1 one year post exclusivity adverse event review adderall xr ® pediatric advisory committee meeting...

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One Year Post Exclusivity Adverse Event Review

ADDERALL XR®

Pediatric Advisory Committee Meeting

March 22, 2006

Susan K. McCune, M.D.Medical OfficerDivision of Pediatric Drug DevelopmentCenter for Drug Evaluation and Research Food and Drug Administration

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Overview

• Background

• Clinical Trials for Initial Approval (adults and children 6-12 years of age)

• Clinical Trials for Exclusivity (Adolescents 13-17 years of age)

• Adderall XR® Use Information

• Adverse Event Reports for Adderall XR® (10/28/04-11/28/05)

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Background Drug Information

• Drug: Adderall XR® Capsules (dextroamphetamine saccharate, amphetamine aspartate monohydrate, dextroamphetamine sulfate, amphetamine sulfate)

• Therapeutic Category: Central nervous system stimulant

• Sponsor: Shire US Inc.• Indication: Treatment of Attention Deficit

Hyperactivity Disorder (ADHD)• Original Market Approval: October 11, 2001

– Adderall was originally marketed in 1960 under the trade name Obetrol®

– Adderall was approved to treat ADHD and narcolepsy in 1996

• Pediatric Exclusivity Granted: October 28, 2004

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Background Drug Information

Therapeutic action of Adderall XR® in ADHD is unknown, although like methylphenidate is thought to block the reuptake of norepinephrine and dopamine into the presynaptic neuron and increase the release of these monoamines into the extraneuronal space.

Peripheral actions include elevations of both diastolic and systolic blood pressure and weak bronchodilator and respiratory stimulant actions.

http://www.learner.org/channel/courses/biology/units/neuro/images.html

Mechanism of action

Drug Delivery SystemEach capsule contains two types of drug-containing beads designed to give a double-pulsed delivery of amphetamines, allowing for once daily administration.

5Drugs to Treat ADHD From the Clinical Practice Guidelines

Stimulants (First-Line Treatment)

Non-StimulantsMethylphenidate

Amphetamine

Pemoline

•Short acting–Ritalin®, Methylin®

•Intermediate acting–Ritalin SR®, Metadate ER®, Methylin ER®

•Long acting–Concerta®, Metadate CD®, Ritalin LA®

•Short acting–Dexedrine®, Dextrostat®

•Intermediate acting–Adderall®, Dexedrine spansule®

•Long acting–Adderall XR®

Antidepressants*(Second-Line Treatment)

•Atomoxetine–Strattera®

•Tricyclic antidepressants–Imipramine, Desipramine

•Bupropion–Wellbutrin®, Wellbutrin SR®

* Not FDA approved for ADHD treatment

Subcommittee on Attention-Deficit/Hyperactivity Disorder and Committee on Quality Improvement. 2001. Clinical Practice Guideline: Treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics 108:1033-1044.

•Cylert® discontinued by Abbott

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From: Rappley, MD, 2005, Attention deficit-hyperactivity disorder, N. Engl. J. Med. 352:165-173

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Clinical Studies For Adderall XR®

Initial Approval

Clinical Trials

•A double-blind randomized placebo-controlled parallel-group study in adults (N=255)

•A double-blind randomized placebo-controlled parallel-group study in children aged 6-12 years (N=584)

•A classroom analog study in children aged 6-12 years compared to placebo (N=51)

•All studies demonstrated significant improvement in patient behavior

(Original Market Approval 10/11/01)

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Exclusivity Studies For Adderall XR® (Granted 10/28/04)

Clinical Trials for Adolescents•PK trial (17 adolescents < 75kg, 6 adolescents >75kg)•A double-blind, randomized, multi-center, parallel-group, placebo-

controlled study in adolescents aged 13-17 years (N=327)•Primary cohort (N=287 weighing < 75 kg) randomized to a fixed dose

treatment for four weeks (placebo, 10 mg, 20 mg, 30 mg, or 40 mg once daily in the morning)

•Secondary cohort (N=40 weighing >75 kg) randomized to a fixed dose treatment for four weeks (placebo, 50 mg or 60 mg once daily)

•The primary efficacy variable was the ADHD-RS-IV total scores for the primary cohort

•Improvements in the primary cohort were statistically significantly greater in all four primary cohort active treatment groups compared with placebo

•Not adequate evidence that doses greater then 20 mg/d conferred additional benefit

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Adderall XR®

Approved Labeling Following Exclusivity Trials

ClinicalPharm

ClinicalStudies

Dosage/Admin

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Adderall XR® Discontinuations and Adverse Events in Exclusivity Trials

Clinical Trial Adverse Events Reported in 5% or More of Patients

• 2-4% reported accidental injury, asthenia (fatigue), dry mouth, dyspepsia, emotional lability, nausea, somnolence, and vomiting

• In adolescents, 8 patients (3.4%) discontinued treatment due to insomnia, depression, motor tics, headaches, light-headedness, and anxiety

11Drug Use Trends: Adderall XR® (2003-2005)

• Number of prescriptions dispensed by retail pharmacies increased from approximately 7.3 million in the pre-exclusivity period (11/03 to 10/04) to approximately 8.6 million in the post-exclusivity period (11/04 to 10/05)1

• Psychiatrists were the most frequent prescribers (31.8%) and pediatricians the second most frequent prescribers (29.7%) in the post-exclusivity period1

• Pediatric retail pharmacy prescriptions (0-16 years of age) accounted for 63.8% of all Adderall XR® prescriptions in the post-exclusivity period1

1Verispan®, LLC, November 2002 to October 2005. Data extracted 12/21/05

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Percentage of Prescriptions for the Top Three Molecules for ADHD Treatment

0%

5%

10%15%

20%

25%

30%35%

40%

45%

50%

11/02-10/03 11/03-10/04 11/04-10/05

Amphetamine/ Dextroamphetamine

Atomoxetine

Methylphenidate


Per

cent

age

of T

otal

Pre

scri

ptio

ns (

%)

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Percentage of Prescriptions for Amphetamine and

Dextroamphetamine Combinations

0%

10%

20%

30%

40%

50%

60%

70%

11/02-10/03 11/03-10/04 11/04-10/05

Adderall XRAmphetamine SaltAdderall


Per

cent

age

of T

otal

Pre

scri

ptio

ns (

%)

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Pediatric Adverse Event Reports for Adderall XR®

October 28, 2004 – November 28, 2005

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Adverse Event Reports for Adderall XR®

All Reports (US) Serious (US) Death (US)

All Ages* 210 (204) 177 (171) 15 (15)

Adults (> 17) 72 (69) 65 (62) 5 (5)

Peds (0-16) 98 (97) 90 (89) 8 (8)


Raw Reports

* Includes 40 reports with no age reported

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Pediatric Adverse Event Reports for Adderall XR® and Adderall®

Adderall XR® Adderall®

98 reports29 immediate release

2 adult reports

3 additional Adderall XR reports

Subtract 29

69 reports4 adults16 duplicates4 no adverse effect

45 reports

27 total pediatric immediate release Adderall® reports

Add 3

48 total pediatric Adderall XR® reports

17Characteristics of Pediatric Adverse Event Report Outcomes and Indications for Adderall

XR® and Adderall®

October 28, 2004 – November 28, 2005Characteristic Adderall XR®

Reports (N=48)Adderall®

Reports (N=27)

Gender Female 12 6

Male 36 21

Indication ADHD/ADD 35 21

Learning Disability 1 0

Unknown 12 6

Age 0 - <1 month 0 0

1 month - < 2 years 0 0

2-5 years 2 2

6-11 years 35 15

12-16 years 11 10

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Characteristic Adderall XR®

(N=48)Adderall®

(N=27)

Outcome box checked on MedWatch form

(multiple boxes may be checked on one report)

Death 5 2

Hospitalization 14 6

Life-threatening 8 1

Disability 2 0

Required intervention 7 2

Other 28 15

None selected 2 2

Adverse Event Reports Adderall XR®


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Deaths in Pediatric Patients Taking Adderall XR® (N=5)


• 10 year old collapsed at home after 22 months of treatment with Adderall XR® 15 mg/d. Autopsy revealed coronary artery anomalies. Other family members were subsequently found to have short QT syndrome.

• 10 year old experienced sudden death while taking Adderall XR®. No details available.

• 12 year old who took methylphenidate for 4 years died suddenly after running cross-country on the first day of Adderall XR® (10mg/d). No autopsy. Mother had a history of ventricular tachycardia.

• 11 year old took Adderall XR® (15mg/d) for approximately 4 months. Two months after discontinuing Adderall XR®, the patient was found unresponsive and could not be revived. Autopsy listed cardiopulmonary arrest of obscure causes. At the time of death, patient was on atomoxetine and bupropion.

• 14 year old made unusual movements and collapsed at school. He developed ventricular fibrillation. He was hospitalized on full support but died 10 days later. No autopsy. He had been on Adderall XR for 3 years.

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Deaths in Pediatric Patients Taking Adderall® (N=2)


• 12 year old experienced sudden cardiac death while running. The patient had been taking Adderall® 30mg/d for 5 months. Concomitant medication was atomoxetine. Autopsy found an unspecified “genetic cardiac problem”.

• 7 year old died during sleep after restarting Adderall® following a summer break. Autopsy found a bicuspid aortic valve.

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Deaths in Pediatric Patients Taking Adderall XR® or Adderall®

(1/1/99 – 11/28/05)N = 23 unduplicated cases

Cause Number

Sudden Death (Unknown Etiology) 11

Sudden Death (Identified cardiac or genetic predisposition)

6

Suicide 4

Other 2

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January 1 1999

December 312003

October 282004

November 282005

Sudden Deaths = 12 Sudden Deaths = 72 Duplicates

No Sudden Deaths

Suicides = 3 No suicides1 suicide

Sudden Deaths and Suicides in Pediatric Patients Taking Adderall XR® or

Adderall® (1/1/99 – 11/28/05)

XX OO

Feb. 92005

Aug. 242005

Health CanadaOff Market

23Categories of Adverse Events Reported for Adderall XR® and Adderall®


AE Category Adderall XR® (N=52*)

Adderall® (N=27)

Psychiatric 17 4

Cardiovascular 15 6

Neurological 5 6

Growth/Nutritional 3 0

Dermatologic 2 2

Respiratory 3 0

Lack of effect 1 7

Other 3 2

No adverse event 3 0

* Includes the 4 reports with no adverse event (3 No adverse Event, 1 Lack of Effect)

24Cardiovascular Adverse Events Reported with

Adderall XR®

October 28, 2004 – November 28, 2005 (N=15 cases)

• Tachycardia (5)• Chest pain (4)• Prolonged QTc (1)• Arrhythmia (3)• Sudden death (4)• Autonomic dysfunction (1)• Unspecified cardiac disorders (2)

NOTE: A case may report more than one adverse eventUnderlined events are unlabeled

25Psychiatric Adverse Events Reported with

Adderall XR®


• Hallucination (4)• Violent behavior (aggression, agitation, hostility, homicidal

ideation, assault) (7)• Psychosis (3)• Suicidal ideation/attempt (4)• Crying/moodiness/irritability (4)• Paranoia (2)• Insomnia (3)• Nightmares/night terrors (1)• Depression (1)• Panic/anxiety (2)


26Neurological Adverse Events Reported with

Adderall XR®


• Dyskinesia (2)• Seizure (1)• Depressed consciousness (1)• Leg spasticity (1)• Tic (2)


27Respiratory Adverse Events Reported with

Adderall XR®


• Respiratory arrest in a patient with severe asthma (1)

• Dyspnea, throat tightness (1)

• Asthma (1)

NOTE: A case may report more than one adverse event

Underlined events are unlabeled

28Dermatologic Adverse Events Reported with

Adderall XR®


• Toxic epidermal necrolysis (1)

• Generalized rash and skin exfoliation (1)



29Growth/Nutrition Adverse Events Reported with

Adderall XR®


• Growth suppression (1)

• Weight loss (2)

• Anorexia (1)


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Other Adverse Events Reported with Adderall XR®


• Suspected glaucoma (1)

• Increased prothrombin time (1)

• Extremely high amphetamine levels (1)



31Summary: Adderall XR® Adverse Event Report Profile

October 28, 2004 – November 28, 2005• 48 unduplicated pediatric reports• Cardiovascular adverse events including sudden death (N=15)

– Known and labeled risk especially in children with structural cardiac abnormalities

– Plan for future studies to be discussed later today by Dr. Graham

• Psychiatric adverse events (N= 17)– To be discussed later today by Dr. Gelperin and Dr. Mosholder

• Serious skin reactions (N=2)– Not currently in the Adderall XR® label– Listed under Adverse Events with Other Methylphenidate HCl Products in

the Concerta® label

• Glaucoma (N=1)– Labeled as a contraindication

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AcknowledgementsDDRE/ODS• Kathleen M. Phelan, R.Ph.

• Kate Gelperin, M.D., M.P.H.

• Mark Avigan, M.D.

• Rosemary Johann-Liang, M.D.

DPDD• Denise Pica-Branco, Ph.D.

• Solomon Iyasu, M.D., M.P.H.

• ShaAvhree Buckman, M.D., Ph.D.

DNDP• Paul Andreason, M.D.

• Thomas Laughren, M.D.

DSRCS/ODS• Carol Pamer, R. Ph.• Judy Staffa, R.Ph., Ph.D.• Toni Piazza-Hepp, Pharm. D.

1 one year post exclusivity adverse event review adderall xr ® pediatric advisory committee meeting...

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