# Vosoritide

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Experimental drug for the treatment of achondroplasia

Pharmaceutical compound

Vosoritide Clinical data Trade names Voxzogo Other names BMN-111 License data US DailyMed: Vosoritide Pregnancy category AU: B2[1][2] Routes of administration Subcutaneous injection ATC code M05BX07 (WHO) Legal status Legal status AU: S4 (Prescription only)[1] US: ℞-only[3][4] EU: Rx-only[5] Identifiers CAS Number 1480724-61-5 DrugBank DB11928 ChemSpider 44210446 UNII 7SE5582Q2P KEGG D11190 Chemical and physical data Formula C176H290N56O51S3 Molar mass 4102.78 g·mol−1 3D model (JSmol) Interactive image SMILES CC[C@H](C)[C@H]1C(=O)NCC(=O)N[C@H](C(=O)N[C@H](C(=O)N[C@H](C(=O)NCC(=O)N[C@H](C(=O)NCC(=O)N[C@@H](CSSC[C@@H](C(=O)N[C@H](C(=O)NCC(=O)N[C@H](C(=O)N[C@H](C(=O)N[C@H](C(=O)N[C@H](C(=O)N[C@H](C(=O)N1)CCCNC(=N)N)CC(=O)O)CC(C)C)CCCCN)CC(C)C)Cc2ccccc2)NC(=O)CNC(=O)[C@H](CCCCN)NC(=O)[C@H](CO)NC(=O)[C@H](CC(C)C)NC(=O)CNC(=O)[C@H](CCCCN)NC(=O)[C@H](CCCCN)NC(=O)[C@H](CC(=O)N)NC(=O)[C@H](C)NC(=O)CNC(=O)[C@H](CCCCN)NC(=O)[C@H](Cc3ccc(cc3)O)NC(=O)[C@H](CCCCN)NC(=O)[C@H](CCCNC(=N)N)NC(=O)[C@H](C)NC(=O)[C@H](CC(=O)N)NC(=O)[C@@H]4CCCN4C(=O)[C@H](Cc5cnc[nH]5)NC(=O)[C@H](CCC(=O)O)NC(=O)[C@H](CCC(=O)N)NC(=O)CNC(=O)[C@@H]6CCCN6)C(=O)O)CC(C)C)CO)CCSC)CO InChI InChI=1S/C176H290N56O51S3/c1-14-95(10)143-172(280)201-84-138(245)209-125(86-234)168(276)221-113(54-65-284-13)159(267)229-124(85-233)152(260)200-81-135(242)206-114(66-91(2)3)150(258)198-83-140(247)211-128(174(282)283)89-286-285-88-127(170(278)224-118(70-98-34-16-15-17-35-98)151(259)199-80-137(244)207-115(67-92(4)5)162(270)217-108(41-23-29-60-182)155(263)223-117(69-94(8)9)164(272)226-122(75-142(250)251)167(275)219-110(160(268)231-143)44-32-63-193-176(188)189)210-139(246)82-197-149(257)105(38-20-26-57-179)215-169(277)126(87-235)230-163(271)116(68-93(6)7)208-136(243)79-196-147(255)103(36-18-24-55-177)213-153(261)106(39-21-27-58-180)218-166(274)121(74-132(185)239)222-144(252)96(11)203-133(240)77-195-148(256)104(37-19-25-56-178)214-165(273)119(71-99-46-48-101(236)49-47-99)225-156(264)107(40-22-28-59-181)216-154(262)109(43-31-62-192-175(186)187)212-145(253)97(12)204-161(269)120(73-131(184)238)227-171(279)129-45-33-64-232(129)173(281)123(72-100-76-190-90-202-100)228-158(266)112(51-53-141(248)249)220-157(265)111(50-52-130(183)237)205-134(241)78-194-146(254)102-42-30-61-191-102/h15-17,34-35,46-49,76,90-97,102-129,143,191,233-236H,14,18-33,36-45,50-75,77-89,177-182H2,1-13H3,(H2,183,237)(H2,184,238)(H2,185,239)(H,190,202)(H,194,254)(H,195,256)(H,196,255)(H,197,257)(H,198,258)(H,199,259)(H,200,260)(H,201,280)(H,203,240)(H,204,269)(H,205,241)(H,206,242)(H,207,244)(H,208,243)(H,209,245)(H,210,246)(H,211,247)(H,212,253)(H,213,261)(H,214,273)(H,215,277)(H,216,262)(H,217,270)(H,218,274)(H,219,275)(H,220,265)(H,221,276)(H,222,252)(H,223,263)(H,224,278)(H,225,264)(H,226,272)(H,227,279)(H,228,266)(H,229,267)(H,230,271)(H,231,268)(H,248,249)(H,250,251)(H,282,283)(H4,186,187,192)(H4,188,189,193)/t95-,96-,97-,102-,103-,104-,105-,106-,107-,108-,109-,110-,111-,112-,113-,114-,115-,116-,117-,118-,119-,120-,121-,122-,123-,124-,125-,126-,127-,128-,129-,143-/m0/s1 Key:IGYWDDBBJPSOTG-WBAGYEQSSA-N

**Vosoritide**, sold under the brand name **Voxzogo**, is a medication used for the treatment of [achondroplasia](/source/Achondroplasia),[3][4][5] a genetic condition that causes severely short stature and disproportionate growth.[4]

Achondroplasia is caused by a genetic mutation that increases the activity of a certain growth regulation [gene](/source/Gene) called [fibroblast growth factor receptor 3](/source/Fibroblast_growth_factor_receptor_3) (*FGFR3*). The overabundance of protein coded by the *FGFR3* gene prevents normal bone growth.[4] Vosoritide works by binding to a specific receptor called [natriuretic peptide receptor B](/source/Natriuretic_peptide_receptor_B) that reduces the growth regulation gene's activity, thus allowing for bone growth.[4]

The most common side effects include injection site reactions (such as swelling, redness, itching, or pain), vomiting, and decreased blood pressure.[3][4][5]

Vosoritide was approved for medical use in the European Union in August 2021,[5][6][7] and in the United States in November 2021.[4][8] The US [Food and Drug Administration](/source/Food_and_Drug_Administration) considers it to be a [first-in-class medication](/source/First-in-class_medication).[9]

## Medical uses

In the European Union, vosoritide is [indicated](/source/Indication_(medicine)) for the treatment of achondroplasia in people two years of age and older whose [epiphyses](/source/Epiphyses) are not closed.[5]

In the United States, vosoritide is indicated to increase growth in children five years of age and older with achondroplasia and open epiphyses (growth plates).[3][4]

## Mechanism of action

**A**: [Chondrocyte](/source/Chondrocyte) with constitutionally active [FGFR3](/source/Fibroblast_growth_factor_receptor_3) that down-regulates its development via the [MAPK/ERK pathway](/source/MAPK%2FERK_pathway)
**B**: Vosoritide (BMN 111) blocks this mechanism by binding to the [atrial natriuretic peptide receptor](/source/Atrial_natriuretic_peptide_receptor) B (NPR-B), which subsequently inhibits the MAPK/ERK pathway at the [RAF-1](/source/C-Raf) protein.[10]

Vosoritide works by binding to a receptor (target) called natriuretic peptide receptor type B (NPR-B), which reduces the activity of [fibroblast growth factor receptor 3](/source/Fibroblast_growth_factor_receptor_3) (FGFR3).[5] FGFR3 is a [receptor](/source/Receptor_(biochemistry)) that normally down-regulates [cartilage](/source/Cartilage) and bone growth when activated by one of the proteins known as [acidic](/source/Acidic_fibroblast_growth_factor) and [basic fibroblast growth factor](/source/Basic_fibroblast_growth_factor). It does so by inhibiting the development ([cell proliferation](/source/Cell_proliferation) and differentiation) of [chondrocytes](/source/Chondrocyte), the cells that produce and maintain the cartilaginous matrix which is also necessary for bone growth. Children with achondroplasia have one of several possible FGFR3 mutations resulting in constitutive (permanent) activity of this receptor, resulting in overall reduced chondrocyte activity and thus bone growth.[10]

The protein [C-type natriuretic peptide](/source/C-type_natriuretic_peptide) (CNP), naturally found in humans, reduces the effects of over-active FGFR3. Vosoritide is a CNP analogue with the same effect but prolonged half-life,[10] allowing for once-daily administration.[11]

## Chemistry

Vosoritide is an [analog](/source/Analog_(chemistry)) of CNP. It is a [peptide](/source/Peptide) consisting of the amino acids [proline](/source/Proline) and [glycine](/source/Glycine) plus the 37 [C-terminal](/source/C-terminal) amino acids from natural human CNP. The complete [peptide sequence](/source/Peptide_sequence) is

- [P](/source/Proline)[G](/source/Glycine)[Q](/source/Glutamine)[E](/source/Glutamic_acid)[H](/source/Histidine)[P](/source/Proline)[N](/source/Asparagine)[A](/source/Alanine)[R](/source/Arginine)[K](/source/Lysine) [Y](/source/Tyrosine)KGANKKG[L](/source/Leucine)[S](/source/Serine) KG[C](/source/Cysteine)[F](/source/Phenylalanine)GLKL[D](/source/Aspartic_acid)R [I](/source/Isoleucine)GS[M](/source/Methionine)SGLGC

with a [disulfide bridge](/source/Disulfide_bridge) between positions 23 and 39 (underlined).[12] The drug must be administered by injection as it would be rendered ineffective by the digestive system if taken [by mouth](/source/Oral_administration).

## History

Vosoritide was developed by [BioMarin Pharmaceutical](/source/BioMarin_Pharmaceutical) and got [orphan drug](/source/Orphan_drug) status in the US as well as the European Union.[5][7][13][9]

The safety and efficacy of vosoritide in improving growth were evaluated in a year-long, double-blind, placebo-controlled, phase III study in participants five years and older with achondroplasia who have open epiphyses.[4] In the study, 121 participants were randomly assigned to receive either vosoritide injections under the skin or a placebo.[4] Researchers measured the participants' annualized growth velocity, or rate of height growth, at the end of the year.[4] Participants who received vosoritide grew an average 1.57 centimeters taller compared to those who received a placebo.[4] The US [Food and Drug Administration](/source/Food_and_Drug_Administration) (FDA) granted the approval of Voxzogo to BioMarin.[4]

## Society and culture

### Controversy

Little People of America, a national nonprofit organization that provides support and information to people of short stature and their families, states "LPA strongly believes that a pharmaceutical intervention focusing on growth velocity is not addressing the actual health and quality of life issues of people with dwarfism. Our height-related challenges are primarily based on inaccessible architecture, lack of universal design, and society’s intolerance and discrimination of people with short stature. We are concerned that this recently approved drug attempts a pharmaceutical solution to a societal issue. Our community acknowledges that the hardships associated with having dwarfism need to be addressed. Yet, we strive for our height to be reframed as a part of the diversity of humanity. We want to reprioritize research goals to be the most meaningful ones for our members, such as reducing spinal stenosis, sleep apnea, and the need for corrective surgeries."[14]

## Research

Vosoritide has resulted in increased growth in a clinical trial with 26 children. The ten children receiving the highest dose grew 6.1 centimetres (2.4 in) in six months, compared to 4.0 centimetres (1.6 in) in the six months before the treatment ([p](/source/P-value)=0.01).[15] The [body proportions](/source/Body_proportions), more specifically the ratio of leg length to upper body length – which is lower in achondroplasia patients than in the average population – was not improved by vosoritide, but not worsened either.[16][17]

## References

1. ^ [***a***](#cite_ref-Voxzogo_APMDS_1-0) [***b***](#cite_ref-Voxzogo_APMDS_1-1) ["Voxzogo APMDS"](https://www.tga.gov.au/resources/auspmd/voxzogo). *Therapeutic Goods Administration (TGA)*. 4 August 2022. [Archived](https://web.archive.org/web/20220806060739/https://www.tga.gov.au/apm-summary/voxzogo) from the original on 6 August 2022. Retrieved 6 August 2022.

1. **[^](#cite_ref-2)** ["Updates to the Prescribing Medicines in Pregnancy database"](https://www.tga.gov.au/resources/resource/guidance/updates-prescribing-medicines-pregnancy-database). *Therapeutic Goods Administration (TGA)*. 21 December 2022. [Archived](https://web.archive.org/web/20220403064059/https://www.tga.gov.au/updates-prescribing-medicines-pregnancy-database) from the original on 3 April 2022. Retrieved 2 January 2023.

1. ^ [***a***](#cite_ref-Voxzogo_FDA_label_3-0) [***b***](#cite_ref-Voxzogo_FDA_label_3-1) [***c***](#cite_ref-Voxzogo_FDA_label_3-2) [***d***](#cite_ref-Voxzogo_FDA_label_3-3) ["Voxzogo 0.4MG- vosoritide kit Voxzogo 0.56MG- vosoritide kit Voxzogo 1.2MG- vosoritide kit"](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=228e8560-04a4-4bb1-a81f-29531a9e4d27). *DailyMed*. [Archived](https://web.archive.org/web/20211219213325/https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=228e8560-04a4-4bb1-a81f-29531a9e4d27) from the original on 19 December 2021. Retrieved 19 December 2021.

1. ^ [***a***](#cite_ref-FDA_PR_20211119_4-0) [***b***](#cite_ref-FDA_PR_20211119_4-1) [***c***](#cite_ref-FDA_PR_20211119_4-2) [***d***](#cite_ref-FDA_PR_20211119_4-3) [***e***](#cite_ref-FDA_PR_20211119_4-4) [***f***](#cite_ref-FDA_PR_20211119_4-5) [***g***](#cite_ref-FDA_PR_20211119_4-6) [***h***](#cite_ref-FDA_PR_20211119_4-7) [***i***](#cite_ref-FDA_PR_20211119_4-8) [***j***](#cite_ref-FDA_PR_20211119_4-9) [***k***](#cite_ref-FDA_PR_20211119_4-10) [***l***](#cite_ref-FDA_PR_20211119_4-11) [***m***](#cite_ref-FDA_PR_20211119_4-12) ["FDA Approves First Drug to Improve Growth in Children with Most Common Form of Dwarfism"](https://web.archive.org/web/20211119220713/https://www.fda.gov/news-events/press-announcements/fda-approves-first-drug-improve-growth-children-most-common-form-dwarfism). *U.S. [Food and Drug Administration](/source/Food_and_Drug_Administration) (FDA)* (Press release). 19 November 2021. Archived from [the original](https://www.fda.gov/news-events/press-announcements/fda-approves-first-drug-improve-growth-children-most-common-form-dwarfism) on 19 November 2021. Retrieved 19 November 2021. This article incorporates text from this source, which is in the [public domain](/source/Public_domain).

1. ^ [***a***](#cite_ref-Voxzogo_EPAR_5-0) [***b***](#cite_ref-Voxzogo_EPAR_5-1) [***c***](#cite_ref-Voxzogo_EPAR_5-2) [***d***](#cite_ref-Voxzogo_EPAR_5-3) [***e***](#cite_ref-Voxzogo_EPAR_5-4) [***f***](#cite_ref-Voxzogo_EPAR_5-5) [***g***](#cite_ref-Voxzogo_EPAR_5-6) ["Voxzogo EPAR"](https://www.ema.europa.eu/en/medicines/human/EPAR/voxzogo). *European Medicines Agency*. 23 June 2021. [Archived](https://web.archive.org/web/20210910052300/https://www.ema.europa.eu/en/medicines/human/EPAR/voxzogo) from the original on 10 September 2021. Retrieved 9 September 2021. Text was copied from this source which is copyright European Medicines Agency. Reproduction is authorized provided the source is acknowledged.

1. **[^](#cite_ref-6)** ["Voxzogo Product information"](https://ec.europa.eu/health/documents/community-register/html/h1577.htm). *Union Register of medicinal products*. [Archived](https://web.archive.org/web/20230304104623/https://ec.europa.eu/health/documents/community-register/html/h1577.htm) from the original on 4 March 2023. Retrieved 3 March 2023.

1. ^ [***a***](#cite_ref-BioMarin_PR_7-0) [***b***](#cite_ref-BioMarin_PR_7-1) ["European Commission Approves BioMarin's Voxzogo (vosoritide) for the Treatment of Children with Achondroplasia from Age 2 Until Growth Plates Close"](https://www.prnewswire.com/news-releases/european-commission-approves-biomarins-voxzogo-vosoritide-for-the-treatment-of-children-with-achondroplasia-from-age-2-until-growth-plates-close-301364307.html) (Press release). BioMarin Pharmaceutical. 27 August 2021. [Archived](https://web.archive.org/web/20210828232914/https://www.prnewswire.com/news-releases/european-commission-approves-biomarins-voxzogo-vosoritide-for-the-treatment-of-children-with-achondroplasia-from-age-2-until-growth-plates-close-301364307.html) from the original on 28 August 2021. Retrieved 9 September 2021 – via PR Newswire.

1. **[^](#cite_ref-8)** ["BioMarin Receives FDA Approval for Voxzogo (vosoritide) for Injection, Indicated to Increase Linear Growth in Children with Achondroplasia Aged 5 and Up with Open Growth Plates"](https://www.prnewswire.com/news-releases/biomarin-receives-fda-approval-for-voxzogo-vosoritide-for-injection-indicated-to-increase-linear-growth-in-children-with-achondroplasia-aged-5-and-up-with-open-growth-plates-301429145.html) (Press release). BioMarin Pharmaceutical. 19 November 2021. [Archived](https://web.archive.org/web/20220806060728/https://www.prnewswire.com/news-releases/biomarin-receives-fda-approval-for-voxzogo-vosoritide-for-injection-indicated-to-increase-linear-growth-in-children-with-achondroplasia-aged-5-and-up-with-open-growth-plates-301429145.html) from the original on 6 August 2022. Retrieved 19 November 2021 – via PR Newswire.

1. ^ [***a***](#cite_ref-New_Drug_Therapy_Approvals_2021_9-0) [***b***](#cite_ref-New_Drug_Therapy_Approvals_2021_9-1) [Advancing Health Through Innovation: New Drug Therapy Approvals 2021](https://web.archive.org/web/20221206210020/https://www.fda.gov/media/155227/download). *U.S. [Food and Drug Administration](/source/Food_and_Drug_Administration) (FDA)* (Report). 13 May 2022. Archived from [the original](https://www.fda.gov/media/155227/download) (PDF) on 6 December 2022. Retrieved 22 January 2023. This article incorporates text from this source, which is in the [public domain](/source/Public_domain).

1. ^ [***a***](#cite_ref-Lorget_10-0) [***b***](#cite_ref-Lorget_10-1) [***c***](#cite_ref-Lorget_10-2) Lorget F, Kaci N, Peng J, Benoist-Lasselin C, Mugniery E, Oppeneer T, et al. (December 2012). ["Evaluation of the therapeutic potential of a CNP analog in a Fgfr3 mouse model recapitulating achondroplasia"](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3516592). *American Journal of Human Genetics*. **91** (6): 1108–14. [doi](/source/Doi_(identifier)):[10.1016/j.ajhg.2012.10.014](https://doi.org/10.1016%2Fj.ajhg.2012.10.014). [PMC](/source/PMC_(identifier)) [3516592](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3516592). [PMID](/source/PMID_(identifier)) [23200862](https://pubmed.ncbi.nlm.nih.gov/23200862).

1. **[^](#cite_ref-ClinicalTrials_11-0)** Clinical trial number *[NCT02055157](https://www.clinicaltrials.gov/show/NCT02055157)* for "A Phase 2 Study of BMN 111 to Evaluate Safety, Tolerability, and Efficacy in Children With Achondroplasia (ACH)" at [ClinicalTrials.gov](/source/ClinicalTrials.gov)

1. **[^](#cite_ref-12)** ["International Nonproprietary Names for Pharmaceutical Substances (INN): List 112"](https://www.who.int/medicines/publications/druginformation/PL112-final.pdf) (PDF). *WHO Drug Information*. **28** (4): 539. 2014.

1. **[^](#cite_ref-13)** ["Food and Drug Administration Accepts BioMarin's New Drug Application for Vosoritide to Treat Children with Achondroplasia"](https://www.prnewswire.com/news-releases/food-and-drug-administration-accepts-biomarins-new-drug-application-for-vosoritide-to-treat-children-with-achondroplasia-301165431.html) (Press release). BioMarin Pharmaceutical. 2 November 2020. [Archived](https://web.archive.org/web/20210910052258/https://www.prnewswire.com/news-releases/food-and-drug-administration-accepts-biomarins-new-drug-application-for-vosoritide-to-treat-children-with-achondroplasia-301165431.html) from the original on 10 September 2021. Retrieved 9 September 2021 – via PR Newswire.

1. **[^](#cite_ref-14)** ["Voxzogo Position Statement"](https://www.lpaonline.org/voxzogo-position-statement). [Archived](https://web.archive.org/web/20240215213941/https://www.lpaonline.org/voxzogo-position-statement) from the original on 2024-02-15. Retrieved 2024-03-10.

1. **[^](#cite_ref-BioMarin_15-0)** ["BMN 111 (vosoritide) Improves Growth Velocity in Children With Achondroplasia in Phase 2 Study"](http://investors.bmrn.com/releasedetail.cfm?ReleaseID=918431). BioMarin. 17 June 2015. [Archived](https://web.archive.org/web/20150909121741/http://investors.bmrn.com/releasedetail.cfm?ReleaseID=918431) from the original on 9 September 2015. Retrieved 12 September 2015.

1. **[^](#cite_ref-Spreitzer_16-0)** Spreitzer H (6 July 2015). "Neue Wirkstoffe – Vosoritid". *Österreichische Apothekerzeitung* (in German) (14/2015): 28.

1. **[^](#cite_ref-arznei-news_17-0)** ["Vosoritid"](http://arznei-news.de/vosoritid) (in German). Arznei-News.de. 20 June 2015. [Archived](https://web.archive.org/web/20160306164058/http://arznei-news.de/vosoritid/) from the original on 6 March 2016. Retrieved 10 September 2015.

## External links

- Clinical trial number *[NCT03197766](https://www.clinicaltrials.gov/show/NCT03197766)* for "A Study to Evaluate the Efficacy and Safety of BMN 111 in Children With Achondroplasia" at [ClinicalTrials.gov](/source/ClinicalTrials.gov)

[Portal](https://en.wikipedia.org/wiki/Wikipedia:Contents/Portals):
- [Medicine](https://en.wikipedia.org/wiki/Portal:Medicine)

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Adapted from the Wikipedia article [Vosoritide](https://en.wikipedia.org/wiki/Vosoritide) by Wikipedia contributors ([contributor history](https://en.wikipedia.org/wiki/Vosoritide?action=history)). Available under [Creative Commons Attribution-ShareAlike 4.0 International](https://creativecommons.org/licenses/by-sa/4.0/). Changes may have been made.