Ivacaftor

Medical uses

Ivacaftor is used for the treatment of cystic fibrosis in people having one of several specifics mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) protein including G551D, G1244E, G1349D, G178R, G551S, S1251N, S1255P, S549N, S549R, or R117H.

Ivacaftor is also included in a combination product, lumacaftor/ivacaftor, in a single pill, which is used to treat people with cystic fibrosis who have the F508del mutation in CFTR.

Adverse effects

The most common adverse reactions experienced by patients who received ivacaftor in the pooled placebo-controlled Phase 3 studies were abdominal pain (15.6% versus 12.5% on placebo), diarrhoea (12.8% versus 9.6% on placebo), dizziness (9.2% versus 1.0% on placebo), rash (12.8% versus 6.7% on placebo), upper respiratory tract reactions (including upper respiratory tract infection, nasal congestion, pharyngeal erythema, oropharyngeal pain, rhinitis, sinus congestion, and nasopharyngitis) (63.3% versus 50.0% on placebo), headache (23.9% versus 16.3% on placebo) and bacteria in sputum (7.3% versus 3.8% on placebo). One patient in the ivacaftor group reported a serious adverse reaction: abdominal pain.

Pharmacodynamics

Ivacaftor is a "potentiator" of CFTR, meaning it increases the probability that the defective channel will be open and allow chloride ions pass through the channel pore.

Distribution

Ivacaftor is approximately 99% bound to plasma proteins, primarily to alpha 1-acid glycoprotein and albumin. Ivacaftor does not bind to human red blood cells.

Biotransformation

Ivacaftor is extensively metabolised in humans. In vitro and in vivo data indicate that ivacaftor is primarily metabolised by CYP3A. M1 and M6 are the two major metabolites of ivacaftor in humans. M1 has approximately one-sixth the potency of ivacaftor and is considered pharmacologically active. M6 has less than one-fiftieth the potency of ivacaftor and is not considered pharmacologically active.

Elimination

Following oral administration, the majority of ivacaftor (87.8%) is eliminated in the faeces after metabolic conversion. The major metabolites M1 and M6 accounted for approximately 65% of total dose eliminated with 22% as M1 and 43% as M6. There was negligible urinary excretion of ivacaftor as unchanged parent. The apparent terminal half-life was approximately 12 hours following a single dose in the fed state. The apparent clearance (CL/F) of ivacaftor was similar for healthy subjects and patients with CF. The mean (±SD) of CL/F for the 150 mg dose was 17.3 (8.4) L/h in healthy subjects at steady state.

Society and culture

The US Food and Drug Administration approved ivacaftor in January 2012 and soon afterwards so too did the European Medicines Agency (EMA) and Canada and across some European countries. Ivacaftor was approved by the FDA in January 2012;

Lumacaftor/ivacaftor was approved by the FDA in July 2015 under breakthrough therapy status and under a priority review.

Economics

The cost of ivacaftor is $311,000 per year, roughly similar to the price of other drugs for extremely rare diseases. In the first 9 months of its second year on the market (2014), ivacaftor sales were $339M, representing 54% of Vertex's product sales revenue. During the same period, drug development expenses were $458M, most of which was spent on cystic fibrosis-related research.

An editorial in JAMA called the price of ivacaftor "exorbitant", citing the support by the Cystic Fibrosis Foundation in its development and the contribution made by fundamental scientific research performed by the National Institutes of Health and relied upon by Vertex in its cystic fibrosis drug discovery programs. The company responded in an email that "while publicly funded academic research provided important early understanding of the cause of cystic fibrosis, it took Vertex scientists 14 years of their own research, funded mostly by the company, before the drug won approval."

The Cystic Fibrosis Foundation, a non-profit organization dedicated to improving healthcare for people with cystic fibrosis, provided $150 million of the funding for the development for ivacaftor in exchange for royalty rights in the event that the drug was successfully developed and commercialized. In 2014, the Foundation sold these royalty rights for $3.3 billion. The Foundation has stated that it intends to spend these funds in support of further research.

Vertex said it would make the drug available free to patients in the United States with no insurance and a household income of under $150,000. In 2012, 24 US doctors and researchers involved in the development of the drug wrote to Vertex to protest the price of the drug, which had been set at about $300,000 per year. In the UK, the company provided the drug free for a limited time for certain patients, then left the hospitals to decide whether to continue to pay for it for those patients. UK agencies estimated the cost per quality adjusted life year (QALY) at between £335,000 and £1,274,000 —well above the National Institute for Health and Care Excellence thresholds.

The drug was not covered under the Ontario Drug Benefit plan until June 2014 when the Province of Ontario and the manufacturer negotiated for what "Ontario Health Minister Deb Matthews had called a “fair price” for taxpayers". The negotiations took 16 months and it was estimated that around 20 Ontarians required the drug at the time.

The province of Alberta began covering the drug in July 2014, and in September the province of Saskatchewan became the third province to include it in its provincial drug plan.

Government delays in agreeing to provide ivacaftor in national health plans led to patient group protests in Wales, England, and Australia.

As of March 2016 the combination drug cost $259,000 a year in the United States.

Research

The clinical trials used in the regulatory approval of ivacaftor are described here.

G551D mutation

Of the approximately 70,000 cases of cystic fibrosis worldwide, 4% (~3,000) are due to a mutation called G551D. The safety and efficacy of ivacaftor for the treatment of cystic fibrosis in patients with this mutation was examined in 2 clinical trials.

The first trial was performed in adults having baseline respiratory function (FEV1) between 32% and 98% of normal for persons of similar age, height, and weight. The baseline average was 64%. Improvement in FEV1 was rapid and sustained. At the end of 48 weeks, people treated with ivacaftor had on average an absolute increase in FEV1 of 10.4%, vs. a decline of 0.2% in the placebo group. Pulmonary exacerbations were reduced by about half in the ivacaftor group relative to the placebo group.

In a second trial conducted in children age 6 to 11, the average improvement in FEV1 was an absolute increase of 12.5% in the ivacaftor group at 48 weeks, compared to a very slight decline in the placebo group.

G1244E, G1349D, G178R, G551S, S1251N, S1255P, S549N, and S549R mutations

A third clinical trial examined the efficacy of ivacaftor in people with cystic fibrosis due to G1244E, G1349D, G178R, G551S, S1251N, S1255P, S549N, or S549R mutations. This trial, which included 39 people of age greater than 6 years, used a crossover design. The people in the trial had FEV1 averaging 78% of normal at baseline. The people in the trial were randomized to receive either ivacaftor or placebo for 8 weeks. This was followed by a 4 to 8 week washout period, then each group received the opposite treatment from what it received in the first part of the trial. At Week 8, the people on treatment with ivacaftor experienced an average absolute improvement in FEV1 of 13.8%, but there was a strong dependence of the efficacy on the exact mutation that a patient had. The detailed data for different mutation types is shown in the U.S package insert.