Unraveling the Journey of Elevidys
Elevidys, also known by several technical names like delandistrogene moxeparvovec-rokl or, SRP-9001 or rAAVrh74.MHCK7.micro-dystrophin, is a revolutionary gene therapy approved for a Duchene muscular dystrophy (DMD/Duchenne). Elevidys was granted accelerated approval by the U.S. Food and Drug Administration (FDA) on June 22, 2023, marking it as the first commercial gene therapy for Duchenne.
First explored by a group of Nationwide Children's Hospital researchers, led by Drs. Jerry Mendell and Louise Rodino-Klapac and later developed by Sarepta Therapeutics, Elevidys is now licensed to Roche for marketing outside the U.S. However, the medicine is currently available only in the United States where Sarepta is the sole licensee for manufacturing and marketing. Elevidys approval was anchored on data demonstrating its effectiveness in assisting Duchenne patients to produce a miniaturized version of the original dystrophin protein, called micro-dystrophin. While further trials assessing the treatment's impact on Duchenne progression continue, the therapy has been shown to improve patients' quality of life. Like all treatments granted accelerated approval, Elevidys' continued approval depends on the positive outcome of these ongoing trials.
The primary goal of this write-up is to explore Duchenne and the exciting world of its treatment options, focusing on Elevidys. Don't worry if some of the scientific terms and medical jargon sound difficult—I will try to break them down into simpler and easily digestible content. We'll look at how Elevidys was made, how it was approved by the FDA, and what this means for our community.
This blog post is fueled by a sense of urgency and passion. It is a response to a surge of questions and concerns from doctors, patients, and parents of Duchenne children who have reached out through platforms such as Oikotan, Duchenne Muscular Dystrophy: Bangladesh Chapter, and others following Elevidys' monumental regulatory approval. I aim to address those questions and soothe your concerns.
Consider this a sequel to my previous blog entries, where I discussed the progress, twists, and turns of Elevidys' journey towards FDA approval [1, 2]. Please note that while I am a committed research trainee, I am neither a certified clinician nor a recognized expert in this field. Thus, treat my writings as a friendly guide for your personal understanding only, and not as medical advice.
Understanding the FDA's Accelerated Approval Program
The Accelerated Approval Program of the U.S. Food and Drug Administration (FDA) is designed to hasten the approval of drugs that could fill unmet medical needs for serious or life-threatening conditions, like Duchenne muscular dystrophy (DMD). This program could be seen as a much-needed shortcut in the lengthy and complex process of drug approval.
The key to this expedited approval is the use of 'surrogate endpoints', which are laboratory measurements or physical signs that can act as an indirect indicator of a drug's effect. Surrogate endpoints do not measure the clinical benefit directly but are expected to predict it. For instance, in DMD, an increase in dystrophin protein levels in the muscles could be used as a surrogate endpoint.
The accelerated approval process allows the drug to get to patients more quickly based on these surrogate endpoints. However, this initial approval is conditional. The pharmaceutical company is obligated to conduct further clinical trials to confirm the predicted clinical benefit. If these subsequent trials do not confirm the expected benefit, the FDA may initiate proceedings to withdraw the approval.
The Marvel of Elevidys' Gene Therapy
Elevidys stands as a beacon of innovation in our fight against Duchenne. Unlike previous genetic therapies, e.g., eteplirsen, golodirsen, viltolersen, and casimersen, which modify how the body reads genetic instructions, Elevidys is a true gene therapy, which aims to transfer an alternative copy of genetic instructions from outside of the body.
Duchenne is caused by mutations in the DMD gene, which is responsible for producing dystrophin, a crucial protein for muscle strength and function. When this gene is mutated, the production of dystrophin is disrupted, leading to the symptoms of Duchenne. To circumvent this, scientists have created a miniaturized version of dystrophin, called micro-dystrophin, which, though not a complete substitute, can still perform critical functions.
To deliver this micro-dystrophin to the muscle cells, scientists used a harmless virus known as adeno-associated virus (AAV). This harmless version of the virus is named the AAVrh74 vector. The virus is engineered to carry the micro-dystrophin gene instead of its own genetic material. This ingenious use of the virus's natural ability to infiltrate cells signals a significant advancement in our efforts to combat Duchenne.
Elevidys: A Preliminary Success
Elevidys' accelerated approval was contingent on preliminary data demonstrating its ability to stimulate micro-dystrophin production in muscles. This increase in micro-dystrophin serves as a surrogate endpoint and is viewed as an early indicator that Elevidys could potentially counteract the effects of the missing or dysfunctional dystrophin in DMD patients.
However, while these early results are promising, it is crucial to underscore that they do not definitively confirm that Elevidys can halt or slow down the progression of DMD. We still lack comprehensive data to make that assertion. The drug's manufacturer, therefore, has a responsibility to continue conducting trials to gather more substantial evidence about the drug's effectiveness. The continued approval of Elevidys is contingent on the positive outcome of these trials.
Elevidys, however, is not a panacea. Genetic considerations dictate its appropriateness, and its impact may not be long-lasting. For now, it is only accessible in the U.S. and carries a hefty price tag. Additionally, it is not recommended for patients harboring certain mutations involving exon 8 and/or exon 9 (some may say, exon 8 through exon 11) in the DMD gene or for those with significant levels of pre-existing antibodies against the AAVrh74 viral vector. Only boys aged 4 to 5 years, who can still walk, don't carry a mutation in the above-mentioned exons, and do not have pre-existing AAVrh74 antibodies, are eligible for Elevidys. This medicine is given only once through an infusion in the bloodstream that lasts one to two hours.
Clinical Trials & The Ongoing Phase III Trial
Let's now delve a little into clinical trials to understand Elevidys' journey better. Think of these trials as relay races where potential treatments are rigorously tested for safety and effectiveness. Clinicians, scientists, patient advocates, and regulatory authorities closely watch every step. Elevidys has sprinted past the accelerated finishing line in this race, establishing itself as a potential torchbearer in Duchenne treatment.
Clinical trials generally follow a three-phase process. Phase I trials evaluate a new drug or treatment in a small group of people for safety and dosage. Phase II trials assess the drug's effectiveness and side effects in a larger group of people. Phase III trials confirm the drug's effectiveness, monitor side effects, and compare its effectiveness to existing medication strategies in a relatively large group of people. The FDA's endorsement of Elevidys springs from a triad of distinct clinical trials – Study 101, 102, and 103. As we navigate this illuminating course, let us jointly unravel these trials, their outcomes, and their implications.
Study 101: The Inception of a Promise
Elevidys’ first clinical trial, known as Study 101 (NCT03375164), was a Phase I/II trial that involved only four boys with Duchenne, aged between 4 and 7 years. The trial checked if Elevidys was safe, worked well, and was easy to tolerate. The boys were watched for four years after getting a single Elevidys treatment. The trial checked if Elevidys worked by doing physical exams, blood tests, urine tests, and immune system checks. Muscle function and tissue exams were also done.
The results of Study 101 were hopeful. The main side effect was vomiting, but Elevidys was generally easy for the boys to tolerate. The treatment increased the levels of micro-dystrophin in the muscles and decreased the levels of creatine kinase in the blood, a sign of muscle damage. The North Star Ambulatory Assessment (NSAA) score, which is a rating scale that is used to measure functional motor abilities in ambulant children with Duchenne, also improved. Though the trial had limitations, like the small number of participants, the results helped push forward the development of gene therapy for Duchenne.
Study 102: Forging Ahead with Intent
The second trial, Study 102 (NCT03769116), was a Phase II trial involving 41 41 boys with Duchenne, aged between 4 to 7 years, and aimed to reconfirm the micro-dystrophin production results seen in Study 101. It evaluated the safety and effectiveness of Elevidys and especially looked at it impacted micro-dystrophin levels and motor function.
The trial had three parts. The first part showed improvement in micro-dystrophin activity and NSAA scores in boys treated with Elevidys, compared to a placebo. The second part showed an increase in NSAA scores in boys treated with Elevidys, whereas the scores decreased in the control group. The third part is currently ongoing and will end in April 2026.
Study 103 (ENDEAVOR trial): Scaling the Spectrum
The ENDEAVOR trial (NCT04626674) tested Elevidys on a larger and more varied group of patients. The aim was to see how Elevidys affected micro-dystrophin protein expression and motor skills.
The results from the first eleven boys treated showed an improvement in NSAA scores, indicating Elevidys could help fight Duchenne. However, the trial's evaluation period of only 12 weeks is questionable as it does not seem to be long enough to show the full effects of the treatment on Duchenne progression.
EMBARK trial: The Decisive Phase
The EMBARK Study (NCT05096221) is an important Phase 3 trial for Elevidys. It tests the treatment on 120 patients with Duchenne, aged between 4 to 7 years. The aim is to see how Elevidys affects the NSAA total score after one year compared to a placebo.
EMBARK is the post-marketing confirmatory study, the results of which are vital for the continued approval of Elevidys. Assuming positive outcomes, the results will form the foundation of a request to expand the approved label.
ENVISION trial: Expanding the Scope
The ENVISION trial (NCT05881408) is a Phase 3 trial that tests Elevidys on a broader group of Duchenne patients. The aim is to see how Elevidys affects the upper limb function, which is an important aspect of Duchenne. In addition to validating the micro-dystrophin production, this trial will also evaluate how well Elevidys can halt or slow down the progression of DMD.
The trial is double-blind and placebo-controlled, with a crossover component. This means all patients will eventually get Elevidys. It also allows the researchers to see how patients respond to both the placebo and the treatment.
Potential risks and considerations
Like other gene therapies, Elevidys may trigger an immune response against the newly introduced protein. This reaction has prompted modifications to ongoing clinical trials and necessitated continuous scientific research to identify risk factors and devise suitable protocols. This would enable patients exhibiting such responses to partake in future studies.
While Elevidys holds substantial therapeutic potential, it is not exempt from potential risks and adverse effects. Some patients may experience side effects, including nausea, vomiting, decreased appetite, and increased liver enzyme levels. More concerning are the cases of acute kidney injury that have been reported in two participants in the Study 103 trial. Besides, other potential adverse effects encompass immune reactions, inflammation, infusion-related reactions, possible liver damage, and a speculative risk of genotoxicity. During clinical trials, these risks were managed using immunosuppressants and by careful monitoring of liver function and other essential health parameters. Balancing these risks against the benefits is a crucial aspect of Elevidys' clinical development.
Elevidys comes with tremendous promise, however, it's essential to approach this novel treatment with a balanced perspective. While it opens a new chapter in the treatment of Duchenne and brings hope to many patients and their families, we must also acknowledge its limitations and potential risks. As we await the results of ongoing clinical trials, we are one step closer to revolutionizing Duchenne's treatment landscape. With further research and advancements, we anticipate even more precise, effective, and accessible treatments for Duchenne in the future.
Navigating the Path of Internal Objections and Limited Approval
At this point, we need to shift gears. Science, particularly medical science, isn't a straightforward journey. It's more akin to a labyrinth, with patient safety and treatment effectiveness as the ultimate goals. Along the way, we encounter objections or get only partial or conditional approval for a drug. However, these aren't roadblocks. They serve as crucial checkpoints. When objections arise from experts and regulatory bodies, they ensure that a new drug is as safe and effective as possible. Elevidys' journey through clinical trials and regulatory inspections is no different. In fact, for a novel treatment like Elevidys, these checkpoints are vital for determining its true potential.
The Valuable Voice of Dissent
Objections are a valuable part of scientific research. Contrary to popular belief, objections don't obstruct progress, they drive it. They challenge established ideas, compelling researchers to reassess the robustness of their methodologies and theories. A significant concern for Elevidys was the potential immune response against the micro-dystrophin protein. While the initial trials showed promise, they couldn't entirely dispel these concerns. These objections paved the way for improved research strategies and innovations to address potential issues.
Understanding the Nuances of Limited Approval
'Limited approval' is an integral concept in Elevidys' journey. It's an acknowledgment by regulatory bodies like the FDA that a medicine has shown promising advantages over existing treatments, thus warranting early patient access. However, it also underscores the need for ongoing evaluation of the treatment's long-term safety and effectiveness. For Elevidys, the FDA's limited approval was based on early clinical trials indicating increased micro-dystrophin levels and potential improvements in motor functions. Nonetheless, it mandated post-marketing studies to further assess these benefits, evaluate long-term safety, and identify the most responsive patient groups. This step exemplifies a commitment to evidence-backed leaps of faith paired with a pledge for continued rigorous scrutiny.
In the broader narrative of Elevidys, internal objections, and limited approvals are critical chapters highlighting the rigor and integrity of the scientific process. Every question asked, every dissenting voice, and every cautious stride forward signifies the relentless pursuit of safe and effective therapies for DMD. These phases are proof of a system that prioritizes patient safety and treatment efficacy above all else.
A Promise of Progress, a pledge for Equity
As Elevidys' journey continues, we must remember that the path, marked with questions, objections, and cautious progress, is a testament to the stringent nature of the scientific process. The goal remains clear: to provide safe and effective therapies for Duchenne muscular dystrophy. Each obstacle encountered on this journey is a steppingstone, moving us closer to this objective. The journey isn't without its challenges, but with each hurdle surmounted, we inch closer to delivering a potential breakthrough for the DMD community.
Elevidys signals a transformation in the therapeutic landscape for Duchenne. This pioneering treatment serves as a beacon of hope for countless individuals worldwide. However, while we rightfully celebrate this milestone in scientific advancement, we must keep sight of the remaining challenges. Among these, securing widespread access to Elevidys and ensuring its affordability are two significant hurdles we face.
The Access and Affordability Dilemma
The introduction of any new drug is often paired with a high price tag, reflecting the intensive research, development, and testing costs involved in its creation. Elevidys is no exception. Its current pricing and distribution strategies might limit accessibility for everyone who could benefit from it. However, if we look at many life-changing drugs – take penicillin, for example – we see a common pattern. Initially, scarce and costly, such medications ultimately become globally accessible and affordable over the course of time. We anticipate a similar progression for Elevidys over time.
Post-Marketing Studies and Amplifying Patient Perspectives
The FDA's approval for Elevidys is not the end of the story; it's an essential chapter in an ongoing narrative. Elevidys' real-world performance and its cost-effectiveness remain key areas for further investigation. Post-marketing studies, also known as Phase 4 clinical trials, will enable us to gather robust data on Elevidys' impact on a larger and more diverse patient population. These studies are designed to validate long-term safety and efficacy, identify patient groups most likely to benefit, and explore potential strategies to enhance the drug's cost-effectiveness and accessibility.
Promoting Equitable Outcomes
As we stand at this significant juncture in Duchenne treatment, it's vital to remember that our mission extends beyond this point. Our commitment to the DMD community goes far beyond the development of effective therapies. We aim to ensure these advancements are equitably accessible and beneficial to everyone affected by the condition. The journey to defeat Duchenne is not a 100-meter sprint but a marathon, requiring our continuous efforts to strive for improved treatments, broader accessibility, and equitable patient outcomes.
Illuminations and Forward Look
This write-up aimed to provide an in-depth exploration of the complexities inherent in the development and approval of a groundbreaking treatment like Elevidys. By delving into the underappreciated aspects, such as the role of internal objections and the significance of limited approval, we have attempted to shed light on many crucial facets that constitute this journey. Additionally, we have highlighted the indispensable requirement of post-marketing studies and the relentless pursuit of improved patient accessibility and affordability.
Each stride we take in the pursuit of a viable treatment for Duchenne represents more than just scientific progress; it embodies hope, resilience, and an unwavering commitment to transforming lives. We invite you to be a part of this mission as we move towards a future where Duchenne muscular dystrophy will be relegated to history books.
Our ambitious mission requires unwavering patience, persistent efforts, and a collective vision for a Duchenne-free future. Let us move forward, steadfast in our commitment and unwavering in our determination. Together, we will shape a future where Duchenne is conquered once and for all.
11 July 2023
Saeed Anwar
Edmonton, Canada