The FDA's accelerated approval of Sarepta Therapeutics' Elevidys (delandistrogene moxeparvovec-rokl), a gene therapy for Duchenne muscular dystrophy (DMD), is under increased scrutiny following an article in the Journal of the American Medical Association (JAMA). David Rind, chief medical officer of the Institute for Clinical and Economic Review, critiques the approval pathway, citing concerns over the therapy's efficacy and high price tag.
Doubts Over Efficacy Endpoints
Elevidys received accelerated approval in June 2023, based on micro-dystrophin expression levels, despite failing to meet its primary efficacy endpoint in two studies. The FDA considered micro-dystrophin expression as "reasonably likely to predict clinical benefit" in 4- to 5-year-old DMD patients. However, this decision has been met with skepticism, particularly after the Phase III EMBARK study also failed its primary endpoint of improving functional mobility compared to placebo.
DMD is a rare neuromuscular disorder caused by mutations in the dystrophin gene, leading to muscle weakness and developmental delays. Elevidys aims to deliver a functional copy of the dystrophin gene to patients' muscles. While the FDA acknowledged the potential risks and unmet medical need, internal reviewers had previously raised concerns that micro-dystrophin levels might not accurately reflect a pharmacologic effect on the disease pathway.
Confirmatory Trial Failure
Sarepta conducted the Phase III EMBARK study to confirm the clinical benefit of Elevidys. However, results announced in October 2023 showed that the trial did not meet its primary endpoint. Despite this, Sarepta maintains that the findings provide "robust evidence" of clinically meaningful benefit. The FDA has accepted Sarepta’s supplemental Biologics License Application, with a decision expected by June 21, 2024.
Pricing Concerns
Adding to the controversy is the cost of Elevidys, priced at $3.1 million per dose, making it one of the most expensive therapies globally. Rind argues that this price is excessive for a therapy that has not demonstrated conclusive clinical efficacy in randomized controlled trials and is not curative. The high cost raises questions about the value and accessibility of the treatment, especially given the uncertainty surrounding its clinical benefits.
FDA's Perspective
In its initial approval announcement, the FDA stated that it considered the potential risks, the severity of DMD, and the urgent unmet medical need. The accelerated approval pathway allows for earlier approval of drugs that treat serious conditions and fill an unmet medical need, based on a surrogate endpoint reasonably likely to predict clinical benefit. However, the ongoing debate highlights the challenges and risks associated with relying on surrogate endpoints, particularly when confirmatory trials fail to validate the predicted clinical benefit.
