Sublingual Epinephrine Takes Another Step Toward Approval in Clinical Study


Aquestive Therapeutics, a pharmaceutical company headquartered in Warren, NJ, released positive topline results from its pivotal phase 3 clinical study of Anaphylm™, a sublingual film placed under the tongue to treat severe, life-threatening allergic reactions, including anaphylaxis.

Anaphylm met all predefined primary and secondary pharmacokinetic (PK) endpoints, achieving a time to maximum concentration (Tmax) consistently faster than traditional auto-injectors. After 30 minutes of dosing, exposure levels were comparable to auto-injectors with no serious adverse effects, and was well-tolerated.

The company received positive feedback from the FDA during a recent meeting and is on track to submit its new drug application (NDA) before the end of the year.

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Said Daniel Barber, President and Chief Executive Officer of Aquestive:

We are extremely pleased with the pivotal study results as well as our recent FDA interaction. When it comes to treating severe allergic reactions including anaphylaxis, we often hear from clinicians that rapid absorption of epinephrine at the first sign of symptoms is critical. Our pivotal study indicates that Anaphylm is comparable to the leading autoinjectors immediately following administration and our time to maximum concentration, or Tmax, is faster than the leading autoinjectors. We believe this performance is unprecedented among the alternate delivery options under development and are excited at the potential of Anaphylm as the only oral medicine for treatment of severe allergies.

In addition, our recent discussions with the FDA remained consistent with our previous interactions. We believe we have a clear understanding of the remaining clinical development steps necessary for a pre-NDA meeting with the FDA in the second half of the year. Our goal continues to be to file our NDA before the end of 2024 following completion of a positive pre-NDA meeting.

Said David Golden, MD, an allergy-immunology consultant at Sinai Hospital of Baltimore and Franklin Square Hospital in Baltimore and an authority on anaphylaxis:

The data from the Anaphylm pivotal study build on the compelling data generated from the prior Anaphylm pilot studies. These latest study results show that the sublingual administration of epinephrine provides rapid and sustained levels of epinephrine similar to approved treatments. Anaphylm is a promising needle-free alternative to the current standard of care, allowing patients to easily carry and administer this life-saving medication.

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Topline Data from Pivotal Phase 3 Study in Adults

The two-part, Phase 3, single-center, open-label, randomized study was designed to compare the PK and pharmacodynamics (PD) of single and repeat doses of Anaphylm versus single and repeat doses of the epinephrine intra-muscular (IM) injection and epinephrine autoinjectors (EpiPen® and Auvi-Q®) in healthy adult subjects. The primary endpoint was to compare the PK of epinephrine following the single administration of Anaphylm to the single administration of Adrenalin (epinephrine IM injection) and autoinjectors in healthy adult subjects. The secondary endpoints included evaluating PK sustainability following repeat administration and the safety and tolerability following single and repeat administrations versus epinephrine IM injection and epinephrine autoinjectors.

The single dose part of the Phase 3 study was designed as a four-period, four-treatment, four-sequence, comparative PK study with 64 enrolled adult subjects. As outlined in the presentation posted to the Company’s website and filed with the SEC today, key findings from the single dosing part of the study included that Anaphylm:

  • Achieved a geometric mean Cmax of 470 pg/mL bracketed by epinephrine autoinjectors AUVI-Q at 521 pg/mL and EpiPen at 469 pg/mL,
  • Generated partial AUCs between (bracketed) autoinjectors and Adrenalin manual IM injection from 5 to 60 minutes
  • Maintained a median Tmax of 12 minutes compared to 20 minutes for EpiPen, 30 minutes for AUVI-Q, and 50 minutes for Adrenalin,
  • Produced a meaningful change from baseline pharmacodynamic measures of blood pressure and heart rate at the first tracked time point of 2 minutes, and
  • Was consistently well tolerated with no SAEs.

The repeat dosing part of the Phase 3 study was designed as a three-period, three-treatment, six sequence, comparative PK study with 36 enrolled adult subjects. As outlined in the presentation posted to the website and filed with the SEC, the key findings from the repeat dosing part of the Study included that Anaphylm:

  • Maintains epinephrine plasma concentrations equal to or greater than existing injection products at all but 1 timepoint out to 2 hours,
  • Demonstrated a median Tmax of 10 minutes after administration of the second dose,
  • Exhibited consistent pharmacodynamics, and
  • Was consistently well tolerated with no SAEs.
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FDA Type C Meeting

The Company also successfully completed a Type C meeting with the FDA that addressed open items from the November 2022 End-of-Phase 2 meeting including addressing (1) the impact of any product hold time, (2) the potential for emesis (vomiting), and (3) the impact of potential mouth conditions such as angioedema (swelling).

In response to these questions, the FDA indicated that the Company has “adequately addressed” the FDA’s previous concerns by removing product hold time from the administration instructions and provided additional information on how to characterize emesis in the Company’s NDA submission.

Regarding mouth conditions, the FDA recommended administering Anaphylm after oral exposure to a known allergen and assessing PK performance thereunder. The Company will execute this study in the second quarter of 2024. This study will replace the Company’s previously planned angioedema study.

The FDA noted that substantial progress had been made in the Anaphylm clinical development program and did not outline any new clinical development requirements. As expected, the FDA reiterated that, as with other epinephrine programs under development, concentrations of epinephrine above known EpiPen levels must be justified from a safety perspective, and PK sustainability remains a focus. Furthermore, the FDA recommended that Aquestive begin its pediatric study after completion of the remaining adult studies. The Company is aligned with this recommendation from the FDA. The FDA reserved judgement on the sufficiency of the Anaphylm clinical development program until completion of ongoing and planned studies, the results of which are expected to be presented at the pre-NDA meeting.

Table 1 provides an updated view on the expected clinical study dates.

Table 1: Anaphylm Clinical Study Timeline Status

Pivotal PK StudiesSupportive PK Studies
FDA Meetings /
CompletedPhase 3 PK Study
Repeat Dose PK Study
 Type C Meeting
Q1 2024 Temperature PK Study 
Q2 2024 Self-administration PK Study
Allergen PK Study
Q3 2024Pediatric PK Study  
H2 2024  Pre-NDA Meeting

The next anticipated meeting with the FDA is the pre-NDA meeting targeted for the second half of 2024. Aquestive’s goal is to file the NDA with the FDA before year end 2024.

A presentation containing additional information about this topline data and the Company’s recent FDA Type C meeting is available on the Events and Presentations page within the Investor page of the Aquestive website.

About Anaphylm™
Anaphylm is a polymer matrix-based epinephrine prodrug candidate product. The product is similar in size to a postage stamp, weighs less than an ounce, and begins to dissolve on contact. No water or swallowing is required for administration. The packaging for Anaphylm is thinner and smaller than an average credit card, can be carried in a pocket, and is designed to withstand weather excursions such as exposure to rain and/or sunlight. The tradename for AQST-109, “Anaphylm” has been conditionally approved by the United States Food and Drug Administration (FDA). Final approval of the Anaphylm proprietary name is conditioned on FDA approval of the product candidate.

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Dave Bloom
Dave Bloom
Dave Bloom is CEO and "Blogger in Chief" of

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