David B. Joseph Lead Pharmacologist DATE: July 17, 2014 SUBJECT: NDA 205,718 (SD # 1 dated September 25, 2013) Sponsor: Helsinn Healthcare SA Drug Product: AKYNZEOTM (netupitant and palonosetron) capsules Comments: I concur with Dr. Zhang’s recommendations for conducting a juvenile rat toxicity study with netupitant alone to support the proposed pediatric development program (see section 1.3.2 in the Executive Summary and page 167 of the Pharmacology/Toxicology review dated June 19, 2014). Based on the age range (0 < 17 years) of patients to be included in the proposed safety and efficacy trial of netupitant + palonosetron fixed dose combination, dosing in the juvenile rat study should begin at a developmental stage comparable to the human neonatal stage. Juvenile animal studies with the drug combination are not considered as necessary to support the pediatric development program for Akynzeo, based on results of the combination toxicity studies of netupitant + palonosetron in adult rats and dogs, and the toxicity profile of palonosetron alone in neonatal rats and dogs (see Pharmacology/Toxicology review of NDA 21,372 dated July 11, 2003 by Dr. Yash Chopra). Recommendations: There are no nonclinical issues which preclude the approval of Akynzeo. I concur with Dr. Zhang’s recommendation for approval and his recommended revisions in the label. __________________________________ ____________ David B. Joseph, Ph.D. Date Lead Pharmacologist Division of Gastroenterology and Inborn Errors Products Reference ID: 3594851 DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE FOOD AND DRUG ADMINISTRATION CENTER FOR DRUG EVALUATION AND RESEARCH PHARMACOLOGY/TOXICOLOGY NDA REVIEW AND EVALUATION Application number: Supporting document/s: 205,718 1 Applicant’s letter date: September 25, 2013 CDER stamp date: September 25, 2013 Product: AKYNZEOTM (netupitant and palonosetron) capsules Indication: Prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of highly emetogenic cancer chemotherapy and moderately emetogenic cancer chemotherapy in adults Applicant: Helsinn Healthcare SA Pazzallo – Lugano, Switzerland U.S. Agent August Consulting, Inc. Austin, TX Review Division: Division of Gastroenterology and Inborn Errors Products (DGIEP) Reviewer: Ke Zhang, Ph.D. Supervisor/Team Leader: David Joseph, Ph.D. Division Director: Donna Griebel, M.D. Project Manager: Mary Chung Template Version: September 1, 2010 1 Reference ID: 3527655 Disclaimer Except as specifically identified, all data and information discussed below and necessary for approval of NDA 205,718 are owned by Helsinn Healthcare SA or are data for which Helsinn Healthcare SA has obtained a written right of reference. Any information or data necessary for approval of NDA 205,718 that Helsinn Healthcare SA does not own or have a written right to reference constitutes one of the following: (1) published literature, or (2) a prior FDA finding of safety or effectiveness for a listed drug, as reflected in the drug’s approved labeling. Any data or information described or referenced below from reviews or publicly available summaries of a previously approved application is for descriptive purposes only and is not relied upon for approval of this NDA. 2 Reference ID: 3527655 NDA 205,718 1.3 1.3.1 Reviewer: Ke Zhang Recommendations Approvability From a nonclinical standpoint, this NDA should be approved for the proposed indication. 1.3.2 Additional Nonclinical Recommendations An oral toxicity study with netupitant alone of at least 8 weeks duration in juvenile rats is needed to support the proposed pediatric clinical efficacy study in patients age 0 to < 17 years. The juvenile rat study should include evaluation of developmental parameters, neurobehavioral effects, and fertility. The sponsor should submit the juvenile rat study protocol for review and evaluation prior to initiation of this study. The sponsor’s proposed timeline for the pediatric study plan should be adjusted according to these recommendations. 1.3.3 Labeling Established Pharmacologic Class (HIGHLIGHTS and section 11) The EPC text phrase for netupitant in the Sponsor’s proposed label is: “substance P/neurokinin 1 (NK1) receptor antagonist”, which is very similar to the EPC text phrase shown for aprepitant in the PRPLLR, and identical to the EPC text phrase in the aprepitant label. Therefore, the proposed EPC text phrase for netupitant is acceptable. (b) (4) The EPC text phrase for palonosetron in the Sponsor’s proposed label is: However, this should be changed to “serotonin3 (5-HT3) receptor antagonist”, which is the EPC text phrase shown for palonosetron in the PRPLLR. Sponsor’s Version: 8.1. Pregnancy (b) (4) Evaluation: 5 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang (b) (4) Recommended Version: 8.1. Pregnancy Pregnancy Category C Risk Summary Adequate and well-controlled studies with AKYNZEO have not been conducted in pregnant women. In animal reproduction studies, no effects on embryo-fetal development were observed following daily administration of netupitant in pregnant rats during the period of organogenesis at doses up to 3.7 times the human AUC at the recommended single human dose to be given with each cycle of chemotherapy. However, a dose-dependent increase in adverse effects on embryo-fetal development was observed following daily administration of netupitant in pregnant rabbits during the period of organogenesis with doses at least 0.2 times the human AUC at the recommended single human dose to be given with each cycle of chemotherapy. Daily administration of netupitant in rats up to 3.7 times the human AUC at the recommended human dose during organogenesis through lactation produced no adverse effects in the offspring. In animal reproduction studies with palonosetron, no effects on embryo-fetal development were observed following oral administration during the period of organogenesis at doses up to 921 and 1841 times the recommended human oral dose in rats and rabbits, respectively. AKYNZEO should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Animal Data Daily administration of up to 30 mg/kg netupitant in rats (3.7 times the human AUC at the recommended single human dose to be given with each cycle of chemotherapy) during the period of organogenesis produced no effects on embryo-fetal development. However, an increased incidence of external and skeletal abnormalities in rabbit fetuses was observed following daily administration of netupitant in rabbits at 10 mg/kg/day and higher (0.2 times the human AUC at the recommended single human dose to be given with each cycle of chemotherapy) during the period of organogenesis. These 6 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang that is supportive of this statement, the review team determined that the statement does not add important information to the labeling. The review team also recommended deletion of the following sentence: The rest of the statements relevant to mechanism of action for palonosetron are similar to those included in the labels for ALOXI Injection and ALOXI Capsules, and are therefore acceptable. Recommended Version: 12.1 Mechanism of Action Netupitant is a selective (NK1) receptors. antagonist of human substance P/neurokinin 1 Palonosetron is a 5-HT3 receptor antagonist with a strong binding affinity for this receptor and little or no affinity for other receptors. Cancer chemotherapy may be associated with a high incidence of nausea and vomiting, particularly when certain agents, such as cisplatin, are used. 5-HT3 receptors are located on the nerve terminals of the vagus in the periphery and centrally in the chemoreceptor trigger zone of the area postrema. Chemotherapeutic agents produce nausea and vomiting by stimulating the release of serotonin from the enterochromaffin cells of the small intestine. Serotonin then activates 5-HT3 receptors located on vagal afferents to initiate the vomiting re?ex. The development of acute emesis is known to depend on serotonin and its 5-HT3 receptors have been demonstrated to selectively stimulate the emetic response. Delayed emesis has been largely associated with the activation of tachykinin family neurokinin 1 (NK1) receptors (broadly distributed in the central and peripheral nervous systems) by substance P. As shown in in vitro and in vivo studies, netupitant inhibition of substance mediated response. (W) 09(4) Sponsor?s Version: 12.3 Pharmacokinetics Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang The proposed subsection for netupitant should be revised as shown below. The rat to human AUC ratios for netupitant were calculated based on the following AUC values: (b) (4) (b) (4) (this value was recommended for inclusion in subsection 12.3 by the Clinical Pharmacology team). The proposed subsection for palonosetron is the same as shown in the label for ALOXI Capsules, and is therefore acceptable. Recommended Version: 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Netupitant Long-term studies in animals to evaluate carcinogenic potential have not been performed with netupitant. Netupitant was not genotoxic in the Ames test, the mouse lymphoma cell mutation test, or the in vivo rat micronucleus test. Daily oral administration of netupitant in rats at doses up to 30 mg/kg (1.9 times the human AUC in male rats and 3.7 times the human AUC in female rats at the recommended human dose) had no effects on fertility or reproductive performance. Palonosetron In a 104-week carcinogenicity study in CD-1 mice, animals were treated with oral doses of palonosetron at 10, 30 and 60 mg/kg/day. Treatment with palonosetron was not tumorigenic. The highest tested dose produced a systemic exposure to palonosetron (Plasma AUC) of about 90 to 173 times the human exposure (AUC= 49.7 ng·h/mL) at the recommended oral dose of 0.5 mg. In a 104-week carcinogenicity study in SpragueDawley rats, male and female rats were treated with oral doses of 15, 30 and 60 mg/kg/day and 15, 45 and 90 mg/kg/day, respectively. The highest doses produced a systemic exposure to palonosetron (Plasma AUC) of 82 and 185 times the human exposure at the recommended dose. Treatment with palonosetron produced increased incidences of adrenal benign pheochromocytoma and combined benign and malignant pheochromocytoma, increased incidences of pancreatic Islet cell adenoma and combined adenoma and carcinoma and pituitary adenoma in male rats. In female rats, it produced hepatocellular adenoma and carcinoma and increased the incidences of thyroid C-cell adenoma and combined adenoma and carcinoma. 11 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Palonosetron was not genotoxic in the Ames test, the Chinese hamster ovarian cell (CHO/HGPRT) forward mutation test, the ex vivo hepatocyte unscheduled DNA synthesis (UDS) test or the mouse micronucleus test. It was, however, positive for clastogenic effects in the Chinese hamster ovarian (CHO) cell chromosomal aberration test. Palonosetron at oral doses up to 60 mg/kg/day (about 921 times the recommended human oral dose based on body surface area) was found to have no effect on fertility and reproductive performance of male and female rats. 2 Drug Information 2.1 Drug Trade Name: AKYNZEOTM (300 mg netupitant and 0.5 mg palonosetron free base equivalent) Code Name: Netupitant: RO0673189, RO0673189-008, 14-NETU Palonosetron HCl: RS-25259-197 Chemical Name: Netupitant: 2-[3,5-Bis(trifluoromethyl)phenyl]-N,2-dimethyl-N-[4-(2-methylphenyl)-6-(4methylpiperazin-1-yl)pyridin-3-yl]propanamide Palonosetron HCl: (3aS)-2-[(S)-1-Azabicyclo[2.2.2]oct-3-yl]-2,3,3a,4,5,6-hexahydro-1oxo-1Hbenz[de]isoquinoline hydrochloride Molecular Formula/Molecular Weight: Netupitant: C30H32F6N4O / 578.61 Palonosetron HCl: C19H24N2O•HCl / 332.87 Structure or Biochemical Description: 12 Reference ID: 3527655 NBA 205, 718 Reviewer: Ke Zhang Table 1 Composition of the Netupitant-Palonosetron Combination Capsule Ingredient Reference Function %wlw Quantity (lug) Nempitant Imam! Active ingredient 14 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang (b) (4) Sucrose acid esters are accepted for use as a food additive within the conditions described in 21 CFR 172.859. Thus, there is reasonable assurance of safety for this excipient. 2.4 Comments on Novel Excipients: (b) (4) Although sucrose acid esters is considered as a novel excipient, it is used as a food additive within the conditions described in 21 CFR 172.859. Therefore, there is reasonable assurance of safety for this excipient. 2.5 Comments on Impurities/Degradants of Concern: None 2.6 Proposed Clinical Population and Dosing Regimen AKYNZEO is indicated for prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of highly emetogenic cancer chemotherapy and for prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy. The proposed dose is one capsule administered approximately one hour prior to the start of chemotherapy. One capsule contains 300 mg netupitant and 0.5 mg palonosetron free base equivalent. Regulatory Background AKYNZEO (netupitant and palonosetron) capsule was developed under IND 73,493. In the pre-NDA meeting on April 16, 2013, the sponsor agreed to submit final study reports of all required nonclinical studies. All needed study reports were submitted in this NDA (see below). Netupitant is an NME. Oral palonosetron, ALOXI (palonosetron HCl) Capsule, is an approved drug product in the U.S. for prevention of acute nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy (NDA 22,233). ALOXI Injection is an approved drug product for intravenous administration, indicated for the prevention of acute nausea and vomiting associated with initial and repeat courses of moderately and highly emetogenic cancer chemotherapy, and the prevention of delayed nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy (NDA 21,372). 17 Reference ID: 3527655 NDA 205,718 3 Reviewer: Ke Zhang Studies Submitted Pharmacology Pharmacokinetics/ADME Toxicology 18 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang 1110511? Study Species Route Duration of Doses GLP treatment Ietupitant Reproductive Toxicity Studies 100 3493' Rat p-o- i-o-weelcs 310-30 Yes (Fertility) 100 T325 Rat p-o. l-u'eeks 1 DID No (Pilot embryo- .-?fetal- DE o-l 11307930 Rat p-o- l-weeks 3.10.30 Yes (Embryoffetal- DB {1?23 Rat p-o- ?om DG I5 to 31-10-30 Yes Postnatal day; 20 of lactation 10055? 1 Rabbit p-o. 2-weeks 113-310-1011 J's?o (Pi-lot embryo- .t'fetal- DC: 5-1 3] 1130.793 1 Rabbit p-o- l-weelcs 3,10-30 Yes (Embqro.?fetal- no 5?13) Ietupitant Local Tolerance Studies WIDTH-1 Rabbit is: 341a}; 0. 1.3-10 Slon irritation Rabbit e-c. Smgle dose 0.5 per animal Yes Slciu sensitization pig Singie 111% 50' Yes 10071 7"1 close-"c hallenge irritation Rabbit local Smgle dose 0.1 per animal Yes 100 .71 1'3 In Tritro hemoljy'sis Rat hep arin? In ritro - No and plasma ated bio od and precipitation and plasma turbidity.r studies mosses In s'itro hemolysis human In ritro - - No and plasma hep arinated precipitation and blood and ti-irbiolitj,r studies plasma Reference ID: 3527655 NDA 205,718 3.1 Reviewer: Ke Zhang Studies Reviewed All studies mentioned above were reviewed except those mentioned under 3.2. 3.2 Studies Not Reviewed All nonclinical studies related to dependence, self-administration, and discrimination were reviewed by the Controlled Substance Staff. The following studies are not reviewed: Skin irritation study in rabbits Skin sensitization in guinea pigs Eye irritation in rabbits Toxicity study of metabolite M4 in BALB/C 3T3 cells 22 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang In Vitro studies: Netupitant and its metabolites (M1, M2, and M3) significantly inhibited the potassium currents of the hERG channel expressed in the CHO cells, with IC50 values of 0.76, 0.84, 43, and 4.4 µM, respectively. Netupitant and metabolite M1 inhibited the rapid component of delayed rectifier potassium current (IKr) by ~21-25% at 3 μM in isolated canine ventricular myocytes (“M” mid-myocardial cells). Metabolite M3 inhibited IKr by ~14% and 57% at 3 and 30 μM, respectively. However, metabolite M2, has no effect on this potassium current at concentrations up to 30 μM. Netupitant (up to 1 μM), M1 (up to 0.3 μM), M2 (up to 3 μM), and M3 (up to 3 μM) had no significant effect on cardiac action potentials in isolated canine cardiac Purkinje fibers. At higher concentrations (3 μM), both netupitant and M1 shortened the action potential duration at 50% of repolarization (APD50), and the action potential duration at 70% and 90% of repolarization (APD70 and APD90, respectively). Netupitant (up to 3 μM), M1 and M2 (up to 30 μM) had no significant effect on cardiac action potential parameters on isolated canine papillary muscle. Metabolite M3, however, significantly prolonged APD50, APD70 and APD90 at 3 and 30 μM in the isolated canine papillary muscle. In Vivo studies: Anesthetized guinea pigs Intravenous administration of netupitant (0.01-1 mg/kg), M1 (0.01, 0.03, 0.1, 0.3, 1 and 3 mg/kg), M2 (0.01, 0.03, 0.1, 0.3, 1 and 3 mg/kg) had no significant effect on the epicardial monophasic action potential in anesthetized guinea pigs. M3 slightly prolonged the monophasic APD70 and APD90 at IV doses of 0.01, 0.03, 0.1, 0.3, 1, and 3 mg/kg in the same animal model. Combined intravenous administration of palonosetron and netupitant (0.3 mg/kg palonosetron and 0.03, 0.1, 0.3, or 1 mg/kg netupitant prolonged the monophasic APD70 and APD90 by 19-38%. Anesthetized rabbits Netupitant at 30 mg/kg IV decreased the mean, systolic and diastolic arterial blood pressure in anesthetized rabbits. However, netupitant at 30 mg/kg had no effects on QT interval. M1 and M3 (1 mg/kg IV) and M2 (30 mg/kg IV) transiently decreased arterial blood pressure in anesthetized rabbits. Premature ectopic beats and tachycardias were noted in 2 of 6 rabbits treated with M3 at 1 mg/kg IV in the anesthetized rabbits. Combined intravenous administration of palonosetron at 3 mg/kg 25 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang and netupitant at 30 mg/kg significantly decreased mean, systolic and diastolic arterial blood pressure, and increased heart rate in anesthetized rabbits. Conscious Dogs Oral administration of netupitant at 2, 10 and 50 mg/kg/day for 5 days had no effects on blood pressure, heart rate, or ECGs in six male telemetered beagle dogs. However, 100 mg/kg netupitant produced increases in blood pressure (↑20%) and heart rate (↑ ~26%), and decreases in RR, PR and QTc intervals. The shortening of QTc was about 5%, and this small reduction may not be of any clinical significance. Oral administration of netupitant in conscious beagle dogs at 50 mg/kg/day for 14 days produced a decrease (↓15-19%) in heart rate and prolonged PR, RR, and QT intervals as compared to the control group. The prolonged corrected QT intervals were approximately 5-8% as compared to the control group. Similarly, oral administration of M1 at 30 mg/kg/day for 14 days produced a decrease in heart rate (↓~37%) and prolonged PR, RR, and QT intervals. The prolonged corrected QT intervals were approximately 11-12% as compared to the control group. Combined oral administration of palonosetron and netupitant had no clear treatment effects on heart rate, blood pressure, and ECGs following treatment at doses of 10/2 mg/kg, 10/10 mg/kg and 10/50 mg/kg of palonosetron/netupitant on day one in conscious telemetered dogs. However, the combination of 10 mg/kg palonosetron and 50 mg/kg netupitant increased heart rate (+17-20%) on treatment day 7 and prolonged the corrected QT intervals (+15-23%) as compared to the pretreatment values on treatment day14. Respiratory system: Oral administration of netupitant had no effects on respiratory parameters including respiratory rate, tidal volume, and minute volume at doses of 2, 10, and 50 mg/kg in dogs. Renal/Urinary systems: Netupitant had no clear effects on renal and urinary systems in female Sprague-Dawley rats following single oral doses of 3, 30 and 100 mg/kg. Gastrointestinal system: Netupitant had no effect on gastrointestinal motility or gastric emptying in female Sprague-Dawley rats following single oral doses of 3, 30 and 100 mg/kg. 26 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang The pharmacokinetic profile of netupitant was assessed in dogs following intravenous (lactate salt, 3 mg/kg) and oral doses (study #2000698). Various salt forms and netupitant free base were administered orally at doses of 70 or 120 mg free base equivalent, which was approximately 5.4 or 8.5 mg/kg, respectively. Plasma netupitant concentrations were determined using an LC-MS method. The results are summarized in the following tables (taken from the study report). Netupitant exhibited a long terminal half-life (34 to 56 hours) following an oral dose. The oral bioavailability of netupitant varied among the free base and salts that were tested. 29 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Netupitant exhibited a terminal half-life in the range of 8-12 hours following oral or intravenous administration. The oral bioavailability of netupitant was 37-62% among the three monkeys with results reported. Distribution: Rat To study the tissue distribution, [14C]-netupitant was given orally (10 mg/kg) and intravenously (5 mg/kg) to albino or pigmented male rats (study #1007004). The total radioactivity in blood, plasma and urine was measured using quantitative whole-body autoradiography. The plasma concentrations of the unchanged drug and its metabolites M1, M2, and M3 were determined using an LC-MS method. Following intravenous administration, the radioactivity was extensively distributed to almost all tissues, with the highest radioactivity levels in the lung, followed by adrenal cortex, spleen, brown fat, liver and pancreas. After oral administration, the radioactivity was found to be highest in the Harderian gland, followed by lung, adrenal, spleen, pituitary, exorbital and intraorbital lachrymal glands, and thyroid. The radioactivity levels were generally higher in tissues than in plasma, except for the brain and spinal cord. 31 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Table 12: Heart Tissue Concentrations of Parent and Metabolites in Dogs . Dose .) Heart C7241. (ngi?g) MIF Stud} 1k g) Netupitant Ml M: M3 1 214.9300 12611113 60 BLQ BLQ 3 307.611 496014620 BLQ BLQ $2311? 05ml" 5. 4992 BLQ BLQ 15 BLQ 41070 5.0 1 2 8060 BLQ 45060 4-we ek 4141131 1899;" 3053 BLQ 64.61" 95 .4 Study 1657:3649 7153513010 BLQ 191615412 NETS-0605 19093;" 9296 53626345353 BLQ QTSI 909 43 89 6 BLQ 82 4.5.66.4 Telemeny 2 1 00 6422 10 5.0 (C7211) 941795?- (C1211) BLQ ((7211) N: Netupitant Based on severe clinical signs noted in (3113111) 4 animals; the high dose level of palonosetron was reduced from 20 to 15 mg?cgr?day from Day 12 onwards 33: values ?'om the high dose recovery group 33 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Netupitant and the metabolites M1 and M3 were identified in the heart tissues with higher level of M1. Protein binding studies The plasma protein binding study was conducted with netupitant using human, dog, rat, and gerbil blood samples (study #1006047). The protein concentrations were determined using liquid scintillation counting. The mouse plasma protein binding was also studied using a dialysis method (study #NETU-08-08), and the protein concentrations were determined using LC-MS/MS. Netupitant exhibited high levels of binding (>99%) to plasma proteins in all species. The fraction of drug in erythrocytes was ~13% in human and dog, and 17-37% in rat. The plasma protein binding of the major metabolites M1, M2, and M3 was also determined using the blood samples from human, dog, and Wistar rat (study #1010388). The results indicated that plasma protein binding was >99% for M1, and 97-99% for M2 and M3 in all species. The blood/plasma concentration ratios for M1, M2, and M3 were 1.1, 0.69, and 0.61, respectively, in humans, 0.73, 0.66, and 0.76, respectively, in dogs, and 0.94, 0.69, and 0.82, respectively, in rat. The blood/plasma concentration ratios for the parent drug were 0.69 in human, 0.77 in dog, and 0.77 in rats. Metabolism: Rat To determine the netupitant metabolite profiles, plasma, urine, bile and feces were collected from bile duct cannulated male Wistar rats (study #1009719) following a single oral (4 mg/kg) and intravenous (2 mg/kg) dose of 14C-netupitant. The results indicated that ~9-15% of the radiolabeled dose was recovered from feces, 12 to 40% in bile, and < 1% in urine through the end of the study (96 hours). In plasma samples, parent drug accounted for over 50% of the total radioactivity, with up to 31% associated with metabolite M1, up to 7% associated with M2, up to 3% associated with M3, and up to 6% associated with a mono-hydroxylated metabolite. In bile samples, the parent drug accounted for 27 to 40% of the total biliary drug-related material. The metabolites in bile included M1 (7-13%), M2 (5-12%), M3 (9-13%), and M8 (2.5-7%). In feces, the parent drug accounted for 50-70% of the total fecal drug-related material, and the metabolites M1 and M2 accounted for 14-24% and 8-16%, respectively. Other metabolites accounted each for < 7% of the total fecal drug-related material. 34 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang A metabolism study with netupitant was performed using human, rat, dog, minipig and marmoset liver microsomes (studies #1003832 and #NETU-10-34). The results indicated that three major metabolites including an N-demethylation product (M1), an Noxidation product (M2), and a hydroxylation product (M3) were present in all species. The results from the study with recombinant expressed human CYP450 isoenzymes indicated that the oxidative steps were catalyzed by CYP3A4, but not by CYP2C9, CYP2C19, or CYP2D6. The apparent Km of 11.3 μM and Vmax of 1.5 nmol/min/mg protein were for the oxidative metabolism of netupitant. The apparent Km of 2.8-9.1 μM was for the N-demethylation of the parent compound to the metabolite M1. Excretion: Rat In a mass balance study in rats, [14C]netupitant was given orally (4.7 mg/kg) and intravenously (4.9 mg/kg) to normal male rats (study #1001466). The excretion of [14C]netupitant following both routes of administration was not completed after one week, with 6.0 ± 1.5% of the oral dose and 7.2 ± 0.8% of the intravenous dose still remaining in the carcass and gastrointestinal tract. Biliary elimination was the major route of excretion, as indicated by the recovery of ~87% of the radioactive dose in feces following intravenous administration. Similarly, ~86% of the dose was recovered in feces following oral administration. The urinary excretion accounted for <1% of the dose. Following intravenous administration, high levels of radioactivity were found in the stomach about one hour after dosing (study #1007004). Dog The netupitant excretion was studied in beagle dogs following oral (5 mg/kg) and intravenous (2 mg/kg) doses of [14C]netupitant (study #1009956). Urine, feces, and cage washings were collected up to 1008 hours (42 days) after dosing. The results indicated that the total excretion was approximately 88% of the dose within two weeks following oral or intravenous administration. The majority of the radioactivity was found in feces, accounting for 88-90% of the administered dose; <2% was recovered in urine. 5.2 Toxicokinetics See each individual toxicity studies. 6 General Toxicology 6.1 Single-Dose Toxicity In the acute oral toxicity study in mice (# NETU-07-23), netupitant was lethal at 1000 and 2000 mg/kg. 36 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang 24, 96, 192, 288, and 384 hour after dosing (3 rats/sex/group). The k?xxmi samples eat 96, 192, 288, and 384 hour after dosing were collected only during week 13. - Dosing Volume: 5 ml/kg Drug lot# and purity: BSOZO4SA01 and 99.8% Formulation/vehicle: Composition for 100 m1 8i] - 0.20% Cellulose Aviccl RC 591 1.60% Nipagin 8% Nipaso] 0.02% Deminemlized water Filled up to 100 ml GURMMOJN mr adjustment to pH 6.0 Observations and times: - Clinical signs: Clinical signs of toxicity were observed daily. - Body weights: Body weights were determined weekly. - Food consumption: Food consumption was determined weekly. - Hematology, Clinical Chemistry, and Urinalysis: at termination. - Gross pathology: Animals were necropsied at termination. - Organ weighed: Following organs were weighed at termination: adrenal gland, brain, heart, kidney, liver, ovary, pituitary gland, prostate gland, spleen, testis, and thyroid gland. - Histopathology: Following organs or tissues were examined histopathologically from each animal in all groups: adrenal glands, aorta, bone (femur) and articulation bone (sternum) with bone marrow, bone marrow smears, brain, bronchi (mainstem), caecum, colon, duodenum, epididymides, eyes, heart, ileum, jejunum, kidneys and 'ureters, larynx, liver, lungs, node (mandibular), node (mesenteric), mammary gland, oesophagus, optic nerves, ovaries and oviducts, pancreas, parathyroid glands, Peyer's patches, pituitary gland, prostate, rectum, salivary glands (nandibular, parotid, sublingual), sciatic nerves, seminal vesicles, skeletal muscle, skin, spinal cord (cervical, thoracic, lumbar), spleen, stomach, testes, thymus, thyroid glands, tongue, trachea, urinary bladder, uterus (horns cervix), vagina, and all gross lesions. Results: 39 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Clinical Signs: Hairloss was noted in all groups including control with higher incidence in the treated females. Mortality: There were no deaths. Body Weights: The mean body weight, terminal body weight gain, and_5% change of the terminal body weight gain are summarized in the following table. Males control 3 mg/kg 10 mg/kg 30 mg/kg Mean body weight Initial 185.8 183.5 186 186.5 Final 455.2 434.9 456.4 422.8 Body weight gain 269.4 251.4 270.4 236.3 change of body weight gain Females control 3 mg/kg 10 mg/kg 30 mg/kg Mean body weight Initial 148.3 149.4 149.7 151.5 Final 265 268.2 260.1 246.2 Body weight gain 116.? 118.8 110.4 94.7 change of body weight gain The mean terminal body weights in the low, mid, and high dose groups were 95.5%, 100.3%, and 93% of the control for males, and 101%, and 93% of the control for females, respectively. Food Consumption: The mean food consumption in males was 27.1?30.9, 25.8-29.5, and 26.1-30.7, and 25.1?28.4 g/animal/day for control, low, mid, and high dose groups, respectively. The mean food consumption in females was 20.4-22.5, 20.2?21.8, 18.8-21.6, and 18.1?20.2 g/animal/day for the control, low, mid, and high dose groups, respectively. Ophthalmologic Examination: There were no treatment related changes. Hematology: Slight decrease 111 hemoglobin. level, mean cell volume, and mean cell hemoglobin was noted in the high dose group as compared to the control. 40 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Treatment-related microscopic ?ndings Lungs Sex Males I Females Status at occropsj,r K0 R1 K0 RI Group Noofanimals Fomny macrophages Minimal Slight - - - - - 2 - Moderate - - - - - - - - - - - - Marked - - - - - - - - - Pc?bronch] Minimal - - K0: terminal sacri?ce; RI: recovery -: Observation not recorded in group 43 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Treatment-related microscopic ?ndings Mesenteric node Sex Males Females Slams at necropsy KO 1 K0 R1 Group No. ofanirnals Diffuse histiocytosis Minimal Slight Moderale - Marked - - - - - - - - - - - llislioeytic aggregates Minimal Slight - - Moderate Marked - - - - - - - - I - - 2 - - K0: terminal sacri?ce; R1: recovery -: Observation not recorded in group 44 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Treatment-related microscopic ?ndings ovaries Sex Status at necropsy Group No. ol?nnimals - C. lutea in?ammation Minimal Slight Moderate Females - K0: terminal sacri?ce; R1: recovery Observation not recorded in group Treatment-related microscopic ?ndings Stomach Sex Status al necropsy Group No. ofanimals - Muoosal erosion Minimal Slight Moderate Marked - Muscle degeneration Minimal 1'2 12 I l' Males KG R1 Ki}: terminal sacri?ce; R1: recover},r -: Observation not recorded in group Reference ID: 3527655 47 K0 3 12 RI Females 4 5 12 L53 h] NDA 205,718 Reviewer: Ke Zhang Tom. 8 Toxieokinouc murders of blowing on! BEST adminimdon o! 3. 10 and 30 MEWS-008 to ma AVAILABLE COPY Duo 04.4.: 0., Tan. Clul can.) run wen- Aucm- wuo ha) 2an 24mm. 5 ml. act-l. hay-I. 4.49m. ?you mm. 24 90.3 90.3 24 2640 I660 593 Md2040 93Pom-moo noon ?on 9 24 599 $99 24 42500 um 4:70 24 25f 24 39942 2990 299 Maimoo moo 2240 25100 251m 2410 runs23am moo 2m 9 3 mo mo 24 27200 moo 245 94.44 24 5 mo 4420 24 34600 moo 384 moon moo 1460 :12 run-344 496000 36100 4220 4 24 996 39o 24 mo 4264 275 mm.- on 2 I560 14m 244 249000 moo 5500 In tunaI500 4520 I420 :44 moo mo 'lnt?rihlcm administration 49 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Tobie 7 Toxiookineuc pamneton of my; followhg on! BEST administration of 3, 10 and 30 ROWMW to AVAILABLE Duo and" my Tm Cm: cm? nut AUGO- wan- COPY lam mu II nun-L want. mum. wan. lay-MNC 63.7 3 2032.6 MNC NC NC NC Female 573028l6.0 MNC I 6.0 NC Nc Fen-Io 28 5 ILS MNC 5 36.5 NC NC 49 3 2014.1 MNC II 39.3 NC NC 0 3 63.! I 313 NC NC Malt 3 55614036.9 MM: 5 NC NC renal. za 3 35.9 24 640 an 21.3 as 3 2? 139 24.6 9 I 57.7 as 3 96 2430 no 0 706567.2 MI 24 683 683 22.8 91 25.7 In 24 512 312 I 54.3 5 "7 NC NC Fen-[25.1 on 3 47.3 253 24 no 50 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Study title: 26-week Oral Toxicity Study with Netupitant in Rats Study no.: NETU-07-21 Study report location: n/a Conducting laboratory and location: Date of study initiation: GLP compliance: QA statement: Drug, lot #, and % purity: (b) (4) August 16, 2007 Yes Yes Netupitant, 27003139, 98.7% Key Study Findings: Rats were treated with netupitant at 0, 1, 3, or 10 mg/kg/day by oral gavage for 26 weeks. Treatment with 10 mg/kg/day resulted in periacinar hepatocytic hypertrophy, thyroid follicular epithelial hypertrophy (males), thymic atrophy, increased aggregations of alveolar macrophages, and syncytial macrophages in mandibular and mesenteric lymph nodes and spleen. The NOAEL is considered to be 3 mg/kg/day based on the microscopic findings, although the high dose of 10 mg/kg/day was well tolerated. Methods Doses: Frequency of dosing: Route of administration: Dose volume: Formulation/Vehicle: Species/Strain: Number/Sex/Group: Age: Weight: Satellite groups: Unique study design: Deviation from study protocol: 0, 1, 3, and 10 mg/kg/day Daily Oral gavage 5 ml/kg Thixotrope vehicle Crl:WI(Han) rats 20/sex/group and additional 10/sex/group in control and high dose groups ~7 weeks Males: 228-232 g Females: 163-166 g 3, 5, 5, and 5/sex/group No No deviation occurred which adversely affected the quality of the study. The dose selection was based on the results of the previous studies including a 52 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Toxicokinetics The toxicokinetic data for netupitant and the metabolites M1, M2, and M3 were summarized in the following sponsor’s tables. The AUC values for netupitant and M1 were generally comparable, whereas the plasma exposure to M2 and M3 was much lower. APPEARS THIS WAY ON ORIGINAL 55 Reference ID: 3527655 NDA 205,718 Data are summarized below: Reviewer: Ke Zhang Toxicoltinetii: parameters of Netupitant Group 2: 1 mg Males Females 4.0 2.0 0.5 2.0 3.0 4.0 1.0 4.0 Cmax ngi'mL 55 .0 1 13 134 123 32.? 230 305 313 0m 55-0 1 13 134 125 32.7? 250 305 313 4039.24 hr-ngiimL 1?40 2430 2550 1530 5330 3T10 30T0 300.334 1340 2430 2550 1530 5330 3T10 3010 1400.351 hr-ngl'mL 040 2430 2550 1530 5330 5210 30T0 AUCIH hr-i-tg-ngimLinu H40 2430 2550 1530 5330 0 3070 AUG. hr-nglimL 1000 nIa Na Na W0 Na Na Na 4100= hr-ltg-ngimUny 1000 nfa nfa ma [1er Na Na Na t'h-g hr 3.12 15.0* 104* 1 15* 103* 353* 41 Group 3: 3 mg Males Females Tmam Canal: ngi'mi5715 T34 1050 Cm Hg noimLi'mg 30 .2 0T0 100 153 702 102 255 350 4000.24 hr-ngl'mL 2730 4300 3050 3510 4110 12300 15500 1?200 300.3-? hr-itg-ngimUmg 02? 1530 2320 2130 1370 42T0 51T0 5T30 300351 hr-ngl'mL 2?30 4500 3050 5510 41 10 12300 15500 1 E200 1400.35.t hr-itg-ngfmUnu 021' 1530 2320 2170 1370 42T0 51 T0 5730 A00. r- ngr'm 3200 nia Na Na 3310* nta Na Na AUG: hr-ltg-ngfm Limg 1020 nia ni'a nia 2040* Ma Na Na hr 3.23 132* 21 233* 2742* 133* Nd Group 4: '10 mg Males Females W23 5352.0 4.0 2.0 2.0 2.0 4.0 4.0 4.0 Email: ngi'mL 500 2050 023 320 313 1250 1 130 1340 kg-ngimUmg 50.0 205 02.3 32.0 51.3 125 113 134 5003.24 hr-ngl'mL 3330 20T00 147*00 15000 13300 24300 24100 2?500 300.334 hr-itg-ngiimUnu 333 2030 14T0 1300 1330 2430 2410 2?50 1400.351 hr-ngi'mL 3330 20700 14200 43400 13300 24300 24100 133000 300135: hr-itg-ngmeimg 333 20T0 1430 4340 1330 2430 2410 13300 4100: hr-ngme 13500* nIa Na Na 250000* Ma Na Na AUG: hr-ltg-ngfm erg 1350* nla Na Na 2300015.1 25-4* 51 .3 305* 01 503* 1 12 E1 dose-normalised to 1 mgr'ltg, approximation, ma not applicable, not determined 3* If was 24hours. this was the maximum time between subsequent doses- 0nly in RECDVEW animals at the high dose, a true value for was obtained after the ?nal dose was administered. 56 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Dosing Solution Analysis The analysis of drug concentration in samples of dosing formulations from each dosegroup was in agreement with target concentrations (between 90% and 110%). Dog: Study title: RO0673189: Thirteen week oral (capsule) toxicity study in dogs 59 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Study no.: 1009175 Study report location: n/a Conducting laboratory and location: Date of study initiation: GLP compliance: QA statement: Drug, lot #, and % purity: (b) (4) November 13 2002 Yes Yes RO0673189-008, BS0204SA01, 99.8% Key Study Findings: Dogs were treated with netupitant at 0, 1, 3, and 10 mg/kg/day via oral capsule for 13 weeks. Treatment with netupitant at 10 mg/kg/day resulted in vacuolated macrophages or vacuolated tingible body macrophages in the lymphoid tissue (mesenteric or mandibular lymph nodes, Peyer's patches or colonic lymphoid tissue), suggesting a drug-induced phospholipidosis. Since the microscopic lesions are not considered to be adverse, the NOAEL is 10 mg/kg/day. Methods Doses: Frequency of dosing: Route of administration: Dose volume: Formulation/Vehicle: Species/Strain: Number/Sex/Group: Age: Weight: 0, 1, 3, and 10 mg/kg/day Daily Oral capsule N/A Empty capsule beagle dogs 3 or 5/sex/group ~5-6 months Males: 9-11 kg Females: 7-10 kg Satellite groups: none Unique study design: No Deviation from study protocol: No deviation occurred which adversely affected the quality of the study. Dose selection was based on the results of the 4-week oral dose toxicity study in dogs (#1006010). Body weight loss was noted at doses of 15 mg/kg/day or higher in this study. The sponsor selected 10 mg/kg/day as the high dose in the current study. There was also a 7-day oral toxicity study in female Beagle dogs with doses up to 15 mg/kg/day (#1006679). In this study, slight body weight loss and aggregates of foamy or vacuolated macrophages in lymphoid tissue and intestinal mucosa, suggesting phospholipidosis, were noted at 15 mg/kg/day. Observations and Results 60 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Oral capsules were used. The test article was packed in capsules on the day before the day of dosing. Study title: 9-Month oral gavage toxicity study in dogs Study no.: NETU-07-22 Study report location: n/a Conducting laboratory and location: Date of study initiation: GLP compliance: QA statement: Drug, lot #, and % purity: (b) (4) October 15, 2007 Yes Yes Netupitant, 27003139, 98.9% Key Study Findings: Dogs were treated with netupitant at 0, 1, 3, and 10 mg/kg/day by oral gavage for 9 months. Treatment with netupitant at 10 mg/kg/day slightly increased the QTc and PQ intervals (males), and produced minimal periacinar hepatocytic hypertrophy (males). Plasma exposure to the metabolite M1 was approximately 2 times that of netupitant. The NOAEL was 10 mg/kg/day. Methods Doses: Frequency of dosing: Route of administration: Dose volume: Formulation/Vehicle: Species/Strain: Number/Sex/Group: Age: Weight: 0, 1, 3, and 10 mg/kg/day Daily Oral gavage 1 ml/kg Thixotrope vehicle beagle dogs 4 or 7/sex/group (see sponsor’s table below) ~5-6 months Males: 8.0-8.2 kg Females: 5.7-5.9 kg Satellite groups: None Unique study design: None Deviation from study protocol: No deviation occurred which adversely affected the quality of the study. 63 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Slightly prolonged QTc intervals were noted in the high-dose males during treatment weeks 13 and 26 (231-240 msec measured post-dose, compared with 213-215 msec at pre-dose). Slightly prolonged PQ intervals were also noted in the high-dose males during treatment weeks 13 and 26 (98-104 msec measured post-dose, compared with 83-93 msec at pre-dose). There were no clear treatment effects on blood pressure. Hematology There were no clearly treatment-related changes. Clinical Chemistry Alkaline phosphatase was increased (131-262 U/L in high dose group compared to 50118 U/L in control group). Urinalysis There were no clearly treatment-related changes. Gross Pathology An enlarged liver was noted in one high-dose male. Organ Weights The absolute and relative liver weights were approximately 139% and 151% of mean control weight in the high-dose males. Histopathology Minimal periacinar hepatocytic hypertrophy was noted in the high-dose males. Toxicokinetics The toxicokinetic data for netupitant and the metabolites M1, M2, and M3 are summarized in the following sponsor’s tables. The AUC values for M1 were approximately 2-fold greater than the AUC values for netupitant. The AUC values for the parent compound and its metabolites in the high-dose group were higher in males. 65 Reference ID: 3527655 NDA 205,718 Toxieokinetie data of Netupitant are summarised below: Reviewer: Ke Zhang Group 2 Group 3 Group 4 Parameters 1 ikg 3 ikg 1D mgikg Day 2.0 1.5 2.0 2.0 4.0 2.0 097ml. 50.2 124 320 257 1010 570 4 kg-ng7mumg 50.2 124 107 05.0 101 57.0 hr-ngme 040 1000 3000 2350 13000 5730 0 hr-kg-ng7mumg 040 1000 1030 702 1300 573 400.. 033* 1300* 3710* 3000* 10000* 7030* 4 400.. hr-kg-ngimLimg 033* 1300* 1230* 1030* 1000* 703* hr 7.37 103* 0.73 11.5* 110* 133* Week 1.0 2.0 2.0 2.0 2.0 2.0 ng7mi. 151 175 404 410 1320 012 0 kg-ngimLi'mg 151 175 101 137 132 01.2 1400 1720 5100 4500 17100 10100 4 hrkg-ngimLimg 1400 1720 1730 1520 1710 1010 hr 103* 111* 110* 13.4* 13.0* 10.01 Week 2.0 1.5 2.0 2.0 2.0 2.0 11.0101. 154 103 470 411 1310 054 0 154 103 157 137 131 05.4 1750 1050 5050 4000 10000 11000 4 hr-kg-ng7mumg 1750 1050 1000 1000 1000 1100 hr 134* 11.7* 13.1* 12.0* 103* 100* Week 2.0 2.0 2.0 2.0 2.0 2.0 ng7mi. 105 210 400 502 1240 001 0 kg-ng7mL7mg 105 210 153 107 124 00.1 1730 2120 5470 0320 20100 14100 4 hr-kg-ng7mL7mg 1730 2120 1020 2110 2010 1410 hr 105* 142* 120* 130* 100* 104* Week 39 hr 24 24 24 24 24@ 247? hr 2.0 1.5 2.0 2.0 2.0 2.0 ng7mi. 147 202 400 417 1200 040 4 kg-ngilemg 147 202 155 130 120 04.0 I hr-ngimL 1000 2200 0200 5520 20500 12400 0 hr-kg-ng7mL7mg 1000 2200 2000 1040 2050 1240 hr 140* 13.7* 130* 12.0* 200*? 21 4* dose?normalised to 'l mgikg. .- approximation. 5 median for Tlast and Tmax. I was used for Recovery animals of Group 4. 1? Resoyery animals excluded. was 24hours. this was the maximum time between subsequent doses. Only in Reeoyery animals. a true yatue for was obtained after the ?nal dose was administered: it was 10310 for males and 95hr for females at the high dose Reference ID: 3527655 66 NDA 205,718 Toxicokinetic data of M2 are summarised below: Reviewer: Ke Zhang Group 2 Group 3 Group 4 Parameters 15ngme 25.9 90.2 135 142 553 529 kg-ngmefmg 25.9 90.2 45.0 47.3 55.3 52.9 hr-ngme 229 452 1150 937 5199 3410 hr-kg-riQImLImg 229 452 393 312 519 341 AUCM 192* 959* 1439* 1190 7950* 3950* 192* 959* 477* 397 795* 395* 11.2 hr 479* 490* 925* 5.92 149* 7.74* Week Tmaf? hr 2.0 2.0 2.0 3.0 2.0 2.0 Cmax ngx?mL 97.9 59.2 193 149 997 595 kg-ngmefmg 97.9 59.2 54.4 49.9 99.7 59.5 41.10.35. hr-ngme 952 554 1590 1299 9339 5190 AUCW 952 554 527 427 933 519 11,2 hr 11.3* 115* 29.0* 159* 149* 105* Week 13 Tm.$ hr 24 192.0 2.0 2.0 2.0 2.9 2.9 ngme 50.3 90.7 139 124 593 999 Cm kg-ngmei?mg 50.3 90.7 49.3 41.2 59.3 90.0 595 524 1550 1319 9930 4990 AUCW hr-kg-ngImLImg 595 524 515 437 993 499 1112 hr 157* 137* 175* 195* 215* 125* Week 29 Taa2.9 2.0 2.9 2.0 2.9 2.9 119me 53.4 75.9 133 191 399 334 Cm. kg-ngmefmg 53.4 75.9 44.2 53.9 39.9 33.4 hr-ngme 737 990 1990 1759 5940 4290 49cm. hr-kg-ngIermg 737 900 532 593 594 420 11.2 hr 205* 199* 199* 295* 349* 242* Week 39 Tlas2.0 2.0 2.0 2.0 2.9 2.9 Cmax ngx'mL 99.9 95.2 149 129 437 449 Cm kg-ngmeImg 99.9 95.2 49.5 49.1 43.7 44.0 I 994 1190 1990 1939 9399 4940 hr- kg-ngimLImg 994 1190 993 543 939 494 to; hr 21.4* 17.7? 215* 249* 345*? 155*? 4 dose?normalised to 'l rug-?kg. approximation. 5 median for Tlast and Tmak. I AUCmsh was used for Recoverv animals of IGroup 4. 9 Recover}:r animals excluded. If Tim was 24 hours. this was the maximum time between subsequent doses. Only,?r in Recovery.r animals. a true value for Tim was obtained after the ?nal dose was administered: it was 199hr for males and 99??I99hr for females at the high dose Reference ID: 3527655 68 NDA 205,718 Reviewer: Ke Zhang Dosing Solution Analysis The analysis of drug concentrations in samples of dosing formulations from each dosegroup was in agreement with target concentrations (between 96% and 101%). Study title: 13-Week oral gavage toxicity study with palonosetron and netupitant in rats Study no.: NETU-07-19 Study report location: n/a Conducting laboratory and location: Date of study initiation: GLP compliance: QA statement: Drug, lot #, and % purity: (b) (4) July 2, 2007 Yes Yes Palonosetron, 26004786, 99.5% Netupitant, BS0307SA01, 99.5% Key Study Findings: Rats were treated with netupitant at 1, 3, and 10 mg/kg/day in combination with palonosetron at 2, 6, and 18 mg/kg/day, respectively, by oral gavage for 13 weeks. Additional groups were treated orally with 10 mg/kg/day netupitant or 18 mg/kg/day 70 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang The dose selection was based on the results of the previous toxicity studies including 7-day and 28-day studies in rats with combination treatment (# NETU-06-20 and # NETU-06-03, respectively). Doses tested in the 28-day study were: 10 mg/kg/day Palonosetron and 3 mg/kg/day Netupitant 18 mg/kg/day Palonosetron and 10 mg/kg/day Netupitant 60 mg/kg/day Palonosetron and 30 mg/kg/day Netupitant The group treated with 60 mg/kg/day palonosetron and 30 mg/kg/day netupitant exhibited hunched posture, reduced body weight, and increased incidence and severity of syncytial macrophages in mesenteric lymph nodes. The sponsor selected 18 mg/kg/day palonosetron and 10 mg/kg/day netupitant as the high-dose combination for the current study. Observations and Results Mortality Two main study toxicity rats and 3 satellite rats died during blood sampling. These deaths were not treatment related. Clinical Signs Increased salivation was noted in the high-dose combination group. Body Weights There were no clearly treatment-related changes. Feed Consumption Slightly lower food consumption was noted in the high dose group during weeks 1 and 2. Ophthalmoscopy There were no clearly treatment-related changes. 73 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Toxicokinetics The toxicokinetic data for palonosetron, netupitant, and the netupitant metabolites M1, M2, and M3 are summarized in the following sponsor’s tables. 75 Reference ID: 3527655 NDA 205,718 Toxiookinetio data of Palonosetron are summarised below. Reviewer: Ke Zhang Summaryr Palonosetron data Parameters Group 2: 2 mgi?kg P5 and1 mgi?kg NT Group 3: 5 mg?tg P5 and 3 mg?tg NT Day1 Week 4 Week Week13 0:111.r 1 Week 4 Week Week 13 Males T135 0.5 0.5 0.5 0.5 Cm. ngme 4.8? 3.80 ?.88 it Cum kg-ngi'mUmg 0.812 0.548 0.528 1.31 AUCiast hr-ngi'mL insuf?c. data 5.83 4.05 3.?1 5.45 AU C135: 1.15 05?? 0.518 0.808 ?.50 Ma nt'a ni'a AUG. hr-I-tg-ngi'mLi'mg 1.2? Na nt'a nfa tm hr 1.04 0.845 0.545 0.505 Females 0.5 0.5 0.5 0.5 Gm? [119me 22.? 28.2 18.2 25.? ii Cm. kg-ngi?mUmg 3.?8 4.8? 3.04 4.28 hr-ngi'mL insuf?c. data 18.0 21.1 11.? 20.5 AUCIBH hr-kg-ngmei'mg 3.00 3.52 1.85 3.42 1 8.8 Na nt'a nfa AUC- hr-kg-ngi'mLi'mg 3.13 We nt'a nfa tug hr 1.01 1.12 0.45? 0.858 Group 4: 18 mgfl-tg PS and 10 NT lGroup 5: 15 P5 Day1 Week 4 Week Week 13 Day1 Week 4 Week Week13 Males T135: hr 8.0 8.0 8.0 8.0 4.0 8.0 8.0 8.0 Tmam hr 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 Cm? {19me 80.8 5?.3 55.5 3?.2 5?.8 58.3 54.4 52.5 Cm: kg-ng?mUmg 4.48 3.?4 3.?0 2.05 3.85 3.02 3.48 82.8 ?0.2 40.4 58.8 8?.3 82.3 ti 4.51 3.80 4.31 2.24 3.88 4.85 4.5? 4.31 84.4 Na Na Na ?2.0 Na nIa ni'a hr-ltg-ngmei'mg 4.58 nfa Ma Ma 4.00 Na Na Na tm hr 1.85 5.14 1.?2 4.88 1.55 1.53 1.?8 Females Tm hr 4.0 8.0 8.0 8.0 8.0 8.0 24.0 8.0 Tmam ngme 125 138 145 104 250 85.4 10? 155 (3.1m kg-ngimUmg ?.02 ?.54 8.04 5.80 14.5 4.80 5.85 8.20 hr-ngi'mL 138 111 124 10? 230 133 158 202 ?.55 5.1? 5.88 5.84 12.8 ?.38 8.33 11.2 AUCM hr-ngi'nfa nfa AUG: hr-kg-ngmei'mg ?.81 Ma Ma Ma 12.8 n?a ni?a nt'a tm hr 0.884 2.?8 2.12 2.15 1.3? 1.3? 5.8? 1.35 P8 Patonosetron. NT Netupitant, it dose?normalised to 1 mgi'kg, xx approximation. nfa not applicable insuffdata: Concentrations were near or below LL00, no calculations performed. Reference ID: 3527655 76 NDA 205,718 Toxicokinetic data of M1 are summarized below. Reviewer: Ke Zhang Summaryr M1 data Parameters Group 2:2 mga'kg P3 and 1 make NT Group 3: 3 PS and 3 mg-?kg NT ?ayr 1 Week 4 Week Week 13 Day 1 Week 4 Week Week 13 Males Tlx?tg 24.3 24.3 24.3 133.39 24.3 24 .3 24.3 133.35 Tma: 3-3 24 .3 3.3 24.3 24.3 24.3 24.3 24.3 Ema: noa'ntL 33.3 131 153 233 35.3 433 435 333 3 31m kg-ngi'mUrng 33.3 131 153 233 23.5 133 135 233 AU Gas; nr-n gi'ntL 323 2453 3113 5123 1313 3333 13333 3233 3 323 2453 3113 5123 53? 2373 3333 4333 nr-n gi'ml. 23?33 44333 3 AUGW 23?33 1433? AUG. nr-n gi'mL NG nIa ne'a nfa NG nfa m'a 3 AUG. nr-kg-ngimUmg NG ma na'a rifa NG rifa rtta nfa 11.2 hr NG MG NG 32.3 N3 ME: 3?.3 Females Tm3 hr 24.0 24.0 24.0 134.03 24.0 24.0 24.0 235.03 Tm hr 24.3 24.3 24.3 24 .3 24.3 24.3 24.3 24.3 Elm nga?ml. 33.3 133 13? 235 ?3.5 422 33? 3 3mm 33.3 133 13? 235 24.5 141 132 253 AU on gimL 524 3?33 4123 4333 13?3 3333 33?3 12333 3 hr-kg-ngfmUmg 524 3?33 4123 4333 45? 3133 3323 4333 nr-n giml. 1?333 ?3333 3 1?333 23333 AUG. nr-n gimL NG nra ne'a nfa NC nfa nr'a Na 3 AUG. nr-kg-ngi?mUmg NG ma n?a rura HG rura n13 n.la 1153.3 Group 4: 13 PS and 13 mg-?kg NT Group 3: 13 mg.le NT Clayr 1 Week 4 Week Week 13 ?Day 1 Week 4 Week Week 13 Males Tlam hr 24.0 24.0 24.0 324.03 3.0 24.0 24.0 235.03 Tm 24.3 24.3 3.3 4.3 3.3 24.3 24.3 24.3 Gm 134 ?31 1313 1113 231 353 3?1 1323 kg-ngi'mUrng 13.4 ?3.1 131 111 23.1 35.3 3?.1 132 AU Ga on 3413 13133 23333 22333 321 23333 22233 23233 3 AUGlae nr-kg-ngfmUmg 341 1313 2333 2233 32 2333 2223 2323 AU on gintL 134333 133333 3 AUGW 13433 13333 AUG. nr-n gimL NG nra neAUG- hr-kg-ngrmUmg NG Na Na Na HG We ate n?a 11.2 NG MG MG 33.3 143 MG NG 53.3 Females hr 24.0 24.0 24.0 235.03 3.0 24.0 24.0 335.03 Trnax 24.3 3.5 3.5 24 .3 3.3 3.3 24.3 43.3 Cm: nga'ntL 134 33? 333 1 1?3 113 3?3 1343 3 33 3 G-nax kg-ngi'mUrng 13.4 33.? 33.3 11? 11.3 3?.3 134 33.3 AU [3:52 hr-n gimL 2323 13533 13333 23433 513 13333 25333 1?333 3 nr-kg-ngmei'mg 232 1353 1333 2343 52 1333 2533 1.?33 nr-n 221333 145333 3 22133 14533 AUG. hr-nga?mL NG nra ni'a nfa NG nfa nra na'a 3 AUG. nr-kg-ngi'mUmg NG nra nta rifa 33.2 N3 N3 NG 33.5 P3 Palonosetron, NT Netupitant, 3 dose?normalised to 1 2:34 approximation. nIa not applicable, ftai'i'cs used for Week 13. NC could not be calculated '5 If Tm was 24hours. this was the maximum time between subsequent doses. in Recotrery,r animals. a true value for was obtained after the ?nal dose was administered. Reference ID: 3527655 78 NDA 205,718 Reviewer: Ke Zhang Dosing Solution Analysis For palonosetron, the concentrations measured in dosing formulations for groups 2 to 5 were in the range of 87–111% of the nominal concentrations. For netupitant, the concentrations measured in dosing formulations for groups 2 to 4 and group 6 were between 89% and 107% of the nominal concentrations. The mean values of the duplicate samples were within the range of 90-110%. Study title: 13-Week oral gavage toxicity study with palonosetron and netupitant in dogs 81 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang The dose selection was based on results of the previous toxicity studies, including a 7day and 28-day study in dogs with combination treatment (# NETU-06-21 and # NETU06-05, respectively). The doses tested in the 28-day dog study were: 10 mg/kg/day palonosetron and 3 mg/kg/day netupitant 15 mg/kg/day palonosetron and 7.5 mg/kg/day netupitant 15 mg/kg/day palonosetron and 15 mg/kg/day netupitant. The groups treated with 15 mg/kg/day palonosetron + 7.5 mg/kg/day netupitant and 15 mg/kg/day palonosetron + 15 mg/kg/day netupitant exhibited tremors and seizure-like episodes. Therefore, the sponsor selected 10 mg/kg/day as the high dose for both palonosetron and netupitant in the current study. Observations and Results Mortality No deaths occurred. Clinical Signs There were no clearly treatment-related signs. Body Weights The terminal body weight gain was reduced in the combination high-dose females (0.9 kg, as compared to 2 kg in the control females). Feed Consumption A slight reduction in food consumption was noted in the combination high-dose group during weeks 1 and 2. Ophthalmoscopy There were no clearly treatment-related changes. 83 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang ECG ECGs were measured before study initiation and on day 2 and weeks 4, 8, and 13 (predose, 2, and 6 hours after dosing). The ST-interval, uncorrected QT-interval, and corrected QT intervals according to Van de Water and Fridericia were slightly prolonged in the high-dose females, as compared to the control females. Hematology There were no clearly treatment-related changes. Clinical Chemistry A slight decrease in albumin concentration occurred in the mid- (31.4 g/L) and highdose (31.5 g/L) males at the end of treatment, as compared to 34.2 g/L in the control males. A slight increase in glucose was noted in the mid- (6.56 mmol/l) and high-dose (6.5 mmol/l) males at the end of treatment, as compared to 5.81 mmol/l in the control males. A slight decrease in triglycerides was seen in high-dose females (0.48 mmol/l) at the end of treatment, as compared to 0.62 mmol/l in the control females. Urinalysis There were no clearly treatment-related changes. Gross Pathology There were no clearly treatment-related changes. Organ Weights Relative liver weights were increased slightly in the high-dose. Histopathology There were no clearly treatment-related changes. Toxicokinetics The toxicokinetic data for palonosetron, netupitant, and the netupitant metabolites M1, M2, and M3 are summarized in the following sponsor’s tables. 84 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Toxicokinetic data of M1 are summarised below: Summary M1 data Group 2: 3 b.w. PS Group 3: 5 b.w. PS Group 4: 10 1:19ka b.w. PS Parameters and 1 b.w. NT and 3 mgikg b.w. HT and 10 b.w. NT Day Week Week Week Day 1 Week Week Week Day 1 Week Week Week Males T1335 hr 24.0 24 .0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0"g Tm? hr 8.0 4.0 4.0 5.0 8.0 8.0 4.0 5.0 8.0 1.5 6.0 1.0 Cram: 119me 60.2 140 147 156 237 669 616 633 455 1360 1710 1510 11 CW kg-ngi'mLimg 60.2 140 147 156 78.9 223 205 211 452730 2820 3060 4310 13600 12600 13500 8220 30200 36000 32600 hr-kg-ngfmUmg 1 110 2730 2820 3060 1440 4550 4210 4490 822 3020 36 00 32 60 AUG. 1990* nIa nia Ma 1090 0* 1113 Na Na 27900* nr'a nIa nr?a hr-kg-ngfmUmg 1990* Ma nla nJ'a 3630nfa nila tn: hr 168* 238* 263* 319* 293* 263* 335* 404* 325* 244* 632* 80.6* Females Twig hr 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.43.3 131 141 147 130 335 350 324 592 1350 1320 1180 11 CW kg-ngi'mUmg 43.3 131 141 147 43.2 111 117 108 59.2 135 132 118 hr-ngilmL 833 2570 281 0 2870 2530 6790 6890 6700 1 1300 29200 27400 24700 hr-kg-ngfmUmg 833 2570 2810 2870 843 2260 2300 2230 1 130 2920 2740 2470 AUG. hr-nngL 2970* nfa ni'a nr?a 9660* Na nfa Ma 30300* We nfa nfa 11 hr-kg-ngfmUmg 2970* nfa nfa nIa 3220* Na nfa nfa 3030* nIa nfa nfa t1r2 hr 427* 28 344* 278* 472* 342* 330* 340* 339* 51 52.6" 47.5'c PS 2 Palonosetron; NT 2 Netupitant, 5: median, dose?normalised to 1 was used for the recoveryr animalsr It T1351 was 24hoursr this 1was the maximum time between subsequent doses. Only in Recovery animals, a the value for T1351 was obtained after the ?nal dose was administered: it was 168?336hr at the high dose. approximation. nfa: not applicable Toxicokinetic data of M2 are summarised below: Summary M2 data Group 2: 3 "1'9le b.w. PS Group 3: 5 b.w. PS Group 4: 10 mgil'kg b.w. PS Parameters and 1 b.w. NT and 3 1119er [1.111. NT and 10 1119ka 5.1111. NT Dav Week Week Week Day Week Week Week Day Week Week Week Males 5 9 hr 3.0 24.1] 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0? Tums hr 2.0 2.0 2.0 2.0 3.0 2.0 2.0 2.0 2.0 2.0 2.0 2.0 ngimL 55.4 46.5 47.2 41.kg-ngmefmg 55.4 46.5 47.2 41.9 48.7 72.9 64.7 66.0 40.0 51.9 53.3 43.2 hr- ngme 227 520 558 548 1510 2560 2200 2310 2550 5370 5210 4680 hr-kg'ngfmUmg 227 520 568 548 504 853 733 770 255 537 521 468 A C- hr- ngme 3 04* 1113 nia nfa 2000* n13 n.1a Na 32 50* nfa ni'a ne'a AUC- hr-kg-ngmel'mg 304* nla ni'a nfa 668* nfa ma nfa 325? m?a Na Na 11.; hr 322" 14.2? 15.7? 15.9' 10.9?" 17.7' 164* 15.7? 980? 47.4' 13 3* 23.2? Females '3 hr 8.0 24.0 8.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0IQ Tm:i hr 2.0 2.0 2.0 2.0 2.0 2.0 1.5 2.0 2.0 2.0 2.0 2.0 36.6 50.2 50.8 45.4 207 183 125 1 10 590 563 453 381 Cm: 119119meme 36.6 50 2 50.8 45,4 68.9 61.0 41.7 388 58.0 56.3 45 3 38,1 185 484 313 527 1140 1310 1110 1060 3930 4500 4030 3720 hr- kg - ngfmUmg 185 484 313 527 379 456 371 353 393 450 403 372 AUG. hl" ngme 278' Na Na nfa 1 270' we nia nfa 4580* nifa ni'a nia AUG- hr-kg-ngfmUmg 23?8" nr?a ni'a nfa 424* n13 mla nfa 458* Ma rule. We 1.,2 hr 386' 10.7' 663' 17.0' 557" 10.6' 10.2? 11.7? 7.34' 9-74' 119" 17.1 P5 Palonosen?on; NT Netupitant, 5: median. dose?nonnalised to 1 was used for the recovery animals. 5 if Tim was 24hours. this was the maximum time between subsequent doses OnlyI in Recovery animals? a true value for Tm was obtained after the ?nal dose was administered: at was 96?168hr for males and 48?96hr for females at the high dose. Reference ID: 3527655 apprommatlon. nla: not applicable 86 NDA 205,718 Study no.: Study report location: Conducting laboratory and location: Date of study initiation: GLP compliance: QA statement: Drug, lot #, and % purity: Reviewer: Ke Zhang 330M01 n/a Non-Clinical Drug Safety F.Hoffmann La-Roche Ltd., Basel, Switzerland 8/20/2001 Yes Yes RO0673189-008, batch #: GPM0403, 99.6% Key Study Findings: Treatment with the test article did not significantly increase the number of revertant colonies/plate. Methods: Strains: Salmonella typhimurium strains TA1535, TA97, TA98, TA100, and TA102 Concentrations in definitive study: 5 to 500 µg/plate and 1 to 100 µg/plate (see sponsor’s tables 1 and 2 below) Basis of concentration selection: Toxicity were observed at concentrations of 200 µg/plate (-S9) and 632 µg/plate (+S9) based on reduction of background growth and reduction or absence of revertant colonies. Negative control: DMSO Positive control: See below. Formulation/Vehicle: DMSO Incubation & sampling time: The plates were incubated at 37°C for 2 days. Positive controls 89 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang TABLE A1 Reverse mxtatim assay using bacteria hurber e1: reuertam ce?lm?ies per p1ate. man Era?lug and starrlartl deviations. Study:r ML: Brill-?D1 Emeriment No.: 1 Experiment Start: 21.03.01 Method: ME Test Cmpemd: RC: Stre?in M1 nation Posi ti we Cartm] 5 (+19pr ate) T?l535 ?59 2?m' tm?mrem l3. 5 2?ami mthracme 4 Stre?in when Positive Curtm'ls W?ate) B74 849 862118 23 24 24:1 -59 sodium guide 1 Reference ID: 3527655 581 562 522:13 96 11B 103 i 10 TA1535 +59 296 262 229 i 24 +59 -59 2132 220125 331 833 31? i 23 332 349 341112 91 +59 TM -59 TA98 +59 187 136 132:8 NDA 205,718 Reviewer: Ke Zhang Ames test (study # 330M01) covers those in the current study, the full review on this study is not performed. Following paragraph is from the sponsor’s report. 7.2 In Vitro Assays in Mammalian Cells Study title: R00673189-008: Mouse Lymphoma Cell Mutation Test Study no.: Study report location: Conducting laboratory and location: Date of study initiation: GLP compliance: QA statement: Drug, lot #, and % purity: 312M01 n/a Non-Clinical Drug Safety department F. Hoffmann-La Roche Ltd, Basel, Switzerland August 8, 2001 Yes Yes R00673189-008 / GPM0403 / 99.5% Key Study Findings: Treatment with test article did not significantly increase the mutant frequencies as compared to the control. Methods: Cell line: mouse lymphoma L5178Y tk+/Concentrations in definitive study: See sponsor’s table 3 Basis of concentration selection: Cytotoxicity was observed at higher concentrations. Negative control: DMSO Positive control: See sponsor’s table below Formulation/Vehicle: DMSO Incubation & sampling time: Incubation times were 3 and 24 hours 93 Reference ID: 3527655 NDA 205,718 The positive control chemicals were supplied and used as tabulated below: Reviewer: Ke Zhang Chemical 4-nitroquinoline l?oxide (NQO) Benzolajpyrene (BP) sulfonat(MMS) Supplier Batch/Lot Molecular Vehicle Stock Final S9 weight cone. cone. [Hg/mL] [ggsz] 190.2 DM SO 10 0.1 - 110H0096 252.3 DMSO 200 and 2 C13 1 l0.1 DMSO 500 5 - Study Validity: The study is valid based on the positive response in the positive control group. Results: Treatment with test article did not significantly increase the mutant frequencies as compared to the control. However, the positive control compounds produced signi?cant increases in mutant frequencies. The results are summarized in the following sponsor?s tables. Reference ID: 3527655 94 NDA 205,718 Reviewer: Ke Zhang Table 3 cont. Summary Table Small and large colony mutant frequencies and viabilities of negative controls, positive controls and treatment groups of R00673189-008 after 3 or 24 exposure in absence of metabolic activation and 3 exposure in presence of metabolic activation. Test article RS ADRS PE MF Proportion Experiment concentration (Mutants per l??viable celIS) small/large (90) small large total colonies DMSO 0 97 102 96 22 83 109 0.27 DMSO 103 98 80' 32 119 158 0.27 treatment 0.103 125 0.0.119 0.104 0.108 0.128 0.0.135 0.52 Linear trend NS MMS 5 58 54 54 398 521 1142 0.76 312M015 DMSO 0 96 94 80 30 108 143 0.28 DMSO 0 105 106 71 38 92 131 0.41 ??tment 150 0.117 0.30 10 103 104 89 35 120 161 0.29 10 77 72 72 47 116 165 0.41 20 82 70 79 35 105 147 0.127 0.38 25 57 28 84 27 108 141 0.144 0.49 27.5 38 20 85 35 70 109 0.50 27168 0.120 0.100 0.38 Linear trend NS 3" 89 82 77 139 281 485 0.49 31? 3 37 34 44 530 995 2073 0.53 NS No signi?cant increases of mutant frequency Signi?cant at 5, 1, 0.1 level 7: Adapted relative survival after treatment below 10 Reference ID: 3527655 96 NDA 205,718 Reviewer: Ke Zhang (cyclophosphamide) produced the expected increase. The results are summarized in the sponsor’s table below. 98 Reference ID: 3527655 NDA 205,718 Table 2 (cont.) Micronucleus Study: Group Median Values Reviewer: Ke Zhang Ratio of to normoehromatic frequency of mieronucleated (MN-PCB) and median values per animal, sex and treatment group. 'Iest item and Dose Animal Ratio MN-PCE (mgikgfday) No Sex Medianf Median" Sex Group Sex Gram Oral doses on two consecutive days. harvest on the following day 1 2.37 0.30 2 1.64 0.17 3 1.11 1.64 0.30 0.27 4 2.01 0.22 5 1.04 0.27 R00673l89-008 160 1.32 0.20 6 1.27 0.02 7 1.37 0.22 8 1.86 1.27 0.15 0.08 9 1.06 0.07 10 0.98 0.08 2.23 0.12 2 2.08 0.15 3 1.18 1.18 0.20 0.17 4 0.91 0.17 0.88 0.20 R00673189-008 400 1.26 0.14 6 2.14 0.07 7 1.33 0.10 8 0.80 1.33 0.13 0.10 9 1.60 0.15 10 0.89 0.10 1 0-76 0.07 2 0.66 0.05 3 2.08 0.76 0.20 0.13 4 1.02 0.25 5 0.60 0.13 R00673189-008 1000 0.76 0.10 6 0.62 0.05 7 0.84 0.10 8 0.82 0.75 0.10 0.10 9 0.75 0.15 10 0.50 0.10 7.4 Other Genetic Toxicity Studies Study title: BACTERIAL MUTATION ASSAY with (impurity) Reference ID: 3527655 100 NDA 205,718 Reviewer: Ke Zhang Study Validity: The study is valid based on the positive response in the positive control group. Results: Treatment with the test article did not significantly increase the number of revertant colonies/plate, whereas the positive control compounds produced the expected significant increases in the number of revertants. The results are summarized in the sponsor’s tables below. 102 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang TRELE 5 - Experiment I - Plate incerpcraticn method - WEE uvrA STUDY NC. 5171.0 3 NT D143 CI Strain: WP: urn; Titre: 36: Dcse level Withcut metabelic activation With metabclic activaticn Plate ceunts Kean 3. E. Plate ccunts Mean 5. E. Untreated 1.5 0.3.1 1:3.5 25r0 1.3 500V 0.5 Regression analysis: Pcints E5 Intercept Slcpe Ccrr. cceff. F-value 1 - 3 - 5.557 -0.0006 ?0.4577: 1.3621 0.21535 1 - 4 - 5.775 -7.0003 -0.37274 1.5702 0.23276 1 - 5 - 5.755 -0.0003 -0.45575 2.0505 0.05755 1 - 6 - 5.561 0.0000 -0.01555 5.0756 0.53756 1 - 3 5.551 0.0000 -0.00515 5.0157 0.55546 1 - 4 6.011 -0.0002 -0.42564 1.5003 0.16444 1 - 5 5.575 -0.0002 -0.53325 2.2727 0.04066 1 - 6 5.551 0.0000 -0.36534 1.1157 0.27575 Pcsitive and negative centrels Treatment 35 Plate ccunts Mean 3. E. Untreated - 155 154 163 17: 13.7 DEED 160 popl 4 37 3E 33 36 1.5 C-Amincanthracene 10 157 155 155 151 3.5 105 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang TABLE 5 - Experiment I - Plate ineerperatien method - T333 NC. 31710 ESL-VENT EMS-CI Strain: TASS Titre: 255 Dese level Witheut metabeli: aetivatien With metabelis aetivatien Plate eeunts Mean 3. E. Plate eeunts Mean 3. E. Untreated 3.0 0.1.2 135000 4.0 Regression analysis: Peints S3 Intercept Elepe Corr P-value 1 3 5.553 ?0.0014 ?0.42071 1.2270 0.35350 1 4 5.545 ?0.0004 ?0.23545 0.7551 0.45130 1 5 5.575 ?0.0005 ?0.55304 3.4351 0.33534 1 5 5.455 ?0.0003 -0.47133 3.1377 0.04332 1 7 5.353 ?0.0001 ?0.23534 1.3475 0.13353 1 3 5.373 0.0000 0.00135 0.0053 0.33503 1 4 5.347 7.0001 0.23043 0.3500 0.35353 1 5 5.334 7.0000 0.03537 0.3473 0.73334 1 5 5.337 0.0000 0.30074 0.3135 0.43445 Pesitive and negative eentrels Treatment 33 Plate eeunts Mean 3 E. Lac: atfpl E-Nitrefluerene 2 ugfpl - 150 177 157 153 4.3 DEED 130 uLfPl 33 33 35 35 1.5 E-Amineanthraeene 1 ugfpl 332 335 354 377 12.1 NT: not tested 3: thinning ef the haekgreund lawn 106 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Study title: BACTERIAL MUTATION ASSAY with (impurity) Study no.: Study report location: n/a Conducting laboratory and location: (W) Date of study initiation: May 18, 2012 GLP compliance: Yes QA statement: Yes Drug, lot and purity: batch TESO15 Key Study Findings: Treatment with did not significantly increase the number of revertant colonies/plate. (W) is an impurity. Methods: Strains: Salmonella typhimurium strains TA1535, TA1537, TA98, TA100 and WP2 uvrA Concentrations in definitive study: 5000, 1580, 500, 158 and 50 ug/plate. (see sponsor?s tables below) Basis of concentration selection: Highest concentration of 5000 ug/plate was used. Negative control: Acetone Positive control: See below. FormulationNehicle: Acetone Incubation sampling time: The plates were incubated at for 72 hours. Positive controls 1 08 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang TABLE 5 - Experiment I - Plate incerperaticn methcd - T51555 STUDY 51720 5 ACE. Strain: TA1555 Titre: 252 Dcse level Withcut metabelic activation With metahclic activatien Plate ccunts Hean E. E. Elate ceunts Mean 3. E. Untreated 0.5 0.1.5 1250 1.2 2500 5.2 5000 1.5 Regression analysis: Pcints S5 Intercept Elcpe Ccrr. cceff. P-value 5 4.542 ?0.0005 ?0.54401 1.7155 0.12555 1 4 4.245 ?0.0001 ?0.:2555 5.7514 0.45154 1 5 4.215 ?0.0001 ?0.:4555 5.5257 0.57555 1 5 4.114 0.0001 0.57575 1.1555 0.25555 1 5 4.051 -0.0002 ?0.10505 5.2575 0.75155 1 4 5.557 0.0002 0.25775 0.5457 0.41555 1 5 5.552 ?.0005 0.45155 1.5755 0.55535 1 5 4.114 ?.0000 0.05410 5.5751 0.71555 Pcsitive and negative centrels Treatment 35 Plate ccunts Mean 3. E. Untreated - 34 14 25 21 5.5 Ecdium Aside 1 ugfpl - 470 455 ?55 455 5.5 DEED 150 uprl :4 15 24 22 1.7 ?-Rnineanthracene precipitaticn 5: thinning cf the hackgreund lawn 1 10 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang TABLE 5 - Experiment I - Plate method - WP: STUDY MG. 31730 SDLTEENT ACE. 1.: VIA Strain: WP3 uvz; Titr 363 Dcse level Witheut metabelic activaticn With metabclic activaticn Plate counts Hean 3. E. Plate ceunts Mean E. Untreated 1.5 0.1.7 1350 3500 3.0 5000 1.7 Eegressien analysis: Pcints 53 Intercept Slcpe Carr. cceff. P-value 1 3 5.632 0.0000 ?0.00063 6 0013 0.33353 1 4 5.676 0.0000 0.04410 0 1336 0.33175 1 5 5.663 0.0001 0.16434 0.6036 0.55715 1 6 5.636 0.0000 0. 3731 0.5570 0.53535 1 3 5.736 0.0000 0.00530 0.0156 0.33733 1 4 5.633 ".0003 0.33477 0.3334 0.36365 1 5 5.751 0.0000 0.05340 6.1333 0.35333 1 6 5.733 0.0000 0.33311 1.3035 0.34633 Pcsitive and negative reatment 33 Plate ccunts Mean 3. E. Untreated - 33 33 34 33 0.6 MES 530 ugfpl 133 154 163 173 13.7 DEED 30 uprl 37 33 33 36 1.5 3-Amineanthracene 10 ugfpl 137 133 133 131 3.3 P: Precipitaticn 4: thinning of the background lawn Reference ID: 3527655 112 NDA 205,718 Reviewer: Ke Zhang Study title: BACTERIAL MUTATION ASSAY with METABOLITE M4 Study no.: NETU-12-41 Study report location: n/a Conducting laboratory and location: Date of study initiation: GLP compliance: QA statement: Drug, lot #, and % purity: (b) (4) September 11, 2012 Yes Yes METABOLITE M4 / 4-NETU.i24 (M4), batch #: ALC1159-02-A Key Study Findings: Treatment with the test article did not significantly increase the number of revertant colonies/plate. Methods: Strains: Salmonella typhimurium strains TA1535, TA1537, TA98, TA100 and WP2 uvrA Concentrations in definitive study: 5000, 1580, 500, 158 and 50 µg/plate. (see sponsor’s tables below) Basis of concentration selection: Highest concentration of 5000 µg/plate was used. Negative control: DMSO Positive control: See below. Formulation/Vehicle: DMSO Incubation & sampling time: The plates were incubated at 37°C for 72 hours. Positive controls 115 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Study Validity: The study is valid based on the positive response in the positive control groups. Results: Treatment with the test article did not significantly increase the number of revertant colonies/plate, whereas the positive control compounds produced the expected significant increases in the number of revertants. The results are summarized in the sponsor’s tables below. 116 Reference ID: 3527655 NDA 205,718 METABGLITE M4: BACTERIAL MUTATIDN AS SAT (S. typhimurium and Reviewer: Ke Zhang 3. eeli} EAELE 5 - Experiment 1 - Plate ineerperatien method - WPE uvr? NC.: 33340 SGLVENT: DMEO Strain: WP: uvrA Titre: 347 Dese level Witheut metabelis aetivatien With metabelie aetivatien Plate counts Kean E. E. Plate counts Mean 3. E. Untreated 0.1.0 1:25r0 1.3 Regression analysis: Peints S3 Intersept Elepe Corr. ceeff. P-valde 1 3 5.656 0.0000 ".05223 3.1335 0.33371 1 4 5.736 ?0.0005 2.7631 0.31335 1 5 5.735 ?0.0004 ?0.73073 4.5057 0.3335 1 6 5.646 ?0.0003 _r_g3349 6.1733 0.33671 1 3 5.732 ?0.0004 ?0.33337 1.1134 0.33333 1 4 5.733 ?0.0004 -0.E5757 2.7601 0.32313 1 5 5.734 ?0.0003 ?7.76133 4.2434 0.33336 1 6 5.671 ?7.0002 ?7.32673 5.3773 0.3330: Pesitive and negative eentrels Treatment 33 Plate seunts Mean 3. E. Untreated - 32 30 EB 30 1.2 MES 533 ugfpl 132 136 223 306 11.7 DEED 133 popl 34 34 34 34 0.0 C-Amineanthraeene 13 ugfpl 130 216 217 n03 3.3 119 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang TABLE 3 - Experiment 1 - Plate ineergeratien method - TR33 STUDY NC. 3:343 NT DMSCI Strain: TA33 Titre: 274 Dese level Witheut metabelis aetivatien With metabelis aetivatien Plate eeunts Kean S. E. Plate eeunts Mean 3. E. Untreated 1.3 3.1:l.r 233V :1.3 EQFF 3.3 Regressien analysis: Peints 33 Intercept Elepe Cerr. P-value 1 3 3.331 ?3 3333 ?3.34713 3.3743 3.32147 1 4 3.322 -3.3333 ?3.43334 1.3331 3.13371 1 3 3.233 1.3331 F.11333 3.4133 3.33333 1 3 3.373 ?r.3331 ?7.137:: 3.7334 3.43333 1 3 3.333 ?3.3337 ?3.33333 1.3731 3.13733 1 4 3.373 ?3.3333 ?3.74233 3.3337 3.33333 1 3 3.334 ?3.3332 ?3.43332 1.7313 3.13133 1 3 3.341 -3.3331 ?3.33333 3.7333 3.31413 Pesitive and negative eentrels Treatment 33 Plate seunts Mean 3. E. DEED 133 uprl :1 37 23 :3 4.3 i-Nitrefluerene ugfpl - 141 131 13: 141 3.1 DEED 133 uprl 43 43 44 43 2.1 i-Emineanthraeene 1 ugfpl 443 337 433 437 33.3 120 Reference ID: 3527655 NDA 205,718 8 Reviewer: Ke Zhang Carcinogenicity On July 1, 2008, the Executive Carcinogenicity Assessment Committee (E-CAC) reviewed the sponsor’s proposal for a 2-year carcinogenicity study of netupitant in rats. The combination of netupitant and palonosetron was developed for prevention of chemotherapy-induced acute and delayed nausea and vomiting. The Committee noted that this indication would not normally trigger the need for a carcinogenicity study; however, a carcinogenicity evaluation may be needed to support other indications (see E-CAC meeting minutes in Appendix). Therefore, the sponsor did not conduct carcinogenicity studies with netupitant to support approval of netupitant + palonosetron combination for the proposed indication. 9 Reproductive and Developmental Toxicology 9.1 Fertility and Early Embryonic Development Study title: Segment I: Oral Study of Fertility and Early Embryonic Development in the Rat Study no.: 257R02 Study report location: n/a Conducting laboratory and location: Non-Clinical Drug Safety F. Hoffmann La-Roche Ltd., Basel, Switzerland Date of study initiation: June 6, 2002 GLP compliance: Yes QA statement: Yes Drug, lot #, and % purity: RO0673189-008 / lot # BS0204SA01, 99.8% Key Study Findings: RO0673189-008 was given by oral gavage at doses of 3, 10, and 30 mg/kg/day to male and females rats starting at two weeks prior to mating, throughout a two-week mating period, and through gestation day 7 in females. Dosing of males continued until necropsy of partnered females, at least until gestation day 14. Treatment with RO0673189-008 at 30 mg/kg/day decreased body weight gain and food consumption. The number of corpora lutea, implantation sites, and fetuses per dam were slightly but statistically lower in the high dose group (30 mg/kg/day) relative to the control group. The sponsor stated that the number of corpora lutea in the high-dose group is within normal limits for this strain of rat. RO0673189-008 did not clearly produce adverse effects on fertility in either sex or early embryonic development. Methods RO0673189-008 was given by oral gavage at doses of 3, 10, and 30 mg/kg/day to males starting two weeks prior to mating, continuing throughout the mating period and 122 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang There were no treatment-related effects on fertility parameters including mating index, fertility index, mating days, and estrus stage. The results are summarized in the following sponsor’s table. The effects on reproduction parameters including the number of corpora lutea, implantation sites, fetuses per female, or pre- and post-implantation loss are summarized in the following sponsor’s table. The numbers of corpora lutea, implantation sites, and fetuses per dam were slightly but statistically lower in the high dose group (30 mg/kg/day) than those in the control group. The sponsor stated that the number of corpora lutea in the high-dose group is within 125 Reference ID: 3527655 NDA 205,718 Doses: Frequency of dosing: Dose volume: Route of administration: Formulation/Vehicle: Species/Strain: # Females/Group: Satellite groups: Study design: Deviation from study protocol: Reviewer: Ke Zhang 0 (vehicle), 3, 10, and 30 mg/kg/day Once daily 5 ml/kg Oral gavage Thixotrope vehicle as aqueous suspensions Wistar rats (HanIbm:WIST) 24 2 females/group See sponsor’s table below No deviation occurred which adversely affected the quality of the study. The age of the females was not stated. The females were sacrificed on day 21 of gestation and assessment of embryo-fetal development was conducted. Observations and Results Mortality: None. Clinical Signs: There were no treatment-related clinical signs of toxicity. Body Weight: Body weights on gestation days 6 and 18 were 228 g and 296 g, respectively, in in the control females. The body weight gains from days 6 to 18 were 68 g in the control females and 47 g in the high dose females. Slightly lower body weight gain was also noted in the mid dose group, but the weight gain in the low-dose group was similar to the control group. Feed Consumption: Decreased food consumption was observed in the middle and high dose groups. Toxicokinetics: TK results are summarized in the following sponsor’s table. 127 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang There were no treatment-related effects on fetal body weight or the fetal sex ratio. The results are summarized in the sponsor’s table below. The Sponsor provided the following explanation for the presentation of median values in the table above: “For statistical analysis the median was used instead of the mean, because it is more appropriate for non-normally distributed data. For the sake of consistency the median was also used for normally distributed data.” Offspring (Malformations, Variations, etc.) The treatment did not affect the total incidence of abnormalities, variations and retardations. The results are summarized in the sponsor’s table below. 129 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang The incidence of fetuses with limb variation (tarsal hyperextension) was 1, 2, and 3 in the control, middle, (2 liters), and high-dose (3 liters) groups, respectively. This change is not considered to be drug-related, given the absence of statistical significance and incidence in the control group. Two fetuses with limb variations (pes adductus) were observed in one litter in the middle dose group. The results are summarized in the sponsor’s table below. These variations were not seen at a higher dose of 100 mg/kg/day in the dose ranging study in rats (study # 041R02). 130 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang and 2 in the high dose group). One female at 30 mg/kg had total litter death. Fetal body weights at 30 mg/kg were decreased by 8% in males, as compared to the control males. Limb and paw anomalies (position anomalies) were observed with higher incidence in the middle and high dose groups. The combined incidence of all findings was 1/135, 1/126, 3/114, and 9/107 among fetuses, and 1/22, 1/22, 3/20, and 6/17 among litters, in the control, low, middle, and high-dose groups, respectively. An increased number of minimally/partially fused sternebrae was noted at 10 (9/114 fetuses, 8/20 liters) and 30 mg/kg/day (16/107 fetuses, 10/17 litters), as compared to the control group (none). Based on the increased incidence of malformations (limb and paw anomalies, minimally/partially fused sternebrae) at 10 and 30 mg/kg/day, the NOAEL for embryofetal development is considered to be 3 mg/kg/day. The NOAEL for maternal toxicity was 10 mg/kg/day, based on the loss of bodyweight in the 30 mg/kg/day group during gestation days 6-19. A consultation was sent to the Reproductive and Developmental Toxicology Subcommittee (RDTS) on March 18, 2014. The committee concluded that the limb and paw anomalies, and minimally/partially fused sternebrae were treatment-related and evidence of developmental toxicity. Methods: RO0673189-008 was given to rabbits by oral gavage during gestation days 6-18 at 0 (vehicle), 3, 10 and 30 mg/kg/day. Dose selection was based on the dose ranging study in rabbits (#1006571), in which, doses of 0, 10, 30, and 100 mg/kg/day were tested. The dose of 100 mg/kg/day was lethal. The dose of 30 mg/kg/day was tested as high dose in other toxicity studies. Doses: Frequency of dosing: Dose volume: Route of administration: Formulation/Vehicle: Species/Strain: # Females/Group: Satellite groups: Study design: Deviation from study protocol: 0 (vehicle), 3, 10, and 30 mg/kg/day Once daily 2 ml/kg Oral gavage Thixotrope vehicle as aqueous suspensions Himalayan Rabbits 20 2 females/group See sponsor’s table below No deviation occurred which adversely affected the quality of the study. 133 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang These rabbits were 18-31 weeks old at the time of pairing and were sacrificed on day 28 post coitum. Observations and Results Mortality: None. Clinical Signs: There were no treatment-related clinical signs of toxicity. Body Weight: Body weights on day 6 and day 19 were 2654 g and 2742 g, respectively, in the control females. The body weight gain from days 6 to 19 was 88 g in the control females, whereas the high dose females lost 70 g (see sponsor’s table below). 134 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Dosing Solution Analysis: The drug concentrations were within the desired range (80120%). The analysis results are summarized in the following table (taken from the study report). 136 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang REPRODUCTION DATA SUMMARY GRGUP 1 GROUP 2 GROUP 3 4 0 HGIKG 3 HEIRS lb 3D HGIKG RUBBER FETUSES TUTLL HADES '51 45 45 ?10 3 DP FETUSES 35.1 35.7 39.5 3T.4 KERN 2.3 2.3 2.4 ET.DEV. 1.1 1.4 0.9 1.2 TOTAL FEMALES Ti 31 ES 57 OF FETUSEE 51.3 61.3 50.5 32.6 KERN l+l 3.5 3.5 3.3 ET.DEV. 1.6 1.5 0.5 1.3 LIVE MALES El 45 15 in LIVE Ti 31 59 63 HEIGHTS UP LIVE TOTAL FETUSIE 32 22 23 l? MEAN 32.5 33.3 32.9 3U.E ST.DEV. 2.3 2.9 2.9 3.6 HELES 31 13 2E 15 MEAN 32.6 32.2 33.2 30.3 5T.DEV. 3J1 3.:1 3.1 3.2 FINALEE 31 13 25 l? MEAN 32.6 33.5 32.9 30.3 ET.DEV. 3.3 3.5 3.2 3.8 WEIGHTS 0? LIVE FETUEES TOTAL FETUSES 135 125 114 1M 32.1 32.9 32.? 3D.1 ST.DEV. 3.2 3.3 3.7 4.3 MALES 51 i5 45 3D HEAR 32.6 32.3 33.? 30.1 5T.DEV. 3.3 3.3 3.5 4.3 FEMALES 31 63 31.? 33.3 32.? 30.3 ST.DEV. 3.1 3.3 3.9 4.3 Iii! Dunnett?Taat based on pooled variance ai ificant. at level 5% {Ir} 1% I Fishaz?i Exact Tan-t significant. at lavagg?t er 1% Steel Tent significlnl: at. level 5% 4[ Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Offspring (Malformations, Variations, etc.) Limb and paw position anomalies were observed with higher incidence in the middle and high dose groups. The combined incidence of all findings was 1/135, 1/126, 3/114, and 9/107 among fetuses, and 1/22, 1/22, 3/20, and 6/17 among litters, in the control, low, middle, and high-dose groups, respectively. The results are summarized in the sponsor’s table below. 140 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang ABNORMAL FINDINGS FROM EXTERNAL AND FRESH VISCERAL EXAMINATION OF FETUSES - Reference ID: Group 1 Group 2 Group 3 Group 4 mgr'kg 3 1t] 3t] mg?tg Number of litters 22 22 2O 11' Number ot' fetuses 135 126 114 lnoidenoes of fetuses with ?lie Ell. "as Flight testis, enlarged; besides with clear 1 0.9 liquid Liver - small white lesion at right lateral lobe 1' 5.2 2 1.5 Gall bladder - clear contents dark content - smell [1.9 - absent ABNORMAL FINDINGS FROM FETAL HEAD SECTIONS SUMMARY Group 1 Group 2 Group 2 Group 4 D- mg?tg 3 1t] mgl'kg so mgl'kg Number ot litters 22 22 20 1? Number of tetuses 135 125 114 Incidences ot tetuses with 11; "it: ?is 1s Lateral ventricles. Dilation 2.3 Third ventricle, Dilation 4.4 19 2 1.9 Clotted blood between skull and cerebral 1 2 1.6 2 1.9 hemispheres Microglossia 1 0.9 Elrain thalamlc region, cystic dilation 1 0.9 142 3527655 NDA 205,718 Reviewer: Ke Zhang SKELETAL EXAMINATIONS SUMMARY STAGE OF DEVELOPMENT AND VARIANTS ON A LITTER BASIS GROUP 1 GROUP 2 GROUP 3 GROUP 4 3 10 value 30 nG/xc or nXAuxuxn 22 22 20 17 err ronxnxun NON-03811110 DIGIT 5 NRDIAL PHALANX. 1:ADDITIONAL HuuxRus LIFT ans RIGHT FORELIMB OSSIFIRD NITACARPALIA 1. RIGHT 19 86? 20 91? 20 100? 16 94? DIGIT 1 PRORINAL PHALANX. RIGRT 47? DIGIT 2 MIDIAL PHALANX. RIGRT DIGIT 3 IIDIAL PRALANX, RIGHT 23? 6 27? 6 30? 9 53? DIGIT 4 NIDIAL PHALANX. RIGHT 94? NITACARPALIA 5. RIGHT 0 0 1 5? DIGIT 5 PROXIMAL PHALANX. RIGHT 0 1 5? 0 DIOIT 5 NRDIAL PRALANX. RIGRT 22 100? 22 100? 20 100? 17 100? NON-OSSIPIID DIGIT 4 MIDIAL PRALANX. RIGHT 0 1 5? 0 DIGIT 5 MIDIAL PHALANX. RIGHT 1 5? 0 2 10? 2 12? ADDITIONAL OSSIFICATION HUNBRUS RIGHT 66? LIFT RIND LIKE INCOMPLITSLY OSSIFIRD TALUS LIFT 0 0 1 5? 0 3 KRDIAL PRALANX. LEFT KIDIAL PHALANX, LIFT 22 100? 22 100? 20 100? 17 100? NON-OSSIFIID TOR 4 NIDIAL PHALANX, LIFT 0 0 1 5? 0 ADDITIONAL OSSIFICATION FIMUR LEFT 65? TIBIA LEFT RIGHT BIND LINE INCOMPLITRLY OSSIFIRD TALUS RIGHT 0 0 1 5? TOR 3 NIDIAL PHALANX. RIGHT NIDIAL PRALANX. RIGRT 22 100? 22 100? 20 100? 16 94? NON-OSSIFIID 4 HIDIAL PHALANX. RIGRT 0 0 1 5? 0 ADDITIONAL FIHUR RIGHT 65? TIBIA RIGHT 145 Reference ID: 3527655 NDA 205,718 SKELETAL EXAMINATIONS SMRY STAGE OF 555515135551 AND ON A FETUSES BASIS Reviewer: Ke Zhang 1 GRGUP 2 GROUP 3 GROUP 4 5 55155 3 55155 15 55155 35 55:55 555555 55 5515555 55551555 135 125 114 153 1591 15551155 555?55515155 51511 5 555151 5551555, 1551 5551115551 555151551155 HUHERUE LEFT 51551 55551155 155555151511 55515155 551555555115 1, 51551 51511 1 55551551 9551555. 51551 51511 2 555151 5551555, 51551 1 1% 3 3% 1 1% 51511 3 555151 5551551, 51551 15% DIGIT 4 HEDIAL RIGHT 58% 551555595115 5. 51551 5 5 1 1% 5 51511 5 55551551 9551551, 51551 5 5 1 1% 5 51511 5 555151 5551551, 51551 132 95% 125 99% 112 95% 152 95% 555-55511155 DIGIT 4 9551555. RIGHT 5 1 1% 51511 5 555151 9551555, 51551 5551115551 555191551155 5555555 RIGHT 43% 1551 5155 1155 155555151511 55511IED 15155 1551 555151 9551555. 1591 555151 9551555, 1591 125 93% 123 93% 155 93% 154 91% 555-55511155 155 4 555151 5551555. 1551 5 5 1 1% 5 5551115551 555151551155 15555 LEFT 25% T1315 LEFT RIGHT KIND LIME INEGHPLETELY 05515155 15155 51551 555151 5551555. 51551 555151 5551555, 51551 122 95% 111 93% 154 91% 152 95% 555-55515155 TOE 4 HID-1.5L PERM. RIGHT Cl Cl 1 1% CI 5551115551 555151551155 55555 51551 25% 11515 51551 147 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang F0 Dams Survival: One female in the low dose group was sacrificed in moribund condition. Clinical signs: No treatment related clinical signs Body weight: Bodyweight gain was reduced in the middle and high dose groups, primarily during the first day of treatment (Day 6 of gestation) to Day 14 of gestation. Feed consumption: Food consumption was reduced in the treatment groups. Uterine content: There were no treatment-related changes (see sponsor’s tables below). Necropsy observation: There were no treatment-related changes. Toxicokinetics: Not done Dosing Solution Analysis: The mean concentrations of Netupitant in the dosing formulations were within 85 to 110% of the nominal concentrations. Other: Gestation length and gestation index were not altered by treatment with Netupitant. The results are summarized in the following sponsor’s tables. 149 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang F1 Generation Survival: Offspring survival was not affected. Clinical signs: There were no treatment-related changes. Bodyweight: Bodyweights in the middle and high dose groups (male and female) were significantly lower on postnatal Days 1 to 28 (see table 15 below). Feed consumption: Food consumption was lower in the middle and high dose group as compared to the control. Physical development: The selected F1 female animals showed no delay in vaginal opening. F1 males from the high dose group showed a 2-day delay in completion of balano-preputial separation as 151 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Neurological assessment: Attainment of the air righting reflex was slightly delayed in the middle and high dose groups, as compared to the control group (see sponsor’s table 17 below). Age at attainment of the surface righting reflex and the number of offspring showing satisfactory pupil and startle responses, motor activity, accelerating rotarod performance, learning ability and memory were unaffected by maternal treatment. Reproduction: There were no treatment-related changes in mating and fertility parameters. Other: Litter size (F2 generation), offspring survival and sex ratio were not altered by maternal treatment of F0 females. The results were presented in the sponsor’s tables 31-37 below. 153 Reference ID: 3527655 NDA 205,718 TABLE 31 Motor activity - group mean scores (beam breaks) (131) Reviewer: Ke Zhang Group 1 2 3 4 Compound Control Nempitant Netupitant Netupitant Dose 0 3 10 30 Group Number Beam Time (minutes) Sex of animals level Total Statistical testHigh 29.5 27.2 10.4 6.2 7,2 2.5 1.3 3.5 6.2 4.4 98.3 SD 16.7 20.0 14.5 8.7 11.9 3.7 4.1 10.6 12.7 9.2 56.5 2M 20 High 49.2 32.6 13.0 9.8 5.7 3.7 3.8 3.8 7.1 4.2 132.7 SD 2 .5 21 1 14.1 12.4 1?4 78 6.8 6.9 15.3 9 64.4 3M 20 High 47.7 24.7 18.7 7.0 10.0 8.6 1.9 3.6 4.6 129.8 SD 28.4 19.9 18.9 9.4 14.1 12.7 6.3 11.4 6.9 10.8 78.1 20 High 39 26.0 5.8 6.0 4.0 3.4 6.5 8.5 4.9 119.4 SD 7 15.6 13 8.6 9.8 6 7 6.3 14.3 12.0 8.4 69.3 Statistical testLow 116.2 7 .2 39.7 24.7 21.6 19.0 8.9 15.2 21.3 -0.9 363.4 SD 38 1 40.? 4'7 3 27.1 29.0 29.9 19.7 30.9 28.9 35.7 181.6 211 20 Low 146.3 79.3 5- 2 42.9 18.0 22.0 16.2 24.8 25.9 21.9 449.3 SD 57 5 22.4 28 5 39.5 22.6 212 29.1 41.8 33.5 148.4 3M 20 Low 129.9 73.1 56.8 40.1 36.2 27.2 5.9 18.3 18.0 15.9 421.0 SD 46.2 -6.2 0 2 36,9 36.4 31.5 9 40.9 27 3 23.9 186.4 41-1 20 Low 129.0 77.9 56.8 39.3 33.8 23.0 291* 25.9 31.4 23.9 4698* SD 31.3 35.4 25.6 30 5 35.7 26.9 42.0 27.8 7.6 24.2 108.3 TABLE 31 - continued Motor activity - group mean scores (beam breaks) (F1) Group 1 2 3 4 Compound Control Nempitant Netupitant Netupitant Dose 0 3 10 30 Group Number Beam Time (minutes) {Sex of animals level Total Statistical testHigh 37.2 31.4 18.3 5.9 7.5 3.6 4.6 7.4 4.5 8.8 128.8 SD 18.8 17.2 17.2 10.4 13.6 7.1 9.8 12.7 15.4 14.7 68.7 2F 20 High .8 28.5 1 7. 4.5 4.. 6.4 2.0 3.0 115.8 SD .7.1 -06 9.7 8.7 7 5 15.6 5.4 8 54.0 3F 20 High 39.9 28.1 17.4 12.8 8.3 8.1 5.8 7. 6.4 137.2 SD 20.7 14.9 14.2 13.3 16.1 145 7 17.1 11.7 10.9 85.4 4F 20 High 33.2 24.6 11.4 7.9 9.5 4.8 3.8 3.0 7.7 7.3 113.1 SD 213 20.8 13.9 11.7 17.2 98 10.1 8.5 13.1 17.7 77.5 Statistical testLOW 132.6 2.2 51.8 27.1 25.0 16.4 24.7 27.3 12.9 30.9 430.7 SD 49.2 36 5 40.1 33.3 32.2 22.6 34.9 37.6 25.5 38.1 149.0 2F 20 Low 129.2 77.4 55.5 36.5 21.6 19.6 16.9 18.9 11.0 13.5 399.9 SD 47.8 33 7 30.5 33.4 28.8 29.2 26.4 35.4 19.2 30.9 125.1 31: 20 Low 142.3 76.8 62.5 41.5 22.6 22.1 18.1 28. 34.9 24.3 473.4 SD 38.6 26.9 38. 3 27.9 26.7 31.5 30.9 37.2 44.6 32.4 188.6 4F 20 Low 116.3 71.3 46.1 37.0 42.7 18.9 19.8 16.0 33.7 1.5 435.1 SD 30.8 33.1 36.0 8.3 34.6 "0 30.8 31.1 7.5 .3 210.3 Reference ID: 3527655 NDA 205,718 TABLE 33 - continued Morris maze perfonnance - group mean values (F1) Reviewer: Ke Zhang Group 1 2 3 4 Compound Control Nerupitant Nempitant Netupitant Dose (mgr'kgfday) 0 3 10 30 Number Group Sex animals Statistical test1171 Wi Fe Wi 1F 20 \Ieall 58.0 1.3 18.8 36.0 0.4 12.6 18.6 0.0 7.3 17.8 0.1 7.3 SD 20.9 0.8 6.4 16.8 0.7 5.1 10.5 0.0 3.1 10.5 0.3 3.8 85.0 30.0 0.0 10.0 2F 20 \Iean 43.9 15.2 36.2 0.6 10.6 25.5 0.2 7.9 17.9 0.0 6.7 SD 16.6 0.8 5.0 24.1 0.8 5.5 16.3 0.5 3.9 7.0 0.0 2.4 45.0 40.0 15.0 0.0 3F 20 Mean 44.8 0.7* 16.6 33 4 0.4 12.3 27.0 0.1 9.6 17.6 0.1 6.7 SD 18.7 0.9 6.6 15 7 0.6 4.5 13.3 0.3 4.3 11.2 0.2 3.5 50.0 35.0 10.0 5.0 4F 20 .N-Iean 53.2 0.8* 19.9 34.6 0.5 12.0 26.1 0.2 8.9 16.9 0.1 6.7 SD 19.0 0.8 5.7 22.1 0.8 6.2 15.3 0.5 4.7 9.6 0.2 3.1 55.0 25.0 15.0 5.0 Trial time (seconds - mean of 3 trials) Number of failed trials (90 seconds) 8 Sector entries (mean of 3 trials) 9/0 Percentage of animals with at least 1 failed trial (90 seconds) TABLE 34 Balano-preputial separation and vaginal opening - group mean age and bulyweigln at attainment (Fl) Group 1 2 3 4 Compound Control Netupitant Netupitant Netupitant Dose (mg/kgfdayl 3 10 30 Group Time of completion for Bodwveight Time of completion for Bodmveight balano preputial separation at balano preputial vaginal opening at vaginal opening Day of age separation Dav of age Statistical test: Wi 1Wi Wi Wi 1 Mean 46 193 33 1 02 SD 1.7 18.5 2.4 13Mean 46 196 33 1 00 SD 2.2 11.8 2.5 12.5 20 20 20 20 3 Mean 23Mean 48?? 189 33 92* SD 3.3 27.3 2.4 12.0 20 20 20 2 0 Reference ID: 3527655 157 NDA 205,718 Reviewer: Ke Zhang F2 Generation Survival: Bodyweight: External evaluation: Litter parameters: There were no effects. Bodyweights on post-natal day 1 to 14 were unaffected. There were no treatment related effects. F2 litter size at birth, offspring survival, and sex ratio were not affected. The results were presented in the sponsor’s tables below. APPEARS THIS WAY ON ORIGINAL 159 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang TABLE 38 Litter size - group mean Tvalues (F2) Group 1 2 3 4 Compound Control Netupitant Nempitaut Netupitant Dose (Illgr?ligfday) 0 3 10 30 Group Implantations Total litter size Live litter size 011 Day Day Before cull After cull Statistical test: Wi Wi Wi Wi 1 Mean 11.5 10.8 10.6 10Mean 12.8 11.8 11.8 11Mean 11.3 10.1 10.1 10Mean 13.1 11.6 11.4 11TABLE 39 Offsp?ng smTival indices - gmup mean values (F2) Group 1 2 3 4 Compomld Control Nerupitant Nerupitant Netupitant Dos-e 0 3 10 30 Group Post implantation Live b11111 Viability actation index survival index hide-x (9b) index o) on Day 14 Statistical test: Wi Fe Fe 1 L-Ieall 92.1 97.3 99.6 100.0 8 8 8 18 2 Mean 92.6 1000* 100.0 100.0 9 9 9 19 3 L-?Iezul 89.2 99.5 100.0 100Mean 89.5 97.7 99.1 100Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang In vitro hemolysis and plasma precipitation and turbidity study using rat blood (#1008464) The intravenous formulation of netupitant had a slight hemolytic effect on rat blood at concentrations up to 500 μg/ml. The formulation was negative in plasma turbidity and plasma precipitation tests with drug concentrations up to 500 μg/ml. In vitro hemolysis and plasma precipitation and turbidity study using human blood (# 1006117) The intravenous formulation of netupitant produced hemolysis in human blood at concentrations ≥ 250 μg/ml. The formulation was also positive in the plasma turbidity and plasma precipitation tests at drug concentrations ≥ 250 μg/ml. The results were summarized in the following tables (taken from the sponsor’s report). Phototoxicity study in mouse fibroblasts (# 1003848) The potential phototoxicity of netupitant was studied in vitro using the 3T3 fibroblast neutral red uptake assay. Murine fibroblasts were incubated with 0.75-96.0 μg/ml 162 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang In the 13-week study in dogs, netupitant was tested orally at 0, 1, 3, and 10 mg/kg/day. Administration of 10 mg/kg/day resulted in vacuolated macrophages or vacuolated tingible body macrophages in the lymphoid tissue (mesenteric or mandibular lymph nodes, Peyer's patches or colonic lymphoid tissue), suggesting a drug-induced phospholipidosis. Since the microscopic lesions are not considered to be adverse, the NOAEL is 10 mg/kg/day. In the 9-month study in dogs, netupitant was tested orally at 0, 1, 3, and 10 mg/kg/day. Treatment with netupitant at 10 mg/kg/day slightly increased the QTc and PQ intervals (males only), and produced minimal periacinar hepatocytic hypertrophy (males only). The NOAEL was 10 mg/kg/day. The results from 4-week oral toxicity studies with palonosetron (RS-25259-197), submitted in NDA 21,372, are described below. In the 4-week oral toxicity study in rats, RS-25259-197 was administered at 6, 18, 60, and 180 mg/kg/day. No treatment-related mortality was observed, but a mild decrease in hemoglobin, other hematology parameters, and liver enzymes were reported in animals in the 60 and 180 mg/kg/day groups. The identified target organs of toxicity in males were liver (increased weights, hepatocellular swelling and glycogen deposition along with decreased liver enzymes) and testes (reduced weights and histological correlates of degeneration/necrosis of the seminiferous epithelium and immature spermatogenic cells in the epididymis). In females, thymus (reduced weight, gross findings of small thymus and histological findings of thymic lymphoid atrophy) was the identified target organ of toxicity. The dose of 18 mg/kg/day was the no effect dose. In the 4-week oral toxicity study in dogs, RS-25259-197 was administered at doses of 2, 6, and 20 mg/kg/day. Only transient clinical signs of salivation were observed in the 6 and 20 mg/kg/day groups. Reductions in absolute and relative weights of testes were observed at the 20 mg/kg dose, but there were no gross or histological correlates. No target organs of toxicity were identified in this study and the high dose of 20 mg/kg/day was considered as the no effect dose. 13-week oral toxicity studies with the combination of palonosetron and netupitant were performed in rats and dogs. In the 13-week oral toxicity study in rats, netupitant was administered at 1, 3, and 10 mg/kg/day in combination with palonosetron at 2, 6, and 18 mg/kg/day, respectively, by oral gavage. Additional groups were treated orally with 10 mg/kg/day netupitant or 18 mg/kg/day palonosetron. Slight increases in absolute and relative liver weights were noted in the high-dose combination group, the netupitant only group, and the palonosetron only group (up to 120% of the mean control weight). Histopathological examination revealed adrenal zona fasciculata hypertrophy, hepatocytic hypertrophy, and syncytial macrophages in the mesenteric lymph nodes, mainly in the high-dose combination and netupitant only groups. These effects are not considered to be adverse. Therefore, the NOAEL was 10 mg/kg/day netupitant + 18 mg/kg/day palonosetron. 165 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang females. Three females had abortions (1 in the middle-dose group and 2 in the highdose group). One female given 30 mg/kg/day had total litter death. Fetal body weights at 30 mg/kg were decreased by 8% in males, as compared to the control males. Limb and paw anomalies (position anomalies) were observed with higher incidence in the middle and high-dose groups. The combined incidence of all findings was 1/135, 1/126, 3/114, and 9/107 among fetuses, and 1/22, 1/22, 3/20, and 6/17 among litters, in the control, low, middle, and high-dose groups, respectively. An increased number of minimally/partially fused sternebrae was noted at 10 and 30 mg/kg/day, as compared to the control group. Based on the increased incidence of malformations (limb and paw anomalies, minimally/partially fused sternebrae) at 10 and 30 mg/kg/day, the NOAEL for embryo-fetal development is considered to be 3 mg/kg/day. The NOAEL for maternal toxicity was 10 mg/kg/day, based on the loss of bodyweight in the 30 mg/kg/day group during gestation days 6-19. A consult request related to the embryo-fetal development study in rabbits was sent to the Reproductive and Developmental Toxicology Subcommittee (RDTS) on March 18, 2014. The committee concluded that the limb and paw anomalies, and minimally/ partially fused sternebrae were treatment-related and evidence of developmental toxicity. In the prenatal and postnatal development study in rats, netupitant was administered by oral gavage to pregnant females from Day 6 after mating to Day 20 of lactation. Bodyweight gain of F0 and F1 generations was reduced in the middle and high dose groups as compared to the respective control groups. F1 males from the high dose group showed a 2-day delay in completion of balano-preputial separation when compared with the controls. Attainment of the air righting reflex was slightly delayed in the middle and high dose groups as compared to the control group. Survival, behavioral development, and reproductive performance of the F1 generation, and survival and growth of F2 offspring up to Day 14 of age were unaffected. None of the observed effects in the offspring (F1 generation) are considered to be adverse, based on the small magnitude of these changes. Therefore, the NOAEL for pre- and postnatal development was 30 mg/kg/day. To evaluate the safety of the sponsor’s pediatric study plan, an 8-week oral toxicity study of netupitant alone in juvenile rats is needed. This study should include evaluation of developmental parameters, neurobehavioral effects, and fertility. The proposed pediatric single-dose PK study (Study #1) using an oral liquid netupitant formulation in combination with Aloxi Injection given orally may be conducted before completion of the juvenile animal studies. However, the definitive juvenile rat toxicity study will be needed to support the pediatric clinical efficacy study in patients age 0 to < 17 years (Study #2). If the sponsor cannot develop an oral liquid formulation of netupitant alone that is suitable for use in patients ≤ 6 years old, the definitive juvenile rat toxicity study will still be needed to support an efficacy study in older pediatric patients (age > 6 to 11 years) using a solid oral dosage form. Please see the Late Cycle Meeting Background Package for additional recommendations related to the juvenile animal study program. 167 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang developmentally toxic and should be given a Pregnancy Category C. From a nonclinical standpoint, this NDA should be approved for the proposed indication. In addition, an oral toxicity study with netupitant alone of at least 8 weeks duration in juvenile rats is needed to support the proposed pediatric clinical efficacy study in patients age 0 to < 17 years. The juvenile rat study should include evaluation of developmental parameters, neurobehavioral effects, and fertility. The sponsor should submit the juvenile rat study protocol for review and evaluation prior to initiation of this study. The sponsor’s proposed timeline for the pediatric study plan should be adjusted according to these recommendations. Reviewer Signature ___________________________________ Ke Zhang, Ph.D. Pharmacologist Division of Gastroenterology and Inborn Errors Products Supervisor Signature__________________________________ David B. Joseph, Ph.D. Lead Pharmacologist Division of Gastroenterology and Inborn Errors Products cc: Orig NDA 205,718 DGIEP DGIEP/PM DGIEP/D. Joseph DGIEP/K. Zhang DGIEP/R. He R/D Init.: D. Joseph 6/17/14 169 Reference ID: 3527655 NDA 205,718 12 Reviewer: Ke Zhang Appendix/Attachments Executive CAC Date of Meeting: July 1, 2008 Committee: David Jacobson-Kram, Ph.D., OND IO, Chair Abby Jacobs, Ph.D., OND IO, Member Paul Brown, Ph.D., OND IO, Member Anne Pilaro, Ph.D., DBOP, Alternate Member Sushanta Chakder, Ph.D., DGP, Acting Supervisory Pharmacologist Ke Zhang, Ph.D., DGP, Presenting Reviewer Author of Draft: Ke Zhang, Ph.D. The following information reflects a brief summary of the Committee discussion and its recommendations. The committee did not address the sponsor’s proposed statistical evaluation for the 2-yr carcinogen bioassay, as this does not affect the sponsor’s ability to initiate the bioassay. The sponsor may seek guidance on the statistical evaluation of bioassay results from agency staff separately. Data files should be submitted electronically following the CDER/CBER Guidance for Industry, Providing Regulatory Submission in Electronic Format – Human Pharmaceutical Product Applications and Related Submissions Using the eCTD Specifications (April 2006). IND # 73,493 Drug Name: Palonosetron HCl and Netupitant (RO0673189), oral combination Sponsor: HelsinnHealthcare SA Lugano, Switzerland Background: Netupitant is a NK1 receptor antagonist and palonosetron is a 5-HT3 receptor antagonist. It was reported that combination of a NK1 receptor antagonist and a 5-HT3 receptor antagonist is more effective in the control of acute and delayed emesis as compared to 5-HT3 receptor antagonist alone. Palonosetron (Aloxi) is an approved drug for prevention of chemotherapy-induced nausea and vomiting. The combination of Netupitant and palonosetron is being developed as a single oral dose for prevention of chemotherapy-induced acute and delayed nausea and vomiting. Netupitant was negative in the Ames tests, in the in vitro mouse lymphoma cell mutation assay, and in the in vivo rat micronucleus test. In the current submission, the sponsor submitted a study protocol for a 2-year carcinogenicity study with netupitant in rats and a final report of a 13-week oral toxicity study with netupitant in rats. Rat Carcinogenicity Study Protocol and Dose Selection: 170 Reference ID: 3527655 Comments on N205718 netupitant and palanosetron, Akynzeo From: A. Jacobs, AD Date: 6/18/14 1. I concur that there are no pharm/tox approval issues. 2. I concur with the pregnancy category of C 3. I have conveyed other comments to the reviewer, and they will be addressed as appropriate. Reference ID: 3527735 CENTER FOR DRUG EVALUATION AND RESEARCH APPLICATION NUMBER: 205718Orig1s000 PHARMACOLOGY REVIEW(S) ADDENDUM TO REVIEW OF NDA 205,718 DATED June 19, 2014 Two excipients in the drug product (AKYNZEO), oleate were described as ?Not present in Database? FDA Inactive Ingredient Database) in table 2, on page 16 of the Pharmacology/Toxicology review of this NDA (this table also appears in the CMC review). The following safety assessment of these excipients is provided on page 16 of the Pharmacology/Toxicology review: 09(4) and oleate are present in the Aloxi capsules I (?m/capsule and ?""capsule, respectively) at amounts than those in AKYNZEO mglcapsule, respectively). Therefore, there is a reasonable assurance of safety for these excipients based on the previous human experience with Aloxi capsules.? However, after revisiting the database, it was discovered that both of these excipients are listed under different names. is listed as CAPRIC at the maximum amount of per capsule. oleate is listed as at the maximum amount of (W) per capsule, and (W) at the maximum amount of per capsule. The specific oleate used in AKYNZEO is identi?ed on the website of its supplier . Therefore, we amend here that these two excipients are in fact present in the FDA Inactive Ingredient Database at the amounts mentioned above, which are much higher than those in the drug product ?""capsule for and (W?capsule for oleate). Patients will ingest only one AKYNZEO capsule on the first day of each cycle of chemotherapy, based on the recommended dosage and administration. Therefore, the information cited from the FDA Inactive Ingredient Database provides a reasonable assurance of safety for and Our original safety assessment of these excipients remains valid (Le. a reasonable assurance of safety is derived from previous human experience). Reference ID: 3629753 MEMORANDUM DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE FOOD AND DRUG ADMINISTRATION CENTER FOR DRUG EVALUATION AND RESEARCH FROM: David B. Joseph Lead Pharmacologist DATE: July 17, 2014 SUBJECT: NDA 205,718 (SD # 1 dated September 25, 2013) Sponsor: Helsinn Healthcare SA Drug Product: AKYNZEOTM (netupitant and palonosetron) capsules Comments: I concur with Dr. Zhang’s recommendations for conducting a juvenile rat toxicity study with netupitant alone to support the proposed pediatric development program (see section 1.3.2 in the Executive Summary and page 167 of the Pharmacology/Toxicology review dated June 19, 2014). Based on the age range (0 < 17 years) of patients to be included in the proposed safety and efficacy trial of netupitant + palonosetron fixed dose combination, dosing in the juvenile rat study should begin at a developmental stage comparable to the human neonatal stage. Juvenile animal studies with the drug combination are not considered as necessary to support the pediatric development program for Akynzeo, based on results of the combination toxicity studies of netupitant + palonosetron in adult rats and dogs, and the toxicity profile of palonosetron alone in neonatal rats and dogs (see Pharmacology/Toxicology review of NDA 21,372 dated July 11, 2003 by Dr. Yash Chopra). Recommendations: There are no nonclinical issues which preclude the approval of Akynzeo. I concur with Dr. Zhang’s recommendation for approval and his recommended revisions in the label. __________________________________ ____________ David B. Joseph, Ph.D. Date Lead Pharmacologist Division of Gastroenterology and Inborn Errors Products Reference ID: 3594851 --------------------------------------------------------------------------------------------------------This is a representation of an electronic record that was signed electronically and this page is the manifestation of the electronic signature. --------------------------------------------------------------------------------------------------------/s/ ---------------------------------------------------DAVID B JOSEPH 07/17/2014 Reference ID: 3594851 DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE FOOD AND DRUG ADMINISTRATION CENTER FOR DRUG EVALUATION AND RESEARCH PHARMACOLOGY/TOXICOLOGY NDA REVIEW AND EVALUATION Application number: Supporting document/s: 205,718 1 Applicant’s letter date: September 25, 2013 CDER stamp date: September 25, 2013 Product: AKYNZEOTM (netupitant and palonosetron) capsules Indication: Prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of highly emetogenic cancer chemotherapy and moderately emetogenic cancer chemotherapy in adults Applicant: Helsinn Healthcare SA Pazzallo – Lugano, Switzerland U.S. Agent August Consulting, Inc. Austin, TX Review Division: Division of Gastroenterology and Inborn Errors Products (DGIEP) Reviewer: Ke Zhang, Ph.D. Supervisor/Team Leader: David Joseph, Ph.D. Division Director: Donna Griebel, M.D. Project Manager: Mary Chung Template Version: September 1, 2010 1 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang TABLE OF CONTENTS 1 EXECUTIVE SUMMARY ......................................................................................... 4 1.1 1.2 1.3 2 DRUG INFORMATION .......................................................................................... 12 2.1 2.2 2.3 2.4 2.5 2.6 2.7 3 PK/ADME ........................................................................................................ 27 TOXICOKINETICS ............................................................................................... 36 GENERAL TOXICOLOGY ..................................................................................... 36 6.1 6.2 7 PRIMARY PHARMACOLOGY ................................................................................. 23 SECONDARY PHARMACOLOGY ............................................................................ 24 SAFETY PHARMACOLOGY ................................................................................... 24 PHARMACOKINETICS/ADME/TOXICOKINETICS .............................................. 27 5.1 5.2 6 STUDIES REVIEWED ........................................................................................... 22 STUDIES NOT REVIEWED ................................................................................... 22 PREVIOUS REVIEWS REFERENCED...................................................................... 23 PHARMACOLOGY ................................................................................................ 23 4.1 4.2 4.3 5 DRUG ............................................................................................................... 12 RELEVANT INDS, NDAS, BLAS AND DMFS ......................................................... 12 DRUG FORMULATION ......................................................................................... 13 COMMENTS ON NOVEL EXCIPIENTS ..................................................................... 13 COMMENTS ON IMPURITIES/DEGRADANTS OF CONCERN ....................................... 17 PROPOSED CLINICAL POPULATION AND DOSING REGIMEN .................................... 17 REGULATORY BACKGROUND .............................................................................. 17 STUDIES SUBMITTED .......................................................................................... 18 3.1 3.2 3.3 4 INTRODUCTION .................................................................................................... 4 BRIEF DISCUSSION OF NONCLINICAL FINDINGS ...................................................... 4 RECOMMENDATIONS ............................................................................................ 5 SINGLE-DOSE TOXICITY ..................................................................................... 36 REPEAT-DOSE TOXICITY .................................................................................... 37 GENETIC TOXICOLOGY ...................................................................................... 88 7.1 7.2 7.3 7.4 IN VITRO REVERSE MUTATION ASSAY IN BACTERIAL CELLS (AMES)....................... 88 IN VITRO ASSAYS IN MAMMALIAN CELLS .............................................................. 93 IN VIVO CLASTOGENICITY ASSAY IN RODENT (MICRONUCLEUS ASSAY) .................. 97 OTHER GENETIC TOXICITY STUDIES.................................................................. 100 8 CARCINOGENICITY ........................................................................................... 122 9 REPRODUCTIVE AND DEVELOPMENTAL TOXICOLOGY .............................. 122 9.1 9.2 9.3 FERTILITY AND EARLY EMBRYONIC DEVELOPMENT ............................................. 122 EMBRYONIC FETAL DEVELOPMENT ................................................................... 126 PRENATAL AND POSTNATAL DEVELOPMENT ....................................................... 148 3 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang (b) (4) Recommended Version: 8.1. Pregnancy Pregnancy Category C Risk Summary Adequate and well-controlled studies with AKYNZEO have not been conducted in pregnant women. In animal reproduction studies, no effects on embryo-fetal development were observed following daily administration of netupitant in pregnant rats during the period of organogenesis at doses up to 3.7 times the human AUC at the recommended single human dose to be given with each cycle of chemotherapy. However, a dose-dependent increase in adverse effects on embryo-fetal development was observed following daily administration of netupitant in pregnant rabbits during the period of organogenesis with doses at least 0.2 times the human AUC at the recommended single human dose to be given with each cycle of chemotherapy. Daily administration of netupitant in rats up to 3.7 times the human AUC at the recommended human dose during organogenesis through lactation produced no adverse effects in the offspring. In animal reproduction studies with palonosetron, no effects on embryo-fetal development were observed following oral administration during the period of organogenesis at doses up to 921 and 1841 times the recommended human oral dose in rats and rabbits, respectively. AKYNZEO should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Animal Data Daily administration of up to 30 mg/kg netupitant in rats (3.7 times the human AUC at the recommended single human dose to be given with each cycle of chemotherapy) during the period of organogenesis produced no effects on embryo-fetal development. However, an increased incidence of external and skeletal abnormalities in rabbit fetuses was observed following daily administration of netupitant in rabbits at 10 mg/kg/day and higher (0.2 times the human AUC at the recommended single human dose to be given with each cycle of chemotherapy) during the period of organogenesis. These 6 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang that is supportive of this statement, the review team determined that the statement does not add important information to the labeling. The review team also recommended deletion of the following sentence: The rest of the statements relevant to mechanism of action for palonosetron are similar to those included in the labels for ALOXI Injection and ALOXI Capsules, and are therefore acceptable. Recommended Version: 12.1 Mechanism of Action Netupitant is a selective (NK1) receptors. antagonist of human substance P/neurokinin 1 Palonosetron is a 5-HT3 receptor antagonist with a strong binding affinity for this receptor and little or no affinity for other receptors. Cancer chemotherapy may be associated with a high incidence of nausea and vomiting, particularly when certain agents, such as cisplatin, are used. 5-HT3 receptors are located on the nerve terminals of the vagus in the periphery and centrally in the chemoreceptor trigger zone of the area postrema. Chemotherapeutic agents produce nausea and vomiting by stimulating the release of serotonin from the enterochromaffin cells of the small intestine. Serotonin then activates 5-HT3 receptors located on vagal afferents to initiate the vomiting re?ex. The development of acute emesis is known to depend on serotonin and its 5-HT3 receptors have been demonstrated to selectively stimulate the emetic response. Delayed emesis has been largely associated with the activation of tachykinin family neurokinin 1 (NK1) receptors (broadly distributed in the central and peripheral nervous systems) by substance P. As shown in in vitro and in vivo studies, netupitant inhibition of substance mediated response. (W) 09(4) Sponsor?s Version: 12.3 Pharmacokinetics Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang (b) (4) Palonosetron In a 104-week carcinogenicity study in CD-1 mice, animals were treated with oral doses of palonosetron at 10, 30 and 60 mg/kg/day. Treatment with palonosetron was not tumorigenic. The highest tested dose produced a systemic exposure to palonosetron (Plasma AUC) of about 90 to 173 times the human exposure (AUC= 49.7 ng•h/mL) at the recommended oral dose of 0.5 mg. In a 104 week carcinogenicity study in SpragueDawley rats, male and female rats were treated with oral doses of 15, 30 and 60 mg/kg/day and 15, 45 and 90 mg/kg/day, respectively. The highest doses produced a systemic exposure to palonosetron (Plasma AUC) of 82 and 185 times the human exposure at the recommended dose. Treatment with palonosetron produced increased incidences of adrenal benign pheochromocytoma and combined benign and malignant pheochromocytoma, increased incidences of pancreatic Islet cell adenoma and combined adenoma and carcinoma and pituitary adenoma in male rats. In female rats, it produced hepatocellular adenoma and carcinoma and increased the incidences of thyroid C-cell adenoma and combined adenoma and carcinoma. Palonosetron was not genotoxic in the Ames test, the Chinese hamster ovarian cell (CHO/HGPRT) forward mutation test, the ex vivo hepatocyte unscheduled DNA synthesis (UDS) test or the mouse micronucleus test. It was, however, positive for clastogenic effects in the Chinese hamster ovarian (CHO) cell chromosomal aberration test. Palonosetron at oral doses up to 60 mg/kg/day (about 921 times the recommended human oral dose based on body surface area) was found to have no effect on fertility and reproductive performance of male and female rats. Evaluation: 10 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Palonosetron was not genotoxic in the Ames test, the Chinese hamster ovarian cell (CHO/HGPRT) forward mutation test, the ex vivo hepatocyte unscheduled DNA synthesis (UDS) test or the mouse micronucleus test. It was, however, positive for clastogenic effects in the Chinese hamster ovarian (CHO) cell chromosomal aberration test. Palonosetron at oral doses up to 60 mg/kg/day (about 921 times the recommended human oral dose based on body surface area) was found to have no effect on fertility and reproductive performance of male and female rats. 2 Drug Information 2.1 Drug Trade Name: AKYNZEOTM (300 mg netupitant and 0.5 mg palonosetron free base equivalent) Code Name: Netupitant: RO0673189, RO0673189-008, 14-NETU Palonosetron HCl: RS-25259-197 Chemical Name: Netupitant: 2-[3,5-Bis(trifluoromethyl)phenyl]-N,2-dimethyl-N-[4-(2-methylphenyl)-6-(4methylpiperazin-1-yl)pyridin-3-yl]propanamide Palonosetron HCl: (3aS)-2-[(S)-1-Azabicyclo[2.2.2]oct-3-yl]-2,3,3a,4,5,6-hexahydro-1oxo-1Hbenz[de]isoquinoline hydrochloride Molecular Formula/Molecular Weight: Netupitant: C30H32F6N4O / 578.61 Palonosetron HCl: C19H24N2O•HCl / 332.87 Structure or Biochemical Description: 12 Reference ID: 3527655 NBA 205, 718 Reviewer: Ke Zhang Table 1 Composition of the Netupitant-Palonosetron Combination Capsule Ingredient Reference Function %wlw Quantity (lug) Nempitant Imam! Active ingredient 14 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Ingredient Reference Function 96th Quantity (mg) Palomsetron HCI Internal Glycerol Ph But. 9 6?m? oleate- Internal - Puti?ed Wm Eur Butylated hydroxyanisolc Eur (BEA) Eur. Theoretical F. We a SizeOhrdgelatincapsde, Internal Capsuleshell lcapsulc ptintgdinblackomthewhite body Reference ID: 3527655 NDA 205,718 3 Reviewer: Ke Zhang Studies Submitted Pharmacology Pharmacokinetics/ADME Toxicology 18 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Study No. Species Route Duration of Doses GLP treatment (mg/kg/day) Netupitant Intravenous Studies 1006l18 Rat ix. 3-day 1.5.10.2.5-25 No 1007386 Rat i.v. l-week 3.10.30 No 1008327 Rat i.v. 14 -day 0. 3. 9, 30 Yes 1006263 Dog ix. 3-day 1.2.3 No 1008498 Dog ix. 3-day 0.50-100 Yes 1008328 Dog ix. 14-day 0.1.3.10 Yes Netupitant/palonosetron Combination Repeated Dose Toxicity Studies (Pivotal) Rat p.o. l3-weeks Yes (plus 8-week recovery) 18P only. ION only NETU-07-18 Dog p-o. 13-weeks Yes (plus 8-week recovery) Netupitant, speci?ed impurities and metabolite M4 Genotoxicity Studies 1004078 Ames in vitro - - - 200 pg/plate Yes 1006128 Ames in vitro - - 500 pg/plate Yes Metabolite M4 Ames in vitro - - 1 - 5000 rig/plate Yes 2-41 i?ed un' Ames in vitro - - 5000 late Yes pec 1111130er #8 I Speci?ed Ames in vitro - - 5000 pg/plate Yes 1013157 Mouse - - 5-30 pg/plate Yes in vitro 1002925 Micronucleus p.o. 2-day 160.400.1000 Yes Test Rat 20 Reference ID: 3527655 NDA 205,718 3.1 Reviewer: Ke Zhang Studies Reviewed All studies mentioned above were reviewed except those mentioned under 3.2. 3.2 Studies Not Reviewed All nonclinical studies related to dependence, self-administration, and discrimination were reviewed by the Controlled Substance Staff. The following studies are not reviewed: Skin irritation study in rabbits Skin sensitization in guinea pigs Eye irritation in rabbits Toxicity study of metabolite M4 in BALB/C 3T3 cells 22 Reference ID: 3527655 NDA 205,718 3.3 Reviewer: Ke Zhang Previous Reviews Referenced The following pharmacology reviews under IND 73,493 were referenced. Full reviews of individual studies are included in this review verbatim: 1. Pharmacology Review (#003 and 004) by Ke Zhang, Ph.D. dated 7/2/2008 4 Pharmacology 4.1 Primary Pharmacology Netupitant is a substance P/neurokinin-1 (NK1) receptor antagonist and palonosetron is a serotonin-3 (5-HT3) receptor antagonist. Some published reports suggest that a combination of a NK1 receptor antagonist and a 5-HT3 receptor antagonist is more effective in the control of acute and delayed emesis as compared to 5-HT3 receptor antagonist alone. In vitro studies: Netupitant binds to the recombinant human NK1 receptor with a pKi of 9.0, to the hNK2 receptor with a pKi of 5.8, and the hNK3 receptor with a pKi of 7.5. Netupitant also binds to the canine and rodent NK1 receptors with a pKi of 8.6 and 8.1, respectively. Three major metabolites, M1 (Ro 68-1133), M2 (Ro 71-3001), and M3 (Ro 73-1519), also bind to the hNK1 receptor, with pKi values of 9.0, 9.0, and 9.1, respectively. A minor metabolite M4 was identified at the level of 2.7% (AUC) or 5.5% (Cmax) of the plasma exposure to netupitant in clinical studies. The results of a binding study indicated that M4 binds to hNK1 receptors with a Ki of 1.6 nM, and to hNK3 receptors with a Ki of 8 μM. M4 was not detected in animals. The effect of netupitant on NK1 receptors can be modulated by palonosetron (C. Rojas and B. Slusher, European Journal of Pharmacology, 2012). In this study, it was demonstrated that palonosetron inhibited the substance P-mediated responses in vitro in NG108-15 cells, and in vivo in nodose ganglia collected from rat treated with cisplatin. In vivo studies: In an emesis model in ferrets, oral administration of netupitant at 3 mg/kg completely blocked the emesis induced by apomorphine (0.125 mg/kg s.c.), morphine (0.5 mg/kg s.c.), ipecacuanha (1.2 mg/kg p.o.), or copper sulfate (100 mg/kg intragastric) (see the sponsor’s Table 3 below). 23 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang In Vitro studies: Netupitant and its metabolites (M1, M2, and M3) significantly inhibited the potassium currents of the hERG channel expressed in the CHO cells, with IC50 values of 0.76, 0.84, 43, and 4.4 µM, respectively. Netupitant and metabolite M1 inhibited the rapid component of delayed rectifier potassium current (IKr) by ~21-25% at 3 μM in isolated canine ventricular myocytes (“M” mid-myocardial cells). Metabolite M3 inhibited IKr by ~14% and 57% at 3 and 30 μM, respectively. However, metabolite M2, has no effect on this potassium current at concentrations up to 30 μM. Netupitant (up to 1 μM), M1 (up to 0.3 μM), M2 (up to 3 μM), and M3 (up to 3 μM) had no significant effect on cardiac action potentials in isolated canine cardiac Purkinje fibers. At higher concentrations (3 μM), both netupitant and M1 shortened the action potential duration at 50% of repolarization (APD50), and the action potential duration at 70% and 90% of repolarization (APD70 and APD90, respectively). Netupitant (up to 3 μM), M1 and M2 (up to 30 μM) had no significant effect on cardiac action potential parameters on isolated canine papillary muscle. Metabolite M3, however, significantly prolonged APD50, APD70 and APD90 at 3 and 30 μM in the isolated canine papillary muscle. In Vivo studies: Anesthetized guinea pigs Intravenous administration of netupitant (0.01-1 mg/kg), M1 (0.01, 0.03, 0.1, 0.3, 1 and 3 mg/kg), M2 (0.01, 0.03, 0.1, 0.3, 1 and 3 mg/kg) had no significant effect on the epicardial monophasic action potential in anesthetized guinea pigs. M3 slightly prolonged the monophasic APD70 and APD90 at IV doses of 0.01, 0.03, 0.1, 0.3, 1, and 3 mg/kg in the same animal model. Combined intravenous administration of palonosetron and netupitant (0.3 mg/kg palonosetron and 0.03, 0.1, 0.3, or 1 mg/kg netupitant prolonged the monophasic APD70 and APD90 by 19-38%. Anesthetized rabbits Netupitant at 30 mg/kg IV decreased the mean, systolic and diastolic arterial blood pressure in anesthetized rabbits. However, netupitant at 30 mg/kg had no effects on QT interval. M1 and M3 (1 mg/kg IV) and M2 (30 mg/kg IV) transiently decreased arterial blood pressure in anesthetized rabbits. Premature ectopic beats and tachycardias were noted in 2 of 6 rabbits treated with M3 at 1 mg/kg IV in the anesthetized rabbits. Combined intravenous administration of palonosetron at 3 mg/kg 25 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Netupitant exhibited a long terminal half-life (11-67 hr). The oral bioavailability was 5287%% for netupitant dihydrochloride salt given in water and 48% for netupitant free base in SSV. Dog 28 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang The oral bioavailability of netupitant was also determined in another study in fasted dogs (study #1006336). In this study, dogs were fasted overnight before drug administration and fed 30 min before dosing (oral gelatin capsules). Netupitant plasma concentrations were determined using an LC-MS method. Based on the AUC determined from the intravenous dose in the above study, the oral bioavailability was 55-57% at a dose of 70 mg free base. It appears that concomitant administration of netupitant with food did not have a major effect on the oral bioavailability. Monkey The pharmacokinetics of netupitant was characterized following a single intravenous administration (mesylate salt) and a single oral administration (free base or tartrate salt) in cynomolgus monkeys (study #1006445), using an LC-MS method for determination of plasma netupitant concentrations. The results are summarized in the following tables (taken from the study report). 30 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Netupitant exhibited a terminal half-life in the range of 8-12 hours following oral or intravenous administration. The oral bioavailability of netupitant was 37-62% among the three monkeys with results reported. Distribution: Rat To study the tissue distribution, [14C]-netupitant was given orally (10 mg/kg) and intravenously (5 mg/kg) to albino or pigmented male rats (study #1007004). The total radioactivity in blood, plasma and urine was measured using quantitative whole-body autoradiography. The plasma concentrations of the unchanged drug and its metabolites M1, M2, and M3 were determined using an LC-MS method. Following intravenous administration, the radioactivity was extensively distributed to almost all tissues, with the highest radioactivity levels in the lung, followed by adrenal cortex, spleen, brown fat, liver and pancreas. After oral administration, the radioactivity was found to be highest in the Harderian gland, followed by lung, adrenal, spleen, pituitary, exorbital and intraorbital lachrymal glands, and thyroid. The radioactivity levels were generally higher in tissues than in plasma, except for the brain and spinal cord. 31 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Table 12: Heart Tissue Concentrations of Parent and Metabolites in Dogs . Dose .) Heart C7241. (ngi?g) MIF Stud} 1k g) Netupitant Ml M: M3 1 214.9300 12611113 60 BLQ BLQ 3 307.611 496014620 BLQ BLQ $2311? 05ml" 5. 4992 BLQ BLQ 15 BLQ 41070 5.0 1 2 8060 BLQ 45060 4-we ek 4141131 1899;" 3053 BLQ 64.61" 95 .4 Study 1657:3649 7153513010 BLQ 191615412 NETS-0605 19093;" 9296 53626345353 BLQ QTSI 909 43 89 6 BLQ 82 4.5.66.4 Telemeny 2 1 00 6422 10 5.0 (C7211) 941795?- (C1211) BLQ ((7211) N: Netupitant Based on severe clinical signs noted in (3113111) 4 animals; the high dose level of palonosetron was reduced from 20 to 15 mg?cgr?day from Day 12 onwards 33: values ?'om the high dose recovery group 33 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang A metabolism study with netupitant was performed using human, rat, dog, minipig and marmoset liver microsomes (studies #1003832 and #NETU-10-34). The results indicated that three major metabolites including an N-demethylation product (M1), an Noxidation product (M2), and a hydroxylation product (M3) were present in all species. The results from the study with recombinant expressed human CYP450 isoenzymes indicated that the oxidative steps were catalyzed by CYP3A4, but not by CYP2C9, CYP2C19, or CYP2D6. The apparent Km of 11.3 μM and Vmax of 1.5 nmol/min/mg protein were for the oxidative metabolism of netupitant. The apparent Km of 2.8-9.1 μM was for the N-demethylation of the parent compound to the metabolite M1. Excretion: Rat In a mass balance study in rats, [14C]netupitant was given orally (4.7 mg/kg) and intravenously (4.9 mg/kg) to normal male rats (study #1001466). The excretion of [14C]netupitant following both routes of administration was not completed after one week, with 6.0 ± 1.5% of the oral dose and 7.2 ± 0.8% of the intravenous dose still remaining in the carcass and gastrointestinal tract. Biliary elimination was the major route of excretion, as indicated by the recovery of ~87% of the radioactive dose in feces following intravenous administration. Similarly, ~86% of the dose was recovered in feces following oral administration. The urinary excretion accounted for <1% of the dose. Following intravenous administration, high levels of radioactivity were found in the stomach about one hour after dosing (study #1007004). Dog The netupitant excretion was studied in beagle dogs following oral (5 mg/kg) and intravenous (2 mg/kg) doses of [14C]netupitant (study #1009956). Urine, feces, and cage washings were collected up to 1008 hours (42 days) after dosing. The results indicated that the total excretion was approximately 88% of the dose within two weeks following oral or intravenous administration. The majority of the radioactivity was found in feces, accounting for 88-90% of the administered dose; <2% was recovered in urine. 5.2 Toxicokinetics See each individual toxicity studies. 6 General Toxicology 6.1 Single-Dose Toxicity In the acute oral toxicity study in mice (# NETU-07-23), netupitant was lethal at 1000 and 2000 mg/kg. 36 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang In a study in Wistar rats (# 1009566), netupitant was administered orally at 0, 500, 1000, 1500 and 2000 mg/kg. The dose of 2000 mg/kg was lethal. Histopathological examination revealed foamy/vacuolated macrophages in the liver, lungs, skeletal muscle, mesenteric lymph nodes, duodenum, spleen, and stomach at doses of 1500 and 2000 mg/kg, suggesting phospholipidosis. In a study with Beagle dogs (# 1009567), netupitant was administered orally at 0, 200, 300 and 400 mg/kg using a capsule formulation. Body weight loss and/or a decrease in body weight gain were noted at all dose-levels. Histopathological examination revealed increased incidence of vacuolated macrophage infiltration in the gall bladder and foamy alveolar macrophage at 400 mg/kg, suggesting phospholipidosis. 6.2 Repeat-Dose Toxicity Mouse: There were three oral toxicity studies in Crl:CD-1(ICR) mice including 7-day (# NETU07-022), 4-week (# NETU-07-025), and 13-week (# NETU-07-026) oral toxicity studies. In the 7-day oral toxicity, netupitant was given by oral gavage to CD-1 mice at 0, 30, 120, and 450 mg/kg/day. The doses of 120 mg/kg/day or higher resulted in body weight loss, and the dose of 450 mg/kg/day was lethal. The dose of 30 mg/kg/day was selected as the high dose for the subsequent 4-week oral toxicity study in mice. In the 4-week oral toxicity, netupitant was given by oral gavage to CD-1 mice at 0, 3, 10, and 30 mg/kg/day. At 30 mg/kg/day, the histopathological exam revealed increased incidence of foamy histiocytes in the liver, lungs, and mandibular lymph nodes. Based on the results, the dose of 10 mg/kg/day was selected as the high dose for the 13-week oral toxicity study. In the 13-week oral toxicity study, netupitant was given by oral gavage to CD-1 mice at 0, 1, 3, and 10 mg/kg/day. There were no clear treatmentrelated changes. The dose of 10 mg/kg/day was the no observed effect level (NOEL). Rat: Oral toxicity studies two weeks and four weeks duration were conducted in rats (# 1007326, # B-167719, # B-167723, # 1006011, and # 1003562). The highest dose tested in these studies was 300 mg/kg/day (2-week studies). Animals were sacrificed prior to study termination at doses of 300 mg/kg/day in the 2-week studies and 100 mg/kg/day in a 4-week study due to body weight loss. Thus, the dose of 100 mg/kg/day exceeded the MTD. Phospholipidosis was noted at doses of 30 mg/kg/day or higher. 37 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang 24, 96, 192, 288, and 384 hour after dosing (3 rats/sex/group). The k?xxmi samples eat 96, 192, 288, and 384 hour after dosing were collected only during week 13. - Dosing Volume: 5 ml/kg Drug lot# and purity: BSOZO4SA01 and 99.8% Formulation/vehicle: Composition for 100 m1 8i] - 0.20% Cellulose Aviccl RC 591 1.60% Nipagin 8% Nipaso] 0.02% Deminemlized water Filled up to 100 ml GURMMOJN mr adjustment to pH 6.0 Observations and times: - Clinical signs: Clinical signs of toxicity were observed daily. - Body weights: Body weights were determined weekly. - Food consumption: Food consumption was determined weekly. - Hematology, Clinical Chemistry, and Urinalysis: at termination. - Gross pathology: Animals were necropsied at termination. - Organ weighed: Following organs were weighed at termination: adrenal gland, brain, heart, kidney, liver, ovary, pituitary gland, prostate gland, spleen, testis, and thyroid gland. - Histopathology: Following organs or tissues were examined histopathologically from each animal in all groups: adrenal glands, aorta, bone (femur) and articulation bone (sternum) with bone marrow, bone marrow smears, brain, bronchi (mainstem), caecum, colon, duodenum, epididymides, eyes, heart, ileum, jejunum, kidneys and 'ureters, larynx, liver, lungs, node (mandibular), node (mesenteric), mammary gland, oesophagus, optic nerves, ovaries and oviducts, pancreas, parathyroid glands, Peyer's patches, pituitary gland, prostate, rectum, salivary glands (nandibular, parotid, sublingual), sciatic nerves, seminal vesicles, skeletal muscle, skin, spinal cord (cervical, thoracic, lumbar), spleen, stomach, testes, thymus, thyroid glands, tongue, trachea, urinary bladder, uterus (horns cervix), vagina, and all gross lesions. Results: 39 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Treatment-related microscopic ?ndings Liver Sex Males Females Status at necropsy K0 R1 Ki) RI Group No. cfanimals hypertrophy - Minimal - Vacuolalion - Minimal - Slight - - - Necrosis - - - - - - - - - :1 - - . Minimal - - - - - - - - - - 4 - - . Slight - - - . . - - - - i - - - - - Single cell necrosis Minimal Slight - - - - - - - - I - - . - Granuloma - - - - - - - - - - 2 - - - Minimal - - - - - - - . - - 1 - - Moderate . - - - - - - - - - 1 - - K0: terminal sacri?ce; R1: recovery -: Observation not recorded in group 42 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Treatment-related microscopic ?ndings Mesenteric node Sex Males Females Slams at necropsy KO 1 K0 R1 Group No. ofanirnals Diffuse histiocytosis Minimal Slight Moderale - Marked - - - - - - - - - - - llislioeytic aggregates Minimal Slight - - Moderate Marked - - - - - - - - I - - 2 - - K0: terminal sacri?ce; R1: recovery -: Observation not recorded in group 44 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Treatmenbrelated microscopic ?ndings Trachea and larynx Sex Males Females Status at necropsy K0 RI K0 R1 Group No. oi?animnls Laiynx - ln [lam malion - - - - - - . - - 2 2 - Minimal - - - - - - - - - 2 - Slight - - - - - - - - - - - 1 - - Epithelial ulceration - - - - .. . - - - . - 1 - Minimal - - - - - - - - - - - - Trachca - In?ammation - - - - - - - 6 - - Minimal - - - - - . - 3 - - Slight - - - - - - - - 2 - - Moderate - - - - - - - - - - 1 - K0: terminal sacri?ce; Rl: recovery -: Observation not recorded in group 46 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Toxicokinetics: The toxicokinetic data of the parent compound were presented in Table 5 and this table is attached below. BEST Tam 5 Toxicoklnodc pamnnton of mm blowhg oral AVAILABLE administration of 3, 10 and 30 R00873189-000 to COPY m? but Good" Day TIMI Clan cam Thu wac- 40cm. ha) 24.) 24mm? hulk: I oval. I mount. haw-n). ludIIU 3 242 596310 2100 1150 2380 293 167 24 5640 5660 I890 renal3100 63) no 24 9540 9513700 moo noon moo N00 renal. 5 I450 944 24 woo 17100 2710 49 3 I660 mo 24 29700 mno 2m 9 6 1220 94! 24 26600 26600 2660 I570 704 24 21.900 27500 91) 49 5 1030 not I490 9m 28: mono moo mo 0 5 mo mo 24 woo J soo loso Fol-4 : 16 3 3630 24 moo moo mo 49 3 2330 mo 24 410m 0000 mo on 2000 2050 344 296000 49200 I640 4 mo son 24 moo 24600 no 6476'! 24 noon mo some 2790 me 2? 49000 49000 I610 49 2100 mo 24 moo 49600 I650 91 3 2540 :44 wow moo mso mom-Mm mnisu?on The plasma levels of the major metabolites and were presented in Tables 6, 7, and 8 and these tables are attached below. 48 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Tom. 8 Toxieokinouc murders of blowing on! BEST adminimdon o! 3. 10 and 30 MEWS-008 to ma AVAILABLE COPY Duo 04.4.: 0., Tan. Clul can.) run wen- Aucm- wuo ha) 2an 24mm. 5 ml. act-l. hay-I. 4.49m. ?you mm. 24 90.3 90.3 24 2640 I660 593 Md2040 93Pom-moo noon ?on 9 24 599 $99 24 42500 um 4:70 24 25f 24 39942 2990 299 Maimoo moo 2240 25100 251m 2410 runs23am moo 2m 9 3 mo mo 24 27200 moo 245 94.44 24 5 mo 4420 24 34600 moo 384 moon moo 1460 :12 run-344 496000 36100 4220 4 24 996 39o 24 mo 4264 275 mm.- on 2 I560 14m 244 249000 moo 5500 In tunaI500 4520 I420 :44 moo mo 'lnt?rihlcm administration 49 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Study title: 26-week Oral Toxicity Study with Netupitant in Rats Study no.: NETU-07-21 Study report location: n/a Conducting laboratory and location: Date of study initiation: GLP compliance: QA statement: Drug, lot #, and % purity: (b) (4) August 16, 2007 Yes Yes Netupitant, 27003139, 98.7% Key Study Findings: Rats were treated with netupitant at 0, 1, 3, or 10 mg/kg/day by oral gavage for 26 weeks. Treatment with 10 mg/kg/day resulted in periacinar hepatocytic hypertrophy, thyroid follicular epithelial hypertrophy (males), thymic atrophy, increased aggregations of alveolar macrophages, and syncytial macrophages in mandibular and mesenteric lymph nodes and spleen. The NOAEL is considered to be 3 mg/kg/day based on the microscopic findings, although the high dose of 10 mg/kg/day was well tolerated. Methods Doses: Frequency of dosing: Route of administration: Dose volume: Formulation/Vehicle: Species/Strain: Number/Sex/Group: Age: Weight: Satellite groups: Unique study design: Deviation from study protocol: 0, 1, 3, and 10 mg/kg/day Daily Oral gavage 5 ml/kg Thixotrope vehicle Crl:WI(Han) rats 20/sex/group and additional 10/sex/group in control and high dose groups ~7 weeks Males: 228-232 g Females: 163-166 g 3, 5, 5, and 5/sex/group No No deviation occurred which adversely affected the quality of the study. The dose selection was based on the results of the previous studies including a 52 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Hematology Slight decreases in hemoglobin, hematocrit, mean corpuscular volume and mean corpuscular hemoglobin were noted in the high dose females. Clinical Chemistry In high dose group, increased total globulin, total protein, cholesterol, triglycerides (females only), phospholipids and decreased albumin/globulin ratio and total bilirubin were noted. Urinalysis There were no clearly treatment related changes. Gross Pathology An accentuated lobular pattern of the liver was noted in one high-dose male and foci on the lungs was observed in 5 high-dose females. Organ Weights Increased absolute and relative liver weights occurred in the high-dose males and females (relative liver weights ~115-121% of the control), decreased absolute and relative thymus weights were noted in the middle and high-dose females, and a minimal increase in relative kidney weight was observed in the high-dose females. Histopathology 54 Reference ID: 3527655 NDA 205,718 Data are summarized below: Reviewer: Ke Zhang Toxicoltinetii: parameters of Netupitant Group 2: 1 mg Males Females 4.0 2.0 0.5 2.0 3.0 4.0 1.0 4.0 Cmax ngi'mL 55 .0 1 13 134 123 32.? 230 305 313 0m 55-0 1 13 134 125 32.7? 250 305 313 4039.24 hr-ngiimL 1?40 2430 2550 1530 5330 3T10 30T0 300.334 1340 2430 2550 1530 5330 3T10 3010 1400.351 hr-ngl'mL 040 2430 2550 1530 5330 5210 30T0 AUCIH hr-i-tg-ngimLinu H40 2430 2550 1530 5330 0 3070 AUG. hr-nglimL 1000 nIa Na Na W0 Na Na Na 4100= hr-ltg-ngimUny 1000 nfa nfa ma [1er Na Na Na t'h-g hr 3.12 15.0* 104* 1 15* 103* 353* 41 Group 3: 3 mg Males Females Tmam Canal: ngi'mi5715 T34 1050 Cm Hg noimLi'mg 30 .2 0T0 100 153 702 102 255 350 4000.24 hr-ngl'mL 2730 4300 3050 3510 4110 12300 15500 1?200 300.3-? hr-itg-ngimUmg 02? 1530 2320 2130 1370 42T0 51T0 5T30 300351 hr-ngl'mL 2?30 4500 3050 5510 41 10 12300 15500 1 E200 1400.35.t hr-itg-ngfmUnu 021' 1530 2320 2170 1370 42T0 51 T0 5730 A00. r- ngr'm 3200 nia Na Na 3310* nta Na Na AUG: hr-ltg-ngfm Limg 1020 nia ni'a nia 2040* Ma Na Na hr 3.23 132* 21 233* 2742* 133* Nd Group 4: '10 mg Males Females W23 5352.0 4.0 2.0 2.0 2.0 4.0 4.0 4.0 Email: ngi'mL 500 2050 023 320 313 1250 1 130 1340 kg-ngimUmg 50.0 205 02.3 32.0 51.3 125 113 134 5003.24 hr-ngl'mL 3330 20T00 147*00 15000 13300 24300 24100 2?500 300.334 hr-itg-ngiimUnu 333 2030 14T0 1300 1330 2430 2410 2?50 1400.351 hr-ngi'mL 3330 20700 14200 43400 13300 24300 24100 133000 300135: hr-itg-ngmeimg 333 20T0 1430 4340 1330 2430 2410 13300 4100: hr-ngme 13500* nIa Na Na 250000* Ma Na Na AUG: hr-ltg-ngfm erg 1350* nla Na Na 2300015.1 25-4* 51 .3 305* 01 503* 1 12 E1 dose-normalised to 1 mgr'ltg, approximation, ma not applicable, not determined 3* If was 24hours. this was the maximum time between subsequent doses- 0nly in RECDVEW animals at the high dose, a true value for was obtained after the ?nal dose was administered. 56 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Parameters were not determined for Group 2. Data for Groups 3 and 4 are summarised below: Toxiool-tinetio parameters of metabolite M2 Group 3: 3 mg Males Females 01 W4 W13 W23 01 W4- W13 W23 Tide-ICmaJt ngr'mL 21.0 23.3 35.3 35.1 23.5 21.3 13.3 20.1 3m -ng?mL?mg ?.00 11.3 11.? ?.33 ?.03 4.32 3.?0 31134.24 hr-ngr'mL 153 333 233 233 40.4 134 203 343 34035..? hr-ltg-ngmUmg 51.0 123 33.1 33.5 13.5 34.? 115 403351 hr-ngimL 103 131 143 143 1 13 22.3 343 403135: hr-ltg-ngrmUmg 33.0 53.? 43.? 3.23 ?.43 115 AUG: hr-ngme 15?* Na Na Na 404* rda Na Na 403: hr-ltg-ngr'm Li'mg 524* Ma nr'a rda 135* n?a rar'a era to: hr 433* 130* 353* 1 04* 133* Nd Group 4: 10 mg NetupitanUI-tgiday Males Females 01 W4 W13 WEE 01 W4- lW13 WEE Tlast 1.0 4.0 2.0 2.0 2.0 2.0 0.5 1.0 Erna}: ngr'mL 54.1 135 3?.0 53.5 ?1.5 34.2 32.0 3?.3 3m -ng?mL?mg 5.41 13.5 3.?0 5.35 ?.15 3.42 3.20 3.?3 14033.34 hr-ngi?mL 323 1330 504 ?23 235 344 543 350 hr-itg-ngmetmg 32.3 133 50.4 ?23 23.5 34.4 54.3 35.0 303,351 323 1330 504 1330 212 344 543 1030 3 403135: hr-ltg-ngrermg 32.3 133 50.4 133 21.2 34.4 54.3 103 AUG: hr-ng?mL ?43* nfa Na Na 233* rda Na Na AUG: hr-ltg-ngr'm Li'mg ?43* Na Na nfa 233* No ni'a nr'a tug hr 3.?2 21 43-3* 213* Nd 304* 234* dose-normalised to 1 approximation, ru'a not applicable, not determined It was 24hours, this was the maximum time between subsequent doses. Only in Renewed,f animals at the high dose, a the value for Tlast was obtained after the ?nal dose was administered. Reference ID: 3527655 58 NDA 205,718 Reviewer: Ke Zhang Dosing Solution Analysis The analysis of drug concentration in samples of dosing formulations from each dosegroup was in agreement with target concentrations (between 90% and 110%). Dog: Study title: RO0673189: Thirteen week oral (capsule) toxicity study in dogs 59 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Mortality No deaths occurred. Clinical Signs There were no clearly treatment-related changes. Body Weights There were no clear treatment effects on body weight. Feed Consumption Slightly lower food consumption was noted in the high dose groups. Ophthalmoscopy There were no clearly treatment-related changes. ECG There were no clear treatment effects on blood pressure, heart rate, or ECGs. These cardiovascular parameters were determined before study initiation and on days 1, 25, 88, and 142 at pre-dose and 1, and 6 hours after dosing. Hematology There were no clearly treatment-related changes. Clinical Chemistry There were no clearly treatment-related changes. Urinalysis There were no clearly treatment-related changes. Gross Pathology Darkness or dark areas were seen in the jejunum in one male each from low dose and high dose groups, and in one male and one female from middle dose group. Organ Weights 61 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Dose selection was based on the results of the 4-week oral dose toxicity study in dogs (# 1006010). Body weight loss was noted at doses of 15 mg/kg/day or higher in this study. The sponsor selected 10 mg/kg/day as the high dose in the current study. There was also a 7-day oral toxicity study in female Beagle dogs (# 1006679), with doses up to 15 mg/kg/day. In that study, slight body weight loss and aggregates of foamy or vacuolated macrophages in lymphoid tissue and intestinal mucosa were observed at 15 mg/kg/day, suggesting phospholipidosis. Observations and Results Mortality One high-dose male was sacrificed due to moribund condition. Clinical Signs There were no clearly treatment-related signs. Body Weights The terminal body weight gains were 41% for the control males and 28% for the highdose males, and 53% for control females and 36% for high-dose females. Feed Consumption Slightly lower food consumption was noted in the high-dose females. Ophthalmoscopy There were no clearly treatment-related changes. ECG 64 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Slightly prolonged QTc intervals were noted in the high-dose males during treatment weeks 13 and 26 (231-240 msec measured post-dose, compared with 213-215 msec at pre-dose). Slightly prolonged PQ intervals were also noted in the high-dose males during treatment weeks 13 and 26 (98-104 msec measured post-dose, compared with 83-93 msec at pre-dose). There were no clear treatment effects on blood pressure. Hematology There were no clearly treatment-related changes. Clinical Chemistry Alkaline phosphatase was increased (131-262 U/L in high dose group compared to 50118 U/L in control group). Urinalysis There were no clearly treatment-related changes. Gross Pathology An enlarged liver was noted in one high-dose male. Organ Weights The absolute and relative liver weights were approximately 139% and 151% of mean control weight in the high-dose males. Histopathology Minimal periacinar hepatocytic hypertrophy was noted in the high-dose males. Toxicokinetics The toxicokinetic data for netupitant and the metabolites M1, M2, and M3 are summarized in the following sponsor’s tables. The AUC values for M1 were approximately 2-fold greater than the AUC values for netupitant. The AUC values for the parent compound and its metabolites in the high-dose group were higher in males. 65 Reference ID: 3527655 NDA 205,718 Toxicokinetic data of M1 are summarised below: Reviewer: Ke Zhang Group2 Group 3 Group4 Parameters 1 7kg 3 1D 1111 Day ngimL 45.0 0711g-ng7mL7mg 45.0 07.0 00.0 43.0 71.4 33.3 7210-0135t hr-ngme 031 1300 3570 2500 14000 0300 14 4001351 031 1300 1 100 050 1400 030 1170 0770* 0300* 1170 1173 1170 14 1170 0770* 3100* n70 1170 1170 11,2 hr 1170 00.01 33.01 1170 1170 1170 Week 4.0 4.0 0.0 0.0 0.0 0.0 140 100 404 415 1050 1070 14 cm 140 100 101 130 105 107 4001331 2020 3200 0010 0720 40000 23100 14 4001331 2020 3200 3300 2010 4000 2310 11,2 hr 21.51 20.01 32.01 43.71 1170 1170 Week 101 201 544 445 1000 1200 14 cmax 101 201 101 140 100 120 4001331 3170 3050 11700 0220 42000 20700 14 AUGlast hr-kg-ng7mL7mg 3170 3050 3000 3070 4200 2070 113 hr 27.11 20.21 03.01 47.71 100* 44.11 Week 26 71330.0 0.0 5.0 2.0 4.0 4.0 cmax ngimL 100 100 520 500 2110 1310 14 cm 100 100 175 107 211 131 41.11::last 3310 4100 10700 11000 45000 20000 14 4001351 hr-kg-rg1mL7mg 3310 4100 3500 3000 4500 2000 1112 hr 33.21 30.21 55.01 50.11 130* 04.01 Week 39 hr 24 24 24 24 24?? 244* Tm: hr 4.0 4.0 0.0 0.0 0.0 4.0 cmax 102 225 555 457 1000 1200 14 em 102 225 105 153 100 120 wuomt1t 3000 4050 12200 0020 45400 20100 14 40013311 hr-kg-r?gImLng 3000 4050 4070 3310 4540 2010 11,2 hr 33.41 30.01 1170 37.01 125*? 132*1 Reference ID: 4'4 dose?normalised to 'l mg-Ikg. approximation. 3 median for Tlast and Tmax. not determined as the elimination phase could not be modelled with the data available, 1 was used for 11? T1331 was 24hours. this was the maximum time between subsequent doses. Only in Recovery animals. a true value for T1351 was obtained after the ?nal dose was administered: it was 33010101 males and females at the high dose Recovery animals of Group 4, Recovery animals excluded, 3527655 67 NDA 205,718 Reviewer: Ke Zhang Dosing Solution Analysis The analysis of drug concentrations in samples of dosing formulations from each dosegroup was in agreement with target concentrations (between 96% and 101%). Study title: 13-Week oral gavage toxicity study with palonosetron and netupitant in rats Study no.: NETU-07-19 Study report location: n/a Conducting laboratory and location: Date of study initiation: GLP compliance: QA statement: Drug, lot #, and % purity: (b) (4) July 2, 2007 Yes Yes Palonosetron, 26004786, 99.5% Netupitant, BS0307SA01, 99.5% Key Study Findings: Rats were treated with netupitant at 1, 3, and 10 mg/kg/day in combination with palonosetron at 2, 6, and 18 mg/kg/day, respectively, by oral gavage for 13 weeks. Additional groups were treated orally with 10 mg/kg/day netupitant or 18 mg/kg/day 70 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang palonosetron. Slight increases in absolute and relative liver weights were noted in the high-dose combination group, the netupitant only group, and the palonosetron only group (up to 120% of the mean control weight). Histopathological examination revealed adrenal zona fasciculata hypertrophy, hepatocytic hypertrophy, and syncytial macrophages in the mesenteric lymph nodes, mainly in the high-dose combination and netupitant only groups. These effects are not considered to be adverse. Therefore, the NOAEL was 10 mg/kg/day netupitant + 18 mg/kg/day palonosetron. 71 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang The dose selection was based on the results of the previous toxicity studies including 7-day and 28-day studies in rats with combination treatment (# NETU-06-20 and # NETU-06-03, respectively). Doses tested in the 28-day study were: 10 mg/kg/day Palonosetron and 3 mg/kg/day Netupitant 18 mg/kg/day Palonosetron and 10 mg/kg/day Netupitant 60 mg/kg/day Palonosetron and 30 mg/kg/day Netupitant The group treated with 60 mg/kg/day palonosetron and 30 mg/kg/day netupitant exhibited hunched posture, reduced body weight, and increased incidence and severity of syncytial macrophages in mesenteric lymph nodes. The sponsor selected 18 mg/kg/day palonosetron and 10 mg/kg/day netupitant as the high-dose combination for the current study. Observations and Results Mortality Two main study toxicity rats and 3 satellite rats died during blood sampling. These deaths were not treatment related. Clinical Signs Increased salivation was noted in the high-dose combination group. Body Weights There were no clearly treatment-related changes. Feed Consumption Slightly lower food consumption was noted in the high dose group during weeks 1 and 2. Ophthalmoscopy There were no clearly treatment-related changes. 73 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Toxicokinetics The toxicokinetic data for palonosetron, netupitant, and the netupitant metabolites M1, M2, and M3 are summarized in the following sponsor’s tables. 75 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Toxicokinetic data of Netupitant are summarised below. Summary Netupitant data Parameters Group 2:2 PS and 1 NT Group 3: 0 9'5 and 3 mgi'kg NT Day 1 Week 4 Week Week 13 Day 1 Week 4 Week Week 13 Males T032 10 0.0 24.0 24.0 00.00 24.0 24.0 24.0 100.02 THE: 10 4 .0 2.0 1.0 2.0 4-0 3.0 3.0 0.5 [3031 01.0 113 109 101 1T1 230 301 40? #093 01.0 113 109 101 5?.0 95T20 1300 3240 2430 5030 0000 ?020 0 AU C4301 424 1T20 1300 3240 32? 2000 2510 AU Cm nr-ngi'mL T490 10300 3 AU 12135., T490 5433 AUG. nr-ngJ'mL MG n?a nTa nfa 2920 nfa nta nta AUG. nr-kg-nngUmg HG Na Na nfa 9T4 nta nta nta 11,: hr NE 20.4 12.3 30.9 3 .T4 13.1 21-4 43.1 Females 10 24.0 24.0 24.0 100.00 24.0 24.0 24.0 230.02 TM 10 3.0 3.0 3.0 24.0 3-0 4.0 4.0 4.0 Gm. 33Cum: kg-ngmetmg 33nr-ngi'mL 1590 4920 5290 T500 44 90 11900 10500 12000 0 nr-kg-ngfmUmg 1590 4920 5290 T500 149? 390? 3500 4150 20900 T0000 3 AUGM nr-kg-ngfmUmg 20900 23333 AUG. 2900 Na nta nta nTa nta ni'a AUG. nr-kg-ngmetmg 2900 n?a ni'a nta 2520 nta nta nta 11.: hr 19.3 2T.3 HG 33.3 1?.2 3?.1 4?.3 00.0 Group 4: 13 PS and 10 MT Group 0: 10 mgikg l-lT Day 1 Week 4 Week Week 13 Day 1 Week 4 Week Week 13 Males Tm '2 10 24.0 24.0 24.0 100.02 0-0 24.0 24.0 100.G7113M 45.5 03.5 00.2 03.0 5?.1 03.3 34.? 00.9 AU Gm nr-nngL 0020 12200 12300 12100 3590 11300 12900 13000 AU Gm nr-kg-ngfmUmg 032 1220 1230 1210 359 1130 1290 1300 AU Gm 3?000 41000 3 AU (2.35., 3T00 4100 AUG: 3440 Na nta nta 3330 nTa nta nta 0 AU nr-kg-ngfmUmg 344 nTa Na Na 033 We nta nta 11.22 10 9.92 12.? 20.9 59.3 3.30 14.0 1?.2 54.5 Females 0.10 10 24.0 24.0 24.0 3200'3 0-0 24.0 24.0 330.02 Tnux in 4.0 3.0 4.0 3.0 2-0 3.0 24.0 2.0 Gm ngimL 021 11T0 1150 1190 301 1210 1090 1230 #02033: 02.1 HT 115 119 30.1 121 109 123 AU Cast nr-ngme 11400 2 5100 24100 2? 1 00 5440 24T00 30000 22000 =3 AU C4351 nr-kg-ngfmUmg 1140 2510 2410 2T10 544 24?0 3000 2200 nr-ngi'mL 130000 99300 0 AU C4351 nr-kg-ngfmUmg 13000 9930 AUG. 31900 n?a nta ni?a 5T400 nfa nta nta AUG. nr-kg-ngfmUmg 3190 n?a ni'a nta 5740 nta nta nta 11,? in 30.3 NC 59.5 03.1 4?.5 MG 3T3 Palenosetron, NT Netupitant, at! dose-normalised to 1 010019.204 approximation, nta not applicabler italics used for Week 13. NC could not be calculated '3 It That was 24hours. this was the maximum time between subsequent doses. Only in Recovery animals. a tme value for Tm was obtained after the ?nal dose was administered. 77 Reference ID: 3527655 NDA 205,718 Toxicokinetic data of M2 are summarised below. Reviewer: Ke Zhang Summary M2 data Parameters Group 2:2 mg?kg PS and 1 mg-?kg HT Group 3: 9 mgr'kg 9'9 and 3 mgr'kg NT Day 1 Week 4 Week Week 13 Dial.r 1 Week 4 Week Week 13 Males Tm nr so so so s4o9 2.9 9.5 9.5 9.5 Cm 15.9 13 .4 19.2 35.2 9 Gm: kg-ngrmUmg 4.99 4.49 9.41 11.? nr-ngi'mL insuf?c- data 43.? 99.5 99.2 325 9 AUG-39 nr-kg-ngfmUmg 14.9 33.2 29.? 1?99 AUGsa-s nr-ngi'mL 325 9 AU Gm. nr-kg-ngfmUmg 199 AUG. NG nfa nIa ma 9 AUG. nr-kg-ngfmUmg 22.3 Females T.aEl 24.99 9.5 Gm ngl'mL 15.9 9 Gm. ttg-ngi'mUmg 5.91 nr-nngL insuf?c- data insuf?c. data 239 9 nr-kg-ngfmUmg ?9.2 nr-ngl'mL 239 9 ?9.2 AUG. nr-nngL nr'a 9 AUG. nr-kg-ngfmUmg nl?a H: l?lr NC Group 4: 19 P5 and 19 MT Group 9119 NT Day 1 Week 4 Week Week 13 9'93.r 1 Week 4 Week Week 13 Males so so 24o 24.119 so 241:: so 24.39.2 24.2 29.2 29.9 43.2 35.1 52.9 39.1 9 Gmax kg-ngrmUmg 3.92 2.42 2.92 2.99 4.32 3.51 5.29 3.nr-kg-ngfmUmg 23.9 1?.4 39.3 32.4 25.9 4?.2 24.? 49.9 AUGH nr-ngl?mL 324 499 9 AU Gee nr-kg-ngfmUmd 32.4 49.9 AUG. l'lr'l'lgt'l'l'AUG: 49.9 Na Na nr'a 49.1 ma nfa WE he 5.95 NG 11.9 12.2 ?.99 13.9 5.42 52.2 Females 24.0 24.11 am 4so9 so 24s 24o also9 29.9 29.3 25.9 29.9 33.? 35.? 49.4 39.? 9 Gm: kg-ngrmUmg 2.99 2.93 2.59 2.99 3.3? 3.5? 4.94 3.9? AU Gee: nr-nngL 324 439 499 495 133 929 9?2 4 ?9 9 nr-kg-ngfmUmg 32 .4 43.9 49.9 49.9 13.3 92.9 9?.2 4?.9 nr-ngJ'mL 99? ?54 9 br-kg-ngfmUmg 99.? ?5.4 AUG. nr-ngJ'mL 1199 n?a ni'a 229 rh?a nla We 9 AUG. nr-kg-ngfmUmg 119 nl'a nr'a ni'a 22.9 rtla nIa nra t? 39.1 NG 99.9 22.9 5.99 49.9 NG 29.9 PS Palonosetron, NT Netupitant, 9 dose?nonnalised to 1 to: approximation. me not applicable, itafics used for Week 13. MG could not be calculated insu?-data: Goncentrations were near or below LL00, no calculations performed. '3 It That was 24hours. this was the mar-:irnurn time between subsequent doses. in Recover}.r animals, a true value for Tag was obtained after the ?nal dose was administered. Reference ID: 3527655 79 NDA 205,718 Reviewer: Ke Zhang Dosing Solution Analysis For palonosetron, the concentrations measured in dosing formulations for groups 2 to 5 were in the range of 87–111% of the nominal concentrations. For netupitant, the concentrations measured in dosing formulations for groups 2 to 4 and group 6 were between 89% and 107% of the nominal concentrations. The mean values of the duplicate samples were within the range of 90-110%. Study title: 13-Week oral gavage toxicity study with palonosetron and netupitant in dogs 81 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang The dose selection was based on results of the previous toxicity studies, including a 7day and 28-day study in dogs with combination treatment (# NETU-06-21 and # NETU06-05, respectively). The doses tested in the 28-day dog study were: 10 mg/kg/day palonosetron and 3 mg/kg/day netupitant 15 mg/kg/day palonosetron and 7.5 mg/kg/day netupitant 15 mg/kg/day palonosetron and 15 mg/kg/day netupitant. The groups treated with 15 mg/kg/day palonosetron + 7.5 mg/kg/day netupitant and 15 mg/kg/day palonosetron + 15 mg/kg/day netupitant exhibited tremors and seizure-like episodes. Therefore, the sponsor selected 10 mg/kg/day as the high dose for both palonosetron and netupitant in the current study. Observations and Results Mortality No deaths occurred. Clinical Signs There were no clearly treatment-related signs. Body Weights The terminal body weight gain was reduced in the combination high-dose females (0.9 kg, as compared to 2 kg in the control females). Feed Consumption A slight reduction in food consumption was noted in the combination high-dose group during weeks 1 and 2. Ophthalmoscopy There were no clearly treatment-related changes. 83 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Toxicokinetic data of M1 are summarised below: Summary M1 data Group 2: 3 b.w. PS Group 3: 5 b.w. PS Group 4: 10 1:19ka b.w. PS Parameters and 1 b.w. NT and 3 mgikg b.w. HT and 10 b.w. NT Day Week Week Week Day 1 Week Week Week Day 1 Week Week Week Males T1335 hr 24.0 24 .0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0"g Tm? hr 8.0 4.0 4.0 5.0 8.0 8.0 4.0 5.0 8.0 1.5 6.0 1.0 Cram: 119me 60.2 140 147 156 237 669 616 633 455 1360 1710 1510 11 CW kg-ngi'mLimg 60.2 140 147 156 78.9 223 205 211 452730 2820 3060 4310 13600 12600 13500 8220 30200 36000 32600 hr-kg-ngfmUmg 1 110 2730 2820 3060 1440 4550 4210 4490 822 3020 36 00 32 60 AUG. 1990* nIa nia Ma 1090 0* 1113 Na Na 27900* nr'a nIa nr?a hr-kg-ngfmUmg 1990* Ma nla nJ'a 3630nfa nila tn: hr 168* 238* 263* 319* 293* 263* 335* 404* 325* 244* 632* 80.6* Females Twig hr 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.43.3 131 141 147 130 335 350 324 592 1350 1320 1180 11 CW kg-ngi'mUmg 43.3 131 141 147 43.2 111 117 108 59.2 135 132 118 hr-ngilmL 833 2570 281 0 2870 2530 6790 6890 6700 1 1300 29200 27400 24700 hr-kg-ngfmUmg 833 2570 2810 2870 843 2260 2300 2230 1 130 2920 2740 2470 AUG. hr-nngL 2970* nfa ni'a nr?a 9660* Na nfa Ma 30300* We nfa nfa 11 hr-kg-ngfmUmg 2970* nfa nfa nIa 3220* Na nfa nfa 3030* nIa nfa nfa t1r2 hr 427* 28 344* 278* 472* 342* 330* 340* 339* 51 52.6" 47.5'c PS 2 Palonosetron; NT 2 Netupitant, 5: median, dose?normalised to 1 was used for the recoveryr animalsr It T1351 was 24hoursr this 1was the maximum time between subsequent doses. Only in Recovery animals, a the value for T1351 was obtained after the ?nal dose was administered: it was 168?336hr at the high dose. approximation. nfa: not applicable Toxicokinetic data of M2 are summarised below: Summary M2 data Group 2: 3 "1'9le b.w. PS Group 3: 5 b.w. PS Group 4: 10 mgil'kg b.w. PS Parameters and 1 b.w. NT and 3 1119er [1.111. NT and 10 1119ka 5.1111. NT Dav Week Week Week Day Week Week Week Day Week Week Week Males 5 9 hr 3.0 24.1] 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0? Tums hr 2.0 2.0 2.0 2.0 3.0 2.0 2.0 2.0 2.0 2.0 2.0 2.0 ngimL 55.4 46.5 47.2 41.kg-ngmefmg 55.4 46.5 47.2 41.9 48.7 72.9 64.7 66.0 40.0 51.9 53.3 43.2 hr- ngme 227 520 558 548 1510 2560 2200 2310 2550 5370 5210 4680 hr-kg'ngfmUmg 227 520 568 548 504 853 733 770 255 537 521 468 A C- hr- ngme 3 04* 1113 nia nfa 2000* n13 n.1a Na 32 50* nfa ni'a ne'a AUC- hr-kg-ngmel'mg 304* nla ni'a nfa 668* nfa ma nfa 325? m?a Na Na 11.; hr 322" 14.2? 15.7? 15.9' 10.9?" 17.7' 164* 15.7? 980? 47.4' 13 3* 23.2? Females '3 hr 8.0 24.0 8.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0IQ Tm:i hr 2.0 2.0 2.0 2.0 2.0 2.0 1.5 2.0 2.0 2.0 2.0 2.0 36.6 50.2 50.8 45.4 207 183 125 1 10 590 563 453 381 Cm: 119119meme 36.6 50 2 50.8 45,4 68.9 61.0 41.7 388 58.0 56.3 45 3 38,1 185 484 313 527 1140 1310 1110 1060 3930 4500 4030 3720 hr- kg - ngfmUmg 185 484 313 527 379 456 371 353 393 450 403 372 AUG. hl" ngme 278' Na Na nfa 1 270' we nia nfa 4580* nifa ni'a nia AUG- hr-kg-ngfmUmg 23?8" nr?a ni'a nfa 424* n13 mla nfa 458* Ma rule. We 1.,2 hr 386' 10.7' 663' 17.0' 557" 10.6' 10.2? 11.7? 7.34' 9-74' 119" 17.1 P5 Palonosen?on; NT Netupitant, 5: median. dose?nonnalised to 1 was used for the recovery animals. 5 if Tim was 24hours. this was the maximum time between subsequent doses OnlyI in Recovery animals? a true value for Tm was obtained after the ?nal dose was administered: at was 96?168hr for males and 48?96hr for females at the high dose. Reference ID: 3527655 apprommatlon. nla: not applicable 86 NDA 205,718 Toxicokinetic data of M3 are summarised below: Reviewer: Ke Zhang Summary M3 data Group 2: 3 b.w. P5 Group 3: 5 b.w. PS Group 4: 10 b.w. PS Parameters and1 b.w. NT and 3 b.w. NT and 10 b.w. NT Dayr Week Week Week Daylr Week Week Week Day 1 Week Week Week ?13 Males Tug.S '5 hr n.c. n.c. n.c. n.c. 8.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0'5 Tm: hr n.c. n.ngme n.c. n.c. no. no 23.9 45.3 43.8 38.3 41.4 82.3 105 ?9.1 Gm kg-ngmefmg n.c. n.c. n.c. n.c. 7.96 15.1 14.6 12.8 4.14 8.23 10.5 7.91 hr-ngme n.c. n.c. n.c. n.c. 113 794 1'62 636 601 1660 2100 1?00 frh?UGrasti hr-kg-ngmei'mg n.c. n.c. no no. 3?.6 265 254 212 60.1 166 210 1?0 AUG- hr-ngImL n.c. nfa nfa nfa n.c. nfa nfa nfa 1200* Ma nfa nfa hr-kg-ngmefmg n.c. nfa nla nfa n.c. nfa m'a nfa 120* nfa nfa nfa hr n.c. n.c. n.c. n.c. n.c. 16.9"t 15]" 18.9? 15.51? 32.01' 82.4' Females hr n.c. n.c. n.c. n.c. 8.0 24 .0 16.0 16.0 24.0 24.0 24.0 24.0lg Tm: hr n.c. n.ngme n.c. n.c. no. no 32.1 28.4 24.5 66.1 100 86.5 2'5? Omar. kg-ngr?mUmg n.c. n.c. n.c. n.c. 5.90 10.? 9.46 8.15 6.61 10.0 8.65 AUGEE hr-ngme n.c. n.c. no. no. 105 556 380 36? 1090 1860 1630 1480 n.c. n.c. n.c. n.c. 35.1 185 127 122 109 186 163 148 AUG- hr- ngme n.c. nfa nfa nfa n.c. nfa rtfa nfa 15r0* nfa nl'a nr'a AUGI. hr-kg-ngmefmg n.c. nfa nfa nfa n.c. nfa nfa nfa 157" nfa nfa nfa 11,: Hr n.c. n.c. n.c. no no 162* 152"t 13.1 21.7" 20.8? P8 Palonosetron; NT Netupitant, 35 median, dose?normalised to 1 could not be calculated 1: was used for the recoveryr animals, [le314 was 24hours, this was the maximum time between subsequent doses. Onlyr in Recovery animals, a true value for Tm was obtained after the final dose was administered: it was 48- 96hr at the high dose, approximation, ni'a'. not applicable Percentage of Netupitant exposure per period in each dose roup M1 M2 M3 Day 1 Group 2 Group 3 Group 4 Group 2 Group 3 Group 4 Group 2 Group 3 Group 4 males females CmAUG- or AUCEJ 142 114 119 32 51 41 5 12 Week 4 Group 2 Group 3 Group 4 Group 2 Group 3 Group 4 Group 2 Group 3 Group 4 males CMAUCIHfemales Cma 10]AUCIEI 189 188 20?r 36 38 32 15 13 Week 7 Group 2 Group 3 Group 4 Group 2 Group 3 Group 4 Group 2 Group 3 Group 4 males females CmAUCIH 1T0 17Week 13 Group 2 Group 3 Group 4 Group 2 Group 3 Group 4 Group 2 Group 3 Group 4 males Cm115114113351females Crwas used when AUCE was reported as approximation 1: was used for the recovery anima?s Reference ID: 3527655 87 NDA 205,718 Study no.: Study report location: Conducting laboratory and location: Date of study initiation: GLP compliance: QA statement: Drug, lot #, and % purity: Reviewer: Ke Zhang 330M01 n/a Non-Clinical Drug Safety F.Hoffmann La-Roche Ltd., Basel, Switzerland 8/20/2001 Yes Yes RO0673189-008, batch #: GPM0403, 99.6% Key Study Findings: Treatment with the test article did not significantly increase the number of revertant colonies/plate. Methods: Strains: Salmonella typhimurium strains TA1535, TA97, TA98, TA100, and TA102 Concentrations in definitive study: 5 to 500 µg/plate and 1 to 100 µg/plate (see sponsor’s tables 1 and 2 below) Basis of concentration selection: Toxicity were observed at concentrations of 200 µg/plate (-S9) and 632 µg/plate (+S9) based on reduction of background growth and reduction or absence of revertant colonies. Negative control: DMSO Positive control: See below. Formulation/Vehicle: DMSO Incubation & sampling time: The plates were incubated at 37°C for 2 days. Positive controls 89 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang TABLE A1 Reverse mxtatim assay using bacteria hurber e1: reuertam ce?lm?ies per p1ate. man Era?lug and starrlartl deviations. Study:r ML: Brill-?D1 Emeriment No.: 1 Experiment Start: 21.03.01 Method: ME Test Cmpemd: RC: Stre?in M1 nation Posi ti we Cartm] 5 (+19pr ate) T?l535 ?59 2?m' tm?mrem l3. 5 2?ami mthracme 4 Stre?in when Positive Curtm'ls W?ate) B74 849 862118 23 24 24:1 -59 sodium guide 1 Reference ID: 3527655 581 562 522:13 96 11B 103 i 10 TA1535 +59 296 262 229 i 24 +59 -59 2132 220125 331 833 31? i 23 332 349 341112 91 +59 TM -59 TA98 +59 187 136 132:8 NDA 205,718 The positive control chemicals were supplied and used as tabulated below: Reviewer: Ke Zhang Chemical 4-nitroquinoline l?oxide (NQO) Benzolajpyrene (BP) sulfonat(MMS) Supplier Batch/Lot Molecular Vehicle Stock Final S9 weight cone. cone. [Hg/mL] [ggsz] 190.2 DM SO 10 0.1 - 110H0096 252.3 DMSO 200 and 2 C13 1 l0.1 DMSO 500 5 - Study Validity: The study is valid based on the positive response in the positive control group. Results: Treatment with test article did not significantly increase the mutant frequencies as compared to the control. However, the positive control compounds produced signi?cant increases in mutant frequencies. The results are summarized in the following sponsor?s tables. Reference ID: 3527655 94 NDA 205,718 Reviewer: Ke Zhang Table 3 cont. Summary Table Small and large colony mutant frequencies and viabilities of negative controls, positive controls and treatment groups of R00673189-008 after 3 or 24 exposure in absence of metabolic activation and 3 exposure in presence of metabolic activation. Test article RS ADRS PE MF Proportion Experiment concentration (Mutants per l??viable celIS) small/large (90) small large total colonies DMSO 0 97 102 96 22 83 109 0.27 DMSO 103 98 80' 32 119 158 0.27 treatment 0.103 125 0.0.119 0.104 0.108 0.128 0.0.135 0.52 Linear trend NS MMS 5 58 54 54 398 521 1142 0.76 312M015 DMSO 0 96 94 80 30 108 143 0.28 DMSO 0 105 106 71 38 92 131 0.41 ??tment 150 0.117 0.30 10 103 104 89 35 120 161 0.29 10 77 72 72 47 116 165 0.41 20 82 70 79 35 105 147 0.127 0.38 25 57 28 84 27 108 141 0.144 0.49 27.5 38 20 85 35 70 109 0.50 27168 0.120 0.100 0.38 Linear trend NS 3" 89 82 77 139 281 485 0.49 31? 3 37 34 44 530 995 2073 0.53 NS No signi?cant increases of mutant frequency Signi?cant at 5, 1, 0.1 level 7: Adapted relative survival after treatment below 10 Reference ID: 3527655 96 NDA 205,718 Reviewer: Ke Zhang (cyclophosphamide) produced the expected increase. The results are summarized in the sponsor’s table below. 98 Reference ID: 3527655 NDA 205,718 Table 2 Reviewer: Ke Zhang Mioronuoleue Study: Group Median Values Ratio of to normoehromatie (PCEFNCE), frequency of mirronueleated polyehromatie and median values per animal, sea: and treatment group. Test item and Bose Animal Ratio PEEHCE EIN-PCE {0.13} 25o Se: Me diam" Median-i 3e: Group Sex Group Oral [loses on two consecutive days. harvest on the following day 111 1.19 0.25 2 111 0.29 0.20 3 111 0.50 0.94 0.25 4 111 1.31 0.25 5 111 0.94 0.25 Negatis?e control 0 1.07 0.15} 5 1.23 0.15 1.31 0.10 3 1.33 1.23 0.07r 0.10 9 0.22 0.0? 10 0.3? 0.20 Positis'e control: single oral dose. harvest on the following day I 1.54 1.23 2 111 1.03 0.95 3 111 0.93 0.93 1.15 1.32 4 111 0.33 1.32 5 111 0.42 1.35 {is'rlophosp hamirle 3 73 1.22 I5 1.03 0.33l 2 0.152 1.22 3 0.31 0.62 0.32 1.22 '3 0.34 1.27r 10 0.153 1.22 99 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Study Validity: The study is valid based on the positive response in the positive control group. Results: Treatment with the test article did not significantly increase the number of revertant colonies/plate, whereas the positive control compounds produced the expected significant increases in the number of revertants. The results are summarized in the sponsor’s tables below. 102 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang TABLE 3 - Experiment I - Plate ineerperatien method - TA1535 STUDY NU. 31710 SDLEFENT DMSCI Strain: TA1535 Titre: 353 Dese level Witheut metabeli: aetivatien With metabelis aetivatien Plate eeunts Kean S. E. Plate eeunts Mean 3. E. Untreated 0.3 0.0.3 1350 3.3 3500 1.3 5000 3.1 Regression analysis: Peints S3 Intersept Slepe Corr. seeff. P-value 1 3 4.143 0.0003 0.13434 3.4333 0.33433 1 4 4.353 ?0.0003 ?0.33133 1.3053 0.33037 1 5 4.133 0.0000 0.70533 3.0313 3.33337 1 3 4.131 0.0000 0.13303 3.5133 0.31353 1 3 4.537 ?0.0003 ?0.33333 1.1333 '.33333 1 4 4.334 -0.0001 ?0.r5533 3.1733 0.33353 1 5 4.373 0.0000 ?0.05713 3.3035 0.33331 1 3 4.375 0.0000 ?0.13333 3.4333 0.33503 Pesitive and negative eentrels Treatment 33 Plate seunts Mean 3. E. Untreated - 34 14 35 31 3.5 Sedium Azide ugfpl 470 433 433 433 3.5 [12-13(3- 13-0 pup: 2-4 19 2d. 2: 1.7 3-Emineanthraeene 1 31 33 103 37 5.4 103 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang TABLE 5 - Experiment I - Plate ineerperatien method - T333 NC. 31710 ESL-VENT EMS-CI Strain: TASS Titre: 255 Dese level Witheut metabeli: aetivatien With metabelis aetivatien Plate eeunts Mean 3. E. Plate eeunts Mean 3. E. Untreated 3.0 0.1.2 135000 4.0 Regression analysis: Peints S3 Intercept Elepe Corr P-value 1 3 5.553 ?0.0014 ?0.42071 1.2270 0.35350 1 4 5.545 ?0.0004 ?0.23545 0.7551 0.45130 1 5 5.575 ?0.0005 ?0.55304 3.4351 0.33534 1 5 5.455 ?0.0003 -0.47133 3.1377 0.04332 1 7 5.353 ?0.0001 ?0.23534 1.3475 0.13353 1 3 5.373 0.0000 0.00135 0.0053 0.33503 1 4 5.347 7.0001 0.23043 0.3500 0.35353 1 5 5.334 7.0000 0.03537 0.3473 0.73334 1 5 5.337 0.0000 0.30074 0.3135 0.43445 Pesitive and negative eentrels Treatment 33 Plate eeunts Mean 3 E. Lac: atfpl E-Nitrefluerene 2 ugfpl - 150 177 157 153 4.3 DEED 130 uLfPl 33 33 35 35 1.5 E-Amineanthraeene 1 ugfpl 332 335 354 377 12.1 NT: not tested 3: thinning ef the haekgreund lawn 106 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang TABLE 7 - Experiment I - Plate ineerperatien method - Tall STUDY NC.: 51710 EDLVENT: DMED Strain: Titre: 343 Dese level Witheut metabelie aetivatien With metabeli: aetivatien Plate eeunts Mean 5. E. Plate eeunts Mean 5. E. Untreated 155 166 153 155 3.5 163 133 143 145 5 0.156 164 147 133 146 13.4 HT NT MT 313 137 145 163 143 7.7 145 147 133 145 3.4 635 164 147 143 151 6.4 154 145 155 154 3.5 1350 135 137 145 137 5.3 155 135 155 151 6.4 3500 136 133 133 A 130 3.5 141 145 136 141 3.6 5000 135 140 146 A 143 3.3 134 154 165 153 1F_l Regression analysis: Peints 55 Intercept Slepe Carr. P-value 1 3 11.331 0.0013 0.35565 3.5310 0.43340 1 4 11.337 0.0007 0.34443 1.1601 0.37354 1 5 13.075 ?0.0001 ?0.13513 0.4517 0.63114 1 6 13.131 ?0.44336 1.5730 0.36603 1 7 11.555 ?0.0001 ?0.31504 0.5553 0.34533 1 3 11.567 0.0006 0.41333 1.3133 0.36363 1 4 13.057 0.0003 0.33673 0.5464 0.36633 1 5 13.153 ?0.0001 ?0.15310 3.7053 0.45375 1 6 13.117 0.0000 0.05330 0.3743 0.71370 Pesitive and negative eentrels Treatment 55 Plate :eunts Mean 5. E. Untreated - 155 165 153 155 3.9 Sedium Aside 1 ugfpl - 564 537 553 5E1 13.3 DEED 150 uprl 156 137 163 145 3.5 E-Amineanthraeene 1 ugfpl 511 535 545 535 6.4 HT: net tested A: thinning ef the haekgreund lawn 1 07 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang TABLE 5 - Experiment I - Plate incerperaticn methcd - T51555 STUDY 51720 5 ACE. Strain: TA1555 Titre: 252 Dcse level Withcut metabelic activation With metahclic activatien Plate ccunts Hean E. E. Elate ceunts Mean 3. E. Untreated 0.5 0.1.5 1250 1.2 2500 5.2 5000 1.5 Regression analysis: Pcints S5 Intercept Elcpe Ccrr. cceff. P-value 5 4.542 ?0.0005 ?0.54401 1.7155 0.12555 1 4 4.245 ?0.0001 ?0.:2555 5.7514 0.45154 1 5 4.215 ?0.0001 ?0.:4555 5.5257 0.57555 1 5 4.114 0.0001 0.57575 1.1555 0.25555 1 5 4.051 -0.0002 ?0.10505 5.2575 0.75155 1 4 5.557 0.0002 0.25775 0.5457 0.41555 1 5 5.552 ?.0005 0.45155 1.5755 0.55535 1 5 4.114 ?.0000 0.05410 5.5751 0.71555 Pcsitive and negative centrels Treatment 35 Plate ccunts Mean 3. E. Untreated - 34 14 25 21 5.5 Ecdium Aside 1 ugfpl - 470 455 ?55 455 5.5 DEED 150 uprl :4 15 24 22 1.7 ?-Rnineanthracene precipitaticn 5: thinning cf the hackgreund lawn 1 10 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang TABLE 5 - Experiment I - Plate method - WP: STUDY MG. 31730 SDLTEENT ACE. 1.: VIA Strain: WP3 uvz; Titr 363 Dcse level Witheut metabelic activaticn With metabclic activaticn Plate counts Hean 3. E. Plate ceunts Mean E. Untreated 1.5 0.1.7 1350 3500 3.0 5000 1.7 Eegressien analysis: Pcints 53 Intercept Slcpe Carr. cceff. P-value 1 3 5.632 0.0000 ?0.00063 6 0013 0.33353 1 4 5.676 0.0000 0.04410 0 1336 0.33175 1 5 5.663 0.0001 0.16434 0.6036 0.55715 1 6 5.636 0.0000 0. 3731 0.5570 0.53535 1 3 5.736 0.0000 0.00530 0.0156 0.33733 1 4 5.633 ".0003 0.33477 0.3334 0.36365 1 5 5.751 0.0000 0.05340 6.1333 0.35333 1 6 5.733 0.0000 0.33311 1.3035 0.34633 Pcsitive and negative reatment 33 Plate ccunts Mean 3. E. Untreated - 33 33 34 33 0.6 MES 530 ugfpl 133 154 163 173 13.7 DEED 30 uprl 37 33 33 36 1.5 3-Amineanthracene 10 ugfpl 137 133 133 131 3.3 P: Precipitaticn 4: thinning of the background lawn Reference ID: 3527655 112 NDA 205,718 Reviewer: Ke Zhang TABLE 6 - Experiment I - Plate incerperatien method - TA33 STUDY 31730 BOLT-TENT ACETDNE Strain: TA33 Titre: 365 Dcse level Withcut metabelic activation With metabclic activaticn Plate ceunts Eean 3. E. Plate ccunts Mean E. Untreated 3.0 0.1.5 135V 7.3 :5rr 1.5 Regression analysis: Pcints E3 Intercept Slcpe Corr. cceff. P-value 1 3 5.731 ?0.0010 ?0.45304 1.3445 0.23073 1 4 5.753 ?0.0011 ?0.70133 3.1103 0.31104 1 5 5.614 ?0.0005 ?0.57603 2.5413 0.02460 1 6 5.510 ?0.0003 ?0.4736: 2.1510 0.04710 1 7 5.363 0.0000 ?0.0l072 0.0467 0.36333 1 3 6.143 ?0.0007 ?0.51535 1.5336 0.15506 1 4 5.333 0.0000 0.01313 0.0415 0.36771 1 5 5.333 0.0000 0.01133 3.0437 0.36661 1 6 5.353 0.0001 0.32315 1.3335 0.13371 Pcsitive and negative Treatment 33 Plate ccunts Mean 3 E. DEED 100 popl 30 33 33 34 2.6 Z-Nitreflucrene 2 ugfpl - 1E0 177 167 1E3 4.3 DEED 100 popl 33 33 35 35 1.5 i-Amineanthracene 1 332 335 354 377 12.1 HT: tested P: precipitaticn net 4: thinning cf the lawn Reference ID: 3527655 113 NDA 205,718 Reviewer: Ke Zhang Study Validity: The study is valid based on the positive response in the positive control groups. Results: Treatment with the test article did not significantly increase the number of revertant colonies/plate, whereas the positive control compounds produced the expected significant increases in the number of revertants. The results are summarized in the sponsor’s tables below. 116 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang TABLE 4 - Experiment 1- Plate incerperaticn method - TA1537 STUDY 33340 3 BLT-FE NT CI Strain: TA1537 Titre: 374 Dcse level Withcut metabolic activatien With metabclic activaticn Plate ceunts Eean S. E. Plate ceunts Mean 3. E. Untreated 1.7 0.1.3 731350 0.3 3500 Regression analysis: Pcints 33 Intercept Elcpe Carr. cceff. P-value 1 3 4.747 ?0.0004 ?0.03333 0.3303 0.33133 1 4 4.667 0.0003 0.30373 1.0031 0.33717 1 5 4.373 ?0.0010 -0.43051 3.0335 0.06340 1 6 4.353 0003 ?0 65630 3.4734 0.00310 1 7 4.355 -0.0003 -0.37343 7.7310 0.03000 1 3 4.335 0 001' 0 40036 1.1577 0.33433 1 4 4.353 0.0003 0.03333 0.3153 0.75360 1 5 4.333 ?0.00r1 ?0.035lr 0.3030 0.76300 1 6 4.345 0.0r01 0.13553 0.7375 0.43635 1 - 7 5.153 ?0.74337 4.3316 0.00003 Pcsitive and negative Treatment 33 Plate ccunts Mean 3. E. DEBS 130 uprl - 13 31 36 33 3.1 3-dmineacridine 50 - 133 133 357 135 37.3 11.5130 popl 25 :2 2:5 24 3-Rmineantnracene 1 ugfpl 133 134 133 131 5.7 3: thinning of the background lawn 1 18 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang TABLE 3 - Experiment 1 - Plate ineergeratien method - TR33 STUDY NC. 3:343 NT DMSCI Strain: TA33 Titre: 274 Dese level Witheut metabelis aetivatien With metabelis aetivatien Plate eeunts Kean S. E. Plate eeunts Mean 3. E. Untreated 1.3 3.1:l.r 233V :1.3 EQFF 3.3 Regressien analysis: Peints 33 Intercept Elepe Cerr. P-value 1 3 3.331 ?3 3333 ?3.34713 3.3743 3.32147 1 4 3.322 -3.3333 ?3.43334 1.3331 3.13371 1 3 3.233 1.3331 F.11333 3.4133 3.33333 1 3 3.373 ?r.3331 ?7.137:: 3.7334 3.43333 1 3 3.333 ?3.3337 ?3.33333 1.3731 3.13733 1 4 3.373 ?3.3333 ?3.74233 3.3337 3.33333 1 3 3.334 ?3.3332 ?3.43332 1.7313 3.13133 1 3 3.341 -3.3331 ?3.33333 3.7333 3.31413 Pesitive and negative eentrels Treatment 33 Plate seunts Mean 3. E. DEED 133 uprl :1 37 23 :3 4.3 i-Nitrefluerene ugfpl - 141 131 13: 141 3.1 DEED 133 uprl 43 43 44 43 2.1 i-Emineanthraeene 1 ugfpl 443 337 433 437 33.3 120 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang I44 BACTERIAL MUTATIDN ASSAY typnimurium and E. eeli} TRELE 7 - Experiment 1 - Plate ineerperatien methed - TA100 STUDY 613.: 33346 6 DLTJE NT DMSCI Strain: T3100 Titre: 356 Dese level Witheut metabelis aetivatien With metabe1is aetivatien Plate ceunts Kean E. E. Plate seunts Mean 3. E. Untreated 165 154 137 143 11.3 156 140 161 153 6.3 0.66 133 136 155 136 6.4 163 140 140 147 7.3 35.1 146 133 145 141 4.5 136 153 176 155 11.6 73.1 130 135 163 135 11.3 166 164 150 160 156 143 136 133 134 4.5 133 145 141 140 3.5 313 133 176 163 157 13133 Regression analysis: Peints 65 Intercept Elepe Corr. P-value 1 - 3 - 11.766 0.00r4 0 03515 6.0665 0.54660 1 - 4 - 11.636 -0.0F13 ?0 1576 6.5055 0.63413 1 - 5 - 11.645 0.0F31 0.36333 1.4363 0.15647 1 - 6 - 11.363 -0 0014 -0.40317 1.7633 0.65711 1 - 3 13.145 0 0F66 ".40140 1.1535 0.36437 1 - 4 13.417 -0.0034 -V.35605 6.3376 0.43133 1 - 5 13.354 -0.0013 -V.36333 1.0107 0.33660 1 - 6 13.366 -0.0014 -0.47037 3.1315 0.64630 Pesitive and negative eentrels Treatment 65 Plate :eunts Mean 6 E. Untreated - 165 154 137 143 11.3 Sedium Aside 1 ugfpl - 5E3 553 563 566 6.6 DEED 166 uprl 163 140 146 147 7.3 3-Amineanthracene 1 ugfpl 1440 1456 1463 1433 16.6 3: thinning sf the backgreund 1awn 1 21 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang up to the day prior to sacrifice. Females were administered the same doses starting at 14 days prior to mating, continuing throughout the mating period and through day 7 of gestation Doses: 0 (vehicle), 3, 10, and 30 mg/kg/day Frequency of dosing: Once a day Dose volume: 5 ml/kg/day Route of administration: Oral gavage Formulation/Vehicle: Thixotrope vehicle as aqueous suspensions (for composition of the thixotrope vehicle, see table below) Species/Strain: Wistar rats (HanIbm:WIST) Number/Sex/Group: 25 Satellite groups: None Study design: See Sponsor’s table below Deviation from study protocol: No deviation occurred which adversely affected the quality of the study. APPEARS THIS WAY ON ORIGINAL The age of the rats was not stated. The doses used in the current study were used previously in other toxicity studies, and the high-dose (30 expected to produce adverse effects such as reduced food consumption and mg/kg/day) was body weights. 123 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang normal limits for this strain of rat. The Sponsor provided the following explanation for the presentation of median values in the table above: “For statistical analysis the median was used instead of the mean, because it is more appropriate for non-normally distributed data. For the sake of consistency the median was also used for normally distributed data.” There were no treatment-related effects on sperm motility, weight of the testis, and sperm counts. 9.2 Embryonic Fetal Development Study title: Segment II: Oral Study for Effects on Embryo-Fetal Development in the Rat Study no.: Study report location: Conducting laboratory and location: Date of study initiation: GLP compliance: QA statement: Drug, lot #, and % purity: 148R02 n/a Non-Clinical Drug Safety F. Hoffmann La-Roche Ltd., Basel, Switzerland May 15, 2002 Yes Yes RO0673189-008, lot#: BS0204SA01, 99.8% Key Study Findings: Treatment with RO0673189-008 at 30 mg/kg/day decreased body weight gain and food consumption. RO0673189-008 did not adversely affect embryo-fetal development. RO0673189-008 was not teratogenic in this study. The maternal NOAEL was 10 mg/kg/day, based on the decrease (31%) in body weight gain in the 30 mg/kg/day females. The NOEL for embryo-fetal development was 30 mg/kg/day. Methods RO0673189-008 was given to pregnant rats by oral gavage at 0 (vehicle), 3, 10 and 30 mg/kg/day during gestation days 6-17. The dose selection was based on the results of a dose ranging study in rats (study # 041R02). In this study, RO0673189-008 was given by oral gavage to pregnant rats during gestation days 6-17 at oral doses of 0, 10, 30 and 100 mg/kg/day. The high dose resulted in clinical signs of toxicity and body weight loss. Reduction of body weight gain was also noted in the mid-dose group (30 mg/kg/day). Therefore, the dose of 30 mg/kg/day was selected as the high dose for the Segment II study. 126 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Dosing Solution Analysis: The analysis of drug concentration in samples of dosing formulations from each dose-group was satisfactory. The analysis results are summarized in the following table (taken from the study report). Necropsy: There were no treatment-related changes. Cesarean Section Data There were no treatment-related effects on the number of implantations or fetuses. The results are summarized in the sponsor’s table below. 128 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang The incidence of fetuses with limb variation (tarsal hyperextension) was 1, 2, and 3 in the control, middle, (2 liters), and high-dose (3 liters) groups, respectively. This change is not considered to be drug-related, given the absence of statistical significance and incidence in the control group. Two fetuses with limb variations (pes adductus) were observed in one litter in the middle dose group. The results are summarized in the sponsor’s table below. These variations were not seen at a higher dose of 100 mg/kg/day in the dose ranging study in rats (study # 041R02). 130 Reference ID: 3527655 NDA 205,718 148R02 SEGMENT II: Reviewer: Ke Zhang TABLE 9 ORAL STUDY FOR EFFECTS ON FETAL DEVELOPMENT IN THE RAT (STUDY NO. SUMMARY OF FETAL EXTERNAL ABNORMALITIES, VARIATIONS AND RETARDATIONS CONTROL 3 10 30 Litters Evaluated 22 21 19 23 Fecuses Evaluated 262 228 198 235 Live 262 228 198 235 Dead 0 0 0 0 TOTAL ABNORMALITIES Fetal Incidence Litter Incidence 1 1 CI 0 4.5 4.8 0.0 0.0 Affected FetuseefLitter 1.5 1.0 0.0 0.0 7.11 4.36 0.00 0.00 TOTAL VARIATIONS Fetal Incidence 1.3 Litter Incidence 13.0 Affected Fetusee/Litter 00.00 3 75 2 96 148R02 TABLE 11 R00673leg?coe: SEGMENT II: ORAL STUDY FOR EFFECTS ON FETAL DEVELOPMENT IN THE RAT (STUDY NO. SUMMARY OF FETAL VISCERAL ABNORMALITIES. VARIATIONS AND RETARDATIONS CONTROL 3 10 30 Litters Evaluated 22 21 19 23 Fetueen Evaluated 139 119 105 123 Live 139 118 105 123 Dead 0 0 0 0 TOTAL ABNORMALITIES Fetal Incidence Litter Incidence 0.0 4.3 Affected FetuseE/Litter MEAN95 0.00 3 48 TOTAL VARIATIONS Fetal Incidence 7? 9 7? 10 5.0 7.6 6.7 0.1 Litter Incidence 5 7 7 22.7 33.3 36.8 26.1 Affected MEAN95 6.3 7.4 10.3 3.3 S.D. 13.52 12.81 23.02 14.34 TOTAL RETARDATIONS Fetal Incidence T.3 Litter Incidence 6 27 3 19.0 26 3 30 4 Affected Fetusee/Litter MEAN95 0 4 6 8.6 6.5 S.D. 13.54 11.18 23.11 10.7? 1 31 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang and 2 in the high dose group). One female at 30 mg/kg had total litter death. Fetal body weights at 30 mg/kg were decreased by 8% in males, as compared to the control males. Limb and paw anomalies (position anomalies) were observed with higher incidence in the middle and high dose groups. The combined incidence of all findings was 1/135, 1/126, 3/114, and 9/107 among fetuses, and 1/22, 1/22, 3/20, and 6/17 among litters, in the control, low, middle, and high-dose groups, respectively. An increased number of minimally/partially fused sternebrae was noted at 10 (9/114 fetuses, 8/20 liters) and 30 mg/kg/day (16/107 fetuses, 10/17 litters), as compared to the control group (none). Based on the increased incidence of malformations (limb and paw anomalies, minimally/partially fused sternebrae) at 10 and 30 mg/kg/day, the NOAEL for embryofetal development is considered to be 3 mg/kg/day. The NOAEL for maternal toxicity was 10 mg/kg/day, based on the loss of bodyweight in the 30 mg/kg/day group during gestation days 6-19. A consultation was sent to the Reproductive and Developmental Toxicology Subcommittee (RDTS) on March 18, 2014. The committee concluded that the limb and paw anomalies, and minimally/partially fused sternebrae were treatment-related and evidence of developmental toxicity. Methods: RO0673189-008 was given to rabbits by oral gavage during gestation days 6-18 at 0 (vehicle), 3, 10 and 30 mg/kg/day. Dose selection was based on the dose ranging study in rabbits (#1006571), in which, doses of 0, 10, 30, and 100 mg/kg/day were tested. The dose of 100 mg/kg/day was lethal. The dose of 30 mg/kg/day was tested as high dose in other toxicity studies. Doses: Frequency of dosing: Dose volume: Route of administration: Formulation/Vehicle: Species/Strain: # Females/Group: Satellite groups: Study design: Deviation from study protocol: 0 (vehicle), 3, 10, and 30 mg/kg/day Once daily 2 ml/kg Oral gavage Thixotrope vehicle as aqueous suspensions Himalayan Rabbits 20 2 females/group See sponsor’s table below No deviation occurred which adversely affected the quality of the study. 133 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Feed Consumption: Decreased food consumption was observed in the middle and high dose groups. Toxicokinetics: TK results are summarized in the following sponsor’s table. 135 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Necropsy: There were no clearly treatment related changes. Cesarean Section Data Three females had abortions (1 in the middle dose group and 2 in the high dose group). Fetal body weights in the high dose group were decreased by 8% in males, as compared to the control males (see sponsor’s table below). 137 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Offspring (Malformations, Variations, etc.) Limb and paw position anomalies were observed with higher incidence in the middle and high dose groups. The combined incidence of all findings was 1/135, 1/126, 3/114, and 9/107 among fetuses, and 1/22, 1/22, 3/20, and 6/17 among litters, in the control, low, middle, and high-dose groups, respectively. The results are summarized in the sponsor’s table below. 140 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang ABNORMAL FINDINGS FROM EXTERNAL AND FRESH VISCERAL EXAMINATION OF FETUSES - Reference ID: Group 1 Group 2 Group 3 Group 4 mgr'kg 3 1t] 3t] mg?tg Number of litters 22 22 2O 11' Number ot' fetuses 135 126 114 lnoidenoes of fetuses with ?lie Ell. "as Flight testis, enlarged; besides with clear 1 0.9 liquid Liver - small white lesion at right lateral lobe 1' 5.2 2 1.5 Gall bladder - clear contents dark content - smell [1.9 - absent ABNORMAL FINDINGS FROM FETAL HEAD SECTIONS SUMMARY Group 1 Group 2 Group 2 Group 4 D- mg?tg 3 1t] mgl'kg so mgl'kg Number ot litters 22 22 20 1? Number of tetuses 135 125 114 Incidences ot tetuses with 11; "it: ?is 1s Lateral ventricles. Dilation 2.3 Third ventricle, Dilation 4.4 19 2 1.9 Clotted blood between skull and cerebral 1 2 1.6 2 1.9 hemispheres Microglossia 1 0.9 Elrain thalamlc region, cystic dilation 1 0.9 142 3527655 NDA 205,718 Reviewer: Ke Zhang An increased number of minimally/partially fused sternebrae was noted at 10 and 30 mg/kg and was considered treatment-related (9/114 fetuses in the middle-dose group and 16/107 fetuses in the high-dose group, as compared to none in the control group). The results are summarized in the following sponsor’s table. The incidence of unilateral or bilateral supernumerary 13th ribs (half to full length of 12th rib) and/or rudimentary 13th ribs (less than half length of 12th rib) was higher in the middle and high dose groups. The incidence of supernumerary 13th ribs was 4/114 fetuses and 4/20 litters in the middle-dose group, and 7/107 fetuses and 5/17 litters in the high-dose group, as compared to 2/135 fetuses and 2/22 litters in the control group. The incidence of rudimentary 13th ribs was 3/114 fetuses and 2/20 litters in the middledose group, and 5/107 fetuses and 3/17 litters in the high-dose group, as compared to 1/135 fetuses and 1/22 litters in the control group. 143 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang SKELETAL EXAMINATIONS SMART STAGE OF DEVELOPMENT AND ON A FETUSES BASIS GROUP 1 GROUP 2 GROUP 3 GROUP 4 HGIKG 3 HGIKG 1D MGEKG 3n HGIKG NUMBER OF FETUSES EIAHINED 135 126 114 102 ABNORMAL CN PREVIOUS 22% CERVICAL CSSIFIED CERVICAL TEFTEBRAL EDDY 1 1 1% 1 1% a CERVICAL FERTEBRAL 5 1 1% ADDITIONAL DESIFICATIDH CERVICAL VERTEBRAL ARCH LEFT 0 1 1% CERVICAL VERTEERAL ARCH RIGHT 1 1% 0 STEFHUH CSSIFIED STEEHFEFA 1 1 1% 2 2% 0 ETEFNFERA STEFHFEEA 61% STEENFBRA 6 1 1% 1 1% a HDH-CSSIFIED STERNEBRA 2 1 1% STEFHEBEA 3 1 1% 0 0 STEENEBFA 4 1 1% 1 1% RIBS SHORTEHED RIB 12, LEFT 1 1% 1 1% RIB 12, RIGHT 1 1% RIBESJ, LEFT SUFBENUMFRART. ONE LEFT SUFEERUHEEARY. CHE FUDIHFHTAET LEFT FIBEEJ. RIGHT SUPEFNUHFAAET. CH3 RIGHT 1 1% 3 3% 5 5% SUPERNUHERARYT CHE RUDIHENTAFY RIGHT 2 1% 2 2% 5% LEFT FCEELIME INCOMPLETELT OFFIFIED METACAFFALIA 1. LEFT DIGIT 1 FEDEIHAL FHALANX, LEFT DIGIT 2 HEDIAL FEALAHI, LEFT 1 1% a 2 2% DIGIT 3 HIDIAL PEALANI. LEFT DIGIT 4 EILIAL LEFT 39% HITACARPALIA 5. LEFT 0 1 1% DIGIT 5 FECXIEAL PHALANX, LEFT 1 1% DIGIT 5 HIDIAL FHALANX. LEFT 133 99% 125 99% 112 92% 104 99% DICIT 4 MFDIAL LEFT a 1 1% it!? Fishar's Exact Teal; significant at level 5% or 1% 1 46 Reference ID: 3527655 ?17 NDA 205,718 9.3 Reviewer: Ke Zhang Prenatal and Postnatal Development Study title: NETUPITANT: Pre- and Post-Natal Development in the Han Wistar Rat by Oral Administration Study no.: NETU-10-23 or GEC0001 (b) (4) Study report location: Conducting laboratory and location: Date of study initiation: GLP compliance: QA statement: Drug, lot #, and % purity: June 25, 2010 Yes Yes Netupitant, Batch #:29003531, 99.6% Key Study Findings: Netupitant was administered to pregnant females from Day 6 after mating to Day 20 of lactation by oral gavage. Bodyweight gain of F0 and F1 generations was reduced in the middle and high dose groups as compared to the respective control groups. F1 males from the high dose group showed a 2-day delay in completion of balano-preputial separation when compared with the controls. Attainment of the air righting reflex was slightly delayed in the middle and high dose groups as compared to the control group. Survival, behavioral development and reproductive performance of the F1 generation and survival and growth of F2 offspring up to Day 14 of age were unaffected. None of the observed effects in the offspring (F1 generation) are considered to be adverse, based on the small magnitude of these changes. Therefore, the NOAEL for pre- and post-natal development was 30 mg/kg/day. Methods: Doses: Frequency of dosing: Dose volume: Route of administration: Formulation/Vehicle: Species/Strain: Number/Sex/Group: Satellite groups: Study design: 0, 3, 10 and 30 mg/kg/day daily 5 ml/kg Oral gavage Thixotrope as aqueous suspensions Harlan Han Wistar strain rats 22/females/group none Netupitant was administered to F0 females from Day 6 after mating to Day 20 of lactation. Deviation from study protocol: No deviation occurred which adversely affected the quality of the study. Observations and Results 148 Reference ID: 3527655 NDA 205,718 TABLE 12 Litter size - group mean values (F1) Reviewer: Ke Zhang Group 1 2 3 4 Compound . Control Nempitant Nempitant Netupitant Dose 0 3 10 30 Group Implantations Total litter size Live litter size on Day Day Before cull After cull Statistical test: Wi Wi Sh Wi 1 Mean 11.1 10.9 10.9 10Mean 11.4 10.6 10.5 10Mean 11.4 10.6 10.4 10Mean 122 11.0 10,9 10TABLE 13 sunival inclices - group mean values (Fl) Group 1 2 '3 :1 Compound Control Nempitant Netupitant Netupitant Dose (111g1'kgr?day) 0 3 10 30 Group Post implantation Lire birth Viability Lactation index 8111511111 index index index (946) 011 Day 21 Statistical test: Sh Fe Fe 1 Mean 92 . 5 100. 0 100.0 99.4L 22 22 22 22 2 Mean 92.0 99.3 100.0 100Mean 92.3 98.3 98.3 100.0 20 20 20 20 4 Mean 90.4 98.8 99.0 100Total number of born Post?iriiplautation survival index (9-0) 1 50 Reference ID: 3527655 . . . . 1; Total number 01 uternle Implantanon sues 100 NDA 205,718 Reviewer: Ke Zhang F1 Generation Survival: Offspring survival was not affected. Clinical signs: There were no treatment-related changes. Bodyweight: Bodyweights in the middle and high dose groups (male and female) were significantly lower on postnatal Days 1 to 28 (see table 15 below). Feed consumption: Food consumption was lower in the middle and high dose group as compared to the control. Physical development: The selected F1 female animals showed no delay in vaginal opening. F1 males from the high dose group showed a 2-day delay in completion of balano-preputial separation as 151 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang Neurological assessment: Attainment of the air righting reflex was slightly delayed in the middle and high dose groups, as compared to the control group (see sponsor’s table 17 below). Age at attainment of the surface righting reflex and the number of offspring showing satisfactory pupil and startle responses, motor activity, accelerating rotarod performance, learning ability and memory were unaffected by maternal treatment. Reproduction: There were no treatment-related changes in mating and fertility parameters. Other: Litter size (F2 generation), offspring survival and sex ratio were not altered by maternal treatment of F0 females. The results were presented in the sponsor’s tables 31-37 below. 153 Reference ID: 3527655 NDA 205,718 TABLE 31 Motor activity - group mean scores (beam breaks) (131) Reviewer: Ke Zhang Group 1 2 3 4 Compound Control Nempitant Netupitant Netupitant Dose 0 3 10 30 Group Number Beam Time (minutes) Sex of animals level Total Statistical testHigh 29.5 27.2 10.4 6.2 7,2 2.5 1.3 3.5 6.2 4.4 98.3 SD 16.7 20.0 14.5 8.7 11.9 3.7 4.1 10.6 12.7 9.2 56.5 2M 20 High 49.2 32.6 13.0 9.8 5.7 3.7 3.8 3.8 7.1 4.2 132.7 SD 2 .5 21 1 14.1 12.4 1?4 78 6.8 6.9 15.3 9 64.4 3M 20 High 47.7 24.7 18.7 7.0 10.0 8.6 1.9 3.6 4.6 129.8 SD 28.4 19.9 18.9 9.4 14.1 12.7 6.3 11.4 6.9 10.8 78.1 20 High 39 26.0 5.8 6.0 4.0 3.4 6.5 8.5 4.9 119.4 SD 7 15.6 13 8.6 9.8 6 7 6.3 14.3 12.0 8.4 69.3 Statistical testLow 116.2 7 .2 39.7 24.7 21.6 19.0 8.9 15.2 21.3 -0.9 363.4 SD 38 1 40.? 4'7 3 27.1 29.0 29.9 19.7 30.9 28.9 35.7 181.6 211 20 Low 146.3 79.3 5- 2 42.9 18.0 22.0 16.2 24.8 25.9 21.9 449.3 SD 57 5 22.4 28 5 39.5 22.6 212 29.1 41.8 33.5 148.4 3M 20 Low 129.9 73.1 56.8 40.1 36.2 27.2 5.9 18.3 18.0 15.9 421.0 SD 46.2 -6.2 0 2 36,9 36.4 31.5 9 40.9 27 3 23.9 186.4 41-1 20 Low 129.0 77.9 56.8 39.3 33.8 23.0 291* 25.9 31.4 23.9 4698* SD 31.3 35.4 25.6 30 5 35.7 26.9 42.0 27.8 7.6 24.2 108.3 TABLE 31 - continued Motor activity - group mean scores (beam breaks) (F1) Group 1 2 3 4 Compound Control Nempitant Netupitant Netupitant Dose 0 3 10 30 Group Number Beam Time (minutes) {Sex of animals level Total Statistical testHigh 37.2 31.4 18.3 5.9 7.5 3.6 4.6 7.4 4.5 8.8 128.8 SD 18.8 17.2 17.2 10.4 13.6 7.1 9.8 12.7 15.4 14.7 68.7 2F 20 High .8 28.5 1 7. 4.5 4.. 6.4 2.0 3.0 115.8 SD .7.1 -06 9.7 8.7 7 5 15.6 5.4 8 54.0 3F 20 High 39.9 28.1 17.4 12.8 8.3 8.1 5.8 7. 6.4 137.2 SD 20.7 14.9 14.2 13.3 16.1 145 7 17.1 11.7 10.9 85.4 4F 20 High 33.2 24.6 11.4 7.9 9.5 4.8 3.8 3.0 7.7 7.3 113.1 SD 213 20.8 13.9 11.7 17.2 98 10.1 8.5 13.1 17.7 77.5 Statistical testLOW 132.6 2.2 51.8 27.1 25.0 16.4 24.7 27.3 12.9 30.9 430.7 SD 49.2 36 5 40.1 33.3 32.2 22.6 34.9 37.6 25.5 38.1 149.0 2F 20 Low 129.2 77.4 55.5 36.5 21.6 19.6 16.9 18.9 11.0 13.5 399.9 SD 47.8 33 7 30.5 33.4 28.8 29.2 26.4 35.4 19.2 30.9 125.1 31: 20 Low 142.3 76.8 62.5 41.5 22.6 22.1 18.1 28. 34.9 24.3 473.4 SD 38.6 26.9 38. 3 27.9 26.7 31.5 30.9 37.2 44.6 32.4 188.6 4F 20 Low 116.3 71.3 46.1 37.0 42.7 18.9 19.8 16.0 33.7 1.5 435.1 SD 30.8 33.1 36.0 8.3 34.6 "0 30.8 31.1 7.5 .3 210.3 Reference ID: 3527655 NDA 205,718 TABLE 35 Pi?e-coital interval - group TGalilee (F l) Reviewer: Ke Zhang Group 1 2 3 4 Control Nempitant Nempitant Netupita nt Dos Cl 3 10 30 Numb er of Pre-coital i11ten'al (days) Gi'oup animals 1-4 5 -8 9-12 13-1 5 20 1 9 1 (95(100(an) <90) (5) (5.) TABLE 36 Mating pe?m?mance and fertility - 3111.111] value; (F1) Group 1 2 3 4 Cmnpeund Control Netupitant Nempitant Netupitant Dos 11135.51; gjdayN11111b er and Number er achieving Percentage Conception Fertilityr sex paired 111a tine ple 2113ch matine rate index 100 100 100 31-1 20 20 20 100 100 100 41Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang TABLE 38 Litter size - group mean Tvalues (F2) Group 1 2 3 4 Compound Control Netupitant Nempitaut Netupitant Dose (Illgr?ligfday) 0 3 10 30 Group Implantations Total litter size Live litter size 011 Day Day Before cull After cull Statistical test: Wi Wi Wi Wi 1 Mean 11.5 10.8 10.6 10Mean 12.8 11.8 11.8 11Mean 11.3 10.1 10.1 10Mean 13.1 11.6 11.4 11TABLE 39 Offsp?ng smTival indices - gmup mean values (F2) Group 1 2 3 4 Compomld Control Nerupitant Nerupitant Netupitant Dos-e 0 3 10 30 Group Post implantation Live b11111 Viability actation index survival index hide-x (9b) index o) on Day 14 Statistical test: Wi Fe Fe 1 L-Ieall 92.1 97.3 99.6 100.0 8 8 8 18 2 Mean 92.6 1000* 100.0 100.0 9 9 9 19 3 L-?Iezul 89.2 99.5 100.0 100Mean 89.5 97.7 99.1 100Reference ID: 3527655 NDA 205,718 10 Reviewer: Ke Zhang Special Toxicology Studies 3-Day IV local tolerance study in rabbits (# 1007324) Netupitant was given intravenously in the marginal ear vein of rabbits at 0 (vehicle control), 1, 3, and 10 mg/kg/day for 3 days. The vehicle was 5% glucose solution. Local reactions including swollen and bluish ear were noted in all treatment groups, but were more severe at the high dose. 161 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang netupitant in the presence of UVA exposure, followed by incubation in the dark for one hour. Under these conditions, netupitant was considered to be non-phototoxic. Antigenicity study (# 1007385) Netupitant was examined in male guinea pigs for active systemic and passive anaphylaxis. In the active systemic anaphylaxis test, 5 male guinea pigs were actively sensitized three times (once every other week) by subcutaneous injection of 6 mg netupitant (alone or in combination with guinea pig serum albumin) in emulsions including Freund’s adjuvant. These animals were then challenged by intravenous injection of 1 mg netupitant (alone or in combination with ovalbumin). In the passive cutaneous anaphylaxis test, 2 male guinea pigs were passively sensitized by subcutaneous injection of sera from actively sensitized guinea pigs. These animals were then challenged by intravenous injection of 1 mg netupitant (alone or in combination with ovalbumin). No signs of antigenicity were observed in these tests. In vitro phospholipidosis study in bovine corneal fibroblasts (# 1009769) To evaluate drug-induced phospholipid accumulation in cytoplasm, bovine corneal fibroblasts were cultured and treated with collagenase. The cells were then exposed to netupitant, M1, M2, or M3 at concentrations of 2.5-20 μM in the culture medium for 72 hours. Accumulated phospholipids were identified as punctuate, black intra-cytoplasmic grains or inclusions, as detected using light microscopy. The results indicated that netupitant, M1, M2 and M3 induced phospholipid accumulation in the cytoplasm at concentrations of 2.5 μM or higher. 11 Integrated Summary and Safety Evaluation The standard antiemetic drug regimen for prevention of CINV (chemotherapy-induced nausea and vomiting) includes an NK1 receptor antagonist, a 5-HT3 receptor antagonist, and a corticosteroid. AKYNZEO capsule is a fixed-dose combination of two active drug substances, netupitant and palonosetron HCl. Netupitant is an NK1 receptor antagonist, and palonosetron is a 5-HT3 receptor antagonist. Palonosetron hydrochloride is an approved drug that is available in two formulations, Aloxi® Injection (approved in 2003) and Aloxi® Capsules (approved in 2008). Aloxi® Injection is indicated for prevention of CINV and prevention of PONV (postoperative nausea and vomiting). Aloxi® Capsule is indicated for prevention of CINV only. The approved IV dose is 0.25 mg and the approved oral dose is 0.5 mg. Netupitant and palonosetron produce antiemetic effects through direct action on separate neuro-pathways (i.e. antagonism of NK1 receptors and 5-HT3 receptors, respectively). These drugs represent two pharmacologic classes in the standard regimen for prevention of CINV, and show a similar pharmacokinetic profile in terms of extended plasma half-life. These factors provided the rationale for development of AKYNZEO as a fixed-dose combination for use in the prevention of CINV. The sponsor seeks market approval of AKYNZEO for prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of highly 163 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang In the 13-week study in dogs, netupitant was tested orally at 0, 1, 3, and 10 mg/kg/day. Administration of 10 mg/kg/day resulted in vacuolated macrophages or vacuolated tingible body macrophages in the lymphoid tissue (mesenteric or mandibular lymph nodes, Peyer's patches or colonic lymphoid tissue), suggesting a drug-induced phospholipidosis. Since the microscopic lesions are not considered to be adverse, the NOAEL is 10 mg/kg/day. In the 9-month study in dogs, netupitant was tested orally at 0, 1, 3, and 10 mg/kg/day. Treatment with netupitant at 10 mg/kg/day slightly increased the QTc and PQ intervals (males only), and produced minimal periacinar hepatocytic hypertrophy (males only). The NOAEL was 10 mg/kg/day. The results from 4-week oral toxicity studies with palonosetron (RS-25259-197), submitted in NDA 21,372, are described below. In the 4-week oral toxicity study in rats, RS-25259-197 was administered at 6, 18, 60, and 180 mg/kg/day. No treatment-related mortality was observed, but a mild decrease in hemoglobin, other hematology parameters, and liver enzymes were reported in animals in the 60 and 180 mg/kg/day groups. The identified target organs of toxicity in males were liver (increased weights, hepatocellular swelling and glycogen deposition along with decreased liver enzymes) and testes (reduced weights and histological correlates of degeneration/necrosis of the seminiferous epithelium and immature spermatogenic cells in the epididymis). In females, thymus (reduced weight, gross findings of small thymus and histological findings of thymic lymphoid atrophy) was the identified target organ of toxicity. The dose of 18 mg/kg/day was the no effect dose. In the 4-week oral toxicity study in dogs, RS-25259-197 was administered at doses of 2, 6, and 20 mg/kg/day. Only transient clinical signs of salivation were observed in the 6 and 20 mg/kg/day groups. Reductions in absolute and relative weights of testes were observed at the 20 mg/kg dose, but there were no gross or histological correlates. No target organs of toxicity were identified in this study and the high dose of 20 mg/kg/day was considered as the no effect dose. 13-week oral toxicity studies with the combination of palonosetron and netupitant were performed in rats and dogs. In the 13-week oral toxicity study in rats, netupitant was administered at 1, 3, and 10 mg/kg/day in combination with palonosetron at 2, 6, and 18 mg/kg/day, respectively, by oral gavage. Additional groups were treated orally with 10 mg/kg/day netupitant or 18 mg/kg/day palonosetron. Slight increases in absolute and relative liver weights were noted in the high-dose combination group, the netupitant only group, and the palonosetron only group (up to 120% of the mean control weight). Histopathological examination revealed adrenal zona fasciculata hypertrophy, hepatocytic hypertrophy, and syncytial macrophages in the mesenteric lymph nodes, mainly in the high-dose combination and netupitant only groups. These effects are not considered to be adverse. Therefore, the NOAEL was 10 mg/kg/day netupitant + 18 mg/kg/day palonosetron. 165 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang The table below summarizes the animal to human AUC multiples for netupitant, calculated from the animal AUC values associated with the NOAEL. Although the multiples from the general toxicity studies in rats and dogs ranged from 0.4 to 1.8, the mild toxicity that occurred in these studies does not raise a concern for the expected plasma exposure in humans at the recommended dose. Furthermore, given that AKYNZEO will be used intermittently administered once with each cycle of chemotherapy), there is minimal concern about the absence of toxicity data obtained with higher systemic exposures to netupitant in repeat-dose studies. It is noted that dose selection for the 13-week and 9-month dog studies was based on 7-day and 4- week oral toxicity studies in dogs, which showed weight loss and aggregates of foamy or vacuolated macrophages in tissue and intestinal mucosa, suggestive of phospholipidosis. These effects occurred at 15 mg/kg/day and higher. Toxicity Study Species NOAEL Exposure (AUC) at Multiples of (mg/kg/day) NOAEL (ng-hr/mL) 13-week oral Rat M: 10 M: 14,000 M: 1 F: 10 F: 26,600 F: 1.8 26-week oral Rat M: 3 M: 6510 M: 0.5 F: 3 F: 17,200 F: 1.2 13-week oral Dog M: 10D M: 11,000 M: 0.8 F: 10b F: 6470 F: 0.4 9-month oral Dog M: 10b M: 20,500 M: 1.4 F: 10b F: 12,400 F: 0.9 Segment 2 Rat F: 30b 52,600 3.7 Reproductive Rabbit F: 3 816 0.06 a: Human exposure at MRHD (300 mg): AUC 14,401 ng?hr/mL b: Highest dose tested The plasma metabolite profile in humans differs substantially from that of rats and dogs. In humans, plasma exposure to the unchanged drug is predominant, with an AUC of at least 3 times that of the major metabolites M1, M2, or M3. In contrast, the AUC for M1 in the rat and dog toxicity studies either exceeded or was similar to the AUC for unchanged drug. The proportional exposure to M1 in rats and dogs was generally increased with dose. In summary, netupitant alone was tested orally for up to 26-weeks in rats and 9?months in dogs. Treatment with netupitant induced phospholipidosis in both rats and dogs. The clinical significance of phospholipidosis in these studies is not clear. Incubation of cultured bovine corneal fibroblasts with netupitant, M1, M2 or M3 also produced phospholipidosis. Oral toxicity studies of 13-weeks duration with the combination of netupitant and palonosetron were performed in rats and dogs. The combination of netupitant and palonosetron did not produce additional toxicity as compared to either compound given alone. Netupitant was negative in the Ames test, mouse cell mutation assay, and rat micronucleus test. Based on the findings in the segment embryo-fetal development study with netupitant in rabbits, AKYNZEO is 1 68 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang developmentally toxic and should be given a Pregnancy Category C. From a nonclinical standpoint, this NDA should be approved for the proposed indication. In addition, an oral toxicity study with netupitant alone of at least 8 weeks duration in juvenile rats is needed to support the proposed pediatric clinical efficacy study in patients age 0 to < 17 years. The juvenile rat study should include evaluation of developmental parameters, neurobehavioral effects, and fertility. The sponsor should submit the juvenile rat study protocol for review and evaluation prior to initiation of this study. The sponsor’s proposed timeline for the pediatric study plan should be adjusted according to these recommendations. Reviewer Signature ___________________________________ Ke Zhang, Ph.D. Pharmacologist Division of Gastroenterology and Inborn Errors Products Supervisor Signature__________________________________ David B. Joseph, Ph.D. Lead Pharmacologist Division of Gastroenterology and Inborn Errors Products cc: Orig NDA 205,718 DGIEP DGIEP/PM DGIEP/D. Joseph DGIEP/K. Zhang DGIEP/R. He R/D Init.: D. Joseph 6/17/14 169 Reference ID: 3527655 NDA 205,718 Reviewer: Ke Zhang In the 13-week oral toxicity study, rats were treated with netupitant at 0, 3, 10, and 30 mg/kg/day. Treatment with netupitant decreased the terminal body weight gain by 12% in males and 19% in females in the high dose group. A slight change in the terminal body weight gain was noted in the mid dose group (10 mg/kg/day). Treatment with netutipant induced phospholipidosis in a dose dependent manner. Minimal necrosis was noted in the liver in four high dose females (none in other groups). Based on the effects on the body weight, the MTD is estimated to be between doses of 10 and 30 mg/kg/day. The decreasing terminal body weight gain at the high dose of 30 mg/kg/day in males (12%) suggests that the MTD is about 30 mg/kg/day. There was no other dose limiting toxicity found in males at this dose. Therefore, the dose of 30 mg/kg/day is considered as MTD for males. Executive CAC Recommendations and Conclusions: The Committee noted that this indication would not normally trigger the need for a carcinogenicity study; however, a carcinogenicity evaluation may be needed to support other indications. The Committee recommended doses of 0 (water gavage), 0 (vehicle), 2, 6, and 20 mg/kg/day for females and 0 (water gavage), 0 (vehicle), 3, 10, and 30 mg/kg/day for males, by oral gavage, based on MTD (decreased body weight gain). The Committee recommended that the sponsor use both untreated (water gavage) and vehicle controls. Hematology and clinical chemistry are generally not needed for 2-year carcinogenicity studies. Main study animals should not be bled during the study. David Jacobson-Kram, Ph.D. Chair, Executive CAC cc:\ /Division File, DGP /Grewal, DGP /Chakder, DGP /Zhang, DGP /ASeifried, OND IO 171 Reference ID: 3527655 Comments on N205718 netupitant and palanosetron, Akynzeo From: A. Jacobs, AD Date: 6/18/14 1. I concur that there are no pharm/tox approval issues. 2. I concur with the pregnancy category of C 3. I have conveyed other comments to the reviewer, and they will be addressed as appropriate. Reference ID: 3527735