CHOLBAM (cholic acid) Now Approved In The U.S. For Patients With Bile Acid Synthesis Disorders

FDA approves oral therapy as a first-in-class treatment

Mar 17, 2015, 20:41 ET from Asklepion Pharmaceuticals, LLC.

BALTIMORE, March 17, 2015 /PRNewswire-USNewswire/ -- Asklepion Pharmaceuticals, LLC. today announced that the U.S. Food and Drug Administration (FDA) approved CHOLBAM™ (cholic acid) as a once-daily treatment for cholic acid deficiency in bile acid synthesis disorders due to single enzyme defects. This indication is based on CHOLBAM's ability to markedly improve or normalize liver function test values and to improve general health, as measured by weight gain. CHOLBAM was also approved as an adjunct to standard of care for peroxisomal disorders including Zellweger spectrum disorders in patients with evidence of liver disease, based on improvements in liver function.

CHOLBAM is the first medication approved by the FDA to turn off a genetically-damaged bile synthesis pathway and prevent its toxic products from damaging the liver. The approval of CHOLBAM is a testament to the pioneering work of Dr. Kenneth Setchell and Dr. James Heubi of Cincinnati Children's Hospital and Medical Center, who were the first to recognize many of the constituent diseases and develop a safe and effective therapy. The U.S. approval of CHOLBAM was based on two pivotal trials that showed improved liver function test values and restoration of growth assessed by weight gain in comparison to the natural history of untreated patients. Some patients in these trials have been healthy on therapy, exhibiting normal liver function for more than 16 years. 

"The FDA approval of CHOLBAM is of vital importance to patients and families who are dealing with bile acid deficiency diseases," said Philip Rosenthal, MD, Director of Pediatric Hepatology at the University of California, San Francisco. "Previously, the patients who rely on this life-saving medicine were only able to receive it through research studies. Making this therapy more widely available is a significant accomplishment of science and collaboration in this rare disease space."

The safety and efficacy of CHOLBAM in patients with bile acid synthesis deficiency disorders were evaluated in a nearly 20-year open label, single arm, investigator-initiated trial at Cincinnati Children's Hospital and Medical Center. FDA noted responses in 28 of 44, or approximately 64 percent, of patients with single enzyme defects and in 11 of 24, or 46% of peroxisomal disorder patients. 

"The approval of CHOLBAM is a significant medical advancement for patients with bile acid deficiency disorders and the physicians who treat them," said Gary Pasternack, MD, PhD, Chief Executive Officer of Asklepion Pharmaceuticals.

"Asklepion is committed to developing and bringing to market treatment options for populations with a high unmet need," added Jeff Courtney, Asklepion's Chief Operating Officer.

Bile acid synthesis disorders caused by single enzyme defects are a group of highly symptomatic conditions that prevent the liver from properly producing bile acids that help the intestines absorb essential fats, vitamins and nutrients. The genetically damaged pathway instead produces toxic products that damage the liver. The disease is most commonly diagnosed in infants.  

In the U.S., there are at least 500 babies born with bile acid deficiencies each year. Children with bile acid deficiency diseases may present during the neonatal period or during early childhood. If untreated, these deficiencies can cause the buildup of defective bile acids that lead to cholestasis, nutrient malabsorption, liver disease, neurologic disease, and, eventually, liver failure and death. Because many physicians are unfamiliar with these diseases, it is believed that the majority of cases go undiagnosed and untreated. 

Zellweger spectrum disorder patients lack peroxisomes and produce abnormally long fatty acids, leading to numerous problems in many organ systems.  Occurring in 1 of 50,000 live births, about 80% of people with these disorders will develop liver disease. Patients with Zellweger spectrum disorders are usually recognized at birth as floppy babies, without muscle tone. 

CHOLBAM works by down regulating cholesterol 7alpha-hydroxylase, the rate limiting step in bile acid synthesis. In doing so, it inhibits the production and accumulation of hepatotoxic and cholestatic bile acid precursors. It also stimulates bile flow and secretion, and facilitates fat absorption at therapeutic doses. Patients with single enzyme defects cannot make cholic acid, and instead make abnormal, toxic intermediate products.  Zellweger spectrum patients make cholic acid, but the lipid side chains that are subsequently added are too long, making the product toxic to the liver.

The main purpose of providing CHOLBAM is to prevent the production of toxic products. CHOLBAM also restores the main functions of cholic acid, including lipid transport in the form of mixed micelles; the activation of co-lipase, and fat digestion and absorption; the absorption of fat-soluble vitamins; and, the induction of bile flow, thus preventing cholestasis. Cholic acid is one of the primary bile acids on which essential physiological functions depend.

The Warnings and Precautions for CHOLBAM include worsening liver disease and biliary obstruction.  Adverse reactions include a 2 percent incidence of diarrhea, and 1 percent incidence of abdominal pain, nausea, intestinal polyp, reflux esophagitis, malaise, jaundice, urinary tract infection, peripheral neuropathy and skin lesion.

The recommended dosage for pediatric patients 1 month of age and older and adults is 10 to 15 mg/kg once daily or in two divided doses.

The safety and effectiveness of CHOLBAM on extrahepatic manifestations of bile acid synthesis or Zellweger spectrum disorders have not been established.

About Bile Acid Synthesis Disorders
Bile acid synthesis disorders are a group of highly symptomatic conditions that affect approximately one in every 50,000-70,000 live births in the U.S. These diseases are caused by genetic errors that produce abnormal bile acid molecules. Classified as rare orphan diseases, bile acid deficiency diseases prevent the liver from properly producing bile acids that help the intestines to absorb essential fats, vitamins and nutrients. Instead, the liver produces toxic products that damage the liver and sometimes the central nervous system.

Common symptoms include poor growth, jaundice, enlarged spleen, liver bleeds and cirrhosis, discolored stools, dark urine, nausea and poor digestion. Since these symptoms are similar to other common liver diseases, patients are often misdiagnosed and go untreated or mistreated.

CHOLBAM is indicated for the treatment of bile acid deficiency diseases in both pediatric and adult patient populations. This indication is based on the ability of CHOLBAM to markedly improve or normalize liver function tests and to improve general health as measured by weight gain.

Important Safety Information
During the initiation of therapy and dose adjustment, patients should be closely monitored.  The lowest dose of CHOLBAM that effectively reduces abnormal liver function tests should be closely monitored with liver function tests, fat soluble vitamin levels, and an INR test or prothrombin time. Concurrent elevations of serum gamma glutamyl transferase and serum alanine aminotransferase may indicate overdose.

Patients that have previously been treated with other bile acids or other cholic acid preparations should be closely monitored in the same manner during the initiation of treatment with CHOLBAM.

After the initiation period, serum and urine bile acids and liver parameters should be evaluated annually, at a minimum, and the dose adjusted accordingly.

Treatment with CHOLBAM should be stopped if in case of abnormal hepatocellular function, as measured by prothrombin time, hepatocellular function does not improve within 3 months of the initiation of CHOLBAM treatment. A concomitant decrease of urine total bile acids should be observed. Treatment should be stopped earlier if there are clear indicators of severe hepatic failure.

As patients with newly diagnosed, or a family history of, familial hypertriglyceridemia may have poor absorption of cholic acid from the intestine, the CHOLBAM dose for patients with familial hypertriglyceridemia will have to be established and adjusted as necessary; an elevated dose may be required in order to suppress urinary bile acids.

About Asklepion Pharmaceuticals, LLC.
Asklepion is a pharmaceutical company focused on the clinical research and development through regulatory approval of innovative therapies for rare pediatric diseases.  Founded in 2006, Asklepion has a pipeline of products addressing other liver diseases and critical care applications in children.


SOURCE Asklepion Pharmaceuticals, LLC.