FDA Grants EUA for Post-Exposure Prophylaxis to High-Risk COVID-19 Outpatient Care: Lilly’s Bamlanivimab & Junshi Bioscience’s Etesevimab
Eli Lilly is back in business with their experimental monoclonal antibody (mAb) product as U.S. demand for monoclonal antibody treatments spike during the Delta-variant has driven surge. In this case, a significant breakthrough as the combination experimental monoclonal antibody (mAb) therapy—including a licensed mAb from a Chinese biotech called Junshi Biosciences (HKEX: 1877; SSE: 688180) secures post-exposure prophylaxis status for certain high-risk people. This is a big deal. The U.S. Food and Drug Administration (FDA) expanded the Emergency Use Authorization (EUA) for the combined monoclonal antibody product (bamlanivimab (LY-CoV555) 700 mg and etesevimab (JSo16/LY-CoV016) 1400 mg) administered together to include post-exposure prophylaxis (PEP) in select individuals for the prevention of SARS-CoV-2 infection. Moving forward, select infusion centers will be able to use these neutralizing antibodies together to treat high-risk individuals 12 years of age and up who have not been fully vaccinated against COVID-19 or are not expected to mount an adequate immune response to complete vaccination, and have been exposed to someone infected with SARS-CoV-2 or who are at a high risk of exposure in an institutional setting, including a nursing home or prison. This authorization follows the national reopening of distribution earlier this month. Positive news indeed that a PEP therapy, albeit still investigational, is available now to treat patients that meet inclusion criteria.
Delta-Surge Required Action for Prophylactic Care
With an ongoing surge in COVID-19 cases, the U.S. political economy faces deep trouble if the contagion isn’t contained relatively soon. U.S. authorities and medical societies have grown increasingly aggressive in inhibiting the use of approved yet off-label treatments such as Ivermectin (monthly prescriptions have skyrocketed over 2,000%) while there are currently no approved early-stage treatments for COVID-19.
The government now makes a move to offer treatments for high-risk demographic cohorts, and in this case, now introduce the use of the Lilly and Junshi Bioscience combined mAb investigational product as a post-exposure prophylaxis, meaning a way to prevent the disease once someone has experienced contact with a SARS-CoV-2 infected person.
Eradication by Vaccination Won’t Work by Itself
The government increasingly acknowledges to American society that vaccination won’t be enough to transcend the public health crisis. Due to the early maturity of existing COVID-19 vaccines, for example, vaccine hesitancy is pervasive around the country, with over 80 million people not comfortable with the jab—at least not yet—despite POTUS recent move to force up to 100 million people to succumb to vaccination.
Myron Cohen, MD, director of University of North Carolina’s Global Health and Infectious Diseases, shared in the recent Lilly press release that “Recent reports suggest that fully vaccinated residents of nursing homes have contracted COVID-19, some of whom became quite ill.” Dr. Cohen continued, “This additional emergency use authorization of monoclonal antibodies for post-exposure prophylaxis in addition to the treatment of COVID-19 offers an achievement in the fight against the pandemic.”
Bring on the Care— TrialSite’s Founder on the Record
TrialSite’s Founder, Daniel O’Connor, suggested that the EUA was important—a positive move by the FDA to get care options out to the people declaring “front line doctors have lamented for nearly 1.5 years that early access treatments, including critically important pre-and post-exposure prophylaxis, are necessary for addition to safe and effective vaccines.”
O’Connor continued, “What is needed to manage and eventually overcome this crisis are a portfolio of options from safe and effective vaccines to a spectrum of affordable early-care treatments, specialized monoclonal antibody options like the Lilly and Junshi combination, in addition to the Regeneron and GSK/Vir products and importantly, data-driven, risk-based targeted public health initiatives that are not politicized.”
TrialSite provides a breakdown of this overall good news in a question and answer format.
Does this move indicate the government’s recognition that a vaccine-centric strategy is not sufficient to overcome SARS-CoV-2?
Yes. Despite widespread vaccination in nations such as Israel, Iceland, and many other places, breakthrough infections rage due to a confluence of factors, including the early maturity of the existing COVID-19 vaccines (first generation) and the overpowering SARS-CoV-2 mutant strains such as the Delta variant.
Hence Daniel Skovronsky, MD, Ph.D., Lilly’s chief scientific and medical office and president of Lilly Research Laboratories, went on the record that although COVID-19 vaccination is improving public health, unfortunately, “with the rise of the highly contagious Delta variant, the virus continues to have a devastating impact on the most vulnerable individuals, including nursing home residents and individuals with medical conditions that put them at high risk for the most severe conditions.”
What is the basis for the expanded EUA?
The FDA reviewed the data from the BLAZE-2 study conducted in partnership with the National Institutes of Allergy and Infectious Disease (NIAID), part of the National Institutes of Health (NIH), and the COVID-19 Prevention Network (CoVPN), that enrolled residents and staff at long-term care facilities, commonly referred to as nursing homes, across the U.S. In this placebo-controlled Phase 3 study, bamlanivimab 4200 mg reduced the risk of contracting symptomatic COVID-19 by up to 80 percent in nursing home residents and up to 57 percent among residents and staff of long-term care facilities.
What is Lilly’s Bamlanivimab?
Also known as LY-CoV555, this monoclonal antibody was actually developed by a partnership between AbCellera Biologics (a University of British Columbia spin-off) and some sharp scientists at Lilly as a treatment for COVID-19. The investigational therapy was first granted EUA by the FDA in November 2020, and 950,000 doses were acquired by the U.S. government as of December 2020. By April 2021, the EUA was revoked.
An IgG1 monoclonal antibody directed against the spike protein of SARS-CoV-2 the drug serves to block viral attachment and entry into human cells, thus neutralizing the pathogen. Of course, the combination with Junshi Biosciences etesevimab was granted a EUA by the FDA just recently. See that fact sheet.
Were shipments halted in June?
Yes. By June 25, 2021, the U.S. government (Office of the Assistant Secretary for Preparedness and Response or ASPR) issued a pause in the distribution of the combination mAbs as well as etesevimab alone (to pair with existing supply of bamlanivimab at a facility for use under the UEA) due to intensifying circulation of SARS-CoV-2 variants.
The government informed that other mAbs were available, including Regeneron’s REGEN-COV and GSK/Vir Biotech’s sotrovimab.
When were shipments allowed again?
On September 2, ASPR, alongside the FDA, resumed the shipment and distribution of bamlanivimab and etesevimab administered together.
Why were they given the greenlight?
Because pseudovirus and authentic virus studies demonstrate that bamlanivimab and etesevimab work together to retain neutralization activity against the Alpha and Delta variants.
Is the mAb combo of bamlanivimab and etesevimab the only way to access these products?
Yes.
What is the track record of bamlanivimab and etesevimab to date?
Bamlanivimab alone or in combination with etesevimab to date has been used in over 535,000 treatment courses, and the government suggests that the treatment could have prevented over 25,000 hospitalizations and 10,000 deaths.
Where can care providers & patients find more information about the use of the combination mAbs under expanded EUA?
The FDA EUA includes a Fact Sheet for Healthcare Providers as well as Fact Sheet for Patients, Parents, and Caregivers in both English and Spanish. Lilly also provides a 24-hour support line at 1-855-LillyC19 (1-855-545-5921). Lilly’s media kit can be found here.
Where can patients find infusion centers?
Patients can check out the NICA Infusion Center Locator or the HHS Therapeutics Distribution Locator to find a potential therapy location.
What is the authority for EUA?
Bamlanivimab and etesevimab together are authorized under Emergency Use Authorization only for the duration of the declaration that circumstances exist justifying the authorization of the emergency use under Section 564(b)(1) of the Act, 21 U.S.C § 360bbb-3(b)(1) unless the authorization is terminated or revoked sooner.
What’s the fine print on investigational products authorized under FDA EUA?
These are not approved drugs—rather, they are still experimental. Lilly must declare that it is not known if bamlanivimab and etesevimab together are safe and effective for the treatment of post-exposure prophylaxis of COVID-19.
What is the treatment patient demographic?
Bamlanivimab and etesevimab together are authorized for the treatment of mild to moderate coronavirus disease 2019 (COVID-19) in adults and pediatric patients (12 years of age and older weighing at least 40 kg) with positive results of direct SARS-CoV-2 viral testing and who are at high risk for progression to severe COVID-19, including hospitalization or death.
Are there other limitations of use?
Yes. For example, the mAb combo therapy can’t be used in states, territories, and U.S. jurisdictions in which the combined frequency of variants resistant to each mAb exceeds 5%. The FDA provides a list of such places here.
Also, the mAb combo cannot be administered to patients who are A) hospitalized due to COVID-19, B) require oxygen therapy due to COVID-19, or C) require an increase in baseline oxygen flow rate due to COVID-19 in those on chronic oxygen therapy due to underlying non-COVID-19-related comorbidity.
Note that this mAb combo hasn’t been studied in hospitalized patients, and use there may be associated with worse clinical outcomes when administered to hospitalized patients with COVID-19 requiring high flow oxygen or mechanical ventilation.
What are FDA’s instructions around Post-Exposure Prophylaxis use?
The mAb combo can be used for PEP of COVID-19 adults and pediatric individuals (12+ a weighing at least 40kg) who are at high risk for progression to severe COVID-19, including hospitalization or death, including A) those who are not fully vaccinated or are not expected to
Bamlanivimab and etesevimab administered together are authorized for post-exposure prophylaxis of COVID-19 in adults and pediatric individuals (12 years of age or older weighing at least 40 kg) who are at high risk for progression to severe COVID-19, including hospitalization or death, and are to mount an adequate immune response to complete SARS-CoV-2 vaccination (for example, individuals with immunocompromising conditions including those taking immunosuppressive medications and A) have been exposed to an individual infected with SARS-CoV-2 consistent with close contact criteria per Centers for Disease Control and Prevention (CDC) or B) who are at high risk of exposure to an individual infected with SARS-CoV-2 because of occurrence of SARS-CoV-2 infection in other individuals in the same institutional setting (for example, nursing homes, prisons).
What are Limitations of Authorized Use: Post-Exposure Prophylaxis
Bamlanivimab and etesevimab are not authorized for use in states, territories, and US jurisdictions in which the combined frequency of variants resistant to bamlanivimab and etesevimab exceeds 5%.
A list of states, territories, and US jurisdictions in which bamlanivimab and etesevimab are and are not currently authorized is available on the following FDA website.
Post-exposure prophylaxis with bamlanivimab and etesevimab is not a substitute for vaccination against COVID-19.
Bamlanivimab and etesevimab together are not authorized for pre-exposure prophylaxis for prevention of COVID-19.
What are safety risks?
Hypersensitivity Including Anaphylaxis and Infusion-Related Reactions
Serious hypersensitivity reactions, including anaphylaxis, have been observed with the administration of bamlanivimab and etesevimab. If signs and symptoms of a clinically significant hypersensitivity reaction or anaphylaxis occur, immediately discontinue administration and initiate appropriate medications and/or supportive care.
Infusion-related reactions, occurring during or up to 24 hours after infusion, have been observed with the administration of bamlanivimab and etesevimab together. These reactions may be severe or life-threatening. Signs and symptoms of infusion-related reactions may include:
fever, difficulty breathing, reduced oxygen saturation, chills, fatigue, arrhythmia (e.g. atrial fibrillation, sinus tachycardia, bradycardia), chest pain or discomfort, weakness, altered mental status, nausea, headache, bronchospasm, hypotension, hypertension, angioedema, throat irritation, rash including urticaria, pruritus, myalgia, vasovagal reactions (e.g. presyncope, syncope), dizziness, and diaphoresis.
Consider slowing or stopping the infusion and administer appropriate medications and/or supportive care if an infusion-related reaction occurs.
Hypersensitivity reactions occurring more than 24 hours after the infusion have also been reported with the use of bamlanivimab and etesevimab under Emergency Use Authorization.
Clinical Worsening After Receiving Bamlanivimab and Etesevimab Administration
Clinical worsening of COVID-19 after administration of bamlanivimab and etesevimab together has been reported and may include signs or symptoms of fever, hypoxia or increased respiratory difficulty, arrhythmia (e.g., atrial fibrillation, sinus tachycardia, bradycardia), fatigue, and altered mental status. Some of these events required hospitalization. It is not known if these events were related to bamlanivimab and etesevimab use or were due to progression of COVID-19.
Limitations of Benefit and Potential Risk in Patients with Severe COVID-19
Treatment with bamlanivimab and etesevimab has not been studied in patients hospitalized due to COVID-19. Monoclonal antibodies, such as bamlanivimab and etesevimab, may be associated with worse clinical outcomes when administered to hospitalized patients with COVID-19 requiring high flow oxygen or mechanical ventilation. See Limitations of Authorized Use.
Adverse Reactions
Adverse reactions observed in those who have received bamlanivimab and etesevimab are anaphylaxis (n=1, 0.07%) and infusion-related reactions (n=16, 1.1%). The most common treatment-emergent adverse events included nausea, dizziness, and pruritus. No treatment-emergent events occurred in more than 1% of participants, and rates were comparable to placebo.
Use in Specific Populations
Pregnancy
There are insufficient data to evaluate a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. Bamlanivimab and etesevimab together should only be used during pregnancy if the potential benefit outweighs the potential risk for the mother and the fetus.
Breastfeeding
There are no available data on the presence of bamlanivimab or etesevimab in human or animal milk, the effects on the breastfed infant, or the effects on milk production. Breastfeeding individuals with COVID-19 should follow practices according to clinical guidelines to avoid exposing the infant to COVID-19.
Investigational mAb Combo Therapy Description
Bamlanivimab is a recombinant, neutralizing human IgG1 monoclonal antibody (mAb) directed against the spike protein of SARS-CoV-2. It was designed to block viral attachment and entry into human cells, thus neutralizing the virus. Bamlanivimab emerged from the collaboration between Lilly and AbCellera to create antibody therapies for the prevention and treatment of COVID-19. Lilly scientists rapidly developed the antibody in less than three months after it was discovered by AbCellera and the scientists at the National Institute of Allergy and Infectious Diseases (NIAID) Vaccine Research Center. Bamlanivimab was identified from a blood sample taken from one of the first U.S. patients who recovered from COVID-19.
Etesevimab (LY-CoV016, also known as JS016) is a recombinant fully human monoclonal neutralizing antibody, which specifically binds to the SARS-CoV-2 surface spike protein receptor-binding domain with high affinity and can block the binding of the virus to the ACE2 host cell surface receptor. Point mutations were introduced into the native human IgG1 antibody to mitigate effector function. Lilly licensed etesevimab from Junshi Biosciences after it was jointly developed by Junshi Biosciences and the Institute of Microbiology, Chinese Academy of Science (IMCAS). Junshi Biosciences leads development in Greater China, while Lilly leads development in the rest of the world.
Results from a Phase 2/3 study in people recently diagnosed with COVID-19 in the ambulatory setting (BLAZE-1, NCT04427501) were published in the New England Journal of Medicine. Results from a Phase 3 study of bamlanivimab in residents and staff at long-term care facilities (BLAZE-2, NCT04497987) were published in the Journal of American Medical Association (JAMA). A Phase 2 study assessing the efficacy and safety of bamlanivimab alone and bamlanivimab with other neutralizing antibodies versus placebo for the treatment of symptomatic low-risk COVID-19 in the outpatient setting (BLAZE-4. NCT04634409) has completed enrollment.
For more information, follow up and read Lilly’s press release.