AstraZeneca's Forxiga (dapagliflozin) has been recommended for approval in the European Union (EU) to extend the indication for heart failure with reduced ejection fraction (HFrEF) to cover patients across the full spectrum of left ventricular ejection fraction (LVEF) including HF with mildly reduced and preserved ejection fraction (HFmrEF, HFpEF).

The Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency based its positive opinion on results from the DELIVER Phase III trial, published in The New England Journal of Medicine (https://www.nejm.org/doi/full/10.1056/NEJMoa2206286)[1] and results from a pre-specified, patient level, pooled analysis of the DAPA-HF and DELIVER Phase III trials published in Nature Medicine (https://www.nature.com/articles/s41591-022-01971-4)[2]. The pooled analysis showed Forxiga to be the first HF medication to demonstrate mortality benefit across the full ejection fraction range[3].

HF is a life-threatening chronic disease in which the heart cannot pump enough blood around the body[4], affecting 15 million people in the EU[5]. Patients with HFmrEF or HFpEF experience an especially high burden of symptoms and physical limitations, and a poor quality of life, which is why improving health status is a key goal of management[6].

Mene Pangalos, Executive Vice President, BioPharmaceuticals R&D, AstraZeneca, said: "Forxiga has already transformed the standard of care for millions of people in the EU living with heart failure. If approved for this new, broader indication for heart failure with mildly reduced or preserved ejection fraction, more patients will be able to benefit from this well-tolerated and guideline-directed treatment. As a leader in cardiorenal disease, AstraZeneca is committed to expanding heart failure treatment options, changing the way we treat this complex disease to improve patient outcomes."

The CHMP recommendation states Forxiga is indicated in adults for the treatment of symptomatic chronic HF.

Results from the DELIVER Phase III trial in patients with HFpEF and HFmrEF showed that Forxiga reduced the composite outcome of cardiovascular (CV) death or worsening of HF by 18% (16.4% in the dapagliflozin group and 19.5% in the placebo group [p<0.001, absolute risk reduction [ARR] 3.1%] over a median follow-up of 2.3 years)[1]. The treatment effect was consistent across the LVEF range, without evidence of attenuation of effect by LVEF[1]. Additionally, the pre-specified, patient level, pooled analysis of the DELIVER and DAPA-HF Phase III trials demonstrated that Forxiga reduced the risk of CV death by 14% (p=0.01, ARR 1.5%), death from any cause by 10% (p=0.03, ARR 1.5%), and total (first and repeat) hospitalisation for HF (hHF) by 29% (p<0.001, ARR 6%) over the median follow-up of 22 months[2].

Forxiga (known as Farxiga in the US) is approved for the treatment of patients with HFrEF in more than 100 countries around the world including the US, the EU, China and Japan. It was most recently approved in Great Britain and Turkey to extend the HF indication to include patients across the full spectrum of left ventricular ejection fraction. The HF indication extension application is currently under review in the US and other countries.

Notes

HF
HF is a chronic, long-term condition that worsens over time[7]. It affects nearly 64 million people globally[8] and is associated with substantial morbidity and mortality[9]. Chronic HF is the leading cause of hospitalisation for those over the age of 65 and represents a significant clinical and economic burden[10]. There are several types of HF often defined by LVEF, a measurement of the percentage of blood leaving the heart each time it contracts, including: HFrEF (LVEF less than or equal to 40%), HFmrEF (LVEF 41-49%) and HFpEF (LVEF greater than or equal to 50%)[11]. Approximately half of all HF patients have HFmrEF or HFpEF, with few therapeutic options available[11,12].

DAPA-HF
DAPA-HF (Dapagliflozin And Prevention of Adverse-outcomes in Heart Failure) was an international, multi-centre, parallel-group, randomised, double-blinded Phase III trial in 4,744 patients with HFrEF, with and without type-2 diabetes (T2D), designed to evaluate the effect of Forxiga 10mg, compared with placebo, given once daily in addition to standard of care (SoC). The primary composite endpoint was time to the first occurrence of a worsening HF event (hospitalisation or equivalent event, i.e. an urgent HF visit), or CV death. The median duration of follow-up was 18.2 months. Key secondary endpoints included the total number of hHF (including repeat admissions) and CV deaths, change from baseline to 8 months in the total symptom score on the Kansas City Cardiomyopathy Questionnaire (KCCQ)[13].

DELIVER
DELIVER was an international, randomised, double-blind, parallel-group, placebo-controlled, event-driven Phase III trial designed to evaluate the efficacy of Forxiga, compared with placebo, in the treatment of HF patients with LVEF greater than 40%, with or without T2D. Forxiga was given once daily in addition to background therapy (regional SoC for all comorbidities, including diabetes and hypertension, with the exception of concomitant use of a sodium-glucose cotransporter 2 (SGLT2) inhibitor)[14].DELIVER is the largest clinical trial to date in HF patients with LVEF above 40%, with 6,263 randomised patients[14].

The primary composite endpoint was the time to first occurrence of CV death, hHF or an urgent HF visit. Key secondary endpoints include the total number of HF events (hHF or urgent HF visit) and CV death, change from baseline in the total symptom score of the KCCQ at eight months, time to the occurrence of CV death and time to the occurrence of death from any cause[14].

Forxiga

Forxiga (dapagliflozin) is a first-in-class, oral, once-daily SGLT2 inhibitor. Research has shown Forxiga's efficacy in preventing and delaying cardiorenal disease, while also protecting the organs - important findings given the underlying links between the heart, kidneys and[ ]pancreas[13,15,16]. Damage to one of these organs can cause the other organs to fail, contributing to leading causes of death worldwide, including T2D, HF and chronic kidney disease (CKD)[ 4,8,17,18].

Forxiga is approved in adults and children aged 10 years and above for the treatment of insufficiently controlled T2D mellitus as an adjunct to diet and exercise. Forxiga is also approved for the treatment of HFrEF in adults and the treatment of CKD in adults based on the findings of the DAPA-HF and DAPA-CKD Phase III trials.

AstraZeneca in CVRM

Cardiovascular, Renal and Metabolism (CVRM), part of BioPharmaceuticals, forms one of AstraZeneca's main disease areas and is a key growth driver for the Company. By following the science to understand more clearly the underlying links between the heart, kidneys and pancreas, AstraZeneca is investing in a portfolio of medicines for organ protection and improving outcomes by slowing disease progression, reducing risks and tackling co-morbidities. The Company's ambition is to modify or halt the natural course of CVRM diseases and potentially regenerate organs and restore function, by continuing to deliver transformative science that improves treatment practices and CV health for millions of patients worldwide.

AstraZeneca

AstraZeneca (LSE/STO/Nasdaq: AZN) is a global, science-led biopharmaceutical company that focuses on the discovery, development, and commercialisation of prescription medicines in Oncology, Rare Diseases, and BioPharmaceuticals, including Cardiovascular, Renal & Metabolism, and Respiratory & Immunology. Based in Cambridge, UK, AstraZeneca operates in over 100 countries and its innovative medicines are used by millions of patients worldwide. Please visit astrazeneca.com (http://www.astrazeneca.com/) and follow the Company on Twitter @AstraZeneca (https://twitter.com/AstraZeneca).

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References

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