BHS TRAINING COURSE AND SEMINARS

Seminar 4 – Supportive care in Hematology

February 20, 2016 Philippe Lewalle Hematopoietic Growth Factors

 I. Granulocyte colony stimulating factors: G-CSFs

 II. Epoietins: synthetic 's

 III. Synthetic platelets growth factor: Thrombopoeitin analog I. Granulocyte colony stimulating factors: G-CSFs Complications of induced Neutropenia

Myelosuppressive chemotherapy

Neutropenia

Febrile neutropenia (FN) Chemotherapy dose delays and dose reductions

Complicated life- threatening infection and Decreased relative dose prolonged hospitalization intensity (RDI)

Reduced survival

Kuderer NM et al. Cancer 2006;106:2258–2266 Chirivella I et al. J Clin Oncol 2006;24;abstract 668 Bosly A et al. Ann Hematol 2007, advance access published 20 October 2007; doi:10.1007/s00277-007-0399-y Granulocyte Colony Stimulating Factors G-CSF effect on Neutrophils

Controls proliferation of committed progenitor cells Acts to increase the influences their maturation into mature neutrophils. phagocytic activity Stimulates the release of neutrophils from bone marrow of mature storage pools and reduces their maturation time. neutrophils.

Dexter TM, 1994. - Dexter TM. Eur J Cancer 1994;30A(3):S15-19. Different innovative recombinant G-CSF molecules

● Neupogen ® () is an Escherichia coli- derived modified recombinant human granulocyte colony stimulating factor (G-CSF) protein, non- glycosylated and having an extra methionine group at the N-terminal end of the peptide chain.

● Granocyte ® (lenograstrim) is a Chinese hamster ovary-derived G-CSF consisting of 174 amino acids with 4% carbohydrate, indistinguishable from native G-CSF.

● Neulasta® () is a pegylated version of Neupogen™

● Lonquex ® (lipegfilgrastrim) is also a pegylated filgrastim but with a different site of Filgrastim

Daily injection Mean 12 injections (11-16) Variation of neutrophils count Clinical practice : 5-6 injections between injections Pegfilgrastim

Clearance is Neutrophil count dependant 1 injection per cycle = 12 injections of filgrastim Neulasta® Pharmacokinetics ●Renal impairment had no influence on PK ●Maximum Neulasta® concentration was achieved approximately 30 hours after SC administration ●Volume of distribution at steady state approximated plasma volume/central compartment ●Elimination is primarily via a neutrophil- mediated clearance mechanism ●Half-life variable: chemotherapy setting 33 hrs compared to 3.37 hours for filgrastim Pediatric Aspects of the Neulasta® Label

The safety and effectiveness of Neulasta™ in pediatric patients have not been established.

The 6 mg fixed dose single-use syringe formulation should not be used in infants, children, and smaller adolescents weighing less than 45 kg. Adverse Effects of G-CSFs

► Injection site disconfort

► Bone pain (20 to 30%): no difference for filgastrim or Pegfilgastrim.

► AML/MDS ? Meta-analysis : 12000 patients 43 versus 22 AML/MDS (RR 1.92)

► Splenic rupture

► Increase Bleomycin-related pulmonry toxicity (26% vs 9%) Meta-analysis of Randomized Controlled Trials Relative risk of FN

Pegfilgrastim (Neulasta) 73%

Filgastrim (Neupogen) 57%

Lenogastrim (Granocyte) 63%

Pegfilgrastim (NF 11%) > Filgastrim (NF19%)

Lipegfilgrastim (Lonquex) 52 %

Pegfilgrastim = Lipegfilgrastim

Li Wang et al : Support Care Cancer. 2015; 23(11): 3131–3140. Efficacy of primary prophylactic G-CSF ( pegfilgrastim, filgrastim or versus placebo )

Aapro: Support Care Cancer. 2010 May; 18(5): 529–541. Efficacy of G-CSFs in preventing infection-related mortality, early mortality and febrile neutropenia

3,493 patients treated with chemotherapy for solid tumours or lymphoma.

Aapro: Support Care Cancer. 2010 May; 18(5): 529–541. Overview of the 6 EORTC recommendations (2010)

► Recommendation 1: Patient-related risk factors for increased incidence of FN and complications of FN*

► Recommendation 2: Chemotherapy regimens associated with increased risk of FN

► Recommendation 3: G-CSF to support intensive chemotherapy regimens**

► Recommendation 4: Impact of the overall FN risk on G-CSF use

► Recommendation 5: G-CSF in patients with existing FN

► Recommendation 6: Choice of formulation

* Note that this title has changed compared to the 2006 guidelines (patient- related risk factors for increased incidence of FN )

** Note that this title has changed compared to the 2006 guidelines (G-CSF to support chemotherapy) Recommendation 1 Patient-related risk factors for increased incidence of FN and complications of FN THE PATIENT: patient-related factors that may increase the risk of FN should be assessed before each chemotherapy cycle

► Age >65 years, advanced disease, previous episodes of FN or lack of G-CSF and absence of antibiotic prophylaxis ,Medical history, Disease characteristic

• Recommendation grade: B

•Addition: ‘Please note that the indiscriminate use of antibiotic prophylaxis for patients undergoing treatment for solid tumours or lymphoma is not recommended…’ FN Cumulative risk probability regarding the number of independant risk factors

Age>65 years Renal disease Cardio-vascular disease Hb< 12gr/dl Planing Dose IDR ≥ 80% No GCSF prophylaxis

Lyman GH et al. Oncol 2005;10:427-437 Primary Prophylactic CSF Administration: Special Circumstances

► When the following clinical factors are present, primary prophylaxis with CSF is often appropriate even with regimens with FN rates of <20% :

● Age >65 years ● Poor performance status ● Previous FN ● Poor nutritional status ● Open wounds or active infections ● More advanced cancer ● Extensive prior treatment, including large XRT ports ● Administration of combined chemoradiotherapy ● Cytopenias due to bone marrow involvement by tumor ● Other serious comorbidities Recommendation 2 Chemotherapy regimens associated with increased risk of FN

THE TREATMENT: consideration should be given to the elevated risk of FN when using certain chemotherapy regimens G- CSF should be administered after autologous stem-cell transplantation

• Recommendation grade: A/B (varies per regimen) Common chemotherapy regimens associated with intermediate or high risk of FN added in 2010

Malignancy FN risk category (%) Chemo regimen FN risk (%) NHL/CLL >20 R-ESHAP as salvage 33.5 after prior rituximab (R) NHL/CLL >20 Hyper CVAD + 11.5-24 with PP rituximab (Burkitt’s Lymphoma) ICE/R-ICE Stanford V Grade 3-4 neutrop 25% MOPPEB-VCAD Grade 3-4 neutrop 49% FC 35 FC 10% despite PP FCR Grade 3-4 neutrop 33.7% Common chemotherapy regimens associated with intermediate or high risk of FN added in 2010

Malignancy FN risk category (%) Chemo regimen FN risk (%) NHL/CLL 10-20 Dose adjusted 19% of cycles EPOCH 51 Mega CHOP-R- 15 Ara-C cyclophos- phamide (mantle cell) RGemP 61% grade 3/4 neutrop RGemOx (elderly) 43% grade 3/4 neutrop Hodgkin’s >20 BEACOPP >90% grade 4 Disease leukopenia 54% grade 3/4 neutrop 10% septic deaths Common chemotherapy regimens associated with intermediate or high risk of FN added / in 2010

Malignancy FN risk category (%) Chemo regimen FN risk (%) Hodgkin’s >20 ABVD (Hodgkin’s 4 Disease Lymphoma) CEC 48% grade 3/4 neutrop IGEV 28% grade 3/4 neutrop NHL R-CHOP/CHOP DA-EPOCH RICE/ICE HD IGEV Recommendation 3 G-CSF to support intensive chemotherapy regimens

THE PURPOSE OF THE TREATMENT: prophylactic G-CSF should be used to support chemotherapy:

► When dose-dense or dose-intense chemotherapy strategies have survival benefits : No other equally effective and safe regimen that does not require CSFs is available.

► If reductions in chemotherapy dose intensity or density are known to be associated with a poor prognosis • Recommendation grade: A Recommendation 4 Impact of the overall FN risk on G-CSF use

FROM RECOMMENDATIONS 1, 2 AND 3 ONE CONCLUDES: Prophylactic G-CSF is recommended if the risk of FN associated with chemotherapy is ≥20%

● Patient characteristics that may increase FN risk should be assessed in those receiving regimens associated with a 10–20% risk of FN • Recommendation grade: A Secondary Prophylactic CSF

► Secondary prophylaxis with a CSF is recommended for patients who experienced a neutropenic complication from a prior cycle of chemotherapy (for which primary prophylaxis was not received), in which a reduced dose or treatment delay may compromise disease-free or overall survival or treatment outcome. In many clinical situations, dose reduction or delay may be a reasonable alternative.

► Dose-dense regimens with CSF support should only be used if supported by convincing efficacy data or within a clinical trial. (There are limited and conflicting data on the value of dose-dense regimens with CSF support in non- Hodgkin lymphoma, and it cannot routinely be recommended.)

► CSFs should not be routinely used for patients with neutropenia who are afebrile. Recommendation 5: Treatment G-CSF in patients with existing FN

EXISTING FN: G-CSF treatment should be considered for patients with ongoing FN who do not respond to expert antibiotics management

● This may reduce the risk of infection-related mortality/morbidity in patients at impending risk of FN-related life-threatening infections, such as severe sepsis or septic shock

● CSFs should not be routinely used as adjunctive treatment with antibiotic therapy for patients with fever and neutropenia. Only if high risk for infection-associated complications or prognostic factors predictive of poor clinical outcomes.

• Recommendation grade: B Recommendation 6 Choice of formulation

WHICH G-CSF?: The use of filgrastim, lenograstim or pegfilgrastim is recommended to prevent FN or FN-related complications, where indicated ● While additional efficacy may be achieved with pegfilgrastim, this requires further clarification and there are few clinically important differences between the three agents • Recommendation grade: A

Filgrastim biosimilars are now also a treatment option in Europe.” There are several biosimilar G-CSFs approved in Europe

Biograstim®/ Filgrastim ratiopharm/ Ratiograstim®/ Tevagrastim®/ Zarzio®/ Nivestim®.

All these new products are manufactured in facilities with state-of-the-art technology. All products have passed the regulatory requirements for approval, mainly phase I and phase III, evaluations and studies on efficacy and safety.

However, there are still some concerns regarding their long-term evaluation, in particular, the limited experience at the time of approval of these products in terms of efficacy, safety and immunogenicity. For this reason, pharmacovigilance should be rigorous. A lot of work remains to be done in terms of clarification with regard to substituting a biosimilar G-CSF for the innovator product. Given that biosimilar products are not generic products, a switch from filgrastim to a biosimilar is considered a change in clinical management.”

Ultimately, only clinical trials and effective post-marketing pharmacovigilance will provide definitive evidence that a biosimilar is comparable to the originator- reference product in terms of efficacy and safety. PROPHYLACTIC APPROACH, NOT A REACTIVE ONE

STEP 1 Assess frequency of FN associated with planned chemotherapy regimen

FN risk ≥20% FN risk 10-20% FN risk <10%

Step 2 Assess factors that increase the frequency/risk of FN High risk Age >65 years

Increased risk (level I Advanced disease History of prior FN and II\ evidence) No antibiotic prophylaxis, no G-CSF use Other factors: Poor performance and/or nutritional status REASSESS AT 2010 (level III and IV Female gender EACH CYCLE addition evidence) Haemoglobin <12g/dL Liver, renal or cardiovascular disease

STEP 3 Define the patient's overall FN risk for planned chemotherapy regimen

Overall FN risk ≥ 20% Overall FN risk < 20%

Prophylactic G-CFS recommended G-CSF prophylaxis not indicated Post Haplo-transplant G-CSF therapy

CD4 levels / ml post transplant + G-CSF - G-CSF

Volpi et al. Blood 2001 Post haplo- transplant G-CSF therapy

IL-12 secretion

Volpi et al. Blood 2001 Effect of G-CSF on cellular immunity

Myelopoiesis CD3+CD4–CD8– cell Immunosuppression

CD11c– TH1¯ (IFN-g¯) IL-3Ra+ TH0 ® TH2 T lymphocyte G-CSFR– 3HdT (PHA, G-CSF iOKT3, alloAg) Type 2 dendritic cell

CD28RC Number Monocyte IL-10 G-CSFR+ IL-12 ¯ TNF-a¯ CD86 ¯ Pegfilgrastim and Filgrastim

PRIMARY PREVENTION OF NEUTROPENIC FEVER:

Cytotoxic chemotherapy Acute lymphoblastic leukemia and acute myeloid leukemia √ √ First line : Combined chemotherapy Non-hodgkin lymphoma (NHL), WHO classification histological type: √ with minimum 50 mg/m² follicular grade III lymphoma, Diffuse large B cell lymphoma (DLBCL), large doxorubicine 750 mg/m² cell anaplastic lymphoma, unspecified peripheral T cell lymphoma cyclophosphamide per cycle. (BEACOPP) Hodgkin √ SECONDARY TREATMENT AND PREVENTION OF NEUTROPENIC FEVER: : Cytotoxic chemotherapy and Hodgkin √ √ 1. neutropenia < 500/mm³ with fever >38°C; Non Hodgkin lymphoma (NHL) √ √ 2. neutropenia < 500/mm³ since 5 days Chronic lymphocytic leukemia √ √ Multiple myeloma √ √ TRAETMENT ONLY

Cytotoxic chemotherapy Other malignancies √ √ neutropenia <500/mm³ with fever > 38°C Filgrastim

SEVERE CHRONIC NEUTROPENIA with the 4 following criteria: - The patient must be more than 3 months old - The absolute neutrophile count is < 0,5 x 1.000.000.000/l, showed at three times in the six last months and responsible for repeated documented infections. - Bone marrow aspirate was performed to confirm the diagnostic and to exclude other causes of neutropenia - Other causes of neutropenia are excluded.

CONGENITAL SEVERE NEUTROPENIA With the 4 following criteria: - The absolute neutrophile count is < 0,5 x 1.000.000.000/l - The neutropenia is responsible for repeated documented infections - Bone marrow aspirate was performed to confirm the diagnostic and to exclude other causes of neutropenia - Other causes of neutropenia are excluded. Filgrastim

 AUTOLOGOUS STEM CELL MOBILIZATION

Acute lymphoblastic leukemia, acute myeloid leukemia, myelodysplastic syndrome in acute myeloid leukemia transformation, Hodgkin lymphoma, non-hodgkin lymphoma, chronic lymphocytic leukemia , multiple myeloma (choriocarcinoma,Testicular germinal tumor, ovarian germ line tumors, Ewing sarcoma, néphroblastoma, neuroblastoma) - For autologous stem cell mobilization, alone or after chemotherapy.

G-CSFs may be used in combination with to mobilize peripheral-blood progenitor cells after failure of G-CSFs alone.

 ALLOGENIC STEM CELL MOBILIZATION

- For allogenic stem cell mobilization on a selected donor II. Epoietins: synthetic erythropoïetins Cancer-Related Anemia *

 Chemotherapy/radiation therapy induced anemia

► Anemia of chronic disease

► Blood loss

► Bone marrow infiltration

► Nutritional deficiency

► Hemolysis

There is no evidence of increased response to erythropoietic proteins with the addition of oral iron supplementation (grade B). There is evidence of improved response to erythropoietic proteins with intravenous iron supplementation (grade B).

EORTC guidelines EUROPEAN JOURNAL OF CANCER 4 3 ( 2 0 0 7 ) 2 5 8 –2 7 0 Hillman (1992) Hb level (g/dL) 12 15 18 3 6 9 Normal Erythropoietin Production 10 1 Erythropoietin(plasma U) • • • • decreasedbyinflammatorycytokines Erythropoietinproductionis increasedbyhypoxia, progenitors Stimulatessurvivaland differentiation of liver. Producedin Glycoproteinof 34 10 and 2 trace amountsin Hb kidney( 10 Lacombe Lacombe (1998, 1999); Levels 3 kDa peritubular brain 10 4 Krantz interstitialcell) (1991); (1991); erythroid Bernaudin and (2000) is biochemically distinct from rHuEPO

rHuEPO Darbepoetin alfa 3 N-linked carbohydrate chains 5 N-linked carbohydrate chains Up to 14 sialic acid residues Up to 22 sialic acid residues 30,400 daltons 37,100 daltons 40% carbohydrate 51% carbohydrate

Increasing biological activity

Longer serum half-life

Egrie JC & Browne JK. Br J Cancer. 2001;84(suppl 1):3-10 rHuEPO: recombinant human erythropoietin Belgian Criterias for ARANESP and EPREX reimbursement

The two major goals of erythropoietic protein therapy are improvement of QoL and prevention of transfusions (grade A). There are no predictive factors of response to erythropoietic proteins that can be routinely used in clinical practice if functional iron deficiency or vitamin deficiency is ruled out; a low serum EPO level (in particular in haematological malignancies) is the only verified predictive factor of some importance. Values must be interpreted relative to the degree of anaemia present (grade B). EORTC guidelines EUROPEAN JOURNAL OF CANCER 4 3 ( 2 0 0 7 ) 2 5 8 –2 7 0 patients treated by myélosuppressive chemotherapy Hemoglobin level <11,0 g/dl. Exclusion and treatement of other causes of anemia. chemotherapy must not be curative : advanced/metastatic malignancy.

Target level of hemoglobin must not be > 12,0 g/dl.

The reimbursement authorization in this indication can be given maximum 2 times per 12 months and is valid only during chemotherapy treatment period until 4 weeks (included) after the end of treatment. What are the concerns with the use of ESAs ?

► Meta-analyses have demonstrated higher risks for thromboembolic events and negative effects on survival associated with ESA use when patients are treated to target hemoglobin levels >120 g/L

► A Canadian meta-analysis of 52 trials (n = 12,006) of ESA use in patients with cancer concluded that ESAs should not be used routinely as an alternative to blood transfusion in patients with CRA. However, data from subgroup analyses support the use of ESAs in certain patient groups. Analysis of patients with CIA and baseline hemoglobin<100 g/L (n = 2646) revealed no excess risk of mortality (RR 0.96, 95%CI 0.73, 1.26) In addition, in patients with CIA, baseline hemoglobin <100 g/L and a target hemoglobin <120 g/L (n = 289), the HR for mortality was not- significant (HR 0.77, 95%CI 0.36, 1.66). What are the benefits of ESAs in CIA ?

► In patients with CIA, ESAs have demonstrated significant benefits including decreased need for RBC transfusions and improvements in QOL

► ESA therapy led to significant reductions in blood transfusions in the overall group, and in the subgroup of patients with CIA and a baseline hemoglobin <100 g/L

Functional Assessment of Cancer Therapy (FACT) Bormanis J Critical Reviews in Oncology/Hematology 87 (2013) 132–139 Health Canada approved indications for ESA therapy in patients with CIA

Bormanis J Critical Reviews in Oncology/Hematology 87 (2013) 132–139 EPO in MDS

Myelodysplastic syndromes (MDS) patients are divided into a lower-risk group, in which apoptotic events in the marrow are prevalent and there is a defective response to (including erythropoietin), and a higher-risk group, in which a block in the maturation of marrow progenitors is the principal alteration. STAT5-defective activation after erythropoietin (EPO) stimulation

STAT5-defective activation after erythropoietin (EPO) stimulation was observed in parallel with conserved STAT5 phosphorylation upon stimulation with -3, and this was attributed to a disturbance in an early stage of the EPO signal transduction pathway. Predictive variables for ESA response in MDS Biological Endogenous erythropoietin levels 500 U/L Marrow blast <10% IPSS low-INT-1 Diagnosis of refractory anemia Normal karyotype

Clinical Transfusion independence Short duration of disease

2011 National Comprehensive Cancer Network guidelines for MDS , symptomatic anemia, in IPSS low or INT-1 MDS patients, the driving parameter, If EPO < 500U/L, the treatment of choice is EPO-alpha, 40,000–60,000 U, 1–3 times weekly subcutaneously (s.c.), or darbepoetin,150–300 g weekly s.c.

In cases of the presence of ringed sideroblasts or an absence of response, the addition of GCSF, 1–2 g/kg 1–3 times per week should be considered, immunosuppressive or hypomethylating agents when endogenous EPO levels are >500 U/L. Starting and ASCO recommendation modifying doses of ESA

► starting dose

► epoetin is 150 U/kg three times a week or 40,000 U weekly subcutaneously;

► darbepoetin is 2.25 g/kg weekly or 500 g every weeks subcutaneously;

► dose modification

► Discontinue ESA treatment when chemotherapy concludes.

► Increase dose to 300 U/kg TIW if no reduction in transfusion requirements or increase in Hb

► after 4 weeks of therapy to achieve and maintain lowest Hb level sufficient to avoid

► need for RBC transfusion

► Increase dose to 60,000 U SC weekly if no increase in Hb by 1 g/dL after 4 weeks of therapy, in the absence of a RBC transfusion to achieve and maintain lowest Hb level sufficient to avoid need for RBC transfusion

► Increase dose up to 4.5 g/kg

► if there is a 1 g/dL increase in Hb after 6 weeks of therapy

► Discontinuing Therapy for No Response

► Continuing epoetin or darbepoetin treatment beyond 6 to 8 weeks in the absence of response (eg, a 1 to 2 g/dL increase in Hb or no diminution of transfusion requirements) does not seem to be beneficial, assuming an appropriate dose increase has been attempted in nonresponders, and ESA therapy should be discontinued. Rizzo J.D. et al : JCO VOLUME 28 NUMBER 33 NOVEMBER 20 2010 Synthetic platelets growth factor: Thrombopoeitin analog (TPO)

Stem cell ► TPO is a potent endogenous TPO haematopoietic growth factor that

Bilineal progenitor cell plays an integral role in platelet production1–3 TPO ● Primarily produced in the liver1 Committed megakaryocyte progenitor cell ● Influences proliferation/differentiation 2 TPO of megakaryocytes ► Drives platelet production via the TPO Immature megakaryocyte receptor (TPO-R)3 TPO ► Decline in platelet mass causes an

Mature megakaryocyte increase in TPO levels to maintain platelet levels ● TPO levels usually remain elevated Platelets during any incident of persistent thrombocytopenia1

1. Kuter D, et al. Blood 2002; 100: 3456–69; 2. Kaushansky K. N Engl J Med 1998; 339: 746–54; 3. Wolber E, Jelkmann W. News Physiol Sci 2002; 17: 6–10. Figure adapted with permission from Kaushansky K. N Engl J Med 1998; 339: 746–54 TPO-R agonists

► A novel therapeutic class of agents for chronic adult ITP which stimulate platelet production: ● Bind and activate the TPO-R, helping to balance platelet production against destruction1 ® ► Agents include TPO peptide agonists (e.g. Nplate []) and TPO non-peptide agonists (e.g. Revolade [])1

TPO romiplostim Revolade

TPO-R

Cell membrane

Figure not to scale Kuter D. Blood 2007; 109: 4607–16 Romiplostim: peptide TPO-R agonist

► Romiplostim is a thrombopoiesis-stimulating recombinant protein, which is administered by subcutaneous injection1 1 ► Genetically engineered in Escherichia coli 2 ► Dipeptide linked to the Fc fragment of IgG (to increase the half-life) ► Stimulates megakaryopoiesis in the same manner as endogenous TPO3 ● Structurally unrelated to TPO3 ● Binds to same site on human TPO-R as endogenous TPO3 ● Competes with TPO for binding to TPO-R4

IgG, immunoglobulin G 1. EMA. NPlate Summary of Product Characteristics. Available from: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_- _Product_Information/human/000942/WC500039537.pdf [Accessed Oct 2011]; 2. Evangelista M, et al. Curr Drug Discov Technol 2007; 4: 162–73; 3. Kuter D. Blood 2007; 109: 4607–16; 4. Broudy V, Lin N. 2004; 25: 52–60; Figure reproduced with permission from: Bussel J, et al. New Engl J Med 2006; 355: 1672–82 Key features of Revolade

► Revolade is the first and only approved oral, small molecule, non-peptide TPO-R agonist1

► Selectively interacts with the transmembrane domain of the TPO-R1

● Binds to the transmembrane domain at a site distinct from the TPO binding site, and therefore does not compete with native TPO1

► Stimulates proliferation and differentiation of human bone marrow progenitor cells into megakaryocytes, resulting in increased platelet production Molecular weight: 442 D1

1. Erickson-Miller C, et al. Stem Cells 2009; 27: 424–30; Chronic ITP Pathogenesis: Impaired Platelet Production and Increased Platelet Destruction

► Impaired platelet production ● Autoantibodies may bind to antigens on megakaryocytes and their precursors that could result in extensive cell damage and ineffective thrombopoiesis1-5 ● Megakaryocytes in chronic ITP patients may Increased Bone Marrow have abnormalities that lead to apoptotic cell Megakaryocytes in chronic ITP* death2

► Increased platelet destruction ● Autoantibodies bind to platelet antigens6,7 ● Antibody-coated platelets are opsonized and prematurely destroyed by macrophages in the spleen and liver6,7

Macrophage Phagocytosing Platelets

1. Gernsheimer T. Blood Rev.2002;16:7-8. 2. Leissinger CA.Curr Opin Hematol.2001;8:299-305. 3. Houwerzijl EJ, et al. Blood.2004;103:500-506. 4. McMillan R, Nugent D. Int J Hematol.2005;81:94-99. 5. McMillan R, et al. Blood.2004;103:1364-1369. 6.Cines DB, Blanchette VS. N Engl J Med. 2002;346:995-1008. 7. Mead AJ, et al. Hematology.2003;8:345-357. *Image Credit: Maslak P. Immune thrombocytopenic purpura. ASH Image Bank 2004;2004:101214. Copyright American Society of Hematology. All rights reserved. Subject Incidence of Durable Platelet

Response

Durable platelet response is defined as achieving at least 6 weekly platelet Placebo Romiplostim responses (≥ 50 x 109/L) during the last 8 80 weeks of treatment in the absence of rescue (%) (%) 70 61 60 49 Response 50 38

40 Platelet 30

20 Durable Durable 10 5 0 2

Splenectomized Non-splenectomized Total Median ~3 μg/kg Median ~2 μg/kg Kuter et al. Lancet 2008;371:395–403 Frequent Side effects Romiplostim (Nplate) vs placebo

► Diziness 17% VS 0%

► Myalgia 14% VS 2%

► Abdominal pain 15% VS 0%

► Pain in extremitis 13% VS 5% Indications and Usage for Revolade

► Revolade is indicated for adult chronic immune (idiopathic) thrombocytopenic purpura (ITP) splenectomised patients who are refractory to other treatments (e.g. corticosteroids, immunoglobulins). Revolade may be considered as second line treatment for adult non- splenectomised patients where surgery is contraindicated.

► Revolade is indicated in adult patients with acquired severe aplastic anaemia (SAA) who were either refractory to prior immunosuppressive therapy or heavily pretreated and are unsuitable for haematopoietic stem cell transplantation.

Prescribing Information for Revolade. RAISE: Study Design

Standard of care Screening + N = 135 50 mg Revolade chronic ITP patients, Randomized ≥1 prior ITP therapy platelet count 2:1 Standard of care <30,000/μL N = 62 + Placebo

6-month treatment period

• RAISE is a phase III, randomized, double-blind, placebo-controlled study of Revolade once daily treatment for 6 months • Randomized patients were stratified by splenectomy status, concomitant maintenance ITP therapy, baseline platelet count ≤15,000/µL • Revolade dose adjustments were allowed (between 25–75 mg) • Reduction of concomitant medication and use of rescue treatments were allowed Cheng G, et al. Lancet. 2011;377:393–402. RAISE: Primary Endpoint Result: Odds of Achieving a Platelet Count between 50-400,000/µL

Odds ratio [99% CI] = 8.2 [3.59–18.73]; P<0.0001

BL 1 2 3 4 5 6 10 14 18 22 26 1 2 4

Cheng G, et al. Lancet. 2011;377:393–402. RAISE: Adverse Events in ≥10% of Patients in Either Treatment Group

Placebo Revolade Patients Experiencing Adverse Event, n (%) n = 61 n = 135 Any AE 56 (92) 118 (87) Headache 20 (33) 41 (30) Diarrhea 6 (10) 17 (13) Nausea 4 (7) 16 (12) Nasopharyngitis 8 (13) 14 (10) Upper respiratory tract infection 7 (11) 14 (10) Fatigue 8 (13) 13 (10) Limb pain 6 (10) 9 (7) Epistaxis 6 (10) 7 (5) Dizziness 6 (10) 5 (4) Edema peripheral 6 (10) 2 (1) Death 1 (2) 0 AE = adverse event

Cheng G, et al. Lancet. 2011;377:393–402. RAISE: Adverse Events of Special Interest

Placebo Revolade Patients Experiencing Adverse Event, n (%) n = 61 n = 135 Bleeding AEs On-therapy bleeding 19 (31) 26 (19) On-therapy serious bleeding 4 (7) 1 (<1) Post-therapy bleeding 6 (10) 6 (4) Thromboembolic AEs (on therapy) 0 2 (1) ALT ≥3x ULN 2 (3) 9 (7) Total bilirubin >1.5x ULN 0 5 (4) Cataracts 6 (10) 11 (8) Malignant disease 1(2) 1 (<1) Reoccurrence of thrombocytopenia 4 (7) 9(7)

AEs = Adverse events; ALT = Alanine aminotransferase; ULN = Upper limit of normal Cheng G, et al. Lancet. 2011;377:393–402. Six-Week Clinical Studies

• Study 773B (Phase 3) randomized 114 patients (2:1) to Revolade 50 mg or placebo

• Study 773A (Phase 2) randomized 117 patients (1:1:1:1) among placebo, 30 mg, 50 mg, or 75 mg of Revolade each administered daily

Primary Efficacy Outcomes : Platelet Count Response (≥50 x 109/L) Rates

Revolade Trial Placebo 50 mg Daily 773B 43/73 (59%)* 6/37 (16%) *P value <0.001 for Revolade versus placebo. 773A 19/27 (70%)* 3/27 (11%)

Prescribing Information for Revolade. Reimbursement criteria Nplate for ITP

Conditions related to previous therapies:

□ Splenectomy or Non splenectomized patient and the splenectomy contraindication is documented in a multidisciplinary meeting including a hematologist a surgeon and a anesthetist. and

□ < 30 x 109/L platelets despite steroids at 1 mg/kg/j during minimum 2 weeks, or □ if the platelets level decreases < 30 x 109/L during the tapering period of long term steroids treatment, or □ documented steroids intolerance or □ documented steroids contraindication

Conditions related to maximal dose:

Maximum dose:10 μg/kg/week No more than 16 weeks if the efficacy is not demonstrated by: a) A platelets count ≥ 30x109/L or b) A bubbling of the basal platelets count with improvement of bleeding episodes. Reimbursement criteria Revolade for ITP

Second line after failure of NPLATE (romiplostim)

No more than 8 weeks if the efficacy is not demonstrated by: a) A platelets count ≥ 30x109/L or b) A bubbling of the basal platelets count before REVOLADE with improvement of bleeding episodes. Thank you