Fingolimod Trial from Years ago surfaces and guess what, the approved dose works…….Amazing

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What is the optimum dose for fingolimod? In the early studies I think they used 5mg and 1.25mg and they both worked about the same. So Novartis dropped the dose and guess what? It worked. They dropped it again and guess what?, it still worked , well at least as good glatiramer acetate but not as good as the approved 0.5mg dose according to this trial started in 2012. Why go to all this trouble? The regulators like to see some form of dose response, because they don’t want people to be exposed to too much drug. However, I guess it was important for patents as dosing schedule can be important as it may allow the drug to be protected for longer once the original patent expires. In the US the dosing schedule was been viewed as inventive and protection seems to be good until 2027. However, in Europe it appears that the Generics have been approved and it is called Fingolimod accord, But will it infringe the existing patents. This happened when glatiramer patents ran out, generics appeared and law suits occurred and if you infringed the paptent it could have cost a lot so the generics didn’t appear whilst the legal battles were ongoing…possibly a few million spent on laywers fees….but maybe a billion in drug sales whilst the legal battles unfurled.

The fingolimod accord was approved in June 2020 and occurred under my radar. If this goes ahead the shackles could be off, as the price could drop. But will it…it should but I bet it won’t. Maybe ProfG or the Novarsians (that’s what they call themselves…apparently they come from another planet near Basel/Basle) reading the post to enlighten us

Efficacy and Safety of 2 Fingolimod Doses vs Glatiramer Acetate for the Treatment of Patients With Relapsing-Remitting Multiple Sclerosis: A Randomized Clinical Trial.Cree BAC, Goldman MD, Corboy JR, Singer BA, Fox EJ, Arnold DL, Ford C, Weinstock-Guttman B, Bar-Or A, Mientus S, Sienkiewicz D, Zhang Y, Karan R, Tenenbaum N; ASSESS Trial Investigators.JAMA Neurol. 2020 Aug 24. doi: 10.1001/jamaneurol.2020.2950#

Importance: Doses of fingolimod lower than 0.5 mg per day were not investigated during the fingolimod clinical development program. Whether lower doses of fingolimod might retain efficacy with fewer safety risks remains unknown.

Objective: To evaluate the efficacy and safety of fingolimod, 0.5 mg, and fingolimod, 0.25 mg, compared with glatiramer acetate and to assess whether these doses of fingolimod show superior efficacy to glatiramer acetate in adult patients with relapsing-remitting multiple sclerosis.

Interventions: Fingolimod, 0.5 mg, or fingolimod, 0.25 mg, orally once per day or glatiramer acetate, 20 mg, subcutaneously once per day.

Design, setting, and participants: The Multiple Sclerosis Study Evaluating Safety and Efficacy of Two Doses of Fingolimod Versus Copaxone (ASSESS) was a phase 3b multicenter randomized rater-blinded and dose-blinded 12-month clinical trial conducted between August 9, 2012, and April 30, 2018 (including the time required to recruit participants). A total of 1461 patients aged 18 to 65 years with relapsing-remitting multiple sclerosis were screened, and 1064 participants were randomized. These participants had at least 1 documented relapse during the previous year or 2 documented relapses during the previous 2 years and an Expanded Disability Status Scale score of 0 to 6 at screening. Data were analyzed between September and November 2018.

Main outcomes and measures: The superiority of the fingolimod doses was tested hierarchically, with fingolimod, 0.5 mg, vs glatiramer acetate, 20 mg, tested first, followed by fingolimod, 0.25 mg, vs glatiramer acetate, 20 mg. The primary end point was the reduction in annualized relapse rate (ARR). Magnetic resonance imaging parameters, safety, and tolerability were also assessed.

Results: Of 1461 adult patients screened, 1064 participants (72.8%) were randomized (mean [SD] age, 39.6 [11.0] years; 792 women [74.4%]) to 3 treatment groups: 352 participants received fingolimod, 0.5 mg, 370 participants received fingolimod, 0.25 mg, and 342 participants received glatiramer acetate, 20 mg. In total, 859 participants (80.7%) completed the study. Treatment with fingolimod, 0.5 mg, was superior to treatment with glatiramer acetate, 20 mg, in reducing ARR (40.7% relative reduction); the relative reduction with fingolimod, 0.25 mg, was 14.6%, which was not statistically significant (for fingolimod, 0.5 mg, ARR, 0.15; 95% CI, 0.11-0.21; for fingolimod, 0.25 mg, ARR, 0.22; 95% CI, 0.17-0.29; for glatiramer acetate, 20 mg, ARR, 0.26; 95% CI, 0.20-0.34). Treatment with both fingolimod doses (0.5 mg and 0.25 mg) significantly reduced new or newly enlarging T2 and gadolinium-enhancing T1 lesions compared with treatment with glatiramer acetate. Adverse events were reported in similar proportions across treatment groups (312 participants [90.4%] in the fingolimod, 0.5 mg, group, 323 participants [88.3%] in the fingolimod, 0.25 mg, group, and 283 participants [87.3%] in the glatiramer acetate group).

Conclusions and relevance: Fingolimod, 0.5 mg, demonstrated superior clinical efficacy compared with glatiramer acetate, 20 mg, and had a superior benefit-risk profile compared with fingolimod, 0.25 mg, in adult participants with relapsing-remitting multiple sclerosis.

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