Clinical Pharmacology for Veozah
Mechanism Of Action
VEOZAH is a neurokinin 3 (NK3) receptor antagonist that blocks neurokinin B (NKB) binding on the kisspeptin/neurokinin B/dynorphin (KNDy) neuron to modulate neuronal activity in the thermoregulatory center. Fezolinetant has high affinity for the NK3 receptor (Ki value of 19.9 to 22.1 nmol/L), which is more than 450-fold higher than binding affinity to NK1 or NK2 receptors.
Pharmacodynamics
Treatment with fezolinetant did not show any clear trends in sex hormones measured (follicle-stimulating hormone, testosterone, estrogen, and dehydroepiandrosterone sulfate) in menopausal women. Transient decrease of luteinizing hormone (LH) levels was observed at peak concentrations of fezolinetant.
Cardiac Electrophysiology
At a dose 20 times the maximum approved recommended dose, fezolinetant does not prolong the QT interval to any clinically relevant extent.
Pharmacokinetics
In healthy women, fezolinetant Cmax and AUC increased proportionally over a dosage range from 20 to 60 mg once daily (0.44 to 1.33 times the approved recommended dosage).
Steady-state plasma concentrations of fezolinetant were reached after two once daily doses, with minimal fezolinetant accumulation.
Absorption
The median (range) time to reach fezolinetant Cmax is 1.5 (1 to 4) hours in healthy women.
Effect of Food
No clinically significant differences in fezolinetant pharmacokinetics were observed following administration with a high-calorie, high-fat meal containing approximately 1000 calories (500-600 calories from fat, 250 calories from carbohydrates, and 150 calories from protein).
Distribution
The mean apparent volume of distribution (Vz/F) of fezolinetant is 189 L. The plasma protein binding of fezolinetant is 51%. The blood-to-plasma ratio is 0.9.
Elimination
The effective half-life (t1/2) of fezolinetant is 9.6 hours in women with vasomotor symptoms. The apparent clearance at steady-state of fezolinetant is 10.8 L/h.
Metabolism
Fezolinetant is primarily metabolized by CYP1A2 and to a lesser extent by CYP2C9 and CYP2C19. A major metabolite of fezolinetant, ES259564, was identified in plasma. ES259564 is approximately 20-fold less potent than the parent. The metabolite-to-parent ratio ranges from 0.7 to 1.8.
Excretion
Following oral administration of fezolinetant, 76.9% of the dose was excreted in urine (1.1% unchanged) and 14.7% in feces (0.1% unchanged).
Specific Populations
There were no substantive differences in the pharmacokinetics of VEOZAH based on race and body weight (93 to 278 pounds).
Women With Renal Impairment
Following single-dose administration of 30 mg fezolinetant, there was no effect on VEOZAH exposure (Cmax and AUC) in women with mild (eGFR 60 to less than 90 mL/min/1.73 m2) to severe (eGFR 15 to less than 30 mL/min/1.73 m2) renal impairment. The AUC of ES259564 (a major metabolite of fezolinetant) in women with moderate (eGFR 30 to less than 60 mL/min/1.73 m2) and severe (eGFR 15 to less than 30 mL/min/1.73 m2) renal impairment increased by approximately 75% and 380%, respectively. VEOZAH has not been studied in individuals with end-stage renal disease (eGFR less than 15 mL/min/1.73 m2).
Women With Hepatic Impairment
Following single-dose administration of 30 mg fezolinetant in women with mild Child-Pugh Class A cirrhosis, the mean Cmax increased by 23% and AUCinf increased by 56%, relative to women with normal hepatic function. In women with moderate Child-Pugh Class B cirrhosis, the mean Cmax of fezolinetant decreased by 15% and AUCinf increased by 96%. The Cmax of ES259564 decreased in both mild and moderate cirrhosis while AUCinf and AUClast increased less than 15%. VEOZAH has not been studied in individuals with severe Child-Pugh Class C cirrhosis.
Drug Interaction Studies
Clinical Studies And Model-Informed Approaches
Strong CYP1A2 Inhibitors
Fezolinetant Cmax increased by 80% and AUC increased by 840% following concomitant use with fluvoxamine (strong CYP1A2 inhibitor).
Moderate CYP1A2 Inhibitors
Fezolinetant Cmax increased by 40% and AUC increased by 360% following concomitant use with mexiletine (moderate CYP1A2 inhibitor) 400 mg every 8 hours.
Weak CYP1A2 Inhibitors
Fezolinetant Cmax increased by 30% and AUC increased by 100% following concomitant use with cimetidine (weak CYP1A2 inhibitor) 300 mg every 6 hours.
No clinically significant differences in fezolinetant exposure were observed in smokers (moderate CYP1A2 inducer).
In Vitro Studies
Cytochrome P450 (CYP) Enzymes
Fezolinetant and ES259564 are not inhibitors of CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, and CYP3A4. Fezolinetant and ES259564 are not inducers of CYP1A2, CYP2B6, and CYP3A4.
Transporter Systems
Fezolinetant is not a substrate nor an inhibitor of P-glycoprotein (P-gp). ES259564 is a substrate of P-gp, but not an inhibitor of P-gp.
Both fezolinetant and ES259564 are not a substrate of BCRP, OATP1B1, and OATP1B3. In addition, ES259564 is not a substrate of OAT1, OAT3, OCT2, MATE1, and MATE2-K.
Animal Toxicology And/Or Pharmacology
Repeat dose toxicity studies were conducted in intact female rats and cynomolgus monkeys. In female rats, daily administration of fezolinetant for 26 weeks at doses equal to or greater than 30 mg/kg/day (56-fold the human AUC24 at the human therapeutic dose) showed uterine atrophy and epithelial mucification of the vagina and cervix. In female cynomolgus monkeys, daily administration for 39 weeks at doses equal to or greater than 10 mg/kg/day (19-fold the human AUC24 at the human therapeutic dose) showed reduced ovarian activity.
Clinical Studies
Effects On Vasomotor Symptoms In Postmenopausal Women
The efficacy of VEOZAH for the treatment of moderate to severe vasomotor symptoms due to menopause was evaluated in the first 12-week, randomized, placebo-controlled, double-blind portion of each of two phase 3 clinical trials. In each of these two trials, after the first 12 weeks, women on placebo were then re-randomized to VEOZAH for a 40-week extension to evaluate safety for up to 52 weeks total exposure.
In Trials 1 (NCT04003155) and 2 (NCT04003142), 1022 women (522 in Trial 1 and 500 in Trial 2) who had a minimum average of 7 moderate to severe vasomotor symptoms per day were randomized to one of two doses of fezolinetant (including the 45 mg dosage strength) or placebo. Randomization was stratified by smoking status.
The mean age of the postmenopausal women was 54 years. Women self-identified as Caucasian (81%), African American (17%), Asian (1%), and Hispanic/Latina ethnicity (24%). The study population included menopausal women with one or more of the following: prior hysterectomy (32.1%), prior oophorectomy (21.6%), or prior hormone therapy use (19.9%). Those who were on prior hormone therapy underwent a wash-out period prior to trial participation.
The co-primary efficacy endpoints for both trials were the mean change from baseline in moderate to severe vasomotor symptoms frequency and severity to Weeks 4 and 12. Data from each trial demonstrated statistically significant and clinically meaningful (≥ 2 hot flashes over 24 hours) reduction from baseline in the frequency of moderate to severe vasomotor symptoms for VEOZAH 45 mg compared to placebo at Weeks 4 and 12. Data from each trial also demonstrated a statistically significant reduction from baseline in the severity of moderate to severe vasomotor symptoms (over 24 hours) at Weeks 4 and 12 for VEOZAH 45 mg compared to placebo.
Results of the co-primary endpoint for change from baseline to Weeks 4 and 12 in mean frequency of moderate to severe vasomotor symptoms over 24 hours from Trials 1 and 2 are shown in Table 2.
Table 2: Mean Baseline and Change from Baseline to Weeks 4 and 12 for Mean Frequency of Moderate to Severe Vasomotor Symptoms over 24 Hours in Women Treated with VEOZAH in Trials 1 and 2
| Parameter |
Trial 1 |
Trial 2 |
VEOZAH
45 mg
(n=174) |
Placebo
(n=175) |
VEOZAH
45 mg
(n=167) |
Placebo
(n=167) |
| Baseline |
| Mean (SD) |
10.4 (3.92) |
10.5 (3.79) |
11.8 (8.26) |
11.6 (5.02) |
| Change from Baseline to Week 4 |
| LS Mean (SE) |
-5.4 (0.30) |
-3.3 (0.29) |
-6.3 (0.33) |
-3.7 (0.33) |
| Difference vs Placebo (95% CI) |
-2.1 (-2.9, -1.3) |
-- |
-2.6 (-3.5, -1.6) |
-- |
| P-value |
< 0.0011 |
-- |
< 0.0011 |
-- |
| Change from Baseline to Week 12 |
| LS Mean (SE) |
-6.4 (0.31) |
-3.9 (0.31) |
-7.5 (0.39) |
-5.0 (0.39) |
| Difference vs Placebo (95% CI) |
-2.6 (-3.4, -1.7) |
-- |
-2.5 (-3.6, -1.5) |
-- |
| P-value |
< 0.0011 |
-- |
< 0.0011 |
-- |
1. Statistically significantly superior compared to placebo at the 0.05 level with multiplicity adjustment.
LS Mean: Least Squares Mean estimated from a mixed model for repeated measures analysis of covariance; SD: Standard Deviation; SE: Standard Error. |
Results of the co-primary endpoint for change from baseline to Weeks 4 and 12 in mean severity of moderate to severe vasomotor symptoms over 24 hours from Trials 1 and 2 are shown in Table 3.
Table 3: Mean Baseline and Change from Baseline to Weeks 4 and 12 for Mean Severity of Moderate to Severe Vasomotor Symptoms over 24 Hours in Women Treated with VEOZAH in Trials 1 and 2
| Parameter |
Trial 1 |
Trial 2 |
VEOZAH
45 mg
(n=174) |
Placebo
(n=175) |
VEOZAH
45 mg
(n=167) |
Placebo
(n=167) |
| Baseline |
| Mean (SD) |
2.4 (0.35) |
2.4 (0.35) |
2.4 (0.34) |
2.4 (0.32) |
| Change from Baseline to Week 4 |
| LS Mean (SE) |
-0.5 (0.04) |
-0.3 (0.04) |
-
0.6 (0.05) |
2.4 (0.32) |
| Difference vs Placebo (95% CI) |
-0.2 (-0.3, -0.1) |
-- |
-0.3 (-0.4, -0.2) |
-- |
| P-value |
0.0021 |
-- |
< 0.0011 |
-- |
| Change from Baseline to Week 12 |
| LS Mean (SE) |
-0.6 (0.05) |
-0.4 (0.05) |
-
0.8 (0.06) |
-0.5 (0.06) |
| Difference vs Placebo (95% CI) |
-0.2 (-0.4, -0.1) |
-- |
-0.3 (-0.5, -0.1) |
-- |
| P-value |
0.0071 |
-- |
< 0.0011 |
-- |
1.Statistically significantly superior compared to placebo at the 0.05 level with multiplicity adjustment.
LS Mean: Least Squares Mean estimated from a mixed model for repeated measures analysis of covariance; SD: Standard Deviation; SE: Standard Error. |
Effects On Endometrium In Postmenopausal Women
In the VEOZAH 45 mg dose group across Trials 1, 2, and 3, endometrial biopsy assessments identified one case of endometrial hyperplasia and one case of endometrial malignancy. The rate of these events in the VEOZAH 45 mg dose group was ≤ 1% with the upper bound of the one-sided 95% confidence limit being ≤ 4%.
Table 4: Incidence of Endometrial Hyperplasia or Carcinoma after 12 Months of Treatment in Trials 1, 2, and 3
| Final Diagnosis |
VEOZAH
45 mg
(n=350) |
Placebo
(n=186) |
| Endometrial Hyperplasia and Carcinoma, n (%) |
2 (0.6%) |
0 |
| One-sided upper limit of 95% CI |
1.8% |
1.6% |
- Simple hyperplasia without atypia
|
1 |
0 |
- Endometrial adenocarcinoma
|
1 |
0 |
Five cases of disordered proliferative endometrium were reported in women receiving VEOZAH 45 mg and four cases were reported in women receiving placebo across the three clinical trials. The EAIR was 1.4 per 100 person-years in VEOZAH 45 mg versus 2.0 per 100 person-years in the placebo group.