The European medicines agency review of pomalidomide in combination with low-dose dexamethasone for the treatment of adult patients with multiple myeloma: summary of the scientific assessment of the committee for medicinal products for human use

Abstract

On August 5, 2013, a marketing authorization valid throughout the European Union (EU) was issued for pomalidomide in combination with dexamethasone for the treatment of adult patients with relapsed and refractory multiple myeloma (MM) who have received at least two prior treatment regimens, including both lenalidomide and bortezomib, and have demonstrated disease progression on the last therapy. Pomalidomide is an immunomodulating agent. The recommended starting dose of pomalidomide is 4 mg once daily taken on days 1-21 of repeated 28-day cycles. The main evidence of efficacy for pomalidomide in MM was based on a phase III multicenter, randomized, open-label study (CC-4047-MM-003) in which pomalidomide plus low-dose dexamethasone therapy (POM+LoDEX) was compared with high-dose dexamethasone alone (HiDEX) in previously treated adult patients with relapsed and refractory multiple myeloma who had received at least two prior treatment regimens, including both lenalidomide and bortezomib, and had demonstrated disease progression on the last therapy. For the intent-to-treat population, median progression-free survival based on International Myeloma Working Group criteria was 15.7 weeks (95% confidence interval [CI]: 13.0-20.1) in the POM+LoDEX group versus 8.0 weeks (95% CI: 7.0-9.0) in the HiDEX group (log-rank p value <.001). Overall survival (secondary endpoint) was also different in the two treatment groups (hazard ratio 0.53 [95% CI: 0.37-0.74]). The most commonly reported adverse reactions to pomalidomide in clinical studies were anemia (45.7%), neutropenia (45.3%) and thrombocytopenia (27%), fatigue (28.3%), pyrexia (21%), peripheral edema (13%), and infections including pneumonia (10.7%). Peripheral neuropathy adverse reactions were reported in 12.3% of patients, and venous embolic or thrombotic (VTE) adverse reactions were reported in 3.3% of patients. Pomalidomide is expected to be teratogenic. This paper summarizes the scientific review of the application leading to approval in the EU. The detailed scientific assessment report and product information, including the summary of product characteristics, are available on the EMA website (http://www.ema.europa.eu).

Keywords: EMA; European Medicines Agency; Imnovid; Multiple myeloma; Pomalidomide.

Figure 1.

Structural formulae of thalidomide, lenalidomide, and pomalidomide. Pomalidomide chemical name: (RS)4-amino-2-(2,6-dioxopiperidin-3-yl)isoindole-1,3-dione; molecular formula: C₁₃H₁₁N₃O_4.

Figure 2.

Progression-free survival based on independent response adjudication committee review of responses by International Myeloma Working Group criteria (stratified log-rank test; intent-to-treat population). Data cutoff: September 7, 2012. Abbreviations: CI, confidence interval; HiDEX, high-dose dexamethasone alone; HR, hazard ratio; KM, Kaplan-Meier; POM+LoDEX, pomalidomide plus low-dose dexamethasone therapy.

Figure 3.

Kaplan-Meier curve, overall survival (intent-to-treat population). Data cutoff: September 7, 2012. Abbreviations: CI, confidence interval; HiDEX, high-dose dexamethasone alone; HR, hazard ratio; KM, Kaplan-Meier; NE, not evaluable; POM+LoDEX, pomalidomide plus low-dose dexamethasone therapy.