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Omaveloxolone
Clinical data
Trade names	Skyclarys
Other names	RTA 408
AHFS/Drugs.com	Monograph
License data	US DailyMed: Omaveloxolone;
Routes of; administration	By mouth
ATC code	N07XX25 (WHO) ;
Legal status
Legal status	US: ℞-only; EU: Rx-only;
Identifiers
	IUPAC name N-((4aS,6aR,6bS,8aR,12aS,14aR,14bS)-1 1-cyano-2,2,6a,6b,9,9,12a-heptamethyl-10,14-dioxo-1,2,3,4,4a,5,6,6a,6b,7,8,8a,9,10,12a,14,14a,14b- octadecahydropicen-4a-yl)-2,2-difluoropropanamide;
CAS Number	1474034-05-3 ;
PubChem CID	71811910;
IUPHAR/BPS	7573;
DrugBank	DB12513;
ChemSpider	34980948 ;
UNII	G69Z98951Q;
KEGG	D10964;
ChEBI	CHEBI:229661;
CompTox Dashboard (EPA)	DTXSID101138251 ;
Chemical and physical data
Formula	C33H44F2N2O3
Molar mass	554.723 g·mol−1
3D model (JSmol)	Interactive image;
	SMILES O=C4C(\C#N)=C/[C@@]5(/C3=C/C(=O)[C@H]2[C@](CC[C@@]1(NC(=O)C(F)(F)C)CCC(C)(C)C[C@H]12)(C)[C@]3(C)CC[C@H]5C4(C)C)C;
	InChI InChI=1S/C32H43NO4/c1-27(2)11-13-32(26(36)37-8)14-12-31(7)24(20(32)17-27)21(34)15-23-29(5)16-19(18-33)25(35)28(3,4)22(29)9-10-30(23,31)6/h15-16,20,22,24H,9-14,17H2,1-8H3/t20-,22-,24-,29-,30+,31+,32-/m0/s1 ; Key:WPTTVJLTNAWYAO-KPOXMGGZSA-N ;
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Omaveloxolone, sold under the brand name Skyclarys, is a medication used for the treatment of Friedreich's ataxia.^[1]^[4] It is taken by mouth.^[1]

The most common side effects include an increase in alanine transaminase and an increase of aspartate aminotransferase, which can be signs of liver damage, headache, nausea, abdominal pain, fatigue, diarrhea and musculoskeletal pain.^[4]

Omaveloxolone was approved for medical use in the United States in February 2023,^[1]^[4]^[5]^[6]^[7] and in the European Union in February 2024.^[2] The US Food and Drug Administration (FDA) considers it to be a first-in-class medication.^[8]

Medical uses

Omaveloxolone is indicated for the treatment of Friedreich's ataxia.^[1]^[4]

Friedreich's ataxia causes progressive damage to the spinal cord, peripheral nerves, and the brain, resulting in uncoordinated muscle movement, poor balance, difficulty walking, changes in speech and swallowing, and a shortened lifespan.^[4] The condition can also cause heart disease.^[4] This disease tends to develop in children and teenagers and gradually worsens over time.^[4]

Although rare, Friedreich's ataxia is the most common form of hereditary ataxia in the United States, affecting about one in every 50,000 people.^[4]

Mechanism of action

The mechanism of action of omaveloxolone and its related compounds has been demonstrated to be through a combination of activation of the antioxidative transcription factor Nrf2 and inhibition of the pro-inflammatory transcription factor NF-κB.^[9]

Nrf2 transcriptionally regulates multiple genes that play both direct and indirect roles in producing antioxidative potential and the production of cellular energy (i.e., adenosine triphosphate or ATP) within the mitochondria. Consequently, unlike exogenously administered antioxidants (e.g., vitamin E or Coenzyme Q10), which provide a specific and finite antioxidative potential, omaveloxolone, through Nrf2, broadly activates intracellular and mitochondrial antioxidative pathways, in addition to pathways that may directly increase mitochondrial biogenesis (such as PGC1α) and bioenergetics.^[10]

History

Omaveloxolone is a second generation member of the synthetic oleanane triterpenoid compounds and in clinical development by Reata Pharmaceuticals. Preclinical studies have demonstrated that omaveloxolone possesses antioxidative and anti-inflammatory activities^[9]^[11] and the ability to improve mitochondrial bioenergetics.^[10] Omaveloxolone is under clinical investigation for a variety of indications, including Friedreich's ataxia, mitochondrial myopathies, immunooncology, and prevention of corneal endothelial cell loss following cataract surgery.

The efficacy and safety of omaveloxolone was evaluated in a 48-week randomized, placebo-controlled, and double-blind study [Study 1 (NCT02255435)] and an open-label extension.^[4] Study 1 enrolled 103 individuals with Friedreich's ataxia who received placebo (52 individuals) or omaveloxolone 150 mg (51 individuals) for 48 weeks.^[4] Of the research participants, 53% were male, 97% were white, and the mean age was 24 years at study entry.^[4] Nine (18%) patients were younger than age 18.^[4] The primary objective was to evaluate the change in the modified Friedreich's Ataxia Rating Scale (mFARS) score compared to placebo at week 48.^[4] The mFARS is a clinical assessment that measures disease progression, namely swallowing and speech (bulbar), upper limb coordination, lower limb coordination, and upright stability.^[4] Individuals receiving omaveloxolone performed better on the mFARS than people receiving placebo.^[4]

The US Food and Drug Administration (FDA) granted the application for omaveloxolone orphan drug, fast track, priority review, and rare pediatric disease designations.^[4]^[8]

Society and culture

Legal status

Omaveloxolone was approved for medical use in the United States in February 2023.^[1]^[4]

In December 2023, the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency adopted a positive opinion, recommending the granting of a marketing authorization for the medicinal product Skyclarys, intended for the treatment of Friedreich's ataxia.^[2] The applicant for this medicinal product is Reata Ireland Limited.^[2] Omaveloxolone was approved for medical use in the European Union in February 2024.^[2]^[3]

References

^ ^a ^b ^c ^d ^e ^f "Skyclarys- omaveloxolone capsule". DailyMed. 12 May 2023. Archived from the original on 1 July 2023. Retrieved 16 December 2023.
^ ^a ^b ^c ^d ^e "Skyclarys EPAR". European Medicines Agency (EMA). 14 December 2023. Archived from the original on 15 December 2023. Retrieved 16 December 2023. Text was copied from this source which is copyright European Medicines Agency. Reproduction is authorized provided the source is acknowledged.
^ ^a ^b "Skyclarys product information". Union Register of medicinal products. 12 February 2024. Retrieved 19 February 2024.
^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m ⁿ ^o ^p ^q "FDA approves first treatment for Friedreich's ataxia". U.S. Food and Drug Administration (FDA). 28 February 2023. Archived from the original on 1 March 2023. Retrieved 28 February 2023. This article incorporates text from this source, which is in the public domain.
^ "Reata Pharmaceuticals Announces FDA Approval of Skyclarys (Omavaloxolone), the First and Only Drug Indicated for Patients with Friedreich's Ataxia". Reata Pharmaceuticals Inc. (Press release). 28 February 2023. Archived from the original on 1 March 2023. Retrieved 28 February 2023.
^ Lee A (June 2023). "Omaveloxolone: First Approval". Drugs. 83 (8): 725–729. doi:10.1007/s40265-023-01874-9. PMID 37155124. S2CID 258567442. Archived from the original on 9 December 2023. Retrieved 16 December 2023.
^ Subramony SH, Lynch DL (May 2023). "A Milestone in the Treatment of Ataxias: Approval of Omaveloxolone for Friedreich Ataxia". Cerebellum. 23 (2): 775–777. doi:10.1007/s12311-023-01568-8. PMID 37219716. S2CID 258843532.
^ ^a ^b New Drug Therapy Approvals 2023 (PDF). U.S. Food and Drug Administration (FDA) (Report). January 2024. Archived from the original on 10 January 2024. Retrieved 9 January 2024.
^ ^a ^b Reisman SA, Lee CY, Meyer CJ, Proksch JW, Ward KW (July 2014). "Topical application of the synthetic triterpenoid RTA 408 activates Nrf2 and induces cytoprotective genes in rat skin". Archives of Dermatological Research. 306 (5): 447–454. doi:10.1007/s00403-013-1433-7. PMID 24362512. S2CID 25733020.
^ ^a ^b Neymotin A, Calingasan NY, Wille E, Naseri N, Petri S, Damiano M, et al. (July 2011). "Neuroprotective effect of Nrf2/ARE activators, CDDO ethylamide and CDDO trifluoroethylamide, in a mouse model of amyotrophic lateral sclerosis". Free Radical Biology & Medicine. 51 (1): 88–96. doi:10.1016/j.freeradbiomed.2011.03.027. PMC 3109235. PMID 21457778.
^ Reisman SA, Lee CY, Meyer CJ, Proksch JW, Sonis ST, Ward KW (May 2014). "Topical application of the synthetic triterpenoid RTA 408 protects mice from radiation-induced dermatitis". Radiation Research. 181 (5): 512–520. Bibcode:2014RadR..181..512R. doi:10.1667/RR13578.1. PMID 24720753. S2CID 23906747.