Myozyme (Alglucosidase Alfa) - Description and Clinical Pharmacology

DESCRIPTION

MYOZYME (alglucosidase alfa), a lysosomal glycogen-specific enzyme, consists of the human enzyme acid alpha-glucosidase (GAA), encoded by the most predominant of nine observed haplotypes of this gene. MYOZYME is produced by recombinant DNA technology in a Chinese hamster ovary cell line. The MYOZYME manufacturing process differs from that for LUMIZYME, resulting in differences in some product attributes. Alglucosidase alfa degrades glycogen by catalyzing the hydrolysis of alpha‑1,4‑ and alpha‑1,6‑ glycosidic linkages of lysosomal glycogen.

Alglucosidase alfa is a glycoprotein with a calculated mass of 99,377 daltons for the polypeptide chain, and a total mass of approximately 110 kilo Daltons, including carbohydrates.  Alglucosidase alfa has a specific activity of 3 to 5 U/mg (one unit is defined as that amount of activity that results in the hydrolysis of 1 µmole of synthetic substrate per minute under the specified assay conditions). MYOZYME is intended for intravenous infusion. It is supplied as a sterile, nonpyrogenic, white to off-white, lyophilized cake or powder for reconstitution with 10.3 mL Sterile Water for Injection, USP. Each 50 mg vial contains 52.5 mg alglucosidase alfa, 210 mg mannitol, 0.5 mg polysorbate 80, 9.9 mg sodium phosphate dibasic heptahydrate, 31.2 mg sodium phosphate monobasic monohydrate. Following reconstitution as directed, each vial contains 10.5 mL reconstituted solution and a total extractable volume of 10 mL at 5.0 mg/mL alglucosidase alfa.  MYOZYME does not contain preservatives; each vial is for single use only.

CLINICAL PHARMACOLOGY

Mechanism of Action

Pompe disease (glycogen storage disease type II, GSD II, glycogenosis type II, acid maltase deficiency) is an inherited disorder of glycogen metabolism caused by the absence or marked deficiency of the lysosomal enzyme GAA.

MYOZYME provides an exogenous source of GAA.  Binding to mannose-6-phosphate receptors on the cell surface has been shown to occur via carbohydrate groups on the GAA molecule, after which it is internalized and transported into lysosomes, where it undergoes proteolytic cleavage that results in increased enzymatic activity. It then exerts enzymatic activity in cleaving glycogen.

Pharmacokinetics

The pharmacokinetics of alglucosidase alfa were evaluated in 13 patients of age ranging from 1 month to 7 months with infantile-onset Pompe disease who received 20 mg/kg (as an approximate 4-hour infusion) or 40 mg/kg (as an approximate 6.5-hour infusion) of MYOZYME every 2 weeks. The measurement of alglucosidase alfa plasma concentration was based on an activity assay using an artificial substrate.  Systemic exposure was approximately dose proportional between the 20 and 40 mg/kg doses. Based on the pharmacokinetic blood samples collected for 12 hours after a 4-hr intravenous infusion of 20 mg/kg (n=5), the estimated mean AUC was 811 mcg•hr/mL with 17% coefficient of variation [CV], Cmax 162 mcg/mL with 19% CV, clearance 25 mL/hr/kg with 16% CV, and half-life 2.3 hr with 17% CV.

The pharmacokinetics of alglucosidase alfa were also evaluated in a separate trial in 14 patients of age ranging from 6 months to 3.5 years with Pompe disease who received 20 mg/kg of MYOZYME as an approximate 4-hour infusion every 2 weeks. The pharmacokinetic parameters were similar to those observed for the 20 mg/kg dose group in the trial of patients of age ranging from 1 month to 7 months.

Nineteen of 21 patients who received treatment with MYOZYME and had pharmacokinetics and antibody titer data available at Week 12 developed antibodies to alglucosidase alfa. Five patients with antibody titers ≥ 12,800 at Week 12 had an average increase in clearance of 50% (range 5% to 90%) from Week 1 to Week 12. The other 14 patients with antibody titers < 12,800 at Week 12 had similar average clearance values at Week 1 and Week 12.

NONCLINICAL TOXICOLOGY

Carcinogenesis, Mutagenesis, Impairment of Fertility

Long-term studies in animals to evaluate carcinogenic potential or studies to evaluate mutagenic potential have not been performed with MYOZYME.

MYOZYME at intravenous doses up to 40 mg/kg, administered every other day (plasma AUC of 64.6 mg•min/mL, 0.4 times the human steady-state exposure at the recommended bi-weekly dose) had no effect on fertility and reproductive performance in mice.

CLINICAL STUDIES

The safety and efficacy of MYOZYME were assessed in 2 separate clinical trials in 39 Pompe disease patients, who ranged in age from 1 month to 3.5 years at the time of first infusion.

Study 1 was an international, multicenter, open-label, clinical trial of 18 infantile-onset Pompe disease patients. This study was conducted between 2003 and 2005. Patients were randomized equally to either 20 mg/kg or 40 mg/kg MYOZYME every two weeks, with length of treatment ranging from 52 to 106 weeks. Enrollment was restricted to patients ages 7 months or less at first infusion with clinical signs of Pompe disease, with cardiac hypertrophy, and who did not require ventilatory support at study entry.

Efficacy was assessed by comparing the proportions of MYOZYME-treated patients who died or needed invasive ventilator support with the mortality experience of an historical cohort of untreated infantile-onset Pompe patients with similar age and disease severity. In the historical cohort, 61 untreated patients with infantile-onset Pompe disease diagnosed by age 6 months, born between 1982 and 2002, were identified by a retrospective review of medical charts. By the age of 18 months, only one of the 61 historical control patients was alive (98% mortality).

Within the first 12 months of treatment, 3 of 18 MYOZYME-treated patients required invasive ventilatory support (17%, with 95% confidence interval 4% to 41%); there were no deaths. With continued treatment beyond 12 months, 4 additional patients required invasive ventilatory support, after receiving between 13 and 18 months of MYOZYME treatment; 2 of these 4 patients died after receiving 14 and 25 months of treatment, and after receiving 11 days and 7.5 months of invasive ventilatory support, respectively. No other deaths were reported through a median follow-up of 20 months. Survival without invasive ventilatory support was greater in the MYOZYME-treated patients (83%) as compared with overall survival in the historical control group (2%). No differences in outcome were observed between patients who received 20 mg/kg versus 40 mg/kg.

Other outcome measures in this study included unblinded assessments of motor function by the Alberta Infant Motor Scale (AIMS). The AIMS is a measure of infant motor performance that assesses motor maturation of the infant through age 18 months and is validated for comparison to normal, healthy infants.  AIMS-assessed gains in motor function occurred in 13 patients.  In the majority of patients, motor function was substantially delayed compared to normal infants of comparable age. The continued effect of MYOZYME treatment over time on motor function is unknown. Two of 9 patients who had demonstrated gains in motor function after 12 months of MYOZYME treatment and continued to be followed regressed despite treatment.

Changes from baseline to Month 12 in left ventricular mass index (LVMI), an evaluation of bioactivity, were measured by echocardiography. For the 15 patients with both baseline and Month 12 echocardiograms, all had decreases from baseline in LVMI (mean decrease 118 g/m², range 45 to 193 g/m²). The magnitude of the decrease in LVMI did not correlate with the clinical outcome measure of ventilator-free survival.

Study 2 was an international, multicenter, non-randomized, open-label clinical trial that enrolled 21 patients who were ages 3 months to 3.5 years at first treatment. All patients received 20 mg/kg MYOZYME every other week for up to 104 weeks. Five of 21 patients were receiving invasive ventilatory support at the time of first infusion.

The primary outcome measure was the proportion of patients alive at the conclusion of treatment. At the 52–week interim analysis, 16 of 21 patients were alive. Sixteen patients were free of invasive ventilatory support at the time of first infusion: of these, 4 died, 2 required invasive ventilatory support, and 10 were free of invasive ventilatory support after 52 weeks of treatment. For the 5 patients who were receiving invasive ventilatory support at baseline, 1 died, and 4 remained on invasive ventilatory support at Week 52. The status of patients at Week 52 overlapped with that of an untreated historical group of patients, and no effect of MYOZYME treatment could be determined.