Omaveloxolone 50mg capsules

BACKGROUND: Friedreich's ataxia (FA) is a rare genetic disorder caused by silencing of the frataxin gene (FXN), which leads to multiorgan damage. Nrf2 is a regulator of FXN, which is a modulator of oxidative stress in animals and humans. Omaveloxolone (Omav) is an Nrf2 activator and has been reported to have antioxidative potential in various disease conditions. The present review was conducted to determine the use of Omav, the only FDA-approved treatment for FA. METHODS: Three electronic databases, Cochrane, PubMed and Google Scholar, were searched with terms such as 'Omaveloxolone', 'Friedreich ataxia', 'genetic diseases', 'autosomal recessive', and 'rare disorders' using various advanced search filters. Articles were screened, extracted, and assessed for quality, and a qualitative synthesis of the data was performed. The study protocol was registered in PROSPERO (CRD42024531449). RESULTS: A total of 201 records were found, with very few published research articles on the topic. Only two randomized clinical trials published in a series of three research articles were included in the current systematic review. Peak load exercise and modified Friedreich's Ataxia Rating Scale (mFARS) values were considered the major outcome measures for determining the efficacy of 150 mg Omav capsules/day in FA. Exploratory outcome measures, such as low-contrast letter visual acuity test, exercise test, T25-FW, 9-HPT, health-related quality of life, and biochemical tests, were also assessed along with adverse events in all the studies. CONCLUSION: Although, the quality of the articles demonstrated low bias. However, the short duration, small sample size, and missing data, including the values of different measures of mFARS scores in patients, limit the generalizability of the results. Further studies with longer durations and in severe patients with foot deformities are needed to clearly define the efficacy of Omav in FA and to determine the optimal drug for FA patients in India.

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Omaveloxolone is approved for the treatment of Friedreich ataxia (FA) in patients aged ≥ 16 years and is under clinical development for pediatric patients. In the MOXIe study, alanine and aspartate aminotransferase (ALT and AST) elevations were among the most common treatment-emergent adverse events (TEAEs) in the omaveloxolone arm and were mild to moderate, generally asymptomatic, transient, and reversible; no patients who received omaveloxolone had laboratory abnormalities that met the Hy's law criteria. Omaveloxolone labels (US and EU) provide guidance for monitoring and managing these elevations. Here, practical use considerations, from experience-based opinions of four FA experts and a hepatologist via semi-structured interviews, are presented. Prior to omaveloxolone initiation, assessment of baseline ALT, AST, and total bilirubin is recommended per label. During treatment, ALT, AST, and total bilirubin should be monitored monthly for the first 3 months and periodically thereafter per label. Reduced frequency of patient monitoring after 3 months is suggested if aminotransferase levels remain normal. Per label, omaveloxolone should be temporarily discontinued if aminotransferases increase to > 5 × the upper limit of normal (ULN) or > 3 × ULN with other evidence of liver dysfunction. Stemming from real-world practical considerations wherein patients are followed up less frequently than in the trial setting, treatment interruption when aminotransferases increase to ≥ 3 × ULN without other signs of hepatic impairment may be considered. When aminotransferase elevations stabilize or resolve, omaveloxolone may be reinitiated with an appropriate increased frequency of monitoring of liver function per label. We propose patients who pause treatment may have testing repeated after 2 weeks, while those with resolving aminotransferase elevations may reinitiate omaveloxolone with stepwise dose titrations and testing every 2 weeks for ≈ 3 months. Use considerations herein may inform decisions on monitoring and managing ALT and AST elevations, which potentially help to encourage the treatment adherence needed to achieve the slowing of FA progression seen in MOXIe.Graphical abstract available for this article.

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This review provides a comprehensive overview of the therapeutic potential of omaveloxone (OMA) for the treatment of Friedreich's ataxia (FA), along with an analysis of the historical development and current status of the synthetic strategies for OMA production. OMA activates the nuclear factor-2-(erythroid-2)-related (Nrf2) pathway in vitro and in vivo, in both animal models and humans. The Nrf2 pathway plays a crucial role in the cellular response to oxidative stress. Furthermore, OMA has been shown to mitigate mitochondrial dysfunction, restore redox homeostasis and downregulate nuclear factor-κB (NF-κB), a key mediator of inflammatory responses. Through these mechanisms, OMA contributes to tissue protection and inflammation reduction in patients with FA. The review also highlights future perspective, focusing on the challenges associated with OMA reprofiling through innovative drug delivery approaches and its potential repurposing for diseases beyond FA.

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BACKGROUND: MOXIe was a two-part study evaluating the safety and efficacy of omaveloxolone in patients with Friedreich's ataxia, a rare, progressive neurological disease with no proven therapy. MOXIe part 2, a randomized double-blind placebo-controlled trial, showed omaveloxolone significantly improved modified Friedreich's Ataxia Rating Scale (mFARS) scores relative to placebo. Patients who completed part 1 or 2 were eligible to receive omaveloxolone in an open-label extension study. OBJECTIVE: The delayed-start study compared mFARS scores at the end of MOXIe part 2 with those at 72 weeks in the open-label extension period (up to 144 weeks) for patients initially randomized to omaveloxolone versus those initially randomized to placebo. METHODS: We performed a noninferiority test to compare the difference between treatment groups (placebo to omaveloxolone versus omaveloxolone to omaveloxolone) using a single mixed model repeated measures (MMRM) model. In addition, slopes of the change in mFARS scores were compared between both groups in the open-label extension. RESULTS: The noninferiority testing demonstrated that the difference in mFARS between omaveloxolone and placebo observed at the end of placebo-controlled MOXIe part 2 (-2.17 ± 1.09 points) was preserved after 72 weeks in the extension (-2.91 ± 1.44 points). In addition, patients previously randomized to omaveloxolone in MOXIe part 2 continued to show no worsening in mFARS relative to their extension baseline through 144 weeks. CONCLUSIONS: These results support the positive results of MOXIe part 2 and indicate a persistent benefit of omaveloxolone treatment on disease course in Friedreich's ataxia. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

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OBJECTIVE: The natural history of Friedreich ataxia is being investigated in a multi-center longitudinal study designated the Friedreich ataxia Clinical Outcome Measures Study (FACOMS). To understand the utility of this study in analysis of clinical trials, we performed a propensity-matched comparison of data from the open-label MOXIe extension (omaveloxolone) to that from FACOMS. METHODS: MOXIe extension patients were matched to FACOMS patients using logistic regression to estimate propensity scores based on multiple covariates: sex, baseline age, age of onset, baseline modified Friedreich Ataxia Rating scale (mFARS) score, and baseline gait score. The change from baseline in mFARS at Year 3 for the MOXIe extension patients compared to the matched FACOMS patients was analyzed as the primary efficacy endpoint using mixed model repeated measures analysis. RESULTS: Data from the MOXIe extension show that omaveloxolone provided persistent benefit over 3 years when compared to an untreated, matched cohort from FACOMS. At each year, in all analysis populations, patients in the MOXIe extension experienced a smaller change from baseline in mFARS score than matched FACOMS patients. In the primary pooled population (136 patients in each group) by Year 3, patients in the FACOMS matched set progressed 6.6 points whereas patients treated with omaveloxolone in MOXIe extension progressed 3 points (difference = -3.6; nominal p value = 0.0001). INTERPRETATION: These results suggest a meaningful slowing of Friedreich ataxia progression with omaveloxolone, and consequently detail how propensity-matched analysis may contribute to understanding of effects of therapeutic agents. This demonstrates the direct value of natural history studies in clinical trial evaluations.

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STRUCTURE: Omaveloxolone {N-[(4aS,6aR,6bS,8aR,12aS,14aR,14bS)-11-cyano-2,2,6a,6b, 9,9,12a-heptamethyl-10,14-dioxo-1,2,3,4,4a,5,6,6a,6b,7,8,8a,9,10,12a,14,14a,14b-octa-decahydropicen-4a-yl]-2,2-difluoropropanamide} is a semisynthetic triterpenoid based on the natural product oleanolic acid. It contains a highly reactive cyanoenone functionality, which binds covalently and reversibly by Michael addition to cysteines in proteins, such as the cysteine-based sensor protein Kelch-like ECH-associated protein 1 (KEAP1). The molecular formula of omaveloxolone is C33H44F2N2O3 and its molecular weight is 554.7 g/mol. MECHANISM OF ACTION: The pathophysiology of Friedreich’s ataxia is associated with an expansion of GAA repeats in the first intron of FXN encoding the small mitochondrial protein frataxin (FXN), which has a role in mitochondrial homeostasis and iron metabolism. FXN deficiency leads to impaired mitochondrial function and increased production of reactive oxygen species (ROS) (1), in turn causing inflammation with further ROS production, creating a vicious cycle that ultimately results in cellular dysfunction (2). Omaveloxolone is an inducer of a network of endogenous cytoprotective proteins regulated by transcription factor nuclear factor-erythroid 2 p45-related factor 2 (NRF2), the master regulator of cellular redox homeostasis. At basal state, the levels of NRF2 are low due to its continuous proteasomal degradation (3) mediated by KEAP1, a substrate adapter of a Cullin-RING E3 ubiquitin ligase. Omaveloxolone (pink circle), via its cyanoenone functionality, binds to sensor cysteines (primarily C151) in KEAP1 and inactivates it (4). As a result, the newly synthesized NRF2 accumulates, forms a heterodimer with a small musculoaponeurotic fibrosarcoma (sMAF) protein, and induces transcription of its target genes by binding to the antioxidant response element (ARE) sequences in their regulatory regions. The NRF2-transcriptional network encompasses an array of broadly cytoprotective proteins (5), including those responsible for the biosynthesis of glutathione (GSH). Collectively, the NRF2 transcriptional targets counteract oxidative and inflammatory stress, and support proteostasis, mitochondrial function, and bioenergetics. Omaveloxolone also inhibits inflammation, in part via NRF2 (which inhibits transcription of proinflammatory genes) and, in part, due to its potential to bind to cysteines in proteins involved in inflammatory cascades (e.g., IKKβ, shown in beige). Omaveloxolone (also known as RTA-408); brand name is SKYCLARYS. Omaveloxolone is the first and only FDA-approved drug for patients with Friedreich’s ataxia. Omaveloxolone has received Orphan Drug, Fast Track, and Rare Pediatric Disease Designations from the FDA, and Orphan Drug Designation for the treatment of Friedreich’s ataxia from the European Commission. It is currently not approved outside of the USA. SKYCLARYS™ is approved in the USA by the FDA and is indicated for the treatment of Friedreich’s ataxia in adults and adolescents aged 16 years and older. The recommended dosage is 150 mg to be taken orally daily. Reata Pharmaceuticals. Headache (37%), nausea (33%), diarrhea (20%), abdominal pain (29%), fatigue (24%), musculoskeletal pain (20%), vomiting (16%), oropharyngeal pain (18%), influenza (16%), muscle spasms (14%), back pain (13%), decreased appetite (12%), rash (10%). The most common laboratory abnormalities (occurring in 37% of patients) are elevated aspartate/alanine transaminases. In clinical trials, most effects diminished or stopped after 12 weeks of treatment. 2014–2020: Phase 1 trials (NCT02029716, NCT03664453, NCT04008186) 2014–present: Phase 2 trials (NCT02255435, NCT02029729, NCT02142959, NCT02128113, NCT03902002, NCT02255422) February 2023: FDA approval for SKYCLARYS™ (omaveloxolone). We thank the Medical Research Council (MR/W023806/1 and MR/T014644/1), the Biotechnology and Biological Sciences Research Council and GlaxoSmithKline (BB/T508111/1, BB/X00029X/1, and BB/T017546/1), Tenovus Scotland (T19/30 and T22/08), Reata Pharmaceuticals, and Medical Research Scotland (PHD-50477-2021) for supporting our research and the COST Action CA20121, supported by the European Cooperation in Science and Technology (www.cost.eu) (https://benbedphar.org/about-benbedphar/). A.T. D.-K. is a member of the Scientific Advisory Board of Evgen Pharma and collaborates with GlaxoSmithKline and Reata Pharmaceuticals. S.D.N. has no interests to declare.

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