FDA Approves Gene Therapy for Treatment of Spinal Muscular Atrophy

[From FDA.gov]

For Immediate Release:

November 24, 2025

The U.S. Food and Drug Administration today approved Itvisma (onasemnogene abeparvovec-brve) for the treatment of spinal muscular atrophy (SMA) in adult and pediatric patients 2 years of age and older with confirmed mutation in the survival motor neuron 1 (SMN1) gene. Itvisma is an adeno-associated virus (AAV) vector-based gene therapy.

“Today’s approval shows the power of gene therapies and offers treatment to patients across the SMA disease spectrum, including patients at various ages, SMA symptoms, and motor functional levels,” said Vinay Prasad, M.D., M.P.H., the FDA’s Chief Medical and Scientific Officer and Director of the Center for Biologics Evaluation and Research. “This exciting area of science continues to change the lives of patients and the FDA is committed to expediting the development of products for unmet medical needs.”

SMA is an autosomal-recessive neurodegenerative disorder caused by mutations in the SMN1 gene, characterized by irreversible and progressive motor neuron loss, leading to progressive muscle atrophy and weakness, and subsequent paralysis and death in the most severe cases. SMA has an incidence of approximately 4-10 per 10,000 live births. Prior to the availability of effective treatment, SMA was considered one of the leading causes of infant mortality due to genetic disease in the U.S.

Itvisma demonstrated substantial evidence of effectiveness for the treatment of SMA in pediatric patients 2 years of age and older with a confirmed mutation in the SMN1 gene based on primary evidence of effectiveness from the adequate and well controlled Phase 3 study,  and the confirmatory evidence of effectiveness from data characterizing the mechanism of the product’s action, as well as efficacy findings from Zolgensma (onasemnogene abeparvovec-xioi) which contains the same active ingredient in an intravenous formulation. The applicant provided adequate justification to support expanding the indication beyond the pivotal study population to include adult patients with SMA, however, warnings and precautions are warranted due to the potentially increased risks of adverse events of special interest (e.g., hepatotoxicity and cardiotoxicity) in adult patients with preexisting chronic medical conditions.

The active ingredient (drug substance) in Itvisma is identical to Zolgensma but formulated at a different concentration. Zolgensma is administered intravenously based on patient weight to pediatric patients less than 2 years of age with SMA due to bi-allelic mutations in the SMN1 gene. Itvisma is a concentrated formulation in a smaller delivery volume, administered directly to the central nervous system via a single intrathecal injection independent of patient weight, which expands treatment options available to patients with SMA older than 2 years of age.

The direct administration of Itvisma into the cerebrospinal fluid surrounding the spinal cord (site of action) allows for delivery to motor neurons with a lower dose of vector, without the need to adjust for the patient’s body weight. This provides a treatment with rapid onset and direct targeting of the genetic root cause of SMA. By addressing the root cause of SMA, Itvisma restores SMN protein production and halts further disease progression.

The FDA review team worked collaboratively to leverage Zolgensma safety data and most of the side effects of Itvisma are consistent with identified risks associated with Zolgensma. Information from the hepatotoxicity boxed warning in the Zolgensma label is retained in the Itvisma label with appropriate modifications. This approach is supported by clinical data showing hepatotoxicity in Itvisma clinical studies.

“Significant unmet need remains in SMA, particularly for patients across various ages and motor function levels, predominantly those 2 years of age and older.” said Vijay Kumar M.D., Acting Director, Office of Therapeutic Products in the FDA’s Center for Biologics Evaluation and Research. “This approval shows our continued commitment to supporting and facilitating treatments for patients with rare diseases.”  

The FDA granted this application Fast Track, Breakthrough Therapy, and Priority Review designations. Itvisma also received Orphan Drug designation, which provides incentives to encourage the development of drugs for rare diseases. Itvisma is manufactured by Novartis Gene Therapies, Inc.

FDA Approves New Safety Warning and Revised Indication that Limits Use for Elevidys Following Reports of Fatal Liver Injury

[From FDA.gov]

For Immediate Release:

November 14, 2025

The U.S. Food and Drug Administration today announced it is taking action to approve new labeling submitted by the company that includes the addition of a Boxed Warning, the agency’s most prominent safety warning, to Elevidys (delandistrogene moxeparvovec-rokl), and that the indication section of the labeling limits the therapy’s indication to ambulatory patients four years of age and older with Duchenne muscular dystrophy (DMD). These actions follow reports of fatal acute liver failure in non-ambulatory patients treated with the product.  

Elevidys is an AAVrh74 adeno-associated virus (AAV) vector-based gene therapy approved for the treatment of DMD in certain patients. In June 2025, the FDA issued a CBER Safety Communication following two reports of fatal acute liver failure in non-ambulatory pediatric males with DMD after receiving Elevidys. In response, the manufacturer voluntarily paused distribution of Elevidys for use in non-ambulatory patients.  

In both fatal cases, patients developed markedly elevated liver enzymes and required hospitalization within two months of Elevidys infusion. An additional serious, non-fatal case of acute liver injury has involved complications such as mesenteric vein thrombosis, bowel ischemia and necrosis, and portal hypertension.  

After a comprehensive evaluation of the available safety data, FDA has now approved substantial labeling revisions for Elevidys, including:  

  • Addition of a Boxed Warning describing the risk of serious liver injury and acute liver failure, including fatal outcomes;  

  • Limiting the indication to ambulatory patients with DMD who are 4 years of age and older with a confirmed mutation in the DMD gene;  

  • Removal of the indication for non-ambulatory patients with DMD;  

  • Addition of a Limitations of Use statement to guide clinical decision-making;  

  • Updates to the Warnings and Precautions, Dosage and Administration, Adverse Reactions, Use in Specific Populations, Clinical Studies, and Patient Counseling Information sections; and  

  • Inclusion of a new Medication Guide for patients and caregivers.  

Key Safety Information for Patients and Health Care Providers  

The revised labeling includes specific safety information and monitoring recommendations:  

  • Liver monitoring: Weekly liver function tests are advised for at least three months after treatment. Patients should remain near an appropriate medical facility for at least two months post-infusion.  

  • Prompt medical attention: Patients should contact their health care provider immediately if they experience yellowing of the skin or eyes, if they miss or vomit corticosteroid doses, or if the patient experiences a change in mental status.  

  • Infection risk: Corticosteroid therapy may suppress immune function, increasing susceptibility to infections and serious complications including death.  

  • Cardiac monitoring: Weekly testing for cardiac injury (troponin-I) is advised for one month following treatment.  

  • Contraindications: Elevidys should not be used in patients with deletions involving DMD exons 8 and/or 9.   

  • Limitations of Use: Elevidys is not recommended in patients with preexisting liver impairment, recent vaccinations, or recent/active infections.  

Postmarketing Requirements  

The FDA is requiring the manufacturer to conduct a postmarketing observational study to further assess the risk of serious liver injury. The study will enroll approximately 200 patients with DMD and follow them for at least 12 months after administration of Elevidys, with periodic liver function assessments.  

Reporting Adverse Events  

Health care professionals and patients are encouraged to report adverse events, including cases of liver injury, to the FDA MedWatch program:  

Adverse events may also be reported to Sarepta Therapeutics, Inc. at 1-888-727-3782.  

The FDA remains committed to the continued evaluation of the safety and effectiveness of gene therapies and will provide updates as new information becomes available. 

FDA Approves Tecelra, First T Cell Therapy for Solid Tumors

On August 2, 2024, the FDA granted accelerated approval for Tecelra (afamitresgene autoleucel) a melanoma-associated antigen A4 (MAGE-A4)-directed genetically modified autologous T cell immunotherapy indicated for the treatment of adults with unresectable or metastatic synovial sarcoma who have received prior chemotherapy, are HLA-A*02:01P, -A*02:02P, 16 -A*02:03P, or -A*02:06P positive and whose tumor expresses the MAGE-A4 antigen as determined by FDA-approved or cleared companion diagnostic devices. Tecelra is contra-indicated in adults who are heterozygous or 52 homozygous for HLA-A*02:05P.[i]

Synovial sarcoma is an uncommon and aggressive cancer that can form in soft tissues such as muscles, fat, joint linings, and ligaments. It is often found in the arm, leg, or foot, and near joints such as the wrist or ankle. It can also form in soft tissues in the lung or abdomen. Although synovial sarcoma can affect people at any age, it is known to occur more commonly in adolescents and adults younger than 30.[ii] Adults with metastatic synovial sarcoma at diagnosis have a 5-year overall survival rate of 10%, versus 76% for those with localized disease at diagnosis.[iii]

Synovial sarcoma (SS) accounts for up to 10% of all soft-tissue sarcomas. In the US, 800-1000 new cases of SS are diagnosed annually. According to an analysis of the Surveillance, Epidemiology, and End Results (SEER) database study, the age-adjusted incidence rate of SS in the US is 0.177 per 100,000 (approximately 580 incident cases) with a prevalence rate of 0.65 per 100,000 (approximately 2129 prevalent cases).[iv]

Tecelra is an autologous T cell immunotherapy composed of a patient’s own T cells. T cells in Tecelra are modified to express a TCR that targets MAGE-A4 expressed by cancer cells in synovial sarcoma. After the patient undergoes leukapheresis, cells are sent for manufacturing. It takes about six weeks for the Tecelra to be returned to the provider, though that time may vary.

The patient is admitted to the hospital and receives a lymphodepleting chemotherapy regimen of fludarabine 30 mg/m2/day intravenously for four days starting on the seventh day before Tecelra infusion (Day-7 to Day -4), and cyclophosphamide 600 mg/m2/day intravenously for 3 days starting the seventh day before Tecelra infusion (Day -7 to Day -5).  Tecelra is administered over an hour as a single intravenous infusion on Day 1.  The patient will remain hospitalized for at least seven days after the infusion. The patient should plan to stay close to a healthcare facility for at least four weeks.[v]

The safety and effectiveness of Tecelra were evaluated in a multicenter, open-label clinical trial. Effectiveness was evaluated based on overall response rate and the duration of response to treatment with Tecelra. Among the 44 patients in the trial who received Tecelra, the overall response rate was 43.2% and the median duration of response was six months. Tecelra was approved under an accelerated approval pathway and a confirmatory trial is ongoing to verify Tecelra’s clinical benefit.[vi]

A Black Box Warning has been issued because patients may experience cytokine release syndrome. Patients may also exhibit Immune Effector Cell-associated Neurotoxicity Syndrome (ICANS).

The current list price for  Tecelra is $727,000. This does not include the pre-treatment or hospitalization costs associated with the administration of the therapy.

Article by Kathy Clark, RN, BSN, CMCN, Vice President, Director of Managed Care. For more information about how this may affect your plan, please contact your Summit ReSources care specialist. The following sources were used as reference material for this article:

[i] FDA Package Insert-Tecelra. https://www.fda.gov/media/180565/download?attachment. Accessed 8/12/2024.

[ii] National Cancer Institute. Synovial Sarcoma. https://www.cancer.gov/pediatric-adult-rare-tumor/rare-tumors/rare-soft-tissue-tumors/synovial-sarcoma#:~:text=Synovial%20sarcoma%20is%20a%20cancer,also%20be%20called%20malignant%20synovioma. Accessed 8/12/2024.

[iii]Blay JY, von Mehren M, Jones RL, Martin-Broto J, Stacchiotti S, Bauer S, Gelderblom H, Orbach D, Hindi N, Dei Tos A, Nathenson M. Synovial sarcoma: characteristics, challenges, and evolving therapeutic strategies. ESMO Open. 2023 Oct;8(5):101618. doi: 10.1016/j.esmoop.2023.101618. Epub 2023 Aug 23. PMID: 37625194; PMCID: PMC10470271. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10470271/ Accessed 8/12/2024.

[iv] Mangla A, Gasalberti DP. Synovial Cell Sarcoma. [Updated 2023 May 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK587366/. Accessed  8/12/2024.

[v] FDA Package Insert-Tecelra. https://www.fda.gov/media/180565/download?attachment. Accessed 8/12/2024.

[vi] FDA. FDA Approves First Gene Therapy to Treat Adults with Metastatic Synovial Sarcoma. https://www.fda.gov/news-events/press-announcements/fda-approves-first-gene-therapy-treat-adults-metastatic-synovial-sarcoma. Accessed 8/12/2024.

GLP-1 Drugs: Where We Are and Where We’re Going

While health plans struggle with coverage questions and the high cost of GLP-1 (glucagon-like peptide-1) drugs, there is no doubt they are not going away. These drugs have caused a revolution in the diabetes and weight loss arenas not only due to their success, but also because of their cost. With many more clinical trials underway to determine if these drugs will be useful in treatment of other diseases, plans should prepare for possible expanded indications in the future and begin to discuss how their coverage decisions may look.

The four most visible and discussed drugs are:

  • Ozempic, which is semaglutide and approved for type 2 diabetes. Manufactured by Novo Nordisk.

  • Wegovy, which is also semaglutide but approved for weight loss. Manufactured by Novo Nordisk.

  • Mounjaro, which is tirzepatide and approved for type 2 diabetes. Manufactured by Eli Lilly.

  • Zepbound, also tirzepatide, approved for weight loss. Manufactured by Eli Lilly.

There is a difference between Ozpempic/Wegovy and Mounjaro/Zepbound. Monjouro/Zepbound is a GIP (glucose-dependent insulinotropic polypeptide) and GLP-1 receptor agonist. Whereas Ozempic and Wegovy are GLP-1 receptor agonists only. They do work in similar ways given both have GLP-1 receptor agonist properties. GLP-1s mimic a hormone produced in the gut to suppress a person’s appetite and regulate blood sugar.

Currently, approximately 80% of plans cover these drugs for type 2 diabetes. Coverage is far less ubiquitous for obesity and weight loss. List price is in the $1000-1300 per month range, with actual net price being lower due to rebates and savings/coupons from the manufacturers. Lilly offers a savings card for those with commercial insurance that does not cover Zepbound. It lists savings up to $563/month, reducing the cost per month to $550.

We are now seeing many more research studies for other indications and treatment with these drugs. Ozempic and Wegovy have recently gained FDA approval for patients with type 2 diabetes and known cardiovascular disease, as well as for adults with established cardiovascular disease and obesity or overweight. These patients are at a greater risk of major cardiovascular events such as stroke, heart attack, or death. Ozempic and Wegovy are proven to significantly lower those risks. Medicare is now paying for these drugs in certain cases, which is new as Medicare has previously been forbidden by law to cover weight loss drugs.

Tirzepatide, the active ingredient in Mounjaro and Zepbound, is now being studied for treatment of kidney disease. Another clinical trial is in progress for Zepbound and its impact on cardiovascular disease. Lilly is anticipating the results of that study in 2025, potentially expanding its labeled indications.

Furthermore, Zepbound is being studied for sleep apnea and, with FDA Fast Track designation, results are expected to be submitted to the FDA midyear 2024. In a Phase 3 study, people on CPAP had a reduction in the average hourly number of apnea episodes by up to 30 (63%) compared with an average reduction of 6 for those who received a placebo. Lilly is also studying Zepbound for treatment of MASH (metabolic associated steatohepatitis) and has met its goal in a Phase 2 study. MASH is a leading cause of liver transplantation.

With the US in the midst of an opioid epidemic in which it is estimated that one person dies of an overdose every five minutes, Penn State College of Medicine is among the first to investigate the potential of GLP-1 drugs for the treatment of addiction. Early results from a small clinical trial look promising and they plan to begin a larger clinical trial later this year of GLP-1 drugs to treat opioid addiction in the outpatient setting.

A recently published retrospective cohort study published in JAMA Network Open on July 5, 2024, noted a decrease in eleven obesity-associated cancers (OACs) in patients taking GLP-1 medications. According to the Centers for Disease Control (CDC), there are thirteen OACs: adenocarcinoma of the esophagus, post-menopausal breast cancer, colorectal cancer, uterine cancer, gallbladder cancer, upper stomach cancer, kidney cancer, ovarian cancer, pancreatic cancer, thyroid cancer, meningioma, and multiple myeloma. GLP-1 drugs were associated with a lower incidence of ten OACs compared to insulin. The study revealed that type 2 diabetes patients prescribed GLP-1 drugs were 65% less likely to get gallbladder cancer and 63% less likely to get meningioma than those prescribed insulin.

Additionally, the risk of pancreatic cancer was 59% lower, and the risk of hepatocellular carcinoma was 53% lower. Other cancers, including ovarian, colorectal, esophageal, endometrial, and kidney, were 48%, 46%, 40%, 36%, and 34% lower, respectively. The risk of multiple myeloma was 41% lower in those taking GLP-1 drugs compared to insulin.

Both Lilly and Novo Nordisk are testing pill forms of these drugs (currently they are given once weekly by subcutaneous injection). This would be appealing to many more people but historically it has been difficult for the body to absorb medication through the gastrointestinal tract. Several other manufacturers have clinical trials in progress for potential competitors. Many of these trials will end with data expected late 2024 and into 2025.

The success of these drugs as a non-invasive treatment for obesity has led to an estimated decrease of 15% in bariatric surgeries. In addition, peripheral businesses are now expanding to serve patients taking these medications. These services include areas such as nutrition coaching, dieticians, behavioral modification, exercise programs, and data collection and analytics to track it all.

Finally, the staggering costs of these popular drugs has come sharply into focus, with US Senator Bernie Sanders leading the charge. In an April 2024 letter to Novo Nordisk, the senator notes that while Novo Nordisk charges $1,349 a month for Wegovy in the US, the drug costs just $187 a month in Denmark, $137 a month in Germany and $92 a month in the UK. Ozempic costs $969 a month in the US compared to just $155 a month in Canada and $59 a month in Germany.

Novo Nordisk’s response suggested that those figures did not take into account the resources spent in the years of research and development, stating it spent $10 billion on development of GLP-1 drugs. Novo Nordisk also stated that it retains 60% of the cost and the other 40% goes to “middlemen” in the complex US health system. The CEO has agreed to testify before the Senate Committee on Health, Education, Labor and Pensions in September 2024.

Looking toward the future, one has only to look at www.ClincalTrials.gov to see the many studies underway and planned for these drugs. Conditions to be studied include the following:

Not only are these drugs are not going away, but there are also several new products in the pipeline. And as indicated by the list above of upcoming trials, there may be several new indications in the near future. Will the upfront cost prevent more serious and ongoing treatment in the future? The answer is yet unclear, but questions like this continue to loom larger. Each plan must review the possibilities and responsibilities it has to its members and organizations in order to make appropriate decisions about coverage.

Article written by Ginny Fisher, RN, BSN, CCM, Managed Care Specialist for Summit Reinsurance Services, Inc. For more information about how this may affect your plan, please contact your Summit ReSources care specialist. The following sources were used as reference material for this article:

  • Biopharma Dive.com

  • JAMA Network Open

  • Penn State Health News

  • Pharmanewsintel.com

  • Morningstar

  • Sanders.senate.gov