Patent Publication Number: US-2023143217-A1

Title: Methods Of Treating Multiple Sclerosis

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application claims the benefit of U.S. Provisional Patent Application No. 63/254,369, filed Oct. 11, 2021, the disclosure of which is incorporated by reference herein. 
    
    
     TECHNICAL FIELD 
     The present disclosure relates to methods of treating multiple sclerosis. 
     BACKGROUND 
     Multiple sclerosis (MS) is a chronic autoimmune inflammatory disease of the central nervous system affecting approximately 2.5 million people worldwide. The disease is clinically perceived by relapses and progressive loss of neurological function, primarily attributed to demyelination, axonal loss, and gliosis culminating in long-term multifocal sclerotic plaques in the brain and spinal cord leading to neurological impairment and severe disability. The two main subtypes of MS are relapsing forms of MS (RMS) which represent 85% of MS patients and include relapsing-remitting disease (RRMS), clinically isolated syndrome, and active secondary progressive disease; and primary progressive MS (PPMS) which affects only 15% of MS patients. 
     Relapses are defined as newly appearing neurological symptoms in the absence of fever or infections that last for more than 24 hours. Relapses may fully recover over days or weeks or lead to persistent residual deficits and accumulation of disability. 
     The natural history of MS is usually divided into two partially overlapping phases, a predominantly inflammatory phase and a predominantly degenerative phase: after an initial phase of relapsing remitting MS, driven by inflammatory mechanism, patients experience a secondary progressive MS characterized by continuous worsening of symptoms independent of the occurrence of relapses, the degenerative phase of MS. Most currently available disease-modifying treatments (DMTs) address the inflammatory phase of MS and are less efficacious in the degenerative phase. 
     Current medical practice encourages early intervention with disease-modifying treatments, with the intent of optimizing long-term clinical outcomes. 
     Key objectives in the management of MS are reducing the rate of relapses and preventing or at least delaying disease progression. Most of the disease-modifying drugs approved for MS have to be administered by injection or infusion (subcutaneous [s.c.], intramuscular [i.m.], or intravenous [i.v.] route). Recently, new disease-modifying drugs administered orally have been approved for RMS. 
     The following injectable drugs have been approved in at least one country for the treatment of MS:
         Interferon (IFN) β-1a 30 mcg i.m. once weekly (Avonex®)   IFN β-1a 22 or 44 mcg s.c. 3 times weekly (Rebif®)   IFN β-1b 250 mcg s.c. every other day (Betaferon®, Extavia®)   Pegylated IFN β-1a 125 mcg subcutaneously every 2 weeks (Plegridy®)   Glatiramer acetate 20 mg s.c. once a day (o.d.) or 40 mg subcutaneously 3 times weekly (Copaxone®)   Glatiramer acetate 20 mg s.c. o.d. (Glatopa®)   Natalizumab 300 mg i.v. every 4 weeks (Tysabri®)   Mitoxantrone i.v. every 3 months (Novantrone®)   Alemtuzumab concentrate for solution for infusion, 12 mg alemtuzumab in 1.2 mL (10 mg/mL) (Lemtrada®)       

     Several oral drugs have also been approved for MS:
         Fingolimod 0.5 mg orally o.d. (Gilenya®)   Teriflunomide 7 mg, 14 mg o.d. (Aubagio®)   Dimethyl fumarate (BG-12) gastro-resistant hard capsules 120/240 mg twice daily (Tecfidera®)   Cladribine 40 to 100 mg orally per treatment week (Mavenclad®)       

     Sphingosine-1-phosphate (SIP) plays a central role in lymphocyte trafficking. SIP is synthesized and secreted by many cell types, including platelets, erythrocytes, and mast cells, and elicits a variety of physiological responses. Lymphocyte egress from primary and secondary lymphoid organs is dependent on the SiP1 receptor. SiP1 receptor modulators block lymphocyte migration out of lymphoid tissue into the lymphatic and vascular circulation, thereby reducing peripheral lymphocyte counts and preventing lymphocyte recruitment to sites of inflammation. Following withdrawal of an SiP1 receptor agonist, the functional lymphocytes return to the circulation from their sites of sequestration. Other functions that do not rely on homing mechanisms, such as antibody generation by B lymphocytes, first-line immunological protection by granulocytes and monocytes, and antigen-dependent T-cell activation and expansion, are not affected by this mechanism. 
     S1P itself induces pleiotropic effects, which are mediated by a family of five G protein-coupled receptors, SiP1-SiP5, located on endothelial cells, vascular and cardiac smooth muscle cells, and cardiac myocytes. The first S1P receptor modulator, fingolimod (FTY720, Gilenya®), which has been approved by the FDA and the EMA for the treatment of MS, is not selective for the S1P1 receptor but interacts with S1P3, S1P4, and S1P5. 
     Ponesimod, an iminothiazolidinone derivative, is an orally active, selective modulator of the S1P1 that induces a rapid, dose-dependent, and reversible reduction in peripheral blood lymphocyte count by blocking the egress of lymphocytes from lymphoid organs. T and B cells are most sensitive to ponesimod mediated sequestration. In contrast, monocyte, natural killer (NK) cell and neutrophil counts are not reduced by ponesimod. Ponesimod is commercially available as PONVORY™, a once-daily oral medication. In the United States the Food and Drug Administration (FDA) has approved PONVORY™ to treat adults with relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease. 
     In the pharmaceutical industry, the path from drug discovery to reaching an approved product is riddled with uncertainty. That path is one that since 2010 and out of more than 12,000 clinical studies, there is very low likelihood of regulatory approval of less than 10% (from Phase 1 to approval). The final path to approval is also not a certainty nor inevitable as failures continue as late as from Phase 3 to approval. This is not only due to the high unpredictability and uncertainty regarding how a pharmaceutical product will impact human biology, but often human behavior is unpredictable in how data is interpreted by regulatory agencies and whether the data warrants approving a study drug as an approved product for use in commerce. 
     SUMMARY 
     The disclosure relates to a pharmaceutical product comprising ponesimod, wherein the pharmaceutical product is packaged, and wherein the package includes a label that identifies ponesimod as an approved product for the treatment of multiple sclerosis. In some embodiments, the patient&#39;s multiple sclerosis is relapsing multiple sclerosis. In other embodiments, the relapsing multiple sclerosis comprises relapsing-remitting disease, clinically isolated syndrome, or active secondary progressive disease. 
     The disclosure provides methods for treating multiple sclerosis in a patient in need thereof, comprising administering an approved product comprising ponesimod in an amount and manner that is described in a drug product label for the approved product and/or in a treatment regimen described herein. 
     The disclosure also provides methods of selling an approved product comprising ponesimod, said method comprising selling such drug product, wherein a drug product label for a reference listed drug for such drug product includes instructions for treating a patient with multiple sclerosis. 
     The disclosure further provides methods of offering for sale a drug product comprising ponesimod, said method comprising offering for sale such drug product, wherein a drug product label for a reference listed drug for such drug product includes instructions for treating a patient with multiple sclerosis. 
     The disclosure further provides methods for reducing clinical management events and/or for easing use of drug treatment for treating multiple sclerosis in a patient in need thereof, comprising administering ponesimod in an amount and manner that is described in a drug product label for an approved product and/or in a treatment regimen described herein, namely administration of about 20 mg of ponesimod orally once daily, with or without utilization of the up-titration dosing procedure also described herein. 
     The disclosure is also directed to an approved drug product as defined herein, wherein the pharmaceutical product comprises ponesimod in tablet form. 
     The disclosure also provides methods for concomitant treatment of a beta-blocker and ponesimod in a patient in need thereof, wherein the patient is being treated with the beta-blocker and ponesimod treatment is to be initiated, and wherein the patient has a resting heart rate of greater than 55 beats per minute during treatment with the beta-block and prior to initiation of ponesimod, comprising administering ponesimod without interruption to the beta-blocker treatment. 
     In other embodiments, the disclosure is directed to methods for concomitant treatment of a beta-blocker and ponesimod for a patient in need thereof, wherein the patient is being treated with the beta-blocker and ponesimod treatment is to be initiated, and wherein the patient has a resting heart rate of less than or equal to 55 beats per minute during treatment with the beta-block and prior to initiation of ponesimod, comprising interrupting the beta-blocker treatment until the patient&#39;s heart rate is greater than 55 beats per minute and initiating ponesimod treatment in a titration regimen comprising administering orally once daily 2 mg of ponesimod on days 1 and 2; 3 mg of ponesimod on days 3 and 4; 4 mg of ponesimod on days 5 and 6; 5 mg of ponesimod on day 7; 6 mg of ponesimod on day 8; 7 mg of ponesimod on day 9; 8 mg of ponesimod on day 10; 9 mg of ponesimod on day 11; and 10 mg of ponesimod on days 12, 13, and 14, followed by administering a 20 mg maintenance dose of ponesimod once daily thereafter, and reinitiating the beta-blocker after ponesimod has been up-titrated to the maintenance dosage. 
     The disclosure also relates to methods of treating multiple sclerosis in a patient in need thereof, wherein the patient has sinus bradycardia, first or second degree AV block, or a history of myocardial infarction or heart failure occurring more than 6 months prior to the initiation of ponesimod treatment, comprising administering an effective regimen of ponesimod to the patient, wherein after a first dose of the ponesimod, the patient is monitored for a period of 4 hours for symptoms of bradycardia. In other embodiments, no first dose monitoring is needed wherein the patient has no sinus bradycardia, no first or second degree AV block, and no history of myocardial infarction or heart failure occurring more than 6 months prior to the initiation of ponesimod treatment. 
     The disclosure further provides methods of reinitiating treatment with ponesimod following a missed dose in a patient in need thereof, wherein the patient is being treated with an oral, once daily 20 mg maintenance dose and fewer than four consecutive maintenance doses have been missed, comprising resuming treatment with the maintenance dose. 
     In other embodiments, the disclosure is directed to methods of reinitiating ponesimod following a missed dose for a patient in need thereof, wherein the patient is being treated with an oral, once daily 20 mg maintenance dose or a 14-day titration regimen comprising administering orally once daily titration doses of 2 mg of ponesimod on days 1 and 2; 3 mg of ponesimod on days 3 and 4; 4 mg of ponesimod on days 5 and 6; 5 mg of ponesimod on day 7; 6 mg of ponesimod on day 8; 7 mg of ponesimod on day 9; 8 mg of ponesimod on day 10; 9 mg of ponesimod on day 11; and 10 mg of ponesimod on days 12, 13, and 14, and four or more consecutive maintenance doses or titration doses have been missed, comprising reinitiating ponesimod with the 14-day titration regimen. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG.  1    shows the testing strategy for the study described in Example 1. 
         FIG.  2 A  shows an overview of primary and main supplementary analyses of relapses (Forest plot with 99% CL). In  FIG.  2 A , n(Pon)=No. of subjects in ponesimod arm; rate(Pon)=mean rate in ponesimod arm; n(Ter)=No. of subjects in teriflunomide arm; and rate(Ter)=mean rate in teriflunomide arm. *=Conducted on the Per Protocol Set; **=Relapses with missing EDSS are imputed as confirmed relapses.  FIG.  2 B  shows the conceptual framework for the Fatigue Symptoms and Impact Questionnaire−Relapsed Multiple Sclerosis (FSIQ-RMS); *=items also present in physical impacts subdomain. 
         FIG.  3 A  shows change from baseline up to week 108 for the FSIQ-RMS weekly symptoms score by visit. MMRM (Main analysis) Analysis Set: Full Analysis Set. In  FIG.  3 A , subjects with available baseline and at least one post-baseline result are included in the analysis, whereby MMRM=mixed effects repeated measurements model with unstructured covariance, treatment, visit, treatment by visit interaction, baseline by visit interaction as fixed effects, baseline FSIQ score, EDSS strata (&lt;=3.5, &gt;3.5), DMT in last 2 years prior randomization strata (Y,N) as covariates. 
         FIG.  3 B  shows cumulative distribution function of change from baseline at week 108 for the FSIQ-RMS weekly symptoms score. 
         FIG.  4    is a Kaplan-Meier curve (main analysis) showing the time to first 12-week confirmed disability accumulation (CDA) up to end-of-study (EOS): Analysis Set: Full Analysis Set. In  FIG.  4   , an event=12 week CDA and subjects without event are censored at their last EDSS assessment without EDSS increase. Unstratified Kaplan-Meier estimates are presented. Bars on graph display pointwise 95% confidence intervals of the estimate. P-value is two-sided and based on the stratified log-rank test. Hazard ratio estimate obtained from stratified Cox regression with Wald confidence limits. Analysis is stratified by EDSS strata (&lt;3.5; &gt;3.5) and disease modifying therapy in last 2 years prior to randomization strata (Y,N). 
         FIG.  5    is a Kaplan-Meier curve (Main analysis) showing the time to first 24-week CDA up to EOS: Analysis Set: Full Analysis Set. In  FIG.  5   , an event=24 week CDA and subjects without event are censored at their last EDSS assessment without EDSS increase. Unstratified Kaplan-Meier estimates are presented. Bars on graph display pointwise 95% confidence intervals of the estimate. P-value is two-sided and based on the stratified log-rank test. Hazard ratio estimate obtained from stratified Cox regression with Wald confidence limits. Analysis is stratified by EDSS strata (&lt;3.5; &gt;3.5) and disease modifying therapy in last 2 years prior to randomization strata (Y,N). 
         FIG.  6    shows the 12-lead electrocardiogram (ECG) heart rate and absolute change from pre-dose at Day 1, by hour (Analysis Set: Safety Set). As per up-titration regimen, the dose of ponesimod on Day 1 is 2 mg. 
         FIG.  7    is a Forest plot (with 99% CL) showing an overview of primary and sensitivity analyses for confirmed relapses up to EOS (Analysis Set: Full Analysis Set). In  FIG.  7   , n(Pon)=subjects in ponesimod group; rate(Pon)=annualized relapse rate in ponesimod group; n(Ter)=subjects in teriflunomide group and rate(Ter)=annualized relapse rate in teriflunomide group. The vertical solid line references the treatment effect from the main analysis. Negative binomial model is applied with Wald confidence limits, offset: log time (years) up to EOS. The main analysis is adjusted for the following covariates: EDSS strata (&lt;3.5; &gt;3.5); DMT in last 2 years prior to randomization strata (Y,N); and number of relapses in year prior to study entry (&lt;1; &gt;2). 
         FIG.  8    is a Forest plot (with 99% CL) showing subgroup analyses of confirmed relapses up to EOS (Analysis Set: Full Analysis Set). In  FIG.  8   , p*=interaction p-value; n(Pon)=no. of subjects in ponesimod group; rate(Pon)=mean rate in ponesimod group; n(Ter)=no. of subjects in teriflunomide group and rate(Ter)=mean rate in teriflunomide group. Negative binomial model is applied with Wald confidence limits, offset: log time (years) up to EOS, in each subgroup separately. Interaction p-value is from likelihood ratio test of interaction term in model with treatment, subgroup and treatment by subgroup interactions. The vertical solid line references the treatment effect from the main analysis. The main analysis is adjusted for the following covariates: EDSS strata (&lt;3.5; &gt;3.5); DMT in last 2 years prior to randomization strata (Y,N); and number of relapses in year prior to study entry (&lt;1; &gt;2). Analyses in subgroups are not adjusted for covariates. 
         FIG.  9    shows change from baseline to week 108 in the FSIQ-RMS for the physical impact sub-domain. 
         FIG.  10    shows change from baseline to week 108 in the FSIQ-RMS for the cognitive/emotional impacts sub-domain. 
         FIG.  11    shows change from baseline to week 108 in the FSIQ-RMS for the coping impact sub-domain. 
         FIG.  12    shows change from baseline to week 108 in FSIQ-RMS weekly symptoms score for patients with baseline fatigue below the median. 
         FIG.  13    shows cumulative distribution function of change from baseline at week 108 in FSIQ-RMS weekly symptoms score for patients with baseline fatigue below the median. 
         FIG.  14    shows change from baseline to week 108 in FSIQ-RMS weekly symptoms score for patients with baseline fatigue above the median. 
         FIG.  15    shows cumulative distribution function of change from baseline at week 108 in FSIQ-RMS weekly symptoms score for patients with baseline fatigue above the median. 
         FIG.  16    shows change from baseline to week 108 in FSIQ-RMS weekly symptoms score for patients without DMT treatment two years prior to randomization. 
         FIG.  17    shows cumulative distribution function of change from baseline at week 108 in FSIQ-RMS weekly symptoms score for patients without DMT treatment two years prior to randomization. 
         FIG.  18    shows change from baseline to week 108 in FSIQ-RMS weekly symptoms score for patients without Gd+/T1 lesions at baseline. 
         FIG.  19    shows cumulative distribution function of change from baseline at week 108 in FSIQ-RMS weekly symptoms score for patients without Gd+/T1 lesions at baseline. 
         FIG.  20    shows change from baseline to week 108 in FSIQ-RMS weekly symptoms score for patients with Gd+/T1 lesions at baseline. 
         FIG.  21    shows cumulative distribution function of change from baseline at week 108 in FSIQ-RMS weekly symptoms score for patients with Gd+/T1 lesions at baseline. 
         FIG.  22    shows change from baseline to week 108 in FSIQ-RMS weekly symptoms score for patients with baseline EDSS ≤3.5. 
         FIG.  23    shows cumulative distribution function of change from baseline at week 108 in FSIQ-RMS weekly symptoms score for patients with baseline EDSS ≤3.5. 
         FIG.  24    shows change from baseline to week 108 in FSIQ-RMS weekly symptoms score for patients having one or fewer relapses at baseline. 
         FIG.  25    shows cumulative distribution function of change from baseline at week 108 in FSIQ-RMS weekly symptoms score for patients having one or fewer relapses at baseline. 
         FIG.  26    shows change from baseline to week 108 in FSIQ-RMS weekly symptoms score for patients having two or more relapses at baseline. 
         FIG.  27    shows cumulative distribution function of change from baseline at week 108 in FSIQ-RMS weekly symptoms score for patients having two or more relapses at baseline. 
         FIG.  28    depicts a bar graph of the total number of differential events in each of the administrative claims databases for each S1P. 
     
    
    
     DETAILED DESCRIPTION OF ILLUSTRATIVE EMBODIMENTS 
     In the present disclosure the singular forms “a”, “an,” and “the” include the plural reference, and reference to a particular numerical value includes at least that particular value, unless the context clearly indicates otherwise. Thus, for example, a reference to “a material” is a reference to at least one of such materials and equivalents thereof known to those skilled in the art, and so forth. 
     When a value is expressed as an approximation by use of the descriptor “about” or “substantially” it will be understood that the particular value forms another embodiment. In general, use of the term “about” or “substantially” indicates approximations that can vary depending on the desired properties sought to be obtained by the disclosed subject matter and is to be interpreted in the specific context in which it is used, based on its function. The person skilled in the art will be able to interpret this as a matter of routine. In some cases, the number of significant figures used for a particular value may be one non-limiting method of determining the extent of the word “about” or “substantially”. In other cases, the gradations used in a series of values may be used to determine the intended range available to the term “about” or “substantially” for each value. Where present, all ranges are inclusive and combinable. That is, references to values stated in ranges include every value within that range. 
     When a list is presented, unless stated otherwise, it is to be understood that each individual element of that list and every combination of that list is to be interpreted as a separate embodiment. For example, a list of embodiments presented as “A, B, or C” is to be interpreted as including the embodiments, “A,” “B,” “C,” “A or B,” “A or C,” “B or C,” or “A, B, or C.” 
     It is to be appreciated that certain features of the disclosure which are, for clarity, described herein in the context of separate embodiments, may also be provided in combination in a single embodiment. That is, unless obviously incompatible or excluded, each individual embodiment is deemed to be combinable with any other embodiments and such a combination is considered to be another embodiment. Conversely, various features of the disclosure that are, for brevity, described in the context of a single embodiment, may also be provided separately or in any sub-combination. It is further noted that the claims may be drafted to exclude any optional element. As such, this statement is intended to serve as antecedent basis for use of such exclusive terminology as “solely,” “only” and the like in connection with the recitation of claim elements, or use of a “negative” limitation. Finally, while an embodiment may be described as part of a series of steps or part of a more general structure, each said step may also be considered an independent embodiment in itself. 
     In some aspects, the present disclosure is directed to methods of avoiding worsening of fatigue-related symptoms in a human patient suffering from multiple sclerosis and fatigue, comprising, optionally, assessing the fatigue-related symptoms of the patient; and administering an effective regimen of ponesimod to the patient, wherein the regimen is sufficient to avoid worsening of the fatigue-related symptoms. As described herein, fatigue is fatigue associated with multiple sclerosis. 
     In certain aspects, the methods are directed to patients that have had no prior disease modifying treatment (DMT) for multiple sclerosis within about two years prior to initiation of treatment with ponesimod. In some embodiments, the methods are directed to patients that have a baseline expanded disability status scale (EDSS) score of &lt;3.5 prior to initiation of treatment with ponesimod. In other embodiments, the methods are directed to patients that have no Gd+/T1 lesions prior to initiation of treatment with ponesimod. Baseline refers to a time period prior to initiation of treatment with ponesimod and/or standard of care treatment. This time period is typically up to about 45 days prior to initiation of treatment, including, for example, up to about 40 days, up to about 35 days, up to about 30 days, up to about 25 days, up to about 20 days, up to about 15 days, or up to about 10 days prior to initiation of treatment with ponesimod and/or standard of care treatment. 
     In other aspects, the present disclosure is directed to methods of reducing the number of combined unique active lesions (CUALs) in a patient suffering from multiple sclerosis, comprising administering an effective regimen of ponesimod to the patient, wherein the regimen is sufficient to reduce the number of CUALs by at least 40% relative to a patient population at substantially the same level of disease progression receiving a standard of care treatment that does not comprise ponesimod. 
     In some aspects, the methods of the disclosure are performed on a human patient suffering from multiple sclerosis. In some embodiments, the patient&#39;s multiple sclerosis is relapsing multiple sclerosis. In other embodiments, the relapsing multiple sclerosis comprises relapsing-remitting disease, clinically isolated syndrome, or active secondary progressive disease. 
     As used herein, the term “avoiding worsening of fatigue-related symptoms” refers to preventing the patient&#39;s fatigue-related symptoms from becoming worse relative to the patient&#39;s fatigue-related symptoms at baseline, wherein baseline refers to a time period prior to initiation of treatment with ponesimod. This time period is typically up to about 45 days prior to initiation of treatment with ponesimod, including, for example, up to about 40 days, up to about 35 days, up to about 30 days, up to about 25 days, up to about 20 days, up to about 15 days, or up to about 10 days prior to initiation of treatment with ponesimod. By avoiding worsening, the methods otherwise relate to stabilizing or improving fatigue-related symptoms. 
     In some embodiments of the methods of the disclosure, the patient&#39;s fatigue-related symptoms are assessed. In some embodiments of the methods of the disclosure, the patient&#39;s fatigue-related symptoms are not assessed prior to initiation of treatment with ponesimod. As used herein, “fatigue-related symptoms” refer to symptoms of fatigue experienced by the patient. 
     In some aspects, the fatigue-related symptoms are symptoms experienced by the patient while doing routine daily activities (e.g. housework, yard work, shopping, working). In some embodiments, the fatigue-related symptoms are those experienced by the patient while doing routine daily activities and include being physically tired, being mentally tired, being physically weak, lacking energy, feeling worn out, or feeling sleepy. 
     In other embodiments, the fatigue-related symptoms are (1) being physically tired, (2) being mentally tired, (3) being physically weak, (4) lacking energy, (5) feeling worn out, (6) feeling sleepy while doing routine daily activities, and (7) feeling worn out while at rest. 
     In some embodiments, the patient&#39;s fatigue-related symptoms are assessed before initiation of ponesimod administration, for example, at baseline. In other embodiments, the patient&#39;s fatigue-related symptoms are assessed after initiation of ponesimod administration to, for example monitor the fatigue-related symptoms during the treatment with ponesimod. In some embodiments, the patient&#39;s fatigue-related symptoms are assessed both before initiation of ponesimod administration and after initiation of ponesimod therapy. 
     The patient&#39;s fatigue-related symptoms may be assessed by ascertaining from the patient the nature and severity of any symptoms of fatigue experienced by the patient. In some embodiments, the patient&#39;s fatigue-related symptoms are assessed using a patient-reported outcome (PRO) questionnaire. 
     In some embodiments, the patient-reported outcome questionnaire is the Fatigue Symptoms and Impact Questionnaire—Relapsing Multiple Sclerosis (FSIQ-RMS) (available from Mapi Research Trust). The FSIQ-RMS is an MS specific 20-item PRO measure that comprises 2 domains: one measuring MS symptoms and one measuring MS-related impacts. See Hudgens S, et al.,  Development and Validation of the FSIQ - RMS: A New Patient - Reported Questionnaire to Assess Symptoms and Impacts of Fatigue in Relapsing Multiple Sclerosis. Value Health.  2019 April; 22(4):453-466. doi: 10.1016/j.jval.2018.11.007. Epub 2019 Feb. 21. PubMed PMID: 30975397. With 7 symptom items and 13 impact items (in 3 impacts subdomains: physical, cognitive and emotional, and coping), the FSIQ-RMS is a comprehensive, valid, and reliable measure of fatigue-related symptoms and impacts in RMS patients.  FIG.  2 B  depicts a conceptual framework for the FSIQ-RMS. 
     In some embodiments, the patient-reported outcome questionnaire is the symptom domain of the FSIQ-RMS. The FSIQ-RMS symptom domain (FSIQ-RMS-S) consists of seven items assessing fatigue-related symptoms with a recall period of 24 hours measured on an 11-point numeric rating scale; the standardized symptom domain score ranges from 0 to 100 with a higher score indicating greater fatigue. This domain (i.e., section 1 of the questionnaire) is completed on 7 consecutive days. 
     The FSIQ-RMS impact domain (FSIQ-RMS-I) consists of 13 items assessing impacts of fatigue-related symptoms with a recall period of 7 days measured on a 5-point verbal descriptor scale, the standardized impact domain score ranges from 0 to 100 with a higher score indicating greater impact. 
     In some aspects of the methods of the present disclosure, the patient is administered an effective regimen of ponesimod. An effective regimen is one that elicits the biological or medicinal response in a human tissue system that is being sought by a researcher, medical doctor, or other clinician, which includes alleviation of one or more symptoms of the disease or disorder being treated. 
     As used herein, the term “ponesimod” refers to the compound (R)-5-[3-chloro-4-(2,3-dihydroxy-propoxy)-benz[Z]ylidene]-2-([Z]-propylimino)-3-o-tolyl-thiazolidin-4-one, which has the following structure: 
     
       
         
         
             
             
         
       
     
     In some embodiments, “ponesimod” also refers to pharmaceutically acceptable salts of ponesimod. The term “pharmaceutically acceptable salt” refers to salts that retain the desired biological activity of the subject compound and exhibit minimal undesired toxicological effects. Such salts include inorganic or organic acid and/or base addition salts depending on the presence of basic and/or acidic groups in the subject compound. For reference see for example Handbook of Pharmaceutical Salts. Properties, Selection and Use, P. Heinrich Stahl, Camille G. Wermuth (Eds.), Wiley-VCH, 2008 and Pharmaceutical Salts and Co-crystals, Johan Wouters and Luc Quéré (Eds.), RSC Publishing, 2012. 
     It is to be understood that the present disclosure encompasses ponesimod in any form including amorphous as well as crystalline forms. It is further to be understood that crystalline forms of ponesimod encompasses all types of crystalline forms including polymorphs, solvates and hydrates, salts and co-crystals (when the same molecule can be co-crystallized with different co-crystal formers) provided they are suitable for pharmaceutical administration. In some embodiments, ponesimod is in crystalline form A or crystalline form C as described in WO 2010/046835, incorporated herein by reference. In some embodiments, ponesimod is in crystalline form C. 
     It should be noted that the amounts of ponesimod described herein are set forth on a ponesimod free base basis. That is, the amounts indicate that amount of the ponesimod molecule administered, exclusive of, for example, solvent (such as in solvates) or counterions (such as in pharmaceutically acceptable salts). 
     In some embodiments, the effective regimen comprises a daily dose of ponesimod. In some embodiments, the daily dose of ponesimod is administered orally. 
     In some embodiments, the daily dose of ponesimod is administered once daily. 
     In some embodiments, the daily dose of ponesimod is about 15 to about 25 mg. In further embodiments, the daily dose of ponesimod is about 15 mg, about 16 mg, about 17 mg, about 18 mg, about 19 mg, about 20 mg, about 21 mg, about 22 mg, about 23 mg, about 24 mg, or about 25 mg. In certain embodiments, the daily dose of ponesimod is about 20 mg. 
     In some embodiments, about 20 mg of ponesimod is administered orally once daily. 
     In other embodiments, the effective regimen comprises an up-titration, followed by a daily maintenance dose of ponesimod. An up-titration is a dosing procedure in which the daily dose of ponesimod is gradually increased over a period of days, culminating with administration of the maintenance dose. 
     In some embodiments, the regimen comprises an up-titration at the initiation of the method of the disclosure. In other embodiments, the regimen comprises an up-titration upon re-initiation of the method after a discontinuation of the method of the disclosure. As used herein, “upon re-initiation of the method after a discontinuation” means an interruption of the administration of ponesimod of at least one, at least two or preferably at least 3 days before treatment is re-initiated. In some embodiments, the regimen comprises an up-titration step at initiation of the method or upon re-initiation of the method after a discontinuation. 
     In some embodiments of the methods of the disclosure, the up-titration regimen one disclosed in U.S. Pat. No. 10,220,023, incorporated herein by reference. For example, in certain aspects, the up-titration comprises administering orally once daily about 2 mg of ponesimod on days 1 and 2; about 3 mg of ponesimod on days 3 and 4; about 4 mg of ponesimod on days 5 and 6; about 5 mg of ponesimod on day 7; about 6 mg of ponesimod on day 8; about 7 mg of ponesimod on day 9; about 8 mg of ponesimod on day 10; about 9 mg of ponesimod on day 11; and about 10 mg of ponesimod on days 12, 13, and 14. 
     In other embodiments of the methods of the disclosure, the up-titration comprises administering orally once daily 2 mg of ponesimod on days 1 and 2; 3 mg of ponesimod on days 3 and 4; 4 mg of ponesimod on days 5 and 6; 5 mg of ponesimod on day 7; 6 mg of ponesimod on day 8; 7 mg of ponesimod on day 9; 8 mg of ponesimod on day 10; 9 mg of ponesimod on day 11; and 10 mg of ponesimod on days 12, 13, and 14. 
     In some embodiments, the maintenance dose is about 20 mg of ponesimod once daily. 
     In some embodiments, the regimen comprises an up-titration step at initiation of the method or upon re-initiation of the method after a discontinuation, comprising administering orally once daily 2 mg of ponesimod on days 1 and 2; 3 mg of ponesimod on days 3 and 4; 4 mg of ponesimod on days 5 and 6; 5 mg of ponesimod on day 7; 6 mg of ponesimod on day 8; 7 mg of ponesimod on day 9; 8 mg of ponesimod on day 10; and 9 mg of ponesimod on day 11; 10 mg of ponesimod on days 12, 13, and 14, followed by the administering of the 20 mg of ponesimod once daily thereafter. 
     In some aspects of the disclosed methods, the regimen is sufficient to avoid worsening of the fatigue-related symptoms. A regimen is sufficient to avoid worsening of the fatigue-related symptoms when the patient&#39;s fatigue-related symptoms (assessed as described herein) after administration of the ponesimod regimen, are either improved or unchanged compared to the patient&#39;s fatigue-related symptoms (assessed as described herein) prior to administration of the ponesimod regimen, for example, at baseline. 
     In other embodiments, the methods of the disclosure are directed to reducing the number of combined unique active lesions (CUALs) in a patient. 
     CUALs are new Gd+T1 lesions plus new or enlarging T2 lesions (without double-counting of lesions). The cumulative number of CUAL is considered a reliable outcome measure of inflammatory MS disease activity. Radiological evidence of disease activity is routinely used to support disease diagnosis and to inform therapeutic decisions targeting no evidence of disease activity (NEDA), clinical (relapses or disability accumulation) or radiological (brain lesions on MRI) perspective. See Lublin F D.  Disease activity free status in MS . Mult Scler Relat Disord. 2012 January; 1(1):6-7. doi: 10.1016/j.msard.2011.08.001. Epub 2011 Aug. 27. PubMed PMID: 25876444. 
     CUALs are detected using magnetic resonance imaging (MRI) techniques. 
     In this aspect of the disclosed methods, the ponesimod regimen administered to the patient is sufficient to reduce the number of CUALs by at least 40% relative to a patient population at substantially the same level of disease progression receiving a standard of care treatment. That is, the patient administered the ponesimod regimen will have acquired at least 40% fewer CUALs as compared to a patient having substantially the same degree of MS progression who is receiving a standard of care treatment. 
     In some embodiments, the ponesimod regimen administered to the patient is sufficient to reduce the number of CUALs by at least 20% to about 65% relative to a patient population at substantially the same level of disease progression receiving a standard of care treatment. In some embodiments, the ponesimod regimen administered to the patient is sufficient to reduce the number of CUALs by at least 30% relative to a patient population at substantially the same level of disease progression receiving a standard of care treatment. In some embodiments, the ponesimod regimen administered to the patient is sufficient to reduce the number of CUALs by at least 50% relative to a patient population at substantially the same level of disease progression receiving a standard of care treatment. In some embodiments, the ponesimod regimen administered to the patient is sufficient to reduce the number of CUALs by at least 55% relative to a patient population at substantially the same level of disease progression receiving a standard of care treatment. 
     As used herein, the term “standard of care treatment” refers to a physician-prescribed treatment of MS. In some embodiments, the standard of care comprises, consists of, or consists essentially of administering an MS treatment that has been approved by a regulatory authority. In some embodiments, the standard of care treatment is Interferon (IFN) β-1a 30 mcg i.m. once weekly (Avonex®), IFN β-1a 22 or 44 mcg s.c. 3 times weekly (Rebif®), IFN β-1b 250 mcg s.c. every other day (Betaferon®, Extavia®), Pegylated IFN β-1a 125 mcg subcutaneously every 2 weeks (Plegridy®), Glatiramer acetate 20 mg s.c. once a day (o.d.) or 40 mg subcutaneously 3 times weekly (Copaxone®), Glatiramer acetate 20 mg s.c. o.d. (Glatopa®), Natalizumab 300 mg i.v. every 4 weeks (Tysabri®), Mitoxantrone i.v. every 3 months (Novantrone®), Alemtuzumab concentrate for solution for infusion, 12 mg alemtuzumab in 1.2 mL (10 mg/mL) (Lemtrada®), Fingolimod 0.5 mg orally o.d. (Gilenya®), Teriflunomide 7 mg, 14 mg o.d. (Aubagio®), Dimethyl fumarate (BG-12) gastro-resistant hard capsules 120/240 mg twice daily (Tecfidera®), or Cladribine 40 to 100 mg orally per treatment week (Mavenclad®). 
     In some embodiments, the standard of care treatment comprises a S1P receptor modulator that is not ponesimod. 
     In other embodiments, the standard of care treatment comprises teriflunomide. In some embodiments, the standard of care treatment comprises administration of about 14 mg of teriflunomide orally once daily. 
     In some embodiments, the patient has had no prior disease modifying treatment (DMT) for multiple sclerosis. In some embodiments, the patient has had no prior disease modifying treatment (DMT) for multiple sclerosis within about two years prior to initiation of treatment with ponesimod. In some embodiments, patients that have had no prior DMT for multiple sclerosis realize improved efficacy from use of ponesimod to address fatigue with respect to a standard of care treatment that does not comprise ponesimod, such as teriflunomide. Accordingly, with respect to these patients and others, the disclosed methods provide health care providers with options for improved outcomes compared to standard of care. 
     In some embodiments, the methods are directed to patients having a baseline expanded disability status scale (EDSS) score of &lt;3.5. In some embodiments, the methods are directed to patients having no Gd+/Tl lesions at baseline. 
     The present disclosure also provides pharmaceutical products comprising ponesimod. Typically, the pharmaceutical product is a package or is packaged, for example, a bottle, a pouch, or a blister pack. 
     In some embodiments, the package includes instructions. In certain embodiments, instructions are for administering ponesimod to a human patient suffering from multiple sclerosis and fatigue in a regimen that is effective to avoid worsening of fatigue-related symptoms. In other embodiments, the package provides instructions and/or fatigue-related symptom data directed to patients having had no prior disease modifying treatment (DMT) for multiple sclerosis for a period of about two years. In further embodiments, the package provides instructions and/or fatigue-related symptom data directed to patients having a baseline expanded disability status scale (EDSS) score of &lt;3.5. In yet other embodiments, the package provides instructions and/or fatigue-related symptom data directed to patients having no Gd+/T1 lesions at baseline. 
     As used herein, the term “group level” refers to a group level change or difference between groups of patients, e.g., group level differences in an outcome seen in clinical trials when comparing the treatment groups. For instance,  FIG.  3 A  shows the mean change from baseline for ponesimod 20 mg and teriflunomide 14 mg over time—and it visually shows the separation or difference in change from baseline in the treatment groups. 
     As used herein, the term “patient level” refers to individual or within patient level of change. As used herein, “clinically meaningful” refers to the practical importance of a treatment effect and whether it has a real genuine, palpable, noticeable effect on symptoms and/or daily life. When interpreting data from a Patient Reported Outcome (PRO), for example, it is helpful to define a level of change on the PRO score over a predetermined time period that should be interpreted as a treatment benefit. Various terms are used for this level of change, including meaningful change threshold (MCT). Ibis threshold can be used to conduct a responder analysis where an individual patient is a responder if the level of change on the PRO score for that patient exceeds the MCT. The proportion of responders between treatment groups can be compared to evaluate treatment effect. For example, in certain embodiments disclosed herein, there is an analysis of the percentage of responders in the ponesimod and teriflunomide treatment groups using an MCT of −6.3 on the FSIQ-RMS weekly symptom score. The percentage of subjects in the stable or improved category is also calculated. And the percentage of responders can also be visualized on a graph (a cumulative distribution function) which shows the cumulative percentage of patients showing all possible levels of change in the respective treatment groups. Accordingly, evaluation of within patient changes using MCT and associated responder analyses are used to provide additional interpretation to a p-value derived from a statistical test 
     As used herein, the term “statistically significant” refers to the likelihood that a relationship between two or more variables is caused by something other than chance. A p-value less than 0.05 (typically &lt;0.05) is a common metric for statistical significance and is indicative of strong evidence against the null hypothesis, as there is less than a 5% probability the null is correct (and the results are random). 
     As used herein, unless otherwise noted, the terms “treating”, “treatment” and the like, shall include the management and care of a subject or patient (preferably mammal, more preferably human) for the purpose of combating a disease, condition, or disorder and includes the administration of a compound described herein to prevent the onset of the symptoms or complications, alleviate one or more of the symptoms or complications, or eliminate the disease, condition, or disorder. 
     The disclosure further relates to a pharmaceutical product comprising ponesimod, wherein the pharmaceutical product is packaged, and wherein the package includes a label that identifies ponesimod as a an approved product for the treatment of multiple sclerosis. In some embodiments, the patient&#39;s multiple sclerosis is relapsing multiple sclerosis. In other embodiments, the relapsing multiple sclerosis comprises relapsing-remitting disease, clinically isolated syndrome, or active secondary progressive disease. 
     The disclosure provides methods for treating multiple sclerosis in a patient in need thereof, comprising administering an approved product comprising ponesimod in an amount and manner that is described in a drug product label for the approved product and/or in a treatment regimen described herein. 
     In certain aspects, methods of selling a drug product comprising ponesimod are also provided. The terms “sale” or “selling” as used herein refers to transferring a drug product, e.g., a pharmaceutical composition or a dosage form, from a seller to a buyer. In some embodiments, a drug product label for a reference listed drug for the drug product includes instructions for the treatment of multiple sclerosis. 
     The term “offering for sale,” as used herein, refers to the proposal of a sale by a seller to a buyer for a drug product, e.g., a pharmaceutical composition or a dosage form. These methods comprise offering the drug product for sale. 
     The term “drug product” is product that contains an active pharmaceutical ingredient that has been approved for marketing by a governmental authority, e.g., the Food and Drug Administration or the similar authority in other countries. In the context of the present disclosure, and as reflected in Example 4, an “approved drug product” as used herein means: a pharmaceutical product that i) has been approved for introduction into commerce by a regulatory agency for use in treating adult humans with relapsing forms of multiple sclerosis, to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease; ii) has an oral, once daily maintenance dosage of 20 mg of ponesimod and, optionally, a 14-day dose titration prior to the maintenance dosage of 20 mg, comprising administering orally, once daily 2 mg of ponesimod on days 1 and 2; 3 mg of ponesimod on days 3 and 4; 4 mg of ponesimod on days 5 and 6; 5 mg of ponesimod on day 7; 6 mg of ponesimod on day 8; 7 mg of ponesimod on day 9; 8 mg of ponesimod on day 10; 9 mg of ponesimod on day 11; 10 mg of ponesimod on days 12, 13, and 14, followed by the 20 mg maintenance dosage of ponesimod on Day 15 and thereafter; and (iii) demonstrated a statistically significant lower annualized relapse rate (ARR), and, optionally, a statistically significant lower number of Gd-enhancing T1 lesions and/or a statistically significant lower number of new or enlarging T2 lesions, without double counting of lesions, in a patient population with relapsing forms of MS, wherein the patients had an expanded disability status scale (EDSS) score of 0 to 5.5 at baseline, had experienced at least one relapse within the year prior, or two relapses within the prior 2 years, or who had at least one gadolinium-enhancing (Gd-enhancing) lesion on a brain MRI within the prior 6 months or at baseline, wherein patients with primary progressive MS were excluded, compared to the patients in the patient population that were administered a once daily 14 mg dosage of teriflunomide. Elements of the approved drug product are further defined in Example 4, Section 14, including Table 4 therein. 
     In particular embodiments of the approved drug product, the patients in the patient population were treated for 108 weeks and ARR was reduced by 30.5% compared to teriflunomide 14 mg. 
     Similarly, “label” or “drug product label” refers to information provided to a patient which provides relevant information regarding the drug product. Such information includes, without limitation, one or more of the description of the drug,  clinical pharmacology , indications (uses for the drug product), contraindication (who should not take the drug product), warnings, precautions, adverse events (side effects), drug abuse and dependence, dosage and administration, use in pregnancy, use in nursing mothers, use in children and older patients, how the drug is supplied, safety information for the patient, or any combination thereof. In certain embodiments, the label or drug product label provides an instruction for use in a patient requiring multiple sclerosis medication. In further embodiments, the label or drug product label identifies ponesimod and provides instructions for its use in a patient requiring multiple sclerosis medication. 
     The term “reference listed drug” or “RLD” as used herein refers to a drug product to which new generic versions are compared to show that they are bioequivalent. It is also a medicinal product that has been granted marketing authorization by a member state of the European Union or by the Commission on the basis of a completed dossier, i.e., with the submission of quality, pre-clinical and clinical data in accordance with Articles 8(3), 10a, 10b or 10c of Directive 2001/83/EC and to which the application for marketing authorization for a generic/hybrid medicinal product refers, by demonstration of bioequivalence, usually through the submission of the appropriate bioavailability studies. 
     In the United States, a company seeking approval to market a generic equivalent must refer to the RLD in its Abbreviated New Drug Application (ANDA). For example, an ANDA applicant relies on the FDA&#39;s finding that a previously approved drug product, i.e., the RLD, is safe and effective, and must demonstrate, among other things, that the generic drug product is the same as the RLD in certain ways. Specifically, with limited exceptions, a drug product for which an ANDA is submitted must have, among other things, the same active ingredient(s), conditions of use, route of administration, dosage form, strength, and (with certain permissible differences) labeling as the RLD. The RLD is the listed drug to which the ANDA applicant must show its ANDA drug product is the same with respect to active ingredient(s), dosage form, route of administration, strength, labeling and conditions of use, among other characteristics. In the electronic Orange Book, there is a column for RLDs and a column for reference standards. In the printed version of the Orange Book, the RLDs and reference standards are identified by specific symbol. 
     A reference standard is the drug product selected by FDA that an applicant seeking approval of an ANDA must use in conducting an in vivo bioequivalence study required for approval. FDA generally selects a single reference standard that ANDA applicants must use in in vivo bioequivalence testing. Ordinarily, FDA will select the reference listed drug as the reference standard. However, in some instances (e.g., where the reference listed drug has been withdrawn from sale and FDA has determined it was not withdrawn for reasons of safety or effectiveness, and FDA selects an ANDA as the reference standard), the reference listed drug and the reference standard may be different. 
     FDA identifies reference listed drugs in the Prescription Drug Product, OTC Drug Product, and Discontinued Drug Product Lists. Listed drugs identified as reference listed drugs represent drug products upon which an applicant can rely in seeking approval of an ANDA. FDA intends to update periodically the reference listed drugs identified in the Prescription Drug Product, OTC Drug Product, and Discontinued Drug Product Lists, as appropriate. 
     FDA also identifies reference standards in the Prescription Drug Product and OTC Drug Product Lists. Listed drugs identified as reference standards represent the FDA&#39;s best judgment at this time as to the appropriate comparator for purposes of conducting any in vivo bioequivalence studies required for approval. 
     In some instances when FDA has not designated a listed drug as a reference listed drug, such listed drug may be shielded from generic competition. If FDA has not designated a reference listed drug for a drug product the applicant intends to duplicate, the potential applicant may ask FDA to designate a reference listed drug for that drug product. 
     FDA may, on its own initiative, select anew reference standard when doing so will help to ensure that applications for generic drugs may be submitted and evaluated, e.g., in the event that the listed drug currently selected as the reference standard has been withdrawn from sale for other than safety and efficacy reasons. 
     In Europe, Applicants identify in the application form for its generic/hybrid medicinal product, which is the same as an ANDA or supplemental NDA (sNDA) drug product, the reference medicinal product (product name, strength, pharmaceutical form, marketing authorization holder (MAH, first authorization, Member State/Community), which is synonymous with a RLD, as follows: 
     1. The medicinal product that is or has been authorized in the European Economic Area (EEA), used as the basis for demonstrating that the data protection period defined in the European pharmaceutical legislation has expired. This reference medicinal product, identified for the purpose of calculating expiry of the period of data protection, may be for a different strength, pharmaceutical form, administration route or presentation than the generic/hybrid medicinal product. 
     2. The medicinal product, the dossier of which is cross-referred to in the generic/hybrid application (product name, strength, pharmaceutical form, MAH, marketing authorization number). This reference medicinal product may have been authorized through separate procedures and under a different name than the reference medicinal product identified for the purpose of calculating expiry of the period of data protection. The product information of this reference medicinal product will, in principle, serve as the basis for the product information claimed for the generic/hybrid medicinal product. 
     3. The medicinal product (product name, strength, pharmaceutical form, MAH, Member State of source) used for the bioequivalence study(ies) (where applicable). 
     The different abbreviated approval pathways for drug products under the Food, Drug, and Cosmetics (FD&amp;C) Act are the abbreviated approval pathways described in sections 505(j) and 505(b)(2) of the FD&amp;C Act (21 U.S.C. 355(j) and 21 U.S.C. 23 355(b)(2), respectively). 
     According to the FDA (“Determining Whether to Submit an ANDA or a 505(b)(2) Application Guidance for Industry,” U.S. Department of Health and Human Services, October 2017, pp. 1-14, the contents of which is incorporated herein by reference), NDAs and ANDAs can be divided into the following four categories: 
     (1) A “stand-alone NDA” is an application submitted under section 505(b)(1) and approved under section 505(c) of the FD&amp;C Act that contains full reports of investigations of safety and effectiveness that were conducted by or for the applicant or for which the applicant has a right of reference or use. 
     (2) A section 505(b)(2) application is an NDA submitted under section 505(b)(1) and approved under section 505(c) of the FD&amp;C Act that contains full reports of investigations of safety and effectiveness, where at least some of the information required for approval comes from studies not conducted by or for the applicant and for which the applicant has not obtained a right of reference or use. 
     (3) An ANDA is an application for a duplicate of a previously approved drug product that was submitted and approved under section 505(j) of the FD&amp;C Act. An ANDA relies on the FDA&#39;s finding that the previously approved drug product, i.e., the reference listed drug (RLD), is safe and effective. An ANDA generally must contain information to show that the generic product (a) is the same as the RLD with respect to the active ingredient(s), conditions of use, route of administration, dosage form, strength, and labeling (with certain permissible differences) and (b) is bioequivalent to the RLD. An ANDA may not be submitted if studies are necessary to establish the safety and effectiveness of the product. 
     (4) A petitioned ANDA is a type of ANDA for a drug product that differs from the RLD in its dosage form, route of administration, strength, or active ingredient (in a product with more than one active ingredient) and for which FDA has determined, in response to a petition submitted under section 505( )(2)(C) of the FD&amp;C Act (suitability petition), that studies are not necessary to establish the safety and effectiveness of the drug product. 
     A scientific premise underlying the Hatch-Waxman Act is that a drug product approved in an ANDA under section 505(j) of the FD&amp;C Act is presumed to be therapeutically equivalent to its RLD. Products classified as therapeutically equivalent can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product when administered to patients under the conditions specified in the labeling. In contrast to an ANDA, a section 505(b)(2) application allows greater flexibility as to the characteristics of the product. A section 505(b)(2) application will not necessarily be rated therapeutically equivalent to the listed drug it references upon approval. 
     The term “therapeutically equivalent to a reference listed drug” means that the drug product is a generic equivalent, i.e., pharmaceutical equivalents, of the reference listed drug product and, as such, is rated an AB therapeutic equivalent to the reference listed drug product by the FDA whereby actual or potential bioequivalence problems have been resolved with adequate in vivo and/or in vitro evidence supporting bioequivalence. 
     “Pharmaceutical equivalents” means drug products in identical dosage forms and route(s) of administration that contain identical amounts of the identical active drug ingredient as the reference listed drug. 
     FDA classifies as therapeutically equivalent those products that meet the following general criteria: (1) they are approved as safe and effective; (2) they are pharmaceutical equivalents in that they (a) contain identical amounts of the same active drug ingredient in the same dosage form and route of administration, and (b) meet compendial or other applicable standards of strength, quality, purity, and identity; (3) they are bioequivalent in that (a) they do not present a known or potential bioequivalence problem, and they meet an acceptable in vitro standard, or (b) if they do present such a known or potential problem, they are shown to meet an appropriate bioequivalence standard; (4) they are adequately labeled; and (5) they are manufactured in compliance with Current Good Manufacturing Practice regulations 
     The term “bioequivalent” or “bioequivalence” is the absence of a significant difference in the rate and extent to which the active ingredient or active moiety in pharmaceutical equivalents or pharmaceutical alternatives becomes available at the site of drug action when administered at the same molar dose under similar conditions in an appropriately designed study. Section 505 (j)(8)(B) of the FD&amp;C Act describes one set of conditions under which a test and reference listed drug shall be considered bioequivalent: 
     the rate and extent of absorption of the [test] drug do not show a significant difference from the rate and extent of absorption of the [reference] drug when administered at the same molar dose of the therapeutic ingredient under similar experimental conditions in either a single dose or multiple doses; or 
     the extent of absorption of the [test] drug does not show a significant difference from the extent of absorption of the [reference] drug when administered at the same molar dose of the therapeutic ingredient under similar experimental conditions in either a single dose or multiple doses and the difference from the [reference] drug in the rate of absorption of the drug is intentional, is reflected in its labeling, is not essential to the attainment of effective body drug concentrations on chronic use, and is considered medically insignificant for the drug. 
     Where these above methods are not applicable (e.g., for drug products that are not intended to be absorbed into the bloodstream), other scientifically valid in vivo or in vitro test methods to demonstrate bioequivalence may be appropriate. 
     For example, bioequivalence may sometimes be demonstrated using an in vitro bioequivalence standard, especially when such an in vitro test has been correlated with human in vivo bioavailability data. In other situations, bioequivalence may sometimes be demonstrated through comparative clinical trials or pharmacodynamic studies. 
     The methods may also comprise, consist of, or consist essentially of selling or offering to sell ponesimod into the stream of commerce. 
     Clinical Management Events 
     As noted herein, sphingosine-1-phosphate receptor modulators (SIPs), a class of oral disease, modifying therapies (DMTs) for multiple sclerosis (MS), are cell-trafficking inhibitors that have been shown to have high efficacy. There are at least four S1Ps that are indicated for MS in the United States: fingolimod, siponimod, ozanimod, and ponesimod. Although these S1Ps share some similarities as a class, the individual S1Ps have differences in selectivity for receptor subtypes and phosphorylation requirements, half-lives, and safety profiles that result in different clinical requirements before and after treatment initiation. Some clinical management events are common across the SIPs, such as complete blood count, electrocardiogram, and liver function tests before treatment initiation. However, each SIP also has unique recommendations for clinical management events described in their US Prescribing Information (USPI), which may impact their overall ease of use. S1Ps with fewer clinical management events may be easier to use than those that require more monitoring. 
     As used herein, clinical management events refer to management of potential or actual events that may require medical intervention. As described herein, clinical management events prior to initiation of treatment include, for example, first-dose monitoring, genotyping, and/or an eye exam. After initiation, events include, for example, drug-drug interactions (DDI), eye exam, and/or liver function tests. 
     The disclosure provides methods for reducing clinical management events before or during treatment of multiple sclerosis in a patient in need thereof, comprising administering ponesimod in an amount and manner that is described in a drug product label for an approved product and/or in a treatment regimen described herein, namely administration of about 20 mg of ponesimod orally once daily, with or without utilization of the up-titration dosing procedure also described herein. The reduction and ease of use are relative to a patient population at substantially the same level of disease progression receiving a standard of care treatment comprising an S1P receptor modulator other than ponesimod, including, for example, fingolimod, siponimod, and ozanimod (see Example 3). 
     Other Aspects of the Disclosure 
     Beta blockers, also known as beta-adrenergic blocking agents, are widely used medications to reduce blood pressure and may be co-administered in MS patients. Concomitant use of ponesimod and drugs that decrease heart rate may be result in bradycardia and heart block. As a result, caution should be applied when ponesimod is initiated in patients receiving treatment with a beta-blocker because of the additive effects on lowering heart rate. In certain embodiments, for patients receiving a stable dose of a beta-blocker, the resting heart rate should be considered before introducing ponesimod treatment. If the resting heart rate is greater than 55 bpm under chronic beta-blocker treatment, ponesimod can be introduced. If the resting heart rate is less than or equal to 55 bpm, beta-blocker treatment should be interrupted until the baseline heart rate is greater than 55 bpm. In this case, treatment with ponesimod can then be initiated and treatment with a beta-blocker can be reinitiated after ponesimod has been up-titrated (via the 14-day titration regimen) to the target maintenance dosage. 
     For example, the negative chronotropic effect of coadministration of ponesimod and propranolol was evaluated in a dedicated pharmacodynamics safety study. In particular, the 14-day dose titration regimen of ponesimod was administered to subjects receiving propranolol (80 mg) once daily. As noted in Example 4, no significant changes in pharmacokinetics of ponesimod or propranolol were observed. 
     In particular embodiments, where a patient is being treated with a beta-blocker and ponesimod treatment is to be initiated, and wherein the patient has a resting heart rate of greater than 55 beats per minute during treatment with the beta-block and prior to initiation of ponesimod, ponesimod is administered without interruption to the beta-blocker treatment. In other embodiments, where a patient is being treated with a beta-blocker and ponesimod treatment is to be initiated, and wherein the patient has a resting heart rate of less than or equal to 55 beats per minute during treatment with the beta-block and prior to initiation of ponesimod, beta-blocker treatment is interrupted until the patient&#39;s heart rate is greater than 55 beats per minute and ponesmod treatment is initiated in a titration regimen comprising administering orally once daily 2 mg of ponesimod on days 1 and 2; 3 mg of ponesimod on days 3 and 4; 4 mg of ponesimod on days 5 and 6; 5 mg of ponesimod on day 7; 6 mg of ponesimod on day 8; 7 mg of ponesimod on day 9; 8 mg of ponesimod on day 10; 9 mg of ponesimod on day 11; and 10 mg of ponesimod on days 12, 13, and 14, followed by administering a 20 mg maintenance dose of ponesimod once daily thereafter, and the beta-blocker is reinitiated after ponesimod has been up-titrated to the maintenance dosage. 
     Because initiation of ponesimod treatment results in a decrease in heart rate (HR), first-dose 4-hour monitoring is also recommended for patients with sinus bradycardia (HR less than 55 beats per minute (bpm)), first- or second-degree (Mobitz type I) AV block, or a history of myocardial infarction or heart failure occurring more than 6 months prior to treatment initiation and in stable condition. As part of the first dose 4-hour monitoring, a first dose of ponesimod (e.g. 2 mg of ponesimod as part of the titration regimen) is administered in a setting where resources to appropriately manage symptomatic bradycardia are available. Patients are to be monitored for 4 hours after the first dose for signs and symptoms of bradycardia with pulse and blood pressure measurements, preferably with a minimum of hourly measurements. Further, in additional embodiments, an electrocardiogram (ECG) is obtained for these patients prior to dosing and at the end of the 4-hour observation period. 
     Accordingly, methods include treating multiple sclerosis in a patient in need thereof, wherein the patient has sinus bradycardia, first or second degree AV block, or a history of myocardial infarction or heart failure occurring more than 6 months prior to the initiation of ponesimod treatment, comprising administering an effective regimen of ponesimod to the patient, wherein after a first dose of the ponesimod, the patient is monitored for a period of 4 hours for symptoms of bradycardia. In other embodiments, no first dose monitoring is needed wherein the patient has no sinus bradycardia, no first or second degree AV block, and no history of myocardial infarction or heart failure occurring more than 6 months prior to the initiation of ponesimod treatment. 
     If any abnormalities are present after four hours, even in the absence of symptoms, monitoring may be continued until the abnormality resolves. Abnormalities include, for example, a heart rate 4 hours post-dose that is less than 45 bpm; a heart rate 4 hours post-dose that is at the lowest value post-dose, suggesting that the maximum pharmacodynamic effect on the heart may not have occurred; and/or an ECG 4 hours post-dose that shows new onset second-degree or higher AV block. 
     If post-dose symptomatic bradycardia, bradyarrhythmia, or conduction related symptoms occur, or if ECG 4 hours post-dose shows new onset second degree or higher AV block or QTc greater than or equal to 500 msec, appropriate management actions can be initiated. For example, the patient can begin continuous ECG monitoring, and can otherwise be monitored until the symptoms have resolved if no pharmacological treatment is required. If pharmacological treatment is required, the patient can be continued to be monitored, including overnight, and the 4-hour monitoring can be repeated after the second dose of ponesimod. 
     In other embodiments, where patients have a preexisting heart and/or cerebrovascular condition; a prolonged QTc interval before dosing or during the 4-hour observation, or at additional risk for QT prolongation, or on concurrent therapy with QT prolonging drug with a known risk of torsades de pointes; and/or receiving concurrent therapy with drugs that slow heart rate or AV conduction, advice from a cardiologist should be sought to determine the most appropriate monitoring strategy, which can include, for example, overnight monitoring during treatment initiation. 
     Although interruption during treatment is not preferred, this disclosure is also related to reinitiating ponesimod after treatment interruption. For example, if fewer than 4 consecutive doses are missed during titration, treatment is resumed with the first missed titration dose and the titration schedule is resumed as that dose and titration day. If fewer than 4 doses are missed during maintenance, treatment is resumed with the maintenance dose. If 4 our more consecutive doses are missed during titration or maintenance, treatment is reinitiated with Day 1 of the 14 day titration regimen, with first dose monitoring as described herein for those patients needing such monitoring. 
     In other embodiments, use or concomitant use of certain drugs with ponesimod should be contraindicated, avoided, or discontinued. For example, methods include treating multiple sclerosis in a patient in need thereof, comprising administering an effective regimen of ponesimod to the patient wherein the treatment further comprises avoiding, contradicting, or discontinuing concomitant use of alemtuzumab. Other methods include treating multiple sclerosis in a patient in need thereof, comprising administering an effective regimen of ponesimod to the patient wherein the treatment further comprises avoiding, contradicting, or discontinuing concomitant use of QT prolonging drugs with known arrhythmogenic properties, heart rate lowering calcium channel blockers (such as, for example, verapamil or diltiazem), or other drugs that reduce heart rate (such as, for example, digoxin). Additional methods include treating multiple sclerosis in a patient in need thereof, comprising administering an effective regimen of ponesimod to the patient wherein the treatment further comprises avoiding, contradicting, or discontinuing concomitant use of strong CYP3A4 and UGT1A1 inducers (such as, for example, rifampin, phenytoin, or carbamazepine) that decrease systemic exposure of the ponesimod. 
     Aspects of the Disclosure—the present disclosure pertains to and includes at least the following additional aspects: 
     1. A method for treating multiple sclerosis in a patient in need thereof, comprising administering an approved drug product comprising ponesimod in an amount and manner that is described in a drug product label for the approved drug product. 
     2. The method of aspect 1, wherein about 20 mg of ponesimod is administered orally once daily 
     3. The method of aspect 1 or aspect 2, wherein the treatment comprises an up-titration step at initiation of the method or upon re-initiation of the method after a discontinuation, comprising administering orally once daily 2 mg of ponesimod on days 1 and 2; 3 mg of ponesimod on days 3 and 4; 4 mg of ponesimod on days 5 and 6; 5 mg of ponesimod on day 7; 6 mg of ponesimod on day 8; 7 mg of ponesimod on day 9; 8 mg of ponesimod on day 10; and 9 mg of ponesimod on day 11; 10 mg of ponesimod on days 12, 13, and 14, followed by administering 20 mg of ponesimod once daily thereafter. 
     4. The method of any one of aspects 1-3, wherein the multiple sclerosis is relapsing multiple sclerosis. 
     5. The method of aspect 4, wherein the relapsing multiple sclerosis comprises relapsing-remitting disease, clinically isolated syndrome, or active secondary progressive disease. 
     6. A method of selling an approved drug product comprising ponesimod, said method comprising selling such drug product, wherein a drug product label for a reference listed drug for such drug product includes instructions for treating a patient with multiple sclerosis. 
     7. A method of offering for sale a drug product comprising ponesimod, said method comprising offering for sale such drug product, wherein a drug product label for a reference listed drug for such drug product includes instructions for treating a patient with multiple sclerosis. 
     8. The method of aspect 6 or aspect 7, wherein the drug product is an ANDA drug product, a supplemental New Drug Application drug product, or a 505(b)(2) drug product. 
     9. A pharmaceutical product comprising ponesimod, wherein the pharmaceutical product is packaged, and wherein the package includes a label that identifies ponesimod as an approved drug product for the treatment of multiple sclerosis. 
     10. A method for treating multiple sclerosis in a patient in need thereof, comprising administering an effective regimen of ponesimod to the patient wherein the treatment further comprises avoiding, contradicting, or discontinuing concomitant use of alemtuzumab. 
     11. A method for treating multiple sclerosis in a patient in need thereof, comprising administering an effective regimen of ponesimod to the patient wherein the treatment further comprises avoiding, contradicting, or discontinuing concomitant use of QT prolonging drugs with known arrhythmogenic properties, heart rate lowering calcium channel blockers (such as, for, example, verapamil or diltiazem), or other drugs that reduce heart rate (such as, for example, digoxin). 
     12. A method for treating multiple sclerosis in a patient in need thereof, comprising administering an effective regimen of ponesimod to the patient wherein the treatment further comprises avoiding, contradicting, or discontinuing concomitant use of strong CYP3A4 and UGT1A1 inducers (such as, for example, rifampin, phenytoin, or carbamazepine) that decrease systemic exposure of the ponesimod. 
     The following Examples are provided to illustrate some of the concepts described within this disclosure. While the Examples are considered to provide an embodiment, it should not be considered to limit the more general embodiments described herein 
     Example A: Fatigue Symptoms and Impact Questionnaire—Relapsing Multiple Sclerosis (FSIQ-RMS) 
     The patient-reported outcome questionnaire used for the below Examples is the Fatigue Symptoms and Impact Questionnaire—Relapsing Multiple Sclerosis (FSIQ-RMS). The FSIQ-RMS is an MS specific 20-item PRO measure that comprises 2 domains: one measuring MS symptoms (7 items) and one measuring MS-related impacts (13 items). The 7 symptom items and 13 impact items (in 3 impacts subdomains: physical, cognitive and emotional, and coping) are presented below. 
     MS Symptoms Domain—7 Items 
     For the MS symptoms domain, the FSIQ-RMS asks about a patient&#39;s fatigue-related symptoms of relapsing MS over the past 24 hours while doing routine daily activities (e.g., housework, yard work, shopping, working, etc.) for Items 1-6 or while at rest (e.g., reading a book, watching TV, etc.) for Item 7. Patients are asked to select a response on a scale of 0 to 10 that best describes their experience and are asked to not skip any questions, with no answers being right or wrong. 

 
     MS-Related Impacts—13 Items 
     For the MS-related impacts domain, the FSIQ-RMS asks about how a patient&#39;s life was affected by fatigue-related symptoms of relapsing MS in the past 7 days. Patients are asked to select a response on a scale of 0 to 4 that best describes their experience and are asked to not skip any questions, with no answers being right or wrong. 

 
     Example 1 
     Study Design 
     A prospective, multicenter, randomized, double-blind, active controlled, parallel-group, phase III, superiority study was conducted. The study was designed to compare the efficacy, safety, and tolerability of ponesimod 20 mg vs teriflunomide 14 mg in adult subjects with relapsing MS. 
     Randomization: Subjects were randomized in a 1:1 ratio to ponesimod 20 mg or teriflunomide 14 mg, stratified by prior use of MS disease modifying treatment (DMT) in the last two years prior to randomization (yes, no) and by baseline expanded disability status scale (EDSS) score (EDSS ≤3.5, EDSS &gt;3.5). 
     Inclusion Criteria 
     This study enrolled adult male and female subjects aged 18 to 55 years with established diagnosis of MS, as defined by the 2010 revision of McDonald Diagnostic Criteria [Polman C H, et al.  Diagnostic criteria for multiple sclerosis:  2010  revisions to the McDonald criteria . Ann Neurol. 2011; 69(2):292-302], with relapsing course from onset (i.e., relapsing-remitting multiple sclerosis and secondary progressive multiple sclerosis [SPMS] with superimposed relapses). The trial included up to a maximum 15% of subjects with SPMS with superimposed relapses. 
     Subjects had active disease evidenced by one or more MS attacks with onset within the period of 12 to 1 months prior to baseline EDSS assessment, or by two or more MS attacks with onset within the 24 to 1 months prior to baseline EDSS assessment, or with one or more gadolinium-enhancing (Gd+) lesion(s) of the brain on an MRI performed within 6 months prior to baseline EDSS assessment. Enrolled subjects were ambulatory with an EDSS score of up to 5.5 inclusive. The subjects were treatment-naïve (i.e., no MS disease-modifying therapy received at any time in the past) or previously treated with interferon (IFN) β-1a, IFN β-1b, glatiramer acetate, dimethyl fumarate, or natalizumab. 
     Exclusion Criteria: 
     Subjects with significant medical conditions or therapies for such conditions (e.g., cardiovascular, pulmonary, immunological, hepatic, ophthalmological, ocular) or lactating or pregnant women were not eligible to enter the study. 
     Subjects with contraindications to MRI or with clinically relevant medical or surgical conditions that, in the opinion of the investigator, would put the subject at risk by participating in the study were not eligible to enter the study. 
     Study/Treatment Duration: 
     For an individual subject, the maximum duration of the study was approximately 118 weeks consisting of 6 weeks of screening, 108 weeks of treatment and 4 weeks of safety follow-up. Subjects discontinuing treatment prematurely had an option to stay in a post-treatment observation period (PTOP) for up to 108 weeks. 
     The study consisted of the following periods: 
     Pre-randomization period—Up to 45 days before randomization. 
     Treatment period: The double-blind treatment period lasted for 108 weeks. It consisted of a randomization visit, visits at two, four, and 12 weeks after randomization, and 12-weekly visits thereafter. 
     End-of-Treatment (EOT): 
     The EOT visit took place at Week 108 (or earlier in case of premature discontinuation of study drug). In all cases, the EOT visit took place one day after the last dose of study drug but no later than 7 days after the last dose of study drug. 
     Subjects who completed treatment until Week 108 were eligible to enroll in an extension study conducted under a separate protocol. Subjects who discontinued study drug prematurely for any reason were not eligible for the extension study. 
     Subjects who prematurely discontinued study drug treatment were subsequently treated according to local standard of care at the investigator&#39;s discretion and were followed in the post-treatment observation period. 
     Post-Treatment Safety Follow-Up (Fu) Period: 
     Teriflunomide is eliminated slowly from plasma. An accelerated elimination procedure was used by all subjects after the last dose of study drug. A safety FU after the last dose of study drug was mandated. 
     All subjects entered the safety FU period: 
     For subjects who entered the extension study, the FU period started after the last dose of study drug and ended with a safety FU visit (FU1) 14-22 days after the last dose of study drug or with an abbreviated FU2 23-37 days after the last dose of study drug (if compliance to the teriflunomide accelerated elimination procedure was assessed as not sufficient at FU1). 
     For subjects who did not enter the extension study, the safety FU period lasted for 30 days after the last dose of study drug and included two safety FU visits (FU1, FU2) at 14-22 and 30-37 days after the last dose of study drug, respectively. 
     Post-treatment observation period (PTOP): 
     Subjects who prematurely discontinued study treatment enter the PTOP which lasts until 108 weeks after randomization (i.e., planned EOT period). It consisted of an abbreviated schedule of assessments at the time of the originally scheduled 12-weekly visits. 
     End-of-Study (EOS) 
     EOS was reached when treatment, safety FU, and, if applicable, PTOP have been completed. 
     For subjects who completed the 108-week treatment period and entered the extension study, the EOS visit corresponded to the FU visit (FU1) conducted 14-22 days after the last study drug dose or to the abbreviated FU2 visit conducted 23-37 days after the last study drug dose (if needed for compliance reasons with the teriflunomide accelerated elimination procedure). 
     For all other subjects, the EOS visit corresponded to the 30-day FU visit (FU2) or to the last visit of PTOP (i.e., Week 108 Visit of the PTOP), whichever was last. 
     Study Treatment: 
     The treatment period consisted of an up-titration period (from Day 1 to 14) and a maintenance period (Day 15 until EOT). 
     During an initial phase of the study, the study drugs in the up-titration period were administered in a double-dummy fashion. Ponesimod (or matching placebo) was presented as tablet, and teriflunomide 14 mg (or matching placebo) was presented as capsule (i.e., daily administration of one tablet and one capsule). At a later phase, the double-dummy material (tablet and capsule) was replaced by the daily administration of one capsule containing either ponesimod or teriflunomide. 
     In the maintenance period, the study treatment consisted of the daily administration of one capsule containing ponesimod 20 mg or teriflunomide 14 mg. 
     To reduce the first-dose effect of ponesimod, an up-titration scheme was implemented from Day 1 to Day 14: 
     Days 1 and 2; 2 mg. 
     Days 3 and 4; 3 mg. 
     Days 5 and 6; 4 mg. 
     Day 7; 5 mg. 
     Day 8; 6 mg. 
     Day 9; 7 mg. 
     Day 10; 8 mg. 
     Day 11; 9 mg. 
     Days 12, 13, and 14; 10 mg. 
     Day 15 until EOT; 20 mg. 
     Primary analysis set for efficacy: The Full Analysis Set (FAS) included all randomized subjects. Subjects were evaluated according to the treatment they were randomized to. 
     Primary efficacy variable/primary timepoint: The primary endpoint was annualized relapse rate (ARR) up to the end of study (EOS) defined as the number of confirmed relapses per subject-year. All available data up to EOS, regardless of treatment discontinuation was included (ITT approach). 
     Secondary efficacy variables and testing strategy: Four secondary efficacy endpoints were analyzed as per the statistical testing strategy outlined in  FIG.  1   .
         Change from baseline to Week 108 in fatigue-related symptoms as measured by the symptoms domain of the FSIQ-RMS patient-reported outcome [Fatigue]   Cumulative number of combined unique active lesions from baseline to Week 108 on brain MRI [CUALs]   Time to first 12-week confirmed disability accumulation (CDA) from baseline to EOS on Expanded Disability Status Scale (EDSS) [12-week CDA]   Time to first 24-week CDA from baseline to EOS on EDSS [24-week CDA]       

     See  FIG.  1    for a schematic representation of the testing strategy. 
     The primary endpoint was powered with α=0.01. The secondary endpoints tested with an overall α=0.05. 
     The sample size for the study was based on the primary endpoint and determined assuming a negative binomial distribution for number of confirmed relapses. A sample size of 1100 subjects (550 per treatment arm) would provide a power of approximately 90% for a significance level of 1%, under the assumption that ARR is 0.320 for teriflunomide 14 mg and 0.215 for ponesimod 20 mg (which corresponds to a rate ratio of 0.67) and using a dispersion=0.9. An annual dropout rate of approximately 15% was assumed for the first year and 7.5% for the second year. 
     Statistical Methods 
     The Full Analysis Set (FAS) included all randomized subjects. In order to adhere to the intention-to-treat principle as much as possible, subjects were evaluated according to the treatment they have been randomized to. 
     The Per-Protocol Set (PPS) comprises all subjects included in the FAS without any major protocol deviations, that impact the assessment of the primary/secondary endpoints, occurring prior to or at randomization. 
     The Safety Set (SAF) included all randomized subjects who received at least one dose of study treatment. Subjects were analyzed based on actual treatment taken, not randomized treatment. 
     A generalized linear model with negative binomial distribution was fitted for the primary efficacy endpoint ARR. Two-sided hypotheses were expressed in terms of the model parameters μP20 mg and μT14 mg. The primary null hypothesis was that the ARR (p) does not differ between ponesimod 20 mg and teriflunomide 14 mg. 
     The null hypothesis was tested by a two-sided Wald test within the negative binomial regression model with a two-sided significance level of 0.01 for conclusive evidence and 0.05 for a positive study. Two-sided 99% and 95% Wald confidence intervals were calculated for the relative reduction in mean ARR for ponesimod 20 mg compared to teriflunomide 14 mg. 
     The primary statistical analysis of the ARR endpoint was performed on the FAS using a negative binomial model for confirmed relapses, with the stratification variables prior use of disease-modifying therapies (DMTs) and EDSS category as well as the number of relapses in the year prior to study entry, included in the model and time in the study as an offset variable. Sensitivity analyses was performed on the PPS and also based on different subgroups derived from baseline variables. 
     The secondary efficacy endpoints were tested if the primary analysis on ARR leads to the rejection of the null hypothesis in favor of ponesimod 20 mg at an overall two-sided significance level of 0.05. A fallback method was used for testing the family of hypotheses related to the following three secondary endpoints: Absolute change of FSIQ-RMS from baseline to Week 108; Cumulative number of CUAL from baseline to Week 108; Time to 12-week CDA from baseline up to EOS. This was followed in a hierarchical manner by testing Time to 24-week CDA from baseline up to EOS; at the remaining alpha. 
     The endpoints were analyzed using the FAS population. All secondary endpoints were also analyzed using the PPS population. 
     Primary Objective 
     To determine whether ponesimod is more efficacious than teriflunomide in terms of reducing relapses in subjects with RMS. 
     Results 
     Disposition and baseline characteristics: A total of 1133 subjects were randomized to the study, 567 to ponesimod 20 mg and 566 to teriflunomide 14 mg. Overall treatment and study discontinuation were balanced across both treatment arms, 83% of subjects completed treatment. The mean age was 36.7 years and 64.9% of subjects were female. Most subjects were recruited in Europe with 50.6% from EU countries. Mean baseline EDSS score was 2.6 and mean disease duration was 7.6 years. Mean pre-study 12-month relapse rate was 1.3, and 42.6% subjects had &gt;1 gadolinium-enhancing (Gd+) T1 lesions. The treatment arms were generally balanced in terms of demographics and baseline disease characteristics. 
     1. Subject And Treatment Information 
     A total of 1468 subjects were screened. Of those, 1133 subjects were randomized (567 to ponesimod 20 mg and 566 to teriflunomide 14 mg) across 162 sites in 28 countries, and 1131 subjects received at least one dose of study drug. The disposition of subjects is summarized in Table 1 and a summary of reasons (primary reason) for treatment discontinuation are shown in Table 2. Overall treatment and study discontinuation were balanced across both treatment arms. A total of 6.5% and 2.5% of the subjects discontinued due to AEs or tolerability related reasons in ponesimod 20 mg and teriflunomide 14 mg, respectively, while 1.9% and 4.3% discontinued due to efficacy related reasons. There were 2 deaths reported during the study—both on teriflunomide 14 mg. 
     1.1 Disposition and Treatment Discontinuation Information 
     
       
         
           
               
             
               
                 TABLE 1 
               
             
            
               
                   
               
               
                 Disposition of subjects 
               
               
                 Analysis Set: Subjects screened 
               
            
           
           
               
               
               
               
            
               
                   
                 Ponesimod 
                 Teriflunomide 
                   
               
               
                   
                 20 mg 
                 14 mg 
                 Total 
               
               
                   
                 N = 567 
                 N = 566 
                 N = 1133 
               
               
                   
                 n (%) 
                 n (%) 
                 n (%) 
               
               
                   
                   
               
            
           
           
               
               
               
               
            
               
                 Subjects screened 
                   
                   
                 1468 
               
               
                 Subjects re-screened 
                   
                   
                 110 
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Subjects randomized 
                 567 
                 (100) 
                 566 
                 (100) 
                 1133 
                 (100) 
               
               
                 Subjects randomized after re-screening 
                 47 
                 (8.3) 
                 36 
                 (6.4) 
                 83 
                 (7.3) 
               
               
                 Subjects treated 
                 565 
                 (99.6) 
                 566 
                 (100) 
                 1131 
                 (99.8) 
               
               
                 Subjects completed treatment as per protocol 
                 471 
                 (83.1) 
                 473 
                 (83.6) 
                 944 
                 (83.3) 
               
               
                 Subjects completed study as per protocol 
                 490 
                 (86.4) 
                 495 
                 (87.5) 
                 985 
                 (86.9) 
               
               
                 Subjects completed treatment and study as per 
                 465 
                 (82.0) 
                 465 
                 (82.2) 
                 930 
                 (82.1) 
               
               
                 protocol 
               
               
                 Subjects stayed in study beyond safety follow-up 
                 67 
                 (11.8) 
                 62 
                 (11.0) 
                 129 
                 (11.4) 
               
               
                 (PTOP) 
               
               
                   
               
               
                 Percentages based on subjects randomized Safety follow-up is up to EOT + 30 days. PTOP = Post-treatment observation period. 
               
            
           
         
       
     
     
       
         
           
               
             
               
                 TABLE 2 
               
             
            
               
                   
               
               
                 Reasons for premature treatment discontinuation 
               
               
                 Analysis Set: Safety Set 
               
            
           
           
               
               
               
               
            
               
                   
                 Ponesimod 
                 Teriflunomide 
                   
               
               
                   
                 20 mg 
                 14 mg 
                 Total 
               
               
                   
                 N = 565 
                 N = 566 
                 N = 1131 
               
               
                   
                 n (%) 
                 n (%) 
                 n (%) 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Subjects who prematurely 
                 94 
                 (16.6) 
                 93 
                 (16.4) 
                 187 
                 (16.5) 
               
               
                 discontinued study treatment 
               
               
                 Reasons for premature 
               
               
                 discontinuation of study treatment 
               
               
                 Subject decision 
                 39 
                 (6.9) 
                 49 
                 (8.7) 
                 88 
                 (7.8) 
               
               
                 Efficacy related 
                 7 
                 (1.2) 
                 14 
                 (2.5) 
                 21 
                 (1.9) 
               
               
                 Tolerability related 
                 8 
                 (1.4) 
                 5 
                 (0.9) 
                 13 
                 (1.1) 
               
               
                 Other 
                 19 
                 (3.4) 
                 26 
                 (4.6) 
                 45 
                 (4.0) 
               
               
                 Not known 
                 5 
                 (0.9) 
                 4 
                 (0.7) 
                 9 
                 (0.8) 
               
               
                 Physician decision 
                 40 
                 (7.1) 
                 23 
                 (4.1) 
                 63 
                 (5.6) 
               
               
                 Adverse event 
                 29 
                 (5.1) 
                 9 
                 (1.6) 
                 38 
                 (3.4) 
               
               
                 Lack of efficacy/treatment failure 
                 4 
                 (0.7) 
                 10 
                 (1.8) 
                 14 
                 (1.2) 
               
               
                 Other 
                 7 
                 (1.2) 
                 4 
                 (0.7) 
                 11 
                 (1.0) 
               
               
                 Pre-specified study treatment 
                 12 
                 (2.1) 
                 16 
                 (2.8) 
                 28 
                 (2.5) 
               
               
                 discontinuation criteria 
               
               
                 Lost to follow-up 
                 2 
                 (0.4) 
                 3 
                 (0.5) 
                 5 
                 (0.4) 
               
            
           
           
               
               
               
               
               
               
            
               
                 Death 
                 0 
                 2 
                 (0.4) 
                 2 
                 (0.2) 
               
            
           
           
               
               
               
               
               
               
            
               
                 Reason not provided 
                 1 
                 (0.2) 
                 0 
                 1 
                 (0.1) 
               
               
                   
               
            
           
         
       
     
     1.2 Demographic and Baseline Characteristics 
     Randomization was stratified by prior-DMT in the last two years prior to randomization (yes: 39.5%; no: 60.5%) and EDSS score at baseline (≤3.5 83.3%; &gt;3.5 16.7%). The mean age was 36.7 years and the majority of subjects (64.9%) were female. Most subjects were recruited in Europe with 50.6% from EU countries. Mean baseline EDSS score was 2.6, mean disease duration was 7.6 years and 97.4% were RRMS subjects. Mean pre-study 12-month relapse rate was 1.3, and 42.6% subjects had ≥1 Gd+T1 lesions on brain MRI. The treatment arms were generally balanced in terms of demographics and baseline disease characteristics (Tables 3 and 4). 
     
       
         
           
               
             
               
                 TABLE 3 
               
             
            
               
                   
               
               
                 Demographic characteristics 
               
               
                 Analysis Set: Full Analysis Set 
               
            
           
           
               
               
               
               
            
               
                   
                 Ponesimod 
                 Teriflunomide 
                   
               
               
                   
                 20 mg 
                 14 mg 
                 Total 
               
               
                   
                 N = 567 
                 N = 566 
                 N = 1133 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Sex [n (%)] 
                   
                   
                   
                   
                   
                   
               
            
           
           
               
               
               
               
            
               
                 N 
                 567 
                 566 
                 1133 
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Male 
                 204 
                 (36.0) 
                 194 
                 (34.3) 
                 398 
                 (35.1) 
               
               
                 Female 
                 363 
                 (64.0) 
                 372 
                 (65.7) 
                 735 
                 (64.9) 
               
               
                 Age (years) 
               
            
           
           
               
               
               
               
            
               
                 N 
                 567 
                 566 
                 1133 
               
               
                 Mean 
                 36.7 
                 36.8 
                 36.7 
               
               
                 SD 
                 8.74 
                 8.74 
                 8.74 
               
               
                 Median 
                 36.0 
                 37.0 
                 37.0 
               
               
                 Q1, Q3 
                 30.0, 44.0 
                 30.0, 44.0 
                 30.0, 44.0 
               
               
                 Min, Max 
                 18, 55 
                 18, 55 
                 18, 55 
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Race [n (%)] 
                   
                   
                   
                   
                   
                   
               
            
           
           
               
               
               
               
            
               
                 N 
                 567 
                 566 
                 1133 
               
            
           
           
               
               
               
               
               
               
               
            
               
                 White 
                 551 
                 (97.2) 
                 553 
                 (97.7) 
                 1104 
                 (97.4) 
               
            
           
           
               
               
               
               
               
               
            
               
                 American Indian or Alaska Native 
                 0 
                 1 
                 (0.2) 
                 1 
                 (0.1) 
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Black or African American 
                 3 
                 (0.5) 
                 2 
                 (0.4) 
                 5 
                 (0.4) 
               
               
                 Other 
                 5 
                 (0.9) 
                 2 
                 (0.4) 
                 7 
                 (0.6) 
               
               
                 Not applicable 
                 8 
                 (1.4) 
                 8 
                 (1.4) 
                 16 
                 (1.4) 
               
               
                 Geographical region/Country of 
               
               
                 enrolling site [n (%)] 
               
               
                 European Union (EU) + UK 
                 289 
                 (51.0) 
                 284 
                 (50.2) 
                 573 
                 (50.6) 
               
               
                 Europe Non-EU + Russia 
                 233 
                 (41.1) 
                 239 
                 (42.2) 
                 472 
                 (41.7) 
               
               
                 North America 
                 32 
                 (5.6) 
                 24 
                 (4.2) 
                 56 
                 (4.9) 
               
               
                 Rest of World 
                 13 
                 (2.3) 
                 19 
                 (3.4) 
                 32 
                 (2.8) 
               
               
                   
               
            
           
         
       
     
     
       
         
           
               
             
               
                 TABLE 4 
               
             
            
               
                   
               
               
                 Baseline disease characteristics 
               
               
                 Analysis Set: Full Analysis Set 
               
            
           
           
               
               
               
               
            
               
                   
                 Ponesimod 
                 Teriflunomide 
                   
               
               
                   
                 20 mg 
                 14 mg 
                 Total 
               
               
                   
                 N = 567 
                 N = 566 
                 N = 1133 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Baseline EDSS 
                   
                   
                   
                   
                   
                   
               
            
           
           
               
               
               
               
            
               
                 N 
                 567 
                 566 
                 1133 
               
               
                 Mean 
                 2.57 
                 2.56 
                 2.56 
               
               
                 SD 
                 1.174 
                 1.229 
                 1.201 
               
               
                 Median 
                 2.50 
                 2.50 
                 2.50 
               
               
                 Q1, Q3 
                 1.50, 3.50 
                 1.50, 3.50 
                 1.50, 3.50 
               
               
                 Min, Max 
                 0.0, 5.5 
                 0.0, 5.5 
                 0.0, 5.5 
               
               
                 Any DMT(a) received within 2 years 
               
               
                 prior to Randomization (eCRF) [n (%)] 
               
               
                 N 
                 567 
                 566 
                 1133 
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Yes 
                 213 
                 (37.6) 
                 211 
                 (37.3) 
                 424 
                 (37.4) 
               
               
                 No 
                 354 
                 (62.4) 
                 355 
                 (62.7) 
                 709 
                 (62.6) 
               
               
                 Time since first symptoms (years) at 
               
               
                 randomization 
               
            
           
           
               
               
               
               
            
               
                 N 
                 567 
                 566 
                 1133 
               
               
                 Mean 
                 7.63 
                 7.65 
                 7.64 
               
               
                 SD 
                 6.781 
                 6.782 
                 6.779 
               
               
                 Median 
                 5.84 
                 5.70 
                 5.77 
               
               
                 Q1, Q3 
                  2.40, 10.97 
                  2.24, 11.03 
                  2.32, 11.01 
               
               
                 Min, Max 
                  0.2, 40.8 
                  0.2, 30.8 
                  0.2, 40.8 
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Number of relapses in last year prior to 
                   
                   
                   
                   
                   
                   
               
               
                 study entry 
               
            
           
           
               
               
               
               
            
               
                 N 
                 567 
                 565 
                 1132 
               
               
                 Mean 
                 1.2 
                 1.3 
                 1.3 
               
               
                 SD 
                 0.61 
                 0.65 
                 0.63 
               
               
                 Median 
                 1.0 
                 1.0 
                 1.0 
               
               
                 Q1, Q3 
                 1.0, 1.0 
                 1.0, 2.0 
                 1.0, 1.0 
               
               
                 Min, Max 
                 0, 4 
                 0, 5 
                 0, 5 
               
               
                 Multiple sclerosis subtype [n (%)] 
               
               
                 N 
                 567 
                 566 
                 1133 
               
            
           
           
               
               
               
               
               
               
               
            
               
                 RRMS 
                 552 
                 (97.4) 
                 552 
                 (97.5) 
                 1104 
                 (97.4) 
               
               
                 SPMS 
                 15 
                 (2.6) 
                 14 
                 (2.5) 
                 29 
                 (2.6) 
               
               
                 Presence of Gd + T1 lesions at baseline 
               
               
                 (from central reader) [n (%)] 
               
            
           
           
               
               
               
               
            
               
                 N 
                 567 
                 564 
                 1131 
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Yes 
                 226 
                 (39.9) 
                 256 
                 (45.4) 
                 482 
                 (42.6) 
               
               
                 No 
                 341 
                 (60.1) 
                 308 
                 (54.6) 
                 649 
                 (57.4) 
               
               
                 Volume of T2 lesions at baseline [mm3] 
               
               
                 (from central reader) 
               
            
           
           
               
               
               
               
            
               
                 N 
                 565 
                 563 
                 1128 
               
               
                 Mean 
                 8301.4 
                 9489.2 
                 8894.3 
               
               
                 SD 
                 10346.28 
                 11265.42 
                 10826.32 
               
               
                 Median 
                 4841.3 
                 5651.0 
                 5171.7 
               
               
                 Q1, Q3 
                  1679.6, 11004.4 
                  2022.9, 12978.7 
                  1851.3, 11754.1 
               
               
                 Min, Max 
                   0, 86053 
                   0, 82776 
                   0, 86053 
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Highly active disease [n (%)] 
                   
                   
                   
                   
                   
                   
               
            
           
           
               
               
               
               
            
               
                 N 
                 567 
                 566 
                 1133 
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Yes 
                 202 
                 (35.6) 
                 200 
                 (35.3) 
                 402 
                 (35.5) 
               
               
                 No 
                 365 
                 (64.4) 
                 366 
                 (64.7) 
                 731 
                 (64.5) 
               
               
                   
               
               
                 (a)DMT = MS disease-modifying treatment. 
               
               
                 RRMS = Relapsing-remitting multiple sclerosis, SPMS = Secondary progressive multiple sclerosis. 
               
            
           
         
       
     
     1.3 Extent of Exposure 
     The mean treatment exposure (irrespective of interruptions) was 96.7 weeks in the ponesimod 20 mg arm and 97.5 weeks in the teriflunomide 14 mg arm. The cumulative exposure to ponesimod 20 mg was 1045 subject-years and was 1057 subject-years for teriflunomide 14 mg arm. 
     
       
         
           
               
             
               
                 TABLE 5 
               
             
            
               
                   
               
               
                 Study treatment exposure 
               
               
                 Analysis Set: Safety Set 
               
            
           
           
               
               
               
            
               
                   
                 Ponesimod 
                 Teriflunomide 
               
               
                   
                 20 mg 
                 14 mg 
               
               
                   
                 N = 565 
                 N = 566 
               
               
                   
                   
               
            
           
           
               
               
               
            
               
                 Treatment exposure, irrespective 
                   
                   
               
               
                 of interruptions (weeks) 
               
               
                 N 
                 564 
                 566 
               
               
                 Mean 
                 96.69 
                 97.45 
               
               
                 SD 
                 29.018 
                 27.022 
               
               
                 Median 
                 108.00 
                 108.00 
               
               
                 Q1, Q3 
                 107.29, 108.71 
                 107.29, 108.57 
               
               
                 Min, Max 
                  0.3, 111.3 
                  0.1, 113.0 
               
               
                 Treatment exposure, irrespective 
               
               
                 of interruptions 
               
               
                 N 
                 564 
                 566 
               
               
                 Cumulative exposure (years) 
                 1045.2 
                 1057.1 
               
               
                   
               
               
                 Treatment exposure based on study drug log. Treatment duration only presented for subjects with available complete treatment end date. Interruptions derived based on study drug log and number of capsules taken. 
               
            
           
         
       
     
     2. Primary Endpoint Analysis 
     Primary efficacy endpoint: Ponesimod 20 mg statistically significantly reduced ARR (confirmed relapses) up to EOS by 30.5% compared to teriflunomide 14 mg (ARR=0.202 for ponesimod 20 mg vs. 0.290 for teriflunomide 14 mg, rate ratio: 0.695 [99% CL: 0.536: 0.902], p=0.0003). The primary endpoint results are robust, all sensitivity and supplementary analyses are in line with the primary analysis. 
     A relapse is defined as new, worsening or recurrent neurological symptoms that occur at least 30 days after the onset of a preceding relapse, and that last at least 24 hours, in the absence of fever or infection. 
     The new, worsening or recurrent neurological symptoms were evaluated by the treating neurologist and, if all the elements of the above definition were verified, and in the absence of another, better explanation of the subject&#39;s symptoms, the event was considered as a relapse. The onset date of the relapse corresponded to the onset date of the symptoms. 
     A relapse was confirmed by the treating neurologist only when the subjects&#39; symptoms were accompanied by an increase in EDSS/FS (functional system) scores, which were consistent with the subject&#39;s symptoms, from a previous clinically stable EDSS/FS assessment (i.e., performed at least 30 days after the onset of any previous relapse), obtained by the efficacy assessor and consistent with the following:
         An increase of at least half a step (0.5 points; unless EDSS=0, then an increase of at least 1.0 points is required) or   An increase of at least 1.0 point in at least two FS scores, or   An increase of at least 2.0 points in at least one FS score (excluding bladder/bowel and cerebral).       

     The primary statistical analysis was performed up to EOS on the FAS using a negative binomial regression model for confirmed relapses, with treatment as a factor and the binary stratification variables (EDSS ≤3.5 versus EDSS &gt;3.5; DMTs within last 2 years prior to randomization [Yes/No]) and the number of relapses in the year prior to study entry (categories 5 1 (or missing) and ≥2) included in the model. The model also included an offset variable defined as the log of time on study (in years) from randomization up to EOS. 
     Ponesimod 20 mg statistically significantly reduced ARR (confirmed relapses) up to EOS by 30.5% compared to teriflunomide 14 mg (ARR=0.202 for ponesimod 20 mg vs. 0.290 for teriflunomide 14 mg, rate ratio: 0.695 [99% CL: 0.536: 0.902], p=0.0003). 
     The primary endpoint results were robust; all sensitivity (see  FIG.  7   ) and supplementary analyses (see  FIG.  2 A ) are in line with the primary analysis. Subgroup analysis [see  FIG.  8   ], shows most notably that there appears to be a treatment-by-EDSS stratum interaction. 
     
       
         
           
               
             
               
                 TABLE 6 
               
             
            
               
                   
               
               
                 Confirmed relapses up to EOS - ARR from negative 
               
               
                 binomial regression (Primary analysis) 
               
               
                 Analysis Set: Full Analysis Set 
               
            
           
           
               
               
               
            
               
                   
                 Ponesimod 
                 Teriflunomide 
               
               
                   
                 20 mg 
                 14 mg 
               
               
                   
                 N = 567 
                 N = 566 
               
               
                   
                   
               
            
           
           
               
               
               
            
               
                 Mean estimate (ARR) 
                 0.202 
                 0.290 
               
               
                 99% CL 
                 (0.165, 0.246) 
                 (0.244, 0.345) 
               
               
                 95% CL 
                 (0.173, 0.235) 
                 (0.254, 0.331) 
               
               
                 Treatment effect (rate ratio) 
                 0.695 
               
               
                 99% CL 
                 (0.536, 0.902) 
               
               
                 95% CL 
                 (0.570, 0.848) 
               
               
                 p-value 
                 0.0003 
               
               
                 Dispersion estimate 
                 0.765 
               
               
                 Number of subjects included in 
                 567 
                 566 
               
               
                 analysis 
               
               
                 Total number of relapses 
                 242 
                 344 
               
               
                 Total time (years) 
                 1119 
                 1137 
               
               
                 Raw ARR 
                 0.216 
                 0.303 
               
               
                   
               
            
           
         
       
     
     3. Secondary Endpoint(S) Main Analyses 
     3.1 Fatigue—Change from Baseline to Week 108 in FSIQ-RMS Weekly Symptoms Score 
     Change from baseline to Week 108 in the FSIQ-RMS weekly symptoms score, based on the full analysis set, was statistically significantly lower in the ponesimod 20 mg arm compared with teriflunomide 14 mg, based on an MMRM analysis (mean=−0.01 for ponesimod 20 mg vs. 3.56 for teriflunomide 14 mg, mean difference: −3.57 [95% CL: −5.83: −1.32J, p=0.0019, an increase from baseline indicates worsening in fatigue symptoms). See  FIG.  3 A . 
     Cumulative distribution function of change is shown in  FIG.  3 B . Results of the study are summarized below in Table 6A. In addition to the observation of statistical significance at the group level change from baseline favoring ponesimod, there is also observed a statistically significant difference in patients who were stable or improved on ponesimod compared to teriflunomide. This suggests a statistically significant and clinically meaningful difference for ponesimod at the patient level. 
     
       
         
           
               
             
               
                 TABLE 6A 
               
             
            
               
                   
               
               
                 Summary of Change from Baseline to Week 108 for FSIQ- 
               
               
                 RMS Weekly Symptoms Score Based on Full Analysis Set. 
               
            
           
           
               
               
               
               
               
               
               
            
               
                   
                 Change in FSIQ-RMS-S: 
                   
                   
                   
                   
                   
               
               
                 Visit 
                 Total Score 
                 N 
                 Ponesimod 
                 N 
                 Teriflunomide 
                 P-Value 
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Week 108 
                 Improved (&lt;−6.3) 
                 105 
                 30.5% 
                 98 
                 29.9% 
                 0.5163 
               
               
                   
                 Stable (−6.3 &lt; 
                 132 
                 38.4% 
                 107 
                 32.6% 
               
               
                   
                 x &lt; +6.3) 
               
               
                   
                 Stable or Improved 
                 237 
                 68.9% 
                 205 
                 62.5% 
                 0.045 
               
               
                   
                 Worsened (≥6.3) 
                 107 
                 31.1% 
                 123 
                 37.5% 
               
               
                   
               
            
           
         
       
     
     The FSIQ-RMS is an MS specific 20-item PRO measure that comprises 2 domains: one measuring MS symptoms and one measuring MS-related impacts. The symptoms domain of the scale was used in this study to compare the effect of ponesimod and teriflunomide on fatigue. This new tool has a number of advantages compared to the available fatigue tools for MS. See Hudgens S, et al.,  Development and Validation of the FSIQ - RMS: A New Patient - Reported Questionnaire to Assess Symptoms and Impacts of Fatigue in Relapsing Multiple Sclerosis. Value Health.  2019 April; 22(4):453-466. doi: 10.1016/j.jval.2018.11.007. Epub 2019 Feb. 21. PubMed PMID: 30975397. With 7 symptom items and 13 impact items (in 3 impacts subdomains: physical, cognitive and emotional, and coping), the FSIQ-RMS is a comprehensive, valid, and reliable measure of fatigue-related symptoms and impacts in RMS patients. 
     The FSIQ-RMS symptom domain (FSIQ-RMS-S) consists of seven items assessing fatigue-related symptoms with a recall period of 24 hours measured on an 11-point numeric rating scale; the standardized symptom domain score ranges from 0 to 100 with a higher score indicating greater fatigue. This domain (i.e., section 1 of the questionnaire) is completed on 7 consecutive days. 
     The FSIQ-RMS impact domain (FSIQ-RMS-I) consists of 13 items assessing impacts of fatigue-related symptoms with a recall period of 7 days measured on a 5-point verbal descriptor scale, ranging from no impact to extreme impact; the impact domain score ranges from 0 to 100 with a higher score indicating greater impact. As the impact domain of the FSIQ-RMS (i.e., section 2 of the questionnaire) has a 7-day recall period, it was completed on the last day (i.e., seventh day) of completion of section 1. 
     FSIQ-RMS was completed during the pre-randomization period, at Visits 6, 7, 10, and 12 (Weeks 12, 24, 60, 84), 14 (EOT), and at unscheduled visits due to relapses (R1, R2, etc.) or other unscheduled visits (U1, U2, etc.) as described below. If applicable, FSIQ-RMS was performed at the corresponding visits in the PTOP. 
     The completion of the FSIQ-RMS during the pre-randomization period was done as follows: At Visit 1 (Screening), subjects who appear eligible based on the assessments made during this visit (but prior to the results from the laboratory assessments are received) were provided with the electronic device containing the FSIQ-RMS. 
     Once the results from the laboratory assessments confirmed the subject&#39;s eligibility, and provided no other assessment performed in the meantime excluded the subject, the site coordinator contacted and asked the subject to start the completion of the FSIQ-RMS. At home, the subject completed the symptom domain of the FSIQ-RMS for 7 days (i.e., section 1 of the questionnaire). On the seventh day, the subject completed the impact domain of the FSIQ-RMS (i.e., section 2 of the questionnaire). The information captured from this assessment was used as the baseline data for the FSIQ-RMS. Ideally, the FSIQ-RMS was completed during the 7 consecutive days preceding the randomization. 
     After randomization, the symptoms domain of the FSIQ-RMS (i.e., section 1 of the questionnaire) was completed by the subject at home on a daily basis, starting in the evening of the day of a visit when the FSIQ-RMS was administered (Day 1 of questionnaire administration cycle) and during the 6 subsequent days (i.e., over 7 days in total). Subjects returned the completed FSIQ-RMS diary at the next scheduled visit. On the seventh day, the subject completed the impact domain of the FSIQ-RMS (i.e., section 2 of the questionnaire). If applicable, at the end of the PTOP, the FSIQ-RMS was completed prior to Visit 14A (Week 108), ideally, during the 7 consecutive days preceding the visit. 
     Results for the secondary endpoint of change from baseline to Week 108 in the symptoms domain of the FSIQ-RMS (assessed over a 7-day period) have shown the superiority of ponesimod 20 mg over teriflunomide 14 mg. 
     3.2 MRI—Combined Unique Active Lesions (CUAL) from Baseline to Week 108. 
     CUAL are new Gd+T1 lesions plus new or enlarging T2 lesions (without double-counting of lesions). 
     The cumulative number of CUAL is considered a reliable outcome measure of inflammatory MS disease activity. Radiological evidence of disease activity is routinely used to support disease diagnosis and to inform therapeutic decisions targeting no evidence of disease activity (NEDA), clinical (relapses or disability accumulation) or radiological (brain lesions on MRI) perspective. See Lublin F D. Disease activity free status in MS. Mult Scler Relat Disord. 2012 January; 1(1):6-7. doi: 10.1016/j.msard.2011.08.001. Epub 2011 Aug. 27. PubMed PMID: 25876444. 
     MRI scans were performed at Visits 2 (Baseline), 10 (Week 60), and 14 (EOT) and at any unscheduled visit (U1, U2, etc.). If applicable, MRI scans also were performed at the corresponding visits in the PTOP (Visits 10A and 14A). Testing at all visits were performed up to 7 days prior to or after the visit date. In case of premature study treatment discontinuation, the MRI at EOT did not need to be performed if the EOT visit occurred within less than 4 weeks of the MRI assessment at Visit 10 (Week 60). 
     MRI variables included the number and volume of new and total Gd+ lesions on T1-weighted MRI scans, number of new and enlarging lesions and lesion volume on T2-weighted MRI, and global measures of loss of brain tissue. 
     Lesion count of MRI performed within 24 months prior to the study were recorded on the MS history page of the eCRF. These scans were not analyzed by the medical image analysis center (MIAC). 
     T1-weighted imaging before and after i.v. administration of 0.1 mmol/kg body weight (=0.2 mL/kg) of Gd as well as PD-T2-weighted imaging was performed. Gd may cause nausea and vomiting and in very rare cases allergic reactions that could require immediate anti-anaphylactic therapy (such as steroids, epinephrine/adrenaline, etc.). 
     Ponesimod 20 mg statistically significantly reduced by 56% the number of CUALs between baseline and week 108 compared to teriflunomide 14 mg (mean CUALs per year=1.405 for ponesimod 20 mg vs. 3.164 for teriflunomide 14 mg, rate ratio: 0.44 [95% CL: 0.36: 0.54], p&lt;0.0001). A total of 4.9% and 4.9% of subjects had a baseline but no post-baseline MRI; sensitivity analyses using a range of methods (data not shown) for imputation of missing data supported the primary results (p&lt;0.0001 in all cases). 
     Ponesimod 20 mg was clearly superior in reducing the number of CUALs vs teriflunomide 14 mg, fully supporting and complementing the results of the primary endpoint. 
     
       
         
           
               
             
               
                 TABLE 7 
               
             
            
               
                   
               
               
                 CUAL from baseline to Week 108 - negative binomial 
               
               
                 regression of lesions per year (Main analysis) 
               
               
                 Analysis Set: Full Analysis Set 
               
            
           
           
               
               
               
            
               
                   
                 Ponesimod 
                 Teriflunomide 
               
               
                   
                 20 mg 
                 14 mg 
               
               
                   
                 N = 567 
                 N = 566 
               
               
                   
                   
               
            
           
           
               
               
               
            
               
                 Mean estimate (Lesions per year) 
                 1.405 
                 3.164 
               
               
                 95% CL 
                 (1.215, 1.624) 
                 (2.757, 3.631) 
               
               
                 Treatment effect (Rate Ratio) 
                 0.444 
               
               
                 95% CL 
                 (0.364, 0.542) 
               
               
                 p-value 
                 &lt;0001 
               
               
                 Dispersion estimate 
                 2.409 
               
               
                 Number of subjects included in 
                 539 
                 536 
               
               
                 analysis 
               
               
                 Total number of lesions 
                 1671 
                 3714 
               
               
                 Total time (years) 
                 1072 
                 1067 
               
               
                 Raw mean lesions/year 
                 1.559 
                 3.481 
               
               
                   
               
               
                 Mean estimate = CUAL per year, Rate Ratio: ponesimod vs. teriflunomide. Negative binomial model is applied with Wald confidence intervals and p-value. Offset: Log Time (years) up to last MRI scan. Covariates: EDSS strata (&lt;=3.5, &gt;3.5), DMT within last 2 years prior to randomization strata (Y, N), and Gd+ T1 lesions at baseline (absent or present). Subjects with baseline and at least one post-baseline MRI are included in the analysis. 
               
            
           
         
       
     
     3.3 EDSS—Time to First 12-Week Confirmed Disability Accumulation (CDA) 
     The 12-week confirmed disability accumulation, also sometimes referred to as disability progression (CDA/CDP) is a common endpoint in RMS studies, while 24-week CDA/CDP is regarded as the more robust and clinically relevant endpoint. See European Medicines Agency,  Guideline on clinical investigation of medicinal products for the treatment of Multiple Sclerosis,  26 Mar. 2015, EMA/CHMP/771815/2011, Rev. 2, Committee for Medicinal Products for Human Use (CHMP). Teriflunomide 14 mg has shown a statistically significant reduction in the risk of 12-week CDP in the TEMSO and TOWER studies. See O&#39;Connor P, et al. N Engl J Med. 2011; 365:1293-30; Confavreux C, et al.;  TOWER Trial Group. Oral teriflunomide for patients with relapsing multiple sclerosis  ( TOWER ):  a randomised, double - blind, placebo - controlled, phase  3  trial . Lancet Neurol. 2014 March; 13(3):247-56. doi: 10.1016/S1474-4422(13)70308-9. Epub 2014 Jan. 23. PubMed PMID: 24461574. 
     A 12-week CDA is an increase of at least 1.5 in EDSS for subjects with a baseline EDSS score of 0.0 or an increase of at least 1.0 in EDSS for subjects with a baseline EDSS score of 1.0 to 5.0, or an increase of at least 0.5 in EDSS for subjects with a baseline EDSS score ≥5.5 which is to be confirmed after 12 weeks. 
     Baseline EDSS is defined as the last EDSS score recorded prior to randomization. The initial EDSS increase, meeting the above criteria, is defined as the onset of disability accumulation. 
     All EDSS measurements (with or without relapse, at a scheduled or unscheduled visit) were used to determine the onset of disability accumulation. However, EDSS scores used for confirmation of disability accumulation were obtained at a scheduled visit (i.e., unscheduled visits cannot be used as confirmatory visits) outside any ongoing relapse. In this context, relapse duration is defined as period between start and end dates if available and limited to 90 days from onset if end date is not available or duration is longer than 90 days. 
     In order to confirm that the EDSS increase is persistent, all EDSS measurements between the onset and the 12-week EDSS confirmation (minus 7-day visit time-window) need to show an increase in EDSS, meeting the criteria for accumulation of disability as defined above. 
     A 12-week CDA was observed in 10.1%, and 12.4% of subjects up to EOS in the ponesimod 20 mg and teriflunomide 14 mg arms, respectively. The risk of 12-week CDA was not found to be statistically significantly different for ponesimod 20 mg as compared with teriflunomide 14 mg (hazard ratio: 0.83 [95% CL, 0.58 to 1.18]; log-rank p=0.2939). Consequently, the formal testing procedure was stopped. See Table A3; see also  FIG.  4   . 
     
       
         
           
               
             
               
                 TABLE A3 
               
             
            
               
                   
               
               
                 Testing strategy: Overview of secondary endpoint results 
               
               
                 Analysis Set: Full Analysis Set 
               
            
           
           
               
               
               
               
               
               
               
            
               
                   
                 Effect 
                   
                   
                 Alpha 
                   
                   
               
               
                 Endpoint 
                 Measure 
                 Estimate 
                 95% CL 
                 available 
                 p-value 
                 Significant 
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
            
               
                 FSIQ-RMS 
                 Mean 
                 −3.57 
                 −5.83, −1.32 
                 0.0167 
                 0.0019 
                 Yes 
               
               
                 change from 
                 difference 
               
               
                 baseline to 
               
               
                 Week 108 
               
               
                 CUAL from 
                 Rate ratio 
                 0.44 
                 0.36, 0.54 
                 0.0333 
                 &lt;.0001 
                 Yes 
               
               
                 baseline to 
               
               
                 Week 108 
               
               
                 Time to first 
                 Hazard ratio 
                 0.83 
                 0.58, 1.18 
                 0.0500 
                 0.2939 
                 No 
               
               
                 12-week CDA 
               
               
                 Time to first 
                 Hazard ratio 
                 0.84 
                 0.57, 1.24 
                 0.0000 
                 0.3720 
                 NA 
               
               
                 24-week CDA 
               
               
                   
               
               
                 CUAL = Combined unique active lesions; CDA = Confirmed disability accumulation; NA = Not applicable. Effect measures display results of Ponesimod 20 mg vs. Teriflunomide 14 mg. 
               
               
                 Alpha available = Alpha available as per testing strategy for testing the corresponding endpoint. 
               
            
           
         
       
     
     3.4 EDSS—Time to First 24-Week Confirmed Disability Accumulation (CDA) 
     24-week CDA was not formally tested and only evaluated in an exploratory manner. A 24-week CDA was observed in 8.1%, and 9.9% of subjects up to EOS in the ponesimod 20 mg and teriflunomide 14 mg arms, respectively. The risk of 24-week CDA for ponesimod 20 mg as compared with teriflunomide 14 mg was not found to be statistically significantly different at a nominal α=0.05 (hazard ratio: 0.84 [95% CL, 0.57 to 1.24]; log−rank p=0.3720). See  FIG.  5   . 
     A 24-week CDA is an increase of at least 1.5 in EDSS for subjects with a baseline EDSS score of 0.0 or an increase of at least 1.0 in EDSS for subjects with a baseline EDSS score of 1.0 to 5.0, or an increase of at least 0.5 in EDSS for subjects with a baseline EDSS score &gt;5.5 which is to be confirmed after 24 weeks. 
     Baseline EDSS is defined as the last EDSS score recorded prior to randomization. The initial EDSS increase, meeting the above criteria, is defined as the onset of disability accumulation. 
     All EDSS measurements (with or without relapse, at a scheduled or unscheduled visit) were used to determine the onset of disability accumulation. However, EDSS scores used for confirmation of disability accumulation were obtained at a scheduled visit (i.e., unscheduled visits cannot be used as confirmatory visits) outside any ongoing relapse. In this context, relapse duration is defined as period between start and end dates if available and limited to 90 days from onset if end date is not available or duration is longer than 90 days. 
     In order to confirm that the EDSS increase is persistent, all EDSS measurements between the onset and the 24-week EDSS confirmation (minus 7-day visit time-window) need to show an increase in EDSS, meeting the criteria for accumulation of disability as defined above. 
     In this study, ponesimod 20 mg reduced by 17% and 16% the risk of 12- and 24-week CDA, respectively, compared to teriflunomide 14 mg, however the difference did not reach statistical significance. This study was not powered for 12- or 24-week CDA, so results were not bound to be statistically different. 
     4. Safety 
     4.1 Summary of All Adverse Events 
     An overview of treatment emergent AEs (TEAEs) is presented in Table 8. 
     
       
         
           
               
             
               
                 TABLE 8 
               
             
            
               
                   
               
               
                 Overview of treatment-emergent adverse events (AE) 
               
               
                 Analysis Set: Safety Set 
               
            
           
           
               
               
               
               
               
            
               
                   
                   
                   
                 Ponesimod 
                 Teriflunomide 
               
               
                   
                   
                   
                 20 mg 
                 14 mg 
               
               
                   
                   
                   
                 N = 565 
                 N = 566 
               
               
                   
                 Characteristic 
                   
                 n (%) 
                 n (%) 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
               
            
               
                   
                 Subject with at least one 
                   
                   
                   
                   
               
               
                   
                 AE 
                 502 
                 (88.8) 
                 499 
                 (88.2) 
               
               
                   
                 Severe AE 
                 39 
                 (6.9) 
                 26 
                 (4.6) 
               
               
                   
                 Drug-Related AE 
                 278 
                 (49.2) 
                 238 
                 (42.0) 
               
               
                   
                 AE leading to study drug 
                 49 
                 (8.7) 
                 34 
                 (6.0) 
               
               
                   
                 discontinuation 
               
               
                   
                 Serious AE 
                 49 
                 (8.7) 
                 46 
                 (8.1) 
               
            
           
           
               
               
               
               
               
            
               
                   
                 Fatal AE 
                 0 
                 2 
                 (0.4) 
               
               
                   
                   
               
            
           
         
       
     
     Overall, the proportion of subjects who experienced at least one TEAE was similar in both treatment arms (88.8% and 88.2% of subjects in the ponesimod 20 mg and the teriflunomide 14 mg arms, respectively). 
     The most common TEAEs in the ponesimod 20 mg arm were ALT increased (19.5%), nasopharyngitis (19.3%), headache (11.5%) and upper respiratory tract infection (10.6%). The most common TEAEs in the ponesimod 20 mg arm were ALT increased (19.5% vs 9.4% in the teriflunomide arm), nasopharyngitis (19.3% vs 16.8%), headache (11.5% vs 12.7%) and upper respiratory tract infections (10.6% vs 10.4%). 
     TEAEs leading to premature treatment discontinuation were reported in 8.7% of ponesimod 20 mg subjects compared to 6.0% of teriflunomide 14 mg subjects [see Table 9]. While the number of events was low, the difference in the type of AEs leading to treatment discontinuation was mainly driven by anticipated class effects on respiratory system and macular edema. No infections led to permanent study treatment discontinuation in the study. 
     
       
         
           
               
             
               
                 TABLE 9 
               
             
            
               
                   
               
               
                 Treatment-emergent AEs leading to premature 
               
               
                 discontinuation of study drug by SOC 
               
               
                 Analysis Set: Safety Set 
               
            
           
           
               
               
               
            
               
                   
                 Ponesimod 
                 Teriflunomide 
               
               
                   
                 20 mg 
                 14 mg 
               
               
                   
                 N = 565 
                 N = 566 
               
               
                 System Organ Class 
                 n (%) 
                 n (%) 
               
               
                   
               
            
           
           
               
               
               
               
               
            
               
                 Subjects with at least one AE 
                 49 
                 (8.7) 
                 34 
                 (6.0) 
               
               
                 Investigations 
                 12 
                 (2.1) 
                 10 
                 (1.8) 
               
            
           
           
               
               
               
               
            
               
                 Respiratory, thoracic and mediastinal 
                 7 
                 (1.2) 
                 0 
               
               
                 disorders 
               
               
                 Eye disorders 
                 5 
                 (0.9) 
                 0 
               
            
           
           
               
               
               
               
               
            
               
                 Gastrointestinal disorders 
                 4 
                 (0.7) 
                 4 
                 (0.7) 
               
               
                 Blood and lymphatic system disorders 
                 3 
                 (0.5) 
                 2 
                 (0.4) 
               
               
                 General disorders and administration 
                 3 
                 (0.5) 
                 2 
                 (0.4) 
               
               
                 site conditions 
               
               
                 Hepatobiliary disorders 
                 3 
                 (0.5) 
                 2 
                 (0.4) 
               
               
                 Pregnancy, puerperium and perinatal 
                 3 
                 (0.5) 
                 3 
                 (0.5) 
               
               
                 conditions 
               
            
           
           
               
               
               
               
            
               
                 Vascular disorders 
                 3 
                 (0.5) 
                 0 
               
            
           
           
               
               
               
               
               
            
               
                 Nervous system disorders 
                 2 
                 (0.4) 
                 4 
                 (0.7) 
               
               
                 Social circumstances 
                 2 
                 (0.4) 
                 1 
                 (0.2) 
               
               
                 Cardiac disorders 
                 1 
                 (0.2) 
                 2 
                 (0.4) 
               
               
                 Musculoskeletal and connective tissue 
                 1 
                 (0.2) 
                 1 
                 (0.2) 
               
               
                 disorders 
               
               
                 Neoplasms benign, malignant and 
                 1 
                 (0.2) 
                 1 
                 (0.2) 
               
               
                 unspecified (incl cysts and polyps) 
               
               
                 Psychiatric disorders 
                 1 
                 (0.2) 
                 1 
                 (0.2) 
               
               
                 Skin and subcutaneous tissue disorders 
                 1 
                 (0.2) 
                 2 
                 (0.4) 
               
            
           
           
               
               
               
               
            
               
                 Reproductive system and breast disorders 
                 0 
                 1 
                 (0.2) 
               
               
                 Surgical and medical procedures 
                 0 
                 1 
                 (0.2) 
               
               
                   
               
               
                 System Organ Classes are based on MedDRA version 21.0. SOCs are sorted by descending order of frequency in the ponesimod arm. 
               
            
           
         
       
     
     There were two deaths reported in the study, one due to coronary artery insufficiency and one due to multiple sclerosis. Both deaths occurred in subjects receiving teriflunomide 14 mg. 
     The proportion of subjects who experienced at least one SAE was similar in both treatment arms (8.7% and 8.1% of subjects in the ponesimod 20 mg and the teriflunomide 14 mg arms, respectively). 
     An overview of AEs of special interest (AESIs) addressing anticipated risks of ponesimod is presented in Table 10. The most common AESIs were reported for category hepatobiliary disorders/liver enzyme abnormality (25.7% vs 14.5% in ponesimod 20 mg compared to teriflunomide 14 mg, respectively), followed by category hypertension (10.1% vs 9.0%/), and pulmonary events (8.0% vs 2.7%). 
     
       
         
           
               
             
               
                 TABLE 10 
               
             
            
               
                   
               
               
                 Treatment-emergent AESIs by category 
               
               
                 Analysis Set: Safety Set 
               
            
           
           
               
               
               
            
               
                   
                 Ponesimod 
                 Teriflunomide 
               
               
                   
                 20 mg 
                 14 mg 
               
               
                   
                 N = 565 
                 N = 566 
               
               
                 AESI Category 
                 n (%) 
                 n (%) 
               
               
                   
               
            
           
           
               
               
               
               
               
            
               
                 Hepatobiliary disorders/ 
                 145 
                 (25.7) 
                 82 
                 (14.5) 
               
               
                 Liver enzyme abnormality 
               
               
                 Hypertension 
                 57 
                 (10.1) 
                 51 
                 (9.0) 
               
               
                 Pulmonary events 
                 45 
                 (8.0) 
                 15 
                 (2.7) 
               
               
                 Effect on heart rate and rhythm 
                 29 
                 (5.1) 
                 24 
                 (4.2) 
               
               
                 (including hypotension) 
               
               
                 Herpetic infection 
                 27 
                 (4.8) 
                 27 
                 (4.8) 
               
               
                 Infection 
                 9 
                 (1.6) 
                 5 
                 (0.9) 
               
               
                 Seizure 
                 8 
                 (1.4) 
                 1 
                 (0.2) 
               
               
                 Macular edema 
                 6 
                 (1.1) 
                 1 
                 (0.2) 
               
               
                 Skin malignancy 
                 5 
                 (0.9) 
                 1 
                 (0.2) 
               
               
                 Non-skin malignancy 
                 1 
                 (0.2) 
                 1 
                 (0.2) 
               
               
                   
               
               
                 Categories are sorted by descending order of frequency in the ponesimod 20 mg arm. AESI - Adverse Event of Special Interest. Infection AESI are identified by the AEs from the Infections and Infestations SOC, only if reported as serious or severe. 
               
            
           
         
       
     
     The proportion of subjects who experienced ALT increase &gt;3×ULN was higher in the ponesimod arm (17.3%) compared to teriflunomide (8.3%) whereas ALT increase &gt;8×ULN was higher in the teriflunomide arm (2.1%) compared to ponesimod (0.7%). Based on the individual case review, most ALT/AST increases ≥3×ULN occurred as a single transient asymptomatic episode, resolving with continued treatment or after protocol mandated treatment discontinuation. All but one case of bilirubin increase ≥2×ULN occurred in subjects with pre-treatment bilirubin increases. One case of potential Hy&#39;s law occurred in a subject with pre-existing transaminase elevation (ALT &gt;5×ULN), and the event fully resolved within 2 weeks after treatment discontinuation. 
     The incidence of treatment-emergent heart rate and rhythm (including hypotension) AESIs on Day 1 was higher in the ponesimod 20 mg arm (2.1%) than in the teriflunomide 14 mg arm (0.4%). See Table 10A. However, the overall incidence of first dose AESI on Day 1 was low (2.1%) in ponesimod. None of these events were serious nor led to permanent discontinuation of study treatment. Discharge criteria at 4 hours post-dose were met for ca. 99% of subjects. No 2nd or higher degree AV block was observed. ECG HR effect: nadir at 2 hours post-dose (siponimod—3-4 hours, fingolimod—around by 6 hours). Low incidence of low HR outliers (post-dose HR 5 40 bpm), all 3 of them with a pre-treatment HR of ≤55 bpm, which is a known risk factor for post-dose bradycardia with S1P receptor modulators. 
     The mean heart rate reduction compared to pre-dose reached a maximum for ponesimod 20 mg at 2-hours post dose, −8.7 bpm compared to −1.7 bpm for teriflunomide 14 mg ( FIG.  6   ). There were 3 subjects with asymptomatic post-dose HR ≤40 bpm in the ponesimod 20 mg arm (none on teriflunomide 14 mg); all of these subjects had a pre-treatment HR &lt;55 bpm, which would require post-dose monitoring according to regulatory precedence of siponimod [Mayzent® USPI]. 
     
       
         
           
               
             
               
                 TABLE 10A 
               
             
            
               
                   
               
               
                 Treatment-emergent AESI by PT: Effect on heart 
               
               
                 rate and rhythm (including hypotension) on Day 1 
               
               
                 Analysis Set: Safety Set 
               
            
           
           
               
               
               
            
               
                   
                 Ponesimod 
                 Teriflunomide 
               
               
                   
                 20 mg 
                 14 mg 
               
               
                   
                 N = 565 
                 N = 566 
               
               
                 Preferred Term 
                 n (%) 
                 n (%) 
               
               
                   
               
            
           
           
               
               
               
               
               
            
               
                 Subjects with at least one AE 
                 12 
                 (2.1) 
                 2 
                 (0.4) 
               
            
           
           
               
               
               
               
            
               
                 Bradycardia 
                 4 
                 (0.7) 
                 0 
               
               
                 Atrioventricular block first degree 
                 3 
                 (0.5) 
                 0 
               
               
                 Defect conduction intraventricular 
                 2 
                 (0.4) 
                 0 
               
               
                 Bundle branch block left 
                 1 
                 (0.2) 
                 0 
               
               
                 Bundle branch block right 
                 1 
                 (0.2) 
                 0 
               
               
                 Sinus arrhythmia 
                 1 
                 (0.2) 
                 0 
               
               
                 Sinus bradycardia 
                 1 
                 (0.2) 
                 0 
               
            
           
           
               
               
               
               
            
               
                 Electrocardiogram QT prolonged 
                 0 
                 1 
                 (0.2) 
               
               
                 Presyncope 
                 0 
                 1 
                 (02) 
               
               
                   
               
               
                 Preferred Terms are based on MedDRA version 21.0. 
               
               
                 Preferred terms are sorted by descending order of frequency in the ponesimod arm. 
               
               
                 AESI - Adverse Event of Special Interest 
               
            
           
         
       
     
     Example 1A: FSIQ-RMS and Physical, Cognitive, and Coping Impact 
     Change from baseline to Week 108 for the physical, cognitive/emotional and coping impacts sub-domains of FSIQ-RMS are shown in  FIG.  9   ,  FIG.  10    and  FIG.  11   , respectively. 
       FIGS.  9 ,  10  and  11    show the FSIQ-RMS physical, cognitive/emotional and coping impacts sub-domains at the group level, based on the full analysis set, for the ponesimod 20 mg treatment arm and the teriflunomide 14 mg treatment arm. 
     Example 1B: Change From Baseline to Week 108—Baseline Fatigue Below the Median 
     Mean change from baseline to Week 108 in FSIQ-RMS weekly symptoms score for patients with baseline fatigue below the median is shown in  FIG.  12   . Cumulative distribution function of change is shown in  FIG.  13   . Results are summarized in Table 11A below. Baseline fatigue (i.e., weekly symptoms score at baseline) is provided in Table 11B and was used for the baseline fatigue below the median in this Example and the baseline fatigue above the median in Example 1C. 
     Almost 65% of low baseline fatigue patients remained stable or improved over the 108 weeks on ponesimod, as compared to about 55% over the 108 weeks on teriflunomide. 
     
       
         
           
               
             
               
                 TABLE 11A 
               
             
            
               
                   
               
               
                 Change From Baseline to Week 108, Baseline Fatigue 
               
               
                 Below the Median for Ponesimod and Teriflunomide 
               
            
           
           
               
               
               
               
               
               
               
            
               
                   
                 Change From 
                   
                   
                   
                   
                   
               
               
                   
                 Baseline to Week 
               
               
                   
                 108: Baseline Fatigue 
               
               
                 Visit 
                 Below the Median 
                 N 
                 Ponesimod 
                 N 
                 Teriflunomide 
                 P-Value 
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
            
               
                 WEEK 108 
                 Improved (&lt;−6.3) 
                 36 
                 19.1% 
                 34 
                 20.9% 
                 0.736 
               
               
                   
                 Stable (−6.3 &lt; x &lt; +6.3) 
                 85 
                 45.2% 
                 55 
                 33.7% 
               
               
                   
                 Stable or Improved 
                 121 
                 64.4% 
                 89 
                 54.6% 
                 0.088 
               
               
                   
                 Worsened (≥6.3) 
                 67 
                 35.6% 
                 74 
                 45.4% 
               
               
                   
               
            
           
         
       
     
     
       
         
           
               
             
               
                 TABLE 11B 
               
             
            
               
                   
               
               
                 Baseline fatigue (symptoms score of FSIQ at baseline). 
               
            
           
           
               
               
               
            
               
                   
                 Ponesmiod 
                 Teriflunomide 
               
               
                   
                   
               
            
           
           
               
               
               
               
            
               
                   
                 Minimum 
                 0.0 
                 0.0 
               
               
                   
                 Q1 
                 14.49 
                 17.93 
               
               
                   
                 Median 
                 30.41 
                 30.71 
               
               
                   
                 Q3 
                 46.33 
                 46.33 
               
               
                   
                 Maximum 
                 95.40 
                 88.40 
               
               
                   
                   
               
            
           
         
       
     
     Example 1C: Change From Baseline to Week 108—Baseline Fatigue Above the Median 
     Mean change from baseline to Week 108 in FSIQ-RMS weekly symptoms score for patients with baseline fatigue above the median is shown in  FIG.  14   . Cumulative distribution function of change is shown in  FIG.  15   . 
     Example 1D: Change From Baseline to Week 108—Patients with No Prior DMT Treatment 
     Mean change from baseline to Week 108 in FSIQ-RMS weekly symptoms score for patients with no prior DMT treatment within about two years prior to initiation of treatment is shown in  FIG.  16   . Cumulative distribution function of change is shown in  FIG.  17   . Results are summarized in Table 12 below. 
     Patient improvement was clinically meaningful in 31.4% of patients on ponesimod (P=0.052), and about 75% of patients on ponesimod remained stable or improved by Week 108 (P=0.003). 
     
       
         
           
               
             
               
                 TABLE 12 
               
             
            
               
                   
               
               
                 Change From Baseline to Week 108 in Patients with no 
               
               
                 Prior DMT Treatment for Ponesimod and Teriflunomide 
               
            
           
           
               
               
               
               
               
               
               
            
               
                   
                 Change From 
                   
                   
                   
                   
                   
               
               
                   
                 Baseline to Week 
               
               
                   
                 108: No Prior DMT 
               
               
                 Visit 
                 Treatment 
                 N 
                 Ponesimod 
                 N 
                 Teriflunomide 
                 P-Value 
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Week 108 
                 Improved (&lt;−6.3) 
                 65 
                 31.4% 
                 54 
                 26.2% 
                 0.052 
               
               
                   
                 Stable (−6.3 &lt; x &lt; +6.3) 
                 91 
                 44.0% 
                 76 
                 36.9% 
               
               
                   
                 Stable or Improved 
                 156 
                 75.4% 
                 130 
                 63.1% 
                 0.003 
               
               
                   
                 Worsened (≥6.3) 
                 51 
                 24.6% 
                 76 
                 36.9% 
               
               
                   
               
            
           
         
       
     
     Example 1E: Change From Baseline to Week 108 in Patients without Gd+T1 Lesions at Baseline 
     Mean change from baseline to Week 108 for change in FSIQ-RMS weekly symptoms score in patients without Gd+T1 lesions at baseline is shown in  FIG.  18   . Cumulative distribution function of change is shown in  FIG.  19   . Results are summarized in Table 13 below. 
     Patients who had stable or improved symptoms of fatigue without baseline Gd+T1 lesions demonstrated a statistically significant difference for ponesimod compared to teriflunomide, about 68% for ponesimod vs. about 57% for teriflunomide (p=0.021). 
     
       
         
           
               
             
               
                 TABLE 13 
               
             
            
               
                   
               
               
                 Change From Baseline to Week 108 in Patients without Gd + T1 Lesions at Baseline 
               
            
           
           
               
               
               
               
               
               
               
            
               
                   
                 Change From 
                   
                   
                   
                   
                   
               
               
                   
                 Baseline to Week 
               
               
                   
                 108: No Gd + T1 
               
               
                 Visit 
                 Lesions 
                 N 
                 Ponesimod 
                 N 
                 Teriflunomide 
                 P-Value 
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Week 108 
                 Improved (&lt;−6.3) 
                 61 
                 30.0% 
                 48 
                 25.8% 
                 0.257 
               
               
                   
                 Stable (−6.3 &lt; x &lt; +6.3) 
                 76 
                 37.4% 
                 58 
                 31.2% 
               
               
                   
                 Stable or Improved 
                 137 
                 67.5% 
                 106 
                 57.0% 
                 0.021 
               
               
                   
                 Worsened (≥6.3) 
                 66 
                 32.5% 
                 80 
                 43.0% 
               
               
                   
               
            
           
         
       
     
     Example 1F: Change From Baseline to Week 108 in Patients with Gd+T1 Lesions at Baseline 
     Mean change from baseline to Week 108 for change in FSIQ-RMS weekly symptoms score in patients with Gd+T1 lesions at baseline is shown in  FIG.  20   . Cumulative distribution function of change is shown in  FIG.  21   . 
     Example 1G: Change from Baseline to Week 108—Baseline EDSS ≤3.5 
     Mean change from baseline to Week 108 for change in FSIQ-RMS weekly symptoms score for patients with lower baseline EDSS is shown in  FIG.  22   . Cumulative distribution function of change is shown in  FIG.  23   . Results are summarized in Table 14 below. 
     
       
         
           
               
             
               
                 TABLE 14 
               
             
            
               
                   
               
               
                 Change From Baseline to Week 108 in Patients with Baseline EDSS ≤3.5 
               
            
           
           
               
               
               
               
               
               
               
            
               
                   
                 Change From 
                   
                   
                   
                   
                   
               
               
                   
                 Baseline to Week 
               
               
                   
                 108: Baseline 
               
               
                 Visit 
                 EDSS &lt;3.5 
                 N 
                 Ponesimod 
                 N 
                 Teriflunomide 
                 P-Value 
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Week 108 
                 Improved (&lt;−6.3) 
                 90 
                 30.6% 
                 75 
                 27.9% 
                 0.318 
               
               
                   
                 Stable (−6.3 &lt; x &lt; +6.3) 
                 120 
                 40.8% 
                 92 
                 34.2% 
               
               
                   
                 Stable or Improved 
                 210 
                 71.4% 
                 167 
                 62.1% 
                 0.010 
               
               
                   
                 Worsened (≥6.3) 
                 84 
                 28.6% 
                 102 
                 37.9% 
               
               
                   
               
            
           
         
       
     
     Example 1H: Change From Baseline to Week 108—Patients with One or Fewer Prior Relapses at Baseline 
     Mean change from baseline to Week 108 for change in FSIQ-RMS weekly symptoms score for patients with one or fewer prior relapses at baseline is shown in  FIG.  24   . Cumulative distribution function of change is shown in  FIG.  25   . 
     Example 11: Change From Baseline to Week 108—Patients with Two or More Prior Relapses at Baseline 
     Mean change from baseline to Week 108 for change in FSIQ-RMS weekly symptoms score for patients with two or more prior relapses at baseline is shown in  FIG.  26   . Cumulative distribution function of change is shown in  FIG.  27   . 
     Example 2: Pre-Specified MRI Endpoints and No Evidence of Disease Activity (NEDA) Status 
     In this study, prespecified MRI-based endpoints and no evidence of disease activity (NEDA) status is evaluated. 
     Patients (18-55 years) with RMS (expanded disability status scale scores: 0-5.5) were randomized (1:1) to receive ponesimod (PON) 20 mg or teriflunomide (TER) 14 mg for 108 weeks. MRI assessments were: volume of T2 lesions; mean number of new gadolinium-enhancing (Gd+) T1 lesions and new/enlarging T2 lesions; and absence of active MRI lesions at week 108. NEDA-3 status (absence of confirmed relapse, Gd+T1 lesions and new/enlarging T2 lesions on annual MRIs, and 12-week confirmed disability accumulation) was evaluated from baseline to week 108. 
     A total of 985/1133 (86.9%) randomized patients completed the study. MRI findings for PON vs TER from baseline to week 108, respectively, were: least square (LS) mean difference (PON-TER) in change from baseline in total volume of T2 lesions: −399.2 mm 3  (95% CLs:—651.5; —146.8, p=0.002); mean number of new Gd+T1 lesions per scan: 0.18 vs 0.43 (rate ratio [RR]:0.42, 95% CLs:0.31; 0.56, p&lt;0.0001); mean numbers of new/enlarging T2 lesions per year: 1.40 vs 3.16 (RR:0.44, 95% CLs:0.36; 0.54, p&lt;0.0001); PON vs TER odds ratio (OR [95% CL]) for absence of new Gd+T1 lesions: 2.18 (1.61; 2.95, p&lt;0.0001) and absence of new/enlarging T2 lesions: 1.71 (1.30; 2.25, p=0.0001). At week 108, 28.2% (159/564) PON vs 18.3% (102/558) TER patients (OR: 1.70, CL:1.27; 2.28, p=0.0004) achieved NEDA-3. The most frequent reason for not achieving NEDA-3 status at week 108 was presence of new/enlarging T2 lesions. 
     Patients treated with ponesimod demonstrated a higher proportion of patients achieving NEDA-3 status compared to those treated with teriflunomide. 
     Conclusions 
     This study demonstrates the superior efficacy of ponesimod over the active control.  Ibis  study is the first study showing a statistically significant effect on fatigue symptoms in a pre-defined secondary endpoint (disease specific validated PRO), targeting a key unmet need. 
     This study also demonstrates that the safety profile of ponesimod appears to be consistent with previously observed safety findings with ponesimod, and the known safety profile of other S1P receptor modulators. The gradual up-titration appears to successfully mitigate first-dose effects of ponesimod and supports forgoing first dose monitoring for patients with no risk factors for symptomatic bradycardia. 
     Example 3—Clinical Management 
     Introduction 
     Sphingosine-1-phosphate receptor modulators (SIPs), a class of oral disease modifying therapies (DMTs) for multiple sclerosis (MS), are cell-trafficking inhibitors that have been shown to have high efficacy. 
     Four S1Ps are indicated for MS in the United States: fingolimod, siponimod, ozanimod, and ponesimod. Although these S1Ps share some similarities as a class, the individual SIPs have differences in selectivity for receptor subtypes and phosphorylation requirements, half-lives, and safety profiles that result in different clinical requirements before and after treatment initiation. 
     Some clinical management events are common across the S1Ps, such as complete blood count, electrocardiogram, and liver function tests before treatment initiation. However, each SIP also has unique recommendations for clinical management events described in their US Prescribing Information (USPI), which may impact their overall ease of use. S1Ps with fewer clinical management events may be easier to use than those that require more monitoring. 
     Objective 
     The objective of this study was to estimate the expected frequencies of differential clinical management events (eg, eye exam, first-dose cardiovascular monitoring, and drug-drug interactions [DDIs]) using real-world data sources of persons with MS; and to compare the use of SCS for the treatment of relapses between ponesimod (PON) and teriflunomide (TER) groups in the OPTIMUM trial (See Example 1). 
     Methods 
     Study Design 
     Retrospective cohort study utilized the following three US administrative claims databases: 
     1) IBM® MarketScan® Commercial Claims and Encounters Database (IBM CCAE); 
     2) IBM® MarketScan® Medicare Supplemental and Coordination of Benefits Database (IBM MDCR); and 
     3) Optum® Clinformatics® Extended Data Mart—Socioeconomic Status (Optum SES). 
     Analyses were performed on data converted to the Observational Medical Outcomes Partnership Common Data Model, version 5.3.1. 
     Inclusion/exclusion criteria: claim for any MS DMT within the index period (1 Jan. 2016-11 Mar. 2019) and no other demyelinating disease diagnosis within 1 year before the index date. The index date was defined as follows:
         1) For each patient, identify all DMT service dates within the index period;   2) Retain DMT service dates with prior MS diagnosis between the study period start date (1 Jan. 2015) and the DMT service date;   3) Retain DMT service dates that fall within a continuous observation period spanning at least 1 year before and 1 year after the DMT service date;   4) Retain DMT service dates on which patient is aged ≥18 years; and   5) Of any remaining DMT service dates, select the earliest date per patient as the index date.       

     Only differential events were quantified; common clinical management events that are applicable to all S1Ps were excluded from analysis, including complete blood count, Varicella zoster virus antibody testing, liver function tests (prior to S1P initiation), electrocardiogram, cancer screening, and pulmonary function tests. 
     Differential clinical management events prior to initiation were first-dose monitoring, genotyping, and an eye exam; after initiation, events were DDIs, eye exam, and liver function tests. The results are summarized below in Table 15. 
     
       
         
           
               
             
               
                 TABLE 15 
               
             
            
               
                   
               
               
                 Differential Clinical Management Events Up to or After Treatment Initiation 
               
            
           
           
               
               
               
               
               
            
               
                 Event 
                 Fingolimod 
                 Siponimod 
                 Ozanimod 
                 Ponesimod 
               
               
                   
               
               
                 1 st  Dose 
                 All Patients 
                 Recommended 
                 N/A 
                 Recommended 
               
               
                 Observation 
                   
                 for Patients with 
                   
                 for Patients with 
               
               
                   
                   
                 Certain Pre- 
                   
                 Certain Pre- 
               
               
                   
                   
                 Existing 
                   
                 Existing 
               
               
                   
                   
                 Cardiac 
                   
                 Cardiac 
               
               
                   
                   
                 Conditions 
                   
                 Conditions 
               
               
                 Eye Exam 
                 All Patients 
                 All Patients 
                 Recommended 
                 All Patients 
               
               
                 (Prior to 
                   
                   
                 for Patients with 
               
               
                 Initiation) 
                   
                   
                 History of 
               
               
                   
                   
                   
                 Uveitis, 
               
               
                   
                   
                   
                 Diabetes 
               
               
                   
                   
                   
                 Mellitus or 
               
               
                   
                   
                   
                 Macular Odema 
               
               
                 Genotyping 
                 N/A 
                 All Patients 
                 N/A 
                 N/A 
               
               
                 (Prior to 
               
               
                 Initiation) 
               
               
                 Differential 
                 Ketoconazole 
                 Moderate 
                 Adrenergic and 
                 Strong CYP3A4 
               
               
                 DDIs 
                 (systemic) 
                 CYP2C9 
                 serotonergic 
                 inducers, strong 
               
               
                   
                   
                 inhibitors, 
                 drugs, BCRP 
                 UGT1A1 
               
               
                   
                   
                 moderate 
                 inhibitors, 
                 inducers 
               
               
                   
                   
                 CYP2C9 
                 MAO 
               
               
                   
                   
                 inducers 
                 inhibitors, 
               
               
                   
                   
                   
                 strong CYP2C8 
               
               
                   
                   
                   
                 inducers, strong 
               
               
                   
                   
                   
                 CYP2C8 
               
               
                   
                   
                   
                 inhibitors 
               
               
                 Eye Exam (3-4 
                 All Patients 
                 N/A 
                 N/A 
                 N/A 
               
               
                 months after 
               
               
                 initiation) 
               
               
                 Periodic Liver 
                 All Patients 
                 N/A 
                 N/A 
                 N/A 
               
               
                 Function Tests 
               
               
                 During 
               
               
                 Treatment 
               
               
                   
               
               
                 S1P, sphingosine-1-phosphate receptor modulator; N/A, not available; DDI, drug-drug interaction; CYP, cytochrome 450; BCRP, breast cancer resistance protein; MAO, monoamine oxidase; UGT, UDP-glucuronosyltransferase. 
               
               
                 aAll S1Ps recommend an eye exam at any time if there is any change in vision while on therapy and regular follow-up exams for patients with a history of diabetes or uveitis. Fingolimod differs in additionally requiring an exam 3 to 4 months post initiation for all patients. 
               
            
           
         
       
     
     Endpoints/Outcomes 
     Total number of differential clinical management events (first-dose observation, eye exam, DDIs) before and during the first year of treatment for each S1P. 
     Prevalence of comorbidities for which a first-dose observation is recommended prior to siponimod or ponesimod. 
     Prevalence of comorbidities (uveitis, macular oedema, diabetes mellitus) for which an eye exam is recommended prior to ozanimod. 
     Relative risk of DDIs among S1Ps (ie, number of drugs taken concomitantly with any DMT for MS that would result in a DDI when taken with an S1P [excluding DDIs common to all S1Ps]). 
     Identified were DDI types, removing all DDI classes common to the 4 SIPs (antineoplastic or immunosuppressive therapies, antiarrhythmic or QT-prolonging drugs, vaccines). Results are summarized below in Table 16. 
     
       
         
           
               
             
               
                 TABLE 16 
               
             
            
               
                   
               
               
                 USPI Drug Interactions Among S1Ps 
               
            
           
           
               
               
               
               
               
            
               
                 Interactions 
                 Fingolimod 
                 Siponimod a   
                 Ozanimod b   
                 Ponesimod 
               
               
                   
               
               
                 Antiarrhythmic drugs, QT- 
                 X 
                 X 
                 X 
                 X 
               
               
                 prolonging drugs, 
               
               
                 drugs that slow heart rate c   
               
               
                 Antineoplastic, immune- 
                 X 
                 X 
                 X 
                 X 
               
               
                 modulating, or immune- 
               
               
                 suppressive therapies 
               
               
                 Vaccinces 
                 X 
                 X 
                 X 
                 X 
               
               
                 Adrenergic and serotonergic 
                   
                   
                 X 
               
               
                 drugs (e.g., opioid drugs, SSRIs. 
               
               
                 SNRIs, TCAs, sympatho- 
               
               
                 mimetic drugs) 
               
               
                 BCRP Inhibitors 
                   
                   
                 X 
               
               
                 Lab Test Interaction d   
                 X 
               
               
                 MAO Inhibitors 
                   
                   
                 X 
               
               
                 Moderate CYP2C9 Inducers 
                   
                 X 
               
               
                 Moderate CYP2C9 Inhibitors 
                   
                 X 
               
               
                 Strong CYP2C8 Inducers 
                   
                   
                 X 
               
               
                 Strong CYP2C8 Inhibitors 
                   
                   
                 X 
               
               
                 Strong CYP3A4 Inducers 
                   
                   
                   
                 X 
               
               
                 Strong UGT1A1 Inducers 
                   
                   
                   
                 X 
               
               
                 Systemic Ketoconazole 
                 X 
               
               
                 Tyramine d   
                   
                   
                 X 
               
               
                   
               
               
                 USPI, US Prescribing Information; S1P, sphingosine-1-phosphate receptor modulator; FIN, fingolimod; SIP, siponimod; OZA, ozanimod; PON, ponesimod; SSRI, selective serotonin reuptake inhibitor; SNRI, selective norepinephrine reuptake inhibitor; TCA, tricyclic antidepressant; BCRP, breast cancer resistance protein; MAO, monoamine oxidase; CYP, cytochrome 450; UGT, UDP-glucuronosyltransferase; DDI, drug-drug interaction. 
               
               
                   a For SIP: 1) Moderate or strong CYP3A4 inhibitors are specified as a DDI only when combined with moderate CYP2C9 inhibitors; here, it is sufficient to identify moderate CYP2C9 inhibitors (including moderate CYP2C9/CYP3A4 dual inhibitors); 2) Strong CYP3A4 inducers are specified as a DDI only when combined with moderate CYP2C9 inducers; here, it is sufficient to identify moderate CYP2C9 inducers (including moderate CYP2C9/strong CYP3A4 dual inducers). 
               
               
                   b OZA&#39;s USPI lists CYP3A4 inhibitors and inducers as DDIs only when combined with other DDI types shown in this table (eg, dual inducers). Thus, for this study, it was not necessary to include these as separate DDI types. 
               
               
                   c Purple highlighting indicates drug interactions that are common to all S1Ps. 
               
               
                   d Pharmacogenomic and laboratory test interactions are not in scope for this study, and interactions with foods and over-the-counter medications will not be detectable in the databases. 
               
            
           
         
       
     
     Results 
     The majority of patients in all databases were female. The results are summarized in Table 17. 
     
       
         
           
               
             
               
                 TABLE 17 
               
             
            
               
                   
               
               
                 Cohorts Demographics in Each Database 
               
            
           
           
               
               
               
               
            
               
                   
                 IBM 
                 IBM MDCR 
                 OPTUM SES 
               
               
                   
                   
               
            
           
           
               
               
               
               
            
               
                 Count 
                 22,051 
                 1,599 
                 17,689 
               
               
                 Female Patients, % 
                 76 
                 74 
                 75 
               
               
                 Age, Years, mean (SD) 
                 48.0 (9.8) 
                 67.9 (6.3) 
                 52.8 (11.8) 
               
               
                   
               
               
                 IBM CCAE, IBM ® MarketScan ® Commercial Claims and Encounters Database; IBM MDCR, IBM ® MarketScan ® Medicare Supplemental and Coordination of Benefits Database; Optum SES, Optum ® Clinformatics ® Extended Data Mart - Socioeconomic Status; SD, standard deviation. 
               
            
           
         
       
     
     In the IBM CCAE, ponesimod had the lowest number of differential clinical management events (1.11) compared with fingolimod (4.00), siponimod (2.19), and ozanimod (1.85). The results are summarized in Table 4. Similar results were obtained in the IBM MDCR and Optum SES databases, as shown in  FIG.  28   . 
     In  FIG.  28   , the IBM CCAE, IBM® MarketScan® Commercial Claims and Insurance Database; IBM MDCR, IBM® MarketScan® Medicare Supplemental and Coordination of Benefits Database; Optum SES, Optum®® Clinformatics® Extended Data Mart—Socioeconomic Status. The differential events are management events that have different recommendations for each SIP, such as first-dose monitoring and eye exam. 
     
       
         
           
               
             
               
                 TABLE 18 
               
             
            
               
                   
               
               
                 Estimated Number of Events of Differential Clinical Management 
               
               
                 Events per Patient in the IBM CCAE Study Cohort 
               
            
           
           
               
               
               
               
               
            
               
                 Events 
                 Fingolimod 
                 Siponimod 
                 Ozanimod 
                 Ponesimod 
               
               
                   
               
            
           
           
               
               
               
               
               
            
               
                 1 st  Dose Monitoring 
                 1 
                 0.09 
                 0 
                 0.09 
               
               
                 (data on file for all 
               
               
                 MS patients) 
               
               
                 Eye Exam Before 
                 1 
                 1 
                 0.09 
                 1 
               
               
                 Intitiation 
               
               
                 Genotyping 
                 0 
                 1 
                 0 
                 0 
               
               
                 DDIs (average 
                 &lt;0.01 
                 0.10 
                 1.76 
                 0.02 
               
               
                 number of S1P&#39;s 
               
               
                 differential DDI 
               
               
                 drugs taken 
               
               
                 concomitantly 
               
               
                 with any MS DMT 
               
               
                 in a 1-year period) 
               
               
                 Eye Exam, 3-4 
                 1 
                 0 
                 0 
                 0 
               
               
                 Months After 
               
               
                 Initiation 
               
               
                 Periodic Liver 
                 1 
                 0 
                 0 
                 0 
               
               
                 Function Tests, 
               
               
                 After Initiation 
                   
                   
                   
                   
               
               
                 Total 
                 4.00 
                 2.19 
                 1.85 
                 1.11 
               
               
                 (Events/Patient) 
               
               
                   
               
            
           
         
       
     
     Per the USPI, first-dose monitoring is recommended for all patients before fingolimod initiation. The cardiovascular risks described in the USPIs for siponimod and ponesimod were observed in 9% of the IBM CCAE cohort. Thus, first-dose events were quantified as 1 per patient for fingolimod, 0.09 events per patient for siponimod and ponesimod, and 0 events for ozanimod, as shown in Table 18. 
     An eye exam is recommended for all patients before fingolimod, siponimod, and ponesimod initiation. For ozanimod, 9% of the IBM CCAE cohort had conditions that trigger the recommendation for an eye exam, which translates into 0.09 events per patient for ozanimod and 1 event per patient for the other S1Ps, as shown in Table 4. 
     In the IBM CCAE, the average number of DDI drugs used concomitantly with any MS DMTs within 1 year was 0.0005, 0.10, 1.76, and 0.02 for fingolimod, siponimod, ozanimod, and ponesimod, respectively, as shown in Table 4. 
     Per the USPI, periodic liver function tests are recommended during fingolimod treatment, which was estimated as 1 event in the year following initiation, as shown in Table 4. 
     Limitations 
     The study design did not include exclusion criteria based on contraindications for each S1P. 
     The study did not consider differences in recommended first-dose monitoring durations (6 hours for fingolimod and siponimod vs 4 hours for ponesimod) or other differences, such as reversibility of lymphocyte counts. 
     Generalizability was limited because each database represents a specific population of patients (eg, the IBM CCAE consists of commercially insured individuals, whereas the IBM MDCR includes those who receive supplemental Medicare coverage). 
     Administrative claims data lack clinical detail; a claim for a filled prescription does not indicate whether the medication was taken as prescribed and overlap of drug exposure dates (determined by overlap in drug supply by &gt;1 day) may not reflect actual concomitant drug use. 
     Because of low sample sizes for newer agents, this analysis assessed risk of DDIs (indicated as concomitant use with any MS DMT) rather than actual DDIs for each S1P. 
     Conclusion 
     The data were consistent across different databases and suggest ponesimod is expected to have the fewest clinical management events among S1Ps and may be easier to use overall than other S1Ps 
     Example 4: Approved Drug Product Label 
     Highlights of Prescribing Information 
     These highlights do not include all the information needed to use PONVORY safely and effectively. See full prescribing information for PONVORY. 
     PONVORY™ (ponesimod) tablets, for oral use 
     Initial U.S. Approval: 2021 
     Indications and Usage 
     PONVORY is a sphingosine 1-phosphate receptor modulator indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults. (1 
     Dosage and Administration 
     Assessments are required prior to initiating PONVORY (2.1) 
     Titration is required for treatment initiation (2.2) 
     The recommended maintenance dosage is 20 mg taken orally once daily (2.2) 
     First-dose monitoring is recommended for patients with sinus bradycardia, first- or second-degree [Mobitz type I] atrioventricular (AV) block, or a history of myocardial infarction or bean figure (2.3) 
     Dosage Forms and Strengths 
     Tablets: 2 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7 mg, 8 mg, 9 mg, 10 mg, and 20 mg (3) 
     Contraindications 
     In the last 6 months. experienced myocardial infarction, unstable angina, stroke transient ischemic attack (TIA), decompensated heart failure requiring hospitalization, or Class III/IV heart failure (4) 
     Presence of Mobitz type II second-degree, third-degree AV block, or sick sinus syndrome, unless patient has a functioning pacemaker (4) 
     Warnings and Precautions 
     Infections: PONVORY may increase the risk of infections. Obtain a complete blood count (CBC) before initiating treatment. Monitor for infection during treatment and for 1-2 weeks after discontinuation. Do not start PONVORY in patients with active infection. (5.1) 
     Bradyarrhythmia and Atrioventricular Condition Delays: PONVORY may result in a transient decrease in heart rate; titration is required for treatment initiation. Check an electrocardiogram (ECG) to assess for preexisting cardiac condition abnormalities before starting PONVORY. Consider cardiology consultation for conduction abnormalities or concomitant use with other drugs that decrease heart rate. (5.2, 7.2, 7.3) 
     Respiratory Effects: May cause a decline in pulmonary function. Assess pulmonary function (e.g., spirometry) if clinically indicated. (5.3) 
     Liver Injury: Discontinue if significant liver injury is confirmed. Obtain liver function tests before initiating PONVORY. (5.4) 
     Increased Blood Pressure (BP): Monitor BP during treatment. (5.5) 
     Cutaneous Malignancies: Periodic skin examination is recommended. (5.6) 
     Fetal Risk: Women of childbearing potential should use effective contraception during and for 1 week after stopping PONVORY. (5.7) 
     Macular Edema: An ophthalmic evaluation is recommended before starting treatment and if there is any change in vision while taking PONVORY. Diabetes mellitus and uveitis increase the risk. (5.8) 
     Adverse Reactions 
     Most common adverse reactions (incidence at least 10%) are upper respiratory tract infection, hepatic transminase elevation and hypertension. (6.1). 
     To report SUSPECTED ADVERSE REACTIONS, contact Janssen Pharmaceuticals, Inc. at 1400-JANSSEN (1400426-7736) FDA at 1400-FDA-1088 or www.fda.gov/medwatch. 
     Drug Interactions 
     Vaccines: Avoid live attenuated vaccines during and for up to 1-2 weeks after treatment with PONVORY (7.4) 
     Strong CYP3A4 and UGT1A1 Inducers: Coadministration with PONVORY is not recommended (7.5) 
     Use in Specific Populations 
     Hepatic Impairment: PONVORY is not recommended in patients with moderate or severe hepatic impairment (Child-Pugh class B and C). (8.6) 
     See 17 for PATIENT COUNSELING INFORMATION and Medication Guide. 
     Full Prescribing Information: Contents* 
     1 INDICATIONS AND USAGE 
     2 DOSAGE AND ADMINISTRATION 
     2.1 Assessments Prior to First Dose of PONVORY 
     2.2 Recommended Dosage 
     2.3 First Dose Monitoring in Patients with Certain Preexisting Cardiac Conditions 
     2.4 Reinitiation of PONVORY After Treatment Interruption 
     3 DOSAGE FORMS AND STRENGTHS 
     4 CONTRAINDICATIONS 
     5 WARNINGS AND PRECAUTIONS 
     5.1 Infections 
     5.2 Bradyarrhythmia and Atrioventricular Conduction Delays 
     5.3 Respiratory Effects 
     5.4 Liver Injury 
     5.5 Increased Blood Pressure 
     5.8 Cutaneous Malignancies 
     5.7 Fetal Risk 
     5.8 Macular Edema 
     5.9 Posterior Reversible Encephalopathy Syndrome 
     5.10 Unintended Additive Immunosuppressive Effects From Prior Treatment With Immunosuppressive or Immune-Modulating Therapies 
     5.11 Severe Increase in Disability After Stopping PONVORY 
     5.12 Immune System Effects After Stopping PONVORY 
     6 ADVERSE REACTIONS 
     6.1 Clinical Trials Experience 
     7 DRUG INTERACTIONS 
     7.1 Anti-Neoplastic, Immune-Modulating, or Immunosuppressive Therapies 
     7.2 Anti-Arrhythmic Drugs, QT Prolonging Drugs, Drugs that may Decrease Heart Rate 
     7.3 Beta-Blockers 
     7.4 Vaccination 
     7.5 Strong CYP3A4 and UGT1A1 Inducers 
     8 USE IN SPECIFIC POPULATIONS 
     8.1 Pregnancy 
     82 Lactation 
     8.3 Females and Males of Reproductive Potential 
     8.4 Pediatric Use 
     8.5 Geriatric Use 
     8.6 Hepatic Impairment 
     10 OVERDOSAGE 
     11 DESCRIPTION 
     12 CLINICAL PHARMACOLOGY 
     12.1 Mechanism of Action 
     12.2 Pharmacodynamics 
     12.3 Pharmacokinetics 
     13 NONCLINICAL TOXICOLOGY 
     13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility 
     13.2 Animal Toxicology and/or Pharmacology 
     14 CLINICAL STUDIES 
     16 HOW SUPPLIED/STORAGE AND HANDLING 
     16.1 How Supplied 
     16.2 Storage and Handing 
     17 PATIENT COUNSELING INFORMATION 
     *Sections or subsections omitted from full prescribing information are not listed. 
     Full Prescribing Information 
     1. Indications and Usage 
     PONVORY is indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults. 
     2. Dosage and Administration 
     2.1 Assessments Prior to First Dose of PONVORY 
     Before initiation of treatment with PONVORY, assess the following: 
     Complete Blood Count 
     Obtain a recent (i.e., within the last 6 months or after discontinuation of prior MS therapy) complete blood count (CBC), including lymphocyte count [see  Warnings and Precautions  (5.1)]. 
     Cardiac Evaluation 
     Obtain an electrocardiogram (ECG) to determine whether preexisting conduction abnormalities are present. In patients with certain preexisting conditions, advice from a cardiologist should be sought and first-dose monitoring is recommended [see  Dosage and Administration  (2.3)  and Warnings and Precautions  (5.2)]. 
     Determine whether patients are taking drugs that could slow heart rate or atrioventricular (AV) conduction [see  Warnings and Precautions  (5.2)]  and Drug Interactions  (7.2, 7.3)]. 
     Liver Function Tests 
     Obtain recent (i.e., within the last 6 months) transaminase and bilirubin levels [see  Warnings and Precautions  [(5.4)]. 
     Ophthalmic Evaluation 
     Obtain an evaluation of the fundus, including the macula [see  Warnings and Precautions  (5.8)]. 
     Current or Prior Medications with Immune System Effects 
     If patients are taking anti-neoplastic, immunosuppressive, or immune-modulating therapies, or if there is a history of prior use of these drugs, consider possible unintended additive immunosuppressive effects before initiating treatment with PONVORY [see  Warnings and Precautions  (5.1, 5.10)  and Drug Interactions  (7.1)]. 
     Vaccinations 
     Test patients for antibodies to varicella zoster virus (VZV) before initiating PONVORY; VZV vaccination of antibody-negative patients is recommended prior to commencing treatment with PONVORY [see  Warnings and Precautions  (5.1)]. If live attenuated vaccine immunizations are required, administer at least 1 month prior to initiation of PONVORY. 
     2.2. Recommended Dosage 
     Maintenance Dosage 
     After dose titration is complete (see  Treatment Initiation ), the recommended maintenance dosage of PONVORY is 20 mg taken orally once daily starting on Day 15. Administer PONVORY orally once daily. Swallow the tablet whole. PONVORY can be taken with or without food. 
     Treatment Initiation 
     A starter pack must be used for patients initiating treatment with PONVORY [ see How Supplied/Storage and Handling  (161)]. Initiate PONVORY treatment with a 14-day titration; start with one 2 mg tablet orally once daily and progress with the titration schedule as shown in Table 19 [see  Warnings and Precautions  (5.2)]. 
     
       
         
           
               
             
               
                 TABLE 19 
               
             
            
               
                   
               
               
                 Dose Titration Regimen 
               
            
           
           
               
               
            
               
                   
                 Daily Dose 
               
               
                   
                   
               
            
           
           
               
               
               
            
               
                   
                 Titration Day 
                   
               
               
                   
                 Days 1 and 2 
                 2 mg 
               
               
                   
                 Days 3 and 4 
                 3 mg 
               
               
                   
                 Days 5 and 6 
                 4 mg 
               
               
                   
                 Day 7 
                 5 mg 
               
               
                   
                 Day 8 
                 6 mg 
               
               
                   
                 Day 9 
                 7 mg 
               
               
                   
                 Day 10 
                 8 mg 
               
               
                   
                 Day 11 
                 9 mg 
               
               
                   
                 Days 12, 13, and 14 
                 10 mg  
               
               
                   
                 Maintenance 
               
               
                   
                 Day 15 and thereafter 
                 20 mg  
               
               
                   
                   
               
            
           
         
       
     
     If dose titration is interrupted, missed dose instructions must be followed [see  Dosage and Administration  (2.4)]. 
     2.3 First Dose Monitoring in Patients with Certain Preexisting Cardiac Conditions 
     Because initiation of PONVORY treatment results in a decrease in heart rate (HR). first-dose 4-hour monitoring is recommended for patients with sinus bradycardia [HR less than 55 beats per minute (bpm)], first- or second-degree [Mobitz type I] AV block, or a history of myocardial infarction or heart failure occurring more than 6 months prior to treatment initiation and in stable condition [see  Warnings and Precautions  (5.3)  and Clinical Pharmacology  (12.2)]. 
     First Dose 4-Hour Monitoring 
     Administer the first dose of PONVORY in a setting where resources to appropriately manage symptomatic bradycardia are available. Monitor patients for 4 hours after the first dose for signs and symptoms of bradycardia with a minimum of hourly pulse and blood pressure measurements. Obtain an ECG in these patients prior to dosing and at the end of the 4-hour observation period. 
     Additional Monitoring After 4-Hour Monitoring 
     If any of the following abnormalities are present after 4 hours (even in the absence of symptoms). continue monitoring until the abnormality resolves: 
     The heart rate 4 hours post-dose is less than 45 bpm 
     The heart rate 4 hours post-dose is at the lowest value post-dose, suggesting that the maximum pharmacodynamic effect on the heart may not have occurred The ECG 4 hours post-dose shows new onset second-degree or higher AV block. 
     If post-dose symptomatic bradycardia, bradyarrhythmia, or conduction related symptoms occur, or if ECG 4 hours post-dose shows new onset second degree or higher AV block or QTc greater than or equal to 500 msec, initiate appropriate management, begin continuous ECG monitoring, and continue monitoring until the symptoms have resolved if no pharmacological treatment is required. If pharmacological treatment is required, continue monitoring overnight and repeat 4-hour monitoring after the second dose. 
     Advice from a cardiologist should be sought to determine the most appropriate monitoring strategy (which may include overnight monitoring) during treatment initiation, if treatment with PONVORY is considered in patients: 
     With some preexisting heart and cerebrovascular conditions [see  Warnings and Precautions  (5.2)] 
     With a prolonged QTc interval before dosing or during the 4-hour observation, or at additional risk for QT prolongation, or on concurrent therapy with QT prolonging drugs with a known risk of torsades de pointes [see  Warnings and Precautions  (5.2)  and Drug Interactions  (7.2)] 
     Receiving concurrent therapy with drugs that slow heart rate or AV conduction [ see Drug Interactions  (7.2, 7.3)]. 
     2.4 Reinitiation of PONVORY After Treatment Interruption 
     Interruption during treatment, especially during titration, is not recommended; however: 
     If fewer than 4 consecutive doses are missed:
         during titration: resume treatment with the first missed titration dose and resume the titration schedule at that dose and titration day.   during maintenance: resume treatment with the maintenance dosage.       

     If 4 or more consecutive doses are missed during titration or maintenance:
         treatment should be reinitiated with Day 1 of the titration regimen (new starter pack).       

     If treatment needs to be reinitiated with Day 1 of the titration regimen (new starter pack), complete first-dose monitoring in patients for whom it is recommended [see  Dosage and Administration  (2.3)]. 
     3. Dosage Forms and Strengths 
     PONVORY is available as round, biconvex, film-coated tablets for oral use. PONVORY contains ponesimod in the following dosage strengths (see Table 20). 
     
       
         
           
               
             
               
                 TABLE 20 
               
             
            
               
                   
               
               
                 Dosage Form and Strengths for PONVORY 
               
            
           
           
               
               
               
               
            
               
                 Tablet 
                 Tablet 
                 Tablet 
                   
               
               
                 Strength 
                 Color 
                 Size 
                 Tablet Debossing 
               
               
                   
               
               
                 2 mg 
                 White 
                 5.0 mm 
                 “2” on one side and an arch on the other side. 
               
               
                 3 mg 
                 Red 
                 5.0 mm 
                 “3” on one side and an arch on the other side. 
               
               
                 4 mg 
                 Purple 
                 5.0 mm 
                 “4” on one side and an arch on the other side. 
               
               
                 5 mg 
                 Green 
                 8.6 mm 
                 “5” on one side and an arch and an “A” on the other side. 
               
               
                 6 mg 
                 White 
                 8.6 mm 
                 “6” on one side and an arch and an “A” on the other side. 
               
               
                 7 mg 
                 Red 
                 8.6 mm 
                 “7” on one side and an arch and an “A” on the other side. 
               
               
                 8 mg 
                 Purple 
                 8.6 mm 
                 “8” on one side and an arch and an “A” on the other side. 
               
               
                 9 mg 
                 Brown 
                 8.6 mm 
                 “9” on one side and an arch and an “A” on the other side. 
               
               
                 10 mg  
                 Orange 
                 8.6 mm 
                 “10” on one side and an arch and an “A” on the other side. 
               
               
                 20 mg  
                 Yellow 
                 8.6 mm 
                 “20” on one side and an arch and an “A” on the other side. 
               
               
                   
               
            
           
         
       
     
     4. Contraindications 
     PONVORY is contraindicated in patients who: 
     In the last 6 months, have experienced myocardial infarction, unstable angina, stroke, transient ischemic attack (TLA), decompensated heart failure requiring hospitalization, or Class III or IV heart failure [see  Warnings and Precautions  (5.2)] 
     Have presence of Mobitz type II second-degree. third-degree atrioventricular (AV) block, or sick sinus syndrome, or sino-atrial block, unless patient has a functioning pacemaker [see  Warnings and Precautions  (5.2)]. 
     5. Warnings and Precautions 
     5.1 Infections 
     Risk of Infections 
     PONVORY causes a dose-dependent reduction in peripheral lymphocyte count to 30-40% of baseline values because of reversible sequestration of lymphocytes in lymphoid tissues [see  Clinical Pharmacology  (12.2)]. PONVORY may therefore increase the susceptibility to infections. Life-threatening and rare fatal infections have been reported in association with other sphingosine 1-phosphate (SIP) receptor modulators. 
     In Study 1 [see  Clinical Studies  (14)]. the overall rate of infections was comparable between the PONVORY-treated patients and those receiving teriflunomide 14 mg (54.2% vs 52.1%, respectively). PONVORY increased the risk of upper respiratory tract infections. Serious or severe infections occurred in 1.6% of PONVORY-treated patients compared to 0.9% of patients receiving teriflunomide 14 mg. 
     Before initiating treatment with PONVORY, results from a recent (i.e., within 6 months or after discontinuation of prior therapy) complete blood count including lymphocyte count should be reviewed. 
     Initiation of treatment with PONVORY should be delayed in patients with active infection until resolution. Lymphocyte counts returned to the normal range in 90% of patients within 1 week of stopping therapy in modeling studies [see  Clinical Pharmacology  (12.2)]. In Study 1, peripheral lymphocyte counts returned to normal range within 2 weeks after discontinuation of PONVORY, which was the first timepoint evaluated. Because residual pharmacodynamic effects, such as lowering effects on peripheral lymphocyte count, may persist for 1 to 2 weeks after discontinuation of PONVORY, vigilance for infection should be continued for 1 to 2 weeks after PONVORY is discontinued [see  Warnings and Precautions  (5.12)]. 
     In Study 1, the proportion of patients who experienced lymphocyte counts less than 0.2×10 9 /L was 3.2%. Effective diagnostic and therapeutic strategies should be employed in patients with symptoms of infection while on therapy. Consider interruption of treatment with PONVORY if a patient develops a serious infection. 
     Herpes Viral Infections 
     Cases of herpes viral infection have been reported in the development program of PONVORY; herpes simplex encephalitis and varicella zoster meningitis have been reported with other S1P receptor modulators. 
     In Study 1, the rate of herpetic infections was 4.8% for both PONVORY-treated patients and those receiving teriflunomide 14 mg. Patients without a healthcare professional confirmed history of varicella (chickenpox) or without documentation of a full course of vaccination against VZV should be tested for antibodies to VZV before initiating PONVORY (see  Vaccinations ). 
     Cryptococcal Infections 
     Cases of fatal cryptococcal meningitis (CM) and disseminated cryptococcal infections have been reported with other SIP receptor modulators. Physicians should be vigilant for clinical symptoms or signs of CM. Patients with symptoms or signs consistent with a cryptococcal infection should undergo prompt diagnostic evaluation and treatment. PONVORY treatment should be suspended until a cryptococcal infection has been excluded. If CM is diagnosed, appropriate treatment should be initiated. 
     Progressive Multifocal Leukoencephalopathy 
     Progressive multifocal leukoencephalopathy (PML) is an opportunistic viral infection of the brain caused by the JC virus (JCV) that typically only occurs in patients who are immunocompromised, and that usually leads to death or severe disability. Typical symptoms associated with PML are diverse, progress over days to weeks. and include progressive weakness on one side of the body or clumsiness of limbs, disturbance of vision, and changes in thinking, memory, and orientation leading to confusion and personality changes. 
     PML has been reported in patients treated with a S1P receptor modulator and other multiple sclerosis (MS) therapies and has been associated with some risk factors (e.g., immunocompromised patients, polytherapy with immunosuppressants). Physicians should be vigilant for clinical symptoms or magnetic resonance imaging (MRI) findings that may be suggestive of PML. MRI findings may be apparent before clinical signs or symptoms. If PML is suspected, treatment with PONVORY should be suspended until PML has been excluded. If PML is confirmed, treatment with PONVORY should be discontinued. 
     Prior and Concomitant Treatment with Anti-neoplastic. Immune-Modulating, or Immunosuppressive Therapies 
     Anti-neoplastic, immune-modulating, or immunosuppressive therapies (including corticosteroids) should be coadministered with caution because of the risk of additive immune system effects [see  Drug Interactions  (7.1)]. 
     Vaccinations 
     Patients without a healthcare professional confirmed history of chickenpox or without documentation of a full course of vaccination against VZV should be tested for antibodies to VZV before initiating PONVORY treatment. A full course of vaccination for antibody-negative patients with varicella vaccine is recommended prior to commencing treatment with POVORY, following which initiation of treatment with PONVORY should be postponed for 4 weeks to allow the full effect of vaccination to occur. 
     No clinical data are available on the efficacy and safety of vaccinations in patients taking PONVORY. Vaccinations may be less effective if administered during PONVORY treatment. 
     If live attenuated vaccine immunizations are required, administer at least 1 month prior to initiation of PONVORY. Avoid the use of live attenuated vaccines during and for 1 to 2 weeks after treatment with PONVORY. 
     5.2 Bradyarrhythmia and Atrioventricular Conduction Delays 
     Since initiation of PONVORY treatment results in a transient decrease in heart rate and atrioventricular (AV) conduction delays, an up-titration scheme must be used to reach the maintenance dosage of PONVORY (20 mg) [see  Dosage and Administration  (2.2)  and Clinical Pharmacology  (12.2)]. 
     Study 1 did not include patients who had: 
     A resting heart rate (HR) less than 50 beats per minute (bpm) on baseline electrocardiogram 
     Myocardial infarction or unstable ischemic heart disease in the last 6 months 
     Cardiac failure (New York Heart Association class III-IV) or presence of any severe cardiac disease 
     Cardiac conduction or rhythm disorders (including sino-atrial heart block, symptomatic bradycardia, atrial flutter or atrial fibrillation, ventricular arrhythmia, cardiac arrest) either in history or observed at screening 
     Mobitz Type II second degree AV block or higher-grade AV block observed at screening 
     QTcF interval greater than 470 ms (females) and greater than 450 ms (males) observed at screening 
     History of syncope associated with cardiac disorders 
     Uncontrolled systemic arterial hypertension Reduction in Heart Rate. 
     Reduction in Heart Rate 
     Initiation of PONVORY may result in a transient decrease in HR. In Study 1, bradycardia at treatment initiation and sinus bradycardia on ECG (defined as HR less than 50 bpm) occurred in 5.8% of PONVORY-treated patients compared to 1.6% of patients receiving teriflunomide 14 mg. After the first titration dose of PONVORY, the decrease in heart rate typically begins within an hour and reaches its nadir within 2-4 hours. The heart rate typically recovers to baseline levels 4-5 hours after administration. The mean decrease in heart rate on Day 1 of dosing was 6 bpm. With up-titration after Day 1, the post-dose decrease in heart rate is less pronounced. Bradycardia resolved in all patients in Study 1 without intervention and did not require discontinuation of PONVORY treatment. On Day 1, 3 patients treated with PONVORY had asymptomatic post-dose HR below or equal to 40 bpm; all 3 patients had baseline HRs below 55 bpm. 
     Atrioventricular Conduction Delays 
     Initiation of PONVORY treatment has been associated with transient atrioventricular conduction delays that follow a similar temporal pattern as the observed decrease in heart rate during dose titration. In Study 1, the AV conduction delays manifested as first-degree AV block (prolonged PR interval on ECG). which occurred in 3.4% of PONVORY-treated patients and in 1.2% of patients receiving teriflunomide 14 mg. The conduction abnormalities typically were transient, asymptomatic, resolved within 24 hours, resolved without intervention, and did not require discontinuation of PONVORY treatment. In Study 1, second- and third-degree AV blocks were not reported in patients treated with PONVORY. 
     If treatment with PONVORY is considered, advice from a cardiologist should be sought for individuals: 
     With significant QT prolongation (QTc greater than 500 msec) 
     With atrial flutter fibrillation or arrhythmia treated with Class Ia or Class III anti-arrhythmic drugs [see  Drug Interactions  (7.2)] 
     With unstable ischemic heart disease, cardiac decompensated failure occurring more than 6 months prior to treatment initiation history of cardiac arrest, cerebrovascular disease (TIA, stroke occurring more than 6 months prior to treatment initiation), or uncontrolled hypertension 
     With a history of Mobitz Type II second degree AV block or higher-grade AV block, sick-sinus syndrome, or sino-atrial heart block [see  Contraindications  (4)]. 
     Treatment Initiation Recommendations 
     Obtain an ECG in all patients to determine whether preexisting conduction abnormalities are present. 
     In all patients, a dose titration is recommended for initiation of PONVORY treatment to help reduce cardiac effects [see  Dosage and Administration  (2.2)]. 
     In patients with sinus bradycardia, first- or second-degree [Mobitz type I] AV block, or a history of myocardial infarction or heart failure with onset more than 6 months prior to initiation first-dose monitoring is recommended [see  Dosage and Administration  (2.1, 2.3)]. 
     PONVORY is not recommended in patients with a history of cardiac arrest, cerebrovascular disease (e.g., TIA, stroke occurring more than 6 months prior to treatment initiation), uncontrolled hypertension, or severe untreated sleep apnea, since significant bradycardia may be poorly tolerated in these patients. If treatment is considered, advice from a cardiologist should be sought prior to initiation of treatment in order to determine the most appropriate monitoring strategy. 
     Use of PONVORY in patients with a history of recurrent syncope or symptomatic bradycardia should be based on an overall benefit-risk assessment. If treatment is considered, advice from a cardiologist should be sought prior to initiation of treatment in order to determine the most appropriate monitoring. 
     Experience with PONVORY is limited in patients receiving concurrent therapy with drugs that decrease heart rate (e.g., beta-blockers, non-dihydropyridine calcium channel blockers—diltiazem and verapamil, and other drugs that may decrease heart rate such as digoxin). Concomitant use of these drugs during PONVORY initiation may be associated with severe bradycardia and heart block. If treatment is considered, advice from a cardiologist should be sought prior to initiation of treatment in order to determine the most appropriate monitoring. 
     For patients receiving a stable dose of a beta-blocker, the resting heart rate should be considered before introducing PONVORY treatment. If the resting heart rate is greater than 55 bpm under chronic beta-blocker treatment, PONVORY can be introduced. If resting heart rate is less than or equal to 55 bpm, beta-blocker treatment should be interrupted until the baseline heart rate is greater than 55 bpm. Treatment with PONVORY can then be initiated and treatment with a beta-blocker can be reinitiated after PONVORY has been up-titrated to the target maintenance dosage [see  Drug Interactions  (7.3)]. 
     For patients taking other drugs that decrease heart rate, treatment with PONVORY should generally not be initiated without consultation from a cardiologist because of the potential additive effect on heart rate [see  Dosage and Administration  (2.3)  and Drug Interactions  (7.2)]. 
     Missed Dose During Treatment Initiation or Maintenance Treatment 
     If 4 or more consecutive daily doses are missed during treatment initiation or maintenance treatment, reinitiate Day 1 of the dose titration (new starter pack) and follow first-dose monitoring recommendations [see  Dosage and Administration  (2.4)]. 
     5.3 Respiratory Effects 
     Dose-dependent reductions in forced expiratory volume over 1 second (FEV 1 ) and reductions in diffusion lung capacity for carbon monoxide (DL CO ) were observed in PONVORY-treated patients mostly occurring in the first month after treatment initiation. In Study 1, the reduction from baseline in percent predicted FEV 1  at 2 years was 8.3% in PONVORY-treated patients compared to 4.4% in patients receiving teriflunomide 14 mg. In Study 1, 7 patients discontinued PONVORY because of pulmonary adverse events. There is insufficient information to determine the reversibility of the decrease in FEV 1  or FVC after treatment discontinuation. PONVORY should be used with caution in patients with severe respiratory disease (i.e., pulmonary fibrosis, asthma, and chronic obstructive pulmonary disease). Spirometric evaluation of respiratory function should be performed during therapy with PONVORY if clinically indicated. 
     5.4 Liver Injury 
     Elevations of transaminases may occur in PONVORY-treated patients. 
     Obtain transaminase and bilirubin levels, if not recently available (i.e., within last 6 months) before initiation of PONVORY. 
     In Study 1, elevations of ALT to 5-fold the upper limit of normal (ULN) or greater occurred in 4.6% of patients treated with PONVORY compared to 2.5% of patients who received teriflunomide 14 mg. Elevation of ALT to 3-fold the ULN or greater occurred in 17.3% of patients treated with PONVORY and 8.3% of patients treated with teriflunomide 14 mg. The median time to an elevation of 3-fold the ULN was 3 months. The majority (89%) of patients with ALT increases 3-fold or greater the ULN continued treatment with PONVORY with values returning to less than three times the ULN within approximately 2-4 weeks. 
     In Study 1, the discontinuation rate because of elevations in hepatic enzymes was 2.3% of patients treated with PONVORY and 1.9% of patients who received teriflunomide 14 mg. 
     Patients who develop symptoms suggestive of hepatic dysfunction, such as unexplained nausea, vomiting, abdominal pain, fatigue, anorexia, rash with eosinophilia, or jaundice and/or dark urine during treatment, should have hepatic enzymes checked. PONVORY should be discontinued if significant liver injury is confirmed. 
     No dosage adjustment is necessary in patients with mild hepatic impairment (Child-Pugh class A). PONVORY is not recommended in patients with moderate or severe hepatic impairment (Child-Pugh class B and C, respectively) [see  Use in Specific Populations  (8.6)  and Clinical Pharmacology  (12.3)]. 
     5.5 Increased Blood Pressure 
     In Study 1, PONVORY-treated patients had an average increase of 2.9 mm Hg in systolic blood pressure and 2.8 mm Hg in diastolic blood pressure compared to 2.8 mm Hg and 3.1 mm Hg in patients receiving teriflunomide 14 mg, respectively. An increase in blood pressure with PONVORY was first detected after approximately 1 month of treatment initiation and persisted with continued treatment. Hypertensive events were reported as an adverse reaction in 10.1% of PONVORY-treated patients and in 9.0% of patients receiving teriflunomide 14 mg. One patient treated with PONVORY experienced a hypertensive crisis but had evidence of longstanding hypertensive heart disease. Blood pressure should be monitored during treatment with PONVORY and managed appropriately. 
     5.6 Cutaneous Malignancies 
     Cases of basal cell carcinoma and other skin malignancies have been reported in patients treated with SIP receptor modulators, including PONVORY. In Study 1, the incidence of basal cell carcinoma was 0.4% in PONVORY-treated patients compared to 0.2% in patients receiving teriflunomide 14 mg. Cases of other cutaneous malignancies, including melanoma and squamous cell carcinoma, have also been reported in patients treated with PONVORY and in patients treated with other SIP modulators. 
     Periodic skin examination is recommended for all patients, particularly those with risk factors for skin cancer. Providers and patients are advised to monitor for suspicious skin lesions. If a suspicious skin lesion is observed, it should be promptly evaluated. As usual for patients with increased risk for skin cancer, exposure to sunlight and ultraviolet light should be limited by wearing protective clothing and using a sunscreen with a high protection factor. Concomitant phototherapy with UV-B radiation or PUVA-photochemotherapy is not recommended in patients taking PONVORY. 
     5.7 Fetal Risk 
     Based on animal studies, PONVORY may cause fetal harm [see  Use in Specific Populations  8.1, 8.3)]. Because it takes approximately 1 week to eliminate PONVORY from the body, women of childbearing potential should use effective contraception to avoid pregnancy during and for 1 week after stopping PONVORY treatment. 
     5.8 Macular Edema 
     S1P receptor modulators, including PONVORY, have been associated with an increased risk of macular edema. In Study 1, macular edema was reported in 1.1% of PONVORY-treated patients compared to none of the patients receiving teriflunomide 14 mg. 
     An ophthalmic evaluation of the fundus, including the macula, is recommended in all patients before starting treatment and again at any time if a patient reports any change in vision while on PONVORY therapy. 
     Continuation of PONVORY therapy in patients with macular edema has not been evaluated. A decision on whether PONVORY should be discontinued should take into account the potential benefits and risks for the individual patient. 
     Macular Edema in Patients with a History of Uveitis or Diabetes Mellitus 
     Patients with a history of uveitis and patients with diabetes mellitus are at increased risk of macular edema during therapy with S1P receptor modulators, including PONVORY. Therefore, these patients should have regular follow-up examinations of the fundus, including the macula, during treatment with PONVORY. 
     5.9 Posterior Reversible Encephalopathy Syndrome 
     Rare cases of posterior reversible encephalopathy syndrome (PRES) have been reported in patients receiving a sphingosine 1-phosphate (SIP) receptor modulator. Such events have not been reported for PONVORY-treated patients in the development program. However, should a PONVORY-treated patient develop any unexpected neurological or psychiatric symptoms/signs (e.g., cognitive deficits, behavioral changes, cortical visual disturbances, or any other neurological cortical symptoms/signs), any symptom/sign suggestive of an increase of intracranial pressure, or accelerated neurological deterioration, the physician should promptly schedule a complete physical and neurological examination and should consider an MRI. Symptoms of PRES are usually reversible but may evolve into ischemic stroke or cerebral hemorrhage. Delay in diagnosis and treatment may lead to permanent neurological sequelae. If PRES is suspected, PONVORY should be discontinued. 
     5.10 Unintended Additive Immunosuppressive Effects From Prior Treatment With Immunosuppressive or Immune-Modulating Therapies 
     When switching from drugs with prolonged immune effects, the half-life and mode of action of these drugs must be considered in order to avoid unintended additive effects on the immune system while at the same time minimizing risk of disease reactivation, when initiating PONVORY. 
     Initiating treatment with PONVORY after treatment with alemtuzumab is not recommended. 
     5.11 Severe Increase in Disability After Stopping PONVORY 
     Severe exacerbation of disease, including disease rebound. has been rarely reported after discontinuation of a S1P receptor modulator. The possibility of severe exacerbation of disease should be considered after stopping PONVORY treatment. Patients should be observed for a severe increase in disability upon PONVORY discontinuation and appropriate treatment should be instituted, as required. 
     5.12 Immune System Effects After Stopping PONVORY 
     After stopping PONVORY therapy, ponesimod remains in the blood for up to 1 week. Starting other therapies during this interval will result in concomitant exposure to ponesimod. Lymphocyte counts returned to the normal range in 90% of patients within 1 week of stopping PONVORY therapy in modeling studies [see  Clinical Pharmacology  (12.2)]. However, residual pharmacodynamics effects, such as lowering effects on peripheral lymphocyte count, may persist for 1 to 2 weeks after the last dose. Use of immune-suppressants within this period may lead to an additive effect on the immune system, and therefore caution should be applied 1 to 2 weeks after the last dose of PONVORY [see  Drug Interactions  (7.1)]. 
     6. Adverse Reactions 
     The following serious adverse reactions are described elsewhere in labeling: Infections [see  Warnings and Precautions  (5.1)] 
     Bradyarrhythmia and Atrioventricular Conduction Delays [see  Warnings and Precautions  (5.2)] 
     Respiratory Effects [see  Warnings and Precautions  (5.3)] 
     Liver Injury [see  Warnings and Precautions  (5.4)] 
     Increased Blood Pressure [see  Warnings and Precautions  (5.5)] 
     Cutaneous Malignancies [see  Warnings and Precautions  (5.6)] 
     Fetal Risk [see  Warnings and Precautions  (5.7)] 
     Macular Edema [see  Warnings and Precautions  (5.8)] 
     Posterior Reversible Encephalopathy Syndrome [see  Warnings and Precautions  (5.9)] 
     Unintended Additive Immunosuppressive Effects From Prior Treatment With Immunosuppressive or Immune-Modulating Therapies [see  Warnings and Precautions  (5.10)] 
     Severe Increase in Disability After Stopping PONVORY [see  Warnings and Precautions  (5.11)] 
     Immune System Effects After Stopping PONVORY [see  Warnings and Precautions  (5.12)]. 
     6.1 Clinical Trials Experience 
     Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. 
     A total of 1438 MS patients have received PONVORY at doses of at least 2 mg daily. These patients were included in Study 1 (2-year active-controlled versus teriflunomide 14 mg) [see  Clinical Studies  (14)] and in a Phase 2 (6-month placebo-controlled) study in patients with MS and the uncontrolled extension studies. 
     In Study 1, 82% of PONVORY-treated patients completed 2 years of study treatment, compared to 82.2% of patients receiving teriflunomide 14 mg. Adverse events led to discontinuation of treatment in 8.7% of PONVORY-treated patients. compared to 6% of patients receiving teriflunomide 14 mg. The most common adverse reactions (incidence at least 10%) in PONVORY-treated patients in Study 1 were upper respiratory tract infection, hepatic transaminase elevation, and hypertension. Table 21 lists adverse reactions that occurred in at least 2% of PONVORY-treated patients and at a higher rate than in patients receiving teriflunomide 14 mg. 
     
       
         
           
               
             
               
                 TABLE 21 
               
             
            
               
                   
               
               
                 Adverse Reactions Reported in Study 1 Occurring in at 
               
               
                 Least 2% of PONVORY-Treated Patients and at a Higher 
               
               
                 Rate Than in Patients Receiving Teriflunomide 14 mg 
               
            
           
           
               
               
               
            
               
                   
                   
                 Teriflunomide 
               
               
                   
                 PONVORY 
                 14 mg 
               
               
                   
                 N = 565 
                 N = 566 
               
               
                 Adverse Reaction 
                 (%) 
                 (%) 
               
               
                   
               
            
           
           
               
               
               
            
               
                 Upper respiratory infection  a   
                 37 
                 34 
               
               
                 Hepatic transaminase elevation  b   
                 23 
                 12 
               
               
                 Hypertension  c   
                 10 
                 9 
               
               
                 Urinary tract infection 
                 6 
                 5 
               
               
                 Dyspnea 
                 5 
                 1 
               
               
                 Dizziness 
                 5 
                 3 
               
               
                 Cough 
                 4 
                 2 
               
               
                 Pain in extremity 
                 4 
                 3 
               
               
                 Somnolence 
                 3 
                 2 
               
               
                 Pyrexia 
                 2 
                 1 
               
               
                 C-reactive protein increased 
                 2 
                 1 
               
               
                 Hypercholesterolemia 
                 2 
                 1 
               
               
                 Vertigo 
                 2 
                 1 
               
               
                   
               
               
                   a  Includes the following terms: nasopharyngitis, upper respiratory tract infection, pharyngitis, respiratory tract infection, bronchitis, respiratory tract infection viral, viral upper respiratory tract infection, tracheitis, and laryngitis. 
               
               
                   b  Includes the following terms: alanine aminotransferase increased, aspartate aminotransferase increased, hepatic enzyme increased, and transaminases increased 
               
               
                   c  Includes the following terms: hypertension, hypertensive crisis, blood pressure increased, blood pressure systolic increased, and blood pressure diastolic increased. 
               
            
           
         
       
     
     In Study 1, the following adverse reactions occurred in less than 2% of PONVORY-treated patients, but at a rate at least 1% higher than in patients receiving teriflunomide 14 mg: viral infection, herpes zoster, hyperkalemia, lymphopenia [see  Warnings and Precautions  (5.1), and macular edema [see  Warnings and Precautions  (5.8)]. 
     Adverse reactions in patients treated with PONVORY in an additional 6-month placebo-controlled study were generally similar to those in Study 1. The following additional adverse reactions occurred in at least 2% of PONVORY 20 mg-treated patients and at a higher rate than in patients receiving placebo (but did not meet the reporting rate criteria for inclusion in Study 1): rhinitis, fatigue, chest discomfort, peripheral edema, joint swelling, blood cholesterol increased, migraine, insomnia, depression, dyspepsia, dry mouth, bradycardia, back pain, and sinusitis. 
     Additionally, in uncontrolled extension trials, the adverse reaction of pneumonia was reported. 
     Seizures 
     In Study 1, cases of seizures were reported in 1.4% of PONVORY-treated patients, compared to 0.2% in patients receiving teriflunomide 14 mg. It is not known whether these events were related to the effects of MS, to PONVORY, or to a combination of both. 
     Respiratory Effects 
     In Study 1, dose-dependent reductions in forced expiratory volume over 1 second (FEV 1 ) were observed in patients treated with PONVORY [see  Warnings and Precautions  (5.3)]. 
     Malignancies 
     In Study 1, two cases of basal cell carcinoma (0.4%) were reported in PONVORY-treated patients, compared to one case of basal cell carcinoma (0.2%) in patients receiving teriflunomide 14 mg, and a case of malignant melanoma was reported in a PONVORY-treated patient. An increased risk of cutaneous malignancies has been reported in association with other SIP receptor modulators, including PONVORY [see  Warnings and Precautions  (5.6)]. 
     7. Drug Interactions 
     7.1 Anti-Neoplastic, Immune-Modulating, or Immunosuppressive Therapies 
     PONVORY has not been studied in combination with anti-neoplastic, immune-modulating, or immunosuppressive therapies. Caution should be used during concomitant administration because of the risk of additive immune effects during such therapy and in the weeks following administration [see  Warnings and Precautions  (5.1)]. 
     When switching from drugs with prolonged immune effects, the half-life and mode of action of these drugs must be considered in order to avoid unintended additive effects on the immune system [see  Warnings and Precautions  (5.10)]. 
     Because of the characteristics and duration of alemtuzumab immune suppressive effects, initiating treatment with PONVORY after alemtuzumab is not recommended. 
     PONVORY can generally be started immediately after discontinuation of beta interferon or glatiramer acetate. 
     7.2 Anti-Arrhythmic Drugs, QT Prolonging Drugs, Drugs that may Decrease Heart Rate 
     PONVORY has not been studied in patients taking QT prolonging drugs. 
     Class Ia (e.g., quinidine, procainamide) and Class III (e.g., amiodarone, sotalol) anti-arrhythmic drugs have been associated with cases of Torsades de Pointes in patients with bradycardia. If treatment with PONVORY is considered. advice from a cardiologist should be sought. 
     Because of the potential additive effects on heart rate, treatment with PONVORY should generally not be initiated in patients who are concurrently treated with QT prolonging drugs with known arrhythmogenic properties, heart rate lowering calcium channel blockers (e.g., verapamil, diltiazem), or other drugs that may decrease heart rate (e.g., digoxin) [see  Warnings and Precautions  (5.2)  and Drug Interactions  (7.3)]. If treatment with PONVORY is considered, advice from a cardiologist should be sought. 
     7.3 Beta-Blockers 
     Caution should be applied when PONVORY is initiated in patients receiving treatment with a beta-blocker because of the additive effects on lowering heart rate; temporary interruption of the beta-blocker treatment may be needed prior to initiation of PONVORY [see  Warnings and Precautions  (5.2)]. Beta-blocker treatment can be initiated in patients receiving stable doses of PONVORY. 
     7.4 Vaccination 
     During, and for up to 1 to 2 weeks after discontinuation of, treatment with PONVORY, vaccinations may be less effective. The use of live attenuated vaccines may carry the risk of infection and should therefore be avoided during PONVORY treatment and for 1 to 2 weeks after discontinuation of treatment with PONVORY [see  Warnings and Precautions  (5.1)]. 
     7.5 Strong CYP3A4 and UGT1A1 Inducers 
     In vitro assessments and limited clinical data indicated that concomitant use of strong CYP3A4 and UGT1A1 inducers (e.g., rifampin, phenytoin, carbamazepine) may decrease the systemic exposure of ponesimod. It is unclear whether this decrease in ponesimod systemic exposure would be considered of clinical relevance. Coadministration of PONVORY with strong CYP3A4 and UGT1A1 inducers is not recommended. 
     8. Use in Specific Populations 
     8.1 Pregnancy 
     Risk Summary 
     There are no adequate and well-controlled studies of PONVORY in pregnant women. In animal studies, administration of ponesimod during pregnancy produced adverse effects on development, including embryo lethality and fetal malformations, in the absence of maternal toxicity. In rats and rabbits, visceral and skeletal malformations occurred at clinically relevant maternal ponesimod exposures (see Data). The receptor affected by ponesimod (sphingosine-l-phosphate receptor 1) has been demonstrated to have an important role in embryogenesis, including vascular and neural development. 
     In the US general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2/-4% and 15%-20%, respectively. The background risk of major birth defects and miscarriage for the indicated population is unknown. 
     Data 
     Animal Data 
     When ponesimod (0, 1, 10, or 40 mg/kg/day) was orally administered to pregnant rats during the period of organogenesis, increased incidences of fetal malformations primarily involving the limbs (syndactyly and ectrodactyly) and cardiovascular system (including ventricular septal defects) were observed at all but the lowest dose tested. A high incidence of embryofetal death was observed at the highest dose tested. Maternal toxicity was not observed, indicating a selective effect on the fetus. Plasma exposure (AUC) at the no-effect dose (1 mg/kg/day) for adverse effects on embryofetal development in rats was lower than that in humans at the recommended human dose (RHD) of 20 mg/day. 
     When ponesimod (0, 0.25, 1, or 4 mg/kg/day) was orally administered to pregnant rabbits during the period of organogenesis, an increase in post-implantation loss and fetal variations (visceral and skeletal) were noted at the highest dose tested. No maternal toxicity was observed. Plasma exposure at the no-effect dose (1 mg/kg/day) for adverse effects on embryofetal development in rabbits was lower than that in humans at the RHD. In a dose-range finding study in pregnant rabbits. oral administration of ponesimod (0, 6, 20, or 60 mg/kg/day) during organogenesis, an increase in embryofetal death and fetal limb malformation (brachydactyly) were observed at the lowest dose tested; at the higher doses, there were no live fetuses. 
     When ponesimod (5, 10, or 20 mg/kg) was orally administered to female rats throughout pregnancy and lactation, the offspring exhibited decreased survival, reduced body weight gain, and reduced fertility and reproductive performance (increases in pre- and post-implantation loss) at the highest dose tested, neurobehavioral impairment (increased locomotor activity) at the mid and high doses, and delayed sexual maturation at all doses tested. A no-effect dose for adverse effects on pre- and postnatal development in rats was not identified. Plasma exposure (AUC) in dams at the lowest dose tested was less than that in humans at the RHD. 
     8.2 Lactation 
     Risk Summary 
     There are no data on the presence of PONVORY in human milk, the effects on the breastfed infant, or the effects of the drug on milk production. When ponesimod was orally administered to female rats during pregnancy and lactation, ponesimod was detected in the plasma of the offspring, suggesting excretion of ponesimod in milk. 
     The developmental and health benefits of breastfeeding should be considered along with the mother&#39;s clinical need for PONVORY and any potential adverse effects on the breastfed infant from PONVORY or from the underlying maternal condition. 
     8.3 Females and Males of Reproductive Potential 
     Contraception 
     Females 
     Before initiation of PONVORY treatment, women of childbearing potential should be counseled on the potential for a serious risk to the fetus and the need for effective contraception during treatment with PONVORY [see  Use in Specific Populations  (8.1)]. Since it takes approximately one week to eliminate ponesimod from the body after stopping treatment, the potential risk to the fetus may persist, and women should use effective contraception during this period [see  Warnings and Precautions  (5.7)]. 
     8.4 Pediatric Use 
     Safety and effectiveness in pediatric patients have not been established. 
     Juvenile Animal Toxicity Data 
     Oral administration of ponesimod (0, 1, 10, 30, or 100 mg/kg/day) to young rats from postnatal day 28 to 91 resulted in lung histopathology (alveolar histiocytosis/edema) and decreased immune function (T-cell dependent antibody response) at the two highest doses tested. Decreased growth (body weight gain and/or long bone length) was observed at all but the low dose, and neurobehavioral impairment (increased locomotor activity) was observed at the highest dose tested. Decreased lymphocyte count and neurobehavioral impairment persisted at the end of a 4-week recovery period. 
     8.5 Geriatric Use 
     Clinical studies of PONVORY did not include patients 65 years of age and over to determine whether they respond differently from younger subjects. Use of PONVORY in elderly patients should be cautious, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy [see  Clinical Pharmacology  (12.3)]. 
     8.6 Hepatic Impairment 
     No dosage adjustment is necessary in patients with mild hepatic impairment (Child-Pugh class A) [see  Clinical Pharmacology  (12.3)]. 
     PONVORY is not recommended in patients with moderate or severe hepatic impairment (Child-Pugh class B and C, respectively), as the risk of adverse reactions may be greater [see  Clinical Pharmacology  (12.3)]. 
     9. Overdosage 
     Symptoms and Signs 
     In patients with overdosage of PONVORY, especially upon initiation/re-initiation of treatment, it is important to observe for signs and symptoms of bradycardia as well as AV conduction blocks, which may include overnight monitoring. Regular measurements of pulse rate and blood pressure are required, and ECGs should be performed [see  Warnings and Precautions  (5.2, 5.5)  and Clinical Pharmacology  (12.2)]. 
     Treatment 
     There is no specific antidote to ponesimod. Neither dialysis nor plasma exchange would result in meaningful removal of ponesimod from the body. The decrease in heart rate induced by PONVORY can be reversed by atropine. 
     In the event of overdose, PONVORY should be discontinued, and general supportive treatment given until clinical toxicity has been diminished or resolved. It is advisable to contact a poison control center to obtain the latest recommendations for the management of an overdose. 
     10. Description 
     PONVORY (ponesimod) is a sphingosine 1-phosphate receptor modulator. 
     The chemical name for ponesimod is (2Z,5Z)-5-[3-chloro-4-[(2R)-2,3-dihydroxypropoxy]benzylidene]-3-(2-methylphenyl)-2-(propylimino)-1,3-thiazolidin-4-one. It has one chiral center with absolute configuration of (R). Its molecular formula is C 23 H 35 ClN 2 O 4 S and its molecular weight is 460.97 g/mol. Ponesimod has the following structural formula: 
     
       
         
         
             
             
         
       
     
     Ponesimod is a white to light yellowish powder that is practically insoluble or insoluble in water. 
     PONVORY (ponesimod) is provided as 2 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7 mg, 8 mg, 9 mg, 10 mg, and 20 mg film-coated tablets for oral administration. 
     Each tablet contains the following inactive ingredients: croscarmellose sodium. lactose monohydrate, magnesium stearate, microcrystalline cellulose. povidone K30. silica colloidal anhydrous. and sodium lauryl sulfate. 
     Each tablet coating contains ferrosoferric oxide (included in 4 mg, 5 mg, 8 mg, and 9 mg film-coated tablets), hydroxypropyl methylcellulose 2910, iron oxide red (included in 3 mg, 4 mg, 7 mg, 8 mg, 9 mg, and 10 mg film-coated tablets), iron oxide yellow (included in 3 mg, 5 mg, 7 mg, 9 mg, 10 mg, and 20 mg film-coated tablets), lactose monohydrate, polyethylene glycol 3350, titanium dioxide, and triacetin. 
     11. Clinical Pharmacology 
     11.1 Mechanism of Action 
     Ponesimod is a sphingosine 1-phosphate (S1P) receptor 1 modulator that binds with high affinity to S1P receptor 1. 
     Ponesimod blocks the capacity of lymphocytes to egress from lymph nodes, reducing the number of lymphocytes in peripheral blood. The mechanism by which ponesimod exerts therapeutic effects in multiple sclerosis is unknown, but may involve reduction of lymphocyte migration into the central nervous system. 
     11.2 Pharmacodynamics 
     Immune System 
     In healthy volunteers, PONVORY induces a dose-dependent reduction of the peripheral blood lymphocyte count from a single dose of 5 mg onwards, with the greatest reduction observed 6 hours post-dose, caused by reversible sequestration of lymphocytes in lymphoid tissues. After 7 daily doses of 20 mg, the greatest decrease in absolute mean lymphocyte count was to 26% of baseline (650 cells/μL), observed 6 hours after administration. Peripheral blood B cells [CD19+] and T cells [CD3+], T-helper [CD3+CD4+], and T-cytotoxic [CD3+CD8+] cell subsets are all affected, while NK cells are not. T-helper cells were more sensitive to the effects of ponesimod than T-cytotoxic cells. 
     PK/PD modeling indicates lymphocyte counts returned to the normal range in greater than 90% of healthy subjects within 1 to 2 weeks of stopping therapy. In Study 1, peripheral lymphocyte counts returned to the normal range within 2 weeks after discontinuation of PONVORY. 
     Heart Rate and Rhythm 
     PONVORY causes a transient dose-dependent reduction in heart rate (HR) and AV conduction delays upon treatment initiation [see  Warnings and Precautions  (5.2)]. The heart rate decreases plateaued at doses greater than or equal to 40 mg [2 times the recommended maintenance dosage], and bradyarrhythmic events (AV blocks) were detected at a higher incidence under PONVORY treatment, compared to placebo. This effect starts within the first hour of dosing and is maximal at 2-4 hours post-dose. HR generally returns to pre-dose values by 4-5 hours post-dose on Day 1, and the effect diminishes with repeated administration. indicating tolerance. 
     The decrease in heart rate induced by ponesimod can be reversed by atropine. 
     Beta-Blockers 
     The negative chronotropic effect of coadministration of PONVORY and propranolol was evaluated in a dedicated pharmacodynamics safety study. The addition of PONVORY to propranolol at steady state has an additive effect on HR effect [see  Drug Interactions  (7.3)]. 
     Cardiac Electrophysiology 
     In a thorough QT study, daily administration of ponesimod doses of 40 mg and 100 mg (respectively 2- and 5-fold the recommended maintenance dose) until steady-state conditions were achieved resulted in prolongation of Fridericia-corrected QT (QTcF) intervals, with the maximum mean (upper bound of 90% two-sided confidence interval) at 11.8 ms (40 mg) and 16.2 ms (100 mg). No subject had absolute QTcF greater than 480 ms or ΔQTcF greater than 90 ms for ponesimod treatment. 
     Pulmonary Function 
     Dose-dependent reductions in FEV 1  and FVC were observed in PONVORY-treated subjects, and were greater than in subjects taking placebo [see  Warnings and Precautions  (5.3)]. These effects can be reversed with administration of a short acting beta2 agonist. 
     11.3 Pharmacokinetics 
     Following ponesimod oral dosing, C max  and AUC increased approximately dose-proportionally in the dose-range studied (1-75 mg). Steady-state levels are approximately 2.0- to 2.6-fold greater than with a single dose, and are achieved following 3 days of administration of the maintenance dose of ponesimod. 
     The pharmacokinetics of ponesimod are similar in healthy subjects and patients with multiple sclerosis, with 25% inter-subject variability across studies. 
     Absorption 
     The time to reach maximum plasma concentration of ponesimod is 2-4 hours post-dose. The absolute oral bioavailability of a 10 mg dose is 84%. 
     Food Effect 
     Food does not have a clinically relevant effect on ponesimod pharmacokinetics; therefore, PONVORY may be taken with or without food. 
     Distribution 
     Following IV administration in healthy subjects, the steady-state volume of distribution of ponesimod is 160 L. 
     Ponesimod is highly bound to plasma proteins (&gt;99%) and is mainly (78.5%) distributed in the plasma fraction of whole blood. Animal studies show that ponesimod readily crosses the blood-brain-barrier. 
     Metabolism 
     Ponesimod is extensively metabolized prior to excretion in humans, though unchanged ponesimod was the main circulating component in plasma. Two inactive circulating metabolites, M12 and M13, have also been identified in human plasma. M13 and M12 are respectively about 20% and 6% of total drug-related exposure. Both metabolites are inactive at S1P receptors at concentrations achieved with recommended doses of ponesimod. 
     Experiments with human liver preparations indicate that metabolism of ponesimod to M13 occurs primarily through a combination of non-Cytochrome P450 (CYP450) enzymatic activities. Multiple CYP450 (CYP2J2, CYP3A4, CYP3A5, CYP4F3A, and CYP4F12) and non-CYP450 enzymes catalyze the oxidation of ponesimod to M12. Ponesimod also undergoes direct glucuronidation (mainly UGT1A1 and UGT2B7). 
     Excretion 
     After a single IV administration. the total clearance of ponesimod is 3.8 L/hour. The elimination half-life after oral administration is approximately 33 hours. 
     Following a single oral administration of  14 C-ponesimod, 57% to 80% of the dose was recovered in feces (16% as unchanged ponesimod), and 10% to 18% in urine (no unchanged ponesimod). 
     Specific Populations 
     Renal Impairment 
     No dose adjustment is necessary in patients with renal impairment. In adult subjects with moderate or severe renal impairment (estimated creatinine clearance [CrCl], as determined by the Cockroft-Gault, between 30-59 mL/min for moderate and &lt;30 mL/min for severe), there were no significant changes in ponesimod C max  and AUC, compared to subjects with normal renal function (CrCl&gt;90 mL/min). The effect of dialysis on the PK of ponesimod has not been studied. Due to the high plasma protein binding (greater than 99%) of ponesimod, dialysis is not expected to alter the total and unbound ponesimod concentration, and no dose adjustments are anticipated based on these considerations. 
     Hepatic Impairment 
     In adult subjects with mild, moderate, or severe hepatic impairment (Child-Pugh class A, B and C, respectively), no change in ponesimod C max  was observed, but ponesimod AUC 0-∞  was increased by 1.3-, 2.0-, and 3.1-fold, respectively, compared to healthy subjects [see  Use in Specific Populations  (8.6)]. 
     Age 
     Age (range: 17 to 65 years) was not identified to significantly influence the PK of ponesimod in population pharmacokinetics analyses. The effect of age (65 years of age and older) on the pharmacokinetics of ponesimod is unknown [see  Use in Specific Populations  (8.5)]. 
     Gender 
     Gender has no clinically significant influence on ponesimod pharmacokinetics. 
     Race 
     No clinically relevant pharmacokinetic differences were observed between Japanese and Caucasian subjects. 
     Drug Interaction Studies 
     Beta-Blockers 
     In a drug-drug interaction study. the dose titration regimen of ponesimod [see  Dosage and Administration  (2.2)] was administered to subjects receiving propranolol (80 mg) once daily at steady state. No significant changes in pharmacokinetics of ponesimod or propranolol were observed. Compared to ponesimod alone, the combination of propranolol and the first dose of ponesimod (2 mg) led to a mean hourly heart rate decrease of 12.4 bpm (90% CI: −15.6 to −9.1). Compared to ponesimod alone, propranolol administered in combination with the first maintenance dose of ponesimod (20 mg) led to a 7.4 bpm (90% CI: −10.9 to −3.9) mean hourly heart rate decrease. 
     Effect of Other Drugs on Ponesimod 
     In vitro studies with human liver preparations indicate that metabolism of ponesimod occurs through multiple distinct enzyme systems, including multiple CYP450 (CYP2J2, CYP3A4, CYP3A5, CYP4F3A, and CYP4F12), UGT (mainly UGT1A1 and UGT2B7), and non-CYP450 oxidative enzymes, without major contribution by any single enzyme. 
     Ponesimod is not a substrate of P-gp, BCRP, OATP1B1, or OATP1B3 transporters. Drugs that are inhibitors of these transporters are unlikely to impact the PK of ponesimod. 
     In vitro assessments and limited clinical data indicated that concomitant use of strong CYP3A4 and UGT1A1 inducers (e.g., rifampin, phenytoin, carbamazepine) may decrease the systemic exposure of ponesimod [see  Drug Interactions  (7.5)]. 
     Effect of Ponesimod on Other Drugs 
     In vitro investigations indicate that at the recommended dose of 20 mg once-daily, ponesimod and its metabolite M13 do not show any clinically relevant drug-drug interaction potential for CYP or UGT enzymes, or transporters. 
     Oral Contraceptives 
     Coadministration of ponesimod with an oral hormonal contraceptive (containing 1 mg norethisterone/norethindrone and 35 μg ethinyl estradiol) showed no clinically relevant pharmacokinetic interaction with ponesimod. Therefore, concomitant use of ponesimod is not expected to decrease the efficacy of hormonal contraceptives. No interaction studies have been performed with oral contraceptives containing other progestogens: however, an effect of ponesimod on their exposure is not expected. 
     12. Nonclinical Toxicology 
     12.1 Carcinogenesis, Mutagenesis, Impairment of Fertility 
     Carcinogenesis 
     Oral administration of ponesimod to mice (0, 50, 150, or 400 mg/kg/day in males and 30, 100, or 300 mg/kg/day in females) for up to 2 years resulted in incidences in hemangiosarcoma and combined hemangioma and hemangiosarcoma in males at all doses and at the highest dose tested in females. Plasma exposure (AUC) at to lowest dose tested in males (50 mg/kg/day) was approximately 5 times that in humans at the recommended human dose (RHD) of 20 mg. 
     Oral administration of ponesimod to rats (0, 3, 10, or 30 mg/kg/day in males and 0, 10, 30 or 100 mg/kg/day in females) for up to 2 years did not result in an increase in tumors. Plasma exposure at the highest dose tested in males (30 mg/kg/day) was approximately 4 times that in humans at the recommended human dose (RHD) of 20 mg. 
     Mutagenesis 
     Ponesimod was negative in a battery of in vitro (Ames, chromosomal aberration in mammalian cells) and in vivo (micronucleus in rat) assays. 
     Fertility 
     In separate studies. oral administration of ponesimod (0, 10, 30, or 100 mg/kg/day) to male and female rats prior to and throughout the mating period and continuing in females to Day 6 of gestation resulted in no effects on fertility. Plasma ponesimod exposures (AUC) at the highest dose tested were approximately 10 (males) and 30 (females) times that in humans at the recommended human dose (RHD) of 20 mg/day. 
     12.2 Animal Toxicology and/or Pharmacology 
     Increases in lung weight and histopathology (alveolar histiocytosis, edema) were observed in oral toxicity studies in mice, rats, and dogs. At the higher doses tested in short-term studies, alveolar histiocytosis was associated with lung edema, emphysema, or hyalinosis, and with bronchioloalveolar hyperplasia after cessation of dosing in rats and alveolar histiocytosis and hyalinosis in dogs. Effects tended to be absent or less severe after chronic treatment. These findings are considered secondary to increased vascular permeability caused by SiPi receptor modulation. The NOAELs for lung findings in the 4-week oral toxicity studies in rats and dogs were associated with plasma exposures (AUC) similar or lower than that expected in humans at the recommended human dose (RHD) of 20 mg/day. 
     In dogs, coronary arterial lesions (thickening of the vessel wall. hyperplasia/hypertrophy of smooth muscles cells of the tunica media. subendocardial fibrosis) involving the papillary muscle of the left ventricle were observed in oral toxicity studies of 13 to 52 weeks in duration. At the NOAEL (2 mg/kg/day) for these findings, plasma exposures (AUC) were approximately 2 times that expected in humans at the RHD. 
     13. Clinical Studies 
     The efficacy of PONVORY was demonstrated in Study 1, a randomized, double-blind, parallel group, active-controlled superiority study in patients with relapsing forms of MS (NCT02425644). Patients were treated for 108 weeks. This study included patients who had an Expanded Disability Status Scale (EDSS) score of 0 to 5.5 at baseline, had experienced at least one relapse within the year prior, or two relapses within the prior 2 years, or who had at least one gadolinium-enhancing (Gd-enhancing) lesion on a brain MRI within the prior 6 months or at baseline. Patients with primary progressive MS were excluded. 
     Patients were randomized to receive either once daily PONVORY, beginning with a 14-day dose titration [see  Dosage and Administration  (2.2)] or teriflunomide 14 mg. Neurological evaluations were performed at baseline, every 3 months during the study, and at the time of a suspected relapse. Brain MRI scans were performed at baseline and at Weeks 60 and 108. 
     The primary endpoint was the annualized relapse rate (ARR) over the study period. Additional outcome measures included: 1) the number of new Gd-enhancing T1 lesions from baseline to Week 108, 2) the number of new or enlarging T2 lesions (without double-counting of lesions) from baseline to Week 108, and 3) the time to 3-month and 6-month confirmed disability progression. A confirmed disability progression was defined as an increase of at least 1.5 in EDSS for patients with a baseline EDSS score of 0, an increase of at least 1.0 in EDSS for patients with a baseline EDSS score of 1.0 to 5.0, or an increase of at least 0.5 in EDSS for patients with a baseline EDSS score at least 5.5, which was confirmed after 3 months and 6 months. 
     A total of 1133 patients were randomized to either PONVORY (N=567) or teriflunomide 14 mg (N=566); 86.4% of PONVORY-treated patients and 87.5% of teriflunomide 14 mg-treated patients completed the study as per protocol. At baseline, the mean age of patients was 37 years, 97% were White, and 65% were female. The mean disease duration was 7.6 years, the mean number of relapses in the previous year was 1.3, and the mean EDSS score was 2.6; 57% of patients had not received any prior non-steroid treatments for MS. At baseline, 42.6% of patients had one or more Gd-enhancing T1 lesions (mean 2.0) on their baseline MRI scan. 
     The ARR was statistically significantly lower in patients treated with PONVORY than in patients who received teriflunomide 14 mg. The number of Gd-enhancing T1 lesions and the number of new or enlarging T2 lesions were statistically significantly lower in patients treated with PONVORY than in patients who received teriflunomide 14 mg. 
     There was no statistically significant difference in the 3-month and 6-month confirmed disability progression outcomes between PONVORY- and teriflunomide 14 mg-treated patients over 108 weeks. 
     The efficacy results for Study 1 are presented in Table 22. 
     
       
         
           
               
             
               
                 TABLE 22 
               
             
            
               
                   
               
               
                 Clinical and NMI Endpoints from Study 1 
               
            
           
           
               
               
               
            
               
                   
                 PONVORY 
                 Teriflunomide 
               
               
                   
                 20 mg 
                 14 mg 
               
               
                 Endpoints 
                 N = 567 
                 N = 566 
               
               
                   
               
            
           
           
               
               
               
            
               
                 Clinical Endpoints 
                   
                   
               
               
                 Annualized Relapse Rate  a   
                 0.202 
                 0.290 
               
            
           
           
               
               
            
               
                 Relative reduction 
                     30.5% (p = 0.0003) 
               
            
           
           
               
               
               
            
               
                 Percentage of patients without relapse  b   
                 70.7% 
                 60.6% 
               
               
                 Proportion of Patients with 3-month 
                 10.8% 
                 13.2% 
               
               
                 Confirmed Disability Progression  c   
               
            
           
           
               
               
            
               
                 Hazard Ratio  d   
                     0.83 (p = 0.29) 
               
            
           
           
               
               
               
            
               
                 MRI Endpoints  b, f   
                   
                   
               
               
                 Mean number of new or enlarging T2 
                 1.40 
                 3.16 
               
               
                 hyperintense lesions per year 
               
            
           
           
               
               
            
               
                 Relative reduction 
                 55.7% (p &lt; 0001) 
               
            
           
           
               
               
               
            
               
                 Mean number of T1 Gd-enhancing 
                 0.18 
                 0.43 
               
               
                 lesions per MRI 
               
            
           
           
               
               
            
               
                 Relative reduction 
                 58.5% (p &lt; 0001) 
               
               
                   
               
               
                 All analyses are based on the full analysis set (FAS), which includes all randomized patients. N refers to the number of patients included in the FAS, per treatment group. 
               
               
                   a  Defined as confirmed relapses per year through the study period (Negative binomial regression model with stratification variables (EDSS ≤ 3.5 versus EDSS &gt; 3.5; not-steroid treatment for MS within last 2 years prior to randomization [Yes/No]) and the number of relapses in the year prior to study entry (&lt;=1, &gt;=2) as marines) 
               
               
                   b  Over the study period of approximately 108 weeks 
               
               
                   c  Disability progression defined as 1.5-point in EDSS for patients with a baseline EDSS score of 0. 1.0-point increase in EDSS for patients with a baseline EDSS score of 1.0 to 5.0. or 0.5-point increase in EDSS for patients with a baseline EDSS score at least 5.5 confirmed 3 months later. Proportion of patients with 3-month confirmed disability progression refers to Kaplan-Meter estimates at Week 108. 
               
               
                   d  Defined as time to 3 months confirmed disability progression through the study period (Stratified Cox proportional hazard model, p-value based on the stratified log rank test) 
               
               
                   e  Not statistically significant 
               
               
                   f  Cumulative number of combined unique active lesions (CUALs), defined as new or enlarging T2 lesions or Gd-enhancing T1 lesions (without double counting), mean lesions per year were 1.41 on ponesimod 20 mg (N = 539). and 3.16 on teriflunomide 14 mg (N = 536), a relative reduction of 56% (p &lt; 0.0001). 
               
            
           
         
       
     
     A similar effect of PONVORY on the ARR and secondary MRI outcomes compared to teriflunomide 14 mg was observed in exploratory subgroups defined by age, gender, prior non-steroid therapy for MS, and baseline disease activity. 
     14. How Supplied/Storage and Handling 
     14.1 How Supplied 
     PONVORY™ (ponesimod) tablet is available as round, biconvex, film-coated tablets supplied in the following dosage strengths and package configurations, Tables 23 and 24. 
     
       
         
           
               
             
               
                 TABLE 23 
               
             
            
               
                   
               
               
                 Starter Pack 
               
            
           
           
               
               
               
               
               
               
            
               
                 Tablet 
                 Tablet 
                 Tablet 
                   
                 Pack 
                 NDC 
               
               
                 Strength 
                 Color 
                 Size 
                 Tablet Debossing 
                 Size 
                 Code 
               
               
                   
               
               
                 2 mg 
                 White 
                 5.0 mm 
                 “2” on one side and an arch on the other side. 
                 Child 
                 NDC 
               
               
                 3 mg 
                 Red 
                 5.0 mm 
                 “3” on one side and an arch on the other side. 
                 Resistant 
                 50458- 
               
               
                 4 mg 
                 Purple 
                 5.0 mm 
                 “4” on one side and an arch on the other side. 
                 Starter 
                 707-14 
               
               
                 5 mg 
                 Green 
                 8.6 mm 
                 “5” on one side and an arch and an “A” on 
                 Pack 
               
               
                   
                   
                   
                 the other side. 
                 (14 
               
               
                 6 mg 
                 White 
                 8.6 mm 
                 “6” on one side and an arch and an “A” on 
                 tablets) 
               
               
                   
                   
                   
                 the other side. 
               
               
                 7 mg 
                 Red 
                 8.6 mm 
                 “7” on one side and an arch and an “A” on 
               
               
                   
                   
                   
                 the other side. 
               
               
                 8 mg 
                 Purple 
                 8.6 mm 
                 “8” on one side and an arch and an “A” on 
               
               
                   
                   
                   
                 the other side. 
               
               
                 9 mg 
                 Brown 
                 8.6 mm 
                 “9” on one side and an arch and an “A” on 
               
               
                   
                   
                   
                 the other side. 
               
               
                 10 mg  
                 Orange 
                 8.6 mm 
                 “10” on one side and an arch and an “A” on 
               
               
                   
                   
                   
                 the other side. 
               
               
                   
               
            
           
         
       
     
     
       
         
           
               
             
               
                 TABLE 24 
               
             
            
               
                   
               
               
                 Maintenance Dose Bottle 
               
            
           
           
               
               
               
               
               
               
            
               
                 Tablet 
                 Tablet 
                 Tablet 
                   
                   
                 NDC 
               
               
                 Strength 
                 Color 
                 Size 
                 Tablet Debossing 
                 Pack Size 
                 Code 
               
               
                   
               
               
                 20 mg 
                 Yellow 
                 8.6 mm 
                 “20” on one side and an 
                 Bottle of 30 tablets with 
                 NDC 
               
               
                   
                   
                   
                 arch and an “A” on the 
                 child-resistant closure. 
                 50458- 
               
               
                   
                   
                   
                 other side. 
                 Each bottle contains a 
                 720-30 
               
               
                   
                   
                   
                   
                 desiccant sachet and a 
               
               
                   
                   
                   
                   
                 polyester coil 
               
               
                   
               
            
           
         
       
     
     14.2 Storage and Handling 
     Starter Pack 
     Store at 20° C. to 25° C. (68° F. to 77° F.); excursions permitted from 15° C. to 30° C. (59° F. to 86° F.) [see  USP Controlled Room Temperature ]. 
     Store in the original package. 
     Maintenance Dose Bottle 
     Store at 20° C. to 25° C. (68° F. to 77° F.); excursions permitted from 15° C. to 30° C. (59° F. to 86° F.) [see  USP Controlled Room Temperature ]. 
     Store in the original package. Do not discard desiccant. Protect from moisture. Keep out of reach of children. 
     15. Patient Counseling Information 
     Advise the patient to read the FDA-approved patient labeling (Medication Guide). 
     Administration 
     Tell patients not to discontinue PONVORY without first discussing this with the prescribing healthcare provider. Advise patients to contact their healthcare provider if they accidently take more PONVORY than prescribed. 
     Instruct patients to administer tablets whole. 
     Risk of Infections 
     Inform patients that they may have an increased risk of infections, some of which could be life-threatening, when taking PONVORY and for 1 to 2 weeks after stopping it, and that they should contact their healthcare provider if they develop symptoms of infection [see Warnings and Precautions (5.1)]. Advise patients that the use of some vaccines containing live virus (live attenuated vaccines) should be avoided during treatment with PONVORY, and PONVORY should be paused 1 week prior and until 4 weeks after a planned vaccination. Recommend that patients postpone treatment with PONVORY for at least 1 month after VZV vaccination. Inform patients that prior or concomitant use of drugs that suppress the immune system may increase the risk of infection. 
     Cardiac Effects 
     Advise patients that initiation of PONVORY treatment results in transient decrease in heart rate [see  Warnings and Precautions  (5.2)]. Inform patients that to reduce this effect, dose titration is required. Advise patients that dose titration is also required if 4 or more consecutive daily doses are missed during treatment initiation or maintenance treatment [see  Dosage and Administration  (2.2, 2.4) and Warnings and Precautions (5.2)]. Inform certain patients with certain preexisting cardiac conditions that they will need to be observed in the doctor&#39;s office or other facility for at least 4 hours after the first dose and after re-initiation if treatment is interrupted or discontinued for certain periods [see  Dosage and Administration  (2.3)]. 
     Respiratory Effects 
     Advise patients that they should contact their healthcare provider if they experience new onset or worsening of dyspnea [see  Warnings and Precautions  (5.3)]. 
     Liver Injury 
     Inform patients that PONVORY may increase liver enzymes. Advise patient that they should contact their healthcare provider if they experience any unexplained nausea, vomiting, abdominal pain, fatigue, anorexia, or jaundice and/or dark urine during treatment [see  Warnings and Precautions  (5.4)]. 
     Cutaneous Malignancies 
     Inform patients that the risk of basal cell carcinoma is increased with the use of PONVORY and that cases of melanoma and squamous cell carcinoma have been reported. Advise patients that any suspicious skin lesions should be promptly evaluated. Advise patients to limit exposure to sunlight and ultraviolet light by wearing protective clothing and using a sunscreen with high protection factor [see  Warnings and Precautions  (5.6)]. 
     Pregnancy and Fetal Risk 
     Inform patients that, based on animal studies, PONVORY may cause fetal harm. Discuss with women of childbearing age whether they are pregnant, might be pregnant, or are trying to become pregnant. Advise women of childbearing potential of the need for effective contraception during treatment with PONVORY and for one week after stopping PONVORY. Advise a female patient to immediately inform her healthcare provider if she is pregnant or planning to become pregnant [see  Warnings and Precautions  (5.7)]. 
     Macular Edema 
     Advise patients that PONVORY may cause macular edema, and that they should contact their healthcare provider if they experience any changes in their vision while taking PONVORY [see  Warnings and Precautions  (5.8)]. Inform patients with diabetes mellitus or a history of uveitis that their risk of macular edema is increased. 
     Posterior Reversible Encephalopathy Syndrome 
     Advise patients to immediately report to their healthcare provider any symptoms involving sudden onset of severe headache, altered mental status, visual disturbances, or seizure. Inform patients that delayed treatment could lead to permanent neurological sequelae [see  Warnings and Precautions  (5.9)]. 
     Severe Increase in Disability After Stopping PONVORY 
     Inform patients that severe increase in disability has been reported after discontinuation of another S1P receptor modulator like PONVORY. Advise patients to contact their healthcare provider if they develop worsening symptoms of MS following discontinuation of PONVORY [see  Warnings and Precautions  (5.11)]. 
     Immune System Effects After Stopping PONVORY 
     Advise patients that PONVORY continues to have effects, such as lowering effects on peripheral lymphocyte count, for 1 to 2 weeks after the last dose [see  Warnings and Precautions  (5.12)]. 
     Active ingredient made in Austria. 
     Manufactured for: Janssen Pharmaceuticals. Inc. Titusville. N.J. 08560 © 2021 Janssen Pharmaceutical Companies 
     Medication Guide 
     PONVORY™ (pon-VOR-ee) (ponesimod) tablets, for oral use 
     What is the most important information I should know about PONVORY? 
     PONVORY may cause serious side effects. including: 
     Infections. PONVORY can increase your risk of serious infections that can be life-threatening and cause death. PONVORY lowers the number of white blood cells (lymphocytes) in your blood. This will usually go back to normal within 1 to 2 weeks of stopping treatment. Your healthcare provider should review a recent blood test of your white blood cells before you start taking PONVORY. 
     Call your healthcare provider right away if you have any of these symptoms of an infection during treatment with PONVORY and for 1 to 2 weeks after your last dose of PONVORY: 
     fever 
     tiredness 
     body aches 
     chills 
     nausea 
     vomiting 
     headache with fever, neck stiffness, sensitivity to light, nausea, or confusion (these may be symptoms of meningitis, an infection of the lining around your brain and spine). 
     Your healthcare provider may delay starting or may stop your PONVORY treatment if you have an infection. 
     Slow heart rate (bradycardia or bradyarrhythmia) when you start taking PONVORY. PONVORY can cause your heart rate to slow down, especially after you take your first dose. You should have a test to check the electrical activity of your heart called an electrocardiogram (ECG) before you take your first dose of PONVORY. 
     Only start your treatment with PONVORY using the Starter Pack. You must use the PONVORY Starter Pack to slowly increase the dose over a 14-day period to help reduce the effect of slowing of your heart rate. It is important to follow the recommended dosing instructions. See “How should I take PONVORY?” 
     Call your healthcare provider if you experience the following symptoms of slow heart rate: 
     dizziness 
     lightheadedness 
     feeling like your heart is beating slowly or skipping beats 
     shortness of breath 
     confusion 
     chest pain 
     tiredness. 
     Follow directions from your healthcare provider when starting PONVORY and when you miss a dose. See “How should I take PONVORY?” 
     See “What are possible side effects of PONVORY?” for more information about side effects. 
     What is PONVORY? 
     PONVORY is a prescription medicine that is used to treat relapsing forms of multiple sclerosis, to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults. 
     It is not known if PONVORY is safe and effective in children. 
     Do not take PONVORY if you: 
     have had a heart attack, chest pain called unstable angina, stroke or mini-stroke (transient ischemic attack or TIA), or certain types of heart failure in the last 6 months. 
     have certain types of heart block or irregular or abnormal heartbeat (arrhythmia), unless you have a pacemaker. 
     Talk to your healthcare provider before taking PONVORY if you have any of these conditions, or do not know if you have any of these conditions. 
     Before you take PONVORY, tell your healthcare provider about all of your medical conditions, including if you: 
     have a fever or infection, or you are unable to fight infections due to a disease or taking medicines that weaken your immune system. 
     have had chicken pox or have received the vaccine for chicken pox. Your healthcare provider may do a blood test for chicken pox virus. You may need to get the full course of vaccine for chicken pox and then wait 1 month before you start taking PONVORY. 
     have slow heart rate. 
     have an irregular or abnormal heartbeat (arrhythmia). 
     have a history of stroke. 
     have heart problems, including a heart attack or chest pain. 
     have breathing problems, including during your sleep (sleep apnea). 
     have liver problems. 
     have high blood pressure. 
     had or now have a type of skin cancer called basal cell carcinoma (BCC), melanoma, or squamous cell carcinoma. 
     have eye problems, especially an inflammation of the eye called uveitis. have diabetes. 
     are pregnant or plan to become pregnant. PONVORY may harm your unborn baby. Talk with your healthcare provider if you are pregnant or plan to become pregnant. If you are a woman who can become pregnant, you should use effective birth control during your treatment with PONVORY and for 1 week after you stop taking PONVORY. Talk to your healthcare provider about what method of birth control is right for you during this time. Tell your healthcare provider right away if you do become pregnant while taking PONVORY or within 1 week after you stop taking PONVORY. 
     are breastfeeding or plan to breastfeed. It is not known if PONVORY passes into your breast milk. Talk to your healthcare provider about the best way to feed your baby if you take PONVORY. 
     Tell your healthcare provider about all the medicines you take, including prescription medicines, over-the-counter medicines, vitamins, and herbal supplements. 
     Using PONVORY and other medicines together may affect each other causing serious side effects. 
     Especially tell your healthcare provider if you take or have taken: 
     medicines to control your heart rhythm (antiarrhythmics), or blood pressure (antihypertensives), or heart beat (such as calcium channel blockers or beta-blockers). 
     medicines that affect your immune system, such as alemtuzumab. 
     medicines such as rifampin, phenytoin, or carbamazepine. 
     You should not receive live vaccines during treatment with PONVORY, for at least 1 month before taking PONVORY, and for 1 to 2 weeks after you stop taking PONVORY. If you receive a live vaccine, you may get the infection the vaccine was meant to prevent. Vaccines may not work as well when given during treatment with PONVORY. 
     Talk with your healthcare provider if you are not sure if you take any of these medicines. 
     Know the medicines you take. Keep a list of your medicines with you to show your healthcare provider and pharmacist when you get a new medicine. 
     How should I take PONVORY? 
     You will receive a 14-day starter pack. You must start PONVORY by slowly increasing doses over the first two weeks. Follow the dose schedule in Table 25 below. This may reduce the risk of slowing of the heart rate. 
     
       
         
           
               
             
               
                 TABLE 25 
               
             
            
               
                   
               
               
                 Dose Schedule 
               
            
           
           
               
               
            
               
                   
                 Daily Dose 
               
               
                   
                   
               
            
           
           
               
               
               
            
               
                   
                 Starter Pack Day 
                   
               
               
                   
                 Day 1 
                 2 mg tablet 1 time a day 
               
               
                   
                 Day 2 
                 2 mg tablet 1 time a day 
               
               
                   
                 Day 3 
                 3 mg tablet 1 time a day 
               
               
                   
                 Day 4 
                 3 mg tablet 1 time a day 
               
               
                   
                 Day 5 
                 4 mg tablet 1 time a day 
               
               
                   
                 Day 6 
                 4 mg tablet 1 time a day 
               
               
                   
                 Day 7 
                 5 mg tablet 1 time a day 
               
               
                   
                 Day 8 
                 6 mg tablet 1 time a day 
               
               
                   
                 Day 9 
                 7 mg tablet 1 time a day 
               
               
                   
                 Day 10 
                 8 mg tablet 1 time a day 
               
               
                   
                 Day 11 
                 9 mg tablet 1 time a day 
               
               
                   
                 Day 12 
                 10 mg tablet 1 time a day 
               
               
                   
                 Day 13 
                 10 mg tablet 1 time a day 
               
               
                   
                 Day 14 
                 10 mg tablet 1 time a day 
               
               
                   
                 Maintenance 
               
               
                   
                 Day 15 and thereafter 
                 20 mg tablet 1 time a day 
               
               
                   
                   
               
            
           
         
       
     
     Take PONVORY exactly as your healthcare provider tells you to take it. 
     Take PONVORY 1 time each day. 
     Swallow PONVORY tablets whole. 
     Take PONVORY with or without food. 
     Do not stop taking PONVORY without talking to your healthcare provider first. 
     Do not skip a dose. 
     Start taking PONVORY with a 14-day starter pack. 
     If you miss taking 1, 2, or 3 tablets in a row of PONVORY in the 14-day starter pack, continue treatment by taking the first dose you missed. Take 1 tablet as soon as you remember. Then, take 1 tablet a day to continue with the starter pack dose as planned. 
     If you miss taking 1, 2, or 3 tablets in a row of PONVORY while taking the 20 mg maintenance dose, continue treatment with the 20 mg maintenance dose. 
     If you miss taking 4 or more tablets in a row of PONVORY, while taking the 14-day starter pack or the 20 mg maintenance dose, you need to restart treatment with a new 14-day starter pack. Call your healthcare provider if you miss 4 or more doses of PONVORY. Do not restart PONVORY after stopping it for 4 or more days in a row without talking to your healthcare provider. If you have certain heart conditions, you may need to be monitored by your healthcare provider for at least 4 hours when you take your next dose. 
     Write down the date you start taking PONVORY so you will know if you miss 4 or more doses in a row. 
     What are the possible side effects of PONVORY? 
     PONVORY may cause serious side effects, including: 
     See “What is the most important information I should know about PONVORY?” 
     breathing problems. Some people who take PONVORY have shortness of breath. Call your healthcare provider right away if you have new or worsening breathing problems. 
     liver problems. PONVORY may cause liver problems. Your healthcare provider should do blood tests to check your liver before you start taking PONVORY. Call your healthcare provider right away if you have any of the following symptoms of liver problems: 
     unexplained nausea 
     vomiting 
     stomach (abdominal) pain 
     tiredness 
     loss of appetite 
     yellowing of the whites of your eyes or skin 
     dark urine. 
     increased blood pressure. Your healthcare provider should check your blood pressure during treatment with PONVORY. 
     types of skin cancer called basal cell carcinoma (BCC), melanoma, and squamous cell carcinoma. Certain types of skin cancer have happened with drugs in the same class. Tell your healthcare provider if you have any changes in the appearance of your skin, including changes in a mole, a new darkened area on your skin, a sore that does not heal, or growths on your skin, such as a bump that may be shiny. pearly white, skin-colored, or pink. Your doctor should check your skin for any changes during treatment with PONVORY. Limit the amount of time you spend in sunlight and ultraviolet (UV) light. Wear protective clothing and use a sunscreen with a high sun protection factor. 
     a problem with your vision called macular edema. Tell your healthcare provider about any changes in your vision. Your healthcare provider should test your vision before you start taking PONVORY and any time you notice vision changes during treatment with PONVORY. Your risk of macular edema is higher if you have diabetes or have had an inflammation of your eye called uveitis. 
     Call your healthcare provider right away if you have any of the following symptoms: 
     blurriness or shadows in the center of your vision 
     a blind spot in the center of your vision 
     sensitivity to light 
     unusually colored (tinted) vision. 
     swelling and narrowing of the blood vessels in your brain. A condition called Posterior Reversible Encephalopathy Syndrome (PRES) has happened with drugs in the same class. Symptoms of PRES usually get better when you stop taking PONVORY. However, if left untreated, it may lead to a stroke. Call your healthcare provider right away if you have any of the following symptoms: 
     sudden severe headache 
     sudden confusion 
     sudden loss of vision or other changes in your vision 
     seizure. 
     severe worsening of multiple sclerosis (MS) after stopping PONVORY. When PONVORY is stopped, symptoms of MS may return and become worse compared to before or during treatment. Always talk to your healthcare provider before you stop taking PONVORY for any reason. Tell your healthcare provider if you have worsening symptoms of MS after stopping PONVORY. 
     The most common side effects of PONVORY include: 
     upper respiratory tract infections 
     elevated liver enzymes (abnormal liver tests) 
     high blood pressure. 
     These are not all of the possible side effects of PONVORY. 
     For more information, ask your healthcare provider or pharmacist. 
     Call your healthcare provider for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. 
     How should I store PONVORY? 
     Store PONVORY at room temperature between 68° F. to 77° F. (20° C. to 25° C.). 
     Store PONVORY in the original package. 
     The bottle of PONVORY contains a desiccant sachet to help keep your medicine dry (protect it from moisture Do not throw away (discard) the desiccant. 
     Keep PONVORY and all medicines out of the reach of children. 
     General information about the safe and effective use of PONVORY. 
     Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use PONVORY for conditions for which it was not prescribed. Do not give PONVORY to other people, even if they have the same symptoms that you have. It may harm them. 
     You can ask your healthcare provider or pharmacist for information about PONVORY that is written for health professionals. 
     What are the ingredients in PONVORY? 
     Active ingredient: ponesimod 
     Inactive ingredients: 
     Tablet core: croscarmellose sodium, lactose monohydrate, magnesium stearate, microcrystalline cellulose, povidone K30, silica colloidal anhydrous, and sodium lauryl sulfate. 
     Tablet coating: ferrosoferric oxide (included in 4 mg, 5 mg, 8 mg, and 9 mg film-coated tablets), Hydroxypropyl methylcellulose 2910, iron oxide red (included in 3 mg, 4 mg, 7 mg, 8 mg, 9 mg, and 10 mg film-coated tablets), iron oxide yellow (included in 3 mg, 5 mg, 7 mg, 9 mg, 10 mg and 20 mg film-coated tablets), lactose monohydrate, polyethylene glycol 3350, titanium dioxide, and triatetin. 
     Manufactured for: Janssen Pharmaceuticals, Inc., Titusville, N.J. 08560 
     © 2021 Janssen Pharmaceutical Companies 
     For more information, go to www.ponvory.com or call 1-800-526-7736. 
     This Medication Guide has been approved by the U.S. Food and Drug Administration Approved: March/2021