TBI

DEMENTIA

Improving Patient Recovery

Reconnecting Neurons.

CERE/A/12/2015/29 Empowering for Life. Therapeutic areas

Stroke Traumatic Brain Injury

• Ischemic Stroke • Due to accident • Alzheimer‘s disease • Haemorragic Stroke • Due to surgery • • … • …

dead tissue

ischemic boundary zone penumbra

Disturbed or interrupted Damage to neuronal structures Neurodegenerative processes blood flow in the brain and brain substances kill neurons and disrupt neuronal networks

Pathophysiological challenges:

• Disruption of the brain‘s regulatory processes including those controlled by (NTFs) • Local deprivation of NTFs in the affected brain tissue

Acute Phase Acute Phase Treatment Rehabilitation Phase Rehabilitation Phase Prevention

• Uncontrolled apoptosis • Excessive neuroinflammation After primary damages the affected part of the • Formation of free radicals brain develops a secondary pathological cascade • Excitotoxicity • Neuronal dysregulation • Neurodegeneration Neuroprotection with Cerebrolysin

Reduction of apoptosis Cerebrolysin Control p<0.005

100

Cerebrolysin reduces apoptosis by decreasing calpain and 80 caspase-3 activity1 tivity (%) 60 Ac 42 40 39 Cerebrolysin has been shown to inhibit calpain in vitro by about 60% 20 (see figure 1)1 and to decrease the number of neuronal progenitor cells Enzymatic 2 0 expressing caspase-3 by a factor of 2.5 . These results confirm anti-apoptotic µ-calpain m-calpain effects of Cerebrolysin. Figure 1: Inhibition of calpain activity1

Modulation of inflammatory response Negative control Positive control Cerebrolysin 1,0 p<0.01

0,8 Cerebrolysin inhibits pro-inflammatory cytokines like IL-1ß and rebrolysin 3 Ce reduces microglial activation 0,6 OD 450 nm

0,4 tivation by Recovery from brain damage should involve the normalization of the 0,2 immune activation surrounding the lesion. Cerebrolysin exhibited to microglial * activation Reduced ac decrease the level of lipopolysacharide induced IL-1β release in a primary 0,0 48 h microglial cell culture model (see figure 2)3. Figure 2: Attenuation of inflammatory response in microglial cell culture model 3

Reduction of free radicals Control Ischemia + Saline Ischemia + Cerebrolysin

Cerebrolysin significantly reduces the formation of free t 4 4 radicals 3 n mol/g ww 2 Free radicals are also involved in many pathological processes like Alzheimer‘s disease or ischemic cascades. Cerebrolysin demonstrated 1 n=4 n=9 n=8 n=4 n=9 n=8 0 to significantly reduce the production of free radicals (2,3-DHBA and 2,3-DHBA 2,5-DHBA 2,5-DHBA) following experimentally induced ischemia in an in-vivo animal Figure 3: Concentrations of 2,3-DHBA and model (see figure 3)4. 2,5-DHBA in the hippocampus 4

Protection against excitotoxicity L-glutamate 1mM *p<0.001 Cerebrolysin counters glutamate activity and inhibits neuronal 400 * excitotoxicity5 300 * 200 * * Excitotoxicity is a pathological process which damages or kills neuronal vival of neurons (%) *

Sur 100 cells by overstimulated neuronal transmission (e.g. glutamate). Cerebrolysin 0 has shown to prevent L-glutamate induced injury of cultured neurons Baseline 10µl 20µl 40µl 80µl c (see figure 4 )5. survival Cerebrolysin/ml medium Figure 4: Dose-dependent increase of neurons 5 Neurorecovery with Cerebrolysin

Neuroplasticity A B

Cerebrolysin enhances neuroplasticity by modulating neuronal connectivity6

In a transgenic animal model of Alzheimer’s disease exhibiting impaired synaptic plasticity, amyloid ß plaque deposition and neurodegeneration, Cerebrolysin significantly increased the number of new synapses in hippocampus (see figure 5 – the increasing signaling in image B). This effect Saline Cerebrolysin was reflected in improved cognitive performance of animals treated with Figure 5: Visualization of immunofluorescent Cerebrolysin6. synaptic endings 6

Neurogenesis

Cerebrolysin stimulates neurovascular reconstruction by promoting neurogenesis2

Cerebrolysin has been shown to enhance Cerebrolysin Control p<0.05 APP tg control neurogenesis in the dentate gyrus in normal and transgenic animal models (see figure 6)2. This result is consistent with the mechanism of counteracting ell Numbers the effects of FGF-2 on neurogensis in APP tg Cerebrolysin vivo by both Cerebrolysin and Ciliary Neurotrophic Factor. BrDU (+) C

1 month treatment

Figure 6: Stimulation of neurogenesis in subgranular zone of the dentate gyrus in a transgenic model of Alzheimer’s disease2

Cerebrolysin is a multi-modal neuropeptide drug which improves the brain’s ability for self-repair by stimulating neurorecovery Clinical benefits for patients

Treatment of neurological disorders with Cerebrolysin helps to increase the quality of life for patients. Its efficacy has been proven in 87 double-blind-studies and trials with more than 17.000 patients.

• Improvement of motor functions and cognitive performance7, 8 • Improvement of activities of daily living (ADLs)7, 8 Stroke • Faster recovery for patients treated with standard therapy combined with Cerebrolysin7, 8 • Reduced infarct volume9

• Improved global outcome of Glasgow Outcome Scale10-12 Traumatic • Improvement of clinical symptoms, cognitive performance, global Brain Injury impressions13 • Increased level of consciousness10-12

• Improvement of cognitive functions14-19 • Improvement of behavioral symptoms15 Dementia • Combination of symptomatic improvement with long-term, disease- modifying treatment effects14-20

Cerebrolysin is safe and well tolerated.

Cerebrolysin product information

Cerebrolysin is a neuropeptide preparation and manufactured in a sophisticated, fully controlled biotechnological process. It consists of amino acids and neuropeptides.

Administration Route of administration Daily Disorder Initiation of treatment Duration of treatment dosage • IV injection for 3 min: Immediately after rt-PA Acute Stroke 10 - 50 ml Up to 21 days Up to 10 ml undiluted or as soon as possible • IV infusion for 15 - 60 min: Post-acute Stroke 10 - 50 ml After acute Stroke Up to 21 days 10 ml - 50 ml diluted to at least 100 ml total volume with: Traumatic brain injury 10 - 50 ml As soon as possible Up to 30 days Saline, Ringer solution or 5% glucose solution 2-4 cycles per year Vascular dementia 5 - 30 ml As soon as possible • 5 ml dosage (undiluted) can be 1 cycle: 5 days weekly/4 weeks administered intramusculary 2-4 cycles per year Alzheimer’s disease 5 - 30 ml As soon as possible 1 cycle: 5 days weekly/4 weeks Name of the medicinal product: Cerebrolysin product: ofName the medicinal -Cerebrolysin INFORMATION PRESCRIBING ABBREVIATED Austria. Unterach, 4866 GmbH, Pharma Neuro EVER of trademark registered form or any in by any electronic or mechanical means, reproduced including be may information storage brochure and retrieval this of systems, without permission part No in writing from the publisher. reserved. Cerebrolysin rights is All a Austria. Unterach, 4866 3, Oberburgau GmbH, Pharma ©2015 Neuro EVER by Copyright 20. 18. 19. 17. 16. 15. 1. 7. 6. 5. 4. 3. 2. 13. 12. 11. 10. 9. 8. 14. for disposal is available in the summary of product characteristics. (Reference SPC – CCDS Version 1.0/Jan –CCDS 2014) 28 Version SPC (Reference characteristics. product of summary the in available is disposal for nature for and storage, contents of precautions precautions the and life, container special special shelf incompatibilities, data, safety preclinical properties, cokinetic of interaction, fertility, pregnancy and on lactation, effects ability to drive and use machines, undesirable effects, overdose, pharmacodynamics pharma properties, and forms other products with medicinal other for use, interaction and precautions warnings special of administration, and method posology form, pharmaceutical ment. Marketing Authorisation Holder: EVER Neuro Pharma Unterach. GmbH, A-4866 Only available on prescription and in pharmacies. More information about post-operative trauma, cerebral contusion or concussion. Contraindications: to Hypersensitivity one of the components of the drug, epilepsy, severe renal impair metabolic and neurodegenerative disorders of the brain, especially senile dementia of Alzheimer‘s - Post-apoplectic type complications - Craniocerebral trauma; preparation (Cerebrolysin

Panisset M., Gauthier S., Moessler H., Windisch M., Cerebrolysin in Alzheimer’s disease: a randomized, double-blind, placebo-controlled trial with aneurotro with trial 109:1089-1104 Transm 2002; JNeural agent. phic placebo-controlled double-blind, arandomized, disease: Alzheimer’s in Cerebrolysin M., Windisch H., Moessler S., Gauthier M., Panisset 43-53 19: 2000; Investig Drug Clin disease. Alzheimer’s with patients in of FPF 1070(Cerebrolysin) Efficacy Group, F., S. Study YaoXiao Yan Q., P. H. F., Cerebrolysin the and Ruether E., Ritter R., Apecechea M., Freytag S., Windisch M., Efficacy of the peptidergic drug Cerebrolysin in patients with senile dementia of the the 1994; 27: of 23-40 dementia senile (SDAT).with Pharmacopsychiatry type patients in Alzheimer Cerebrolysin drug nootropic peptidergic the of Efficacy M., Windisch S., Freytag M., Apecechea R., Ritter E., Ruether Bae C. Y., Cho C. Y., Cho K., Hoon Oh B., Choi K. G., Lee H. S., et al., A double-blind, placebo-controlled, multicenter study of Cerebrolysin for Alzheimer’s disease. disease. 1566-1571 48: Alzheimer’s 2000; for Soc Geriatr J Am Cerebrolysin of study multicenter placebo-controlled, Adouble-blind, al., et S., H. Lee G., K. Choi B., Oh Hoon Y., K., Y., Cho C. Cho C. Bae mild to moderate Alzheimer’s disease. Int Clin Psychopharmacol 2001; 16: with 253-263 patients in Psychopharmacol Clin Int Cerebrolysin disease. with study Alzheimer’s moderate to mild placebo-controlled double-blind, A28-week, al., et J., Spatt D., Klingler E., Diabl E., Kinzler R., Huasmann E., Ruether 13: 46-54 2006; JNeurol Eur disease. Cere of Alzheimer’s dosages three of moderate to mild study with patients in brolysin placebo-controlled double-blind, A24-week, al., et M., Varela C., V., Sampedro Couceiro M., Laredo R., Cacabelos A., X. Alvarez controlled randomized clinical of trials. Journal of Dementia and Geriatric ameta-analysis Cognitive Disorders, disease: 2015 Alzheimer’s (in press) moderate to mild in Cerebrolysin E., Doppler C., J. Vester L., Froelich J., V., J. Jia Proano S., Gauthier vioral performance. J Neural Transm 2003; 110; Transm 2003; JNeural 1313-27beha improved with performance. vioral associated are disease Alzheimer’s of model transgenic in a mark trade Cerebrolysin of effects neuroprotective The al., et E. Rockenstein Transm 1996; 267-273 47; J Neural Cerebrolysin; derivate peptide the by reduced is glutamate by induced neurons telencephalon cultured of Death al., et B. Hutter-Paier 45/4; To No 325-331 Shinkei; acid. salicylic with radicals hydroxyl of detection – gerbil the in death neuronal delayed on of FPF 1070 (Cerebrolysin) effect Y(1993): T., Mizuno Itou Protective A, TKanazawa Y., Kondo Sugita 59; 281- Transm 2000; JNeuronal 292 neuro-protection, of mechanism a potential vitro: in and vivo in activation microglial reduces Cerebrolysin al., et X.A. 2007; Alvarez 113;Neuropathol 265-275Acta disease, Alzheimer’s of model transgenic APP an in neurogenesis on Cerebrolysin of Effects al., et E. Rockenstein 2000; Trans 145-157 Neural J calpain. 107: protease, dependent Ca++- Calcium intracellular the on preparation peptide derived brain of a effect Inhibitory al., Ret Wronski traumatic brain injury, CNS Neurol Disord Drug Targets 2015; Targets Drug 14:587-99 Disord in Neurol CNS outcomes injury, clinical brain on traumatic treatment cerebrolysin of effects severityy-related the evaluating study cohort multi-center D. F. Aretrospective, al., et Muresanu 18:271-278 2003; Psychopharmacology Clin Int injury, brain traumatic postacute and outcomewith clinical slowing, in patients cognition onelectroencephalogram of Cerebrolysin Positive et al., Effects X.A. Alvarez acute of Psychiatrietraumatic 2006;7:12-20 injury, brain Neurochirurgie J treatment Neurol the in agent neurogenic and neurotrophic of study –apilot injury brain traumatic in Cerebrolysin al., et A. Witzmann R., P.,König Waanders 2012;43(3):630-6 Stroke trial. randomized placebo-controlled, blind, adouble of Results Asia: in stroke ischemic acute with patients in Cerebrolysin Investigators, (CASTA) Asia in Treatment Stroke Acute Cerebrolysin the for Z. Hong J., Tuomilehto N.M., Bornstein M., Brainin W.D., Heiss 12 2015]. 2015. November 10.1161/STROKEAHA.115.009416 Stroke. print of doi: ahead online [published trial multicenter blind, double- placebo-controlled, A randomized, (CARS): stroke after recovery and Cerebrolysin al. et CD O, Popescu V, Bajenaru DF, Hoemberg WD, Heiss Muresanu 112: Transm 2005, JNeural 415-428 trial, arando controlled stroke: mized acute with patients in Cerebrolysin with treatment Neuroprotective Group, Study Cerebrolysin the and H. P., Moessler Kalvach G., Ladurner Chen C. C., Wei S. T., Tsaia S.C., Chen X.X., Cho D. Y., Cerebrolysin enhances cognitive recovery of mild traumatic brain injury patients: double-blind, placebo- study, 2013;controlled, randomized British of Journal Neurosurgery Online:1-5; Early double-blind, patients: 2013; injury brain Foundation Neurosurgical The traumatic mild of recovery cognitive enhances D. Y., Cho Cerebrolysin X.X., Chen T., S. Tsaia Wei S.C., C., C. Chen ® concentrate) in aqueous solution. List of excipients: Sodium hydroxide and water for injection. Therapeutic indications: Organic, ® - Solution for injection. Qualitative and quantitative composition: One ml contains 215.2 mg of porcine brain-derived brain-derived 215.2 porcine of mg contains ml One composition: quantitative and Qualitative injection. for -Solution EVER Neuro Pharma GmbH Pharma Neuro EVER www.everpharma.com 4866 Unterach 4866 Oberburgau 3 Oberburgau Austria ------

CERE/A/12/2015/29