Leqvio
inclisiran
Species
MonkeyRatRabbit
Longest study
40 wk
Genotox
Conducted Conducted
Carcinogenicity
Conducted Conducted
Repro
Conducted Conducted
First dose
Not conducted Not stated publicly
Speciesopen answer page →
Species
Rat and cynomolgus monkey (both pharmacologically active); rabbit for EFD
“The drug was pharmacologically active in both rats and NHPs, and therefore these assessments represent characterization of both on-target and off-target effects.”
Why that species
Complete homology to human/cynomolgus PCSK9; partial homology (seed region match) gives partial activity in rodents and rabbit
“The applicant states that the nucleotide sequence of inclisiran exhibits complete homology to the analogous sequences in the human and Cynomolgus monkey PCSK9 genes and partial homology to the rat and mouse PCSK9 gene sequences.”
Surrogate molecule
No surrogate; clinical siRNA used (human PCSK9 transgenic mice for pharmacology only)
“Sequence homology was sufficient to result in pharmacologic activity (LDL-C decreases) of inclisiran in all three species.”
Species: general tox
Rat (29 weeks) and non-human primate (40 weeks)
“Toxicological characterization of inclisiran was performed in studies of 29 weeks in rats and 40 weeks in NHPs at doses up to 8 times (≤ 250 mg/kg Q4W) and 19 times (300 mg/kg Q4W) the MRHD (based on BSA), respectively.”
Species: DART
Rat (fertility, EFD, pre/postnatal) and rabbit (EFD)
“Embryo-fetal assessments in rats and rabbits and a pre and postnatal development study in rats did not demonstrate evidence of reproductive or developmental risk at any dose tested, representing up to 5 and 10 times clinical MRHD (BSA), respectively (≤ 150mg/kg/day in both species). Inclisiran produced no adverse impact on fertility or early embryonic development in rats at up to 8 times the MRHD (BSA) (≤ 250 mg/kg/day).”
Species: carcinogenicity
Rat (2-year) and Tg rasH2 mouse (6-month)
“Inclisiran was evaluated in a lifetime (2 year) rat carcinogenicity study at up to 8 times the clinical MRHD (BSA) (≤ 250 mg/kg Q4W) and in a 6-month study in Tg rasH2 mice (≤ 1500 mg/kg Q4W). Inclisiran lacked tumorigenic potential in these studies.”
Surrogate used in
No surrogate used; inclisiran itself pharmacologically active in all three nonclinical species tested
“Sequence homology was sufficient to result in pharmacologic activity (LDL-C decreases) of inclisiran in all three species.”
Study lengthopen answer page →
Longest pivotal study
40 weeks
“Inclisiran was also well-tolerated in repeat dose studies up to 29-weeks of duration in rats and 40-weeks of duration in monkeys.”
Pivotal GLP studies
Rat 29-week and monkey 40-week SC Q4W (13-week recovery); plus 4- and 15-week studies and 13-week monkey statin combination
“Toxicological characterization of inclisiran was performed in studies of 29 weeks in rats and 40 weeks in NHPs at doses up to 8 times (≤ 250 mg/kg Q4W) and 19 times (300 mg/kg Q4W) the MRHD (based on BSA), respectively.”
Route in tox
Subcutaneous, weekly to every 4 weeks (more frequent than clinical Q6M)
“It is important to note that animals were dosed more frequently in toxicology studies (QD to Q4W) than in clinical studies (Q3M or Q6M).”
Skipped studiesopen answer page →
Genotoxicity
Conducted: standard panel, negative
“Inclisiran was negative in an adequate panel of mutagenicity assays.”
Carcinogenicity
Conducted: 2-year rat (to ~100 weeks) and 26-week TgRasH2 mouse; no tumorigenic potential
“Inclisiran lacked tumorigenic potential in these studies.”
Reproductive & developmental
Rat fertility, rat and rabbit EFD, rat PPND; no reproductive or developmental risk; no NHP ePPND
“Embryo-fetal assessments in rats and rabbits and a pre and postnatal development study in rats did not demonstrate evidence of reproductive or developmental risk at any dose tested, representing up to 5 and 10 times clinical MRHD (BSA), respectively (≤ 150mg/kg/day in both species).”
Safety pharmacology
Standalone monkey CV/respiratory telemetry (up to 250 mg/kg); CNS endpoints incorporated into 40-week monkey study
“A dedicated safety pharmacology study to evaluate neurological function was not performed; however, neurological evaluations were incorporated into the 40- week repeat dose toxicology study where monkeys were administered 0, 30, 100 or 300 mg/kg inclisiran by subcutaneous injection every 28 days.”
Genotox: Ames
Bacterial reverse mutation (Ames): negative
“A standard battery of two in vitro and one in vivo GLP-compliant genetic toxicology studies were completed with inclisiran: an in vitro bacterial reverse mutation (Ames) assay, an in vitro chromosomal aberration test in cultured human peripheral blood lymphocytes, and an in vivo rat bone marrow micronucleus assay. Inclisiran was neither mutagenic nor clastogenic in the three valid assays.”
Genotox: in vitro mammalian
Chromosomal aberration in human peripheral blood lymphocytes: negative
“A standard battery of two in vitro and one in vivo GLP-compliant genetic toxicology studies were completed with inclisiran: an in vitro bacterial reverse mutation (Ames) assay, an in vitro chromosomal aberration test in cultured human peripheral blood lymphocytes, and an in vivo rat bone marrow micronucleus assay. Inclisiran was neither mutagenic nor clastogenic in the three valid assays.”
Genotox: in vivo
Rat bone marrow micronucleus: negative
“A standard battery of two in vitro and one in vivo GLP-compliant genetic toxicology studies were completed with inclisiran: an in vitro bacterial reverse mutation (Ames) assay, an in vitro chromosomal aberration test in cultured human peripheral blood lymphocytes, and an in vivo rat bone marrow micronucleus assay. Inclisiran was neither mutagenic nor clastogenic in the three valid assays.”
Carcinogenicity model
2-year rat (up to 250 mg/kg Q4W, 8x MRHD) and 6-month Tg rasH2 mouse (up to 1500 mg/kg Q4W); no tumorigenic potential
“Inclisiran was evaluated in a lifetime (2 year) rat carcinogenicity study at up to 8 times the clinical MRHD (BSA) (≤ 250 mg/kg Q4W) and in a 6-month study in Tg rasH2 mice (≤ 1500 mg/kg Q4W). Inclisiran lacked tumorigenic potential in these studies.”
Carcinogenicity timing
2-year rat and 6-month Tg rasH2 mouse studies completed before the marketing application
“Inclisiran was evaluated in a lifetime (2 year) rat carcinogenicity study at up to 8 times the clinical MRHD (BSA) (≤ 250 mg/kg Q4W) and in a 6-month study in Tg rasH2 mice (≤ 1500 mg/kg Q4W). Inclisiran lacked tumorigenic potential in these studies.”
hERG / QT
Monkey CV telemetry up to 250 mg/kg SC: no effects on PR, QT/QTc, QRS or arrhythmias
“The applicant conducted a cardiovascular and respiratory safety study in conscious telemetered male Cynomolgus monkeys with SC injections of up to 250 mg/kg bw of inclisiran. Neither statistically significant effects on PR, QT or QTc intervals, or QRS duration, nor abnormal ECG waveforms or arrhythmias were attributed to administration of inclisiran.”
First doseopen answer page →
First-in-human starting dose
Not stated in public reviews
Why it's blank
The public FDA and EMA reviews of Leqvio don't say how the first human dose was chosen. That rationale is in the IND, which is confidential, so it is missing for most approved products.
How it's usually set for oligonucleotides outside oncology
Find the highest dose with no adverse effects (NOAEL) in each animal species, convert it to a human equivalent dose, usually by body surface area, pick the most appropriate species, then divide by a safety factor (default 10) to get the maximum recommended starting dose.
“In general, one should consider using a safety factor of at least 10. The MRSD should be obtained by dividing the HED by the safety factor.”
This product's starting point
NOAEL / key findings: NOAEL = highest doses (250 mg/kg rat, 300 mg/kg monkey Q4W); non-adverse liver, kidney, injection site, lymph node accumulation findings (FDA pharmacology/toxicology review, p. 39)
NOAEL / key findings
NOAEL = highest doses (250 mg/kg rat, 300 mg/kg monkey Q4W); non-adverse liver, kidney, injection site, lymph node accumulation findings
“Since none of the findings were considered adverse, the NOAEL was 300 mg/kg/28 days and provides a 19-fold exposure multiple to clinical exposure based on body”
Risksopen answer page →
Immune & cytokine safety
Delayed/suppressed TDAR (KLH IgM/IgG) in 40-week monkey study, reversible; sporadic low-titre ADA without PD impact
“In a 40-week toxicity study in NHPs, delayed or suppressed IgM (data not shown) and IgG (see Figure 1, below) responses were observed across the dose range at ≥ 2 times the clinical MRHD (BSA) (≥ 30 mg/kg Q4W) in response to keyhole limpet hemocyanin (KLH) sheep antigen”
Biodistribution & persistence
QWBA: highest in injection site, liver, kidney cortex; minimal brain/CNS; slow tissue elimination (t1/2 >100 h)
“In rats, inclisiran-associated radioactivity widely distributed to most tissues with the highest concentrations (based on Cmax) observed at the subcutaneous dose site, and in the liver (target organ), and kidney cortex (site of elimination).”
Modality-specific risk
Tissue accumulation of siRNA (hepatocyte vacuolation, renal basophilic granules), injection-site inflammation, immune (TDAR) effects
“Toxicities with inclisiran were generally non-adverse and largely secondary to tissue accumulation of drug.”
Anti-drug antibodies: animals
Sporadic low-titre ADA in monkeys near end of dosing: 5 animals (15-week) and 3 (40-week)
“In the 15 and 40-week toxicology studies conducted in monkeys there were sporadic incidences of animals developing ADA at or near the end of the dosing periods. Five animals in the 15-week study and three animals in the 40 week study developed low titre ADA.”
Anti-drug antibodies: patients
Treatment-emergent ADA in 90/1,830 (5%) adults over 18 months; 33/1,830 (2%) positive before treatment
“Confirmed positivity was detected in 33/1,830 (2%) patients prior to receiving LEQVIO and in 90/1,830 (5%) patients during the 18 months of treatment with LEQVIO.”
Label warnings
- Hypersensitivity Reactions
Hypersensitivity & infusion reactions
US prescribing information, Warnings and PrecautionsDailyMed ↗
Tox packageopen answer page →
Before first-in-human
First-in-human: where
Not stated in public reviews
Not reported in the public reviews. Reviewers summarise selectively, so this usually means it wasn't discussed publicly, not that it wasn't studied.
Repeat-dose tox before first-in-human
Not stated in public reviews
Not reported in the public reviews. Reviewers summarise selectively, so this usually means it wasn't discussed publicly, not that it wasn't studied.
First-in-human starting dose
Not stated in public reviews
Why it's blank
The public FDA and EMA reviews of Leqvio don't say how the first human dose was chosen. That rationale is in the IND, which is confidential, so it is missing for most approved products.
How it's usually set for oligonucleotides outside oncology
Find the highest dose with no adverse effects (NOAEL) in each animal species, convert it to a human equivalent dose, usually by body surface area, pick the most appropriate species, then divide by a safety factor (default 10) to get the maximum recommended starting dose.
“In general, one should consider using a safety factor of at least 10. The MRSD should be obtained by dividing the HED by the safety factor.”
This product's starting point
NOAEL / key findings: NOAEL = highest doses (250 mg/kg rat, 300 mg/kg monkey Q4W); non-adverse liver, kidney, injection site, lymph node accumulation findings (FDA pharmacology/toxicology review, p. 39)
Longest repeat-dose systemic studies
Longest repeat-dose study and recovery
40-week cynomolgus monkey (SC, every 28 days) with 13-week recovery
“A 40-Week Repeat Subcutaneous Injection Toxicity and Toxicokinetic Study in the Cynomolgus Monkey Followed by a 13-Week Recovery Period (study no.: 5001352) Doses: 0, 30, 100, and 300 mg/kg/every 28 days by SC injection”
Pivotal GLP studies
Rat 29-week and monkey 40-week SC Q4W (13-week recovery); plus 4- and 15-week studies and 13-week monkey statin combination
“Toxicological characterization of inclisiran was performed in studies of 29 weeks in rats and 40 weeks in NHPs at doses up to 8 times (≤ 250 mg/kg Q4W) and 19 times (300 mg/kg Q4W) the MRHD (based on BSA), respectively.”
DART package
Species: DART
Rat (fertility, EFD, pre/postnatal) and rabbit (EFD)
“Embryo-fetal assessments in rats and rabbits and a pre and postnatal development study in rats did not demonstrate evidence of reproductive or developmental risk at any dose tested, representing up to 5 and 10 times clinical MRHD (BSA), respectively (≤ 150mg/kg/day in both species). Inclisiran produced no adverse impact on fertility or early embryonic development in rats at up to 8 times the MRHD (BSA) (≤ 250 mg/kg/day).”
Reproductive & developmental
Rat fertility, rat and rabbit EFD, rat PPND; no reproductive or developmental risk; no NHP ePPND
“Embryo-fetal assessments in rats and rabbits and a pre and postnatal development study in rats did not demonstrate evidence of reproductive or developmental risk at any dose tested, representing up to 5 and 10 times clinical MRHD (BSA), respectively (≤ 150mg/kg/day in both species).”
PPND / ePPND: when
Rat PPND completed before the marketing application; no developmental risk. No NHP ePPND conducted
“Embryo-fetal assessments in rats and rabbits and a pre and postnatal development study in rats did not demonstrate evidence of reproductive or developmental risk at any dose tested, representing up to 5 and 10 times clinical MRHD (BSA), respectively (≤ 150mg/kg/day in both species).”
Carcinogenicity
Species: carcinogenicity
Rat (2-year) and Tg rasH2 mouse (6-month)
“Inclisiran was evaluated in a lifetime (2 year) rat carcinogenicity study at up to 8 times the clinical MRHD (BSA) (≤ 250 mg/kg Q4W) and in a 6-month study in Tg rasH2 mice (≤ 1500 mg/kg Q4W). Inclisiran lacked tumorigenic potential in these studies.”
Carcinogenicity model
2-year rat (up to 250 mg/kg Q4W, 8x MRHD) and 6-month Tg rasH2 mouse (up to 1500 mg/kg Q4W); no tumorigenic potential
“Inclisiran was evaluated in a lifetime (2 year) rat carcinogenicity study at up to 8 times the clinical MRHD (BSA) (≤ 250 mg/kg Q4W) and in a 6-month study in Tg rasH2 mice (≤ 1500 mg/kg Q4W). Inclisiran lacked tumorigenic potential in these studies.”
Carcinogenicity timing
2-year rat and 6-month Tg rasH2 mouse studies completed before the marketing application
“Inclisiran was evaluated in a lifetime (2 year) rat carcinogenicity study at up to 8 times the clinical MRHD (BSA) (≤ 250 mg/kg Q4W) and in a 6-month study in Tg rasH2 mice (≤ 1500 mg/kg Q4W). Inclisiran lacked tumorigenic potential in these studies.”
Safety marginopen answer page →
Safety margin at NOAEL
NOAEL ~48.9x (rat) and ~99.6x (monkey) human AUC at 300 mg; 99x/101x by Cmax
“They are 99-fold and 101-fold based on Cmax and 48.9-fold and 99.6-fold based on AUC in rats and monkeys, respectively, compared to the 300 mg human clinical dose.”
NOAEL / key findings
NOAEL = highest doses (250 mg/kg rat, 300 mg/kg monkey Q4W); non-adverse liver, kidney, injection site, lymph node accumulation findings
“Since none of the findings were considered adverse, the NOAEL was 300 mg/kg/28 days and provides a 19-fold exposure multiple to clinical exposure based on body”
Efficacy evidenceopen answer page →
Efficacy evidence
PCSK9/LDL-C lowering in human PCSK9 transgenic mice and healthy NHPs
“Pharmacodynamic activity, measured as reduced PCSK9 levels and/or LDL-C lowering, was demonstrated in transgenic mice expressing human PCSK9 (hPCSK9) and in healthy non-human primates (NHPs).”
Why that model
Disease models judged of minimal value: PCSK9 target validated clinically by antibodies; species differences in cholesterol fractions
“In response to a request, the applicant clarified that in vivo studies in animal disease models of hypercholesterolemia would be of minimal impact to the understanding of inclisiran’s biology and pharmacology in human. The argumentation included among others the facts that use of PCSK9 antibodies in clinical practice has validated PCSK9 as a pharmacologic target for reducing LDL-C and that there are species differences in cholesterol fractions.”
Reviewer's view of the efficacy data
EMA: pharmacodynamics demonstrated in transgenic mice and monkeys; the four species used considered relevant
“Pharmacodynamics of inclisiran was demonstrated in transgenic mice and monkeys. The four animal species used for non-clinical studies, especially the general and reproductive toxicology studies, are considered relevant.”
Flexibilityopen answer page →
Flexibility accepted
Juvenile toxAcceptedBeyond the letter
No juvenile toxicology study
Why: Unlikely to generate additional information; agreed in CHMP scientific advice · Other reason
“In accordance with EMA advice, a juvenile toxicology study was not conducted since it was unlikely to generate additional information from what is already available [CHMP Scientific Advice 2017]”
“The applicant´s view is agreed to.”
DARTVerdict not stated
No NHP enhanced pre/postnatal study despite offspring TDAR suppression with PCSK9 antibodies; rat PPND only
Why: Unlike IgG antibodies, inclisiran is unlikely to cross the placental barrier · Pharmacology or kinetics
“An ePPND NHP study was not conducted for inclisiran, but (in contrast to IgG-based Mab therapeutics) inclisiran is unlikely to cross the placental barrier.”
Impurity or metaboliteAcceptedBeyond the letter
Unspecified impurity limit exceeds ICH Q3A threshold; qualified by levels in pivotal toxicology lots, no dedicated impurity studies
Why: Impurities qualified by the repeat-dose toxicity studies · Other reason
“The limit for the single largest individual unspecified impurity of % exceeds the ICH Q3A threshold of 0.2% based on a 300 mg dose.”
“The absence of dedicated impurity studies is adequately justified. Impurities can be considered qualified based on the repeat dose toxicity studies.”
Safety pharmacologyVerdict not stated
No dedicated neurological safety pharmacology study; neurological evaluations in 40-week monkey study
“A dedicated safety pharmacology study to evaluate neurological function was not performed; however, neurological evaluations were incorporated into the 40- week repeat dose toxicology study”
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