Status of FDA approval June 11, 2010 — The US Food and Drug Administration's (FDA's) Peripheral and Central Nervous System Drugs Advisory Committee has recommended approval for the novel oral agent fingolimod in the treatment of patients with relapsing-remitting multiple sclerosis (MS). The highly anticipated drug is the first in a new class of disease-modifying agents called sphingosine 1 phosphate receptor modulators. Fingolimod's sponsor, Novartis, was seeking a new drug application for patients with MS to reduce the frequency of clinical exacerbations and to delay the accumulation of physical disability. Novartis plans to market fingolimod as Gilena. If approved by the FDA, it will be the first oral agent for patients with MS, giving them a welcome alternative to currently available injectable therapies. The committee spent hours discussing a long list of questions posed by the FDA but was unanimous in its decision to recommend fingolimod's approval.   History of research and development First synthesized in 1992, fingolimod was derived from an immunosuppressive natural product, myriocin (ISP-I) through chemical modification. Myriocin was isolated from the culture broth a type of vegetative wasp (Isaria sinclairii) that was an eternal youth nostrum in traditional Chinese medicine. Showing postive results in both in vitro (mixed lymphocyte reaction) and in vivo screening (prolonging rat skin graft survival time), myriocin was modified through a series of steps to yield fingolimod, code named at the time FTY720. Structure activity relationship (SAR) studies on myriocin homologs and partially synthetic derivatives showed that the configuration at the carbon bearing the 3-hydroxy group or the 14-ketone, the 6-double bond, and the 4-hydroxy group were not important for its activity and simplification of the structure of ISP-I was done in an attempt to reduce toxicity and improve drugability. Elimination of side chain functionalities and removal of chiral centers was part of the simplification process and an intermediate compound (ISP-I-28) with the carboxylic acid of myriocin transformed to a hydroxymethyl group was generated. ISP-I-28 was found to be less toxic and more effective at lenghtening rat skin allograft time than ISP-1. (source: http://en.wikipedia.org/wiki/Fingolimod).   Clinical trials (source: http://en.wikipedia.org/wiki/Fingolimod). 1.  Organ transplant:  in a previous phase III clinical trial of kidney transplantation, fingolimod was found to be no better than the existing standard of care.   2. Multiple sclerosis: in two Phase III clinical trials, fingolimod reduced the rate of relapses in relapsing-remitting multiple sclerosis by over half compared both to placebo and to the active comparator interferon beta-1-a. A double-blind randomized control trial comparing fingolimod to placebo found the drug reduced the annualized frequency of relapses to 0.18 relapses per year at 0.5 mg/day or 0.16 relapses per year at 1.25 mg/day, compared to 0.40 relapses per year for those patients taking the placebo. The probability of disease progression at 24 month followup was lower in the fingolimod groups compared to placebo (hazard ratio 0.70 at 0.5 mg and 0.68 at 1.25 mg). Fingolimod patients also had better results according to MRI imaging of new or enlarged lesions at 24 month followup. Side effects leading to discontinuation of the study drug were more common in the higher dose group (14.2% of patients) than at the lower dose (7.5%) or placebo (7.7%). Serious adverse events in the fingolimod group included bradycardia, relapse, and basal-cell carcinoma. Seven episodes of bradycardia occurred during the monitoring period after administration of the first dose, and were asymptomatic in six of these cases. There was a higher rate of lower respiratory tract infections (including bronchitis and pneumonia) in the fingolimod groups (9.6% at 0.5 mg, 11.4% at 1.5 mg) than the placebo group (6.0%). Other adverse events reported on the study drug included macular edema, malignant neoplasms, and laboratory abnormalities.   Develope r of the product: Novartis.