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1
Dalteparin (Fragmin) NDA 20-287 S-035
FDA Oncologic Drugs Advisory Committee Meeting
September 6, 2006
2
Introduction
Connie Newman, M.D.
Executive Director
Worldwide Regulatory Affairs
Pfizer Inc
3
Proposed IndicationDalteparin sNDA 20-287 S-035
Dalteparin sodium (Fragmin) is also indicated for the extended treatment of symptomatic venous thromboembolism [(VTE), proximal deep vein thrombosis (DVT) and/or pulmonary embolism (PE)] to reduce the recurrence of VTE in patients with cancer
4
Agenda
Regulatory Background Connie Newman, M.D.
Background on VTE and Cancer
Craig Eagle, M.D.
CLOT Study Design Results
Agnes Y. Y. Lee, M.D.
Interpretation and Discussion Craig Eagle, M.D.
Conclusions Craig Eagle, M.D.
5
Consultants Available to the Committee
Agnes Y. Y. Lee, M.D., MSc, FRCPCAssociate Prof., Medicine, McMaster University
Hamilton Health Sciences Henderson Hospital
Hamilton, ON
Steven Piantadosi, M.D., Ph.D. Prof. of Oncology
Director of Biostatistics
Johns Hopkins Oncology Center
Baltimore, MD
Mark Levine, M.D., MSc, FRCPC Prof., Departments of Clinical Epidemiology & Biostatistics, and Medicine, McMaster University
Henderson Research Centre
Buffett Taylor Chair in Breast Cancer Research
McMaster University
Hamilton, ON
Frederick R. Rickles, M.D., FACPProf. of Medicine, Pediatrics and Pharmacology and Physiology
The George Washington University
Fellow, Center for Science and Technology
Healthcare Division
Mitretek Systems, Inc.
Falls Church, VA
6
Regulatory HistoryDalteparin (Fragmin)
First approved in Germany in 1985 for anticoagulation during hemodialysis and hemofiltration
Currently approved in over 80 countries worldwide Approved for extended treatment of symptomatic VTE
to reduce the recurrence of VTE in patients with cancer in 19 countries
First US approval 1994, for prophylaxis of deep vein thrombosis (DVT) which may lead to pulmonary embolism (PE) in patients undergoing abdominal surgery who are at risk for thromboembolic complications
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Approved Dalteparin Indications US Package Insert
Prophylaxis of DVT which may lead to PE in;
Patients undergoing abdominal surgery (December 22,1994)
Patients undergoing hip replacement surgery (March 30, 1999)
Medical patients who are at risk for thromboembolic complications due to severely restricted mobility during acute illness (December 10, 2003)
Prophylaxis of ischemic complications in unstable angina and non-Q-wave MI when concurrently administered with aspirin therapy (May 25, 1999)
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Regulatory BackgroundDalteparin sNDA 20-287 S-035
March 16, 2004 - Pfizer submitted sNDA for an indication in patients with VTE and cancer supported by data from the “CLOT” trial*
January 14, 2005 - FDA issued “approvable” letter of sNDA
March 14, 2006 - FDA issued “non-approvable” letter
June 9, 2006 - FDA advised Pfizer of intention to have Oncologic Drugs Advisory Committee evaluate the “CLOT” trial results
* Randomized Comparison of Low Molecular Weight Heparin versus Oral Anticoagulant Therapy for Long-Term Anticoagulation in Cancer Patients with Venous Thromboembolism
9
Agenda
Regulatory Background Connie Newman, M.D.
Background on VTE and Cancer
Craig Eagle, M.D.
CLOT Study Design Results
Agnes Y. Y. Lee, M.D.
Interpretation and Discussion Craig Eagle, M.D.
Conclusions Craig Eagle, M.D.
10
Background: VTE & Cancer
Craig Eagle, M.D. Pfizer, Inc
Medical Director
11
Association of VTE and cancer first noted by Trousseau in 1865
4 to 7-fold increase in risk of venous thrombosis in cancer patients
The estimated annual incidence of VTE in cancer patients is about 1:200
VTE causes symptoms and signs by venous obstruction, inflammation and embolization
VTE is a Common Complication in Patients with Malignancy
12
Clinical Problem
Patients with deep vein thrombosis have a painful swollen leg which limits their mobility
13
Clinical Problem
Thrombus in a deep vein can fragment and embolize to the lung
Patients with pulmonary embolism frequently present with shortness of breath and chest pain
Ventilation Perfusion
14
Clinical Problem
Pulmonary embolism can be fatal
15
Vitamin K antagonist OAC (INR 2.0 - 3.0)
≥ 3 months
LMWH or UFH
5 to 7 days (until INR >2)Initial treatment
Long-term therapy
Treatment for VTE
7th ACCP anti-thrombotic guidelines Chest 2004; 126: 401S-428S
16
Cumulative Incidence of Recurrent VTE During Anticoagulant Therapy
Hazard ratio 3.2(95% CI 1.9, 5.4)
Prandoni P, et al, Blood. 2002;100:3484-3488
17
Comparison of Warfarin and LMWH
Warfarin Problem LMWH Advantages
Reduces the function of coagulation factors including prothrombin
Inhibits activated coagulation factors in particular factor Xa
Difficulty maintaining therapeutic control
More predictable anticoagulant response
Interruption & reversal of OAC for thrombocytopenia and procedures
Only interrupted if platelets very low. Much simpler to handle if procedure required
Venous access Does not require lab monitoring
Multiple interactions with drugs No or few interactions with drugs
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Dalteparin Studies for Initial Treatment of VTE
Comparator PatientsTotal
Patients Cancer
Dalteparin dose Duration
Heparin + OAC1
56 64000-7500 IU BID
+OAC
5-7 days
Heparin + OAC2 179 23100-120 IU/kg BID
+OAC
5-10 days
Heparin + OAC3 802 70200 IU/kg/d
+OAC
5-10 days
DalteparinAdjusted dose &200 IU/kg/d4
223 22 100 IU/kg BID 5-10 days
Heparin5 194 64 ≤ 15 000 IU 5-10 days
1. study: 86-96-291; 2. studies 88-96-297, 89-96-060 3. studies: 94-96-414, 93-96-549, 94-96-235; 4. studies: 91-96-389, 91-96-544; 5. study: 88-96-259
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Conclusion: VTE Management in Cancer Patients is Suboptimal
Cancer patients with VTE are at increased risk of recurrent VTE compared to non-cancer patients
No FDA approved medication for prevention of recurrent VTE in cancer patients
LMWH therapy has the potential to confer clinical benefit in the management of VTE
Dalteparin has been shown to be effective for initial treatment of VTE
CLOT study was designed to evaluate extended use of dalteparin in cancer patients
20
Agenda
Regulatory Background Connie Newman, M.D.
Background on VTE and Cancer
Craig Eagle, M.D.
CLOT Study Design Results
Agnes Y. Y. Lee, M.D.
Interpretation and Discussion Craig Eagle, M.D.
Conclusions Craig Eagle, M.D.
21
CLOT Study Design & Results
Agnes Y. Y. Lee, M.D.
22
CLOT Study
Study Question:
Is long-term therapy with LMWH dalteparin more effective than oral anticoagulant (OAC) therapy in preventing recurrent venous thromboembolism (VTE) in patients with cancer?
Lee AYY et al. New Engl J Med 2003;349:146-153.
23
Study Design
Multi-national, multi-center, randomized, open-label study
Follow-up for 6 months (or until death)
Telephone contact every 2 weeks
Clinic visits at 1 week, months 1, 3, and 6
Follow-up for survival up to 12 months
RCancer patients with proximal DVT, PE or both
Control Group (Standard):Dalteparin + OAC
Experimental Group:Dalteparin alone
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5 to 7 days
dalteparin 200 IU/kg OD
oral anticoagulant (INR 2.0 to 3.0) x 6 mo
Control Group
dalteparin 200 IU/kg OD x 1 mo then ~150 IU/kg OD x 5 mo
Experimental Group
rand
omiz
a tio
n
1 month 6 months
Study Treatments
25
Outcome Events
Primary endpoint* Objectively documented, symptomatic recurrence of
DVT, PE or both
Secondary endpoints Composite endpoint of symptomatic and objectively
documented recurrence of PE, DVT or central venous thrombosis of upper limbs, neck or chest
Bleeding (major and all) Death
* Originated as a two co-primary endpoint study (VTE and Major bleed) redefined by Steering Committee March 24, 1999 based on ICH guidelines E9, 1998 and prior to first patient enrolled May 3, 1999. Protocol amendment dated September 13, 1999
26
Efficacy:Ascertainment and Adjudication
Suspected VTE investigated by objective testing following pre-specified diagnostic algorithms
Details sent to a blinded central adjudication committee for confirmation of VTE
Patients contacted every 2 weeks to
ascertain symptoms of VTE
Patients instructed to report urgently symptoms of VTE
to investigators
27
Safety: Ascertainment and Adjudication
Bleeding Events Clinically overt
Blinded central adjudication committee
Reviewed and categorized as major or minor according to standard definitions
Deaths Cause of death determined by blinded central
adjudication committee first 6 months
Cause of death determined by local investigator from 6-12 months
28
Statistical Analysis
Efficacy Analysis Recurrent VTE
Intention-to-treat population (all randomized subjects)
Included all events up to 6-month visit or death
Time to first recurrent VTE event
Log-Rank (LR) test (2-sided alpha = 0.05)
Safety Analysis Bleeding
As-treated population (at least one dose)
Included events up to 48 hours after stopping study drug
Time to first bleed (major and any)
LR test (2-sided alpha = 0.05)
Overall survival ITT population Included all deaths over 6 and
12 months LR test (2-sided alpha = 0.05)
29
CLOT Study Results
30
Study Milestones
First patient enrolled May 1999
Last patient enrolled October 2001
Last 6-month follow-up April 2002
Results first presented at ASH, December 2002
Published N Engl J Med July 2003
31
677 Randomized*
dalteparinn=338
OACn=338
Analysis Populations
3 Subjects
not dosed n=335n=338
EfficacyITT
Safety As Treated
* Includes one subject randomized to OAC without having given written informed consent
n=163n=180Completed Treatment
32
Baseline Characteristics
Dalteparin n=338
OAC n=338
Gender
Female (%)
Male (%)
179 (53.0)
159 (47.0)
169 (50.0)
169 (50.0)
Median age (range) 64 (22-85) 64 (28-89)
Smoker (%) 33 (9.8) 42 (12.4)
Previous VTE (%) 39 (11.5) 36 (10.7)
Qualifying VTE
DVT only (%)
PE only (%)
PE/DVT (%)
235 (69.5)
64 (18.9)
39 (11.5)
230 (68.0)
65 (19.2)
43 (12.7)
33
Baseline Characteristics
Dalteparin n=338 (%)
OAC n=338 (%)
ECOG PS
0
1
2
3
80 (23.7)
135 (39.9)
118 (34.9)
5 ( 1.5)
63 (18.6)
150 (44.4)
122 (36.1)
3 ( 0.9)
Solid tumor
No evidence
Localized
Metastatic
298 (88.2)
36 (10.7)
39 (11.5)
223 (66.0)
308 (91.1)
33 ( 9.8)
43 (12.7)
232 (68.6)
Hematological malignancy 40 (11.8) 30 ( 8.9)
34
Frequency of Follow-Up
Dalteparin
n=338
OAC
n=338
Scheduled Visits (avg per patient) 1024 (3.0) 954 (2.8)
Telephone Contacts (avg per patient) 2327 (6.9) 2286 (6.8)
Unplanned Visits (avg per patient) 354 (1.0) 390 (1.2)
Total Contacts (avg per patient) 3705 (11.0) 3630 (10.7)
35
Efficacy Endpoints
Primary: Symptomatic recurrent DVT and/or PE
Secondary: Symptomatic DVT, PE or central venous
thrombosis of upper limb, neck, chest
36
0 30 60 90 120 150 180 2100%
5%
10%
15%
20%
25%
Days Post Randomization
Rec
urr
ent
VT
EEfficacy Endpoint:Recurrent VTE (ITT Analysis)
DalteparinOACRisk Reduction = 52%
HR 0.48 (95% CI 0.30, 0.77)Log-rank p = 0.0017
37
RR 95% CI n
COX Model* 0.51 (0.32 ,0.81) 676
Tumor Type
Solid Tumor 0.45 (0.28, 0.71) 606
Breast 0.83 (0.12, 5.68) 108
Gastrointestinal 0.54 (0.23, 1.26) 164
Lung 0.35 (0.14, 0.85) 90
Genitourinary 0.41 (0.13, 1.24) 155
Other 0.59 (0.22, 1.63) 89
Hematological 6.80 (0.38, 121.74) 70
Extent of Malignancy
Metastatic 0.43 (0.27, 0.71) 455
Non-metastatic 0.61 (0.15, 2.45) 151
0.1 1 10 100 1000
Subgroup Analyses
*adjusting for factors found to be prognostic for outcome (extent of tumor, type of tumor, smoking status and age)
Favors Dalteparin Favors OAC
38
0 30 60 90 120 150 180 2100%
5%
10%
15%
20%
25%
Secondary Endpoint: Recurrent DVT, PE, or CVT
Days Post Randomization
DalteparinOAC
Rec
urr
ent
VT
E
Risk Reduction = 49%HR 0.51 (95% CI 0.32, 0.80)Log-rank p=0.003
39
Safety Endpoints
Bleeding (major and any)
Death
Adverse Events
40
Safety Endpoint: Bleeding
Dalteparin n=338 (%)
OAC n=335 (%)
Log-rank p-value
Major bleed 19 (5.6) 12 (3.6) 0.28
Associated with death 1 0
Critical site (intracranial, intraspinal, intraocular, pericardial, or retroperitoneal)
4 3
Transfusion of > 2 units of packed RBC or drop in hemoglobin of at least 2.0 g/dL
14 9
Any bleed 46 (13.6) 62 (18.5) 0.05
41
0 30 60 90 120 150 180 2100.0
0.1
0.2
0.3
0.4
0.5
Time to First Adjudicated-positive Major Bleeding - (As-treated Population)
DalteparinOAC
Inci
den
ce o
f B
leed
ing
Days from Randomization
Log-rank p=0.28
42
0 30 60 90 120 150 180 2100.0
0.1
0.2
0.3
0.4
0.5
Time to First Adjudicated-positive Bleeding (Major/Minor) (As-treated Population)
Days from Randomization
DalteparinOAC
Inci
den
ce o
f B
leed
ing
Log-rank p=0.05
43
Investigator Reported Reasons for Treatment Discontinuation
Dalteparin
n=338
n (%)
OAC
n=335
n (%)
Recurrent VTE 21 (6.2) 47 (14.0)
Death / due to cancer 56 (16.6) / 52 (15.4) 24 (7.2) / 17(5.1)
Contraindication to Rx 12 (3.6) 25 (7.5)
Bleeding 10 (3.0) 19 (5.7)
Other 2 (0.6) 6 (1.8)
AE / Abnormal lab values 22 (6.5) 24 (7.2)
Underlying cancer 17 (5.0) 21 (6.3)
Investigator decision 1 (0.3) 5 (1.5)
Patient decision 20 (5.9) 14 (4.2)
Patient unable to swallow 0 (0.0) 4 (1.2)
Other 9 (2.7) 8 (2.4)
Total discontinued 158 (46.7) 172 (51.3)
44
0 30 60 90 120 150 180 210 240 270 300 330 360 3900%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Overall Survival: ITT PopulationS
urv
ival
Days After Randomization
Overall population Dalteparin (n=338)OAC (n=338)
12-monthHR = 0.9495% CI (0.77, 1.15) Log-rank p= 0.57
6-monthHR = 0.93 95% CI (0.73, 1.18) Log-rank p= 0.56
45
* 1 fatal PE in dalteparin and 1 fatal PE in OAC occurred after a previous PE and so were not counted as a fatal PE endpoint
** 2 cases in dalteparin group and 1 case in OAC occurred >48 h after study drug discontinuation, so were not included in summary of major bleeds
Adjudicated Cause of Death During First 6 Months
Dalteparin n=131 deaths
OAC n=137 deaths
Progressive cancer 119 124
Fatal PE* 6 8
Fatal bleed** 3 1
Other 3 4
46
Drug-Related Treatment Emergent Adverse Events ≥3% (As-Treated)
System Organ Class (disorders) Preferred Term
Dalteparinn=337
OACn=331
N % N %
Blood & Lymphatic System
Anaemia NOS 5 1.5 11 3.3
Thrombocytopenia 15 4.5 7 2.1
General & Administration Site Condition
Fatigue 8 2.4 12 3.6
Injection site reaction 34 10.1 5 1.5
Investigations
Alanine aminotransferase 12 3.6 2 0.6
Aspartate aminotransferase 11 3.3 3 0.9
Gamma-glutamyltransferase 19 5.6 3 0.9
International normalized ratio - - 18 5.4
Prothrombin time prolonged 1 0.3 11 3.3
Skin & Subcutaneous tissues
Ecchymosis 29 8.6 9 2.7
47
Conclusions from CLOT
In cancer patients with acute VTE,
Long-term dalteparin therapy substantially reduced the risk of symptomatic, recurrent VTE by 52% compared to OAC therapy
Risk of bleeding similar between dalteparin and OAC therapy
No difference in overall mortality between dalteparin and OAC therapy
48
Agenda
Regulatory Background Connie Newman, M.D.
Background on VTE and Cancer
Craig Eagle, M.D.
CLOT Study Design Results
Agnes Y. Y. Lee, M.D.
Interpretation and Discussion Craig Eagle, M.D.
Conclusions Craig Eagle, M.D.
49
CLOT Study – Interpretation and Discussion
Craig Eagle, M.D.Pfizer, Inc
Medical Director
50
Points of Discussion
Key characteristics of the CLOT trial design
On-treatment mortality analysis
Robustness of data
Risk/Benefit
51
Key Characteristics of the CLOT Trial Design
Open label study design
Initial treatment regimen
Dalteparin dosing
6 month treatment duration
52
CLOT Study: Design Rationale
Rationale for open label study: Unsafe to blindly manage anticoagulant therapy
(e.g. thrombocytopenia, surgery, invasive procedures) Easy to unblind
(off-study coagulation tests common) Difficult for sham INRs to mimic reality
(multiple clinical factors in each case can determine INR levels) Undesirable to do sham blood work
(frequent venipuncture, painful procedures, extra blood taken from cancer patients who can be anemic)
Undesirable and impractical to do placebo subcutaneous injections(can cause hematoma at placebo injection sites)
53
CLOT Study: Minimize Bias
Safeguards to minimize bias:
A priori definition of VTE recurrence based on objective investigations
Telephone check every 2 weeks on follow-up in both groups
Diagnostic algorithms for recurrent VTE
Independent blinded Central Adjudication Committee reviewed and adjudicated all primary and secondary outcome events
54
CLOT Study: Initial Treatment Regimen Rationale
Use of dalteparin in both arms for initial treatment was adopted after careful consideration by the CLOT Steering Committee
No LMWH was approved for use in cancer patients at the time of trial conception
Limit the number of variables in the trial
Documented effectiveness of dalteparin
55
CLOT Study: Dalteparin Dosing Rationale
Efficacy of Dalteparin 200 IU/kg shown in acute VTE treatment (previous trials and literature)
1st Month Increased risk of recurrent VTE highest in 1st
month after initial occurrence (exacerbated in cancer patients), therefore, higher dose administered
Following 5 months Dose lowered to 150 IU/kg reflecting decreased
risk of recurrent VTE and need to minimize bleeding
56
CLOT Study: 6 Month Treatment Duration Rationale
Potential advantages of dalteparin vs. OAC in long-term treatment of patients with cancer
Long-term OAC Standard of Care: Patients with extensive cancer treated with OAC
often until death Patients without evidence of active cancer
treated with OAC for a minimum of 3-6 months
57
Points of Discussion
Key characteristics of the CLOT trial design
On-treatment mortality analysis
Robustness of data
Risk/Benefit
58
0 50 100 150 200
On-Treatment Mortality Analyses
0 50 100 150 2000%
25%
50%
75%
100%
Log-rank p-value < 0.001 Log-rank p-value = 0.23
1 day definition 14 day definition
DalteparinOAC
Su
rviv
al D
istr
ibu
tio
n
Analysis time (days)
59
Mortality Analyses
On-Treatment1 day
ITT
Dalteparin OAC Dalteparin OAC
54 14 54 14
4 5 4 5
1 0 1 0
0 2 0 2
0 0 12 34
0 0 42 67
0 0 18 15
Number of Deaths Included in Analysis 59 21 131 137
X
X
6 Months
X
X
Discontinuation of study medication due to clinical management
VTE or CVT
DeathXStudy drug treatment
Discontinuation due to other reasons
XX
X
60
0 30 60 90 120 150 180 210 240 270 300 330 360 3900%
20%
40%
60%
80%
100%
Conclusions for Mortality Analysis
On-treatment mortality analysis is biased due to informative censoring
The appropriate analysis of mortality follows intention to treat (ITT) principle and shows no difference between the two treatment arms
Su
rviv
al
Days After Randomization
61
Points of Discussion
Key characteristics of the CLOT trial design
On-treatment mortality analysis
Robustness of data
Risk/Benefit
62
Robustness of Data
Magnitude of the benefit
Consistency of subgroups
Competing risk
63
0 30 60 90 120 150 180 2100%
5%
10%
15%
20%
25%
Days Post Randomization
Primary Endpoint: Recurrent VTE
DalteparinOACRisk Reduction = 52%
HR 0.48 (95% CI 0.30, 0.77)Log-rank p= 0.0017
Rec
urr
ent
VT
E
64
RR 95% CI n
COX Model* 0.51 (0.32 ,0.81) 676
Tumor Type
Solid Tumor 0.45 (0.28, 0.71) 606
Breast 0.83 (0.12, 5.68) 108
Gastrointestinal 0.54 (0.23, 1.26) 164
Lung 0.35 (0.14, 0.85) 90
Genitourinary 0.41 (0.13, 1.24) 155
Other 0.59 (0.22, 1.63) 89
Hematological 6.80 (0.38, 121.74) 70
Extent of Malignancy
Metastatic 0.43 (0.27, 0.71) 455
Non-metastatic 0.61 (0.15, 2.45) 151
0.1 1 10 100 1000
Subgroup Analyses
*adjusting for factors found to be prognostic for outcome (extent of tumor, type of tumor, smoking status and age)
Favors Dalteparin Favors OAC
65
CLOT Study: A Single Pivotal Trial to Support Clinical Effectiveness
Compelling p-value for primary efficacy analysis Two sided p value <0.0025 provides strength
of evidence of 2 independent trials with p<0.05*
Consistency across subgroups
Dalteparin is proven to be an effective anticoagulant for primary prophylaxis in various clinical settings
* T. Fleming and B. Richardson JID 2004:190;666-74Some Design Issues in Trials of Microbicides for the Prevention of HIV Infection. JID 2004:190, pg 666-674
66
Robustness of Data
Magnitude of the benefit
Consistency of subgroups
Competing risk
67
Competing Risk:Death and Recurrence of VTE
Could mortality account for the significant dalteparin benefit?
Two scenarios in which mortality would be informative regarding the relative risk of VTE:
1. The mortality rate would have to be different between the two treatment groups
2. The mortality censoring would have to affect the probability of VTE differentially in the treatment groups
68
Competing Risk:Death and Recurrence of VTE
Scenario One: Mortality rates are different between the treatment groups Cumulative mortality at all times within the 6-month
observation period was almost identical in the two treatment groups
Therefore the degree of mortality censoring is non-informative regarding the relative risk
69
Competing Risk:Death and Recurrence of VTE
Scenario Two: The mortality censoring would have to affect the probability of VTE differentially in the treatment groups Most (> 90%) deaths in both treatment groups were
due to cancer
Therefore it is unlikely that the probability of VTE for subjects who died relative to the observed probability would have differed between the two groups
70
Competing Risk:Death and Recurrence of VTE
Mortality Censoring and benefit within the initial 30 days
Most deaths occurred after the benefit of dalteparin was established in the initial 30 days and during the period (days 30-180) when the probability of VTE was relatively low
Dalteparin OAC
Censored 23 (6.8%) 22 (6.5%)
VTEs* 12 (3.6%) 34 (10.1%)
*VTE RR=0.35, p=0.001
71
Competing Risk:Death and Recurrence of VTE
Conclusion
In the CLOT study, the benefit of dalteparin relative to OAC is estimated accurately despite the high cancer mortality
72
Points of Discussion
Key characteristics of the CLOT trial design
On-treatment mortality analysis
Robustness of data
Risk/Benefit
73
Risk/Benefit: VTE vs. Major BleedIncidence per 30 Days Exposure
0.00
0.02
0.04
0.06
0.08
0.10
0.12
Day1-7
Day8-30
Day31+
Total
0.00
0.02
0.04
0.06
0.08
0.10
0.12
Day1-7
Day8-30
Day31+
Total
VTE Major Bleed
Fragmin
OAC
Inci
den
ce P
er 3
0 D
ays
Exp
osu
re
74
Risk/Benefit Summary
Dalteparinn=338
OAC n=338
VTE 27 53
Major Bleeds 19 12
Death due to:
PE 6 8
Major Bleeds 1 0
Results applicable to clinical practice: Different tumor types and extent of cancer were included Self-injections shown to be feasible and acceptable Treatment is well-tolerated over extended period, flexible and
can be continued until end of lifeControl arm results consistent with previous studies
75
Agenda
Regulatory Background Connie Newman, M.D.
Background on VTE and Cancer
Craig Eagle, M.D.
CLOT Study Design Results
Agnes Y. Y. Lee, M.D.
Interpretation and Discussion Craig Eagle, M.D.
Conclusions Craig Eagle, M.D.
76
Conclusion
Craig Eagle, M.D. Pfizer, Inc
Medical Director
77
VTE Management in Cancer Patients is Suboptimal
In patients with cancer: VTE recurrence is more common (HR 3.2) VTE complicates management of cancer No FDA approved medication for the extended use in
reducing recurrence of VTE without concomitant warfarin requiring blood monitoring
Oral anti-coagulant (OAC) Difficult to maintain and manage
Dalteparin Established efficacy and safety in prophylaxis of VTE
in non-cancer patients Predictable dosing and reduced need for monitoring
78
Summary of CLOT Study
Highly significant (p=0.0017) reduction in recurrence rate of VTE (52% reduction dalteparin vs OAC) Compelling p-value
Results consistent across study subsets
Favorable risk/benefit profile
Builds on previous clinical trial experience with dalteparin in VTE
79
Conclusion
Dalteparin provides cancer patients with VTE:
An effective treatment (52% reduction in recurrence of VTE)
A favorable treatment in terms of risk/benefit
A more manageable therapeutic option