DEPARTMENT OF HEALTH AND HUMAN SERVICES

UNITED STATES FOOD AND DRUG ADMINISTRATION

CENTER FOR DRUG EVALUATION AND RESEARCH

PULMONARY-ALLERGY DRUGS ADVISORY COMMITTEE

Monday, June 6, 2005

8:00 a.m.

5600 Fishers Lane

Room 1066

Rockville, Maryland

P A R T I C I P A N T S

Erik R. Swenson, M.D., Chairman

Teresa Watkins, R.Ph., Executive Secretary

MEMBERS:

Mark L. Brantly, M.D.

Steven E. Gay, M.D., M.S.

I. Marc Moss, M.D.

Calman P. Prussin, M.D.

Theodore F. Reiss, M.D., Industry Representative

Karen Schell, RRT, Consumer Representative

David A. Schoenfeld, Ph.D.

SGE CONSULTANTS AND GUESTS (VOTING):

Jeffrey S. Barrett, Ph.D.

Lawrence Hunsicker, M.D.

Allan R. Sampson, Ph.D.

Jurgen Venitz, M.D., Ph.D.

Mary Lou Drittler, SGE Patient Representative

GOVERNMENT EMPLOYEES (VOTING):

James Burdick, M.D.

Roslyn B. Mannon, M.D.

Michael A. Proschan, Ph.D.

John Tisdale, M.D.

FDA STAFF:

Mark J. Goldberger, M.D., M.P.H.

Renata Albrecht, M.D.

Marc Cavaille-Coll, Ph.D.

Arturo Hernandez, M.D.

Jyoti Zalkikar, Ph.D.

C O N T E N T S

Call to Order and Opening Remarks,

Erik R. Swenson, M.D. 4

Conflict of Interest Statement,

Teresa A. Watkins, R.Ph. 7

FDA Introductory Remarks,

Renata Albrecht, M.D. 8

Sponsor Presentation:

Introduction, Michael Scaife, Ph.D. 14

Current State of Lung Transplantation,

Jeffrey Golden, M.D., University of

California, San Francisco 20

Clinical Evidence of Efficacy and Safety,

Sarah Noonberg, M.D., Ph.D. 28

Statistical Considerations,

Ronald W. Helms, Ph.D.,

Rho, Inc.; University of North Carolina 59

Safety and Benefit-Risk,

Stephen Dilly, M.D., Ph.D. 65

Questions from the Panel 70

FDA Presentation:

Overview of Clinical Trial Efficacy and

Safety Evaluation Discussion of Analysis,

Arturo Hernandez, M.D. 88

Safety Considerations and Conclusions,

Marc Cavaille-Coll, M.D., Ph.D. 105

Statistical Evaluation,

Jyoti Zalkikar, Ph.D. 111

Questions from the Panel (Continued) 121

C O N T E N T S (Continued)

Open Public Hearing:

Esther Suss, Ph.D. 151

John C. Sullivan 156

Bill Stein 158

Renee Moeller 162

Charge to the Committee, Renata Albrecht, M.D. 163

Committee Discussion and Vote 168

P R O C E E D I N G S

Call to Order

DR. SWENSON: Good morning, everyone. I

am Dr. Erik Swenson, from the University of

Washington, and I will be chairing this session.

This is the meeting of the Pulmonary and Allergy

Drugs Advisory Committee and today we are going to

be discussing inhaled cyclosporine, a product to be

presented by Chiron.

Let me begin with just a few items to keep

us on schedule and for organizational purposes.

One, I would request that everyone with cell

phones, please turn them off or at least down to

some vibrating or some innocuous mode. Then, we

will go around and introduce everyone here at the

table. I would ask that when you are questioning

anything during this meeting to please identify

yourself first. The transcriber will need to know

who is speaking. We have microphones here. All

you need to do is simply push down "talk" to go

ahead and be heard but, please, turn it off when

you have finished. If we get more than three

microphones on at one time things get confusing.

Without any further ado, I am going to

turn the meeting over to Dr. Teresa Watkins for

some introductory comments.

Introduction of the Committee

DR. WATKINS: Let's first go around the

table, starting with Dr. Reiss, if you will

introduce yourself and your affiliations, please?

DR. REISS: My name is Ted Reiss. I am

vice president of clinical research at Merck

Research Labs. I am the non-voting industry

representative.

DR. BRANTLY: My name is Mark Brantly. I

am from the University of Florida. I am a

professor of medicine.

DR. TISDALE: My name is John Tisdale and

I am in the intramural program of NIDDK.

DR. PRUSSIN: My name is Calman Prussin.

I am a clinical investigator with National

Institute of Allergy and Infectious Diseases.

DR. MANNON: I am Roslyn Mannon and I am a

transplant nephrologist and medical director of the

intramural solid organ transplant program at NIDDK.

DR. GAY: I am Steven Gay, assistant

professor at the University of Michigan, associate

director of the lung transplant program and

director of clinical support services.

DR. HUNSICKER: I am Larry Hunsicker, from

the University of Iowa. I am a transplant

nephrologist and professor of medicine, and I am a

member of the Chemical Immunosuppression Advisory

Committee but guesting on this one.

DR. VENITZ: I am Jurgen Venitz. I am a

clinical pharmacologist and associate professor at

Virginia Commonwealth University.

MS. DRITTLER: I am Mary Lou Drittler. I

am a lung transplant recipient and I am a patient

representative from here, in Silver Spring.

DR. BURDICK: I am Jim Burdick. I am

director of the Division of Transplantation and

Healthcare System, HRSA and a transplant surgeon.

DR. MOSS: I am Mark Moss. I am an

associate professor of medicine at Emory University

and section chief at Grady Memorial Hospital.

DR. BARRETT: I am Jeff Barrett. I am a

clinical pharmacologist from the University of

Pennsylvania and Children's Hospital of

Philadelphia.

DR. PROSCHAN: I am Mike Proschan and I am

a statistician from the National Heart, Lung and

Blood Institute.

DR. SCHOENFELD: I am David Schoenfeld. I

am a biostatistician and professor of medicine at

Harvard Medical School and Massachusetts General

Hospital.

DR. SAMPSON: I am Allan Sampson,

professor of statistics, Department of Statistics

at the University of Pittsburgh.

MS. SCHELL: I am Karen Schell. I am a

respiratory therapist from Emporia Kansas, and I am

the consumer representative.

DR. CAVAILLE-COLL: I am Marc

Cavaille-Coll, medical team leader, Division of

Special Pathogen and Immunologic Drug Products.

DR. ALBRECHT: I am Renata Albrecht,

director, Division of Special Pathogen and

Immunologic Drug Products.

DR. HERNANDEZ: I am Arturo Hernandez, a

medical reviewer for FDA, Division of Special

Pathogens and Immunologic Drug Products, and I am a

transplant surgeon.

Conflict of Interest Statement

DR. WATKINS: With that, thank you.

Welcome everyone. I am now going to now read the

conflict of interest statement.

The following announcement addresses the

issue of conflict of interest with regard to this

meeting and is made a part of the record to

preclude even the appearance of such at this

meeting.

Based on the submitted agenda for the

meeting and all financial interests reported by the

committee participants, it has been determined that

all interests in firms regulated by the Center for

Drug Evaluation and Research present no potential

for an appearance of a conflict of interest at this

meeting.

With respect to FDA's invited industry

representative, we would like to disclose that Dr.

Theodore Reiss is participating in this meeting as

a non-voting industry representative acting on

behalf of regulated industry. Dr. Reiss' role on

this committee is to represent industry interests

in general and not any one particular company. Dr.

Reiss is employed by Merck.

In the event that the discussions involve

any other products or firms not already on the

agenda for which an FDA participant has a financial

interest, the participants are aware of the need to

exclude themselves from such involvement and their

exclusion will be noted for the record.

With respect to all other participants, we

ask in the interest of fairness that they address

any current or previous financial involvement with

any firms whose products they may wish to comment

upon. Thank you. With that, we will have opening

remarks from Dr. Albrecht.

FDA Introductory Remarks

DR. ALBRECHT: Thank you, Dr. Watkins.

Good morning, everybody. On behalf of the Division

of Special Pathogen and Immunologic Drug Products

and the Office of Drug Evaluation IV, I would like

to welcome everyone to today's meeting.

We wish to thank the members of the

Pulmonary Advisory Committee, the Chair, Dr.

Swenson, and our consultants for taking the time

out of their schedules to come to Rockville and

join us here to discuss this application. I also

wish to express our appreciation to Chiron and the

investigators for the time and effort that they

have put into developing this drug product and to

the Chiron staff for their willingness and

preparation for this advisory committee meeting. I

would also like to recognize the dedication of the

Division staff and the long hours they have put in

for reviewing this application.

Let me speak briefly about this new drug

application for cyclosporine inhalational solution

and why we are bringing this application to the

advisory committee. Could I have someone run the

slides? I apologize, there are some slides that go

with this presentation so that you may follow

along.

Let me continue. There are currently no

FDA-approved products for the prevention of chronic

rejection in patients with lung allografts. There

are approximately 1100 transplants done in the U.S.

annually and the survival at five years is lower

than survival in other organ transplants such as

heart, kidney or liver transplants. Prevention of

rejection and increase in survival are critical

and, therefore, there is a clear need for safe and

effective therapy.

Next slide. Chiron has submitted the NDA

for Pulminiq and requested that the cyclosporine

inhalational solution be approved for the increase

in survival and prevention of chronic rejection in

lung transplant patients. The drug development

program and the NDA for this product are not

conventional. Unlike applications for

immunosuppressants in kidney, heart of liver

transplants for example, this NDA contained results

from one single Phase II study conducted at one

center. This trial enrolled 66 patients out of a

planned 136 patients. However, we learned that

there was a survival advantage, 88 percent survival

in patients who received aerosolized cyclosporine

plus a tacrolimus-based systemic immunosuppressive

regimen compared to 53 percent survival in patients

receiving aerosolized propylene glycol vehicle in

addition to a tacrolimus-based systemic

immunosuppressive regimen.

Therefore, the agency agreed to file and

review this NDA application. Based on the NDA

review of the information in the application, we

were unable to conclude that the observed

difference in survival and chronic rejection was

due to study drug. Therefore, we determined it was

important to bring this application to the advisory

committee for the following reasons:

This would represent the first drug for

immunosuppression in patients with lung

transplantation to garner FDA approval. This is a

new drug application. Although oral and systemic

cyclosporine are well characterized, cyclosporine

inhalational solution is a new formulation of

cyclosporine. It is seeking a new indication. It

is administered by a new route and it requests a

new dosage regimen. As I mentioned, we weren't

able to conclude that the differences in chronic

rejection and survival were due to the study drug.

For these reasons, we determined it was important

to have this application discussed in an open

public forum.

We have asked the help of the pulmonary

product advisory committee because it is a standing

committee with expertise in pulmonary disease. We

have invited experts in statistics and

transplantation to help with the deliberation, and

we are very much interested in the committee's

input regarding the adequacy of the clinical and

statistical evidence whether aerosolized

cyclosporine is safe and effective for the proposed

indication.

This morning Chiron will present most of

the background information, starting with Dr.

Michael Scaife's presentation on the drug

development program. Then Dr. Jeff Golden will

provide an overview of lung transplantation. Dr.

Sarah Noonberg will discuss the results of the

efficacy study, followed by Dr. Steven Dilly's

presentation and Dr. Ron Helms' views.

The FDA presentation will follow the

Chiron presentations and we will focus on those

areas that proved challenging during the course of

the review. Dr. Arturo Hernandez will discuss the

study design, various clinical issues and outcome

demographic characteristics and dosing. Dr. Marc

Cavaille-Coll will provide a summary of the safety

issues and Dr. Jyoti Zalkikar will give the

statistical presentation.

Then, in the afternoon, we would like you

to discuss, give advice and vote on a few

questions. So, as you listen to the presentations

this morning, please keep these questions in mind

for later discussion. The first question: Is

there sufficient information to make the

determination whether the observed survival

difference in study ACS001 is due to study

treatment or some other factors?

In your deliberations, we will ask you to

recall the statistical issues that were raised by

the application; differences in baseline donor and

recipient characteristics; whether the product

demonstrated an effect on various clinical outcomes

or things such as acute rejection, bronchiolitis

obliterans syndrome, obliterative bronchiolitis.

Depending on whether you conclude that the

answer is yes or no, we have a few additional

questions, namely, if the answer is yes we would

like you to talk about the generalizability or,

more specifically, the labeling issues that you

would recommend be put into a product label. If

the answer is no we would like you to consider what

additional studies you would recommend be

conducted. In these discussions we would also like

you to give us some suggestions regarding patient

population, drug dosing regimen, as well as

efficacy and endpoints that could be included in

such studies.

The next question would be whether the

safety of the product has been adequately

characterized for its intended use. Again, in this

particular question we would like you to also

consider the amount of preclinical and clinical

information that is available in this application;

infection about the cyclosporine and the vehicle,

as well as the number of patients who have been

exposed to the proposed dosage regimen.

If the answer to this question as well as

the preceding one is yes, then we would like you to

give us suggestions about what population the

product should be labeled for; what information we

should include in labeling on dosing regimen, dose

preparation and administration, dosing intervals

and duration of treatment. In addition, if you

could give us guidance on what should be included

in the labeling regarding the expected benefit on

acute rejection, BOS, OB and so forth. If your

answer to the latter question is no, then we would

like you to give us some advice about what

preclinical and clinical information would be

needed.

With that, thank you and I will turn it

back to Dr. Swenson.

DR. SWENSON: Thank you, Dr. Albrecht. We

will proceed now with the sponsor presentation and

I would like Dr. Michael Scaife to go ahead and

begin this, and I will let him introduce his

colleagues and their different presentations.

Sponsor Presentation

Introduction

DR. SCAIFE: First of all, good morning,

ladies and gentlemen. My name is Michael Scaife.

On behalf of Chiron, I would like to thank the FDA

as well as members of the advisory panel for this

opportunity today to present to you on the safety

and efficacy of an inhalable form of cyclosporine

that will be referred to throughout the talk as

either CyIS or the product's trade name, Pulminiq.

The first point I would like to make is

that currently in the United States there are no

drugs or combination of drug therapies approved for

the treatment of chronic rejection following lung

transplantation. The prognosis for these patients

is really poor. Despite aggressive care, only 45

percent of lung transplant recipients will be alive

five years following transplantation. This is much

worse than for other solid organ transplant

recipients. This is an orphan population in the

U.S. On average less than 1100 lung transplants

are performed each year.

We are here today to talk about certain

aspects of Pulminiq, a medication that is an

aerosolized form of cyclosporine dissolved in an

inert vehicle, propylene glycol. As you all know,

cyclosporine is not a new chemical entity.

Cyclosporine was approved by the FDA in 1983 and

currently has been approved in most countries of

the world. It is available in oral, IV and ocular

forms. In the U.S. it has been approved for the

prophylaxis of allogeneic heart, liver and kidney

graft rejection, and for the treatment of

refractory rheumatoid arthritis and plaque

psoriasis. In Europe cyclosporine is also approved

for use following bone marrow and pancreatic

transplantation, as well as for a variety of

immune-modulated pathologies such as nephrotic

syndrome, atopic dermatitis and Bessay syndrome.

Pulminiq is simply an inhalable form of

cyclosporine so, in essence, we are here today to

talk about a well-known drug given by a new route

of administration to enable delivery to the

required site of action. As I mentioned, Pulminiq

is a simple formulation consisting of cyclosporine

dissolved in propylene glycol, with no other

ingredients. Propylene glycol is also not new to

pharmaceutics. Since the initial inhalation tox

studies of propylene glycol in the '40s it has been

widely used as a compounding agent for intravenous

and oral pharmaceuticals, as well as foods. In

fact, it is currently listed by the FDA as an

approved inactive ingredient for use in inhalation

products.

Several preclinical inhalation studies

have been performed both with Pulminiq as well as

with the vehicle alone. Specifically, you will see

in the briefing book that we make mention of two

one-month studies in the rat and the dog and a

three-month study in the rat. I won't go into the

specific details but, as you will see, doses given

in those animals were in multiples 15, 17 times the

dose that we expected in man. The

histopathological findings again are detailed in

the book. You will find that aside from some small

punctate findings in the larynx in a few of the

animals, there were no long-lasting changes and, in

our view, the results are not significant.

How did Chiron first become aware of the

work on inhalable cyclosporine at the University of

Pittsburgh Medical Center, which we will refer to

from now on as UPMC? Well, in fact, from a sales

rep who was detailing our inhalable topromycine

product, TOBI, which is used for the treatment of

pseudomonas infections in cystic fibrosis patients.

The slide here details the development

activities at UPMC. The preclinical study started

in '88, followed in '91 by human studies in lung

transplant patients with chronic rejection. In '97

UPMC started a randomized, double-blind,

placebo-controlled study of cyclosporine that ended

in August, 2003. The results of this and other

studies will form the discussion of today's

meeting.

You may ask why did Chiron want to acquire

the rights to develop this product. Well, we

looked at the results of 15 years of work at one of

the largest lung transplant centers in the U.S. We

asked ourselves the same questions, frankly, and

had the same concerns as anyone would have had. It

is a single-center study. It was being conducted

by a single lead investigator. Has the study been

conducted appropriately? Are the data robust? Are

the striking effects seen on survival benefit real?

And, if so, are they due to cyclosporine or some

other factor or factors?

We did our initial due diligence of the

data and how it had been collected and we concluded

that the effect is real. Based upon our

conviction, we acquired the right to file an NDA

for the product. As you know, the FDA encourages

the filing of applications for products that

address a clear unmet medical need with a

demonstrated significant clinical benefit and an

acceptable safety profile. We went to UPMC and we

extensively audited the hospital records. We went

in and we collected all of these data on

standardized forms, and we analyzed the data in

every possible manner, as you will hear later.

In may, 2004 we met with the FDA. We

posed a very simple question, would the agency

consider the positive findings from one clinical

study, conducted by one principal investigator to

be registerable? The FDA response, and I think Dr.

Albrecht referred to it so she will forgive me for

paraphrasing I hope, was assuming that the data are

robust--and I happily stress the word "robust"--we

encourage you to file. It is rare for us at the

FDA to be provided with significant survival data

for such a product. Based upon this positive

meeting, Chiron filed an NDA for Pulminiq in

October, 2004.

I would like to acknowledge the

collaborative position taken by the FDA throughout

the NDA process. We have been encouraged to

maintain a dialogue with the reviewers and it is in

this spirit that we are here today.

The finding was accepted by the FDA and

priority review status was granted in December,

2004. Ladies and gentlemen, Chiron is here today

because we believe the data on survival benefit are

real and clinically relevant, as well as

statistically significant. We will present data

that confirm that CyIS is safe and efficacious for

the requested indication, which is to increase the

survival and prevent chronic rejection in patients

receiving allogeneic lung transplants in

combination with standard chronic immunosuppressive

therapy.

With that, I would like to introduce to

the panel and the audience the agenda for the

Chiron presentation as well as the speakers, their

background and affiliation. The first speaker is

Dr. Jeff Golden who is professor of clinical

medicine and surgery at the University of

California in San Francisco. Dr. Golden is also

the medical director of the lung transplant program

at UCSF.

We have asked Dr. Golden to speak to you

today for two main reasons, firstly, because he is

an eminent practicing physician and scientist who

actually treats and cares for lung transplant

patients, as well as being an active researcher

into the mechanisms of acute and chronic lung

rejection phenomena. Secondly, because he was not

involved in the study and we wanted his independent

views on the clinical findings. Dr. Golden will

address the current status of lung transplantation.

He will be followed by Dr. Sarah Noonberg

who is the clinical leader at Chiron for this

project. Dr. Noonberg will present to you the

clinical evidence for the efficacy and safety of

CyIS.

Dr. Noonberg will be followed by Dr. Ron

Helms, an emeritus professor of statistics at the

University of North Carolina. Why did we ask him

to be here today? As statisticians and physicians

have analyzed the data from every possible angle

and found the positive effect of Pulminiq on

survival to be clinically as well as statistically

robust, the FDA statisticians expressed some

concerns about our analyses and so we asked Prof.

Helms to look at our approaches, assumptions and

methodologies, as well as those of the FDA

reviewers, and to let us have his candid opinion.

He will share those views with you today.

The final presentation by Chiron will be

given by Dr. Stephen Dilly. He is the chief

medical officer for Chiron BioPharmaceuticals. He

will review the case for approval of Pulminiq

including a discussion of our proposed postapproval

study. We will then hand over the meeting to the

Q&A session that will be moderated by myself.

Finally, we have a list of additional

experts, both internal and external. I would like

to make the special point that we have the pleasure

of having Dr. Trulock here who is a world renowned

expert on lung transplantation and, again, as you

know, you are free to ask any of our experts for

additional information. With that, I would like to

hand over to Dr. Golden. Thank you very much.

Current State of Lung Transplantation

DR. GOLDEN: Thanks. I am extremely

delighted to be here as somebody who takes care of

patients after transplantation. I am here really

to give an overview of the current state of lung

transplant.

Just a brief statement about myself, about

15 years ago I helped start a lung transplant

program at the University of California in San

Francisco. In the past few years we have been

doing about 30 transplants a year, and this year we

are on a pace for 40 transplants. Just to give you

a perspective, this puts us in about the top 10

percent in terms of volume of annual transplants in

the world.

About two years ago I was asked to visit

Chiron and give a review of lung transplant. At

that time I was first shown some data from the

University of Pittsburgh on aerosolized

cyclosporine. Subsequently, as some of you may

know, I did attend the first FDA meeting in 2004

where I similarly presented an overview of lung

transplant. Well, I am back and actually nothing

has changed.

I would like to summarize on the next

slide the main points in terms of where we are in

lung transplant. First, the long-term survival of

lung transplant is 50 percent by five years. This

is a poor survival. Second, bronchiolitis

obliterans, or chronic rejection, is the primary

cause of this poor survival. Third, the future of

lung transplant really demands that we learn how to

prevent bronchiolitis obliterans.

By way of history, before cyclosporine

there had been approximately 40 lung transplants in

the world. Looking at their survival, the median

survival was somewhere around 10 days. One patient

lived 10 months. After the introduction of

cyclosporine there were one-year survivals, such

that eventually there was 75 percent one-year

survival in lung transplant. With this large

improvement compared to the pre-cyclosporine era,

the interest in lung transplant really took off.

As you can see from this slide, early on

in 1985 there were about a dozen transplants and as

of 2003 there are somewhere around 1700 transplants

in the world, about 1100 in the United States.

These are done for various recipient categories you

see listed here. Approximately half are for

emphysema or alpha-1 antitrypsin deficiency, cystic

fibrosis, and another large area is idiopathic

pulmonary fibrosis. Although in this registry

analysis it is 17 percent, at UCSF 60 percent of

our lung transplant patients have idiopathic

pulmonary fibrosis, a disease for which there is no

therapy and a disease that has a five-year

survival, somewhat similar to lung cancer.

However, despite this increased one-year

survival and this tremendous increase in the number

of transplants done around the world, we are,

unfortunately, still stuck at a low 50 percent

survival of around 4.5 to 5 years. Although one

might say emphysema has a slightly better outlook

at 4 and 5 years than idiopathic pulmonary

fibrosis, in general lung transplant survival is

about 50 percent at 4.5 to 5 years.

To give you some perspective, if you look

at kidney transplant at that interval of 4.5 years

after transplant there is 90 percent survival. And

if you look at heart and liver transplant it is

about 75 percent survival. Not only do we have

this 50 percent survival at 4 to 5 years, but this

has not changed in almost 20 years. We have

plateau'd in terms of poor survival in that period

of time.

As I say, the problem responsible for this

poor mortality clearly is bronchiolitis obliterans.

In this histology section, with an artery here, the

obliterative lesion that is established as a

fibroplastic plug diminishes the airway diameter

such that, instead of being this size, it is

reduced and constricted down to this tiny lumen

here secondary to this fibroproliferative process

of the lesion of bronchiolitis obliterans.

Bronchiolitis obliterans or chronic

rejection is diagnosed in two ways, histologically

through a transbronchial biopsy or clinically. The

problem with the histologic diagnosis of a

transbronchial biopsy is that it is a specific

finding but it is not very sensitive.

Transbronchial biopsy is simply not sensitive

sufficiently to diagnose this chronic airway

process. Therefore, over the years we have

developed a clinical diagnosis in the absence of a

histologic finding on the transbronchial biopsy

such that we look at specific decrease in air flow

when there is no alternative cause, and we label

this bronchiolitis obliterans syndrome.

It is important to stress that

obliterative bronchiolitis and bronchiolitis

obliterans syndrome, or BOS, are really histologic

and clinical manifestations of the same airway

process. Patients develop progressive shortness of

breath with this graft failure, progressive airflow

obstruction and recurrent pulmonary infections.

Regrettably, once this chronic rejection develops

the airway damage is progressive and irreversible

and patients die of graft failure and related

infections.

The registry for transplant would say that

somewhere around 5 years the percent of patients

dying from different etiologies would be

bronchiolitis obliterans about 30 percent, but

actually you cannot separate this from infections

which are always present in the setting of this

airway damage. Furthermore, in this registry

setting where they describe organ failure, that is

obviously bronchiolitis obliterans. So, when you

add up these categories of bronchiolitis obliterans

organ failure and related airway infections,

including pseudomonas, aspergillus, etc., let me

simply state that bronchiolitis obliterans

complications relate to the vast majority of deaths

at 4.5 to 5 years after lung transplantation.

No matter what we have done in the last 18

years, we have not prevented this development of

chronic rejection, this airway process, whether we

give tacrolimus, different combinations of

cyclosporine, micofenolate, azathioprine,

prednisone and, in fact, I could put rapomyacin up

there and various other lytic therapies and various

approaches to prednisone pulses for acute

rejection, etc. Despite all this systemic

immunosuppression, we really have not changed the

incidence of chronic airway rejection closely

related, unfortunately, to the poor survival at 4.5

to 5 years.

We now appreciate that there are

non-immune factors that relate to airway damage, be

these infection or reflux disease. These

non-alloimmune factors clearly relate to immune

activation. In fact, I believe we are now

understanding that when we see chronic airway

rejection and we increase systemic

immunosuppression we actually are helping to

promote such non-alloimmune factors, especially

infections which cause further airway immune

activation and actually make the process worse.

We have always known that there are

alloimmune factors such as acute rejection that

relate to damage of the organ. We are now

appreciating these non-alloimmune factors, again,

be it early airway damage with transplant, various

infections, reflux disease which is a very new

concept in terms of what injures the airway--that

these non-alloimmune stimuli, in consort with

alloimmune rejection, together damage the graft

leading to progressive, additive epithelial injury,

inflammation and fibroblastic repair culminating in

the picture I showed you of bronchiolitis

obliterans.

One newer concept in terms of immune

factors is called lymphocytic

bronchitis/bronchiolitis. One might call it airway

rejection. This histology reveals lymphocytic

bronchitis/bronchiolitis and airway disease wherein

you have submucosal lymphocytes working their way

into the mucosa. Let me point out that lymphocytic

bronchitis/bronchiolitis has been highly related to

the subsequent development of the more fibrotic

bronchiolitis obliterans. This concept of an

airway inflammation based on immune reaction in the

airway, lymphocytic bronchitis, was not on the

radar screen 15 years ago when the concept of

inhaled cyclosporine was conceived.

We have always known that acute rejection

is one of the factors that relates to the

subsequent development of bronchiolitis obliterans.

However, I want to separate out the airway process

from acute rejection which is a perivascular

process diagnosed by transbronchial biopsy. I

should emphasize that a transbronchial biopsy has

variable adequacy for obtaining small airway

samples to diagnose whether it is bronchiolitis

obliterans or the early airway inflammation of

lymphocytic bronchitis.

If I was designing a study today of any

inhaled immunosuppressant therapy I would try to

learn more about the biology of the airways. We,

at UCSF, and some other institutions have been

doing endobronchial biopsy. This is not standard

but we are learning a lot more about the airway

biology in terms of lung transplantation.

On my last slide I want to just emphasize

that although I might expect systemic

immunosuppression to clear up a perivascular

process, I am suggesting that bronchiolitis

obliterans, chronic rejection, is an airway process

and it makes eminent sense to employ inhaled

cyclosporine to treat the epithelium. It is clear

now that the epithelium is key to the development

of bronchiolitis obliterans. Bronchiolitis

obliterans is an airway disease.

Just to finish, my colleagues in the lung

transplant world are very excited about the

potential benefit of inhaled cyclosporine. As I

say, the epithelium is key and it makes eminent

sense to develop a system of local immune

suppression to the airway and the mucosa. Frankly,

given the poor survival of our transplant

recipients which, as I already mentioned, has not

changed in almost 20 years, I personally feel that

inhaled cyclosporine fulfills an unmet need.

I questioned whether I was going to say

the following but I think I will. On a personal

note, for people like myself who take care of these

patients, who see them terribly short of breath in

various diagnostic categories who go on to have a

lung transplant and then regain a normal life,

including family life, going back to work--to all

of a sudden see these patients once again slowly

develop progressive airway rejection, chronic

rejection and shortness of breath is extremely

disheartening to the patients, to say the least,

their family and, frankly, for their physicians.

Thank you for your attention.

Clinical Evidence of Efficacy and Safety

DR. NOONBERG: Good morning. My name is

Sarah Noonberg and I am the clinical leader for the

inhaled cyclosporine project. Over the next 45

minutes I will be reviewing the clinical data

supporting the use of inhaled cyclosporine in lung

transplant recipients.

I will begin with a brief discussion of

early preclinical and open-label clinical trials of

inhaled cyclosporine at UPMC. These trials

generated a lot of interest in inhaled cyclosporine

and really set the stage for the pivotal

randomized, double-blind, placebo-controlled trial

which we, at Chiron, refer to as ACS001.

I will then describe the study design and

baseline characteristics of patients in ACS001

before moving into a discussion of efficacy,

focusing primarily on the endpoints of survival and

chronic rejection. I will then switch gears and

summarize the safety data that has been generated

for inhaled cyclosporine from a safety database of

102 patients. Although the favorable safety

profile is clearly an important aspect of the drug,

I am going to be spending much less time reviewing

safety listings as this is an area of general

agreement with the FDA.

Finally, as with all studies, there are

limitations to ACS001 both with respect to study

design, as well as choice of the primary endpoint.

I am going to end this presentation with a

discussion of some of those limitations and how we

view them in light of the clear strengths of the

study.

As Dr. Golden has described, the

introduction of cyclosporine as an

immunosuppressant truly revolutionized lung

transplantation and allowed for the possibility of

long-term survival. Within a few years of FDA

approval investigators at UPMC began to develop an

aerosolized formulation, and within five years they

initiated preclinical trials.

In the first set of experiments

non-transplanted dogs were given a single dose of

inhaled cyclosporine. The dose was well tolerated

and revealed that pulmonary concentrations were

10- to 100-fold higher than concentrations in other

tissues. In addition, there was no change in lung

function and no histologic abnormalities.

In a canine lung transplant model dogs

were given single agent immunosuppression with

inhaled cyclosporine and investigators reported a

dose-dependent decrease in the frequency and

severity of allograft rejection.

In a rat transplant model rats were given

an identical dose of either inhaled cyclosporine or

intramuscular cyclosporine. Inhaled cyclosporine

was found to be at least as effective as

intramuscular cyclosporine in causing a

dose-dependent decrease in proinflammatory cytokine

production, as well as a decrease in allograft

rejection but with far lower systemic exposure to

cyclosporine.

These encouraging preclinical results led

to the development of a series of open-label

non-comparative trials with inhaled cyclosporine at

UPMC. These trials enrolled two different groups

of patients, both with established complications of

lung transplantation. In the first set of

protocols lung transplant recipients with

documented chronic rejection were given inhaled

cyclosporine in addition to their standard

immunosuppressive regimen. Investigators reported

improvement in rejection histology and

stabilization of pulmonary function relative to

pre-enrollment data. But, more importantly, these

patients had improved survival both compared to

contemporary UPMC unenrolled controls as well as

controls from a historical lung transplant

registry.

In the next set of protocols patients with

refractory acute rejection, defined as acute

rejection that failed to respond to

immunosuppressive intensification--this represents

a step earlier in the disease process as acute

rejection--as a risk factor for the subsequent

development of chronic rejection and was the

logical next population to study. When these

patients were given inhaled cyclosporine, again, in

addition to their standard immunosuppressive

regimen, investigators reported an improvement in

rejection histology, a reduction in proinflammatory

cytokine production, and a dose-dependent increase

in pulmonary function, all relative to

re-enrollment data. Once again, these patients had

improved survival compared to contemporary UPMC

unenrolled controls.

Despite the non-comparative nature of

these trials and their inherent limitations, they

made quite an impact in the transplant community,

and have led to unregulated compounding of inhaled

cyclosporine by a number of U.S. transplant

centers. In a survey of 2002, published in Chest,

of transplant practices 10 percent of U.S.

transplant centers already used inhaled

cyclosporine. They compound it in their pharmacies

and they give it to patients with progressive

chronic rejection.

These open-label trials were clearly

provocative but their interpretation is limited by

the lack of an adequate control group. However,

they laid the framework for the very first and one

of the only randomized, double-blind,

placebo-controlled trials in the lung transplant

population. Unlike the previous protocols that

enrolled patients with established complications of

lung transplantation, this trial was designed to

test the efficacy of inhaled cyclosporine in

preventing rejection and improving outcomes when

given prophylactically to patients shortly after

their single or double lung transplant procedure.

The trial had two phases. In a pilot

phase, the first phase, 10 patients were given

open-label inhaled cyclosporine and were followed

prospectively. They formed a cohort designed to

test the safety and tolerability of the drug in

this patient population. In the second phase, the

randomized phase, 58 patients were randomized and

56 were randomized and treated with either inhaled

cyclosporine or placebo, which in this case was

inhaled propylene glycol, the vehicle used to

create the inhalation solution. The primary

endpoint of the study was rate of acute rejection,

and secondary, prospectively defined endpoints of

survival, rate of chronic rejection and pulmonary

function.

The criteria for enrollment into ACS001

were fairly straightforward. To be included, you

had to be a recipient of a single or double lung

transplant and be 18 years of age or older.

Exclusion criteria included the presence of active

fungal or bacterial pneumonia or anastomotic

infections prior to the initiation of appropriate

antimicrobial therapy. Patients with bronchial

stenosis greater than 80 percent had to be treated

with standard techniques prior to enrollment.

Patients who failed to wean from mechanical

ventilation and women of childbearing potential

unwilling to use birth control were also excluded.

It is important to note that all patients met study

inclusion and exclusion criteria.

All patients in ACS001 were treated with

standard-of-care immunosuppressive therapy

following transplantation, and all were randomized

and enrolled within the first 7-42 days following

their transplant surgery. A total of 26 patients

were treated with inhaled cyclosporine and 30 were

treated with placebo. All patients underwent an

initial 10-day dose escalation period where they

were initiated on low dose inhaled cyclosporine at

100 mg, and that dose or equivalent volume of

placebo was gradually increased to a maximally

tolerated dose up to a protocol-specified maximum

of 300 mg. The dose or equivalent volume that they

reached on day 10 was the dose that they continued

3 times a week for a period of 2 years.

After completion of dosing patients

continued to be followed for study endpoints up to

the study end date of August 21, 2003. This

corresponded to 2 years after the last patient was

enrolled and, therefore, could complete their

2-year period of dosing. Therefore, the total

length of follow-up per patient depended on the

timing of enrollment and ranged from 24 months for

the last patient enrolled up through 56 months for

the first patient enrolled.

ACS001 was a randomized trial, and the

randomization scheme was developed by the

Department of Statistics at the University of

Pittsburgh. The randomization was stratified by

CMV mismatch, defined as donor positive/recipient

negative, versus all other combinations. This was

chosen because international registry data has

demonstrated that patients with CMV mismatch have a

32 percent increased relative risk of death in the

first year compared with other combinations, with a

p value of less than 0.0001. Therefore, the

assertion that the randomization was not stratified

by any variables known to affect outcome is

incorrect. The randomization was also stratified

by enrollment period and distinguishes patients who

generally had a less complicated postoperative

course, were stable and met exclusion criteria by

7-21 days versus those that had a relatively more

complicated postoperative course and met exclusion

criteria and were stable between 22 and 42 days

after the surgery. In line with ICH guidelines, it

is impractical and often counterproductive to

stratify by more than 2 factors in a study of this

size.

This slide illustrates the baseline

characteristics of patients enrolled in ACS001.

Overall, the two groups were well matched with

respect to the majority of relevant baseline

demographic characteristics. Donors were similarly

well matched for clinically relevant variables.

However, as can be expected from any randomized

study, there were a few important imbalances. The

two variables where clinically relevant imbalances

existed were with respect to primary diagnosis and

transplant type.

As Dr. Golden has demonstrated, the

primary diagnosis leading to transplantation can

have an important impact on survival. Patients

with COPD have traditionally been associated with

better outcomes, especially within the first year,

and this is statistically significant. Nearly

twice as many placebo patients had this more

favorable diagnosis. In addition, patients with

idiopathic pulmonary fibrosis or IPF have

historically had among the worst survival, both

short-term and long-term, and this is statistically

significant at one year and at five years, and

there were far more patients with IPF in the

inhaled cyclosporine group compared to placebo.

Both of these factors together could potentially

bias results for better outcomes in the placebo

group.

By contrast, double lung transplant

recipients have historically had marginally

improved survival compared to single lung

transplant recipients in the first several years,

and this difference becomes increasingly pronounced

with time but is not statistically significant at

one year or at five years, the time period of

interest for ACS001. However, there were more

double lung transplant recipients in the inhaled

cyclosporine group and this could potentially bias

results towards better outcomes in the inhaled

cyclosporine group. Therefore, although imbalances

exist, they are split between groups and would not

be expected to strongly influence results in one

direction or the other.

The protocol specified that patients were

to continue study drug for a period of two years.

However, due to the nature of the patient

population with its high mortality rate, frequent

complications and frequent hospitalizations, not

all patients could complete the two-year period of

dosing and this is not surprising. Roughly

two-thirds completed at least one year of therapy

and roughly half completed the full two years of

therapy. As the protocol specified that dosing

should be held temporarily in the presence of an

infection not responding to treatment, not all

patients had each and every one of their scheduled

doses. However, this just reflects the protocol

rather than any lack of compliance.

The median duration of dosing was

comparable among the two groups. Of the patients

that did prematurely discontinue dosing, the

primary reasons were adverse events in the placebo

group and withdrawal of consent in the inhaled

cyclosporine group. Of the six who withdrew

consent, two were due to early tolerability

problems; two were primarily due to unrelated

medical problems; and one was due primarily to an

unrelated social problem and for one the reason was

unknown.

Although no patients were lost to

follow-up, five patients, three in the inhaled

cyclosporine group and one in the placebo group,

were taken off the study, the randomized trial, and

crossed over into an open-label rescue protocol of

inhaled cyclosporine. Their data was censored at

the time of crossover and the treatment groups

remained blinded. In both groups there were

patients that were withdrawn due to protocol

deviations and violations that largely included

medical non-compliance and smoking.

This slide summarizes the important

efficacy and safety results from study ACS001.

Treatment with inhaled cyclosporine led to

significantly improved survival and chronic

rejection-free survival compared to placebo but did

not affect the rate of acute rejection. Treatment

with inhaled cyclosporine was not associated with

increased risk of nephrotoxicity, infections,

malignancies or any systemic toxicities known to

occur when cyclosporine is given orally or

intravenously. However, similar to other inhaled

drugs, inhaled cyclosporine was associated with

mild to moderate respiratory tract irritation and

bronchospasm.

I will first discuss the effect of inhaled

cyclosporine on survival. Using an unadjusted

analysis, inhaled cyclosporine was associated with

a significant survival advantage compared to

placebo, with a relative risk of death of 0.213 and

a p value of 0.007. This corresponds to a 79

percent decreased risk of death in patients treated

with inhaled cyclosporine compared to placebo.

This slide is the Kaplan-Meier plot of survival

duration from the time of transplantation to the

study end date, and is the primary reason that we

are all here today.

During the period of the study there were

3 deaths in the inhaled cyclosporine group compared

to 14 deaths in the placebo group. The results are

not only highly statistically significant but also

clinically very important. This is the first time

a cohort of lung transplant recipients has had

survival comparable to recipients of other solid

organ transplants and marks a major advance in

outcomes for this patient population.

The importance of an unadjusted analysis

rests on its robustness and how well it compares to

analyses that control for other baseline

characteristics that might affect outcome.

Therefore, we performed univariate analyses

adjusting for potential risk factors that might

affect survival, and found that the relative risk

of death and the p values were remarkably

consistent.

This graph illustrates the relative risk

of death and 95 confidence intervals when the

survival data is adjusted by a number of different

factors that have been documented in the literature

to potentially affect outcome. We also include two

factors suggested by the FDA, ICU time after

transplantation and the use of donors who at some

point during their hospitalization prior to

harvesting were treated with an inotrope. Neither

of these two factors is supported by the literature

or registry data as having an impact on survival.

For the case of donor inotrope use, it is not

considered in guidelines for optimal donors or

marginal donors. However, the key message is that

regardless of the baseline characteristic none of

these factors appreciably impacts the relative risk

of death and lends strong support to the validity

of the unadjusted analysis, and this is what is

meant by a robust endpoint.

In order to further test the robustness of

the survival endpoint, we performed multivariate

analyses which adjust for clinically relevant

baseline characteristics simultaneously. As not

all characteristics can ever be simultaneously

input into a single statistical model, the job of

the clinician is to decide which of these are the

most clinically relevant.

In order to determine the most clinically

relevant factors we searched through the literature

to determine those that had been documented to be

short-term or long-term prognostic factors. We

then reviewed registry data to determine the level

of significance and, finally, we discussed these

factors with transplant physicians who care for

these patients. The general agreement was that the

most clinically relevant factors were transplant

type, CMV mismatch, primary diagnosis, early acute

rejection--all shown in green. We also include in

our model the variable of enrollment period as this

was a randomization stratification variable and it

is in accordance with ICH guidelines.

This slide also illustrates the relative

distribution of 16 different baseline

characteristics that have been documented in the

literature to potentially affect short-term or

long-term outcome. As is evident, the majority are

balanced or, if anything, would favor better

outcomes in the placebo group.

This slide illustrates the results of the

multivariate analyses when these factors are

successively added into a Cox proportional hazards

model. The key point is the consistency of the

treatment effect. The addition of the five most

clinically relevant factors into this study does

not have any appreciable impact on the relative

risk of death or the p values, and provides even

further support for the robustness of the survival

endpoint.

Robustness was further evaluated by

performing a number of sensitivity analyses around

the survival endpoint. When we did so, we found

that the relative risk of death remained

consistent. The top row illustrates the unadjusted

analysis on the full data set. When we include

patients who were randomized and treated the

results are essentially unchanged. When we look at

survival relative to first dose of study drug

rather than time of transplantation, again the

results are essentially unchanged. When we exclude

three placebo patients who had early mortality and

died within the first three months--when we just

take them out of the analysis and we only analyze

the remaining 27, it remains statistically

significant. When we take out 14 patients who did

not receive at least 80 percent of the protocol

maximum dosing adjusted for death, we lose 25

percent of the sample size but still maintain

statistical significance and the relative risk of

death is barely altered.

The FDA has raised concern about the

effects of early pneumonia. So, if we remove from

analysis 15 patients who had an episode of

pneumonia within one month of initiation of study

drug we have lost greater than 25 percent of the

patient population and, therefore, expect that the

p value is going to increase but the key point is

that the relative risk of death, the treatment

effect, is barely changed.

Questions have also been raised about the

effects of ICU time after transplantation. If five

patients who were in the ICU greater than 14 days

were removed from analysis, the results are

statistically significant and in favor of the

inhaled cyclosporine group. Therefore, we have

looked at the survival data from a number of

different angles and found the survival data to be

robust.

To assess the duration of the survival

benefit we collected additional survival data 10

months after the study ended, and we found that the

survival benefit persisted. At that point there

were 5 deaths in the inhaled cyclosporine group

compared to 15 deaths in the placebo group, with a

p value of 0.017.

This post-study follow-up is important and

it is useful and supportive data. However, it has

its limitations. The first is that the study had

ended and it ended almost a year earlier. The data

was analyzed and patients were unblinded; treatment

groups were known. In addition, except for those

patients who had crossed over into an open-label

protocol, all patients were off study drug for a

substantial period of time, ranging anywhere from

10 months to a maximum of 3.5 years. When you

consider that the median time to diagnosis of

chronic rejection is 16-20 months, it is going to

confound the results. Also, there were placebo

patients that had crossed over and were now

receiving inhaled cyclosporine so the net effect,

as expected, is that it is going to trend toward

the null.

This is what the FDA refers to as the

five-year data and believes that it is the most

appropriate time point to analyze the survival

data, but for the reasons that I have just

described we disagree and we believe that the data

is best analyzed at the prospectively defined study

end date.

In order to verify that the placebo

population was representative of what would be

expected in a larger U.S. transplant population,

the placebo survival curve was compared with data

from the United Network for Organ Sharing, or UNOS,

that maintains a large transplant registry.

Placebo patients were matched with UNOS controls

who were transplanted during the same period of

enrollment as ACS001, and they were matched by the

variables on the slide. Matching also excluded

patients who died before they could have possibly

enrolled into ACS001.

This slide illustrates the results and

shows that both early mortality and late mortality

in the placebo group are extremely consistent with

what is expected in a larger multicenter patient

population. Roughly 50 percent survival at 4.5

years is exactly what has been documented in the

literature for years. Therefore, any analyses that

exclude early deaths or late deaths or deaths due

to particular causes have to be viewed with caution

as they would no longer lead to a placebo group

whose survival is representative. By comparison,

when the ACS001 inhaled cyclosporine group is

compared to the UNOS controls the relative risk of

death of 0.252 is very comparable to what was seen

in ACS001 where the relative risk of death was

0.213.

This is a busy slide but it makes a very

important point and brings us into our next topic,

namely, the primary reason for the improved

survival in patients treated with inhaled

cyclosporine is that inhaled cyclosporine prevented

chronic rejection. This slide illustrates the

timing and cause of death for both groups. As

expected, early deaths were predominantly due to

infectious causes. However, subsequently nearly

all deaths are associated with chronic rejection.

Of the five deaths that the agency calls attention

to in the mid portion of the graph as driving the

statistical significance, four out of the five had

chronic rejection. By contrast, in the inhaled

cyclosporine group the curve becomes flat and late

mortality is not occurring.

One question that has been raised is why

is the survival difference statistically different

at two years when all patients would have completed

their study drug. The reason, as evident from this

graph, is that chronic rejection is the predominant

cause of death in the first year so you wouldn't

expect to see early large separation of the two

curves. However, after a year it is the major

contributor, as Dr. Golden has demonstrated, to

mortality.

To review, chronic rejection is an

umbrella term for patients with histologic evidence

of bronchiolitis obliterans, or OB, documented by

transbronchial biopsy. It is also representative

of patients with clinical evidence of bronchiolitis

obliterans syndrome, or BOS, using a sustained and

unexplained decline in FEV1 as a surrogate marker.

It is not uncommon for patients to have

bronchiolitis obliterans but, due to the

progressive nature, they haven't met clinical

criteria for BOS. It is also not uncommon for

patients to have BOS but, due to the insensitive

nature of transbronchial biopsy in making the

diagnosis they don't have OB. So, these two

groups, patients with OB and patients with BOS, are

overlapping but they all represent patients with

chronic rejection. So, looking at each group

individually may be informative but it has to be

viewed as a subset analysis. Consistent with

direct delivery to the airway epithelium, the site

of chronic rejection, treatment with inhaled

cyclosporine led to a 72 percent decrease in the

risk of chronic rejection or death. As you will

see, when we performed the same univariate and

multivariate analyses, the results are even more

robust.

This slide illustrates the Kaplan-Meier

estimate of chronic rejection-free survival and

uses a composite endpoint of first diagnosis of OB,

first diagnosis of BOS or death. There are two

important points here. One is that there is

general agreement with the FDA that the rate of

biopsy and the rate of pulmonary function testing

is comparable between the two groups so that the

difference isn't driven by increased testing in one

group or the other.

The second is that the use of a composite

endpoint of chronic rejection and death implies

that patients who die and, therefore, can't go on

to be diagnosed with chronic rejection are counted

as events rather than censored in the statistical

analysis. To censor deaths in a statistical

analysis of chronic rejection would require the

assumption that there is no relationship between

chronic rejection and death, an assumption that we

know to be invalid.

The agency issued guidelines in April of

2005 endorsing a progression-free survival analysis

for similar oncology endpoints to avoid a type of

bias known as informative censoring. As with the

survival endpoint, we found a remarkable

consistency of the chronic rejection-free survival

endpoint when we performed a series of univariate

analyses. None of these baseline characteristics

had any appreciable impact on the treatment effect

or its significance, which speaks to the robustness

of this endpoint as well.

This slide illustrates the result of

multivariate analyses on the chronic rejection-free

survival endpoint. Once again, the addition of the

5 most clinically relevant factors in this

study--adding them into a Cox proportional hazards

model has essentially no real impact on the

treatment effect of the confidence intervals and

the p values remain highly statistically

significant.

Valid questions have been raised about

whether the survival benefit is so strong that any

composite endpoint that includes survival would be

statistically significant. Therefore, for

exploratory reasons we performed an analysis of

chronic rejection with death censored. This

clearly biases results against the inhaled

cyclosporine group due to the larger number of

deaths in the placebo group. As mentioned, this is

referred to as informative censoring. However that

said, when we performed the analysis the results

were still statistically significant and in favor

of the inhaled cyclosporine group. Chronic

rejection occurred in 50 percent of placebo

patients and 27 percent of inhaled cyclosporine

patients.

This slide illustrates the Kaplan-Meier

estimate of time to chronic rejection with deaths

censored and clearly illustrates a statistically

significant effect on chronic rejection independent

of death despite the large bias inherent in the

analysis. This analysis is important because it

leads to the conclusion that treatment with inhaled

cyclosporine prevents chronic rejection, the

leading cause of late mortality in lung transplant

patients.

However, the primary endpoint of the study

was not survival or chronic rejection but rate of

acute rejection and this endpoint was not met.

Approximately 70 percent of patients in both groups

had at least 1 episode of documented grade 2 or

higher acute rejection prior to study termination.

After the start of dosing rates were comparable

between the 2 groups, with a p value of 0.73.

Dr. Golden has explained the paradigm

shift that has occurred in the transplant community

in terms of how acute and chronic rejection are now

understood. Acute rejection is primarily a

vascular process so an immunosuppressant with low

vascular exposure would not be expected to have a

significant effect, and that is what we are seeing

in ACS001. By contrast, chronic rejection is an

airway process. It is mediated in the airway

epithelium so an immunosuppressant delivered

directly to the airway epithelium would be expected

to have an effect, and that too is what we are

seeing in ACS001.

Now I am going to switch gears and briefly

discuss safety. This slide illustrates the

relative systemic exposure to cyclosporine when

given by an inhalation route compared to an oral

route. A 300 mg dose of inhaled cyclosporine has

been demonstrated to lead to a mean peak blood

concentration of 206 ng/mL, roughly 11-14 percent

of what you would expect in an oral dose. the

levels at 24 hours are barely detectable by

standard assays, and these numbers are reflected in

the mean AUC, or area under the curve, which

suggests a roughly 8-fold lower systemic exposure

to cyclosporine when it is given by an inhaled

route compared to an oral route. This low systemic

exposure explains why no additional systemic

toxicities were seen in the inhaled cyclosporine

group compared to placebo.

Data to support the safety of inhaled

cyclosporine and propylene glycol come from

multiple sources, and this is outlined in much

further detail in the briefing book. The first are

preclinical toxicology studies in dogs and rats,

performed both by Chiron as well as referenced in

the literature. These studies show that no

unexpected toxicities were seen when animals were

treated at many-fold higher doses than what would

be used clinically.

The next source is the randomized,

placebo-controlled ACS001 trial where safety data

from 30 placebo patients were compared with safety

data from 36 inhaled cyclosporine patients, the 26

randomized and the 10 placebo.

The next source is ACS002, which was a

retrospective safety analysis of 70 patients

enrolled in 1/7 different open-label protocols of

inhaled cyclosporine in patients with refractory

acute and chronic rejection. The ISS, or

integrated safety summary, is a combination of all

patients treated with inhaled cyclosporine in

either ACS001 or ACS002 and represents 102 unique

patients in our safety database.

To summarize our clinical safety data,

review of the adverse event listings in ACS001

revealed that inhaled cyclosporine was safe. There

was no increased risk of nephrotoxicity,

neurotoxicity, infections, malignancies or any

other toxicities that occur with oral or

intravenous cyclosporine. In addition, there were

no new or unexpected systemic toxicities.

So, the key point is that treatment with

inhaled cyclosporine led to a 79 percent decreased

risk of death compared to placebo, with no systemic

toxicity. However, inhaled cyclosporine was

associated with respiratory tract irritation and

bronchospasm and this will be discussed in the next

slide. Review of adverse event data in ACS002 and

the ISS confirmed the safety findings of ACS001,

and no new safety signals were seen after review of

the serious adverse event data.

After review of the ACS001 adverse event

listings and case report forms, it became clear

that there were two distinct but interrelated

safety signals that appeared to be a direct result

of inhaled cyclosporine. The first was

bronchospasm manifested primarily by cough,

exacerbated dyspnea and wheezing. The second was

respiratory tract irritation manifested primarily

by pharyngitis but also laryngitis and non-cardiac

chest pain. In general, these events were mild to

moderate. They occurred early in the patient's

treatment course and diminished with time, and once

they resolved it was rare for them to recur. But,

most importantly, there was no progression to more

serious respiratory complications such as acute

respiratory failure or ARDS. The adverse event of

lung consolidation was noted in higher frequency in

the inhaled cyclosporine group but the clinical

relevance of this finding is unclear as underlying

causes such as pneumonia, lung mass, atelectases or

other underlying causes were comparable between the

2 groups.

Having reviewed the most important

clinical results for inhaled cyclosporine, it is

appropriate to take a step back and take a look at

some of the outstanding issues surrounding the

data. Study ACS001 was conducted at a single

center, and this was discussed with the FDA well

before Chiron decided to move ahead and file the

NDA. However, it is important to note that no

other transplant studies or registry analyses have

ever shown a survival benefit comparable to what

was seen in the inhaled cyclosporine group of

ACS001.

We also looked at the placebo group and

found that survival was comparable to a multicenter

matched database. Single-center trials are not

ideal. However, they do have one important

advantage. Because confounding due to differences

in patient care is minimized, single-center trials

are actually better at determining a treatment

effect than multicenter trials of the same size.

Finally, Chiron has committed to a multicenter

postapproval trial to further study the efficacy

and safety of inhaled cyclosporine.

The sample size of N equals 56 for

efficacy and N equals 102 for safety is small.

However, the lung transplant population is

exceedingly small, with 1100 lung transplants

performed in the United States each year. Despite

the small sample size, the survival and chronic

rejection data are highly statistically significant

so the sample size was sufficient to test the

hypothesis that inhaled cyclosporine improves

survival and chronic rejection-free survival.

Cyclosporine and propylene glycol are

well-known and well-characterized, and the safety

profile of inhales cyclosporine is extremely

favorable, especially in light of the survival

benefit. Again, Chiron has committed to creating a

larger efficacy and safety database through a

postapproval trial.

The randomization code was susceptible to

unblinding and CRF assembly was retrospective. The

randomization code used a patient subject number

followed by an A, B, C or D designation, with A and

D referring to placebo patients, B and C referring

to inhaled cyclosporine patients, and it is

possible that the study could have become unblinded

due to the simple nature of this designation.

However, there are several factors that make this

very unlikely. First is that the principal

investigator was never exposed to the subject

numbers. Second, the investigator removed 3

inhaled cyclosporine patients from the inhaled

cyclosporine arm only to cross over into an inhaled

cyclosporine open-label rescue protocol. In

addition, the pathologist reading the

transbronchial biopsies and making the

determination of bronchiolitis obliterans was never

exposed to study numbers.

The issue with retrospective CRF assembly

is whether somehow in the retrospective nature of

filling out these forms an assessment of an outcome

is altered. However, when the outcome is death, or

the presence or absence of bronchiolitis obliterans

on an original histopathology report, or whether

FEV1 has declined by 20 percent or more from a

post-transplant maximum, these are hard endpoints

and would not be expected to be altered by

retrospective CRF assembly.

Treatment groups were not balanced on each

and every baseline characteristic. The purpose of

randomization is not to eliminate all imbalances

but, rather, to randomly distribute them between

groups. The two treatment groups are comparable,

and of the clinically relevant baseline

characteristics we examined the majority are

balanced or, if anything, would favor better

outcomes in the placebo group.

Finally, when imbalances do occur in

clinically relevant variables statistical models

can be used to adjust for these both in univariate

or multivariate analyses, and we have presented

such analyses that show that the data is robust.

So, we feel extremely confident in saying that

baseline imbalances did not explain the efficacy of

inhaled cyclosporine.

The study did not meet its primary

endpoint of decreased rate of acute rejection.

However, scientific understanding has evolved since

the design of ACS001 and the lack of an effect on

acute rejection is consistent with low systemic

exposure. The design of the study doesn't impact

the assessment of survival or chronic rejection or

alter how the data is obtained. It is also

important to note that survival and chronic

rejection were prospectively defined secondary

endpoints. These analyses are not post hoc nor do

they constitute data mining.

Finally, the survival and chronic

rejection data are clinically important,

statistically significant and scientifically sound.

Inhaled cyclosporine is delivered directly to the

airways, the site of chronic rejection. Inhaled

cyclosporine prevented chronic rejection and, in

doing so, markedly improved survival. The

importance of this data is illustrated by the fact

that physicians from 30 different transplant

centers in the United States, which represents

almost half of all active lung transplant centers,

have requested early access to inhaled cyclosporine

as part of our early access program.

We have been advised to make it clear to

the advisory committee where there are differences

of opinion between Chiron and the FDA, and that is

really why we are here today. So, this slide

illustrates five of the most important areas where

we disagree.

First, we believe that covariates in a

statistical model should be chosen based on an

association with the clinical outcome rather than

because of an imbalance. In the case of ICU time,

the use of ICU time greater than ten days, there is

an imbalance toward the placebo group. However,

this is not documented to be associated with

survival. If an ICU time greater than seven days

is chosen that imbalance is minimized, and if an

ICU time greater than four days is chosen the

imbalance is reversed. We believe that it is

important to differentiate patients who had an

earlier, easier postoperative course from those who

had a harder postoperative course, but believe that

this is best accomplished by the randomization

stratification variable enrollment period, early

versus late.

In the case of donor inotropic support, we

have yet to find a single reference that even

considers this variable, much less finds it

clinically relevant and the FDA has called this one

of the most clinically relevant factors in the

study.

We do have variables and we do have data

on donor quality through other variables that have

been documented in the literature to be clinically

important, such as donor age, donor bacterial

colonization, donor graft, ischemic time, and these

are balanced between the two groups. The important

point is that the use of a covariate that is

imbalanced but not clinically relevant will always

cause results to trend toward the null and that is

what we have seen with the FDA analyses.

Second, in analyses of survival we

disagree that patients whose use of donor inotrope

or the donor inotrope data is missing--we disagree

that these patients should be excluded from

analyses. In the FDA analysis, by excluding

long-term survivors in the inhaled cyclosporine

group, the treatment effect and p values are going

to be altered inappropriately.

Three, we believe that survival is best

analyzed at the prospectively defined study end

date rather than one year after--or nearly a year

after the study was over. I have already discussed

our reasons for this.

Four, we believe that patients with

bronchiolitis obliterans, or OB, should be included

in an analysis of chronic rejection. The diagnosis

of OB has a specificity of over 95 percent.

Patients with BOS and OB represent overlapping

subsets and, therefore, to look at either one

alone, we believe, is a subset analysis.

Finally, five, analyses of BOS should not

censor deaths. This is clearly informative

censoring, and when deaths are not censored and

BOS-free survival is analyzed the results are

statistically significant and remain so when

controlled for by CMV mismatch, primary diagnosis

and early acute rejection. Analyses that censor

death can be informative but we have shown in our

chronic rejection that although they can be

informative they shouldn't be used as the primary

analysis.

So, I would like to end with a summary of

the clinical data that I presented. In the lung

transplant population with no appropriate approved

drugs, very few randomized clinical trials and a

dismal prognosis that hasn't changed in almost 20

years, treatment with inhaled cyclosporine was

associated with a 79 percent decrease in the risk

of death. Treatment with inhaled cyclosporine was

associated with a 72 percent decrease in the risk

of chronic rejection or death. We have

demonstrated that our efficacy results are robust

through a number of different analyses. We have

also demonstrated that the ACS001 placebo

population is representative of a larger U.S.

transplant population. We have demonstrated that

treatment with inhaled cyclosporine was not

associated with any systemic toxicities. Finally,

inhaled cyclosporine was associated with local

respiratory tract irritation and bronchospasm, a

relatively small price to pay in light of the

profound survival benefit.

Thank you. I would like to end and turn

this presentation over to Dr. Ronald Helms,

Professor Emeritus of Biostatistics of the

University of North Carolina, who is going to spend

a few minutes discussing the statistical

considerations of the study.

Statistical Considerations

DR. HELMS: Thank you, and thank you for

the opportunity to come and address this group here

this morning. My time is short so I am going to

dive right in, if I may.

Why are we here? Well, this survival

curve tells why we are here, the profound

difference in survival in these two treatment arms,

as has been discussed at length already.

A second reason I am here is that this is

a very interesting project, a very interesting

project. Let me first establish a disclaimer and

my conflict of interest issue. The views that are

expressed in this presentation are mine alone and

do not represent either the FDA or Chiron or Rho,

my current employer, or the University of North

Carolina, my former employer. It is possible that

these views may represent the best interests of

future lung transplant patients. In terms of

financial conflict of interest, neither Rho nor I

have any financial stake in the outcome of this

submission. Less than half a percent of Rho's

total income this year will come from Chiron.

Chiron pays Rho an hourly consulting fee for my

time plus travel expenses and, in fact, my board of

directors told me they would prefer that I work on

other projects that are more financially rewarding

to the company.

[Laughter]

So, I am here despite that. Also, neither

Rho nor Chiron has edited my presentation and I

have reviewed the briefing documents that you have

seen from both the FDA and Chiron, plus some other

more comprehensive documentation. So, I feel

unconflicted here.

So, why am I here? Well, coming back to

the results of this study and the fact that it is a

very interesting project--it is a very interesting

project and we have a problem. By "we" I mean the

professionals sitting here around the table, the

FDA professionals, the Chiron staff--we have a

problem.

This Kaplan-Meier graph tells that this

product has the potential to save the lives of a

statistical number of lung transplant patients.

The NDA does not meet the usual regulatory

requirements for approval. Should it be approved?

Well, there are advantages and

disadvantages to approval in this case. The

results indicate that if approved, widespread use

of this product would probably save the lives of

around 300 to 350 lung transplant patients a year.

Now, I should just comment that my comments here

are really aimed at the non-statisticians on this

panel. The statisticians know how to interpret

relative risk and those kinds of things. I thought

it would be useful to translate this into lives

saved after a period of time when the product was

in widespread use. It appears to improve the

survival probability by about 30 or 35 percentage

points. You see the numbers there, somewhere

around 50-90 percent, and there are about 1000 or

1100 transplant patients so if you do the

arithmetic it comes out to around 300 to 350 lung

transplant lives saved a year.

Another advantage is--and this is a

practical advantage--if this product were approved

FDA could require Chiron to conduct the

sufficiently large follow-up study that Chiron has

proposed. If the study were negative the approval

could be withdrawn and, as a practical matter,

without approval the follow-up study will never be

done. Off-label use of the product would

ultimately become a standard of care and failure to

use it would be considered unethical and subject to

lawsuits and those sorts of things. And it is an

interesting aside that we have a very closely

related case. Cyclosporine, which is used

universally in the treatment of lung transplants,

is not approved for that indication; it is all

off-label use. The studies have never been done.

There are some obvious obstacles to

approval. We have the results of only one small

unconfirmed study. This is a serious problem. It

is a serious problem. This one study has a number

of flaws that have been noted by both Chiron and

FDA. Here are some opinions, one of these is very

important; some are potentially important; and some

really are inconsequential in my opinion.

The very important flaw in this clinical

trial from a statistical perspective is that the

stated primary outcome was acute rejection, not

mortality or survival. The statistical methods

that we routinely use for Phase III confirmatory

studies aren't very helpful with this problem, the

problem of switching the primary endpoint from what

was stated in the protocol to a secondary endpoint.

But good, old-fashioned common sense can be

helpful. When you see that big an effect on

survival you very likely made an important

discovery.

Now, we could use, as statisticians, a

branch of statistics called decision theory for

formal risk-benefit analyses here but the fact is

that if we did that the analyses would be based on

a number of assumptions and if you are strongly

opposed to approval here you challenge the

assumptions, and rightly so. The result is so big,

the difference in survival is so big here that we

can tell what the outcome would be anyway, that it

would lead to a decision in favor of the product.

Some potentially important flaws--let me

address those. My time is brief and I won't go

into statistical details but there is an important

side note here. At least as of a few weeks ago,

the FDA and Chiron biostatisticians had confirmed

each other's statistical calculations. The point

is that there is no issue about correctness of

populations. Now, you are going to hear different

perspectives obviously from Chiron and FDA. In my

opinion, the issues here are about how to use and

interpret the statistics, not the actual results,

and I think that is good to know.

There are some potentially important flaws

that have already been mentioned and you will hear

some more about that in the FDA presentation. The

randomization, if done improperly, could be an

important flaw; the lack of balance with respect to

important baseline characteristics; unmasking or

unblinding--we used to call it unblinding but then

I worked with some ophthalmologists and they taught

me to use the word "unmasking." The study was

conducted in such a manner that the investigators

could have been unmasked essentially, and the study

was conducted at a single clinical center, not

multiple centers.

I want to cut to the chase because my time

is limited. The bottom line is I reviewed each of

the potentially important flaws and my conclusions

for each one were that each was either not a flaw

at all or was relatively unimportant. For example,

the randomization failed to balance with respect to

all the baseline factors. It rarely does in

clinical trials, even large clinical trials. It

has been my experience over the last 15 years since

I began looking at this that only one out of

hundreds of clinical trials was balanced with

respect to all important baseline factors. So, it

is not a case of failure. On request, on somebody

else's time, I will be happy to talk about some of

these issues.

There are some unimportant flaws in the

clinical trial, and they are listed there. We

don't have to spend time on that.

Let me raise an important ethical point

for the members of the panel. Suppose the data

from this study were the results of an interim

analysis half way through the study, and suppose

the members of this advisory panel were instead

sitting as the study's data and safety monitoring

board, would we be ethically bound to terminate the

study to protect future patients who might be

assigned to placebo? I suspect that many of you

have sat as members of data and safety monitoring

boards and faced precisely this question in the

middle of a study. I have. And I believe that

everyone on the DSMBs in which I participated would

have stopped this study to protect placebo

patients, the results of the study are that

compelling.

I think there is another important ethical

point. I think the people in this room--again, the

FDA staff, the advisory panel, the Chiron

staff--are ethically bound to find a way to make

this product available on-label to U.S. lung

transplant patients. It will be used off-label.

It already is being used off-label but without

approval for some years this product will only be

available to people who can afford to pay for it

from their own funds because it won't be covered by

insurance. So, we have a product that would be

made available to wealthy people and not others.

We also, I think, are ethically bound to

find a way to make it necessary for Chiron to

conduct the proposed postapproval follow-up study.

If we don't, it won't be done. Realistically, it

can only be done as a postapproval study for

financial reasons that Chiron can talk to you

about.

What an interesting project! Thank you

for the opportunity to talk to you.

Safety and Benefit-Risk

DR. DILLY: Thank you, Prof. Helms and

thank you, everyone, for your patience in following

through our presentation. I am going to conclude

with about five minutes of remarks to end the

Chiron presentation.

What I would like to do is consider some

of the issues relevant to the potential approval of

Pulminiq. Clearly, we believe the best way to help

lung transplant patients now is to make CyIS

available. Lung transplant, as you heard, is in

many ways the poster child of the orphan drug

indication. Despite the incentive provided by the

orphan drug designation, no drugs have been

developed for lung transplantation, probably

because the economics simply don't work for a

conventional development program. So, if we are

looking for new drugs, it is going to come from

sources like this.

Now, we are not suggesting for a moment

that the burden of evidence is any different for an

orphan indication. Rather, what we are suggesting

is that we must consider the evidence that exists

on its merit and, in fact, the case for approval of

this drug is very strong.

The scientific premise for inhaled

cyclosporine is extremely straightforward. We are

giving an effective drug, with systemic toxicity,

by inhalation to achieve higher lung levels. This

has been done, of course, successfully in asthma,

in COPD, in cystic fibrosis. It is a well

precedented approach. In fact, as you heard, the

idea is so straightforward that many lung

transplant centers were already using inhaled

cyclosporine empirically before the clinical data

of ACS001 were known.

Of course, these are the essential

clinical data. Patients who received inhaled

cyclosporine in the pivotal trial lived

significantly longer than those who did not. You

have heard compelling arguments that the difference

in survival was due to inhaled cyclosporine and

that the benefit is highly likely to be

generalizable to other patients in other treatment

centers. Publication of these data will rightly

have a major impact on the treatment of lung

transplantation with or without approval of

Pulminiq. The case for benefit is very strong.

Also as you have heard, there is very little risk

of harm. This is a known drug. Local toxicity in

the lung is minor and systemic exposure is not

clinically important. Finally, this is a very

small population with an entirely clear-cut

diagnosis, lung transplantation. So, the chances

of a major public health problem from broad usage

is very, very small. In other words, the

demonstrated benefit far outweighs the potential

for harm. The bottom line is patients will live

longer if inhaled cyclosporine is made available to

them.

Of course, some questions remain open

because of the nature of the clinical program

conducted to date. So, the right thing to do for

patients is to approve inhaled cyclosporine now and

conduct the appropriate postapproval study to

address those outstanding questions. So, I would

like to finish the Chiron comments by considering

what that postapproval study should look like.

The central question really is how to give

inhaled cyclosporine. We have seen benefits from

therapy lasting for up to two years. All logic

dictates that for a chronic rejection endpoint

chronic therapy should be better. We need to study

that. We need to study dosing beyond two years.

We need to work on making the first few doses as

tolerable as possible so we can get as many

patients as possible onto an effective dosing

regimen.

We would also love to know more about the

interplay of the key clinical endpoints, survival,

rejection, lung function. You can only interpret

so far based on a single, relatively small study

with such a bright line survival effect. We

believe that 300 mg of inhaled cyclosporine by

nebulizer three times a week is a perfectly

appropriate inhaled regimen and the right thing to

put in the label, but there are some questions we

need a bigger study to answer.

How do patients do if they actually

tolerate a dose below 300 mg--100 mg or 200 mg? Is

the need for systemic dose intensification reduced

with effective long-term inhaled therapy? What is

the best way to deal with treatment interruptions,

for instance during concomitant illnesses? Of

course, it will be informative to have a much

bigger safety experience.

So, here is our proposal, essentially this

is a very large single-arm study with external

controls. We believe that we could draw the

control arm now from the UNOS database. From the

comments you heard from Dr. Golden and others, we

know what happens to lung transplant patients

treated with current standard of care. So, 250

patients will be treated with a labeled regimen of

inhaled cyclosporine for 5 years. A placebo group

is not appropriate and not necessary given the

robust survival advantage already demonstrated with

inhaled cyclosporine. There will be 2 external

controls, firstly, about a thousand matched

patients with long-term follow-on data drawn from

the UNOS database. Secondly, a group of

contemporaneous controls who will not receive

inhaled cyclosporine. The exact size of this

group, of course, will be somewhat dependent on the

rapidity of uptake of inhaled cyclosporine therapy.

So, we would expect that the availability of those

patients would go down over time.

What I am attempting to describe to you

here is a study that is entirely doable in the

postapproval context. The primary endpoint will be

chronic rejection-free survival, with all-cause

mortality and lung function as secondary endpoints.

We see three safety endpoints as particularly

interesting: Firstly, infections requiring

hospitalization because we believe that that signal

in favor of the lower incidence of pneumonia on the

inhaled cyclosporine group in ACS001 is probably

real and due to decreased lung damage from chronic

rejection, making the lungs less susceptible to

infection. Secondly, we want to look at renal

dysfunction and malignancy as readouts of systemic

immunosuppressive status, as well as diligent

follow-up for the other safety events. In fact,

this will be the largest study ever done and the

longest study ever done in the lung transplant

setting.

In conclusion, based on what we know now

lung transplant patients will clearly live longer

with inhaled cyclosporine. The outstanding

questions can be addressed in a postapproval study

and so we believe that inhaled cyclosporine should

be approved now.

Now I would like to invite Dr. Scaife to

the podium as well and we can take your questions.

DR. SCAIFE: Thank you very much, Dr.

Dilly. We can open to the FDA and the panel for

questions.

Questions from the Panel

DR. SWENSON: Go ahead.

DR. SCHOENFELD: I just had a few

questions on acute rejection since that endpoint

wasn't exactly described. How is that diagnosed?

DR. SCAIFE: Dr. Sarah Noonberg?

DR. NOONBERG: It is diagnosed by

transbronchial biopsy and it is graded 0-4. So, it

is the same transbronchial biopsy that can be used

to make the diagnosis of bronchiolitis obliterans.

DR. SCHOENFELD: So, was there sort of a

program of periodic transbronchial biopsies in

these patients during the study?

DR. NOONBERG: Yes, approximately the

first month and then three to four months afterward

for a period of two years and then as clinically

relevant. It should be noted that the mean greatly

exceeded that. All patients had the minimum and

the mean was far higher.

DR. SCHOENFELD: Another question about

acute rejection, once a patient has bronchiolitis

obliterans can they have acute rejection also?

DR. NOONBERG: Yes.

DR. SCHOENFELD: I see. So, it can happen

after the chronic rejection has begun.

DR. SWENSON: Dr. Hunsicker?

DR. HUNSICKER: I would like to ask Dr.

Golden if he would be willing to comment on this.

Let me give perhaps a little bit of a setting for

my concerns here. We have a study in which the

primary outcome was not met and the secondary

outcome is met that at the time the study was

conceived didn't correspond to biology that was

understood. The understanding of biology has

changed but--I would like to say I am not a

pulmonary person but I am a transplanter--is still

not very well understood. So, I think I need to

have somebody who really understands the pulmonary

rejection business to tell me a little bit about

the preclinical information on the impact of local

immunosuppression for chronic rejection in the

lungs. Right now the general assumption is that

most of the effects of immunosuppression are

central. I grant you that there is some very real

interest in the possibility of local immunocytes

being locally immunosuppressed but this is not what

I would call a robustly well understood part of

science. So, since we can't look at this really in

most of the forms of transplantation, it may be

that we have some better understanding of this from

the pulmonary point of view and I would like to get

the best understanding I can have of what is

currently understood about the impact of local

immunosuppression for pulmonary rejection.

DR. GOLDEN: First of all, nobody knows

with precision exactly where you are treating

locally along the airway. I would infer, given

that there is a difference in chronic rejection,

that that is generally a more peripheral airway

portion.

DR. HUNSICKER: Let me clarify that. I

wasn't talking where along the airway, I was

talking about central immunological events as

opposed to peripheral immunological events. Most

of us have assumed that the primary effects of

immunosuppression are central rather than in the

peripheral organs, particularly of the calcineurin

inhibitors. So, what I want to know is, is it

known what the effects of local immunosuppression

in lung rejection are in experimental models for

instance?

DR. GOLDEN: Let me make sure I understand

the question. You want to know when you give

systemic immunosuppression centrally how that might

affect the airway.

DR. HUNSICKER: Actually, it is the other

way around. Let's assume that when cyclosporine

gets into the body where it really is doing its

thing is in the lymph nodes and the spleen, and

stuff like that where the cells are being

developed. Then it doesn't make a whole lot of

sense that local application should be effective.

If, in fact, there is local effect on the lymphatic

cells that are in the bronchi, then it might make

sense. Right now this is something that is not

understood in other forms of rejection because we

can't get at the local tissues quite so well. What

is known about this?

DR. GOLDEN: I think this is a new area.

To answer it the best I can, one would have to

infer that systemic therapy does not reach a level

of mucosal benefit, that applying the medicine

locally, as you say, must have some local immune

benefit. The slide I showed of the mucosa with

lymphocytes moving into the submucosa--I can only

infer that systemic therapy or having a central

effect on lymph nodes, etc., as you say, is not

reaching a level of immunosuppression along the

airway that is benefitted by a direct local

application to the epithelium of an

immunosuppressant.

I must say that there are ongoing studies

now with other agents, like inhaled rapomyacin, to

also try and treat this. That is an animal study,

very preliminary. So, the best answer is I really

don't know. I infer that there is a benefit

locally to applying, as you can uniquely do in the

lung as you said, to a mucosal process.

DR. PRUSSIN: Calman Prussin, NIAID. Just

to follow-up, in all immunologic and allergic lung

diseases I know T-cells are being activated in the

lung locally and expressing cytokines locally. So,

if you are applying that drug locally you would

expect that it would have an effect there as

opposed to cells that are in the spleen which are

mostly resting and not producing cytokines. So, it

does make sense immunologically.

DR. SWENSON: Dr. Gay?

DR. GAY: Steve Gay, University of

Michigan. I had a question concerning the early

stoppage of the trial. Pittsburgh is a fairly

aggressive transplant institution and it seems as

if the study was initially powered for 120

patients. The study was stopped at 56 patients. I

was wondering what factors led to the early

stoppage with the fact that the primary endpoint

was clearly not achieved at that point.

DR. DILLY: The original sample size

estimate was based on the availability of patients

during the predefined study duration, and the study

ended on the day that the study was intended to

end. That was not influenced by the primary

endpoint. It was simply that there were

approximately 120-odd patients during that period

who were transplanted at Pittsburgh and around half

of those patients went on to the study. So, in

100

fact, this was a pretty good enrollment of eligible

patients at the site.

DR. SWENSON: Dr. Proschan?

DR. PROSCHAN: I also have a question

about that because you say it was not influenced by

the results. Does that mean the results were not

known at that time?

DR. DILLY: The study was done blinded at

that time so the results were not known and the

blind was well preserved. We really became aware

of those results after the unblinding.

Another thing that we have looked at in

some detail--and perhaps Dr. Noonberg or Dr. Capra

would like to talk about this--is whether there was

something special about the patients that went into

the study. Was there something about the placebo

group and whether these were a selected group of

patients? All the evidence says is that these were

the same kind of patients as were not enrolled in

the study.

DR. NOONBERG: When we compared the

placebo and ACS001 to UPMC unenrolled controls we

101

found that the survival curves were comparable,

with a p value of 0.99, so these didn't represent a

select group of patients. One of the reasons for

the poor enrollment is that there just simply

weren't enough transplants performed during that

period of time. During those three years there was

a far lower time for--I am just going to stop and

show this slide quickly that demonstrate the

survival of screen failures, so patients who were

not enrolled in ACS001 and those that were enrolled

into the placebo group.

But to go back to my previous thought, I

mean, they couldn't have enrolled 136 patients.

There were 105 transplants performed during the

enrollment period. The enrollment period didn't

stop early; the enrollment period had a three-year

duration and it stopped at that three-year

duration. It just didn't enroll the requisite

number of patients that it anticipated.

DR. SWENSON: I believe Dr. Proschan has

another question, but for the members of the panel

here, if you will just simply hit your "talk"

102

button we will be able to see the light on and you

needn't raise your hand. That will probably be

easier for us. Dr. Proschan?

DR. PROSCHAN: I guess I was just

following up on that because, you know, usually

even if it is the primary endpoint to stop early

there are boundaries that you use and, you know,

the commonly used boundary is called the

O'Brien-Flemming type of boundary, and this trial

would not have met that level of evidence. But

that is a concern, mainly motivated by my thinking

that the results were known at the time you stopped

and, therefore, the possibility on a random high.

DR. SWENSON: Dr. Moss?

DR. MOSS: I have a question I guess for

Dr. Noonberg but you, guys, might answer it too.

It has to do with the generalizability of your

results and I think you showed it on that slide.

Normally when you have figures on a study you say

we screened this many people; these many were

excluded and we were left with 10 percent of the

population. That wasn't included in any documents

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but I think you brought it out a little bit there

so could you just go over that and say, you know,

these many people were screened and these many were

excluded and you were left with what percentage of

the patients that were actually enrolled in the

study, so we can get an idea about the

generalizability of your data?

DR. SCAIFE: Dr. Noonberg?

DR. NOONBERG: You want to go back to that

last slide?

DR. MOSS: I think the data was there but

you never mentioned it before. You don't need the

slide, just how many people were screened and how

many were excluded and you were left with this many

people so we can see how generalizable your data

are.

DR. NOONBERG: Right. There were 105

transplants performed during the roughly 3-year

enrollment period and there were 68

patients--actually, 58 patients enrolled during

that 3-year period; 10 were enrolled the year

previous. So, approximately half and, as I say,

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the survival in the enrolled and the placebo

survival in the unenrolled group is comparable,

with a p value of 0.99.

DR. SWENSON: Dr. Venitz?

DR. VENITZ: I want to follow-up on Dr.

Hunsicker's question in a different way. He was

questioning the biology supporting localized

administration versus systemic administration. You

obviously looked at exposure to cyclosporine after

inhalation relative to oral or systemic

administration. Did you look at exposure to the

lung in either clinical or preclinical models and

compare systemic administration to inhalation?

DR. DILLY: We actually have access to

data on a scintigraphy study looking at labeled

inhaled cyclosporine, conducted by Dr. Corcoran at

the University of Pittsburgh, and I think it would

be extremely relevant to show you those data. I

will give you the editorial comment while Sarah

retrieves the slide.

But with the 300 mg dose put into a

nebulizer, what we have seen is that about 25 mg is

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the applied dose to the lung. That is achieving

dose levels in the lung that would require

approximately doubling of the systemic

immunosuppressive dose, and that is our central

premise, which is that that is not something that

you could routinely do in clinical practice because

of the toxicities.

DR. NOONBERG: Again, just going back to

the first animal experiments in 1988 where they

just gave single doses of inhaled cyclosporine,

they found that pulmonary concentrations were

10- to 100-fold higher than concentrations in other

tissues. In the rat model that I described

pulmonary concentrations were at least 3-fold

higher than systemic concentrations. So, that is

the data that we have for preclinical.

DR. VENITZ: Again just to follow-up, how

does that compare if you give cyclosporine

systemically? You are talking about what happens

after inhalation. Right? The levels in the lung

are higher than in other tissues, higher than in

plasma?

106

DR. NOONBERG: Right.

DR. VENITZ: And I am wondering how would

that compare if a dose of cyclosporine was given

intravenously to those animals. What lung

concentrations would you be able to achieve?

DR. DILLY: What we showed was a 25 mg

dose applied to the lung through inhalation. You

have to remember that when you put 300 mg into a

nebulizer an awful lot goes into the atmosphere and

an awful lot doesn't get into the lung. That 25 mg

applied dose, in terms of mg/g lung weight, equates

to approximately an 8-fold higher systemic dose.

If you assume 100 percent bioavailability of the

systemic dose you have given parenterally, that

would mean that you are looking at something like a

200 mg dose given orally to get to the same lung

levels. That is based on AUC calculations. If you

are thinking about peak levels, then the difference

is far greater because, of course, you get the

early distribution phenomenon into the lung.

DR. VENITZ: And that is in humans? Any

preclinical data to back that up?

107

DR. DILLY: Actually, that is in the

briefing book. The best data we got is in humans.

It is actually in the briefing book.

DR. SWENSON: Dr. Burdick?

DR. BARRETT: In Dr. Golden's presentation

he showed some data looking at BOS as a disease

progression marker. However, in the documentation

provided both BOS and FEV1 were not determined to

be significantly different between the two groups.

So, assuming chronic rejection as the indication

here for this product, can you give some reasons

why you think that occurred?

DR. SCAIFE: Dr. Bill Capra is the lead

statistician for Chiron.

DR. CAPRA: Actually, CyIS did show an

effect on BOS, specifically BOS-free survival. The

reason why our results are different than the FDA's

is that the FDA censors BOS in their analysis and

this is informative censoring. Because the reasons

for death are disease related, it is invalid to

censor deaths in a disease progression endpoint.

The FDA has recently issued a guidance on

108

this type of endpoint for oncology studies where

they recommend using a progression-free survival

endpoint in such an analysis rather than time to

progression analysis. If you do such an analysis

with this BOS what you see is an effect of

cyclosporine on improving BOS-free survival with a

p value of 0.99.

DR. BARRETT: Could you comment on the

FEV1 though?

DR. CAPRA: Sure. We looked at FEV1 in a

number of ways. We looked at change from baseline

to the final value; change from post-transplant to

the final value. We looked at time adjusted area

under the curves and we looked at slopes. In none

of these analyses did we see a statistical

significance. However, in each and every analysis

the point estimate favored the active group. As an

example, up here I have the results of the change

from baseline to the final value and we see that

the placebo group increased by 0.15 L and the

active group increased by 0.40 L. So, there seemed

to be a trend, however it was not statistically

109

significant.

We think there are some limitations to the

FEV1 analysis and we think one of the major

limitations is the informed censoring. Because

there is such a large number of deaths and because

the FEV1 values cannot be obtained from subjects

after they die it goes against censoring. Also,

FEV1 itself is highly variable. Any single subject

might have short-term fluctuations and what BOS

does is it basically ignores those short-term

fluctuations and looks for a sustained 20 percent

decrease. So, when you look at BOS, removing some

of that variability, and when you address the

informed censoring by use of progression-free

survival endpoint rather than time to progression

endpoint, we see an effect of cyclosporine on lung

function, namely, BOS-free survival with a p value

of 0.019.

DR. DILLY: Can I just add one

supplementary comment? This is exactly the kind of

question that we need to nail down in the next

study because what we want to do is take a large

110

group of patients, enroll them, nail down what

their lung function is and follow them over time

because, remember, the objective of this treatment

is to preserve the lungs in a good condition. So,

actually a no-effect on FEV1 in that context in a

large group of patients would be a great outcome,

and that is what we want to show next.

DR. SWENSON: Dr. Gay?

DR. GAY: My question is to follow Dr.

Moss' question from a while ago. I am still not

clear on the number of patients, why the number is

so small, the number of patients that were included

in the study. It is essentially a single-site

study in which every therapy is an off-label one

for the treatment of rejection in transplantation.

I am trying to get a grasp of why there were so

many screening failures, essentially 50 percent

screening failures in the study over the course of

the three years. Why weren't more patients

included or made available to be included in the

study, and what were the reasons for that?

DR. DILLY: In fact, what we would

111

consider the 50 percent enrollment of eligible

patients as quite good in a clinical study. Our

experience has been typically when we are trying to

enroll clinical trials, which is what we do for a

living, that we see something like 25-40 percent

enrollment into the study. So, when we went into

Pittsburgh and we looked at this whole body of data

we were quite reassured that the patients had gone

to the study in an elegant way; that about half of

them got into the study; and there was nothing

particularly strange about the patients that did

and the patients that didn't. So, we did not see

that as an issue and we came back to the fact that

we saw the data as robust.

DR. SWENSON: Dr. Prussin?

DR. PRUSSIN: I was impressed by the

heterogeneity in terms of the cyclosporine group in

terms of the dose that they received. You know,

some of the subjects received all the doses for the

full length of the study, and various documents

suggest that something like 9/36 received 1 month

or less. So, my question is did you ever stratify

112

the analysis for survival based on how much drug

they received? It is pretty impressive that 9 of

these patients received only a month of drug and

yet presumably had a fairly good survival.

DR. SCAIFE: Dr. Noonberg?

DR. NOONBERG: There are several responses

to that question. The first is that ACS001 wasn't

a dose-response study and we don't have formal

dose-response data. However, in one of our

sensitivity analyses we did exclude patients, 14,

who didn't receive at least 80 percent of the

protocol maximum dosing and they are excluded from

analysis. As would be expected, the p value is

going to go up due to loss of power, however, the

treatment effect is essentially unchanged.

DR. PRUSSIN: But on the flip side, why

did the patients who essentially didn't receive

drug respond to a drug they didn't get? That is

what I am more concerned about, not the ones that

did receive the drug. Yes, they responded even if

the p value is going to be higher, but the ones

that essentially were on the active side of the

113

protocol but who effectively did not receive drug

still had an effect in their survival. Correct?

DR. NOONBERG: I mean, we used an

intent-to-treat analysis so we include those

patients, but there are placebo patients that have

long-term survival too. This isn't a uniformly

fatal diagnosis so you would expect to see

variability in survival. But we include the

intent-to-treat analysis in accordance with

guidelines.

DR. SWENSON: Dr. Noonberg, I have a

question that somewhat follows up on that very same

one but is occasioned by one of your graphs here,

and that is you continue to see and, in fact, you

even highlighted that more patients seemed to be

prevented in their chronic rejection appearance

following the cessation of their two-year therapy,

if I read this graph correctly. Can you explain

why this drug may, in fact, have benefits beyond

its cessation?

DR. NOONBERG: The CR that is in green on

this graph doesn't represent new diagnoses of

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chronic rejection but, rather, deaths associated

with chronic rejection. So, they are not

necessarily new rejection episodes. So, this just

highlights the strong association of chronic

rejection with death and the fact that you don't

see that in the inhaled cyclosporine group. But

the chronic rejection episodes are actually

occurring throughout the process.

DR. SWENSON: Okay. Dr. Hunsicker?

DR. HUNSICKER: On that same graph, it was

not clear to me when you put that up--you don't

have to put it back up again, I think we have all

seen it--how you made the diagnosis of chronic

rejection in those cases. Was that either well

defined BOS or a biopsy, or was that a clinical

definition of chronic rejection based on the fact

the patient had died with lung disease?

DR. NOONBERG: It is either by

transbronchial biopsy with histologic proof of the

lesion of bronchiolitis obliterans or clinical

BOS--

DR. HUNSICKER: So, all of those patients

115

that had the CR in green there either had one or

the other?

DR. NOONBERG: Correct.

DR. HUNSICKER: I have a couple of other

questions just to be sure I am correct on this, you

referred to the analysis plan. First of all, there

was a prospective analysis plan that specified that

the total survival at the end of the study was to

be used as the primary outcome rather than the data

at the end of two years of treatment? I wasn't

quite sure. There were three or more different

types of analysis that were discussed in the

briefing books. What did the original prospective

analysis plan say was to be used as the primary

evaluation? Was it total survival at March 31, or

whatever it was, or was it supposed to be at the

end of the two years of treatment?

DR. NOONBERG: It should have been at the

end of the study. Dr. Aldo Iacona, the principal

investigator is nodding his head so, yes.

DR. PROSCHAN: But it was not survival; it

was acute rejection.

116

DR. HUNSICKER: Well, I understand--

DR. NOONBERG: Right, but the survival is

the secondary endpoint--

DR. PROSCHAN: We have so many secondary

endpoints to look at, we have to figure out which

endpoint we are looking at.

DR. HUNSICKER: And the second question I

have is that I thought I found in the briefing book

that of the ten patients who were put into the

so-called pilot thing, five of them had eventually

died. Is this correct?

DR. NOONBERG: That is correct.

DR. HUNSICKER: So, five out or ten

patients, and they received treatment for the full

two years or at least as much of the two full years

as one would have expected them to get?

DR. NOONBERG: Correct. When those

patients are included in the statistical analysis,

and that was one of the sensitivity analyses that

we performed, the results were still statistically

significant. They died but the timing of death is

very important, as well as the fact that they

117

died--

DR. HUNSICKER: Sure.

DR. NOONBERG: Here is a Kaplan-Meier of

survival from time of transplantation to study end

date including the randomized and the pilot, with a

p value of 0.018.

DR. SWENSON: At this time we should

break. I know there are more questions and they

can be taken up in our other discussion sessions

later today. We will reconvene at 10:15.

[Brief recess.]

DR. SWENSON: We should make a start on

the next session, and Dr. Hernandez, of the FDA,

will lead the discussion.

FDA Presentation

Overview of Clinical Trial Efficacy

and Safety Evaluation

Discussion of Analysis

DR. HERNANDEZ: Thank you. Good morning.

During this presentation I will describe the

Division's perspective on the application for

cyclosporine inhalation solution. I will start by

118

saying that this is not a regular NDA application.

The study, submitted to support the proposed

indication, is a small Phase II study that failed

to meet its primary endpoint for the prevention of

acute rejection. However, the potential for the

prevention of chronic rejection and improved

survival are very important aspects for the lung

transplant population for which long-term survival

is mostly limited by chronic rejection.

The agency considered that the potential

survival benefit in this specific transplant

population was reason enough to accept this new

drug application for review. The proposed

indication for cyclosporine inhalation solution

requested by Chiron is for increase in survival and

prevention of chronic rejection in patients who

receive allogeneic lung transplantation, in

combination with standard immunosuppression.

In my presentation I will give an overview

of the data submitted in this NDA. Then I will

summarize study ACS001 objectives, outcomes and

limitations. I will describe the FDA review which

119

will address the following subjects: Acute

rejection, obliterative bronchiolitis,

bronchiolitis obliterans syndrome and FEV1 data,

and survival. Then I will discuss the recipient

and baseline characteristics, donor baseline

characteristics, the primary causes of death,

available autopsy results, dosing information and

related outcomes and, finally, Dr. Cavaille-Coll

will give you a summary of the safety

considerations and our summary conclusions.

The data submitted to support this

application was derived from two reports generated

by Chiron Corp. That report was referred to as

ACS001 and ACS002. The study ACS001 is actually

the name given by Chiron to the study report that

summarizes the findings from the University of

Pittsburgh Medical Center, protocol 003. In this

protocol a total of 68 patients were studied in two

phases. First, 10 patients were enrolled in an

open phase and treated with cyclosporine inhalation

solution. Then the total of 58 patients were

randomized to cyclosporine inhalation solution

120

which contains propylene glycol as a vehicle or

propylene glycol vehicle alone.

From here I will refer to these groups as

cyclosporine inhalation solution as CyIS or

propylene glycol group as PG. Twenty-six patients

received CyIS and 30 patients received propylene

glycol vehicle. This was administered by

inhalation with a nebulizer. It should be noted

that all patients received concurrent

tacrolimus-based systemic immunosuppressive

therapy.

Study ACS002 was the name that Chiron

Corp. gave to the study report that summarizes the

findings on adverse events in 70 patients selected

from seven open-label studies conducted at UPMC. I

will refer to these study reports later. Also, I

will refer to the ACS001 study and study ACS002 to

avoid confusion.

The rest of my discussion will focus on

study ACS001, and the primary objective of this

study was to determine if cyclosporine delivered to

the lung allograft by inhalation prevents the

121

development of acute cellular rejection.

As you can see from this slide, the study

failed to show superiority of cyclosporine

inhalation solution over PG vehicle. The mean

number of acute rejections of grade 2 or higher per

patient was 1.3 in the cyclosporine arm and 1.2 in

the PG arm. The median number of acute rejections

grade 2 or higher was 1 in both arms. Therefore,

the study failed the primary endpoint.

However, we noted that the sponsor

reported a difference in mortality and obliterative

bronchiolitis between the two arms. In the study

report and database OB was reported as 1 for its

presence or 0 for its absence. No additional

histopathology information was provided. The

specimens for diagnosis of OB were obtained by

transbronchial biopsies.

The reporting mortality was 12 percent in

the CyIS arm and 40 percent in the PG arm. The

applicant noted that this represents a 79 percent

decrease in risk for mortality in this specific

population. The reported rate of bronchiolitis

122

obliterans or death was 19 percent in the CyIS arm

and 60 percent in the PG arm, with a reported p

value of 0.003. It should be noted that this

difference is mostly driven by the difference in

mortality.

In study ACS001 all patients were followed

up for three years after enrollment, and thereafter

were followed up to document mortality. At the

time of the study end when the last patient

completed two years of aerosolized treatment in

August, 2003, the mortality was 12 percent in the

cyclosporine arm and 40 percent in the PG arm.

Follow-up data obtained through July, 2004 was

submitted in the NDA and it showed mortality of 19

percent in the cyclosporine arm and 50 percent in

the PG arm. Additional information submitted in

the safety update in May, 2005 showed a mortality

rate of 31 percent in the CyIS arm and 50 percent

in the PG arm.

At the time the NDA was submitted to the

agency, the limitations of the study were known to

us. These included the following: This was a

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single-center Phase II study. There was a small

sample size. The study intended to enroll 136

patients. The case report forms were created

retrospectively. Therefore, some important

recipient and donor implementation was not

captured. Some data were not systematically

collected, for example, prospective routine

transbronchial biopsies. Some data were not

available, for example, some donor characteristics

or information on management on acute rejection

episodes grade 2 or higher that appeared prior to

enrollment.

FDA concerns included the lack of effect

on the primary endpoint. We also shared the

sponsor's concerns that the study may have become

unblinded. For example, patients at UPMC with

identification numbers ending in letters B or C

received cyclosporine inhalation solution, while

those patients with numbers ending in A or D

received PG. This may have allowed the

investigators to identify if a given patient was

receiving propylene glycol or cyclosporine

124

inhalation solution.

Protocol documentation was limited.

Chronic rejection or survival were not designed as

the primary endpoints. Furthermore, the protocol

for this study did not specify how secondary

endpoints would be analyzed, and there was no

pre-specified statistical analysis plan.

There were nine protocol amendments. The

study was stopped before completing enrollment.

There were various protocol violations and there

was no stratification by risk factors important for

chronic rejection or mortality. We can give an

example such as double lung versus single lung.

Despite randomization, there were imbalances in

baseline characteristics.

Now I would like to describe our approach

to the analysis of chronic rejection and mortality

in study ACS001. Acute rejection is considered a

major risk factor for the development of chronic

rejection or obliterative bronchiolitis, and a

number of acute rejection episodes experienced

early after transplantation are considered to have

125

a significant impact on the subsequent development

of OB.

Even though acute and chronic rejection

represent different histopathology and

pathophysiology, there is general consensus that

the frequency, intensity and duration of acute

rejection episodes are correlated with subsequent

development of obliterative bronchiolitis.

Strong evidence suggests that acute

rejection is the principal cause of chronic

allograft dysfunction. However, the role of other

immunologic and non-immunological factors have to

be considered. Therefore, we examined the

following data on acute rejection, obliterative

bronchiolitis histological findings, FEV1 and BOS

clinical manifestations of the disease, and

mortality as a clinical outcome.

Obliterative bronchiolitis is an important

cause of mortality after the first year from

transplantation, accounting approximately for 30

percent of deaths. FEV1 is the best surrogate

marker available for OB, and has been proven

126

successful in describing--very important--the

pattern of lung function decline, described as

acute or chronic BOS onset; the identification of

the main risk factors for BOS; and the extent and

the rate of progression of OB.

The International Society of Heart and

Lung Transplantation subcommittee has recommended

that the slope of serial FEV1 measurements over

time, before and after a therapeutic intervention,

should be used to compare treatment responses.

Therefore, if chronic rejection is

effectively prevented, we should expect to observe

an evident therapeutic effect on FEV1 and BOS.

Obliterative bronchiolitis, as defined in the study

report, was documented by transbronchial biopsies

and was found in 12 percent of the CyIS patients

and 30 percent of the propylene glycol patients.

Now there are three points that I would

like to make regarding FEV1. First, as you can

see, FEV1 values pre-enrollment, that is, after the

transplantation but before randomization to the

cyclosporine or PG arms, were not available in 40

127

percent if the patients. This data is shown in the

first row. Second, by 3 months there is FEV1 data

on essentially all patients, all 26 patients in the

CyIS arm and 26/30 in the PG patients. Third, you

will notice that there is a difference in mean FEV1

values between the 2 groups. At all point times

the mean FEV1 values are higher for the CyIS group

as compared to the PG group. Even before treatment

assignment higher mean FEV1 values were observed in

the cyclosporine inhalation group. This difference

may be attributable to the greater number of double

lung transplants that were performed in this group,

which we will discuss later in greater detail.

Here is a graphical presentation of the

data shown in the previous slide. You can see that

even though the FEV1 values in the cyclosporine

inhalation group are higher than the PG group, the

yellow line below, the two curves are essentially

parallel. Therefore, it does not appear that

cyclosporine inhalation solution has an effect on

FEV1.

Complete FEV1 values were not available so

128

BOS, bronchiolitis obliterans syndrome, as defined

by the International Society of Heart and Lung

Transplantation could not be calculated using these

criteria. Therefore, an alternative definition of

BOS, defined by the sponsor and qualified by an

independent investigator was used.

As seen in this graph, the time to BOS

between the 2 arms is similar, and the log-rank b

value is 0.214. This also indicates that the

cyclosporine inhalation solution has no effect on

BOS. Patients who died without double-blind of

BOS, as defined by the applicant, were censored at

the time of the last follow-up for BOS.

We observed a difference in OB and

mortality at the end of the study in August, 2003.

OB was present in 12 percent in the cyclosporine

inhalation solution versus 30 percent in the PG

group. Mortality was 12 percent in the CyIS arm

versus 47 percent in the PG group. No difference

was observed in acute rejection, FEV1 or BOS. As a

clinician, FEV1 values are really, really

important. Questions like "how are you breathing"

129

are really important questions.

The association between acute rejection

and chronic rejection and the effect on patients

and graft survival is well documented in registry

and published literature. Acute rejection is a

major risk factor for the development of chronic

rejection or obliterative bronchiolitis. In light

of the strong association between acute rejection

and chronic rejection, the difference observed in

OB was not expected in the absence of differences

in acute rejection, FEV1 or BOS, and this warrants

further exploration.

Therefore, we asked the question is the

mortality difference between cyclosporine

inhalation solution and PG in the absence of

differences in acute rejection, FEV1 or BOS due to

treatment effect or could other factors account for

this difference? For example, difference in

baseline characteristics of donors and recipients

between the study arms, or other factors such as

study conduct.

I want to remind you that there was no

130

difference in acute rejection grade 2 or higher at

randomization to the drug or to the placebo arm.

In contrast, there is a clinical and meaningful

difference in acute rejection grade 2 or higher

before treatment assignment. Thirty-one percent in

the CyIS arm and 42 percent in the PG patients had

grade 2 or higher acute rejection prior to

enrollment. Although data were incomplete,

approximately 40 percent of the CyIS allografts and

50 percent of the PG allografts were colonized with

bacteria or fungi. So, this data is incomplete but

I still think it is worth mentioning it. So, if we

assume that patients who had acute rejection grade

2 or higher prior to enrollment received some type

of steroid treatment or any other treatment

augmentation, they could be predisposed to

infectious complications such as pneumonia or

sepsis.

Now I will discuss other imbalances in

patient characteristics. There is well documented

association between the type of lung transplant and

survival. In this study there is an imbalance in

131

the number of single lung and double lung

transplants between the two arms. Single lung

transplants were done in 58 percent in the CyIS arm

and 80 percent of the PG patients. Conversely,

double lung transplants were done in 42 percent of

the CyIS patients and 20 percent of the PG

patients. This difference is statistically

significant at a level of 10 percent. FEV1

pre-enrollment was lower in the PG arm and may be a

reflection of more single lung transplants in this

group.

The imbalance between single and double

lung transplant is important. The literature and

registry data show an advantage for long-term

survival and freedom from BOS in double versus

single lung transplants. Single lung

transplantation is associated with lower exercise

tolerance, poorer pulmonary mechanics, and higher

infectious complications such as pneumonia.

The International Society of Heart and

Lung Transplant registry data show that the there

is a difference in survival between single and

132

double lung transplant patients. The half-life of

double lung transplant patients is 5.3 years, as

shown in the top line, while the half-life for

single lung transplants is 3.9 years. The average

survival is shown in green in this graph.

As noted before, the information on donor

characteristics was incomplete. Therefore, we

examined the data available that was informative

about the state of the donor lung, and we noted a

difference in donor inotropic support. Fifty

percent of the donor lung transplantations to the

CyIS patients and 83 percent of the donor lung

transplantations to the PG arm came from donors

that received inotropic support.

PaO2/FiO2 ratio is an indicator of the

severity of acute lung injury and it is useful to

indirectly assess the degree of ischemic

re-perfusion injury sustained by an allograft.

PaO2/FiO2 ratio of greater than 200 percent

indicates limited alveolar damage and gas exchange.

Another difference between the two arms

was the time in the ICU. While most of the

133

patients stayed in the ICU for less than 10 days, 4

percent in the cyclosporine arm patients and 20

percent in the PG patients were in the ICU for more

than 10 days, and this is kind of important in a

single center where the criteria for keeping the

patients in the ICU pretty much remained the same

The other important thing is that it will reflect

how the patients are in terms of degree of severity

of the disease. Patients are not allowed to go out

of the ICU if there is something that still needs

to be taken care of. So, it is a good reflection

of the degree of sickness that these patients have.

PaO1/FiO2 ratio is an indicator of the

ability of the lung to perform adequate gas

exchange, and it is useful to indirectly assess the

severity of acute allograft injury. The baseline

PaO2/FiO2 ratio on ICU admission was worse in the

PG group, suggesting a major degree of ischemic

re-perfusion injury in these allografts. Also,

perioperative renal dysfunction was in 4 percent in

the cyclosporine inhalation solution and 13 percent

in the PG patients. Prolonged ICU stay, inadequate

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gas exchange and perioperative renal dysfunction

are factors that reflect a more severe condition

after surgery.

We also looked at the time to the first

pneumonia. As noted, there were more cases of

pneumonia in the PG arm and this was within the

first one to two months of the study. The outcome

in patients with these pneumonias is summarized in

the next slide.

A large number of patients in the PG arm

had early pneumonias and there was a strong

relationship between pneumonia and death. The

relationship is not surprising given what we know

about the causes of death after lung

transplantation. The occurrence of these early

pneumonias is not likely to be related to any

treatment effect but may be related to baseline

donor and recipient characteristics or other events

which occurred prior to enrollment. These events

include but are not limited to episodes of acute

rejection requiring additional immunosuppressive

therapy or microbial colonization of the graft.

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I would like to underline that early

pneumonia may lead to histopathological findings

compatible with obliterative bronchiolitis. This

has been documented to be a risk factor for the

development of obliterative bronchiolitis. There

were five patients in cyclosporine inhalation

solution arm and two patients in the PG arm who

developed pneumonia in the first month. By two

months there were an additional three PG patients

with pneumonia. Of these patients that developed

pneumonia, 2/5 died in the cyclosporine arm and

7/13 in the PG arm; 1/5 developed OB in the

cyclosporine inhalation solution and 7/13 in the PG

group; and BOS was observed in 3/5 in the CyIS arm

and 3/13 in the PG arm.

I want to make two observations. There is

a strong association between early pneumonia and

risk of death. Second, early pulmonary infections

and early acute rejection episodes are well

recognized risk factors for the subsequent

development of chronic rejection.

This table show the primary causes of

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death by July, 2004. Three patients in the

cyclosporine inhalation solution arm and seven

patients in the PG group died of infections,

pneumonia or sepsis. In the CyIS arm one patient

died of graft failure and in one patient the cause

was unknown. In the PG group two patients died of

OB; one patient died of pulmonary embolism and

another from congestive heart failure, and one from

lung cancer. There were three patients in which

the cause of death was unknown. The distribution

of causes of death is consistent with registry data

where infections remain the major cause of death

during the first year after transplantation while

chronic rejection begins to become an important

cause of death after one year, as seen in table 3,

reference 1 in your background package.

Autopsy results--from the available data

in the application CRFs, narratives and data sets

we learned that some patients who died had autopsy

performed. In the cyclosporine inhalation solution

arm one patient had autopsy and OB was not

reported. In the propylene glycol arm 15 patients

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died and there were six autopsies. In two of these

OB was reported and four of them died of infection,

and there was no OB reported out of the six

reports.

The protocol specified that patients

should receive treatment for two years. The dose

should be titrated from 100 mg to 300 mg for the

first three days of treatment, then daily dosing up

to three consecutive days with the maximum

tolerated dose, and thereafter three times weekly

dosing for two years. There was a lot of

variability in individual patient dosing in this

trial.

This table shows the number of doses

received by patients. The protocol dosing schedule

was not followed in many patients. In fact, six

CyIS and five PG patients received less than 25

doses, as you can see circled in this slide. The

large variation in the number of doses received

makes it difficult to establish a relationship

between the specific treatment regimen and the

improvement in survival.

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Six cyclosporine inhalation solution

patients who received less than 25 doses are shown

on this table. Two patients received a single

dose; others received 3, 12, 13 and 24 doses

respectively. The doses show that not all patients

succeeded in titrating up to 300 mg. Five out of

these six patients experienced adverse events

directly related to the administration of the

cyclosporine inhalation solution, and three

patients discontinued due to adverse events, and

three additional patients withdrew consent. We

noted, however, that all six patients survived and

all are included in the mortality calculations as

cyclosporine inhalation solution successes.

There were five patients in the PG arm who

received less than 25 doses and, as can be seen,

four/five died. Could these be attributable to the

lack of cyclosporine inhalation solution? All

these deaths are included in the mortality

calculation as PG failures.

In addition to the 3 cyclosporine

inhalation solution who withdrew consent after

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receiving 1, 3 and 13 doses, 3 additional patients

withdrew consent--these are the last 3 rows in this

slide--1 at 4 months and 2 others at 20 months.

The right-hand column shows that 2 of these 3

additional patients survived.

At this point I would like to turn the

podium over to Dr. Cavaille-Coll to discuss our

safety considerations and give our conclusions.

Safety Considerations and Conclusions

DR. CAVAILLE-COLL: Good morning. We are

in general agreement with the applicant that the

systemic safety profile of cyclosporine after oral

or intravenous administration is well characterized

and that the amount of systemic exposure to

cyclosporine, meaning what was deposited in the

lung and entered in the bloodstream before being

eliminated, was not associated with detectable

increases in systemic toxicity. There is more

limited information on the safety of cyclosporine

when administered by inhalation in a propylene

glycol solution.

As you have heard, propylene glycol is

140

classified as an additive that is generally

recognized as safe for use in food, mainly through

studies using oral and dermal exposure. It is used

to absorb extra water and maintain moisture in

certain medicines, cosmetics or food products. It

is a solvent for food colors and flavors. However,

information on the inhalation toxicity of propylene

glycol is more limited. There is no approved

product for inhalation containing nearly 100

percent propylene glycol such as this product.

The applicant has submitted some

preclinical safety data, including a 28-day study

in dogs and a 28-day inhalation study in rats. The

28-day inhalation study in dogs demonstrated lung

irritation, alveolar and interstitial inflammation

in all cyclosporine dose groups and the vehicle

control. Laryngeal inflammation with ulceration

was seen in the mid-dose group males. Inflammatory

cell infiltrates, lymphocytes, plasma cells,

monocytes were seen in the control and treated

group as well. The dog studies did not contain a

sham control. Thus, this confounded the separation

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of the extent of pulmonary toxicity due to

cyclosporine versus that of the propylene glycol

vehicle. No additional cyclosporine inhalation

toxicity was observed in the animals. Dose levels

in the dogs were limited, however, by the maximum

feasible dose. However, serum cyclosporine levels

in the high dose group exceeded the human exposure

by 2.5-fold.

Again, there were also studies that were

done in rats which showed similar findings, except

that the doses in rats did exceed about 80-fold the

human exposure and there was evidence of increasing

toxicity with increasing doses of cyclosporine.

The rat studies did include an air control and did

show that even in the propylene glycol group there

were findings that were not present in the sham

control animals.

I would like to address now the clinical

safety. In the usual safety review we would look

at the rates of adverse events, the grade of

severity, the duration of the events and their

reversibility, as well as the temporal relationship

142

to dosing with the study drug. Collection of such

information is facilitated by the use of

prospectively designed case report forms. The

latter often provide another very useful source of

safety information in the form of handwritten

comments by the investigators on the margins of the

pages of the case report forms. Such forms and

comments were not available and it is in the

context of these limitations that we must evaluate

the safety of this product. Evaluation of safety

in this fragile population receiving systemic

immunosuppression and numerous medications is

admittedly complicated.

There are no prospectively designed case

report forms to guide the systematic collection of

safety data throughout the conduct of the study

including but not limited to the use of concomitant

medications used to prevent or treat the

complications associated with the administration of

study drug. Clinical safety data was collected

retrospectively from source materials from one

double-blind, controlled study and a number of

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small open-label, uncontrolled studies at the

University of Pittsburgh Medical Center.

Comparative safety data is available on only 26

randomized subjects in study ACS001, or 36 subjects

that include the first 10 non-randomized subjects

from the study. Additional non-comparative safety

data was obtained in report ACS002 by pooling data

from seven open-label, uncontrolled studies that

enrolled 70 lung transplant recipients who were

receiving similar tacrolimus-based systemic

immunosuppression.

Subjects in study ACS001 were titrated in

a double-blind fashion to a maximum tolerated dose

not to exceed 300 mg or the propylene glycol

control equivalent. That dose was then to be

administered three times a week for up to two

years. As mentioned earlier, there was a great

variation in dose, 100 mg to 300 mg per day, the

number of doses administered and, consequently,

duration of exposure. I think we have seen those

slides before. Subjects also received per protocol

premedication with aerosolized lidocaine and

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bronchodilators to improve tolerance.

This slide comes from the integrated

summary of safety and lists basically the adverse

events that occurred with a statistical

significance of greater than 10 percent. I think

we are in general agreement with the applicant's

description of the safety data they were able to

collect. We do note that there seemed to have been

more respiratory, and thoracic adverse events in

the cyclosporine group compared to the propylene

glycol group. In all these categories, of course,

as I mentioned before, the significance was greater

than 10 percent. As in the 28-day preclinical

animal studies, there was a sham treatment group to

help discern the potential contribution of inhaled

propylene glycol to the respiratory tolerability in

both treatment groups. Here we do see that more

events occurred in the cyclosporine group. These

findings in general are consistent with the

respiratory safety findings that were found in the

28-day preclinical animal studies.

Another thing we look at when we are

145

evaluating safety is the discontinuations and

withdrawal of consent. Although a greater

proportion of subjects in the propylene glycol

group, 33 percent, were reported to discontinue

study drug due to an adverse event, other than

death, than in the cyclosporine group, 15 percent,

this comparison must be interpreted with caution.

Six patients in the cyclosporine group, or

23 percent, were reported to have discontinued due

to withdrawal consent compared to none in the

propylene glycol group. Further examination of the

individual case report forms revealed a number of

respiratory adverse events associated with the

study drug administration which could have

influenced their continued willingness to

participate in the study. Taken together, a

similar proportion of subjects discontinued study

drug due to adverse events or tolerability in the

propylene glycol group and the cyclosporine group.

We also have some non-comparative data

that was presented in report ACS002 from a pool of

70 lung transplant recipients. Again, these

146

represent a variety of lung transplant types,

mostly patients with refractory acute rejection

and/or OB who were treated with cyclosporine

inhalation solution in seven open-label,

uncontrolled studies at UPMC. They were also

receiving systemic tacrolimus-based

immunosuppression. These, again, represent an

experience of a wide range of dosing and duration

of treatment, which is really very difficult to

interpret. Patients were generally administered

the maximum tolerated dose which was individualized

and depended on the characteristics of the patients

and their response to medication.

In summary, the overall safety database is

smaller than usually expected in a commercial

application. Respiratory adverse events were

common despite premedication and limited the

maximum doses used and the durations of the