Proposal To Refuse To Approve a New Drug Application for Sotagliflozin Oral Tablets, 200 Milligrams and 400 Milligrams; Opportunity for a Hearing, 12471-12473 [2021-04342]
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Federal Register / Vol. 86, No. 40 / Wednesday, March 3, 2021 / Notices
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Food and Drug Administration
[Docket No. FDA–2021–N–0208]
Proposal To Refuse To Approve a New
Drug Application for Sotagliflozin Oral
Tablets, 200 Milligrams and 400
Milligrams; Opportunity for a Hearing
AGENCY:
Food and Drug Administration,
HHS.
ACTION:
Notice.
The Director of the Center for
Drug Evaluation and Research (Center
Director) of the Food and Drug
Administration (FDA or Agency) is
proposing to refuse to approve a new
drug application (NDA) submitted by
Lexicon Pharmaceuticals, Inc. (Lexicon)
for sotagliflozin oral tablets, 200
milligrams (mg) and 400 mg, in its
present form. This notice summarizes
the grounds for the Center Director’s
proposal and offers Lexicon an
opportunity to request a hearing on the
matter.
DATES: Submit either electronic or
written requests for a hearing by April
2, 2021; submit data, information, and
analyses in support of the hearing and
any other comments by May 3, 2021.
ADDRESSES: You may submit hearing
requests, documents in support of the
hearing, and any other comments as
follows. Please note that late, untimely
filed requests and documents will not
be considered. Electronic requests for a
hearing must be submitted on or before
April 2, 2021; electronic documents in
support of the hearing and any other
comments must be submitted on or
before May 3, 2021. The https://
www.regulations.gov electronic filing
system will accept hearing requests
until 11:59 p.m. Eastern Time at the end
of April 2, 2021, and will accept
documents in support of the hearing
and any other comments until 11:59
p.m. Eastern Time at the end of May 3,
2021. Documents received by mail/hand
delivery/courier (for written/paper
submissions) will be considered timely
if they are postmarked or the delivery
service acceptance receipt is on or
before these dates.
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SUMMARY:
Electronic Submissions
Submit electronic comments in the
following way:
• Federal eRulemaking Portal:
https://www.regulations.gov. Follow the
instructions for submitting comments.
Comments submitted electronically,
including attachments, to https://
www.regulations.gov will be posted to
the docket unchanged. Because your
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comment will be made public, you are
solely responsible for ensuring that your
comment does not include any
confidential information that you or a
third party may not wish to be posted,
such as medical information, your or
anyone else’s Social Security number, or
confidential business information, such
as a manufacturing process. Please note
that if you include your name, contact
information, or other information that
identifies you in the body of your
comments, that information will be
posted on https://www.regulations.gov.
• If you want to submit a comment
with confidential information that you
do not wish to be made available to the
public, submit the comment as a
written/paper submission and in the
manner detailed (see ‘‘Written/Paper
Submissions’’ and ‘‘Instructions’’).
Written/Paper Submissions
Submit written/paper submissions as
follows:
• Mail/Hand delivery/Courier (for
written/paper submissions): Dockets
Management Staff (HFA–305), Food and
Drug Administration, 5630 Fishers
Lane, Rm. 1061, Rockville, MD 20852.
• For written/paper comments
submitted to the Dockets Management
Staff, FDA will post your comment, as
well as any attachments, except for
information submitted, marked and
identified, as confidential, if submitted
as detailed in ‘‘Instructions.’’
Instructions: All submissions received
must include the Docket No. FDA–
2021–N–0208 for ‘‘Proposal to Refuse to
Approve a New Drug Application for
Sotagliflozin Oral Tablets, 200
Milligrams and 400 Milligrams;
Opportunity for a Hearing.’’ Received
comments, those filed in a timely
manner (see ADDRESSES), will be placed
in the docket and, except for those
submitted as ‘‘Confidential
Submissions,’’ publicly viewable at
https://www.regulations.gov or at the
Dockets Management Staff between 9
a.m. and 4 p.m., Monday through
Friday, 240–402–7500.
• Confidential Submissions—To
submit a comment with confidential
information that you do not wish to be
made publicly available, submit your
comments only as a written/paper
submission. You should submit two
copies total. One copy will include the
information you claim to be confidential
with a heading or cover note that states
‘‘THIS DOCUMENT CONTAINS
CONFIDENTIAL INFORMATION.’’ The
Agency will review this copy, including
the claimed confidential information, in
its consideration of comments. The
second copy, which will have the
claimed confidential information
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redacted/blacked out, will be available
for public viewing and posted on
https://www.regulations.gov. Submit
both copies to the Dockets Management
Staff. If you do not wish your name and
contact information to be made publicly
available, you can provide this
information on the cover sheet and not
in the body of your comments and you
must identify this information as
‘‘confidential.’’ Any information marked
as ‘‘confidential’’ will not be disclosed
except in accordance with 21 CFR 10.20
and other applicable disclosure law. For
more information about FDA’s posting
of comments to public dockets, see 80
FR 56469, September 18, 2015, or access
the information at: https://
www.govinfo.gov/content/pkg/FR-201509-18/pdf/2015-23389.pdf.
Docket: For access to the docket to
read background documents or the
electronic and written/paper comments
received, go to https://
www.regulations.gov and insert the
docket number, found in brackets in the
heading of this document, into the
‘‘Search’’ box and follow the prompts
and/or go to the Dockets Management
Staff, 5630 Fishers Lane, Rm. 1061,
Rockville, MD 20852, 240–402–7500.
FOR FURTHER INFORMATION CONTACT:
Kevin Fain, Center for Drug Evaluation
and Research, Food and Drug
Administration, 10903 New Hampshire
Ave., Bldg. 22, Rm. 6419, Silver Spring,
MD 20993, 301–796–5842, Kevin.Fain@
fda.hhs.gov.
SUPPLEMENTARY INFORMATION:
I. Proposal To Refuse To Approve NDA
210934
Sanofi-aventis U.S. LLC (Sanofi),
Lexicon’s predecessor-in-interest,
submitted NDA 210934 for sotagliflozin
oral tablets in 200 and 400 mg strengths
on March 22, 2018, pursuant to section
505(b)(1) of the Federal Food, Drug, and
Cosmetic Act (FD&C Act) (21 U.S.C.
355(b)(1)). Sanofi proposed that
sotagliflozin tablets be indicated as an
adjunct to insulin therapy to improve
glycemic control in adults with type 1
diabetes mellitus (T1DM).
On March 22, 2019, the Office of Drug
Evaluation II (ODE II) in the Office of
New Drugs (OND) in FDA’s Center for
Drug Evaluation and Research (CDER)
issued a complete response letter to
Sanofi under § 314.110(a) (21 CFR
314.110(a)) stating that NDA 210934
could not be approved in its present
form, describing the specific
deficiencies, and, where possible,
recommending ways that Sanofi might
remedy these deficiencies. The
application in its present form is not
approvable because the data submitted
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Federal Register / Vol. 86, No. 40 / Wednesday, March 3, 2021 / Notices
do not show that the drug is safe under
the proposed conditions of use. The
deficiencies, which are summarized
below, include the following:
(1) The data demonstrated that the
addition of sotagliflozin to insulin is
associated with an increased risk of
diabetic ketoacidosis (DKA), a serious
and often life-threatening consequence
of insulin insufficiency.
a. In particular, the submitted clinical
trial data showed a nearly 8-fold excess
risk of DKA associated with
sotagliflozin. Based on an FDA analysis
of all three trials, an overall estimated
hazard ratio (95 percent confidence
interval) for DKA associated with
sotagliflozin was 7.9 (3.2, 19.9).
b. The majority of these cases required
hospitalization and treatment in the
intensive care unit, which underscores
the seriousness of this risk.
c. Although DKA is an inherent risk
in T1DM, the magnitude of excess risk,
severity of the cases, and characteristics
of DKA (e.g., euglycemic DKA)
associated with sotagliflozin treatment
raised significant safety concerns,
particularly because they occurred in a
clinical trial setting, where patients are
carefully selected for enrollment and
receive more intensive safety
monitoring than in clinical practice.
d. Time-to-event analyses of the
clinical trial data showed earlier
development of DKA in sotagliflozintreated patients than in patients
assigned to placebo, without evidence
that the risk stopped increasing over
time.
e. The clinical trial data did not
identify a patient group at lower risk of
DKA, but instead showed the DKA risk
was associated with sotagliflozin
regardless of sex, age, duration of
diabetes, method of insulin delivery, or
body mass index.
f. Overall, risk mitigation strategies
used in the clinical trials were not
sufficient to address the excess DKA
risk observed in the clinical trials, as
evidenced by the nearly 8-fold excess
risk.
g. Data analyses assessing the impact
of risk mitigation strategies
implemented during the course of the
trials were inadequate to provide
reassurance that these strategies would
be successful in reducing DKA risk postapproval.
(2) The data demonstrated the
significant DKA risk resulting from the
addition of sotagliflozin to insulin was
not justified by the drug’s modest
clinical benefits.
a. The data showed that sotagliflozin
reduced HbA1c, a validated surrogate
endpoint for clinical benefits expected
due to improved glycemic control in the
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treatment of diabetes mellitus, including
T1DM. However, the effect on HbA1c in
the sotagliflozin clinical trials was
modest.
b. In the three pivotal trials, addition
of sotagliflozin to insulin resulted in
statistically significant reductions in
HbA1c at Week 24. The treatment
difference relative to placebo was
approximately ¥0.3 percent with
sotagliflozin 200 mg and ¥0.4 percent
with sotagliflozin 400 mg.
c. In the extension of two pivotal
trials to 52 weeks, the effect of
sotagliflozin on HbA1c was smaller
(¥0.23 percent and ¥0.33 percent
HbA1c reductions with the 200 mg and
400 mg doses, respectively), and there
are no longer term data to evaluate
persistence of effect. The decrease in
treatment effect from Week 24 to Week
52 is clinically relevant, as the major
benefits to consider with sotagliflozin
treatment are related to improved longterm glycemic control reducing the risk
of microvascular complications.
d. The improved HbA1c associated
with sotagliflozin was not accompanied
by an increased rate of hypoglycemia
(defined as glucose ≤ 55 mg/dL) in the
clinical trials, an adverse clinical effect
that occurs with insulin therapy;
however, this observation does not
outweigh the increased rate of DKA. The
data did not show sotagliflozin was
associated with an overall decrease in
the rate of severe hypoglycemia.
e. In addition to improved glycemic
control, other clinical benefits
associated with sotagliflozin, small
reductions in body weight and blood
pressure, were not sufficient to
outweigh the serious risk of DKA.
f. The data did not show that
sotagliflozin was associated with an
effect on glycemic variability and timein-range that provided benefits distinct
from reduced HbA1c.
g. Patient reported outcome measures
were not adequate in directly reflecting
important aspects of the patient’s
experience with T1DM and how
sotagliflozin treatment affected these
important aspects.
The complete response letter stated
that Sanofi is required either to resubmit
the application, fully addressing all
deficiencies listed in the letter, or take
other actions available under § 314.110
(i.e., withdraw the application or
request an opportunity for a hearing).
Applicable regulations, including 21
CFR 10.75, also provide a mechanism
for applicants to obtain formal review of
one or more decisions reflected in a
complete response letter (see FDA’s
guidance for industry and review staff
‘‘Formal Dispute Resolution: Sponsor
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Appeals Above the Division Level’’
(May 2019)).1
Sanofi submitted a formal dispute
resolution request (FDRR) on September
3, 2019, concerning the complete
response letter issued by ODE II. Peter
Stein, Director of CDER’s OND, denied
the FDRR by correspondence dated
November 29, 2019, based on his
determination that the drug’s
immediate, sustained, and substantial
increase in DKA risk outweighed the
modest benefit on glycemic control and
any potential additional benefits (e.g.,
reductions in body weight and blood
pressure). Sanofi submitted another
FDRR on December 19, 2019, for review
of the OND denial. On January 30, 2020,
FDA was notified that NDA 210934 had
been transferred from Sanofi to Lexicon.
Robert Temple, Deputy Director for
Clinical Science, CDER, denied the
second FDRR on behalf of CDER by
correspondence dated March 11, 2020,
based on his determination that the
drug’s DKA risk outweighed its benefits,
reaffirming the reasoning in OND’s
denial of the prior FDRR.
On November 10, 2020, Lexicon
submitted a request for an opportunity
for a hearing under § 314.110(b)(3) on
whether there are grounds under section
505(d) of the FD&C Act for denying
approval of NDA 210934.
II. Notice of Opportunity for a Hearing
For the reasons stated above and as
explained in further detail in the
complete response letter and the
November 29, 2019, and March 11,
2020, FDRR denials, notice is given to
Lexicon and all other interested persons
that the Center Director proposes to
issue an order refusing to approve NDA
210934 on the grounds that the
application fails to meet the criteria for
approval under section 505(d)(2) of the
FD&C Act because data submitted in the
application do not show that the
product would be safe under the
proposed conditions of use.2
Lexicon may request a hearing before
the Commissioner of Food and Drugs
1 Available at https://www.fda.gov/media/
126910/download. FDA updates guidances
periodically. To make sure you have the most
recent version of a guidance, check the FDA Drugs
guidance web page at https://www.fda.gov/drugs/
guidance-compliance-regulatory-information/
guidances-drugs.
2 Section 505(d)(2) of the FD&C Act provides that
FDA shall refuse to approve an NDA if ‘‘the results
of . . . tests show that such drug is unsafe for use
under [the] conditions [prescribed, recommended,
or suggested in the proposed labeling] or do not
show that such drug is safe for use under such
conditions[.]’’ For the reasons explained in this
notice, CDER has concluded that the data and
information submitted in the NDA do not show that
the drug is safe for use under the proposed
conditions of use.
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Federal Register / Vol. 86, No. 40 / Wednesday, March 3, 2021 / Notices
(the Commissioner) on the Center
Director’s proposal to refuse to approve
NDA 210934. If Lexicon decides to seek
a hearing, it must file: (1) A written
notice of participation and request for a
hearing (see the DATES section) and (2)
the studies, data, information, and
analyses relied upon to justify a hearing
(see the DATES section), as specified in
§ 314.200 (21 CFR 314.200).
As stated in § 314.200(g), a request for
a hearing may not rest upon allegations
or denials, but must present specific
facts showing that there is a genuine
and substantial issue of fact that
requires a hearing to resolve. We note in
this regard that because CDER proposes
to refuse to approve NDA 210934 based
on the multiple deficiencies
summarized above, any hearing request
from Lexicon must address all of those
deficiencies. Failure to request a hearing
within the time provided and in the
manner required by § 314.200
constitutes a waiver of the opportunity
to request a hearing. If a hearing request
is not properly submitted, FDA will
issue a notice refusing to approve NDA
210934.
The Commissioner will grant a
hearing if there exists a genuine and
substantial issue of fact or if the
Commissioner concludes that a hearing
would otherwise be in the public
interest (§ 314.200(g)(6)). If a hearing is
granted, it will be conducted according
to the procedures provided in 21 CFR
parts 10 through 16 (21 CFR 314.201).
Paper submissions under this notice
of opportunity for a hearing should be
filed in one copy. Except for data and
information prohibited from public
disclosure under 21 U.S.C. 331(j) or 18
U.S.C. 1905, submissions may be seen
in the Dockets Management Staff Office
between 9 a.m. and 4 p.m., Monday
through Friday, and on the internet at
https://www.regulations.gov. This notice
is issued under section 505(c)(1)(B) of
the FD&C Act and §§ 314.110(b)(3) and
314.200.
Dated: February 25, 2021.
Patrizia Cavazzoni,
Acting Director, Center for Drug Evaluation
and Research.
[FR Doc. 2021–04342 Filed 3–2–21; 8:45 am]
BILLING CODE 4164–01–P
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DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Food and Drug Administration
[Docket No. FDA–2020–N–1413]
Michael Gurry: Final Debarment Order
AGENCY:
Food and Drug Administration,
HHS.
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17:29 Mar 02, 2021
Jkt 253001
ACTION:
Notice.
The Food and Drug
Administration (FDA or Agency) is
issuing an order under the Federal
Food, Drug, and Cosmetic Act (FD&C
Act) permanently debarring Michael
Gurry from providing services in any
capacity to a person that has an
approved or pending drug product
application. FDA bases this order on a
finding that Mr. Gurry was convicted of
a felony under Federal law for conduct
that relates to the regulation of a drug
product under the FD&C Act. Mr. Gurry
was given notice of the proposed
permanent debarment and an
opportunity to request a hearing to show
why he should not be debarred. As of
October 22, 2020 (30 days after receipt
of the notice), Mr. Gurry had not
responded. Mr. Gurry’s failure to
respond and request a hearing
constitutes a waiver of his right to a
hearing concerning this action.
DATES: This order is applicable March 8,
2021.
ADDRESSES: Submit applications for
termination of debarment to the Dockets
Management Staff, Food and Drug
Administration, 5630 Fishers Lane, Rm.
1061, Rockville, MD 20852, 240–402–
7500, or at https://www.regulations.gov.
FOR FURTHER INFORMATION CONTACT:
Jaime Espinosa (ELEM–4029) Division
of Enforcement, Office of Strategic
Planning and Operational Policy, Office
of Regulatory Affairs, Food and Drug
Administration, 12420 Parklawn Drive,
Rockville, MD 20857, 240–402–8743,
debarments@fda.hhs.gov.
SUPPLEMENTARY INFORMATION:
SUMMARY:
I. Background
Section 306(a)(2)(B) of the FD&C Act
(21 U.S.C. 335a(a)(2)(B)) requires
debarment of an individual from
providing services in any capacity to a
person that has an approved or pending
drug product application if FDA finds
that the individual has been convicted
of a felony under Federal law for
conduct relating to the regulation of any
drug product under the FD&C Act. On
January 13, 2020, Mr. Gurry was
convicted as defined in section 306(l)(1)
of the FD&C Act when judgment was
entered against him in the U.S. District
Court for the District of Massachusetts,
after a jury verdict, on one count of
racketeering conspiracy in violation of
18 U.S.C. 1962(d). The pattern of
racketeering activity he was convicted
of included engaging in multiple acts of
mail fraud (18 U.S.C. 1341) and wire
fraud (18 U.S.C. 1343).
The factual basis for this conviction is
as follows: Mr. Gurry held executive
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12473
management positions, to include Vice
President of Managed Markets, of Insys
Therapeutics Inc. (Insys), a Delaware
Corporation, with headquarters in
Chandler, Arizona. Insys developed and
owned a drug called SUBSYS, a liquid
formulation of fentanyl to be applied
under the tongue. FDA approved
SUBSYS for the management of
breakthrough pain in adult cancer
patients who are already receiving and
are already tolerant to opioid therapy for
their underlying persistent cancer pain.
From early 2012 and continuing through
2015, Mr. Gurry participated in a
conspiracy whereby employees of Insys
bribed medical practitioners in various
states to get those practitioners to
increase prescribing SUBSYS to their
patients, many of whom did not have
cancer. Mr. Gurry, along with his
coconspirators, measured the effect of
these bribes on each practitioner’s
prescribing habits and on the revenue
that each bribed practitioner generated
for Insys. Mr. Gurry, along with his
coconspirators, reduced or eliminated
bribes paid to those practitioners who
failed to meet the minimum
prescription requirements or failed to
generate enough revenue to justify
additional bribes. To further this
conspiracy, Mr. Gurry and his
coconspirators misled and defrauded
health insurance providers to ensure
those providers approved payment for
SUBSYS. Insys achieved this goal by
establishing the ‘‘Insys Reimbursement
Center’’, which was designed to shift the
burden of seeking prior authorization
for SUBSYS from practitioners to Insys.
This allowed Insys to determine what
medical information was presented to
insurers. Mr. Gurry and his
coconspirators directed Insys employees
to mislead insurers to obtain payment
authorization.
As a result of this conviction, FDA
sent Mr. Gurry, by United Parcel
Service, on September 21, 2020, a notice
proposing to permanently debar him
from providing services in any capacity
to a person that has an approved or
pending drug product application. The
proposal was based on a finding, under
section 306(a)(2)(B) of the FD&C Act,
that Mr. Gurry was convicted of a felony
under Federal law for conduct relating
to the regulation of a drug product
under the FD&C Act. The proposal also
offered Mr. Gurry an opportunity to
request a hearing, providing him 30
days from the date of receipt of the letter
in which to file the request, and advised
him that failure to request a hearing
constituted an election not to use the
opportunity for a hearing and a waiver
of any contentions concerning this
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Agencies
[Federal Register Volume 86, Number 40 (Wednesday, March 3, 2021)]
[Notices]
[Pages 12471-12473]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2021-04342]
[[Page 12471]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration
[Docket No. FDA-2021-N-0208]
Proposal To Refuse To Approve a New Drug Application for
Sotagliflozin Oral Tablets, 200 Milligrams and 400 Milligrams;
Opportunity for a Hearing
AGENCY: Food and Drug Administration, HHS.
ACTION: Notice.
-----------------------------------------------------------------------
SUMMARY: The Director of the Center for Drug Evaluation and Research
(Center Director) of the Food and Drug Administration (FDA or Agency)
is proposing to refuse to approve a new drug application (NDA)
submitted by Lexicon Pharmaceuticals, Inc. (Lexicon) for sotagliflozin
oral tablets, 200 milligrams (mg) and 400 mg, in its present form. This
notice summarizes the grounds for the Center Director's proposal and
offers Lexicon an opportunity to request a hearing on the matter.
DATES: Submit either electronic or written requests for a hearing by
April 2, 2021; submit data, information, and analyses in support of the
hearing and any other comments by May 3, 2021.
ADDRESSES: You may submit hearing requests, documents in support of the
hearing, and any other comments as follows. Please note that late,
untimely filed requests and documents will not be considered.
Electronic requests for a hearing must be submitted on or before April
2, 2021; electronic documents in support of the hearing and any other
comments must be submitted on or before May 3, 2021. The https://www.regulations.gov electronic filing system will accept hearing
requests until 11:59 p.m. Eastern Time at the end of April 2, 2021, and
will accept documents in support of the hearing and any other comments
until 11:59 p.m. Eastern Time at the end of May 3, 2021. Documents
received by mail/hand delivery/courier (for written/paper submissions)
will be considered timely if they are postmarked or the delivery
service acceptance receipt is on or before these dates.
Electronic Submissions
Submit electronic comments in the following way:
Federal eRulemaking Portal: https://www.regulations.gov.
Follow the instructions for submitting comments. Comments submitted
electronically, including attachments, to https://www.regulations.gov
will be posted to the docket unchanged. Because your comment will be
made public, you are solely responsible for ensuring that your comment
does not include any confidential information that you or a third party
may not wish to be posted, such as medical information, your or anyone
else's Social Security number, or confidential business information,
such as a manufacturing process. Please note that if you include your
name, contact information, or other information that identifies you in
the body of your comments, that information will be posted on https://www.regulations.gov.
If you want to submit a comment with confidential
information that you do not wish to be made available to the public,
submit the comment as a written/paper submission and in the manner
detailed (see ``Written/Paper Submissions'' and ``Instructions'').
Written/Paper Submissions
Submit written/paper submissions as follows:
Mail/Hand delivery/Courier (for written/paper
submissions): Dockets Management Staff (HFA-305), Food and Drug
Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852.
For written/paper comments submitted to the Dockets
Management Staff, FDA will post your comment, as well as any
attachments, except for information submitted, marked and identified,
as confidential, if submitted as detailed in ``Instructions.''
Instructions: All submissions received must include the Docket No.
FDA-2021-N-0208 for ``Proposal to Refuse to Approve a New Drug
Application for Sotagliflozin Oral Tablets, 200 Milligrams and 400
Milligrams; Opportunity for a Hearing.'' Received comments, those filed
in a timely manner (see ADDRESSES), will be placed in the docket and,
except for those submitted as ``Confidential Submissions,'' publicly
viewable at https://www.regulations.gov or at the Dockets Management
Staff between 9 a.m. and 4 p.m., Monday through Friday, 240-402-7500.
Confidential Submissions--To submit a comment with
confidential information that you do not wish to be made publicly
available, submit your comments only as a written/paper submission. You
should submit two copies total. One copy will include the information
you claim to be confidential with a heading or cover note that states
``THIS DOCUMENT CONTAINS CONFIDENTIAL INFORMATION.'' The Agency will
review this copy, including the claimed confidential information, in
its consideration of comments. The second copy, which will have the
claimed confidential information redacted/blacked out, will be
available for public viewing and posted on https://www.regulations.gov.
Submit both copies to the Dockets Management Staff. If you do not wish
your name and contact information to be made publicly available, you
can provide this information on the cover sheet and not in the body of
your comments and you must identify this information as
``confidential.'' Any information marked as ``confidential'' will not
be disclosed except in accordance with 21 CFR 10.20 and other
applicable disclosure law. For more information about FDA's posting of
comments to public dockets, see 80 FR 56469, September 18, 2015, or
access the information at: https://www.govinfo.gov/content/pkg/FR-2015-09-18/pdf/2015-23389.pdf.
Docket: For access to the docket to read background documents or
the electronic and written/paper comments received, go to https://www.regulations.gov and insert the docket number, found in brackets in
the heading of this document, into the ``Search'' box and follow the
prompts and/or go to the Dockets Management Staff, 5630 Fishers Lane,
Rm. 1061, Rockville, MD 20852, 240-402-7500.
FOR FURTHER INFORMATION CONTACT: Kevin Fain, Center for Drug Evaluation
and Research, Food and Drug Administration, 10903 New Hampshire Ave.,
Bldg. 22, Rm. 6419, Silver Spring, MD 20993, 301-796-5842,
[email protected].
SUPPLEMENTARY INFORMATION:
I. Proposal To Refuse To Approve NDA 210934
Sanofi-aventis U.S. LLC (Sanofi), Lexicon's predecessor-in-
interest, submitted NDA 210934 for sotagliflozin oral tablets in 200
and 400 mg strengths on March 22, 2018, pursuant to section 505(b)(1)
of the Federal Food, Drug, and Cosmetic Act (FD&C Act) (21 U.S.C.
355(b)(1)). Sanofi proposed that sotagliflozin tablets be indicated as
an adjunct to insulin therapy to improve glycemic control in adults
with type 1 diabetes mellitus (T1DM).
On March 22, 2019, the Office of Drug Evaluation II (ODE II) in the
Office of New Drugs (OND) in FDA's Center for Drug Evaluation and
Research (CDER) issued a complete response letter to Sanofi under Sec.
314.110(a) (21 CFR 314.110(a)) stating that NDA 210934 could not be
approved in its present form, describing the specific deficiencies,
and, where possible, recommending ways that Sanofi might remedy these
deficiencies. The application in its present form is not approvable
because the data submitted
[[Page 12472]]
do not show that the drug is safe under the proposed conditions of use.
The deficiencies, which are summarized below, include the following:
(1) The data demonstrated that the addition of sotagliflozin to
insulin is associated with an increased risk of diabetic ketoacidosis
(DKA), a serious and often life-threatening consequence of insulin
insufficiency.
a. In particular, the submitted clinical trial data showed a nearly
8-fold excess risk of DKA associated with sotagliflozin. Based on an
FDA analysis of all three trials, an overall estimated hazard ratio (95
percent confidence interval) for DKA associated with sotagliflozin was
7.9 (3.2, 19.9).
b. The majority of these cases required hospitalization and
treatment in the intensive care unit, which underscores the seriousness
of this risk.
c. Although DKA is an inherent risk in T1DM, the magnitude of
excess risk, severity of the cases, and characteristics of DKA (e.g.,
euglycemic DKA) associated with sotagliflozin treatment raised
significant safety concerns, particularly because they occurred in a
clinical trial setting, where patients are carefully selected for
enrollment and receive more intensive safety monitoring than in
clinical practice.
d. Time-to-event analyses of the clinical trial data showed earlier
development of DKA in sotagliflozin-treated patients than in patients
assigned to placebo, without evidence that the risk stopped increasing
over time.
e. The clinical trial data did not identify a patient group at
lower risk of DKA, but instead showed the DKA risk was associated with
sotagliflozin regardless of sex, age, duration of diabetes, method of
insulin delivery, or body mass index.
f. Overall, risk mitigation strategies used in the clinical trials
were not sufficient to address the excess DKA risk observed in the
clinical trials, as evidenced by the nearly 8-fold excess risk.
g. Data analyses assessing the impact of risk mitigation strategies
implemented during the course of the trials were inadequate to provide
reassurance that these strategies would be successful in reducing DKA
risk post-approval.
(2) The data demonstrated the significant DKA risk resulting from
the addition of sotagliflozin to insulin was not justified by the
drug's modest clinical benefits.
a. The data showed that sotagliflozin reduced HbA1c, a validated
surrogate endpoint for clinical benefits expected due to improved
glycemic control in the treatment of diabetes mellitus, including T1DM.
However, the effect on HbA1c in the sotagliflozin clinical trials was
modest.
b. In the three pivotal trials, addition of sotagliflozin to
insulin resulted in statistically significant reductions in HbA1c at
Week 24. The treatment difference relative to placebo was approximately
-0.3 percent with sotagliflozin 200 mg and -0.4 percent with
sotagliflozin 400 mg.
c. In the extension of two pivotal trials to 52 weeks, the effect
of sotagliflozin on HbA1c was smaller (-0.23 percent and -0.33 percent
HbA1c reductions with the 200 mg and 400 mg doses, respectively), and
there are no longer term data to evaluate persistence of effect. The
decrease in treatment effect from Week 24 to Week 52 is clinically
relevant, as the major benefits to consider with sotagliflozin
treatment are related to improved long-term glycemic control reducing
the risk of microvascular complications.
d. The improved HbA1c associated with sotagliflozin was not
accompanied by an increased rate of hypoglycemia (defined as glucose <=
55 mg/dL) in the clinical trials, an adverse clinical effect that
occurs with insulin therapy; however, this observation does not
outweigh the increased rate of DKA. The data did not show sotagliflozin
was associated with an overall decrease in the rate of severe
hypoglycemia.
e. In addition to improved glycemic control, other clinical
benefits associated with sotagliflozin, small reductions in body weight
and blood pressure, were not sufficient to outweigh the serious risk of
DKA.
f. The data did not show that sotagliflozin was associated with an
effect on glycemic variability and time-in-range that provided benefits
distinct from reduced HbA1c.
g. Patient reported outcome measures were not adequate in directly
reflecting important aspects of the patient's experience with T1DM and
how sotagliflozin treatment affected these important aspects.
The complete response letter stated that Sanofi is required either
to resubmit the application, fully addressing all deficiencies listed
in the letter, or take other actions available under Sec. 314.110
(i.e., withdraw the application or request an opportunity for a
hearing). Applicable regulations, including 21 CFR 10.75, also provide
a mechanism for applicants to obtain formal review of one or more
decisions reflected in a complete response letter (see FDA's guidance
for industry and review staff ``Formal Dispute Resolution: Sponsor
Appeals Above the Division Level'' (May 2019)).\1\
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\1\ Available at https://www.fda.gov/media/126910/download. FDA
updates guidances periodically. To make sure you have the most
recent version of a guidance, check the FDA Drugs guidance web page
at https://www.fda.gov/drugs/guidance-compliance-regulatory-information/guidances-drugs.
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Sanofi submitted a formal dispute resolution request (FDRR) on
September 3, 2019, concerning the complete response letter issued by
ODE II. Peter Stein, Director of CDER's OND, denied the FDRR by
correspondence dated November 29, 2019, based on his determination that
the drug's immediate, sustained, and substantial increase in DKA risk
outweighed the modest benefit on glycemic control and any potential
additional benefits (e.g., reductions in body weight and blood
pressure). Sanofi submitted another FDRR on December 19, 2019, for
review of the OND denial. On January 30, 2020, FDA was notified that
NDA 210934 had been transferred from Sanofi to Lexicon. Robert Temple,
Deputy Director for Clinical Science, CDER, denied the second FDRR on
behalf of CDER by correspondence dated March 11, 2020, based on his
determination that the drug's DKA risk outweighed its benefits,
reaffirming the reasoning in OND's denial of the prior FDRR.
On November 10, 2020, Lexicon submitted a request for an
opportunity for a hearing under Sec. 314.110(b)(3) on whether there
are grounds under section 505(d) of the FD&C Act for denying approval
of NDA 210934.
II. Notice of Opportunity for a Hearing
For the reasons stated above and as explained in further detail in
the complete response letter and the November 29, 2019, and March 11,
2020, FDRR denials, notice is given to Lexicon and all other interested
persons that the Center Director proposes to issue an order refusing to
approve NDA 210934 on the grounds that the application fails to meet
the criteria for approval under section 505(d)(2) of the FD&C Act
because data submitted in the application do not show that the product
would be safe under the proposed conditions of use.\2\
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\2\ Section 505(d)(2) of the FD&C Act provides that FDA shall
refuse to approve an NDA if ``the results of . . . tests show that
such drug is unsafe for use under [the] conditions [prescribed,
recommended, or suggested in the proposed labeling] or do not show
that such drug is safe for use under such conditions[.]'' For the
reasons explained in this notice, CDER has concluded that the data
and information submitted in the NDA do not show that the drug is
safe for use under the proposed conditions of use.
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Lexicon may request a hearing before the Commissioner of Food and
Drugs
[[Page 12473]]
(the Commissioner) on the Center Director's proposal to refuse to
approve NDA 210934. If Lexicon decides to seek a hearing, it must file:
(1) A written notice of participation and request for a hearing (see
the DATES section) and (2) the studies, data, information, and analyses
relied upon to justify a hearing (see the DATES section), as specified
in Sec. 314.200 (21 CFR 314.200).
As stated in Sec. 314.200(g), a request for a hearing may not rest
upon allegations or denials, but must present specific facts showing
that there is a genuine and substantial issue of fact that requires a
hearing to resolve. We note in this regard that because CDER proposes
to refuse to approve NDA 210934 based on the multiple deficiencies
summarized above, any hearing request from Lexicon must address all of
those deficiencies. Failure to request a hearing within the time
provided and in the manner required by Sec. 314.200 constitutes a
waiver of the opportunity to request a hearing. If a hearing request is
not properly submitted, FDA will issue a notice refusing to approve NDA
210934.
The Commissioner will grant a hearing if there exists a genuine and
substantial issue of fact or if the Commissioner concludes that a
hearing would otherwise be in the public interest (Sec.
314.200(g)(6)). If a hearing is granted, it will be conducted according
to the procedures provided in 21 CFR parts 10 through 16 (21 CFR
314.201).
Paper submissions under this notice of opportunity for a hearing
should be filed in one copy. Except for data and information prohibited
from public disclosure under 21 U.S.C. 331(j) or 18 U.S.C. 1905,
submissions may be seen in the Dockets Management Staff Office between
9 a.m. and 4 p.m., Monday through Friday, and on the internet at
https://www.regulations.gov. This notice is issued under section
505(c)(1)(B) of the FD&C Act and Sec. Sec. 314.110(b)(3) and 314.200.
Dated: February 25, 2021.
Patrizia Cavazzoni,
Acting Director, Center for Drug Evaluation and Research.
[FR Doc. 2021-04342 Filed 3-2-21; 8:45 am]
BILLING CODE 4164-01-P