FDA EXPANDS AUTHORIZED USE OF REGEN-COV? (CASIRIVIMAB AND IMDEVIMAB)
Regeneron Pharmaceuticals, Inc.?(NASDAQ:?REGN) today announced that the?U.S. Food and Drug Administration?(FDA) updated the Emergency Use Authorization (EUA) for the investigational COVID-19 antibody cocktail REGEN-COV? (casirivimab and imdevimab). The authorization now includes post-exposure prophylaxis in people at high risk for progression to severe COVID-19, who are not fully vaccinated or are not expected to mount an adequate response to vaccination, and have been exposed to a SARS-CoV-2 infected individual, or who are at high risk of exposure to an infected individual because of infection occurring in the same institutional setting (such as in nursing homes or prisons).
In those who require repeat dosing for ongoing exposure, REGEN-COV can also now be administered monthly. This new indication in people aged 12 and older is in addition to the previously granted authorization to treat?non-hospitalized patients. REGEN-COV is not a substitute for vaccination against COVID-19, and is not authorized for pre-exposure prophylaxis to prevent COVID-19.
"Today's FDA authorization enables certain people at high risk of?developing severe COVID-19 infection?to access REGEN-COV if they have been?exposed?to the virus ? the first time an antibody treatment has been authorized for this purpose," said?George D. Yancopoulos, M.D., Ph.D., President and Chief Scientific Officer of Regeneron. "With this authorization, the FDA specifically highlights the needs of immunocompromised people, including those taking immunosuppressive medicines, who may not mount an adequate response to vaccination, who are exposed to a person with COVID-19 or are in an institutional setting and are at high risk of exposure because of infection occurring in the same setting. Today's FDA decision to expand the use of REGEN-COV in post-exposure settings is a very helpful step, and we continue to work with the FDA as it undertakes its review of REGEN-COV in a broader group of people including in a pre-exposure prophylactic setting for people who are immunocompromised, and in patients hospitalized due to COVID-19."
Experts estimate that approximately 3% of the?U.S.?population may not respond fully to COVID-19 vaccination because of immunocompromising conditions or immunosuppressive medicines. This?includes?people receiving chemotherapy, people with hematologic cancers such as chronic lymphocytic leukemia, people receiving stem cells or hemodialysis, people who have received organ transplants, and/or people taking certain medications that might blunt immune response (e.g., mycophenolate, rituximab, azathioprine, anti-CD20 monoclonal antibodies, Bruton tyrosine kinase inhibitors). This authorization enables these groups to use REGEN-COV to prevent infection in post-exposure and certain institutional settings.
Under the EUA for post-exposure prophylaxis, REGEN-COV can be administered by subcutaneous injection or intravenous infusion. For people who aren't expected to mount an adequate immune response to vaccination and who have an ongoing exposure to SARS-CoV-2 for more than four weeks, the initial 1,200 mg dose can be followed by subsequent repeat dosing of REGEN-COV 600 mg once every four weeks, for the duration of ongoing exposure.
REGEN-COV has not been approved by the FDA, but is currently?authorized?for the duration of the declaration that circumstances exist justifying the authorization of the emergency use under section 564(b)(1) of the Act, 21 U.S.C. ? 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.
Multiple analyses, including a recent publication in?Cell, have shown that REGEN-COV retains potency against the main variants of concern circulating within the?U.S., including Delta (B.1.617.2; first identified in?India), Gamma (P.1; first identified in?Brazil) and Beta (B.1.351; first identified in?South Africa). Consequently, REGEN-COV remains available for use across the?U.S., and Regeneron will continue actively monitoring the potency of REGEN-COV against emerging variants.
The development and manufacturing of REGEN-COV have been funded in part with federal funds from the?Biomedical Advanced Research and Development Authority?(BARDA), part of the?U.S. Department of Health and Human Services'?Office of the Assistant Secretary for Preparedness and Response, under OT number: HHSO100201700020C.
Regeneron is?collaborating?with Roche to increase global supply of the antibody cocktail, with Roche primarily responsible for development and distribution outside the?U.S.?Regeneron and Roche share a commitment to making the antibody cocktail available to COVID-19 patients around the globe and will support access in low- and lower-middle-income countries through drug donations to be made in partnership with public health organizations.
About the Clinical Data Supporting the EUA Extension
The REGEN-COV EUA for post-exposure prophylaxis is based on data from multiple groups.
A pivotal Phase 3 trial jointly run with the National Institute of Allergy and Infectious Diseases?(NIAID), part of the?National Institutes?of Health?(NIH), assessed REGEN-COV for post-exposure prophylaxis of COVID-19 in household contacts of individuals infected with SARS-CoV-2 (index case). REGEN-COV was found to:
- Reduce the risk of symptomatic infections by 81%?in those who were not infected when they entered the trial (p<0.0001).
- There were 1,505 participants (753 REGEN-COV, 752 placebo) who were not infected (seronegative with a negative PCR test) when they entered the trial.
- In a post-hoc analysis in the subgroup of participants who met the criteria for high risk for progression to severe COVID-19 (570 REGEN-COV, 567 placebo), there was a 76% risk reduction in COVID-19 with REGEN-COV treatment compared to placebo (p<0.0001).
- Adverse events were reported in 20% (265/1,311) of REGEN-COV participants and 29% (379/1,306) of placebo participants. Injection site reactions (all mild to moderate) occurred in 4% (55) of REGEN-COV participants and 2% (19) of placebo participants. Hypersensitivity reactions occurred in 0.2% (2) of REGEN-COV participants, all of which were mild in severity.
- Reduced the risk of symptomatic infections by 62%?in a broader group of asymptomatic participants, regardless of infection status, based on a post-hoc analysis (p<0.0001).
- There were 2,378 participants who were asymptomatic when they entered the trial, regardless of serology (1,201 REGEN-COV, 1,177 placebo).
- Adverse events for uninfected individuals are reported above, and for infected individuals (n=311) were reported in 34% (52/155) of REGEN-COV participants and 48% (75/156) of placebo participants. Injection site reactions (all mild to moderate) occurred in 4% (6) of REGEN-COV participants and 1% (1) of placebo participants. There were no cases of hypersensitivity reaction.
- REGEN-COV is not authorized for use in patients:
- who are hospitalized due to COVID-19, OR
- who require oxygen therapy due to COVID-19, OR
- who require an increase in baseline oxygen flow rate due to COVID-19 in those on chronic oxygen therapy due to underlying non-COVID-19 related comorbidity
- Monoclonal antibodies, such as REGEN-COV, may be associated with worse clinical outcomes when administered to hospitalized patients with COVID-19 requiring high-flow oxygen or mechanical ventilation
- not fully vaccinated?or?who are not expected to mount an adequate immune response to complete SARS-CoV-2 vaccination (for example, individuals with immunocompromising conditions including those taking immunosuppressive medications)?and
- have been exposed to an individual infected with SARS-CoV-2 consistent with close contact criteria per?Centers for Disease Control and Prevention?(CDC)?or
- who are at high risk of exposure to an individual infected with SARS-CoV-2 because of occurrence of COVID-19 infection in other individuals in the same institutional setting (for example, nursing homes, prisons)
- Post-exposure prophylaxis with REGEN-COV is not a substitute for vaccination against COVID-19
- REGEN-COV is not authorized for pre-exposure prophylaxis for prevention of COVID-19
- Contraindication: REGEN-COV is contraindicated in individuals with previous severe hypersensitivity reactions, including anaphylaxis, to REGEN-COV
- Warnings and Precautions:
- Hypersensitivity Including Anaphylaxis and Infusion-Related Reactions:?Serious hypersensitivity reactions, including anaphylaxis, have been observed with administration of REGEN-COV. If signs or symptoms of a clinically significant hypersensitivity reaction or anaphylaxis occur, immediately discontinue administration and initiate appropriate medications and/or supportive therapy. Hypersensitivity reactions occurring more than 24 hours after the infusion have also been reported with the use of REGEN-COV under EUA. Infusion-related reactions, occurring during the infusion and up to 24 hours after the infusion, have been observed with administration of REGEN-COV. These reactions may be severe or life threatening
- Signs and symptoms of infusion-related reactions may include: fever, difficulty breathing, reduced oxygen saturation, chills, nausea, arrhythmia (e.g., atrial fibrillation, tachycardia, bradycardia), chest pain or discomfort, weakness, altered mental status, headache, bronchospasm, hypotension, hypertension, angioedema, throat irritation, rash including urticaria, pruritus, myalgia, vasovagal reactions (e.g., pre-syncope, syncope), dizziness, fatigue and diaphoresis. Consider slowing or stopping the infusion and administer appropriate medications and/or supportive care if an infusion-related reaction occurs
- Clinical Worsening After REGEN-COV Administration:?Clinical worsening of COVID-19 after administration of REGEN-COV has been reported and may include signs or symptoms of fever, hypoxia or increased respiratory difficulty, arrhythmia (e.g., atrial fibrillation, tachycardia, bradycardia), fatigue, and altered mental status. Some of these events required hospitalization. It is not known if these events were related to REGEN-COV use or were due to progression of COVID-19
- Limitations of Benefit and Potential for Risk in Patients with Severe COVID-19:?Monoclonal antibodies, such as REGEN-COV, may be associated with worse clinical outcomes when administered to hospitalized patients with COVID-19 requiring high-flow oxygen or mechanical ventilation. Therefore, REGEN-COV is not authorized for use in patients who are hospitalized due to COVID-19, OR who require oxygen therapy due to COVID-19, OR who require an increase in baseline oxygen flow rate due to COVID-19 in those on chronic oxygen therapy due to underlying non-COVID-19?related comorbidity
- Hypersensitivity Including Anaphylaxis and Infusion-Related Reactions:?Serious hypersensitivity reactions, including anaphylaxis, have been observed with administration of REGEN-COV. If signs or symptoms of a clinically significant hypersensitivity reaction or anaphylaxis occur, immediately discontinue administration and initiate appropriate medications and/or supportive therapy. Hypersensitivity reactions occurring more than 24 hours after the infusion have also been reported with the use of REGEN-COV under EUA. Infusion-related reactions, occurring during the infusion and up to 24 hours after the infusion, have been observed with administration of REGEN-COV. These reactions may be severe or life threatening
- Adverse Reactions:
- COV-2067 (Treatment):?Infusion-related reactions (adverse event assessed as causally related by the investigator) of grade 2 or higher severity have been observed in 10/4,206 (0.2%) of those who received REGEN-COV at the authorized dose or a higher dose. Three subjects receiving the 8,000 mg dose of REGEN-COV, and one subject receiving the 1,200 mg casirivimab and 1,200 mg imdevimab, had infusion-related reactions (urticaria, pruritus, flushing, pyrexia, shortness of breath, chest tightness, nausea, vomiting, rash) which resulted in permanent discontinuation of the infusion. All events resolved. Anaphylactic reactions have been reported in the clinical program in subjects receiving REGEN-COV. The events began within 1 hour of completion of the infusion, and in at least one case required treatment including epinephrine. The events resolved
- COV-2069 (Post-exposure prophylaxis):?In subjects who were SARS-CoV-2 negative at baseline (Cohort A), injection site reactions (all grade 1 and 2) occurred in 55 subjects (4%) in the REGEN-COV group and 19 subjects (2%) in the placebo group. The most common signs and symptoms of injection site reactions which occurred in at least 1% of subjects in the REGEN-COV group were erythema and pruritus. Hypersensitivity reactions occurred in 2 subjects (0.2%) in the REGEN-COV group and all hypersensitivity reactions were grade 1 in severity. In subjects who were SARS-CoV-2 positive at baseline (Cohort B), injection site reactions, all of which were grade 1 or 2, occurred in 6 subjects (4%) in the REGEN-COV group and 1 subject (1%) in the placebo group. The most common signs and symptoms of injection site reactions which occurred in at least 1% of subjects in the REGEN-COV group were ecchymosis and erythema
- COV-2093 (Subcutaneous Dosing):?Injection site reactions occurred in 12% and 4% of subjects following single dose administration in the REGEN-COV and placebo groups, respectively. Remaining safety finding following subcutaneous administration in the REGEN-COV group were similar to the safety findings observed with intravenous administration in COV-2067. With repeat dosing, injection site reactions occurred in 252 subjects (35%) in the REGEN-COV group and 38 subjects (16%) in the placebo group; all injection site reactions were grade 1 or 2 in severity. Hypersensitivity reactions occurred in 8 subjects (1%) in the REGEN-COV group; and all hypersensitivity reactions were grade 1 or 2 in severity. There were no cases of anaphylaxis.
- Patient Monitoring Recommendations: Clinically monitor patients during infusion and observe patients for at least 1 hour after intravenous infusion or subcutaneous dosing is complete
- Use in Specific Populations:
- Pregnancy:?There are insufficient data to evaluate a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. REGEN-COV should only be used during pregnancy if the potential benefit outweighs the potential risk for the mother and the fetus
- Lactation:?There are no available data on the presence of casirivimab and/or imdevimab in human milk or animal milk, the effects on the breastfed infant, or the effects of the drug on milk production. The development and health benefits of breastfeeding should be considered along with the mother's clinical need for REGEN-COV and any potential adverse effects on the breastfed child from REGEN-COV or from the underlying maternal condition