Biologic Lung Volume Reduction (BioLVR) In Advanced Upper Lobe Emphysema: Phase 2 Results

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1 Page 1 of 38 AJRCCM Articles in Press. Published on January 29, 2009 as doi: /rccm oc Biologic Lung Volume Reduction (BioLVR) In Advanced Upper Lobe Emphysema: Phase 2 Results Gerard J. Criner 1, Victor Pinto-Plata 2, Charlie Strange 3, Mark Dransfield 4, Mark Gotfried 5, William Leeds 6, Geoffrey McLennan 7, Yael Refaely 8, Sanjiv Tewari 9, Mark Krasna 10 and Bartolome Celli 2 1. Temple University, Philadelphia, PA, USA. 2. Caritas-St. Elizabeth s Medical Center, Boston, MA, USA. 3. Medical University of South Carolina, Charleston, SC, USA. 4. University of Alabama Birmingham, Birmingham, AL, USA. 5. Pulmonary Associates, Phoenix, AZ, USA. 6. Veritas Clinical Specialties, Topeka, KS, USA. 7. University of Iowa, Iowa City, Iowa, USA. 8. Rabin Medical Center, Tel Aviv, Israel. 9. Akron Medical Center, Akron, Ohio, USA. 10. St. Joseph s Medical Center, Baltimore, Maryland, USA. Corresponding Author: Gerard J.Criner MD Director, Pulmonary and Critical Care Medicine And Temple Lung Center Temple University School of Medicine 745 Parkinson Pavilion 3401 North Broad Street Philadelphia, Pa Phone: Fax: crinerg@tuhs.temple.edu Source of support for study: Aeris Therapeutics, Inc., Woburn, MA Running head: Biologic Lung Volume Reduction (BioLVR) Number of Figures: 3 1 Copyright (C) 2009 by the American Thoracic Society.

2 Page 2 of 38 Number of Tables: 3 Word count Main body: 3689 This article has an online data supplement which is available from this issue's table of content online at 2

3 Page 3 of 38 Abstract: Context: Biologic Lung Volume Reduction (BioLVR) is a new endobronchial treatment for advanced emphysema that reduces lung volume through tissue remodeling. Study Objective: Assess the safety and therapeutic dose of BioLVR Hydrogel in upper lobe predominant (ULP) emphysema Study Design: Open labeled, multicenter Phase 2 dose-ranging studies were performed with BioLVR Hydrogel administered to 8 subsegmental sites (4 in each upper lobe) involving: 1) low dose treatment (n = 28) with 10 ml per site (LD); and 2) high dose treatment (n=22) with 20 ml per site (HD). Safety was assessed by the incidence of serious medical complications. Efficacy was assessed by change from baseline in pulmonary function tests, dyspnea score, 6 minute walk distance, and health related quality of life (HRQOL). Results: Following treatment there were no deaths and 4 serious treatment-related complications. A reduction in RV/TLC at 12-weeks (primary efficacy outcome) was achieved with both LD (-6.4±9.3%, p=0.002) and HD (-5.5±9.4%, p=0.028) treatments. Improvements in pulmonary function in HD (6 months: ΔFEV 1 = +15.6% (p=0.002), ΔFVC = +9.1% (p=0.034)) were greater than in LD patients (6 months: ΔFEV 1 = +6.7% (p=0.021), ΔFVC = +5.1% (p=0.139)). LD and HD treated groups both demonstrated improved symptom scores and HRQOL. Conclusions: BioLVR improves physiology and functional outcomes up to 6 months with an acceptable safety profile in ULP emphysema. Overall improvement was larger, and responses more durable with 20 ml/site than 10 ml/site dosing. 3

4 Page 4 of 38 Keywords: Pulmonary emphysema, emphysema, chronic obstructive pulmonary disease, COPD, biologic lung volume reduction, BioLVR, bronchoscopic lung volume reduction, lung volume reduction, lung volume reduction surgery, LVRS. Clinical trial registry information: NCT and NCT registered at 4

5 Page 5 of 38 Introduction Lung hyperinflation in moderate to severe emphysema is associated with expiratory airflow limitation, reduced exercise capacity, and dyspnea that is only partially responsive to bronchodilator therapy. 1-3 Lung Volume Reduction Surgery (LVRS), a treatment that decreases hyperinflation through targeted resection of damaged tissue, improves physiology, symptoms, exercise capacity and survival in selected patients 4, 5 However, LVRS is associated with high morbidity, requires hospitalization for 8 to 14 days, and has an operative mortality of 5% to 20%. 6-8 Despite its potential benefits, these limitations have diminished the clinical application of LVRS in patients with advanced emphysema, such that current estimates suggest only procedures are performed annually in the United States. Biologic Lung Volume Reduction (BioLVR) is an novel endobronchial therapy that reduces lung volume via administration of a fibrinogen biopharmaceutical suspension and thrombin solution that polymerize in situ to form a hydrogel The hydrogel contains biodegradable complexes of poly-l-lysine and chondroitin sulfate that initiate a localized inflammatory reaction which collapses, remodels, and volume-reduces areas of emphysematous lung over 3 to 6 weeks. BioLVR therapy has been tested in large animal models, and its safety demonstrated in Phase 1 clinical trials at sub-therapeutic doses. The objective of this study was to characterize the safety, efficacy, and radiographic response to BioLVR out to 6 months following bilateral dosing with either 10 ml/site (low dose or LD) or 20 ml/site (high dose or HD) at 8 pulmonary subsegments. 5

6 Page 6 of 38 Methods Patient Selection Criteria: Enrollment was limited to patients with symptomatic GOLD (Global Initiative on Chronic Obstructive Pulmonary Disease) Stage III and IV chronic obstructive pulmonary disease with clinical and radiographic features of emphysema. 12 All study participants were either ineligible for, or had refused LVRS. Additional specific inclusion criteria were: 1) upper lobe predominant emphysema on high resolution CT images as determined by principal investigators in consultation with their thoracic radiologist; 2) persistent moderate to severe dyspnea; 3) age > 40 yrs; 4) forced expiratory volume in 1 second (FEV 1 ) to forced vital capacity (FVC) ratio < 70% and FEV 1 < 45% predicted; 5) total lung capacity (TLC) > 110% predicted and residual volume (RV) > 150% predicted. Study exclusion criteria were: 1) bullous emphysema (single lesion > 5 cm in largest dimension on CT scan); 2) co-morbid conditions that increased anesthesia or bronchoscopy risk; 3) alpha-1 anti-protease deficiency; 4) pulmonary hypertension (e.g., pulmonary systolic pressure > 45 mm Hg); 5) smoking within 4 months of enrollment; and 6) high risk for LVRS mortality (i.e., FEV 1 < 20% predicted and diffusing capacity (DLco) < 20% predicted). 13 Study Design Results summarized here are from three Phase 2 trials performed between February 2007 and August 2008 to define the optimal BioLVR dose to safely produce therapeutic lung reduction in ULP emphysema. The trials were identical in design except for dosing strategy and number and location of participating centers (Figure 1, Flow Diagram). All trials were open- 6

7 Page 7 of 38 labeled, non-randomized, and non-controlled. The first trial, performed at a single site (Israel), evaluated LD therapy in 8 patients. The second trial (at 5 sites) performed concurrently in the United States (US), evaluated LD therapy in 20 patients. The third trial (at 8 sites) was initiated following completion of enrollment in the LD studies and evaluated HD therapy in 22 US patients. All protocols were reviewed and approved by the appropriate national regulatory agencies and committees at the participating hospitals. All patients provided written informed consent at study enrollment. Patients were organized into two treatment groups. The Low Dose (LD) group included 28 patients treated with 10 ml/subsegment of BioLVR Hydrogel at eight sites, four in each lung. Fourteen LD patients received treatment during two sessions separated by 6 to 12 weeks, and fourteen received treatment during a single session. The High Dose (HD) group included 22 treated with 20 ml/subsegment of BioLVR Hydrogel at eight sites, four in each lung. Ten HD patients received treatment during two sessions separated by 6 to 12 weeks, and twelve received treatment during a single session. Screening evaluations were completed over three separate visits within a two-week window. Pulmonary function (spirometry, lung volume measurements, and diffusing capacity) and 6 MWT were performed according to published guidelines Echocardiography, electrocardiography, clinical pathology (hematology, coagulation studies, and serum chemistry measurements), Medical Research Council Dyspnea (MRCD) score, Basal Dyspnea Index/Transitional Dyspnea Index (BDI/TDI) score, health status assessment using the St. 7

8 Page 8 of 38 George s Respiratory Questionnaire (SGRQ), and high resolution chest CT (HRCT) were performed once during screening. Description of the BioLVR Procedure The most damaged lung segments were selected for BioLVR by pre-procedural HRCT. Back-up treatment sites were identified in case of inaccessible primary sites. The flexible bronchoscope was advanced into the subsegmental orifice of the airway selected for treatment and wedged to prevent reagent backflow during administration. A dual lumen catheter (medical grade Pebax construction, O.D mm) was guided distally under direct vision until the tip was 3-4 cm beyond the end of the bronchoscope. Syringes containing the two BioLVR reagents, Fibrinogen Suspension and Thrombin Solution, were connected to the appropriate luer connectors of the catheter and proportionately delivered using a handheld administration device over seconds to ensure rapid polymerization of the Hydrogel. Immediately following delivery of the Hydrogel, 60 ml of air was injected twice through the instrument channel of the scope to push the reagents peripherally. After 30 seconds, the bronchoscope was repositioned at the next treatment site. BioLVR treatments were performed in the operating room under general anesthesia (n = 9 LD patients, n = 1 HD patient) or conscious sedation (n = 2 LD patients, n = 6 HD patients), or in the bronchoscopy suite under conscious sedation (n=13 LD patients, n=15 HD patients) depending upon investigator preference. 8

9 Page 9 of 38 Outcome Measures The primary efficacy endpoint was a reduction in gas trapping measured by a decrease in RV/TLC at three months compared to baseline. Additional efficacy measures included changes from baseline to 6 months in RV/TLC, and changes at 3 and 6 months in post bronchodilator FEV 1, FVC, DLco, 6 MWT distance, Medical Research Council Dyspnea (MRCD) score, Basal Dyspnea Index/Transitional Dyspnea Index (BDI/TDI) score, and the St. George s Respiratory Questionnaire (SGRQ) total domain score. Changes from baseline in mean response, and a responder analysis, in which the percentage of patients demonstrating a clinically meaningful improvement from baseline for outcome measures where minimal clinically important difference (MCID) criteria exist, were performed at each follow-up time point. 18, 19 Radiological responses to BioLVR were assessed after 6 weeks to determine the location and extent of tissue remodeling, and to assess mediastinal or pleural changes. Safety BioLVR safety was assessed in terms of the incidence of serious medical complications and adverse events observed during the study. A serious medical complication was prospectively defined as: 1) death; 2) respiratory failure > 24 hours duration; 3) pneumothorax; 4) pneumonia; 5) empyema; 6) lung abscess; 7) pulmonary embolus; 8) heart failure; 9) cardiac ischemia or myocardial infarction; 10) cardiac arrhythmia requiring medical treatment; 11) severe COPD exacerbations requiring admission to an intensive care unit; 12) a decline in lung 9

10 Page 10 of 38 physiology post-treatment resulting in permanent loss of function. The definition incorporated the definitions of major pulmonary or cardiac morbidity used in the NETT, as well as other significant medical complications indentified by BioLVR investigators as potentially associated with BioLVR therapy. 20 Data Presentation, Retention of Subjects, and Statistical Analysis Safety results were available for 27 of 28 patients in the LD group, and 20 of 22 patients in the HD group out to 6 months. Efficacy results were available for 26 of 28 patients in the LD group, and 17 of 22 patients in the HD group out to 6 months (Figure 1, Flow Diagram). Baseline demographics, medication usage, incidence of serious medical complications and adverse events, and magnitude of improvement in physiological and functional outcomes were similar for patients treated during a single treatment session and during 2 separate sessions among both LD and HD patients. Therefore, at each dose, results for patients treated during a single session were combined with those of patients treated over 2 sessions for analysis. All efficacy results are reported relative to completion of bilateral therapy. One patient in the LD treatment group did not complete the study as per protocol. This patient withdrew after week 6 follow-up because of worsening symptoms associated with preexisting Alzheimer s disease. Five patients in the HD treatment group did not complete the study as per protocol. One failed to return for follow-up and did not respond to correspondence from the investigating site. A second withdrew from the study 6 weeks after completing unilateral treatment to undergo a lung transplant due to lack of therapeutic benefit from BioLVR treatment. Three additional patients scheduled to receive split dose therapy did not complete screening for 10

11 Page 11 of 38 their second treatment within the time window defined by the protocol due to personal conflicts, and were ineligible for completion therapy. These three patients continued to participate in the safety and intention to treat portion of the study. Efficacy outcomes at 6 weeks, and 3 and 6 months post bilateral treatment were compared to baseline. Results are reported as the percentage change from baseline for FEV 1, FVC, and RV/TLC ratio, and absolute change from baseline in appropriate units for MRCD, TDI, 6 MWT distance, and SGRQ. The statistical significance of changes from baseline for each outcome was assessed by two-tailed paired t-test. Statistical significance of outcome measures included in the responder analysis was assessed using the Fisher 2-tailed Exact Test. Statistical significance was defined as a P value < Safety outcome measures are summarized using descriptive statistics. Results Baseline demographics Every center enrolled at least 1 patient (range 1 to 16 patients/center). Demographics at enrollment are summarized in Table 1. LD and HD treatment groups were similar in age, gender distribution, smoking history, and medication usage. Oxygen usage at rest, with activity, and during sleep was greater in HD than in LD. A larger fraction of HD patients had participated in pulmonary rehabilitation before study enrollment compared to LD. Body mass index was greater in HD compared to LD, but within the normal range in both groups. 11

12 Page 12 of 38 Baseline physiological and functional parameters are summarized in Table 2. 6 MWT distance was significantly lower in HD than LD patients. HD patients had a lower mean FEV 1, lower % predicted FEV 1, and lower FEV 1 /FVC ratio than LD patients. Safety Results No deaths were encountered in either treatment group. There were three adverse events meeting the definition of a Serious Medical Complication in the LD group. One patient developed aspiration pneumonia after eating 8 hours following BioLVR, and then had a myocardial infarction. This patient recovered with medical therapy after a 2 week hospitalization. Another patient developed pleuritic chest pain 2 days following BioLVR, received analgesics, fell, fractured her leg and experienced myocardial ischemia. This patient responded to medical treatment after a 5 day hospitalization. A third patient developed pneumonia four days after BioLVR. This patient was evaluated in an emergency room, and recovered with outpatient medical therapy. There was one adverse event meeting the definition of a Serious Medical Complication in the HD group. This patient developed a deep venous thrombosis and pulmonary embolus four days post procedure. This event developed within a week of therapy, and prolonged the initial hospitalization by 6 days. Other medically significant adverse events were observed following BioLVR treatment that required treatment. BioLVR was predictably associated with leukocytosis, fever, and/or malaise within 8 to 24 hours of treatment in 22 of 25 LD patients, and 20 of 22 HD patients. In most cases, this treatment-related reaction was self limited and resolved within hours. This reaction was primarily responsible for determining duration of hospitalization, which was 12

13 Page 13 of ±1.44 days (Range 1-8 days) for LD patients and 2.0±1.71 days (Range 1-8 days) for HD patients. A substantial fraction of patients experiencing post-treatment inflammatory reactions also developed transient shortness of breath. Respiratory symptoms were considered to be due to the post-biolvr inflammatory reaction if they developed within 24 hours of treatment and resolved concurrently with fever and malaise. Respiratory compromise of longer duration was attributed to a COPD exacerbation. COPD exacerbations within the first 6 months of treatment were observed in five of twenty-eight LD patients. Four of these occurred in the peri-procedural period, required in-hospital treatment, and were attributed to the BioLVR procedure. One exacerbation occurred several months after the procedure (on Day 130 post treatment) and was believed not to be related to treatment. This was of moderate severity, required hospitalization for 1 week, and resolved with bronchodilators, antibiotics, and steroids. COPD exacerbations within the first 6 months of treatment were observed in nine of twenty-two HD patients. Five of these occurred in the peri-procedure period, required hospitalization, and were attributed to the BioLVR procedure. The remaining 4 events occurred between 2 weeks and 2 months after treatment (on Days 14, 23, 38, and 63). Two were felt to possibly be associated with therapy (Day 14 and Day 23 events). All were of moderate severity and required hospitalization and intensification of medical treatment. Efficacy Results The primary endpoint, a statistically significant reduction in RV/TLC at 3 months, was achieved with both dosing regimens. Additional efficacy data out to 6 months are summarized in Table 3. At 6 weeks, both treatments were associated with statistically significant increases in FEV 1 and FVC, reductions in RV/TLC, reduced symptoms of dyspnea (by the MRCD and 13

14 Page 14 of 38 BDI/TDI dyspnea scores), and improvements in HRQOL. At 3-month follow-up, favorable responses in FEV 1, FVC, RV/TLC, dyspnea scores, and HRQOL were sustained in both treatment groups. DLco did not change significantly in either group. At 6-month follow-up, FEV 1 remained significantly better than baseline in the LD group, but improvements from baseline in FVC, RV and RV/TLC were no longer statistically significant. By contrast, improvements in all physiological outcome measures remained significantly improved compared to baseline in HD patients. The mean improvement in FEV 1 at 6 months following HD therapy was 15.6±16.8% compared to 6.7±12.9% following LD therapy (p=0.07). Responder Analysis Figure 2 shows the percentage of patients in each treatment group meeting established MCID criteria according to the American Thoracic Society and European Respiratory Society for outcome measures where such criteria exist. 18 The percentage of LD patients meeting MCID criteria for FEV 1 and FVC declined over time. By comparison, HD patients had only a small decline in response rates for FEV 1 between 3 and 6 months, whereas response rates for FVC increased. The fraction of patients in both treatment groups experiencing MCID improvements in dyspnea scores, HRQOL, and 6 MWT distance, remained stable between 6 weeks and 3 months follow-up, but decreased at 6 months. 14

15 Page 15 of 38 Radiologic Responses to BioLVR Neither LD nor HD BioLVR was associated with radiologic evidence of scarring outside of treatment sites, or with treatment-related mediastinal or pleural pathology. At 6 weeks, radiologic scarring was observed at 57±17% of LD treatment sites, and 68±20% of HD treatment sites. The number of sites demonstrating remodeling at 6 weeks correlated with improvement in FEV 1 at 6 weeks for LD (r = 0.36, p=0.05, n=27) and HD (r = 0.57, p=0.015, n=19) patients. This correlation was sustained at 6 months for HD (r=0.51, p=0.030) patients, but not for LD (r=0.25, p>0.10) patients. HRCT images showing the pattern of remodeling among LD and HD patients are presented in Figure 3. Discussion BioLVR is a first-in-class biopharmaceutical that reduces hyperinflation by initiating a localized inflammatory reaction, which collapses nonfunctional emphysematous lung to nonsurgically produce therapeutic lung volume reduction. We show that BioLVR reagents instilled in 8 subsegments can safely reduce lung volumes and improve pulmonary function with an acceptable side effect profile. There were no deaths during the course of our study. Four medical complications defined as serious occurred over 69 treatment sessions. Procedurerelated COPD exacerbations were observed in 11 of 50 patients. All required hospitalization and were clinically significant, but resolved with conventional medical treatment and without longterm sequelae. BioLVR produced changes in lung anatomy through biologic remodeling that were associated with improvements in lung physiology. In contrast to LVRS, which requires major 15

16 Page 16 of 38 thoracic surgery, BioLVR produced these changes through the bronchoscopic co-administration of 2 liquid reagents that flow into the alveolar compartment and polymerize. The resulting hydrogel collapses and remodels the targeted lung region over 4 to 6 weeks. The hydrogel s physical properties and its site and mode of action overcome the effects of collateral ventilation which limit the therapeutic effectiveness of endobronchial one-way valves designed to promote lung volume reduction through regional atelectasis. 21, 22 BioLVR causes an acute, self-limited, mild-to-moderate inflammatory reaction inherent to its mechanism of action. This reaction is associated with leukocytosis, fever, malaise, shortness of breath, nausea, and pleuritic chest pain that develop in the majority of treated patients. These systemic manifestations of BioLVR therapy generally resolve within hours with supportive medical care including antipyretics, intravenous fluids, and anti-emetics. Other side effects following BioLVR were less frequent. However, post treatment COPD exacerbations of moderate severity were observed in a significant fraction of patients. The majority of COPD exacerbations (4 of 5 in the LD group and 5 of 9 in the HD group) occurred with the first few days of treatment and were felt to be directly related to the procedure. Two additional exacerbations in HD patients, occurring within the 1 st month post treatment, were also deemed possibly related to the procedure given their temporal proximity to BioLVR. The overall procedural rate of COPD exacerbations (11 events among 50 patients) observed with BLVR is similar to that reported with other endobronchial lung volume reduction procedures However, between 1 and 6 months following BioLVR, the incidence of COPD exacerbations among both LD and HD decreased. Among the 27 patients completing follow-up out to 6 months in the LD group, the projected annual incidence of exacerbations between 1 and 6 months was 16

17 Page 17 of exacerbations/pt/yr (1 event per 27 patients over years of follow-up). Among the 17 patients in the HD group completing follow-up over the same period, the projected annual incidence of exacerbations was 0.28 exacerbations/pt/yr (2 events per 17 patients over years of follow-up). By comparison to surgical and alternative endobronchial methods for achieving lung volume reduction, BioLVR demonstrated an acceptable overall safety profile in patients with severe ULP emphysema. LVRS is associated with a 5 to 20% 90 day mortality (5.5% in NETT), endobronchial valve therapy with a 1 % 90 day mortality, and airway bypass with an approximately 3% 90 day mortality. 20, 23, 25 In this series, there were no deaths among 50 patients treated during 69 treatment sessions. Serious pulmonary and cardiovascular complications within 30 days of treatment, defined as respiratory failure, re-intubation post procedure, clinically significant hemoptysis, pneumonia, pulmonary embolus, cardiac ischemia, or arrhythmias have been observed in up to 58% of patients treated with LVRS, 8-10% of patients treated with endobronchial valves, and 27% of patients treated with airway bypass In the current study 4 of 50 patients (8%) treated with BioLVR experienced such events. Although preliminary, these data suggest that BioLVR has a safety profile that is better than LVRS, and similar to other endobronchial lung volume reduction methods. Improvements in spirometry, extent of gas trapping, dyspnea, and HRQOL were observed in both LD and HD patients at 6 weeks, and 3 and 6 months following BioLVR although responses differed with dose. Among LD patients, mean improvements were maximal at 6 weeks and 3 months post treatment, with a subsequent decline in mean responses and in the 17

18 Page 18 of 38 fraction of responders meeting MCID criteria between 3 and 6 months. These declines may in part reflect the limited effectiveness of LD therapy, as well as the natural progression of pulmonary disease in severe emphysema. Among HD patients, mean improvements in physiological outcomes showed little decline between 6 weeks and 6 months. Furthermore, the fraction of HD patients showing clinically meaningful improvements in physiological outcomes remained either unchanged, or increased between 6 weeks and 6 months. Because enrollment of LD patients was completed prior to HD patients, and several sites participated in both studies, improved responses following HD therapy may in part reflect a learning effect among investigators. However, at sites that participated only in HD or LD treatment, results still suggested larger, more durable responses among HD patients. Despite small patient numbers and variability in responses in both groups, these findings suggest that 20 ml/site BioLVR dosing produces both greater initial and more durable therapeutic responses than 10 ml/site dosing without obvious increased toxicity. Following BioLVR, HRCT imaging showed scarring and atelectasis at treatment sites confirming the ability to endobronchially direct therapy to specific anatomic locations. BioLVR responses, which correspond radiologically to sites of increased linear density, occurred only at preselected target sites. Treatment was not associated with mediastinal, pleural or parenchymal pathology beyond the anticipated remodeling reactions. Radiographic responses were observed more consistently, and were larger in size following HD compared to LD therapy (Figure 3), suggesting a relationship between the degree of anatomic remodeling and magnitude of posttreatment physiological and functional improvement. 18

19 Page 19 of 38 In summary, BioLVR is a unique endobronchial treatment for lung hyperinflation in severe ULP emphysema. Its acts at the alveolar rather than the airway level to remodel the lung and produce durable benefit. BioLVR has a predictable side effect profile and can be safely administered either under general anesthesia or conscious sedation using a flexible bronchoscope. The Phase 2 dose-ranging studies suggest a dose-response relationship, with improvements in objective physiological outcome measures that are larger and more durable following 20 ml/site than10 ml/site dosing. HD therapy was associated with a higher incidence of peri-procedural COPD exacerbations (p=ns), but not with other medical complications. Physiological, functional and symptomatic improvements at 6 months are favorable, although confirmation in larger randomized controlled trials is required. BioLVR may represent a safer alternative to LVRS for patients with severe ULP emphysema, making definitive treatment for lung hyperinflation more readily available and less risky. 19

20 Page 20 of 38 Acknowledgements The following individuals are acknowledged for their contributions to the study: Akron General Medical Center: Deborah Hudock, CNS and Akhil Bindra M.D. MUSC: Esther Cummings-Williams, CNS and Gerard Silvestri, M.D. Pulmonary Associates, Phoenix: Liyi Fu, M.D., J. Burr Ross, M.D., and David M. Baratz, M.D. University of Alabama, Birmingham: Umair Gauhar, M.D., Sherry Tidwell, RRT, and Necole Seabron, CRT. Temple University Medical Center: John Travaline M.D., Wissam Chatila, M.D.; Michael Keresztury, M.D. Nat Marchetti M.D., and Gayle Jones, CRN. St. Joseph s Hospital, Baltimore, MD: Pat Johnson, CRN and Kristen Gowan, CRN Rabin Medical Center, Petach Tivka, Israel: Avital Yacobi, Mordechai Kremer, M.D. and Ariel Farkash, M.D. University of Iowa: Janet Keating RA, Andrea Chapman RA, Phyllis Pirotte RN, Kim Sprenger RN, Kim Baker MD 20

21 Page 21 of 38 References 1. Celli B, ZuWallack R, Wang S, Kesten S. Improvement in resting inspiratory capacity and hyperinflation with tiotropium in COPD patients with increased static lung volumes. Chest. Nov 2003;124(5): Celli BR. Pathophysiology of chronic obstructive pulmonary disease. Chest Surg Clin N Am. Nov 1995;5(4): O'Donnell DE. Hyperinflation, dyspnea, and exercise intolerance in chronic obstructive pulmonary disease. Proc Am Thorac Soc. Apr 2006;3(2): Berger RL, Wood KA, Cabral HJ, et al. Lung volume reduction surgery: a meta-analysis of randomized clinical trials. Treat Respir Med. 2005;4(3): Fishman A, Martinez F, Naunheim K, et al. A randomized trial comparing lung-volumereduction surgery with medical therapy for severe emphysema. N Engl J Med. May ;348(21): Meyers BF. Complications of lung volume reduction surgery. Semin Thorac Cardiovasc Surg. Oct 2002;14(4): Martinez FJ, Chang A. Surgical therapy for chronic obstructive pulmonary disease. Semin Respir Crit Care Med. Apr 2005;26(2): Naunheim KS, Wood DE, Krasna MJ, et al. Predictors of operative mortality and cardiopulmonary morbidity in the National Emphysema Treatment Trial. J Thorac Cardiovasc Surg. Jan 2006;131(1): Ingenito EP, Berger RL, Henderson AC, Reilly JJ, Tsai L, Hoffman A. Bronchoscopic lung volume reduction using tissue engineering principles. Am J Respir Crit Care Med. Mar ;167(5): Ingenito EP, Reilly JJ, Mentzer SJ, et al. Bronchoscopic volume reduction: a safe and effective alternative to surgical therapy for emphysema. Am J Respir Crit Care Med. Jul ;164(2): Reilly J, Washko G, Pinto-Plata V, et al. Biological lung volume reduction: a new bronchoscopic therapy for advanced emphysema. Chest. Apr 2007;131(4): Global Initiative for Chronic Obstructive Lung Disease strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease: an Asia-Pacific perspective. Respirology. Jan 2005;10(1): Patients at high risk of death after lung-volume-reduction surgery. N Engl J Med. Oct ;345(15): Wanger J, Clausen JL, Coates A, et al. Standardisation of the measurement of lung volumes. Eur Respir J. Sep 2005;26(3): Aggarwal AN, Agarwal R. The new ATS/ERS guidelines for assessing the spirometric severity of restrictive lung disease differ from previous standards. Respirology. Sep 2007;12(5): ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. Jul ;166(1): Brooks D, Solway S, Gibbons WJ. ATS statement on six-minute walk test. Am J Respir Crit Care Med. May ;167(9): Cazzola M, MacNee W, Martinez F, et al. Outcomes for COPD pharamoclogical trials: from lung function to biomarkers. Eur Respir J. 2008;31:

22 Page 22 of Gross NJ. Chronic obstructive pulmnonary disease outcome measurements: what's important? what's useful? Proc Am Thorac Soc. 2005;2: Criner GJ, Sternberg AL. National emphysema treatment trial: the major outcomes of lung volume reduction surgery in severe emphysema. Proc Am Thorac Soc. May ;5(4): Cetti EJ, Moore AJ, Geddes DM. Collateral ventilation. Thorax. May 2006;61(5): Fessler HE. Collateral ventilation, the bane of bronchoscopic volume reduction. Am J Respir Crit Care Med. Mar ;171(5): Cardoso PF, Snell GI, Hopkins P, et al. Clinical application of airway bypass with paclitaxel-eluting stents: early results. J Thorac Cardiovasc Surg. Oct 2007;134(4): Wan IY, Toma TP, Geddes DM, et al. Bronchoscopic lung volume reduction for endstage emphysema: report on the first 98 patients. Chest. Mar 2006;129(3): Yim AP, Hwong TM, Lee TW, et al. Early results of endoscopic lung volume reduction for emphysema. J Thorac Cardiovasc Surg. Jun 2004;127(6): Wood DE, McKenna RJ, Jr., Yusen RD, et al. A multicenter trial of an intrabronchial valve for treatment of severe emphysema. J Thorac Cardiovasc Surg. Jan 2007;133(1):

23 Page 23 of 38 Figure Legends Figure 1 Study flow diagram showing patient progression through the three Phase 2 trials that form the basis of this report. Figure 2 - Responder analysis showing the percentage of treated patients with responses greater than MCID values at 6 weeks, 3 months, and 6 months following low dose (LD) and high dose (HD) BioLVR therapy. MCID values were taken from recently published guidelines [18] Figure 3 Coronal CT images obtained in the supine position at full lung inflation showing treatment sites at baseline (pre-treatment) and 6 weeks following LD (Pt 1, Pt 2, Pt 3 and Pt 4) and HD (Pt 5, Pt 6, Pt 7, and Pt 8) BioLVR therapy. Numbering on the scans corresponds to treated sites showing evidence of scarring reactions.

24 Page 24 of 38 TABLES Table 1. Patient Demographics Low Dose (N=28) High Dose (N=22) P-Value 1 Parameter Age (yrs) N Mean (SD) 65.1 (5.86) 66.0 (4.56) Median Range 53, 76 59, 74 Gender [n, (%)] N Male 19 (67.9) 11 (50.0) Female 9 (32.1) 11 (50.0) BMI (kg/m 2 ) N Mean (SD) 23.2 (3.23) 25.1 (3.48) Median Range 15.5, , 32.9 Smoking History (pack yrs) N Mean (SD) 57.0 (26.60) 59.7 (22.11) Median Range 20, , 100 Oxygen Use at Rest (L) N Mean (SD) 0.8 (1.25) 1.6 (1.59) Median Range 0, 3.5 0, 7.0 Oxygen Use with Activity (L) N Mean (SD) 1.4 (1.81) 2.9 (2.04) Median Range 0, 5.0 0, 8 Oxygen Use during Sleep (L) N Mean (SD) 1.1 (1.30) 2.1 (1.46) Median Range 0, 3.5 0, 6 Using Any Oxygen [n, (%)] N No 12 (48.0 ) 3 (13.6) Yes 13 (52.0) 19 (86.4) Pulmonary Rehabilitation Prior 6 Months [n, (%)] N 28 22

25 Page 25 of 38 No 13 (46.4) 0 < Yes 15 (53.6) 22 (100.0) Medication Use Short acting β-agonist 21 (75%) 21 (95%) Short anticholinergic 7 (25%) 5 (23%) Long acting β-agonist 24 (86%) 16 (73%) Long acting anticholinergic 18 (64%) 16 (73%) Inhaled corticosteroid 21 (75%) 15 (68%) Theophylline preparation 7 (25%) 5 (23%) Systemic corticosteroid 3 (11%) 6 (27%) lipoxogenase inhibitors 4 (14%) 2 (9%) t-test 2 Fisher s exact test Definition of abbreviations: BMI; body mass index

26 Page 26 of 38 Table 2. Baseline Physiology * Low Dose (N=28) High Dose (N=22) P-Value 1 Parameter FEV 1 Post Bronchodilator (L) N Mean (SD) 0.85 (0.216) 0.76 (0.227) 0.14 Median Range 0.49, , 1.27 % Predicted FEV 1 Post Bronchodilator N Mean (SD) 29.9 (5.66) 28.0 (7.15) 0.31 Median Range 20, 39 16, 43 FEV 1 /FVC N Mean (SD) 0.33 (0.070) 0.31 (0.065) 0.30 Median Range 0.19, , 0.44 RV (L) N Mean (SD) 4.8 (1.29) 4.4 (0.92) 0.24 Median Range 3.0, , 7.1 % Predicted RV N Mean (SD) (45.03) (29.94) 0.53 Median Range 127, , 270 TLC (L) N Mean (SD) 7.3 (1.46) 6.9 (1.24) 0.24 Median Range 4.9, , 9.1 % Predicted TLC N Mean (SD) (9.79) (12.86) 0.95 Median Range 108, , 140 RV/TLC N Mean (SD) 0.64 (0.087) 0.64 (0.078) 0.77 Median Range 0.46, , 0.79

27 Page 27 of 38 6 MWT Distance (m) N Mean (SD) (97.67) (83.87) Median Range 156, , 442 MRCD Score N 2.5 (0.59) 2.6 (0.67) 0.55 Mean (SD) Median 2, 4 2, 4 Range 1 t-test * 2 patients in the LD group and 1 patient in the HD group did not meet the TLC and RV criteria for study inclusion, but because they satisfied all other inclusion criteria, they were accepted into the study. Definition of abbreviations:fev 1, forced expiratory volume in one second; FVC, forced vital capacity; RV, residual volume; TLC, total lung capacity; 6 MWT, 6 minute walk test; MRCD score, Medical Research Council Dyspnea score

28 Page 28 of 38 Table 3. Summary of Efficacy Response to BioLVR Treatment Outcome 6 Weeks 3 Months 6 Months % ΔFEV 1 (post-bd) %ΔFVC (post-bd) LD HD LD HD LD HD +22.0± ± ± ±12.9 (p=0.003)* (p=0.002)* (p=0.004)* (0.021)* +11.8±13.5 (p < 0.001)* +9.7±14.2 (p=0.002)* %ΔRV -10.2±12.4 (p=<0.001)* %ΔRV/TLC -6.7±7.0 (p<0.001)* %ΔDLco +3.0±15.4 (p=0.231)* Δ6MWD (m) +40.2±40.8 (p=<0.001)* ΔMRCD -0.9±0.68 (p<0.001)* TDI +3.6±2.69 (p<0.001)* ΔSGRQ (total -12.8±14.1 domain score) (p<0.001)* +10.3±15.9 (p=0.021)* -9.7±14.5 (p=0.022)* -5.8±10.2 (p=0.045)* -6.3±23.2 (p=0.093)* -7.9±70.7 (p=0.660)* -0.6±0.96 (p=0.020)* +2.1±4.35 (p=0.070)* -12.0±15.8 (p=0.008)* +9.8±16.7 (p=0.005)* -10.1±13.4 (p=0.001)* -6.4±9.3 (p=0.002)* +0.1±14.6 (p=0.711)* +38.6±52.9 (p=0.001)* -0.7±0.75 (p<0.001)* +4.0±3.09 (p<0.001)* -14.2±13.7 (p<0.001)* +11.9±16.3 (p=0.006)* -9.1±14.3 (p=0.018)* -5.5±9.4 (p=0.028)* -3.6±23.9 (p=0.144)* +6.4±70.0 (p=0.705)* -0.7±0.83 (p=0.002)* +4.6±2.00 (p<0.001)* -17.3±12.9 (p<0.001)* +5.1±16.1 (p=0.139)* -7.1±16.8 (p=0.053)* -4.2±11.2 (p=0.086)* +2.5±15.6 (p=0.338)* +25.5±53.2 (p=0.024)* -0.6±1.14 (p=0.037)* +2.8±4.03 (p=0.007)* -6.9±8.8 (p=0.012)* +15.6±16.8 (p=0.002)* +9.1±15.5 (p=0.034)* -9.0±11.2 (p=0.006)* -5.9±8.2 (p=0.012)* +0.8±21.7 (p=0.319)* +9.9±51.2 (p=0.481)* -0.3±1.05 (p=0.264)* +3.2±3.99 (p=0.004)* -9.7±18.8 (p=0.057)* *p value is for comparison of outcome to baseline at each time point Definition of abbreviations: RV/TLC, Residual Volume to Total Lung Capacity Ratio; DLco, Diffusing Capacity; 6MWD, 6 Minute Walk Distance; TDI, Transitional Dyspnea Index; SGRQ, St. George s Respiratory Questionnaire; Δ=change

29 Page 29 of 38 Figure 1 Study Flow Diagram Low Dose Treatment Group (10 ml/subsegment) High Dose Treatment Group 20 ml/subsegment Trial #: clincaltrials.gov NCT Site(s): 1, Israel # patients: 8 Trial #: clinicaltrails.gov NCT Sites: 5, United States # patients: 20 Trial #: clinicaltrails.gov NCT Sites: 8, United States # patients: 22 LD n=28 enrolled HD n=22 enrolled All 3 studies with identical: 1. Inclusion/Exclusion criteria 2. Screening procedures 3. Primary endpoints 4. Outcome measures 5. Timing of follow-up 1 drop-out due to unrelated medical condition 28 completed bilateral therapy 17 completed bilateral therapy 1 lost to follow-up 1 drop-out to pursue lung txplt 3 failed to comply with protocol for retreatment 27 patients with available 6 wk, 3 month, and 6 month follow-up included in this report. 17 patients with available 6 wk, 3 month, and 6 month follow-up included in this report.

30 Page 30 of 38 Figure 2 - Responder Analysis LD (10 ml/site) and HD (20 ml/site) BioLVR Therapy FEV 1 FVC % pts achieving MCID (p=0.001) 44.4 (p<0.001) (p<0.001) 50 (p=0.002) (p=0.002) (p=0.003) weeks 3 months 6 months LD HD % pts achieving MCID (p=0.001) (p<0.001) (p=0.001) (p=0.003) (p=0.004) (p=0.05) weeks 3 months 6 months LD HD MRCD TDI Scores % pts achieving MCID (p<0.001) 70.8 (p<0.001) 56.2 (p<0.001) 62.5 (p<0.001) 61.1 (p<0.001) 50 (p=0.003) 35.3 LD HD % pts achieving MCID (p<0.001) 80 (p<0.001) 56.2 (p<0.001) (p<0.001) (p<0.001) 78 (p<0.001) 70.6 LD HD weeks 3 months 6 months 0 6 weeks 3 months 6 months 6 MWT Distance SGRQ Total Domain Score % pts achieving MCID (p<0.001) (p=0.004) 48.1 (p=0.003) (p=0.02) (p=0.02) (p=0.05) weeks 3 months 6 months LD HD % pts achieving MCI D p<0.001 p< p< p<0.001 p= p= weeks 3 months 6 months LD HD MCID criteria for each outcome measure: FEV 1 & FVC = +12% MRCD = 1 unit decrease TDI = 1 unit increase 6 MWT distance = +50 m SGRQ = 8 unit decrease

31 Page 31 of 38 Figure 3 - HRCT Images following LD and HD BioLVR Therapy Pt 1 Baseline Pt 1 6 wks post Pt 2 Baseline Pt 2 6 wks post Pt 3 6 wks post Pt 3 Baseline Pt 4 Baseline Pt 4 6 wks post LD BioLVR Pt 5 Baseline 1 Pt 6 Baseline Pt 5 6 wks post Pt 6 6 wks post Pt 7 Baseline Pt 7 6 wks post Pt 8 Baseline HD Pt 8 6 wks post

32 Page 32 of 38 Biologic Lung Volume Reduction (BioLVR) In Advanced Upper Lobe Emphysema: Phase 2 Results Gerard J. Criner, Victor Pinto-Plata, Charlie Strange, Mark Dransfield, Mark Gotfried, William Leeds, Geoffrey McLennan, Yael Refaely, Sanjiv Tewari Mark Krasna and Bartolome Celli ONLINE DATA SUPPLEMENT 1

33 Page 33 of 38 Expanded Methods section for Online Repository Patient Selection Criteria: All participants had severe airflow obstruction, radiographic evidence of emphysema, respiratory symptoms despite medical therapy, and were either not eligible for LVRS or lung transplantation, or had refused these treatment options. Specific inclusion criteria for BLVR therapy were: a clinical diagnosis of advanced emphysema; upper lobe predominant disease determined by radiological assessment of high resolution CT images; persistent symptoms of dyspnea despite optimal medical therapy; age > 40 yrs; a ratio of forced expiratory volume in 1 second (FEV 1 ) to forced vital capacity (FVC) ratio < 70% and an FEV 1 < 45% predicted; hyperinflation, defined by a total lung capacity (TLC) > 110% predicted and residual volume (RV) > 150% predicted. Specific exclusion criteria included: bullous emphysema, defined as any single lesion > 5 cm in largest dimension on CT scan; co-morbid conditions that would increase risk for anesthesia or bronchoscopy; a diagnosis of alpha-1 anti-protease deficiency; pulmonary hypertension (e.g. baseline pulmonary systolic pressure > 45 mm Hg); and smoking within 4 months of study enrollment. Patients determined to be at high risk for mortality with LVRS based upon published findings of the National Emphysema Treatment Trial (NETT) (i.e. FEV 1 < 20% predicted and diffusing capacity (DLco) < 20% predicted) were also excluded. Study Design The study consisted of three Phase 2 trials planned to define the BLVR dose required to safely produce therapeutic lung volume reduction in patients with advanced ULP emphysema. The trials were identical in design except for dosing strategy. There were 10 clinical sites (9 in the United States and 1 in Israel). All trials were open-labeled, non-randomized, and non-controlled. The first trial, in one site (Israel), evaluated LD therapy in 8 patients. The second (5 sites) performed concurrently in the United States (US), evaluated LD therapy in 20 patients. The third (8 sites), initiated following completion of enrollment in the LD studies, evaluated HD therapy in 22 patients in the US. All protocols were reviewed 2

34 Page 34 of 38 and approved by the appropriate national regulatory agencies and committees at the participating hospitals. All patients provided written informed consent at study enrollment. To assess clinical responses to dose variation, patients were organized into two treatment groups. The first, designated the Low Dose (LD) treatment group, included 28 patients treated with 10 ml/subsegment of BLVR Hydrogel at eight sites, four in each lung. By protocol design, fourteen LD patients were scheduled to receive treatment during two sessions separated by 6 to 12 weeks. The remaining fourteen LD patients were scheduled to receive treatment during a single session. The second group included 22 treated with 20 ml/subsegment of BLVR Hydrogel at eight sites, four in each lung. This group was designated the High Dose (HD) treatment group. By design, ten HD patients were scheduled to receive treatment during two sessions separated by 6 to 12 weeks. The remaining twelve patients were scheduled to receive treatment during a single session. Screening evaluations were completed over the course of three separate visits within a two-week window. Pulmonary function and 6 MWT were performed according to published guidelines. Pulmonary function parameters were determined as the average of three measurements completed on different days to ensure that pre-treatment values represented a stable baseline state for each patient. The remaining tests, including echocardiography, electrocardiography, clinical pathology (hematology, coagulation studies, and serum chemistry measurements) and chest CT imaging were performed once during screening. The same was true for the Medical Research Council Dyspnea (MRCD) score, Basal Dyspnea Index/Transitional Dyspnea Index (BDI/TDI) score, and health status using the St. George s Respiratory Questionnaire (SGRQ). BLVR Procedure ULP disease was determined by investigators in conjunction with their chest radiologist at each clinical site. The most damaged areas of lung were selected for BLVR treatment as determined by review 3

35 Page 35 of 38 of chest CT images prior to the procedure. Potential back-up sites were identified in the event that one or more of the primary treatment sites could not be accessed at treatment time. Treatments were delivered at the subsegmental airway level. A flexible bronchoscope was introduced into the airway and a visual inspection performed to identify and evaluate accessibility of the treatment sites. The bronchoscope was then advanced into the subsegmental orifice of the first treatment site and wedged into position to prevent backflow of BLVR reagents. A dual lumen catheter (Pebax construction, O.D mm) with stylette in place was advanced until the catheter tip was visualized. The stylette was then removed, and the catheter was further advanced distally such that catheter tip was positioned 3-4 cm beyond the end of the bronchoscope. The Fibrinogen Suspension was prepared for administration by passing it back and forth 10 times between two syringes (10 ml for LD treatment, 20 ml for HD treatment) connected by a 3-way stopcock. The syringes containing the Fibrinogen Suspension and Thrombin Solution were connected to the appropriate luer connectors of the dual lumen catheter and clipped into an administration device, a plastic molded gun that delivered reagents in correct proportion to ensure rapid polymerization of the Hydrogel at the catheter tip. Reagents were delivered over seconds, after which the catheter was removed and rinsed before the next treatment. The bronchoscope was left in wedge position for at least 30 seconds following instillation of the reagents to ensure polymerization, and was then repositioned at the next treatment site. A prophylactic course of antibiotics (e.g., ciprofloxacin, levofloxacin, augmentin or imipenem) was administered beginning immediately prior to BLVR treatment and continued 48 hours or until discharge. The hydrogel also contains antibiotics to help prevent infection locally at the site of dosing. Antibiotics were additionally prescribed by investigators to treat clinical syndromes suggestive of infection. BLVR treatments were performed using a flexible bronchoscope either in the operating room under general anesthesia (n = 9 LD patients, n = 1 HD patient), in the operating room under conscious sedation (n = 2 LD patients, n = 6 HD patients), or in the bronchoscopy suite under conscious sedation 4

36 Page 36 of 38 (n=13 LD patients, n=15 HD patients) depending upon investigator preference. Patients were hospitalized for observation periods up to 48 hours following treatment. Treatments were performed using either conscious sedation or general anesthesia. During the procedures, cardiac rate and rhythm, peripheral oxygen saturation, and blood pressure were continuously monitored. In patients who received split-dose therapy, re-testing was performed at 1, 3 and 6 weeks following treatment. The values at 6 weeks following unilateral treatment were used to assess each patient s candidacy for continued study participation. Patients were required to meet the same eligibility criteria at 6-week follow-up as for initial study enrollment. Upon completion of bilateral therapy at 8 sites (either during split dosing or during a single session) all patients were evaluated at 1 week, 6 weeks, 3 months, and 6 months. Outcome Measures The primary efficacy endpoint of the study was a reduction in gas trapping measured as a significant decrease in RV/TLC 3 months after treatment compared to baseline. Additional efficacy measures included changes from baseline to 6 months in RV/TLC, and changes at 3 and 6 months in post bronchodilator FEV 1, FVC, 6 MWT distance, Medical Research Council Dyspnea (MRCD) score, Basal Dyspnea Index/Transitional Dyspnea Index (BDI/TDI) score, and in the St. George s Respiratory Questionnaire (SGRQ). To further characterize the pattern of response and relative effectiveness of LD and HD BLVR therapy for advanced emphysema, a responder analysis, in which the percentage of patients demonstrating a clinically meaningful improvement from baseline following treatment, was performed at each follow-up time point. Clinically meaningful improvement was defined using published criteria set forth by the American Thoracic Society and European Respiratory Society for the relevant clinical outcome. 5