On Feb. 12, a U.S. Food and Drug Administration (FDA) advisory committee will debate whether to recommend Johnson & Johnson’s esketamine spray for major depression. It may be an uphill battle, although any positive results in this extremely difficult-to-treat patient population will no doubt be taken into account.
Esketamine is related to ketamine, a well-known party drug. Esketamine nasal spray is being developed by Janssen Research & Development, a J&J company. Esketamine is a glutamate receptor modulator that they believe restores synaptic connections in brain cells in individuals with major depressive disorder.
Esketamine also appears to induce a dreamlike sensation in some users, which has the agency concerned, although the probability of abuse seems low. “Ketamine abuse is relatively uncommon in the general population,” agency staff wrote in a report ahead of the meeting.
However, there are concerns that patients receiving the drug in a doctor’s office might experience the euphoria and dissociation as they leave. It takes about 90 minutes for those “high” symptoms to resolve. There are also concerns about elevated blood pressure.
On September 21, 2018, Janssen announced results from a Phase III trial of the esketamine spray that was disappointing. It failed to show statistical significance for the primary endpoint, change in a depression severity rating scale score from baseline to four weeks, for the 84 mg dose plus an oral antidepressant compared to oral antidepressant and placebo.
However, analyses of the primary endpoint and key secondary endpoints favored the esketamine plus oral antidepressant groups over the control group.
At the time, Husseini K. Manji, Janssen Research & Development’s Global Head, Neuroscience Therapeutic Area, stated, “Together with the recently announced results from four other Phase III studies, these data provide continued support for a positive benefit-risk assessment for esketamine nasal spray as a potentially novel treatment approach for patients living with treatment-resistant depression. One-third of patients with major depressive disorder do not respond to existing therapies, and they need new treatment options.”
Earlier trials showed some benefit in patients who had failed at least two prior treatments. In one of the trials, about 69 percent of the study group responded to the drug after 4 weeks compared to 52 percent in the intranasal placebo group. And 52.2 percent of the esketamine group achieved remission compared to only 31 percent of the placebo group at Week 4.
The company’s New Drug Application (NDA) was accepted on Sept. 4., 2018. It is based on five pivotal Phase III trials—three short-term studies, one withdrawal maintenance of effect study, and one long-term safety study.
The studies defined treatment-resistant depression as patients who didn’t respond to two or more antidepressants of adequate dose and duration.
The FDA staff report also noted there were six deaths in patients taking esketamine in the trial, three of which were suicide. Since those patients had treatment-resistant severe depression, that’s unlikely to be a side effect of the drug itself. Reviewers wrote, “Given the small number of cases, the severity of the patients’ underlying illness, and the lack of a consistent pattern among these cases, it is difficult to consider these deaths as drug-related.”
Janssen has a target action date for the drug of March 4. It had received Breakthrough Therapy designation for treatment-resistant depress in addition to depressed people at risk of suicide. Data from a study in suicidal patients is expected this year.
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