Auvelity Prescription Update

The weekly data for Axsome's lead drug Auvelity (which has been approved for Major Depression Disorder), has turned in a new weekly prescription high three weeks in row to 10,400, for the latest week ending. Data from IQVIA. Thank you for reading.

Auvelity Week 4 Prescriptions

Again, courtesy of research analyst Mizohu, is Auvelity compared to other recent Major Depression drug launches. The table is somewhat hard to read, the week 4 change in total prescriptions (TRx's via IQVIA) is 17% w/w change (308 to 360), which is impressive. We will keep tracking Auvelity's launch, but for right now, it's very positive. Again, thanks to Mizuho for the market research. Please click on the table below, for better viewing.  

Auvelity Week Two Prescriptions

When looking at the launch of Axsome's Auvelity for MDD, it is important to note the week 1 to week 2 change of prescriptions percentage. This could give us a general indication of trajectory of public uptake. From below, and courtesy of research analyst Mizohu, is Auvelity compared to other recent Major Depression drug launches. The table is somewhat hard to read, the week 2 change from week 1 in total prescriptions (TRx's via IQVIA) is 394% w/w change (32 to 158), which is impressive. We will keep tracking Auvelity's launch, but for right now, it's very positive. Again, thanks to Mizuho for the market research. Please click on the table below, for better viewing. 

Relmada Phase 3 MDD Results

Relmada Therapeutics (RLMD) has been working on a new MDD drug (major depressive disorder) known as REL-1017, an NMDA (NMDAR) channel blocker. The company released top-line results on Thursday October 13th. The top line results revealed that the drug showed to be effective (-14.9 reduction from baseline), but the placebo group also displayed a reduction in depressive symptoms (-13.9 from baseline) on the MADRS 10 Total Score. The .9 differential between the two groups at day 28 was deemed to be a clinical trial failure. 

The company did a secondary clinical trial analysis, and determined that when excluding clinical sites with implausibly high or low placebo responses (4-5 of the total sites), showed a meaningful difference between REL-1017 and placebo to the effect of 4.9 points on the MADRS 10 versus placebo p=0.05. 

Based on the results above, Relmada may have to run another phase 3 clinical trial for MDD to proceed to an NDA filing. The timeline to starting and completing would be around one year based on this just completed clinical trial, then filing an NDA would require additional time. Most likely to get REL-1017 approved for MDD, could take two years from the start of an additional clinical phase 3 MDD trial to FDA approval, if everything goes well. Note that Relmada does not have Breakthrough Therapy Designation (BTD) for REL-1017, MDD. 

Axsome Therapeutics Auvelity, was just granted FDA approval for MDD in August 2022, with a planned launch early 4th quarter 2022. Auvelity, provides a fast-acting oral anti depressant therapy. REL-1017 would have competed directly with Axsome's Auvelity, as both provide a fast acting response, which is an unmet need to current MDD drugs on the market. Axsome's stock had an upward response after the Relmada results were revealed, while Relmada chart below, sold off.                                  

Auvelity Receives FDA Approval for MDD

Today Axsome Therapeutics announced the FDA has approved their drug, AXS-05 for Major Depressive Disorder. The commercialized product (AXS-05) will be named Auvelity. This is a good day for patients suffering from MDD, as Auvelity is a new oral mechanism of action, which acts very quickly, and has shown durability in clinical trials, that led to the FDA approval. The company plans to start selling the product early in the fourth quarter. The press release is here Auvelity FDA Approval.  The stock had a very strong day as expected, up +40%. Below is a daily chart of Axsome.                                            

                               

AXS-05 Proposed Labeling for MDD Indication

Axsome's New Drug Application (NDA) for Major Depressive Disorder, has progressed to product labeling discussions with the FDA.  This puts Axsome a step closer to potential FDA approval. The company released the following SEC document below. 

On June 24, 2022, Axsome Therapeutics, Inc. (the “Company”) received from the U.S. Food and Drug Administration (the “FDA”) proposed labeling for the Company’s AXS-05 product candidate with respect to its New Drug Application (the “NDA”) for AXS-05 for the treatment of major depressive disorder. The Company is reviewing the proposed labeling and will reply to the FDA to secure final labeling agreement.

Axsome's stock had a good week based on the document that the company filed on June 24th, 2022. Weekly chart below, AXSM stock advancing 66.15% under heavy volume.

AXS-05 Priority Review for MDD

Axsome Therapeutics issued a press release this morning with the good news that lead drug candidate AXS-05 for MDD (major depression disorder) has received Priority Review from the FDA, with a PDUFA date of 8-22-21. The Priority Review is an FDA six month review to determine whether or not to approve a drug, versus a ten month standard review. Statistically, this gives the chance of approval a higher probability then if the company received a standard ten month review timeline. This also lifts the risk the stock has been under lately, as investors have ruled out the scenario of RTF (refuse to file), and standard review from the FDA. If the drug is approved by August, then I would expect the company to start commercialization with a salesforce, and sales occurring in the fourth quarter of this year. Just a reminder, the patent for AXS-05 extends out to 2034 at the very earliest, and potentially up to 2040. So at the minimum, the company will have thirteen years of exclusivity. Below is a daily chart of Axsome. The stock had a good day today up +11% under strong volume, but I expect more appreciation for the stock over the next few weeks. Thank you for reading.

 

                                   

                                          

            

AXS-05 Phase 3 Results for MDD (GEMINI)

Axsome Therapeutics (AXSM) is higher today after releasing phase 3 results with AXS-05 for the indication of Major Depressive Disorder or (MDD). The press release is here, AXS-05 Achieves Primary Endpoint in Gemini Phase 3. Some major points from the outstanding results are as follows.

• AXS-05 at week 6 versus placebo  p=0.002
• Rate of remission of depression week 6 versus placebo  p=0.001
• Week 1 AXS-05 versus placebo p=0.007

All scores are based on the Montgomery-Asberg Depression Rating Scale or MADRS. The phase 3 clinical trial details can be found here NCT04019704. The company will file for FDA approval in the second half of 2020 for the indication of MDD, and potentially get approved for that indication in the first half of 2021. Below is the chart of the stock that appreciated +70% today.

AXS-05 and SAGE-217

Axsome and SAGE Therapeutics are in phase 3 development for two promising drugs that treat Major Depressive Disorder or MDD. Both companies have completed phase 2 clinical trials with very good results, and each have achieved the Breakthrough Therapy Designation (BTD) from the FDA. What's different from the current Selective Serotonin Reuptake Inhibitors or SSRI's, is that both AXS-05 and SAGE-217 are fast acting oral delivery drugs that show efficacy within days of treatment, compared to many weeks.
Let's see how AXS-05 and SAGE-217 compare in a side by side analysis of important facts to consider. From the file below, and from listening to company conference calls, both AXS-05 and SAGE-217 could get FDA approval and to commercialization around the same time in 2021. What stands out is that while SAGE Therapeutics currently sports an 8.49B market cap, Axsome Therapeutics just a 768M market cap. Thank you for reading.

Drug	AXS-05	SAGE-217
Action	NMDA	GABA
phase 2	ph 2 compare	ph 2 placebo
Remission wk 6	47%	45% *
BTD	√	√
Pivotal	√	√
phase 3 MDD	n= 300	n= 450
Start	6/1/2019	12/1/2018
End Expected	12/31/2019	12/31/2019
Safety Data Ext	n= 300	n= 600
NDA Filing est	6/1/2020	6/1/2020
Approval est	3/1/2021	3/1/2021
Delivery-oral	b.i.d.	qd
Patent	2034	2034
Market Cap	768M	8.49B
*15 day dosing

AXS-05 Path to Approval for MDD

• Axsome Therapeutics met with the FDA and was given an expedited pathway of AXS-05 for Major Depressive Disorder or MDD. Under this new agreement, the company's phase 2 clinical trial known as Ascend for MDD was given pivotal status, and will only need one other pivotal phase 3 with efficacy, to file a New Drug Application (NDA).
• The company plans to enroll for a new phase 3 placebo clinical trial in the 2nd quarter of 2019, with an expected completion date by the end of 2019. The company plans on initiating this phase 3 with an increased number of clinical sites recruiting participants, which will allow for completion faster over the successfully completed phase 2 Ascend clinical trial for MDD.
• The timeline for filing an NDA would then be in the first half of 2020. If this timeline holds up, AXS-05 could potentially get to commercialization around the same time as Sage Therapeutics drug SAGE-217, which is also pursuing the same MDD indication.

AXS-05 was given Breakthrough Therapy Designation (BTD) from the FDA for Major Depressive Disorder, and the patent extends out to 2034. Thank you for reading.

FDA Advisory Committee Votes 17-1 in Support of Zulresso for PPD

Today the Advisory Committee (ADCOM) voted 17-1 in support of Sage Therapeutics drug Zulresso for Postpartum Depression (PPD). The first and only drug if approved for this unmet medical need, will go into commercialization early 2019 under the name of Zulresso. The press release is here FDA Advisory Committee Votes 17-1. 
The future for the company gets even more exciting with once daily oral drug SAGE-217, which is in phase 3 testing for Major Depressive Disorder or MDD, and has a market potential several times larger than PPD.
SAGE has a talented management team, with plenty of cash to run pivotal clinical trials, and bring new drugs for other indications to market. SAGE-217 has patent to April 2034. Thank you for reading.
 

SAGE-217 Gets Expedited Development - $175.76

Very good news from SAGE Therapeutics this morning. The FDA has agreed to give SAGE Therapeutics an expedited pathway for oral drug SAGE-217 for the indications of Postpartum Depression (PPD) and Major Depressive Disorder (MDD). Below is copied directly from the press release this morning.

• Expedited SAGE-217 development plan to support potential NDA submission for MDD and PPD together
•  Previously completed placebo-controlled study in MDD considered as pivotal; initiation of one additional Phase 3 pivotal trial anticipated in 2H of 2018  
• Ongoing study in PPD designated as pivotal; results expected in 4Q 2018
• If successfully developed, SAGE-217 has the potential to be the first durable, rapid-acting, oral, short-course treatment for MDD and PPD

The second half of 2018 will be packed with clinical trial data for PPD and MDD. SAGE-217 is an oral once daily delivered drug with patent to April 2034. Thank you for reading.

NMDA Receptor Modulators for CNS Disorders

We originally wrote about this topic here NMDA Receptor Modulators for Depression. There are now several companies interested in bringing a variety of NMDA drugs into the clinic, either as mono-therapy or coupled with enhancers.  Let's have a look at some of the companies, their drug, and indications that they are targeting.

Avanir:  Otsuka

AVP-786  Dextromethorphan + Quinidine
Ph 3  Agitation in Alzheimer's Disease
Ph 2  Residual Schizophrenia
Ph 2  Major depressive disorder (adjunct)

Axsome: AXSM

AXS-05  Dextromethorphan + Bupropion  

Ph 3 Treatment resistant depression

Ph 1 Agitation in Alzheimer's Disease

Cerecor:  CERC
CERC-301  NR2B Specific NMDA antagonist oral
Ph 2 Major depressive disorder (adjunct)

JNJ / Janssen
Esketamine  intranasal
Phase 3 adjunct with anti-depressant for TRD

Naurex:  Allergan
NMDA receptor partial agonist with selective properties
Ph 2 NRX-1074  IV
Ph 1 NRX-1074 Oral
Ph 3 GLYX-13 (Rapastinel) Weekly IV Major Depressive disorder

Vistagen:  VSTA
AV-101  NMDA selective antagonist oral
Ph 2 AV-101 Major depressive disorder 

Over the next couple years, we should see some meaningful clinical readouts from some of these companies.  Potentially NMDA drugs may provide for a more efficacious and safer, sustainable therapy, aside from current antidepressants for some of the above indications. Thank you for reading.

Otsuka's Commitment to AVP-786

Otsuka a focused CNS company, and the producer of Abilify, purchased drug AVP-786 for $3.5 billion through their acquisition with Avanir on November 13, 2014.  To get a sense of just how committed the company is to AVP-786, we have to look at the clinical trials that have started since the acquisition, and compare that to the number of clinical trials the company has started with another Otsuka drug Brexpiprazole, deemed the second generation drug of Abilify, that would compete in the indications similar to AVP-786.

Clinical Trials Started Since Acquisition
(3)  Alzheimer's Agitation - U.S.        phase 3
(1)  Residual Schizophrenia                phase 2
(1)  Disinhibition                                   phase 2
(1)  Alzheimer's Agitation - Japan     phase 3

Ongoing Trials With AVP-786
(1)  Treatment Resistant Major Depression Disorder  phase 2

New Otsuka Clinical Trials with Brexpiprazole
(0)
The company was previously in clinical trials prior to the acquisition of AVP-786, for Alzheimer's Agitation, MDD, and Schizophrenia as co- partner with Lundbeck.  But has not initiated anything new since agreeing to acquire AVP-786 from Avanir late 2014.  

Bottom Line:  Some significance into the timing of initiating clinical trials, may help us identify a companies priority in their clinical pipeline.  Thank you for reading.
 

Assessing the Success of AVP-786 for Patients with Treatment Resistant Major Depressive Disorder

Assessing the success of a clinical trial depends on many factors.  Trial design, primary endpoint, prior drug trials, safety and tolerability, competitor success with similar drug, and what is deemed successful by FDA standards, are just a few factors to consider.  Avanir Pharmaceuticals is nearing the end of a phase 2 clinical trial for AVP-786 as Adjunctive Therapy in Patients with Major Depressive Disorder With Inadequate Response to Anti-Depressant Treatment in clinical trial NCT02153502.

The first important factor to consider is that AVP-786 is the deutered version of AVP-923.  Both drugs were tested in a Phase 1, Single-center, Randomized, Double-blind, Double-dummy, 2-way Crossover Study Comparing AVP-786 with AVP-923 here NCT02336347.  The two drugs exhibited a similar PK and safety profile.  This is important because we will be using data from two AVP-923 clinical studies that had a subset of patients tested for depression, with either the BDI-2 (Beck Depression Inventory-II) or the Cornell Depression Scale.

Avanir ran a phase 3 clinical trial with AVP-923 evaluating the safety and efficacy of AVP-923 in PBA (Pseudobulbar Affect) patients with ALS or MS, trial named (STAR) here NCT00573443. The mean change from baseline at day 84 in the Beck Depression Inventory (BDI-II) Total Score was used as a secondary endpoint.  Patients with moderate depression on the BDI-II scale, greater than 18, scored a significant p=0.03 while taking AVP-923, 30mg dextromethorphan / 10mg quinidine.  Below is the Avanir, JP Morgan Healthcare Conference presentation in January 2014.

2014 JP Morgan Healthcare Conference
Treatment-Resistant MDD Clinical Rationale
The Beck Depression Inventory-II (BDI-II) was included as a secondary efficacy endpoint in the pivotal phase 3 trial in PBA patients
Major Depression Excluded
Among patients with baseline BDI-II scores >10, AVP-923 treatment was associated with a reduction in depression symptoms
STAR Trial; Avanir data on file

Endpoint BDI-II
(n=50)  -3.36  AVP-923 30/10
(n=55)    -2.3   AVP-923 20/10
(n=52)    -1.1    Placebo

P Value
0.065   AVP-923 30/10
0.378   AVP-923 20/10

"Among a subset of patients with baseline BDI-II scores > 18, AVP-923 30/10 was
associated with statistically significant improvement (p=0.03)".

Using the description below for the (p=0.03) subset, the trial had patients classified primarily in the moderate depression range, as the presentation listed major depression as excluded. The following is a breakdown of the BDI-II, which is a 21-item self-report instrument intended to assess the existence and severity of symptoms of depression, summed to give a single score. The BDI-II uses a 4-point for each item ranging from 0 to 3.

BDI-II Depression Scale
0-13 is considered minimal range 
14 to 19 mild depression
20 to 28 moderate depression
29 to 63 severe depression
  

In a phase 2 clinical trial for Alzheimer's patients experiencing agitation. Trial NCT01584440 utilized a secondary endpoint called the Cornell Scale for Depression in Dementia (CSDD): which a statistical p=0.02 was observed. 

Bottom Line:
Although the number of patients were relatively small in the two above trials showing benefits of AVP-923 for depression, it does give us some guidelines to the probabilities for potential success in the current clinical trial coming to completion.  Thank you for reading.

Allergan Buys NMDA drug for $560 Million

Allergan says yes to CNS (central nervous system) and NMDA (N-methyl-D-aspartate) modulating drugs for depression, with the purchase of private company Naurex for $560 million.  We previously wrote about NMDA drugs and Naurex here, NMDA Receptor Modulators.  NMDA drugs are rapidly gaining press as mono and adjunct therapy for depression patients.  Avanir is currently in a phase 2 clinical trial with their NMDA modulator AVP-786, as an adjunctive therapy in patients with Major Depressive Disorder, with an inadequate response to anti depressant treatment. Avanir will complete their phase 2 clinical trial in the first half of 2016.  Naurex has already tested NRX-1074 as an IV as adjunctive in a phase 2 study for patients with Major Depressive Disorder.  Next, the company will test an oral NRX-1074 in a planned phase 2 clinical trial as mono-therapy for Major Depressive Disorder (MDD).

Bottom Line:  At this point we have no idea how NRX-1074 oral will perform, compared to their completed intravenous phase 2 clinical trial for patients with Major Depressive Disorder (MDD). Avanir with drug AVP-786, is most likely two years ahead of NRX-1074 in the clinical trial process. Thank you for reading.      

Rexulti & AVP-923 Safety Profile Comparison

There is not an FDA approved drug for the treatment of agitation in patients with dementia of the Alzheimer's type.  Otsuka Pharmaceuticals has a total of five phase 3 clinical trials that have been in progress, or about to start.  The two drugs that are addressing this indication are Rexulti (Brexpiprazole), and AVP-923 (AVP-786). Rexulti is a joint 50% ownership between Lundbeck and Otsuka.  AVP-923 (AVP-786) is 100% owned by Otsuka, with a milestone and royalty licensing agreement with Concert Pharmaceuticals.  The side effect comparison between Rexulti and AVP-923 is below.

Rexulti (Brexpiprazole)
In clinical trials here phase 3 Schizophrenia, the 2 mg group of Rexulti exhibited the following side effect profile.
Insomnia 13.4%
Headache 9.3%
Agitation 8.6%
In clinical trials here phase 3 Adjunctive Major Depression, the 2 mg group of Rexulti exhibited the following side effect profile.
Weight Increase 8.0%
Akathisia 7.4%

AVP-923 (AVP-786)
In a phase 2 clinical trial for patients with agitation of the Alzheimer's type, the following side effect profile was exhibited.
Falls 8.6%
Diarrhea 5.9%
Urinary Tract Infection 5.3%

Falls had a baseline skew, that had more patients in the treatment group (17.2% to 12.6%) and 25% more patient-day exposure to AVP-923 than placebo, noted here JAMA DM/Q Phase 2 Alz. Agitation.  In addition from that phase 2 clinical trial, there were no new cardiovascular safety signals and no clinically significant changes in QTc observed in the study.  These results above are consistent with several other clinical trials that Avanir has run with AVP-923, for traumatic brain injury, or stroke here Prism II, with diarrhea being the most commonly reported adverse event.

Bottom Line:  Otsuka has advanced the deutered version of AVP-923, (known as AVP-786) into three phase 3 clinical trials for the treatment of agitation in patients with dementia of the Alzheimer's type, to begin soon.  The company also has two ongoing clinical trials in progress with Rexulti for the same patients, that started in 2013. The patent for Rexulti runs until 2027 US and until 2025 EU, the patent for AVP-786 runs until 2030 in the US, and 2028 in the EU. Thank you for reading.
              

FDA Approves Rexulti (Brexpiprazole)

Late Friday the FDA approved Otsuka and Lundbeck's atypical antipsychotic drug Rexulti (Brexpiprazole), as mono therapy for Acute Schizophrenia, and as adjunct therapy for Major Depressive Disorder. We previously wrote about Brexpiprazole here Lundbeck Clinical Trials Update .  Otsuka, the maker of Abilify has been under pressure to replace lost sales of the world's number one selling drug Abilify (Top Selling Drugs) in 2014, due to patent expiration in 2015. Rexulti (Brexpiprazole) has been the drug to replace Abilify for several similar CNS indications. Under the marketing agreement Lundbeck (co-developer and co-commercialization) will get 45% of Brexpiprazole U.S. net sales, and 50% net sales in Europe.  The patent for Rexulti runs until 2027 US, and 2025 in the EU. The label for Rexulti is below.

INDICATIONS and IMPORTANT SAFETY INFORMATION for REXULTI ^®(brexpiprazole)
INDICATIONS
REXULTI is indicated for:

• Use as an adjunctive therapy to antidepressants in adults with major depressive disorder
• Treatment of schizophrenia in adults

IMPORTANT SAFETY INFORMATION

Increased Mortality in Elderly Patients with Dementia-Related Psychosis

Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk (1.6 to 1.7 times) of death compared to placebo (4.5% vs 2.6%, respectively). Although the causes of death were varied, most of the deaths appeared to be cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. REXULTI is not approved for the treatment of patients with dementia-related psychosis.

Rexulti (Brexpiprazole) deemed the second generation Abilify, is getting a similar safety label as Abilify, even though the side effect profile between the two drugs varies, with Rexulti showing improvement in some areas such as akathisia.  It will be interesting to see what kind of label AVP-786 gets for the Treatment of Agitation in Patients with Dementia of the Alzheimer's Type.  AVP-786 is about to enter phase 3 clinical trials in September. Thank you for reading.
 

NMDA Receptor Modulators for Depression

NMDA (N-mythel-D-asparate) roots track back to a drug known as Ketamine or street name Special K, with hallucination effects.  Ketamine is an NMDA receptor antagonist originally used as an anaesthetic.  The glutamate receptor subtype known as (NMDA) plays a central role of modulating brain activity in the central nervous system, such as synaptic transmission, synaptic plasticity, and excitotoxicity. Pharmaceutical firms have been developing NMDA type drugs for over two decades, and a few including Memantine, and Nuedexta are being marketed for other indications outside of depression.
There have been several studies modulating the NMDA receptor, that have shown efficacy in patients with treatment-resistant depression.  A trial performed by Avanir Pharmaceuticals for pseudobulbar affect with drug AVP-923 (Nuedexta), showed efficacy in a subset of patients for depression using the Beck Depression Inventory II or BDI-II. Data showed that the dextromethorphan (an NMDA receptor antagonist, sigma 1 agonist) / quinidine combination was effective in patients with BDI-II scores greater than 18 at inclusion with AVP-923 30/10, and was associated with a statistically significant improvement of (p=0.03). What's also significant is that major depression was an exclusion into the trial.  Avanir is now in a phase 2 clinical trial with AVP-786, for major depressive disorder patients as adjunct to current antidepressant here NCT02153502.  I think the chances of success are high, based on how the dextromethorphan/quinidine combination performed in the subset of patients in prior trials.
Private company Naurex, is also working on NMDA drugs for depression patients. The company has displayed good data in early clinical trials using IV, and soon to be launched an oral NMDA drug for depression.  Thank you for reading.

AVP-786 is Concert Pharmaceutical's deutered enhanced version of AVP-923.

Lundbeck Clinical Trials - Update

Lundbeck and their marketing partner Otsuka (the manufacturer of the #1 selling drug Abilify) are major players in the central nervous system (CNS) space.  An update on new phase 3 trial data for depression and schizophrenia are listed below.  The links are below.

12-10-2014
Lundbeck 2014 Press Releases
Trial: (NCT01360645) Phase 3
Brexpiprazole as adjunct for Major Depressive Disorder (MDD)
Study 1 (2mg + ADT (N=175): -3.21, p=0.0002)  MADRS

12-11-2014
Lundbeck 2014 Press Releases
Trial: (NCT01396421) Phase 3
Brexpiprazole as mono-therapy for adults with Acute Schizophrenia.
Total Score (4mg: -19.65, p=0.0006) PANSS

Both studies achieved significant efficacy results, which may lead to approval from the FDA mid 2015.  Brexpiprazole has patent exclusivity through 2026.