FDA Reviewers Deliver Split Opinion On New Heart Drug From The Medicines Organization

FDA reviewers presented two dramatically various views of The Medicines Company’s investigational new drug cangrelor. One particular reviewer says the drug should not be approved with out a new trial and even states that the CHAMPION trials “were carried out unethically” and must not be accepted “on that reality alone.”  But two other reviewers advocate approval.

On Wednesday the FDA’s Cardiovascular and Renal Drugs Advisory Committee will meet to go over two proposed indications for cangrelor. The 1st is for the reduction of thrombotic cardiovascular occasions including stent thrombosis in individuals undergoing PCI. The second is for the servicing of antiplatelet therapy in patients with acute coronary syndromes or individuals with stents who have discontinued antiplatelet therapy because they are awaiting surgical treatment and are at large risk for thrombotic events.

The most damaging point of view comes from the typically outspoken and controversial FDA reviewer Tom Marciniak. (He has been a major critic of rosiglitazone and rivaroxaban and has not hesitated in the past to disagree with fellow FDA workers members.)  Marciniak maintains that the CHAMPION trials did not show that cangrelor was both superior or noninferior to clopidogrel in the CHAMPION trials. Some of his chief factors are:

• Clopidogrel was not administered optimally (as well late and with an inadequate loading dose) in the management arm.


• A lot higher prices of bleeding in cangrelor sufferers.


• Cangrelor was much better only in the subgroup of sufferers with secure angina.


• No comparison with the newer antiplatelet agents prasugrel or ticagrelor.

But two other FDA clinical reviewers supply a much more generous recommendation, even though it might not inspire much self confidence amid the panel members. The reviewers create that the main efficacy endpoint was “carefully crafted following post-hoc analyses” of 2 prior failed trials. Their recommendation seems based much more on technical points than a  view of the benefits as robustly sturdy. For instance, they agree with Marciniak that fewer control sufferers obtained the larger 600 mg dose of clopidogrel, but don’t believe the outcomes must be discounted because the increased dose is still not mandated by labeling or guidelines.

A crucial viewpoint was also shared by the FDA statistical reviewer, who noted that after adjusting for the imbalance in the loading dose the primary endpoint would no longer be important in favor of cangrelor.

In a 2nd report, Marciniak argues that cangrelor need to not be approved for ethical motives simply because the clinical trials were imbalanced simply because clopidogrel was not used optimally. CHAMPION PHOENIX, he writes:

was unethical because it delayed use of clopidogrel until soon after coronary angiography or later on and since it prohibited regimen use of prasugrel, ticagrelor, and glycoprotein IIb/IIIa inhibitors (GPIs). The PHOENIX informed consent documents (ICDs) failed to inform patients concerning the positive aspects of earlier use of clopidogrel and the use of prasugrel, ticagrelor, and GPIs. The sufferers in PHOENIX were not informed about “appropriate different procedures or courses of treatment, if any, that may well be advantageous to the subject”…

For the 2nd birding indication the two  reviewers advised a full response letter due to the absence of clinical information supporting the indication. Marciniak did not give a recommendation about this indication.

FDA Reviewers Deliver Split Opinion On New Heart Drug From The Medicines Organization