TRANSLARNA 1000mg oral suspension pellets medication leaflet

Translarna 125 mg granules for oral suspension

Translarna 250 mg granules for oral suspension

Translarna 1000 mg granules for oral suspension

Translarna 125 mg granules for oral suspension

Each sachet contains 125 mg ataluren.

Translarna 250 mg granules for oral suspension

Each sachet contains 250 mg ataluren.

Translarna 1000 mg granules for oral suspension

Each sachet contains 1000 mg ataluren.

For the full list of excipients, see section 6.1.

Granules for oral suspension.

White to off-white granules.

Translarna is indicated for the treatment of Duchenne muscular dystrophy resulting from a nonsensemutation in the dystrophin gene, in ambulatory patients aged 2 years and older (see section 5.1).

The presence of a nonsense mutation in the dystrophin gene should be determined by genetic testing(see section 4.4).

Treatment with Translarna should only be initiated by specialist physicians with experience in themanagement of Duchenne/Becker muscular dystrophy.

Ataluren should be administered orally every day in 3 doses.

The first dose should be taken in the morning, the second at midday, and the third in the evening.

Recommended dosing intervals are 6 hours between morning and midday doses, 6 hours betweenmidday and evening doses, and 12 hours between the evening dose and the first dose on the next day.

The recommended dose is 10 mg/kg body weight in the morning, 10 mg/kg body weight at midday,and 20 mg/kg body weight in the evening (for a total daily dose of 40 mg/kg body weight).

Medicinal product no longer authorised

Translarna is available in sachets of 125 mg, 250 mg or 1000 mg. The table below providesinformation on which sachet strength(s) to use in the preparation of the recommended dose by bodyweight range.

Number of sachets

Weight Morning Midday Evening

Range 1000 1000 1000(kg) 125 mg 250 mg 125 mg 250 mg 125 mg 250 mgmg mg mgsachets sachets sachets sachets sachets sachetssachets sachets sachets12 14 1 0 0 1 0 0 0 1 015 16 1 0 0 1 0 0 1 1 017 20 0 1 0 0 1 0 0 1 021 23 0 1 0 0 1 0 1 1 024 26 0 1 0 0 1 0 0 2 027 31 0 1 0 0 1 0 1 2 032 35 1 1 0 1 1 0 1 2 036 39 1 1 0 1 1 0 0 3 040 44 1 1 0 1 1 0 1 3 045 46 0 2 0 0 2 0 1 3 047 55 0 2 0 0 2 0 0 0 156 62 0 2 0 0 2 0 0 1 163 69 0 3 0 0 3 0 0 1 170 78 0 3 0 0 3 0 0 2 179 86 0 3 0 0 3 0 0 3 187 93 0 0 1 0 0 1 0 3 194 105 0 0 1 0 0 1 0 0 2106 111 0 0 1 0 0 1 0 1 2112 118 0 1 1 0 1 1 0 1 2119 125 0 1 1 0 1 1 0 2 2

If there is a delay in the administration of ataluren of less than 3 hours after the morning or middaydoses or less than 6 hours after the evening dose, the dose should be taken with no changes to thesubsequent dose schedules. If there is a delay of more than 3 hours after the morning or midday dosesor more than 6 hours after the evening dose, the dose should not be taken, and patients should resumetheir usual dosing schedule. Patients should not take a double or extra dose if a dose is missed. It isimportant to administer the correct dose. Increasing the dose above the recommended dose may beassociated with reduced effectiveness.

The safety and efficacy of ataluren in patients aged 65 and older have not yet been established (seesection 5.2).

No dosage adjustment is required for patients with mild or moderate renal impairment. Treatment ofpatients with severe renal impairment (eGFR <30 ml/min) or end-stage renal disease is notrecommended (see sections 4.4 and 5.2).

Medici al product no longer authorised

No dosage adjustment is required for patients with mild, moderate or severe hepatic impairment (seesection 5.2).

Paediatric patients with body weight ≥12 kg are treated as per the dosing recommendations by bodyweight range (see above dosing table). The recommended dose is the same for all age ranges, i.e.

10 mg/kg body weight in the morning, 10 mg/kg body weight at midday, and 20 mg/kg body weight inthe evening (for a total daily dose of 40 mg/kg body weight).

The safety and efficacy of Translarna in children <12kg and aged 6 months to 2 years have not yetbeen established. No data are available.

Translarna should be administered orally after mixing it to a suspension in liquid or in semi-solid food.

Sachets should only be opened at the time of dose preparation. The full contents of each sachet shouldbe mixed with, at least 30 ml of liquid (water, milk, fruit juice) or 3 tablespoons of semi-solid food(yoghurt or apple sauce). The prepared dose should be mixed well before administration. The amountof the liquid or semi-solid food can be increased based on patient preference. Patients should take theentire dose.

For instructions on reconstitution of the medicinal product before administration, see section 6.6.

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Concomitant use of intravenous aminoglycosides (see sections 4.4 and 4.5).

Patients who do not have a nonsense mutation

Patients must have a nonsense mutation in the dystrophin gene as part of their underlying disease state,as determined by genetic testing. Patients who do not have a nonsense mutation should not receiveataluren.

An increase in ataluren exposure and in ataluren metabolite has been reported in patients with severerenal impairment (eGFR <30 ml/min). The toxicity of the metabolite is unknown. Higher atalurenexposure was associated with potential decrease in efficacy. Therefore, patients with severe renalimpairment or end-stage renal disease should be treated with ataluren only if the anticipated clinicalbenefit outweighs the potential risk, and should be closely monitored for possible metabolite toxicityand decrease in efficacy. A lower ataluren dose should be considered.

Treatment should not be initiated in previously untreated patients with eGFR <30 ml/min (see sections4.2 and 5.2).

Changes in lipid profile

Because changes in lipid profile (increased triglycerides and cholesterol) were reported for somepatients in clinical trials, it is recommended that total cholesterol, LDL, HDL, and triglycerides bemonitored on an annual basis in nonsense mutation Duchenne muscular dystrophy (nmDMD)patients receiving ataluren, or more frequently as needed based on the patient’s clinical status.

Medicinal product no longer uthorised

Hypertension with use of concomitant systemic corticosteroids

Because hypertension with use of concomitant systemic corticosteroids was reported for somepatients in clinical trials, it is recommended that resting systolic and diastolic blood pressure bemonitored every 6 months in nmDMD patients receiving ataluren concomitantly withcorticosteroids, or more frequently as needed based on the patient’s clinical status.

Renal function monitoring

Because small increases in mean serum creatinine, blood urea nitrogen (BUN), and cystatin C wereobserved in the controlled studies of nmDMD, it is recommended that serum creatinine, BUN, andcystatin C be monitored every 6 to 12 months in nmDMD patients receiving ataluren, or morefrequently as needed based on the patient’s clinical status.

Potential interactions with other medicinal products

Caution should be exercised when ataluren is co-administered with medicinal products that areinducers of UGT1A9, or substrates of OAT1 or OAT3 (see section 4.5).

Aminoglycosides

Aminoglycosides have been shown to reduce the readthrough activity of ataluren in vitro. In addition,ataluren was found to increase nephrotoxicity of intravenous aminoglycosides. The co-administrationof these medicinal products with ataluren should be avoided (see section 4.3). Since the mechanism bywhich ataluren increases nephrotoxicity of intravenous aminoglycosides is not known, concomitantuse of other nephrotoxic medicinal products with ataluren is not recommended. If this is unavoidable(e.g. vancomycin to treat MRSA) careful monitoring of renal function is advised (see section 4.5).

Aminoglycosides

Ataluren should not be co-administered with intravenous aminoglycosides, based on cases ofdecreased renal function observed in a clinical trial in patients with nmCF (see section 4.3).

Elevations of serum creatinine occurred in several nmCF patients treated with ataluren andintravenous aminoglycosides together with other antibiotics for cystic fibrosis exacerbations. Theserum creatinine elevations resolved in all cases, with discontinuation of the intravenousaminoglycoside, and either continuation or interruption of Translarna. These findings suggested thatco-administration of Translarna and intravenous aminoglycosides may potentiate the nephrotoxiceffect of the aminoglycosides. Therefore, if treatment with intravenous aminoglycosides is necessarythe treatment with Translarna should be stopped and can be resumed 2 days after administration of theaminoglycoside has ended. The effect of co-administration of ataluren with other nephrotoxicmedicinal products is unknown.

Dehydration may be a contributing factor in some of these cases. Patients should maintain adequatehydration while taking ataluren (see section 4.4).

Effect of other medicinal products on ataluren pharmacokinetics

Based on in vitro studies, ataluren is a substrate of UGT1A9. Co-administration of rifampicin, a stronginducer of metabolic enzymes including UGT1A9, decreased ataluren exposure by 29%. Thesignificance of these findings for humans is unknown. Caution should be exercised when ataluren isco-administered with medicinal products that are inducers of UGT1A9 (e.g. rifampicin).

Medicinal product no longer authorised

Effect of ataluren on pharmacokinetics of other medicinal products

Based on in vitro studies, ataluren has the potential to inhibit UGT1A9, organic anion transporter 1(OAT1), organic anion transporter 3 (OAT3) and organic anion transporting polypeptide 1B3(OATP1B3). Co-administration of ataluren with mycophenolate mofetil in healthy subjects did notaffect the exposure of its active metabolite, mycophenolic acid (a substrate of UGT1A9). No doseadjustment is required when ataluren is co-administered with medicinal products that are substrates of

UGT1A9.

In a clinical study to evaluate the potential for ataluren to inhibit the OATP1B3 transport system usinga single-dose of 80 mg telmisartan, an in-vitro selective OATP1B3 substrate, ataluren increased theexposure to telmisartan by 28%. This effect is considered clinically not relevant. However, themagnitude of this effect could be larger for the 40 mg dose of telmisartan. Therefore, caution shouldbe exercised when ataluren is co-administered with medicinal products that are substrates of OAT1 or

OATP1B3 because of the risk of increased concentration of these medicinal products (e.g. oseltamivir,aciclovir, captopril, furosemide, bumetanide, valsartan, pravastatin, rosuvastatin, atorvastatin,pitavastatin).

Caution should also be exercised when ataluren is co-administered with OAT3 substrates (e.g.

ciprofloxacin), especially those OAT3 substrates with a narrow therapeutic window. In a clinicalstudy, the extent of exposure for ciprofloxacin was 32% higher in the presence of ataluren. In aseparate clinical study, the extent of exposure for adefovir was 60% higher in the presence of ataluren.

Caution should be exercised when ataluren is co-administered with adefovir.

Based on the in vitro studies, ataluren is not expected to be an inhibitor of neither p-gp mediatedtransport nor of cytochrome P450 mediated metabolism. Similarly, ataluren is not expected in vivo tobe an inducer of cytochrome P450 isoenzymes.

Coadministration of corticosteroids (deflazacort, prednisone, or prednisolone) with ataluren did notaffect the plasma concentrations of ataluren. No clinically relevant change in the plasmaconcentrations of corticosteroids was seen with co-administration of ataluren. These data indicate noapparent drug-drug interaction between corticosteroids and ataluren, and no dose adjustments arerequired.

Medicinal products that affect the p-glycoprotein transporter

In vitro, ataluren is not a substrate for the p-glycoprotein transporter. The pharmacokinetics of atalurenare unlikely to be affected by medicinal products that inhibit the p-glycoprotein transporter.

There are no adequate data from the use of ataluren in pregnant women. Studies in animals haveshown reproductive toxicity only at doses that resulted in maternal toxicity (see section 5.3).

As a precautionary measure, it is recommended to avoid the use of ataluren during pregnancy.

It is unknown whether ataluren/metabolites are excreted in human milk. Availablepharmacodynamic/toxicological data in animals have shown excretion of ataluren/metabolites in milk(see section 5.3). A risk to the breastfed new-borns/infants cannot be excluded.

Breast-feeding should be discontinued during treatment with ataluren.

Medicinal product no longer authorised

Non-clinical data revealed no hazard for humans based on a standard male and female fertility study inrats (see section 5.3).

The effect of ataluren on driving, on cycling, or on using machines has not been tested. Patients whoexperience dizziness should use caution when driving, cycling or using machines.

The safety profile of ataluren is based on pooled data from two randomised, double-blind, 48-weekplacebo-controlled studies conducted in a total of 232 male patients with Duchenne musculardystrophy (nmDMD) caused by a nonsense mutation treated at the recommended dose of40 mg/kg/day (10, 10, 20 mg/kg; n=172) or at a dose of 80 mg/kg/day (20, 20, 40 mg/kg; n=60), ascompared to placebo-treated patients (n=172).

The most common adverse reactions in the 2 placebo-controlled studies were vomiting, diarrhoea,nausea, headache, upper abdominal pain, and flatulence, all occurring in ≥5% of all ataluren-treatedpatients. In both studies, 1/232 (0.43%) patients treated with ataluren discontinued due to an adversereaction of constipation and 1/172 (0.58%) placebo patients discontinued treatment due to an adversereaction of disease progression (loss of ambulation).

An open-label study was performed including patients aged 2-5 years (n=14) to evaluate the PK andsafety of ataluren. A higher frequency of malaise (7.1%), pyrexia (42.9%), ear infection (28.6%), andrash (21.4%) were reported in patients aged 2-5 years compared with patients 5 years of age and older.

However, these conditions are reported more frequently in the younger children in general. Safety datafrom 28 weeks of therapy showed a similar safety profile of ataluren in patients 2-5 years as comparedwith patients aged 5 years and older.

Adverse reactions were generally mild or moderate in severity, and no treatment-related seriousadverse events were reported among ataluren-treated patients in these 2 studies.

The adverse reactions reported in patients with nmDMD treated with the recommended daily dose of40 mg/kg/day ataluren in the 2 placebo-controlled studies are presented in Table 1. Adverse reactionsreported in >1 patient in the 40 mg/kg/day group at a frequency greater than that of the placebo groupare presented by MedDRA System Organ Class, Preferred Term, and frequency. Frequency groupingsare defined to the following convention: very common (≥ 1/10) and common (≥ 1/100 to < 1/10).

Medicinal product no longer authorised

Table 1. Adverse reactions reported in >1 ataluren-treated patients with nmDMD at a frequencygreater than placebo in the 2 placebo-controlled studies (pooled analysis)

System Organ Class Very common Common Frequency notknown

Metabolism and nutrition Decreased appetite, Change in lipiddisorders hypertriglyceridaemia profile(increasedtriglycerides andcholesterol)

Nervous system disorders Headache

Vascular disorders Hypertension

Respiratory, thoracic, and Cough, epistaxismediastinal disorders

Gastrointestinal disorders Vomiting Nausea, upper abdominalpain, flatulence,abdominal discomfort,constipation

Skin and subcutaneous tissue Rash erythematousdisorders

Musculoskeletal and Pain in extremity,connective tissue disorders musculoskeletal chest pain

Renal and urinary disorders Haematuria, enuresis Change in renalfunction tests(increasedcreatinine, bloodurea nitrogen,cystatin C)

General disorders and Pyrexia, weight decreasedadministration site conditions

In a 48-week open-label extension study in patients with nmDMD patients who were ambulant or non-ambulant demonstrated a similar safety profile. Long term safety data is not available.

Description of selected adverse reactions (laboratory abnormalities)

Serum lipids

An increase in serum lipids, i.e. cholesterol and triglycerides, was observed. There have been casesreported where this increase to abnormal high values was already observed after 4 weeks.

Renal function tests

During the randomised, placebo-controlled studies, small increases in mean serum creatinine, BUN,and cystatin C were observed. The values tended to stabilize early in the study and did not increasefurther with continued treatment.

Reporting suspected adverse reactions after authorisation of the medicinal product is important. Itallows continued monitoring of the benefit/risk balance of the medicinal product. Healthcareprofessionals are asked to report any suspected adverse reactions via the national reporting systemlisted in Appendix V.

Medicinal product no longer authorised

Healthy volunteers receiving a single oral dose of 200 mg/kg of ataluren experienced transient,low-grade symptoms of headache, nausea, vomiting, and diarrhoea. No serious adverse reactions wereobserved in these subjects. In the event of a suspected overdose, supportive medical care should beprovided including consulting with a healthcare professional and close observation of the clinicalstatus of the patient.

Pharmacotherapeutic group: Other drugs for disorders of the musculo-skeletal system, ATC code:

M09AX03

A nonsense mutation in DNA results in a premature stop codon within an mRNA. This premature stopcodon in the mRNA causes disease by terminating translation before a full-length protein is generated.

Ataluren enables ribosomal readthrough of mRNA containing such a premature stop codon, resultingin production of a full-length protein.

Nonclinical in vitro experiments in nonsense mutation cellular assays and fish larvae cultured in anataluren solution have shown that ataluren enabled ribosomal readthrough with a bell-shaped(inverted-U shaped) concentration-response relationship. It is hypothesised that the in vivo doseresponse relationship may also be bell-shaped, but in vivo data were too limited to confirm thishypothesis in a mouse model for nmDMD and in humans.

Nonclinical in vitro studies suggest that continuous exposure to ataluren may be important formaximizing activity and that effects of the active substance on ribosomal read-through of prematurestop codons reverse shortly after withdrawal of ataluren.

The efficacy and safety of Translarna were assessed in 2 randomised, double-blind,placebo-controlled, trials in nmDMD. The primary efficacy endpoint in both trials was change in 6

Minute Walk Distance (6MWD) at Week 48. Other endpoints included in both trials were time topersistent 10% worsening in 6MWD, change in time to run/walk 10 meters at Week 48, change intime to climb 4 stairs at Week 48, and change in time to descend 4 stairs at Week 48. Patients wererequired to have documented confirmation of the presence of a nonsense mutation in the dystrophingene as determined by gene sequencing.

Study 1 evaluated 174 male patients, aged 5 to 20 years. All patients were required to be able to walk≥75 meters without the need for assistive devices during a screening 6-Minute Walk Test (6MWT).

The majority of patients in all treatment groups were Caucasian (90%). Patients were randomised in a1:1:1 ratio and received ataluren or placebo 3 times per day (morning, midday, and evening), with 57receiving ataluren 40 mg/kg/day (10, 10, 20 mg/kg), 60 receiving ataluren 80 mg/kg/day (20, 20,40 mg/kg), and 57 receiving placebo.

Medicinal product no longer authorised

In Study 1, a post hoc analysis of the primary endpoint showed that from baseline to Week 48, patientsreceiving ataluren 40 mg/kg/day had a 12.9 meters mean decline in 6MWD, and patients receivingplacebo had a 44.1-meter mean decline in 6MWD (Figure 1). Thus, the mean change in observed6MWD from baseline to Week 48 was 31.3 meters better in the ataluren 40 mg/kg/day arm than in theplacebo arm (p=0.056). In a statistical based model the estimated mean difference was 31.7 meters(adjusted p=0.0367). There was no difference between ataluren 80 mg/kg/day and placebo.

These results indicate that ataluren 40 mg/kg/day slows the loss of walking ability in nmDMDpatients.

Figure 1. Mean Change in 6-Minute Walk Distance (Study 1)

- 12.9 m

TRANSLARNA 10 mg/kg, 10 mg/kg, 20 mg/kg (N=57)

- 40 Placebo (N=57)

- 44.1 m

Baseline 6 12 18 24 30 36 42 48

Weeks

A post-hoc analysis of time to persistent 10% worsening in 6MWD showed that 26% of patients in theataluren 40 mg/kg/day arm had progressed at Week 48 compared to 44% in the placebo group(p=0.0652) (Figure 2). There was no difference between ataluren 80 mg/kg/day and placebo. Theseresults indicate that fewer patients receiving ataluren 40 mg/kg/day worsened in 6MWD over 48weeks.

Me Meters (±SE)dicinal product no longer authorised

Figure 2. Kaplan-Meier Curve of Time to Persistent 10% 6MWD Worsening (Study 1)26% worsening60 44% worsening

TRANSLARNA 10 mg/kg, 10 mg/kg, 20 mg/kg (N=57)20 Placebo (N=57)0 6 12 18 24 30 36 42 48 54 60

Weeks

In timed function tests (TFTs), tests of time to run/walk 10 meters, time to climb 4 stairs, and time todescend 4 stairs, ataluren-treated patients demonstrated smaller increases in the time it takes torun/walk 10 meters, climb 4 stairs, and descend 4 steps, indicating slowing of nmDMD progressionrelative to placebo.

The mean change in timed function tests from baseline to Week 48 was better in the ataluren 40mg/kg/day arm than placebo in time to run/walk 10 meters (better by 1.5 seconds), time to climb4 stairs (better by 2.4 seconds), and time to descend 4 stairs (better by 1.6 seconds), Figure 3.

Me Percent Not 10% Worseneddicinal product no longer authorised

Figure 3. Mean Change in Timed Function Tests (Study 1)6MWD Results in Patients with a Baseline 6MWD < 350 meters.

In patients with a baseline 6MWD <350 meters, the mean change in observed 6MWD from baseline to

Week 48 was 68 meters better in the ataluren 40 mg/kg/day arm than in the placebo arm (p=0.0053).

In these patients, the mean change in timed function tests from baseline to Week 48 was better in theataluren 40 mg/kg/day arm than placebo in time to run/walk 10 meters (better by 3.5 seconds), time toclimb 4 stairs (better by 6.4 seconds), and time to descend 4 stairs (better by 5.0 seconds).

Study 2 evaluated 230 male patients, ages 7 to 14 years. All patients were required to be able to walk≥150 meters and less than 80% predicted without the need for assistive devices during a screening6MWT. The majority of patients in both treatment groups were Caucasian (76%). Patients wererandomised in a 1:1 ratio and received ataluren 40 mg/kg/day (n=115) or placebo (n=115) 3 times perday (morning, midday, and evening).

Ataluren-treated patients experienced clinical benefit as measured by numerically favorabledifferences versus placebo across the primary and secondary efficacy endpoints. As the primaryendpoint (change in 6MWD from baseline to Week 48) did not reach statistical significance (p≤0.05),all other p-values should be considered nominal.

In the ITT population, the difference between the ataluren and placebo arms in mean change inobserved 6MWD from baseline to Week 48 was 15.4 meters better in the ataluren 40 mg/kg/day armthan in the placebo arm. In a statistical based model the estimated mean difference was 13.0 meters(p=0.213), Figure 4. Separation between ataluren and placebo was maintained from Week 16 throughthe end of the study.

Medinal p oduct no longer authorised

Figure 4. Mean Change in 6-Minute Walk Distance (Study 2)

- 1 0

- 2 0

- 3 0

- 4 0

- 4 2 .2

- 5 0

T R A N S L A R N A 1 0 m g /k g/1 0 m g /k g , 2 0 m g /k g (N = 1 1 4 ) -5 7 .6

- 6 0

P la c e b o (N = 1 1 4 )

- 7 0

- 8 0

B a s e lin e 8 1 6 2 4 3 2 4 0 4 8

W e e k s

Over 48 weeks, ataluren-treated patients showed less decline in muscle function, as evidenced bysmaller increases in the time to run/walk 10 meters, climb 4 steps, and descend 4 steps in the ataluren-treated group relative to placebo. The differences favoring ataluren versus placebo in mean changes intimed function tests at Week 48 in the ITT population reached the threshold for a clinically meaningfuldifference (changes ~1 to 1.5 seconds).

The mean change in timed function tests from baseline to Week 48 was better in the ataluren40 mg/kg/day arm than placebo in observed time to run/walk 10 meters (better by 1.2 seconds,p=0.117), time to climb 4 stairs (better by 1.8 seconds, p=0.058), and time to descend 4 stairs (betterby 1.8 seconds, p=0.012), Figure 5.

Me M e te rs ( S E )dicinal product nlonger authorised

Figure 5. Mean Change in Timed Function Tests (Study 2)

Time to 10% worsening in 6MWD was defined as the last time that 6MWD was not 10% worse thanbaseline. In the ITT population, the hazard ratio for ataluren versus placebo was 0.75 (p=0.160),representing a 25% reduction in the risk of 10% 6MWD worsening.

The safety, pharmacokinetics and exploratory effectiveness of Translarna were assessed in an open-label study in children between 2 and 5 years of age with nmDMD. The efficacy of Translarna inchildren aged 2 - 5 years has been established on extrapolation from patients aged >5years.

In the clinical program investigating the efficacy and safety of monotherapy ataluren in patients withnonsense mutation cystic fibrosis, no statistically significant effect was observed in the primary andkey secondary clinical outcome measures (ppFEV1 and pulmonary exacerbation rate) in adults andchildren aged 6 years and older.

An open-label exploratory study (Study 045) was conducted in 20 subjects with nonsense mutation

Duchenne muscular dystrophy (nmDMD) aged 2 to 7 years to explore quantitative levels of dystrophinin muscle tissue before and after 40 weeks of treatment with ataluren. Dystrophin was measured usingthe electrochemiluminescence (ECL) and immunohistochemistry (IHC) assays. From each subject, 3needle biopsies were taken from the gastrocnemius and the tibialis anterior at baseline and at the endof the treatment. Study 045 also included assessment of functional outcomes (i.e., the revised North

Star Ambulatory Assessment [rNSAA] and Timed Function Tests [TFTs]).

The baseline median dystrophin levels as measured by ECL was 0.42% of normal (range 0.00% to41.85%). At the end of the study, the median dystrophin level was 0.33% of normal (range 0.04% to48.55%).

For IHC, the median percentage of positive fibres at baseline was 73% (range 0.42% to 99.6%). At theend of the study, the median percentage of positive fibres was 66% (range 0.51% to 99.77%).

At the end of the study, the mean (median) worsening from baseline on the rNSAA was 0.1 (1.0)points in total score and the mean (median) change from baseline for the time to stand, to run or walk10 meters, climb 4 stairs, and descend 4 stairs was -1.56 (-0.6), -0.41 (-0.35), -1.09 (-0.5), and -2.43 (-0.7) seconds, respectively.

Med cinl product no longer authorised

The European Medicines Agency has waived the obligation to submit the results of studies withataluren in two subsets of the paediatric population from birth to less than 28 days and infants from28 days to less than 6 months in nmDMD, as per Paediatric Investigation Plan (PIP) decision in thegranted indication (see section 4.2 for information on paediatric use).

The European Medicines Agency has deferred the obligation to submit the results of studies withataluren in one subset of the paediatric population aged 6 months to less than 2 years old in nmDMD,as per Paediatric Investigation Plan (PIP) decision in the granted indication (see section 4.2 forinformation on paediatric use).

This medicinal product has been authorised under a so-called ‘conditional approval’ scheme. Thismeans that further evidence on this medicinal product is awaited.European Medicines Agency willreview new information on this medicinal product at least every year and this SmPC will be updated asnecessary.

Administration of ataluren on a body weight-adjusted basis (mg/kg) resulted in similar steady-stateexposures (AUC) among children and adolescents with nmDMD over a broad range of body weights.

Although ataluren is practically insoluble in water, ataluren is readily absorbed after oraladministration as a suspension.

General characteristics of ataluren after administration

Peak plasma levels of ataluren are attained approximately 1.5 hours after dosing in subjects whoreceived medicinal product within 30 minutes of a meal. Based on the urinary recovery ofradioactivity in a single-dose study of radiolabelled ataluren, the oral bioavailability of ataluren isestimated to be ≥ 55%. Ataluren plasma concentrations at steady state increase proportionally withincreasing dose. Steady-state plasma concentrations are dose-proportional for ataluren doses between10 and 50 mg/kg, and no accumulation is observed after repeated dosing.

In vitro, ataluren is 99.6% bound to human plasma proteins and the binding is independent of plasmaconcentration. Ataluren does not distribute into red blood cells.

Ataluren is metabolized by conjugation via uridine diphosphate glucuronosyltransferase (UGT)enzymes, predominantly UGT1A9 in liver, intestine and kidney.

In vivo, the only metabolite detected in plasma after oral administration of radio-labelled ataluren wasthe ataluren-O-1β-acyl glucuronide; exposure to this metabolite in humans was approximately 8% ofthe plasma AUC of ataluren.

Ataluren plasma half-life ranges from 2-6 hours and is unaffected either by dose or repeatedadministration. The elimination of ataluren is likely dependent on hepatic and renal glucuronidation ofataluren followed by renal and hepatic excretion of the resulting glucuronide metabolite.

After a single oral dose of radiolabelled ataluren, approximately half of the administered radioactivedose is recovered in the faeces and the remainder was recovered in the urine. In the urine, unchangedataluren and the acyl glucuronide metabolite account for <1% and 49%, respectively, of theadministered dose.

Mdicinal product no longer authorised

Steady-state plasma concentrations are dose-proportional for ataluren doses between 10 and 50 mg/kg,and no accumulation is observed after repeated dosing. Based on data in healthy volunteers, therelative bioavailability of ataluren is approximately 40% lower at steady-state than after the initialdose. The onset of reduction in relative bioavailability is estimated to occur approximately 60 hoursafter the first dose. The steady-state is established after approximately two weeks of thrice dailydosing.

Characteristic in specific groups of subjects or patients

Based on data from subjects ranging in age from 2 years to 57 years, there is no apparent effect of ageon ataluren plasma exposure. Age-adjusted dosing is not required.

The pharmacokinetics of ataluren has been evaluated in study PTC124-GD-030 over a duration of 4weeks. Ataluren plasma concentrations in patients from 2 to less than 5 years old were consistent withthose seen in patients above the age of 5 years receiving the 10/10/20 mg/kg dose regimen.

Females were not studied in nmDMD clinical trials. However there were no apparent effects of genderon ataluren plasma exposure in other populations.

It is unlikely that the pharmacokinetics of ataluren are significantly affected by UGT1A9polymorphisms in a Caucasian population. Due to the low number of other races included in theclinical studies, no conclusions can be drawn on the effect of UGT1A9 in other ethnic groups.

No dosage adjustment is required for patients with mild or moderate renal impairment.

In a pharmacokinetic study in subjects with varying degrees of renal impairment, following a singledose administration, ataluren plasma exposure changed by -13%, 27%, and 61% for the mild,moderate and severe groups, respectively, and 46% for the end-stage renal disease group comparedwith the normal renal function group. In addition, a 3 to 8 fold increase in ataluren metabolite has beenreported in patients with severe renal impairment (eGFR <30 ml/min). Following multiple dosing, theincrease in ataluren and ataluren metabolite is anticipated to be higher in patients with severe renalimpairment and end-stage renal disease when compared with patients with normal renal function atsteady state. Patients with severe renal impairment (eGFR <30 ml/min) or end-stage renal diseaseshould be treated with ataluren only if the anticipated clinical benefit outweighs the potential risk (seesections 4.2 and 4.4).

Based on a pharmacokinetic assessment conducted in groups with either mild, moderate or severehepatic impairment versus a control group of healthy subjects, no dose adjustment is required forpatients with any degree of hepatic impairment. No apparent differences of the total ataluren exposurein the control, mild, and severe hepatic impairment groups were observed. An approximately 40%decrease of mean total ataluren exposure in the moderate hepatic impairment group versus the controlgroup was noted probably due to the small sample size and variability.

Non-ambulatory

There were no apparent differences in either steady-state relative bioavailability or apparent clearancedue to loss of ambulation. No dosing adjustment is needed for patients who are becoming non-ambulatory.

Non-clinical data reveal no special hazard for humans based on conventional studies of safetypharmacology and genotoxicity.

Medicinal product no l nger authorised

A standard package of reproduction toxicity studies was available. No effects on male and femalefertility were observed, but effects of early juvenile treatment on fertility during adulthood were notinvestigated. In rats and rabbits embryo-foetal toxicity (e.g. increased early resorptions, post-implantation loss, decreased viable foetuses) and signs of delayed development (increased skeletalvariations) were found in the presence of maternal toxicity. Exposure at the no observed adverse effectlevel (NOAEL) was similar to (rabbit) or 4 times (rat) the systemic exposure in humans (40mg/kg/day). Placental transfer was shown of radiolabelled ataluren in rats. At a single tested, relativelylow, maternal dose of 30 mg/kg, the concentration of foetal radioactivity was ≤ 27% of the maternalconcentration. In the rat pre/postnatal developmental toxicity study, at exposure about 5 times humanexposure, significant maternal toxicity as well as effects on offspring body weight and development ofambulatory activity were observed. The maternal systemic exposure at the no observed effect level(NOEL) for neonatal toxicity was about 3 times human exposure. At a single, relatively low, maternaldose of 30 mg/kg radiolabelled ataluren, the highest measured concentration of radioactivity in ratmilk was 37% of the maternal plasma concentration. Presence of radioactivity in pup plasmaconfirmed absorption from the milk by the pups.

Renal toxicity (nephrosis in the distal nephron) occurred in repeat oral dose studies in mice at systemicexposure equivalent to 0.3 times the steady state AUC in patients administered Translarna atrespective morning, midday, and evening doses of 10-, 10-, 20-mg/kg and higher.

In a 26-week transgenic mouse model for carcinogenicity, no evidence of carcinogenicity was found.

In a 2-year rat carcinogenicity study, one case of hibernoma was found. In addition, at exposure muchhigher than in patients an increase of (rare) urinary bladder tumours was found. Significance of theurinary bladder tumours for humans is considered unlikely.

One out of two 26-week rat repeat dose studies, initiated in 4-5 weeks old rats, showed a dose relatedincrease of the incidence of malignant hibernoma, a rare tumour in rats. In addition, one case ofmalignant hibernoma was found at the highest dose in a 2-year rat carcinogenicity study. Backgroundincidence of this tumour type in rats as well as humans is very low and the mechanism causing thesetumours in the rat studies (including its relation to ataluren treatment) is unknown. The significancefor humans is not known.

A 1-year study in 10-12 weeks old dogs demonstrated findings in the adrenal gland (focalinflammation and degeneration in the glucocorticoid-producing regions of the cortex) and a mildcompromise of cortisol production after exogenous stimulation with adrenocorticotropic hormone.

These findings were seen in dogs at systemic exposure equivalent to 0.8 times the steady state AUC inpatients administered Translarna at respective morning, midday, and evening doses of 40 mg/kg/dayand higher. In a rat distribution study a high adrenal concentration of ataluren was observed.

In addition to the above mentioned effects, several other less adverse effects were found in the repeatdose studies; in particular decreased body weight gain, food intake and increased liver weight withouta histological correlate and of unclear clinical significance. Also rat and dog studies showed changesin plasma lipid (cholesterol and triglycerides) suggestive of changes in fat metabolism.

No adverse findings, including in the adrenal gland, were observed in a 3-month study in neonataldogs (1-week old) followed by a 3-month recovery period up to steady state systemic exposuresequivalent to the steady state AUC in patients. In preliminary studies in neonatal dogs (1-week old),initial systemic exposures equivalent to 5-10 times the steady state AUC in patients were not toleratedin some animals.

Polydextrose (E1200)

Medicinal product no longr authorised

Macrogol

Poloxamer

Mannitol (E421)

Crospovidone

Hydroxyethyl cellulose

Artificial vanilla flavour: maltodextrin, artificial flavours and propylene glycol.

Silica, colloidal anhydrous (E551)

Magnesium stearate

Not applicable

4 years

Each prepared dose is best administered immediately after preparation. The prepared dose should bediscarded if not consumed within 24 hours of preparation if kept refrigerated (2 - 8 °C), or within3 hours at room temperature (15 - 30 °C).

This medicinal product does not require any special storage conditions.

For storage conditions after dilution of the medicinal product, see section 6.3.

Heat-sealed laminated aluminium foil sachet: polyethylene terephthalate (child resistance),polyethylene (colouring and polyester/foil bond), aluminium foil (moisture barrier), adhesive(polyurethane class), copolymer of ethylene and methacrylic acid (sealant resin for packagingintegrity).

Pack of 30 sachets.

Sachets should only be opened at the time of dose preparation. The full contents of each sachet shouldbe mixed with at least 30 ml of liquid (water, milk, fruit juice), or 3 tablespoons of semi-solid food(yoghurt or apple sauce). The prepared dose should be mixed well before administration. The amountof the liquid or semi-solid food can be increased based on patient preference.

Any unused medicinal product or waste material should be disposed of in accordance with localrequirements.

PTC Therapeutics International Limited

Unit 1,52-55 Sir John Rogerson’s Quay,

Dublin 2

D02 NA07

Ireland

Medicinal product no longer authorised

Translarna 125 mg granules for oral suspension

EU/1/13/902/001

Translarna 250 mg granules for oral suspension

EU/1/13/902/002

Translarna 1000 mg granules for oral suspension

EU/1/13/902/003

Date of first authorisation: 31 July 2014

Date of latest renewal: 20 June 2022

Detailed information on this medicinal product is available on the website of the European Medicines

Agency http://www.ema.europa.eu.

Medicinal product no longer authorised