Identification

Summary

Givosiran is a 5-aminolevulinic acid synthase-directed small interfering RNA (siRNA) used in the prophylaxis of acute hepatic porphyria.

Brand Names
Givlaari
Generic Name
Givosiran
DrugBank Accession Number
DB15066
Background

Givosiran is a small interfering RNA (siRNA) directed towards 5-aminolevulinic acid synthase, a critical enzyme in the heme biosynthesis pathway.5 It is manufactured by Alnylam Pharmaceuticals and was first approved for use in the United States in November 2019 for the treatment of adults with acute hepatic porphyria, a genetic disorder in which the overproduction of toxic heme intermediates leads to neuro-, nephro-, and gastrotoxicity.5 Givosiran represents an important step forward in the treatment of acute hepatic porphyria as it is the first approved pharmacotherapy for the prevention of acute attacks - previous strategies involved non-therapeutic measures (e.g. trigger avoidance), intravenous hemin for the treatment of attacks, and liver transplantation in refractory cases.3 Givosiran is the second-ever FDA-approved member of the siRNA drug class (the first being patisiran), a new class of drugs promising an important and exciting step forward in the treatment of genetic disorders.

Type
Biotech
Groups
Approved, Investigational
Biologic Classification
Gene Therapies
Antisense oligonucleotides
Synonyms
  • Givosiran
External IDs
  • ALN-AS1
  • WHO 10280

Pharmacology

Indication

Givosiran is indicated for the treatment of adults with acute hepatic porphyria.5

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Associated Conditions
Contraindications & Blackbox Warnings
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Pharmacodynamics

Givosiran decreases the rate at which toxic byproducts of heme synthesis are produced in the livers of patients with acute hepatic porphyria, thus preventing their accumulation and associated neuro-, nephro-, and gastrotoxicity.5,2 As givosiran works at the transcriptional level, it has a long duration of action and can be administered subcutaneously on a monthly basis. Although givosiran appears to be relatively well-tolerated, hepatic and renal toxicity were noted during clinical trials. Patients receiving therapy with givosiran should undergo routine laboratory monitoring of liver and kidney function.5

Mechanism of action

Acute hepatic porphyrias are a class of genetic disorders involving deficiencies in the pathway responsible for heme synthesis in liver hepatocytes.2 The rate-limiting step in heme synthesis is the first enzyme in the pathway, 5-aminolevulinic acid synthase (ALAS1), which is controlled via a negative feedback loop by the presence of heme end-product in the liver.2 Deficiencies in later enzymes in the pathway result in low circulating levels of heme, which in turn stimulates the up-regulation of ALAS1. The overexpression of ALAS1, in combination with downstream enzyme deficiencies, leads to the overproduction and accumulation of toxic heme intermediates which are ultimately responsible for the neurovisceral symptoms characteristic of acute hepatic porphyrias.5,2

Givosiran is a double-stranded small interfering RNA (siRNA) directed at ALAS1 mRNA in hepatocytes.5 It is covalently bound to a ligand containing three N-acetylgalactosamine (GalNAc) residues that facilitate uptake into hepatocytes via asialoglycoprotein receptors (ASPGRs), which are highly expressed on the cell surface of hepatocytes and are selective for glycoproteins containing GalNAc residues.7 Following endocytosis into hepatocytes, the antisense strand of givosiran is loaded into an enzyme complex called the RNA-induced silencing complex (RISC), which uses the antisense strand to seek out and selectively cleave the complementary mRNA sequence (in this case found between nucleotide 918 and 937 of the ALAS1 mRNA).7 Cleavage of the ALAS1 mRNA results in its degradation, preventing the synthesis of the ALAS1 enzyme and ultimately leading to reduced circulating levels of neurotoxic heme intermediates.

TargetActionsOrganism
AALAS1 mRNA
cleavage
Humans
Absorption

The mean steady-state Cmax and AUC24 of givosiran are 321 ng/mL and 4130 ng·h/mL, respectively, and increase proportionally over the dosing range.5 The Tmax following subcutaneous injection is approximately 3 hours.5

Volume of distribution

The apparent central volume of distribution is 10.4 L.5 Both givosiran and AS(N-1)3' givosiran distribute primarily to the liver following subcutaneous administration.5

Protein binding

Plasma protein binding is inversely proportional to givosiran concentration, ranging from 92% at 1 μg/mL to 21% at 50 μg/mL.5 The specific plasma protein to which givosiran is bound is unclear.

Metabolism

Givosiran is metabolized to shorter oligonucleotides by nuclease enzymes. Its active metabolite, AS(N-1)3' givosiran, carries equal potency to the parent drug and its AUC0-24 comprises approximately 45% of the parent drug AUC at the recommended givosiran dosage.5 In vitro studies suggest that givosiran is not a substrate of the CYP enzyme system.5

Route of elimination

Approximately 5-14% of the dose recovered in urine is unchanged parent drug, and 4-13% is AS(N-1)3' givosiran.5

Half-life

Both givosiran and its active metabolite, AS(N-1)3' givosiran, have an elimination half-life of 6 hours.5

Clearance

The apparent clearance of givosiran is 35.1 L/hr.5

Adverse Effects
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Toxicity

Little information is currently available regarding the toxicity of givosiran. Weekly subcutaneous dosing of up to 30 mg/kg in both female and male rats resulted in no apparent effects on fertility or reproductive function.5

Pathways
Not Available
Pharmacogenomic Effects/ADRs
Not Available

Interactions

Drug Interactions
This information should not be interpreted without the help of a healthcare provider. If you believe you are experiencing an interaction, contact a healthcare provider immediately. The absence of an interaction does not necessarily mean no interactions exist.
DrugInteraction
AbacavirGivosiran may decrease the excretion rate of Abacavir which could result in a higher serum level.
AcebutololThe serum concentration of Acebutolol can be increased when it is combined with Givosiran.
AceclofenacThe risk or severity of nephrotoxicity can be increased when Aceclofenac is combined with Givosiran.
AcemetacinThe risk or severity of nephrotoxicity can be increased when Acemetacin is combined with Givosiran.
AcenocoumarolThe serum concentration of Acenocoumarol can be increased when it is combined with Givosiran.
AcetaminophenThe serum concentration of Acetaminophen can be increased when it is combined with Givosiran.
Acetylsalicylic acidThe risk or severity of nephrotoxicity can be increased when Acetylsalicylic acid is combined with Givosiran.
AclidiniumGivosiran may decrease the excretion rate of Aclidinium which could result in a higher serum level.
AcrivastineGivosiran may decrease the excretion rate of Acrivastine which could result in a higher serum level.
AcyclovirThe serum concentration of Acyclovir can be increased when it is combined with Givosiran.
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Food Interactions
No interactions found.

Products

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Product Ingredients
IngredientUNIICASInChI Key
Givosiran sodium5XE21E41RTNot AvailableNot applicable
Brand Name Prescription Products
NameDosageStrengthRouteLabellerMarketing StartMarketing EndRegionImage
GivlaariSolution189 mg / mLSubcutaneousAlnylam Netherlands B.V.2020-12-01Not applicableCanada flag
GivlaariInjection, solution189 mg/1mLSubcutaneousAlnylam Pharmaceuticals, Inc.2019-12-12Not applicableUS flag
GivlaariInjection, solution189 mg/mLSubcutaneousAlnylam Netherlands B.V.2020-12-16Not applicableEU flag

Categories

Drug Categories
Classification
Not classified
Affected organisms
  • Humans and other mammals

Chemical Identifiers

UNII
ROV204583W
CAS number
1639325-43-1

References

Synthesis Reference

Brian Bettencourt, Kevin Fitzgerald, William Querbes, Robert J. Desnick, Makiko Yasuda, "Compositions and methods for inhibiting expression of the ALAS1 gene." US Patent US10119143B2, issued November, 2018.

General References
  1. Chan A, Liebow A, Yasuda M, Gan L, Racie T, Maier M, Kuchimanchi S, Foster D, Milstein S, Charisse K, Sehgal A, Manoharan M, Meyers R, Fitzgerald K, Simon A, Desnick RJ, Querbes W: Preclinical Development of a Subcutaneous ALAS1 RNAi Therapeutic for Treatment of Hepatic Porphyrias Using Circulating RNA Quantification. Mol Ther Nucleic Acids. 2015 Nov 3;4:e263. doi: 10.1038/mtna.2015.36. [Article]
  2. Bonkovsky HL, Dixon N, Rudnick S: Pathogenesis and clinical features of the acute hepatic porphyrias (AHPs). Mol Genet Metab. 2019 Mar 6. pii: S1096-7192(19)30084-8. doi: 10.1016/j.ymgme.2019.03.002. [Article]
  3. Sardh E, Harper P, Balwani M, Stein P, Rees D, Bissell DM, Desnick R, Parker C, Phillips J, Bonkovsky HL, Vassiliou D, Penz C, Chan-Daniels A, He Q, Querbes W, Fitzgerald K, Kim JB, Garg P, Vaishnaw A, Simon AR, Anderson KE: Phase 1 Trial of an RNA Interference Therapy for Acute Intermittent Porphyria. N Engl J Med. 2019 Feb 7;380(6):549-558. doi: 10.1056/NEJMoa1807838. [Article]
  4. Fontanellas A, Avila MA, Anderson KE, Deybach JC: Current and innovative emerging therapies for porphyrias with hepatic involvement. J Hepatol. 2019 Aug;71(2):422-433. doi: 10.1016/j.jhep.2019.05.003. Epub 2019 May 16. [Article]
  5. FDA Approved Drug Products: Givlaari subcutaneous injection [Link]
  6. Supplementary Appendix for Phase 1 trial of an RNA interference therapy for acute intermittent porphyria [File]
  7. Study Protocol for Phase 1 trial of an RNA interference therapy for acute intermittent porphyria [File]
ChemSpider
88297697
RxNav
2265712
Wikipedia
Givosiran

Clinical Trials

Clinical Trials
PhaseStatusPurposeConditionsCount
3CompletedTreatmentAcute Hepatic Porphyria (AHP) / Acute Intermittent Porphyria (AIP) / ALA Dehydratase Deficient Porphyria (ADP) / Hereditary Coproporphyria (HCP) / Porphyrias, Acute / Variegate Porphyria1
1CompletedTreatmentAcute Hepatic Porphyria (AHP) / Acute Intermittent Porphyria (AIP) / Porphyrias, Acute1
1CompletedTreatmentAcute Intermittent Porphyria (AIP)1
1, 2CompletedTreatmentAcute Intermittent Porphyria (AIP)1
Not AvailableApproved for MarketingNot AvailableAcute Hepatic Porphyria (AHP)1

Pharmacoeconomics

Manufacturers
Not Available
Packagers
Not Available
Dosage Forms
FormRouteStrength
Injection, solutionSubcutaneous189 MG/ML
Injection, solutionSubcutaneous189 mg/1mL
SolutionSubcutaneous189 mg / mL
Prices
Not Available
Patents
Patent NumberPediatric ExtensionApprovedExpires (estimated)Region
US9631193No2017-04-252033-03-15US flag
US10131907No2018-11-202028-08-24US flag
US10125364No2018-11-132033-03-15US flag
US8106022No2012-01-312029-12-12US flag
US10119143No2018-11-062034-10-03US flag
US8546143No2013-10-012022-01-09US flag
US9133461No2015-09-152033-05-14US flag
US8828956No2014-09-092028-12-04US flag
US9708610No2017-07-182024-01-01US flag
US10273477No2019-04-302024-03-08US flag
US9708615No2017-07-182024-03-08US flag
US9150605No2015-10-062025-08-28US flag
US11028392No2014-10-032034-10-03US flag

Properties

State
Solid
Experimental Properties
Not Available

Targets

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Kind
Nucleotide
Organism
Humans
Pharmacological action
Yes
Actions
Cleavage
Region between nucleotide 918 and 937 of the ALAS1 mRNA; target for givosiran. The specific mRNA sequence targeted by givosiran is not explicitly given but can be inferred based on the structure of the molecule provided in the prescribing information and the study protocol from NCT02452372. The antisense strand of the double-stranded siRNA is the template used to seek out and cleave the ALAS1 mRNA, so its complementary sequence (provided here) should be the target mRNA sequence.
References
  1. FDA Approved Drug Products: Givlaari subcutaneous injection [Link]
  2. Study Protocol for Phase 1 trial of an RNA interference therapy for acute intermittent porphyria [File]

Drug created at May 20, 2019 14:46 / Updated at May 28, 2022 06:24