CENTER FOR DRUG EVALUATION AND
`CENTER FOR DRUG EVALUATION AND
`RESEARCH
`RESEARCH
`
`APPLICATION NUMBER:
`APPLICA TION NUMBER:
`22-334
`22—334
`
`PHARMACOLOGY REVIEW(S)
`PHARMACOLOGY REVIEW! S!
`
`

`

`MEMORANDUM
`
`Afinitor (everolimus)
`
`Date: March 24,2009
`To: File for NDA #22-334
`From: John K. Leighton, PhD, DABT
`Associate Director for Pharmacology
`Office of Oncology Drug Products
`
`I have examined pharmacology/toxicology supporting review, memoranda and labeling
`provided by Drs. Luan Lee and Haleh Saber. I concur with their conclusions that
`Afinitor may be approved. No additional pharmacology or toxicology studies are
`necessary for the proposed indication.
`
`Appears This Way
`On Original
`
`

`

`---------------------------------------------------------------------------------------------------------------------
`This is a representation of an electronic record that was signed electronically and
`this page is the manifestation of the electronic signature.
`---------------------------------------------------------------------------------------------------------------------
`/s/
`John Leighton
`3/24/2009 03: 32 : 48 PM
`PHAMACOLOGIST
`
`

`

`MEMORANDUM
`
`Date: March 23, 2009
`From: Haleh Saber, Ph.D.
`Pharmacology Acting Team Leader
`Drug Oncology Products
`Division of
`To: File for NDA #22,334
`AfinitorQl (everolimus) tablets
`Re: Approvability for Pharmacology and Toxicology
`
`inhibitor of
`
`were provided in support of
`
`AfinitorQl (everolimus) is indicated for the treatment of patients with advanced renal cell
`carcinoma after disease progression following treatment with sunitinib or sorafenib.
`Nonclinical studies that investigated the pharmacology and toxicology of everolimus
`the NDA. Everolimus, an ether derivative of sirolimus, is an
`the mTOR pathway. mTOR is a serine-threonine kinase downstream of
`PI3K1AKT pathway, which acts as a growth factor and nutrient sensor. Inhibition of
`mTOR by everolimus was shown to reduce cell proliferation, angiogenesis, and glucose
`uptake in in vitro and/or in vivo studies. In the Highlight section ofthe label, the
`pharmacologic class of Afinitor is defined as "kinase inhibitor" to be consistent with
`other products in this class. Of note, everolimus is approved in Europe as an
`immunosuppressive agent, under the name CerticanQl.
`
`temsirolimus, another mTOR inhibitor approved for the treatment of
`
`Pharmacology, safety pharmacology, pharmacokinetic/ ADME, and toxicology studies
`supporting the marketing application of Afinitor for the proposed indication were
`conducted in in vitro systems and in animal species. Based on the general toxicology
`studies, toxicities associated with everolimus were comparable to those reported for
`renal cell
`carcinoma. Everolimus-related findings included effects in the male reproductive system,
`coagulation pathway, GI tract, lungs, metabolism/endocrine system, and lymphoid
`tissues. Nonclinical studies in rodents indicated that everolimus and/or its metabolites
`crossed the blood-brain barrier and the placenta, and were excreted into milk of lactating
`animals.
`
`Everolimus was negative for evidence of genetic toxicity in the standard battery of
`
`tests
`described by ICH S2. Everolimus was negative for evidence of carcinogenicity in two
`rodent studies. Reproductive toxicology studies conducted with everolimus included the
`male fertility, embryo-fetal toxicity and prenatal! postnatal development toxicity studies.
`Everolimus resulted in infertility in male rats, with partial recovery after 10-13 weeks of
`treatment-free period. Oral doses of everolimus in female rats resulted in increased pre-
`implantation loss, suggesting that the drug may reduce female fertility. Everolimus was
`embryo-fetal toxic when administered to pregnant rats; toxicities included decreased
`fetus, malformation (e.g., sternal Cleft) and retarded skeletal development. In
`rabbits, embryo-fetal toxicity was evidenced as increased resorption. Because ofthe
`embryo-fetal effects, Pregnancy Category D is recommended for everolimus. The
`prenatal and postnatal development study in rats at doses tested showed no adverse
`
`number of
`
`

`

`effects on delivery and lactation and no drug-related effects on the developmental
`parameters in the offspring (morphological development, motor activity, learning, or
`survival
`
`fertility
`
`assessment). However, reduced body weight and slight reduction in
`
`were noted in offspring.
`
`The nonclinical studies were reviewed in detail by Dr. Shwu-Luan Lee. The nonclinical
`findings are summarized in the "Executive Summary" and "Discussion and Conclusions"
`of the review, and reflected in the product labeL.
`
`Recommendation: I concur with Dr. Lee's conclusion that pharmacology and
`toxicology data support the approval ofNDA 22,334 for Afinitor. There are no
`outstanding non-clinical issues related to the approval of Afinitor for the proposed
`indication.
`
`Appears This Way
`On Originai
`
`2
`
`

`

`This is a representation of an electronic record that was signed electronically and
`this page is the manifestation of the electronic signature.
`---------------------------------------------------------------------------------------------------------------------
`/s/
`Haleh Saber
`3/23 /2 009 03: 4 8 : 54 PM
`PHAMACOLOG 1ST
`
`

`

`DEPARTMENT OF HEALTH AND HUMAN SERVICES
`PUBLIC HEALTH SERVICE
`FOOD AND DRUG ADMINISTRA nON
`CENTER FOR DRUG EVALUA nON AND RESEARCH
`
`PHARMACOLOGY/TOXICOLOGY REVIEW AND EVALUATION
`
`NDANUMBER:
`
`SERIAL NUMBER:
`
`DATE RECEIVED BY CENTER:
`
`DRUG NAME:
`
`INDICATION:
`
`SPONSOR:
`DOCUMENTS REVIEWED:
`
`REVIEW DIVISION:
`
`PHARMrrox REVIEWER:
`PHAR/TOX SUPERVISOR:
`
`DIVISION DIRECTOR:
`
`PROJECT MANAGER:
`
`22-334
`
`000
`
`6/30/2008
`
`AfinitorCí (everolimus)
`
`Treatment of advanced renal cell carcinoma
`Novartis Pharmaceutical Corporation
`Electronic submission
`Division of Drug Oncology Products
`Shwu-Luan Lee, Ph.D.
`
`Haleh Saber, Ph.D.
`
`Robert Justice, M.D., M.S.
`Christy Cotrell
`
`Date of
`
`review submission to Division File System (DFS): 3/12/09
`
`

`

`TABLE OF CONTENTS
`
`EXECUTIVE SUMMRY .............................................................................................. 1
`
`2.6 PHARMACOLOGYITOXICOLOGY REVIEW ...................................................5
`
`2.6.1 INTRODUCTION AN DRUG HISTORy...................................................................5
`
`2.6.2 PHARMACOLOGY ....................................................................................................... 12
`summary ......................................................................................................................12
`2.6.2.1 Brief
`2.6.2.2 Primary pharmacodynamics ................................................................................................. 13
`2.6.2.3 Secondary pharmacodynamics ............................................................................................. 19
`2.6.2.4 Safety pharmacology ............................................................................................................ 19
`2.6.2.5 Pharmacodynamic drug interactions.....................................................................................20
`
`2.6.3 PHARMACOLOGY TABULATED SUMMRy.......................................................20
`
`2.6.4 PHARMACOKINETICSITOXICOKINETICS ..........................................................20
`summary ......................................................................................................................20
`2.6.4.1 Brief
`2.6.4.2 Methods of Analysis ............................................................................................................. 21
`2.6.4.3 Absorption ............................................................................................................................21
`2.6.4.4 Distribution...........................................................................................................................23
`2.6.4.5 M.etabolism ........................................................................................................................... 31
`2.6.4.6 Excretion................................................................................................................................ 35
`2.6.4.7 Pharmacokinetic drug interactions........................................................................................36
`2.6.4.8 Other Pharmacokinetic Studies............................................................................................. 36
`2.6.4.9 Discussion and Conclusions ................................................................................................. 36
`2.6.4.10 Tables and figures to include comparative TK summary ..................................................... 36
`
`2.6.5 PHARMACOKINETICS TABULATED SUMMRy.............................................. 38
`
`2.6.6 TOXICOLOGy...............................................................................................................39
`2.6.6.1 Overall toxicology summary ................................................................................................39
`2.6.6.2 Single-dose toxicity .............................................................................................................. 40
`2.6.6.3 Repeat-dose toxicity ............................................................................................................. 41
`2.6.6.4 Genetic toxicology ................................................................................................................ 72
`2.6.6.5 Carcinogenicity .............................................................................,....................................... 87
`2.6.6.6 Reproductive and developmental toxicology ...................................................................... 105
`2.6.6.7 Local tolerance ...................................................................................................................121
`2.6.6.8 Special toxicology studies .................................................................................................. 122
`2.6.6.9 Discussion and Conclusions ............................................................................................... 127
`2.6.6.10 Tables and Figures..............................................................................................................130
`
`2.6.7 TOXICOLOGY TABULATED SUMMAY ...........................................................130
`
`OVERALL CONCLUSIONS AN RECOMMENDATIONS.............................................135
`
`APPENDIx/ATTACHMENTS ...............................................................................................136
`
`

`

`Reviewer: Shwu-Luan Lee, Ph.D.
`
`NDA No. 22-334
`
`EXECUTIVE SUMMARY
`
`I. Recommendations
`
`A. Recommendation on approvability
`There are no pharmacology/toxicology issues which preclude approval of everolimus
`(AfinitorQì) for the requested indication.
`
`B. Recommendation for nonc1inical studies
`No additional non-clinical studies are required for the proposed indication.
`
`C. Recommendations on labeling
`Recommendations on labeling have been provided within team meetings and
`communicated to the sponsor.
`
`II. Summary of nonclinical findings
`
`A. Brief overview of nonclinical findings
`Everolimus (RADOO 1) is a hydroxyethyl derivative of rapamycin. Everolimus binds to FKBP-
`12, an intracellular protein, resulting in an inhibitory complex formation. The complex binds
`to mTOR (mammalian larget Qfrapamycin) and inhibits mTOR kinase activity.
`
`tissues/organs of
`
`the immune system. Tissue elimination of
`
`The oral bioavailability of everolimus was low, e.g. approximately 5% in mice and 6% in
`monkeys. Everolimus binding to plasma proteins was ~ 75% in human, 85% in monkey, 93%
`in rats, and )099% in mouse plasma, at concentrations tested. In rats, tissue concentration of
`radioactivity was generally highest in the GI tract, pancreas, lungs, kidneys, liver, and
`radioactivity was slow; at Hr 144
`(Day 6 post-dose) radioactivity was detectable in some tissues/organs, e.g. in liver, kidneys,
`and GI tract. Everolimus penetrated the brain dose dependently, with a brain:blood
`concentration ratio of3:1 after an intravenous dose of30 mg/kg. Everolimus is extensively
`metabolized. There appears to be an appreciable first-pass effect contributing to low oral
`bioavailability ofthe parent drug. Cytochrome P450 isoenzyme 3A4 (CYP3A4) was the major
`enzyme involved in the biotransformation of everolimus in human liver microsomes. Excretion
`of everolimus and/or its metabolites was mostly via the bile; urinary excretion was negligible.
`In the rat, elimination was mainly via the bile (~71 % in bile duct cannulated rats following i.v.
`the dose). Everolimus and its metabolites penetrated
`radioactivity was
`3.5: 1. After repeated administration, evidence of drug accumulation was observed only in rats
`at relatively high and toxic doses (in 4 week studies, no accumulation was found in the 26
`week study). In monkeys, dose-normalized exposure tended to decrease with increasing doses
`(except at very high doses).
`
`administration) and feces (69% to 82% of
`
`the placenta and were excreted into milk in rats; the milk:blood AUC ratio of
`
`Everolimus showed minimal or no effect in safety pharmacology studies when evaluated for
`effects on the cardiovascular, central nervous, or respiratory systems. However, myocarditis
`was observed in several toxicology studies. In safety pharmacology studies, orally
`
`

`

`Reviewer: Shwu-Luan Lee, Ph.D.
`
`NDA No. 22-334
`
`administered everolimus at doses up to 50 mg/kg in mice induced slight increases in total
`urinary potassium and chloride levels, but no effects on gastrointestinal transit time were seen.
`
`Repeat dose toxicology studies conducted in mice, rats, minipigs and monkeys have identified
`the following toxicities:
`· Reproductive organs: males (e.g. atrophy in testes, epididymis, and prostate; l sperm count
`and motility), females (ovary: reduced follcular development, uterus: atrophy)
`· Hematopoietic/lymphoid system:
`
`~ l lymphocytes, t neutrophils, t monocytes, t % band cells, associated with lymphoid
`atrophy in lymph nodes, thymus and/or spleen (in minipigs and monkeys)
`~ t RBC, HGB, and Hct in rats, associated with l serum iron and hemosiderosis in the spleen.
`
`t RBC, HGB, and Hct: also in mice and minipig, but decreased in monkeys.
`
`~ l Platelets, t fibrinogen, t aPTT
`~ Sternum hypocellularity was found in minipigs.
`· GI tract: stomach (acute inflammation at glandular tissue and mucosal hyperplasia!
`hypertrophy in rats), intestine (small and large intestines: erosion and mucosal atrophy in
`phages and mucosal inflammation in monkeys). The GI
`lesions may have contributed to l food consumption, weight loss, malnutrition and related
`
`minipigs, aggregation of
`
`macro
`
`clinical chemistry findings (l albumin, A1G ratio, and phosphorus, in all species)
`· Lung: accumulation or foamy alveolar macrophages (all species)
`· Skin: ulceration, scabs, lesions (all species)
`· Metabolism/endocrine: t cholesterol and triglyceride (all species)
`· Pancreas: necrosis and exocrine cell vacuolation in minipigs, degranulation of exocrine cells
`and degeneration of pancreatic islet cells in monkeys; t amylase and lipase
`· Heart: in rats and/or monkeys: myocarditis, myocardial degeneration and/or fibrosis
`· Eye (mainly in lens): swelling and disruption offibers in the anterior cortex (rat only)
`hydronephrosis and pigment in renal
`tubular epithelium in rats, tubular degeneration with karyomegaly, interstitial inflammation
`and basophilic tubules in mice
`
`· Kidney: t BUN and creatinine, increased incidence of
`
`Everolimus did not show mutagenic activity in bacterial Ames test in Salmonella or in TK
`mutation test in L5178Y mouse lymphoma cells. Everolimus did not demonstrate clastogenic
`activity in a chromosome aberration test in V79 Chinese hamster cells, and did not increase
`micronucleus formation in mice after oral doses up to 500 mg/kg (1500 mg/m2).
`
`Everolimus was not carcinogenic in the rodents. In the 104 week studies, oral treatment with
`everolimus at up to 0.9 mg/kg induced toxicities comparable to findings in other repeat dose
`toxicology studies. The 0.9 mg/kg dose in mice and rats corresponded respectively to 4.3 and
`0.2 times the estimated clinical exposure at the recommended human dose of 10 mglday. No
`drug-related neoplastic findings were observed.
`
`2
`
`

`

`Reviewer: Shwu-Luan Lee, Ph.D.
`
`NDA No. 22-334
`
`numbers of
`
`Everolimus was shown to have adverse effects on male and female reproductive organs. See
`above for effects observed in repeat-dose toxicology studies. In a 13 week male fertility study
`in rats, an oral dose of5 mg/kg (30 mg/m2, corresponding to 81 % ofthe AUCo-24h at the
`recommended human dose of 10 mg/day), resulted in male infertility. The adverse effect was
`not fully recovered after a 10-13 week treatment-free period. When administered to female
`rats, prior to mating and continued to gestation day 16, everolimus at oral doses:: 0.1 mg/g
`(0.6 mg/m2, ~ 4% the AUCo-24h at recommended human dose of 10 mg/day) induced embryo-
`fetal toxicities including increased pre- and post-implantation loss and resorptions, decreased
`live fetuses and malformations (e.g., sternal cleft) and retarded skeletal
`development. In rabbits, embryo-fetal toxicity was evidenced by increased resorption at 0.8
`mg/kg (9.6 mg/m2, ~ 1.6 times the recommended human dose on body surface area basis). In a
`prenatal and postnatal development study in rats, oral treatment of everolimus in pregnant
`females (Fo) from gestation day 6 to lactation day 21 did not induce maternal toxicities or
`adverse effects on delivery and lactation parameters. The F i pups of dams treated at 0.1 mglkg
`(0.6 mg/m2, approximately 10% ofthe recommended human dose based on the body surface
`area) had reduced body weights (up to 9% reduction from the control) and showed a slight
`reduction in survivaL. There were no drug-related effects on the developmental parameters
`(morphological development, motor activity, learning, or fertilty assessment) in the F i
`generation.
`
`B. Pharmacologic activity
`Primary pharmacology:
`Everolimus (RADOO 1) is a derivative of rapamycin. Similar to rapamycin (sirolimus) and
`temsirolimus, the antiproliferative activity of everolimus results from the inhibition of mTOR
`(mammalian larget Qf rapamycin) activity. mTOR a serine-threonine kinase, downstream of
`PI3K-AKT pathway, is implicated in protein sysnthesis and cell cycle control. Everolimus has
`various human cancer
`cell lines. In xenograft models tested, the down-regulation ofp70 S6 kinase (S6K), a kinase
`downstream from mTOR and involved in protein translation, has been directly related to
`everolimus anti-tumor activity.
`
`been shown to be an inhibitor of
`
`tumor
`
`growth in xenograft models of
`
`Secondary pharmacology:
`The immunosuppressive effect of everolimus was demonstrated in an in vitro assay, where
`everolimus blocked lymphocyte proliferation in response to a mitogenic stimulus. In Europe,
`everolimus is used as an immunosuppressant in organ transplant patients to prevent transplant
`rejection. Additionally, in in vitro assays, everolimus exhibited a direct inhibitory effect on
`mouse and human osteoclast formation and activity, and to a lesser extent osteoblast
`differentiation.
`
`C. Nonclinical safety issues relevant to clinical use
`The toxicities in the target organs identified in the animals, e.g., metabolic-endocrine (e.g.
`hyperlipidemia), GI tract (stomatitis), lung (pneumonitis), kidney (Î serum creatinine) and
`inflammation in skin and mucus (oral mucositis, mouth ulcers), were also reported in the patients.
`
`3
`
`

`

`Reviewer: Shwu-Luan Lee, Ph.D.
`
`NDA No. 22-334
`
`All toxicities of everolimus reported in animals, including those seen in the eye, kidney, liver,
`pancreas, reproductive organs, and embryo/fetus should be considered as potential risks to
`humans.
`
`Appears This Way
`On Original
`
`4
`
`

`

`Reviewer: Shwu-Luan Lee, Ph.D.
`
`NDA No. 22-334
`
`2.6 PHARMA
`
`COL OGynOXICOLOGY REVIEW
`
`2.6.1 INTRODUCTION AND DRUG HISTORY
`
`22-334
`
`1 O
`
`OO/June 30, 2008INDA
`Yes () No (x)
`Norvatis Pharmaceuticals Corporation
`One Health Plaza
`East Hanover, NJ 07936-1080
`Novartis Pharma Stein AG Schaffhauserstrasse
`CH-4332 Stein Switzerland
`Shwu-Luan Lee
`Drug Oncology Products
`February 27, 2009
`
`Division of
`
`AFINITOR(ß
`Everolimus
`RADOOl, SDZ RAD, SDZ 222-666
`40-0-(2-hydroxyethyl)-rapamycin
`(IR,9S, 12S, 15R, 16E, 18R, 19R,21R,23S,24E,26E,
`28E, 30S,32S,35R)-1,18-dihydroxy-12-HIR)-2-
`((1 S,3R,4R)-4-(2-hydroxyethoxy)- 3- methoxy-
`cyclohexyl)-I-methylethyl J -19,30- dimethoxy-
`15,17,21,23,29,35-hexamethyl-ll,36- dioxa-4-
`aza-tricyclo(30.3.1.0")hexatriaconta- 16,24,26,28-
`tetraene-2,3,1 0, 14,20-pentaone
`159351-69-6
`CS3H83NOl4
`958.22 gm/mole
`
`5
`
`NDAnumber:
`Review number:
`Sequence number/date/type of submission:
`Information to sponsor:
`Sponsor and/or agent:
`
`Manufacturer for drug substance:
`
`Reviewer name:
`Division name:
`Review completion date:
`
`Drug:
`
`Trade name:
`Generic name:
`Code name:
`Chemical name:
`
`CAS registry number:
`Molecular formula:
`Molecular weight:
`Structure:
`
`

`

`Reviewer: Shwu-Luan Lee, Ph.D.
`
`NDA No. 22-334
`
`?',i .
`HO~O..rl
`H3C..O~
`/' /~,~"
`L~¿ ~ ~æ
`N ~ ~c I
`
`~c'-o......yO
`
`~c
`
`?
`
`/CH,
`
`:/
`
`CH
`
`..
`
`H,c/""
`/
`..
`
`,
`CH,
`
`,.
`
`Relevant INsINAsIDMFs: IN 66279; NDAs (not approved) '__
`
`21628,
`
`b\4)
`
`Pharmacologic class: kinase inhibitor
`Mechanism of action: mTOR inhibitor
`
`Intended clinical population: for the treatment of advanced renal cell carcinoma
`
`Clinical formulation: tablets: 5 and 10 mg everolimus, with
`Excipients:
`butylated hydroxytoluene (Ph.Eur., USPINF)
`magnesium stearate (Ph.Eur., USPIN)
`
`crospovidone (Ph.Eur., USPINF)
`lactose (Ph.Eur., USPINF)
`
`Route of administration: Oral
`
`b\4,)
`
`Disclaimer: Tabular and graphical information are constructed by the reviewer unless cited
`otherwise.
`
`Studies reviewed within this submission:
`Study Number
`Study Title
`Pharmacology
`Primary
`pharmacodynamics
`In vitro studies
`
`(Bjornsti M-A, Houghton P J (2004)) The TOR pathway: A target for cancer
`chemotherapy. Nature Reviews Cancer; 4:335-48.
`
`(Abraham RT and Gibbons 11 (2007)) The Mammalian Target of
`
`Rapamycin Signaling
`Pathway: Twists and Turns in the Road to Cancer Therapy. Clin Cancer Res 13; 3109-
`14.
`
`RD-2004-00475
`
`Synthesis and in vitro biological profie of
`
`RAD choline-ester
`
`the RAD metabolite NVP-ATG181-NX-1, a
`
`6
`
`

`

`Reviewer: Shwu-Luan Lee, Ph.D.
`
`NDA No. 22-334
`
`Study Number
`RD-2001-01088
`
`RD-2002-03223
`RD- 2006-02213
`
`RD-2000-02544
`
`RD- 2000-02151
`RD-2003-03495
`
`RD-2002-03252
`
`RD-2001-00852
`
`In vivo studies
`RD-2000-02541
`
`RD-2001-00450
`
`RD-2000-02545
`RD-2002-03817
`
`RD-2002-03707
`
`RD-2000-02547
`RD- 2000-02548
`
`RD-2000-02549
`
`RD- 2004-01547
`
`RD- 2006-013 83
`
`Study Title
`Enzymatic profile ofRAD001: In vitro inhibition of
`
`In vitro antiproliferative activity of
`
`1 against a broad panel of
`
`protein kinases
`(Sarbassov DD, Ali SM, Kim D-H, et aI, 2004) Rictor, a Novel Binding Partner of
`mTOR, Defines a Rapamycin-Insensitive and Raptor-Independent Pathway that
`Regulates the Cytoskeleton Current BioI; 14:1296 - 302.
`*(Kim D-H, et aI, (2002)) mTOR interacts with raptor to form a nutrient-sensitive
`complex that signals to the cell growth machinary. Cell 110: 163-175.
`*(Kim D-H, et aI, (2002)) mTOR interacts with raptor to form a nutrient-sensitive
`complex that signals to the cell growth machinary. MoL. Cell 11: 895-904.
`*(Hara K, et aI, (2002)) Raptor, a binding partner oftarget ofrapamycin (TOR),
`mediate TOR action. Cell 110: 177-189.
`RAOO
`
`tumor cell lines
`breast, NSCLC and
`
`The in vitro antiproliferative activity ofRA001 against a panel of
`renal tumor lines
`Downregulation ofm TOR targets in tumor cell lines in vitro (comparison with CCI-
`779)
`RAD001 inhibits the growth factor-stimulated activation ofp70 S6 kinase
`Molecular analysis of a panel of tumor cell lines with known response to RADOO 1 in
`vitro
`
`translation initiation by
`
`(Gingras AC, Raught B, Sonenberg N (2001)) Regulation of
`FRAP/mTOR. Genes Dev; 15:807-26.
`1 with activation ofthe
`Comparison ofthe antiproliferative activity of
`RAOO
`PTEN/PI-3 kinase/Akt/m TOR pathway in tumor cell lines
`(Majumder PK, Febbo PG, BikoffR, et al (2004)) mTOR inhibition reverses Akt-
`dependent prostate intraepithelial neoplasia through regulation of apoptotic and HIF-1-
`dependent pathways. Nat Med; 10:594-601.
`RAOO 1: effects on endothelial and fibroblast cell proliferation
`(Shinohara ET, Cao C, Niermann K, et aI, (2005)) Enh anced radiation damage of
`tumor vasculature by mTOR inhibitors. Oncogene; 24(35):5414-22
`
`Downregulation of m TOR targets in tumors and skin derived from KB-3 1 human
`epidermoid carcinoma xenograft studies
`Prolonged inactivation of in tumors and skin derived from CA20948 pancreatic tumor-
`bearing rats
`Inhibition of
`
`the mTOR target in rat peripheral lymphocytes
`Prolonged inactivation ofp70S6K in peripheral blood mononucleocytes derived from
`CA20948 pancreatic tumor- bearing rats and non-tumor-bearing rats
`(Mabuchi S Altomar e DA, Connolly DC, et aI, (2007a)) RA DOOI (Everolimus)
`delays tumor onset and progression in a transgenic mouse model of ovarian cancer.
`Cancer Res; 67(6) 2408-13.
`Effect of the rapamycin derivative, RAD001, in the syngeneic CA20948 rat pancreatic
`tumor model
`Studies on the tolerability of athymic BALB/c nulnu (nude) mice to RA001
`the antitumor activity ofRA001 in experimental xenograft tumor
`models of pancreatic cancer
`RAD001 is an effective antitumor agent in experimental KB-31 xenograft tumor
`models of epidermoid cancer
`(Pende M, Kozma SC, Jaquet M, et al (2000)) Hypoinsulinaemia, glucose intolerance
`and outcome among endocrine treated patients. Br J Cancer; 86:540-5.
`I~Fluoro-deoxy-glucose C"FDG) tumour metabolism detected by positron emission
`tomography (PET) imaging in mice: RAD001 decreases uptake of 18FDG by B16/BL6
`melanoma metastases and H596 human tumour xenografts
`RAD001 does not decrease uptake of I~FDG by human tumour xenografts with low
`sensitivity in vitro to RAD001
`
`Evaluation of
`
`7
`
`

`

`Reviewer: Shwu-Luan Lee, Ph.D.
`
`NDA No. 22-334
`
`Study Number
`RD-2001-00853
`
`RD-2001-00854
`
`Secondary
`pharmacodynamics:
`Bone remodeling
`RD-2002-03782
`Immunosuppression
`(kidney tranplant)
`
`Safety Pharmacology
`Neurological, gastro-
`intestinal and renal effects
`RAD 02-c
`PKF-93-02177
`Cardiovascular effects
`0120037-DITU 1014
`
`0770800
`
`982042
`
`RD-2000-0 1460
`Pulmonary effects
`RD-2000-01492
`Pharacokinetics/ ADME
`DMPK(CH) R98-707
`
`DMPK(CH) ROO-874
`
`DMPK(CH) 1997/287
`
`DMPK(CH) ROO-1253
`
`DMPK(CH) ROO-1253-01
`
`DMPK(CH) ROO-1253-02
`
`DMPK(CH) 1997/515
`
`Study Title
`RAD001: effects on angiogenesis-induced by growth factor- impregnated,
`subcutaneous implants in mice
`RAD001: effects in an orthotopic B16/BL6 melanoma model in C57BL/6 mice
`(Mabuchi S, Altomare DA, Connolly DC, et aI, (2007a)) RAD001 (Everolimus) delays
`tumor onset and progression in a transgenic mouse model of ovarian cancer. Cancer
`Res; 67(6) 2408-13.
`(Manegold PC, Paringer C, Kulka U et al (2008)) Antiangiogenic therapy with
`mammalian target ofrapamycin inhibitor RAD001 (everolimus) increases
`radiosensitivity in solid cancer. Clin Cancer Res; 14(3):892-900.
`
`The effect ofRA001 on mouse and human osteoclast formation and activity
`
`(Saunders RN, Metcalfe MS, Nicholson ML (2001)) Rapamycin in transplantation: A
`review ofthe evidence. Kidney Int; 59:3-16.
`(Schuler W, Sedrani R, Cottens S, et al (1997)) SDZ RAD, a new rapamycin
`derivative: pharmacological prooerties in vitro and in vivo. Transplantation; 64:36-42.
`(Kovarik JM, Kaplan B, Tedesco Silva H, et al (2002)) Exposure-response
`relationships for everolimus in de novo kidney transplantation: defining a therapeutic
`range. Transplantation; 73:920-5.
`
`General pharmacology of SDZ RAD
`Primary observation test ofRA001
`
`Effect ofFTY720 and RAD N BHT on HERG Currents Recorded from Stably
`Transfected HEK293 Cells
`Electrophysiological Safety Measurements ofhERG Currents in Stably Transfected
`HEK293 Cells
`Effect ofRAD N BHT on action potential parameters in sheep isolated cardiac
`Purkinje fibres.
`Cardiovascular effects ofRAD in anesthetized pigs
`
`Effect ofRAD on lung functionin the guinea-oig
`
`Pharmacokinetics and excretion after single intravenous and peroral administration (0.9
`mg/kg) of3H-labeIed RAD001 to mice
`Absorption, disposition and excretion in cynomolgus monkeys after single
`intravenous (1 mg/kg) and oral (5 mg/g) administration of eH)SDZ RAD
`Quantitative determination of rapamycin and SDZ RA in blood samples after single
`and multiple administration in human and monkey
`In vitro blood distribution, plasma protein binding and stability ofRAD001 in mouse
`plasma
`RAD001: Stability in mouse, monkey and human plasma. Addendum 1 to report: In
`vitro blood distribution, plasma protein binding and stability ofRAD001 in mouse
`plasma.
`Addendum 2 to report: In vitro blood distribution, plasma protein binding ofRAD001
`in rat plasma.
`
`total radioactivity in rats after peroral administration of
`Distribution and excretion of
`1.5 mg/kg C4C)-labeled SDZ RAD
`
`8
`
`

`

`Reviewer: Shwu-Luan Lee, Ph.D.
`
`NDA No. 22-334
`
`Study Number
`DMPK(CH) R98-194
`
`DMPK(CH) R98-732
`
`DMPK(CH) R98-708
`
`DMPK(CH) ROO-2214
`DMPK(CH) R98-706
`
`DMPK(CH) ROO-1806
`
`303-013
`
`DMPK(CH) R98-1404
`DMPK(CH) R99-2448
`
`Study Title
`Whole-body autoradioluminography in albino and pigmented rats after po and iv doses
`of rJHJRADOO 1
`Embryofetal transfer in pregnant rats on Day 13 and Day 17 of gestation after po
`administration of rJHJRAOO 1
`Galactogenic transfer, kinetics, and metabolism in milk and blood after single peroral
`administration (0.9 mg/kg) of3H-labeled RAD001 to lactating rats
`Dose-dependent brain penetration in rat
`Disposition in rats after single and repeated once daily peroral administration (0.5
`mg/kg/day) of3H-labeled RADOOl for 21 consecutive days
`Biotransformation in mice following a single oral and intravenous dose (0.9 mq/kq) of
`rJHJRA001
`Absorption, distribution, metabolism, and excretion in rats after single intravenous (1
`mg/kg, 10 mg/kg) and oral (1. mg/ki, 15 mg/kg) administration of(3HJSDZ RAD 666
`Biotransformation in cynomolgus monkev following a single oral dose of (3HJRA001
`Inhibition ofRAD001 in vitro metabolism by ketoconazole, itraconazole, and
`fluconazole
`
`Toxicology
`Single dose toxicology
`
`, 393131
`
`393118
`f-
`Repeat dose toxicology
`95/SPM052/0888
`
`96/SPM 090/0404
`
`96/SPM08311130 and
`0770978 t
`
`971033
`95/SPM04911 008
`
`96/SPM07811 067
`
`1534-1463-045
`Special repeat dose studies
`-- 617951
`
`Impurity investigation
`96/SPM09110532
`
`991094
`634676
`Genotoxicity
`In vitro studies
`Mut.Bakt.27/95
`Z59
`1463/4-1052
`
`Impurity investigation
`Mut.Bakt. 66/96
`Z63
`
`001801
`
`Acute oral toxicity study - mice
`Acute oral toxicity study - rats
`
`. ...
`D\'lJ
`
`SDZ RAD: Toxicity study by oral gavage administration to Hanlbm Wistar rats for 4
`weeks followed by a 2 week reversibilty period
`SDZ RAD: A repeat toxicity study by oral gavage administration to Hanlbm Wistar
`rats for 4 weeks followed by a 2 week reversibilty period
`SDZ RAD: Toxicity study by oral gavage administration Hanlbm Wistar rats for 26
`weeks followed by a four-week reversibility period (t: histopathological examination
`of slides of archived kidney samples from 96/SPM0831l130)
`SDZ RAD: 4-week oral (gavage) toxicity study in minipigs
`SDZ RAD: Toxicity study by oral gavage administration to cynomolgus monkeys for 4
`weeks followed by a 2-week reversibility period
`SDZ RAD: Toxicity study by oral (gavage) administration to cynomolgus monkeys for
`26 weeks
`SDZ RAD: 52-week oral (gavage) toxicity study in the cynomolgus monkey
`
`SDZ RAD: A comparative 2-week oral (gavage) toxicity study in the rat with a micro-
`emulsion and a solid dispersion
`
`l4)
`~'
`
`Comparative toxicity study in HanIbm Wistar rats with batches differing in by-product
`content
`4-week oral toxicity study in rats (batch comnarison)
`A comparative 2-week oral (gavage) toxicity study in the rat with two different batches
`
`SDZ RAD 666: Mutagenicity test using Salmonella typhimurium
`SDZ RA 666: Chromosome aberration test with V79 Chinese hamster cells
`SDZ RAD: Mutation at the thymidine kinase (tk) locus of mouse lymphoma L5 178Y
`cells using the microtitreCI fluctuation technique
`
`SDZ RAD (solid dispersion): Mutagenicity test using Salmonella tvvhimurium
`SDZ RAD (solid dispersion): Chromosome aberration test with V79 Chinese hamster
`cells
`Mutagenicity test using Salmonella typhimurium (Batch control)
`
`9
`
`

`

`Reviewer: Shwu-Luan Lee, Ph.D.
`
`NDA No. 22-334
`
`Study Number
`001831
`In vivo studv
`MK36
`
`Carcinogenicity
`SPM118/973229
`
`SPM113/973228
`
`Reproductive and
`developmental toxicity
`Fertility and early
`embryonic development
`7073R
`Embryofetal development
`3074R
`
`4070K
`Prenatal and postnatal
`development
`987105
`Local tolerance
`246781
`246792
`Other toxicity
`96/SPM098/0796
`
`Study Title
`Chromosome aberration test with V79 Chinese hamster cells
`
`SDZ