Introduction. For further information please contact:

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1 Product Monograph

2 Introduction Teva UK Limited is one of the biggest pharmaceutical companies in the UK. We re proud to be part of the Teva Pharmaceutical Industries group, and we make medicines that help improve lives. For further information please contact: Teva UK Limited Ridings Point, Whistler Drive, Castleford, WF10 5HX T: F: W:

3 Contents Bladder conditions including interstitial cystitis 2 Clinical overview 4 Mode of action 10 Postulated mode of action 12 Hyaluronic acid and chondroitin sulphate in the GAG layer 13 Molecular weight comparison 14 Clinical studies with Cystistat 15 Related studies 26 Product information 27 Material Safety information 28 Appendix A: Identification of a defective GAG layer: Riedl s test 30 Further information 31

4 Bladder conditions including interstitial cystitis There is increased awareness within the field of urology of the existence of a number of non-malignant bladder conditions. These include irritable bladder syndrome (IBS), painful bladder syndrome (PBS), overactive bladder (OAB), interstitial cystitis (IC), nonbacterial cystitis (NBC), infective cystitis and radiation-induced cystitis (RIC). 1,2 Whilst some of these, e.g. infective cystitis or radiation-induced cystitis, have definable aetiology, the majority of them do not. They may even be considered as the same or different diseases, or different stages of the same condition(s) depending upon the viewpoint of the individual specialist. This makes diagnosis and treatment of such conditions very difficult. 3 IC is one such term applied to some or all of these conditions with obscure aetiology, and is a severe, debilitating chronic disorder of the bladder. 3 Multiple, complex aetiologies are postulated with individual sufferers exhibiting a wide range and degree of severity of symptoms. 4 This makes diagnosis and treatment difficult. 5 It is widely accepted that IC is the result of a functional defect of the bladder urothelium, possibly leading to leakage of urine constituents into the bladder wall or irritation of the bladder surface by these components. 5,6,7 This can lead to effects within the bladder epithelium, e.g. local inflammatory or immune reactions, or alterations of nervous transmission. 8 Deficiency in the glycosaminoglycan (GAG) layer, which is believed to be the principal protective barrier between the urine and the bladder epithelium, may be a cause or a result of the disease. 3,7,9 A defective GAG layer can be identified using the Riedl s test (see Appendix A). The Pathology The bladder urothelium becomes inflamed and irritated. This can lead to scarring and stiffening of tissue with associated reduction in bladder capacity. The condition may be non-ulcerative or ulcerative, with the non-ulcerative form being more common. Cystoscopic examination may reveal glomerulations (submucosal pinpoint haemorrhages) in either condition. Ulcerative IC may be more severe and involve diminished bladder capacity and characteristic Hunner s Lesions (star-shaped sores). 4,10 The variable nature of the condition may lead to variable responses to treatment. 4 The Symptoms Symptoms include severe bladder or pelvic pain with increased urinary frequency (up to 60 times in 24 hours in severe cases) and urgency to pass water, in the absence of bacterial infection or other definable aetiology. 11,12 These symptoms have a severe impact on the lifestyle of the patient and can be costly both to the individual and to society in general. Examples of the problems experienced are given below: 11,13 n Dietary restrictions n Requirement for constant access to bathroom n Fatigue due to sleep interruption/pain n Limitations on travel n Compromised family/social/sexual relationships n Fear of pregnancy n Threat to employment n Stress and/or depression 2 ReplenishRestoreRevive

5 The Treatment Options Dietary modification, bladder re-training, exercise and stress reduction may all play a role in the control of IC. Various medical treatments have been tried but with limited success. A number of oral medicinal products may be used to treat some or all of the associated symptoms e.g. analgesics for pain relief. However, very few therapies exist specifically for the condition. Sodium pentosan polysulphate may be given orally (but is currently unlicensed in the UK) or dimethyl sulphoxide may be given intravesically (again currently unlicensed). Surgical options include bladder distension, cystolysis (denervation), bladder augmentation and urinary diversion with or without cystectomy. Electrical nerve stimulation may also be used, as may a variety of experimental treatments. 14,15,16 Cystistat (sodium hyaluronate) represents a localised treatment for IC, and may be suitable for consideration as a first line treatment. Since other bladder conditions, e.g. radiation-induced cystitis, chronic or recurrent urinary tract infections, may also relate to damage or defects of the GAG layer, they may also benefit from treatment with Cystistat. Cystistat has been shown to be effective in the treatment of IC or PBS where the lining of the bladder has become compromised. 17 This results in patients having moderate to severe symptoms which can have a major impact on their quality of life. 11 Repeated urinary tract infections (ruti) caused by bacteria may have a long-term effect on the integrity of the bladder wall, and it is considered that the more rutis a patient has the more severe and irreversible the damage to the bladder lining. (IC)/PBS Recurrent Bacterial (RBC) Radiation-Induced (RIC) (includes chemotherapy) Simple THESE CONDITIONS HAVE A MAJOR IMPACT ON PATIENTS LIVES (The diagnosis of these conditions is Consultant/ Hospital led) Other treatments are effective Cystistat has been approved * for the temporary replacement of the GAG layer in the bladder 18 International Painful Bladder Foundation *Cystistat is approved as a Class III medical device 3

6 Clinical overview AUTHOR YEAR PUBLICATION TITLE INDICATION NO. PATIENTS OUTCOME Ratliff et al Urol Clin North Am Parsons Urol Clin North Am The Etiology of The therapeutic role of sulfated polysaccharides in the urinary bladder Parsons et al Neurourol Urodyn Abnormal sensitivity to intravesical potassium in interstitial cystitis and radiation cystitis Hurst World J Urol Structure, function and pathology of proteoglycans and glycosaminoglycans in the urinary tracts and Radiation Morales et al J Urol Intravesical hyaluronic acid in the treatment of refractory interstitial cystitis 25 The paper shows a positive result to the treatment of refractory interstitial cystisis, showing a 56% positive (including partial) response rate at four weeks, increasing to 71% by week 12 Hurst et al Cystistis The role of glycosaminoglycans in normal bladder physiology and the pathopyhsiology of interstitial cystitis Porru et al Urol Int Results of treatment of refractory interstitial cystitis with intravesical hyaluronic acid 10 The paper reviews a trial of Hyaluronic Acid (HA) used intravesically in 10 patients with typical findings of IC. The results showed a 30% positive response rate at week six, maintained until week 24 Ho et al Cystistis Epidemiology of interstitial cystitis 4 ReplenishRestoreRevive

7 Clinical overview (continued) AUTHOR YEAR PUBLICATION TITLE INDICATION NO. PATIENTS OUTCOME McCarty Med Hypotheses Enhanced synovial production of hyaluronic acid may explain rapid clinical response to highdose glucosamine in osteoarthritis Osteoarthritis The paper looks at HA and its clinical benefits such as pain relief and anti-inflammatory properties Agarwal et al Br J Urol Int cystitis - a time for revision of name and diagnostic criteria in the new millenium? Nordling et al J Urol Cystistat for the treatment of interstitial cystitis: A three year follow-up study Sommariva et 2001 Urodinamica Our experience in the al. 28 treatment of interstitial cystitis 20 started 19 completed three months 11 opted to continue after three months At three years, seven patients received a mean of 37 months of therapy 15 The paper reviews the term interstitial cystisis and its validity in the current environment and suggests Painful Bladder Syndrome as a better term to describe the syndrome Delgado et al Proceedings of the 41 st Annual Meeting of the Infectious Diseases Society of America Hyaluronic acid in the prevention of radiation-induced cystitis Steinhoff Eur Urol Suppl The Efficacy of Chondroitin Sulphate in Treating Radiationinduced 90 The study shows that weekly instillations of HA protect the bladder, decreases radiation-induced toxicity and risk of infection 18 Small study looking at the usage of chondroitin sulphate as an intravesical treatment 5

8 Clinical overview AUTHOR YEAR PUBLICATION TITLE INDICATION NO. PATIENTS OUTCOME Singh et al Proceedings of the ICS (International Continence Society) 33 rd Annual Meeting Nikolopoulos et al Proceedings of the 41 st Annual Meeting of the Infectious Diseases Society of America Prospective randomised controlled trial of intravesical dimethylsulphoxide (DMSO) vs Cystistat (hyaluronic acid) in the treatment of female patients with interstitial cystitis (IC) Preliminary results on the use of sodium hyaluronate intravesical instillations for the preventive treatment of women with recurrent bacterial cystitis Constantinides et al Br J Urol Int Prevention of recurrent bacterial cystitis by intravesical administration of hyaluronic acid: a pilot study Recurrent Bacterial Recurrent Bacterial 30 The aim of the study was to compare Cystistat to DMSO 167 The response rate of women with RBC showed positive results, significantly reducing time to relapse and recurrence of bacterial infection in women with RBC 40 Gang et al Proceedings of the Eastern China Urology Congress, Shanghai China 2004 Kallestrup et 2005 Scand J Urol al. 17 Nephrol Intravesical instillation of sodium hyaluronate for the treatment on intractable nonbacterial cystitis: a multi-centre study Treatment of interstitial cystistis with Cystistat : A hyaluronic acid product Riedl Eur Pharmacother Management of cystitis. Business briefing Mañas et al Int J Radiat Oncol Biol Phys Prevention of urinary tract infections in palliative radiation for vertebral metastasis and spinal compression: a pilot study Non-bacterial Radiationinduced 20 The paper shows patients suffering from RBC can benefit from receiving intravesical instillations of sodium hyaluronate, showing significant relief from cystitis symptoms ReplenishRestoreRevive

9 Clinical overview (continued) AUTHOR YEAR PUBLICATION TITLE INDICATION NO. PATIENTS OUTCOME Palylyk-Cowell Issues Emerg Health Technol Chondroitin Sulfate for interstitial cystitis The paper looks at Chondroitin Sulphate as a treatment for interstitial cystitis. Highlights poor clinical evidence for Uracyst Lipovac et al Int J Gynecol Obstet Prevention of recurrent bacterial urinary tract infections by intravesical instillation of hyaluronic acid Recurrent Bacterial 20 Ahmad et al Int Urogynecol J Sequential hydrodistension and intravesical instillation of hyaluronic acid under general anaesthesia for treatment of refractory interstitial cystitis: a pilot study Iavazzo et al Eur Urol Hyaluronic acid: An effective alternative treatment of interstitial cystitis, recurrent urinary tract infections and hemorrhagic cystitis? Pohl-Boskamp Instructions for use: Gepan instill, Recurrent Urinary Tract Infections and Hemorrhagic 23 Riedl et al Int Urogynecol J Hyaluronan treatment of interstitial cystitis/ painful bladder syndrome / Painful Bladder Syndrome 126 The paper indicates that timely instillations of hyaluronantherapy may lead to complete symptom remission or even cure in part of the IC/PBS patients, although some patients may need continuous intravesical therapy 7

10 Clinical overview AUTHOR YEAR PUBLICATION TITLE INDICATION NO. PATIENTS OUTCOME Nickel et al Br J Urol Int A real-life multicentre clinical practice study to evaluate the efficacy and safety of intravesical chondroitin sulphate for the treatment of interstitial cystitis Baldder Health UK (Formerly The COB Foundation) 44 Mylan Institutional, Ireland The COB Foundation / Painful Bladder Syndrome Handbook 2017 Cystistat Instructions For Use Nickel et al J Urol A multicenter, randomized, doubleblind, parallel group pilot evaluation of the efficacy and safety of intravesical sodium chondroitin sulfate vs vehicle control in patients with interstitial cystitis/painful bladder syndrome Sommariva et 2010 Minerva Urol al. 47 Nefrol Efficacy of sodium hyaluronate in the management of chemical and radiation cystitis Damiano et al Eur Urol Prevention of recurrent urinary tract infections by intravesical administration of hyaluronic acid and chondroitin sulphate: A placebo-controlled randomised trial / Painful Bladder Syndrome / Painful Bladder Syndrome Urinary Tract Infection (UTI) The difference in treatment effect was not statistically significant, although twice as many patients reported a clinical benefit with intravesical chondroitin sulfate treatment compared with vehicle control treatment 69 Intravesical sodium hyaluronate seems a valid and quick therapeutic solution for iatrogenic cystitis from chemo or radiotherapy 57 Compared with placebo, HA-CS intravesical instillations significantly reduced UTI rate without severe side effects while improving symptoms and quality of life over a 12 month period in patients with recurrent UTI 8 ReplenishRestoreRevive

11 Clinical overview (continued) AUTHOR YEAR PUBLICATION TITLE INDICATION NO. PATIENTS OUTCOME Manu-Marin et al. 49 The effect of Cystistat treatment on patients with interstitial cystitis/painful bladder syndrome (IC/PBS) / Painful Bladder Syndrome 14 started 12 completed The paper showed a decrease in urination frequency by 1-4 urinations per day Engelhardt et al Int Urogynecol J Long-term results of intravesical hyaluronan therapy in bladder pain syndrome/interstitial cystitis (PBS/IC) / Painful Bladder Syndrome Questionnaire sent to 70 patients 48 responded Intravesical hyaluronan shows long-term efficacy in a follow-up cohort of 44 BPS/IC patients Hüther et al Proceedings of the 24 th European Conference on Biomaterials Deciphering the mechanism of hyaluronic acid treatment for interstitial cystitis in an in vitro bladder model HA treatment enhanced GAGs synthesis and reduced the level of inflammatory cytokines Raymond et al Curr Urol The clinical effectiveness of intravesical sodium hyaluronate (Cystistat ) in patients with interstitial cystitis/ painful bladder syndrome (PBS/IC) and recurrent urinary tract infection (ruti) PBS/IC and urinary tract infection (UTI) 13 rutis eight PBS/IC In ruti patients Cystistat treatment produced significant improvements in pain score (p=0.05), frequency (p=0.03) and quality of life (p=0.02). In PBS/IC patients pain (p=0.02), urgency (p=0.01), nocturia (p=0.01) and quality of life (p=0.04) were improved. In both groups, comparison is with pre-instillation parameters 9

12 Mode of action Epithelium The GAG layer Irritants Hyaluronic acid NORMAL GAG LAYER n Epithelium protected from urinary irritants by the glycosaminoglycan (GAG) layer 13 DEFECTIVE GAG LAYER n Loss of hyaluronic acid and other GAGs 13 n The bladder wall is open to harmful irritants resulting in urgency of urination and pain ReplenishRestoreRevive

13 Cystistat replenishes the backbone of the GAG layer 25 Glycosaminoglycans (GAGs) form the principal protective barrier (the GAG layer) between urine and the bladder epithelium 9 Superficial GAGs Hyaluronic acid backbone CHONDROITIN SULPHATE ONLY REPLACES SUPERFICIAL GAGs n Chondroitin is a cell-surface proteoglycan and does not bond directly to the luminal layer 23 CYSTISTAT REPLACES THE HYALURONIC ACID BACKBONE OF THE GAG LAYER n Hyaluronic acid in Cystistat replenishes the backbone of the GAG layer enabling the binding of other GAG molecules to form a strong impermeable barrier 13,25 Cystistat is approved through the CE Mark approval process it is a Class III medical device for the temporary replacement of the GAG layer in the bladder. This is the principal protective layer of the bladder wall between urine and the epithelium, and effectiveness has been demonstrated with Cystistat for the treatment of (IC), Recurrent Bacterial (RBC), Radiation-Induced (RIC) and Chemotherapy-Induced (CIC) 11

14 Postulated mode of action Sodium hyaluronate is a substance that occurs naturally within the body (Figure 1), being a constituent of the glycosaminoglycan (GAG) layer present on the luminal surface of the bladder urothelium, and of the fluids of the eyes and joints. 13,53,54 Cystistat is instilled directly into the bladder and is believed to temporarily replace the GAG layer in the bladder, which may be deficient in patients with interstitial cystitis (IC). The rationale for this proposed mode of action is based on the suggestion by Parsons 19 and others that the GAG layer is deficient in IC patients. GAGs are polymeric amino-sugars, or mucopolysaccharides, which are found together with proteins in proteoglycans. 55 Proteoglycans are the major constituents of mucus, including that which forms a coating on the bladder epithelium (Figure 2). 19 This mucus layer is viscous and sticky, and adheres to the bladder wall. It also binds to water molecules. These properties facilitate the protective function of the mucus, shielding the epithelium from toxic solutes, crystals, bacteria etc. 9 In IC, patients are believed to have a leaky bladder urothelium. This may relate to a deficiency in the protective GAG layer. 19 Hyaluronate is one of the major components of the GAG layer within the bladder (Figure 3). 13,56 Instillation of sodium hyaluronate directly into the bladder is believed to temporarily replace the bladder lining and thus provide relief from the symptoms of IC. 17 Intravesical instillation of Cystistat may benefit patients by relieving the distressing symptoms of pain, increased frequency and urgency of urination, nocturia and haematuria associated with IC. 22 Figure 1. Structural formula of hyaluronic acid 55 O H COO H OH H O H OH H O H HO CH 2 OH Figure 2. Section of bladder wall indicating position of the GAG layer 19 H H Protein complex O NHCOCH 1 H Bladder lumen mucin layer Endothelium Lamina propria Smooth muscle Figure 3. Structural make up of the glycosaminoglycan layer. (Adapted from Stryer, 1988) 56 Chondroitin sulphate chain O Keratin sulphate chain Link protein Hyaluronic acid backbone 12 ReplenishRestoreRevive

15 Hyaluronic acid and chondroitin sulphate in the GAG layer Chondroitin sulphate Chondroitin sulphate molecules form the side chains of the proteoglycan complexes. The bricks of the glycosaminoglycan (GAG) layer Hyaluronic acid Hyaluronic acid molecules form the backbone of the proteoglycan complexes. The foundations of the GAG layer Harmful irritants Proteoglycan chains Harmful irritants Hyaluronic acid (Cystistat ) Uracyst Cystistat Chondroitin sulphate doesn t provide the hyaluronic acid structure for the proteoglycan chains to bind to, only replacing superficial GAGs Hyaluronic acid in Cystistat replenishes the backbone of the GAG layer enabling the binding of other GAG molecules to form a strong impermeable barrier 13,25 Chondroitin is a cell-surface proteoglycan, and doesn t bond directly to the luminal layer 23 Hyaluronic acid is proven to significantly increase total number of GAGs in the bladder 51 13

16 Molecular weight comparison The hyaluronic acid within Cystistat is of a greater molecular weight compared with other commercially available preparations Average molecular weight of HA found in Cystistat, Hyacyst and ialuril 57 Molecular weight of hyaluronic acid (kda) Cystistat (hyaluronic acid) 619kDa 152 kda Hyacyst (hyaluronic acid) 152kDa ialuril (hyaluronic acid + chondroitin sulphate) 152kDa Molecular weight values determined in vitro Vial 1 Vial 2 Vial 3 Total Product Lot No MW 1a MW 1b Av MW 1 MW 2a MW 2b Av MW 2 MW 3a MW 3b Av MW 3 Av MW Cystistat Hyacyst HY-1511/ ialuril Molecular weight is absolute and based on the light scattering detector. The recovery of hyaluronic acid in sample Hyacyst #HY-1511/1 is significantly higher (about 2.5%) than the expected content (0.8%). The sample ialuril # contains in addition to hyaluronic acid, chondroitin. It s not possible to get baseline separated peaks for the hyaluronic acid and chondroitin. Therefore the integration limits were set at the minimum of the not perfect resolved peaks. Cystistat provides larger hyaluronic acid building blocks than other GAG replacement therapies and is proven to deliver consistently high patient response rates from eight weeks to five years 17,22,33,38,39,47,55 14 ReplenishRestoreRevive

17 Clinical studies with Cystistat Numerous clinical studies have been conducted with Cystistat which is instilled into the bladder using a urinary catheter Morales (1996) 22 Based on the assumption that interstitial cystitis results from a defective mucous lining of the bladder epithelium, Morales investigated the activity of hyaluronic acid in the treatment of this disease. A total of 25 patients, refractory to other medical treatments for interstitial cystitis, participated in intravesical instillations of hyaluronic acid at a dose of 40mg for four weeks and then monthly. This gave a 56% response rate at week four which increased to 71% by week 12. This was maintained until week 20. Beyond week 24, there was a moderate decrease in effectiveness. Delgado (2003) 29 Radiation-induced cystitis limits the possibility of complete treatment due to alterations to treatment schedules. Delgado retrospectively studied 90 patients with cervix or uterine cancer in The first 45 patients received standard care; the second 45 patients were treated with standard care plus weekly bladder instillations of hyaluronic acid. The author concluded that the weekly bladder instillations protected the bladder, decreased radiation-induced toxicity and risk of infection (probably enhancing the quality of life), and reduced delays in scheduled radiotherapy. Constantinides (2004) 33 Further investigations carried out by Constantinides set out to assess the effect of bladder instillations with hyaluronic acid on the rate of recurrence of urinary tract infection (UTI) in 40 women (mean age 35 years) with a history of recurrent infections. Each received intravesical hyaluronic acid 40mg/50ml once weekly for four weeks then once monthly for four months. Following this regime, no patients experienced a UTI during the five month treatment phase and 28 (70%) were recurrence free at the end of the follow-up. The mean time to recurrence was 96 days before treatment and 468 days following treatment. Tolerability was reported as excellent and no patients interrupted their treatment. The author concluded that instillations of hyaluronic acid had a significant effect on the rate of UTI on the women with a history of recurrent UTIs. Kallestrup (2005) 17 Kallestrup conducted a study to determine whether hyaluronic acid was effective in reducing the urinary frequency and pain associated with PBS and IC. In a prospective, open label, uncontrolled study, 20 patients (age range: years) all suffering from PBS and IC received weekly instillations of hyaluronic acid for one month then monthly for a further two months. There was a mean decrease in nocturia and pain of 40% and 30% respectively. Mañas (2006) 36 In a study of 71 patients looking at prevention of UTI in palliative radiation for vertebral metastasis and spinal compression, Mañas demonstrated that, in patients receiving usual care (34) compared with patients receiving usual care plus treatment with hyaluronic acid once weekly (37), the patients that received the usual care and hyaluronic acid treatment had a 5.7-fold decrease in UTI prevalence compared with the patients that had received usual care. These findings suggested that bladder instillations of hyaluronic acid can effectively prevent UTIs in this group of patients. Ahmad (2007) 39 A pilot study conducted by Ahmad suggested that sequential hydrodistention and hyaluronic acid therapy under general anaesthetic may be carried out for resistant cases of IC. A total of 23 refractory patients were recruited with an average age of 53.4 years. All underwent anaesthetic cystoscopy, hydrodistention and hyaluronic acid instillation. The bladder was then drained with the patients awake. 74% of patients responded with immediate improvement of symptoms. The average anaesthetic bladder capacity increased in the responder group from an average of 492ml (median 500ml) to an average of 776ml (median 700ml). In the responders, healing of ulceration and resolution of inflammation occurred. 15

18 Clinical studies with Cystistat Lipovac (2007) 38 In an additional study carried out by Lipovac, 20 women with a history of recurrent urinary tract infections each received nine intravesical instillations of hyaluronic acid over six months. They were assessed prospectively over 47.6 weeks and compared with a retrospective review of patients charts covering 36.2 ± 6.2 weeks. The total number of urinary tract infections was 67 before treatment and 10 after treatment. Engelhardt (2010) 50 In order to consider the long-term outcome of intravesical hyaluronan therapy in bladder pain/ic, Engelhardt reported on a questionnaire sent out to 70 patients with a history of BPS and IC that had undergone intravesical instillations of hyaluronan therapy in with a high symptom response rate 80%. The aim was to establish the initial status of the bladder using a VAS. Of 70 questionnaires issued, 48 responded after a mean follow-up of 4.9 years. 50% of patients were still free of bladder symptoms at five years, without any other additional therapy, and 41.7% of patients symptoms recurred within the first year following instillation therapy, but remained symptom free with hyaluronan maintenance alone (12/48). Sommariva (2010) 47 Benefits of Cystistat to patients have been demonstrated in studies carried out in patients suffering from chemical and radiation cystitis. In a prospective study, carried out by Sommariva, 69 male patients aged years with iatrogenic acute cystitis were enrolled into the study. Patients had received radiotherapy for the treatment of prostate cancer. Patients were given 40mg/ml of intravesical sodium hyaluronate weekly from 8-24 weeks. In all but two patients, symptoms were relieved after four weeks of treatment. Overall, 67 (97%) patients reported complete relief of dysuria and pain, and the mean Visual Analogue Scale (VAS) score dropped from 8.6 to a value of 0.9 at the end of treatment. No adverse reactions were observed in this group. Hüther (2011) 51 Hüther et al. investigated the role of Cystistat in the treatment of IC using a specifically developed in vitro bladder model. Following induction of inflammation with tumour necrosis factor-α (TNF-α) for 24 hours, treatment with 0.8mg/mL hyaluronic acid for 24 or 48 hours was found to increase sulphated GAG synthesis and to reduce the level of inflammatory cytokines. Raymond (2012) 52 To build on the existing data supporting the efficacy of HA (Cystistat ) in women with UTIs and PBS/IC, Raymond et al. investigated the use of 40mg/50ml HA in eight women with PBS/ IC and 13 with recurrent UTIs. Patients were treated every four weeks and received a mean of nine instillations. At 21 months of follow-up, pain score (p=0.05), frequency (p=0.03) and quality of life (p=0.02) were significantly improved by treatment in patients with recurrent UTIs. In those with PBS/IC, pain (p=0.02), urgency (p=0.01), nocturia (p=0.01) and quality of life (p=0.04) were significantly improved at 15 months of follow-up. Response rates in the UTI and PBS/IC groups were 53% and 75%, respectively. The authors concluded that intravesical HA can be used with minimal side effects and good compliance in both groups of patients with PBS and recurrent UTIs. 16 ReplenishRestoreRevive

19 Intravesical hyaluronic acid in the treatment of refractory interstitial cystitis 22 Morales A, Emerson L, Nickel JC et.al. Intravesical hyaluronic acid in the treatment of refractory interstitial cystitis J Urol 1996; 156: Objectives Based on the assumption that interstitial cystitis results from a defective mucous lining of the bladder epithelium, we investigated the activity of hyaluronic acid in the treatment of this disease. Hyaluronic acid is an important glycosaminoglycan present in all connective tissues, including the glycosaminoglycan layer of the vesical mucosa. It exhibits a variety of pharmacological properties that enhance its appeal for the therapy of interstitial cystitis. Patients and methods A total of 25 patients with characteristic findings of interstitial cystitis refractory to other medical treatments participated in a trial of intravesical hyaluronic acid at a dose of 40mg weekly for four weeks and then monthly. Response to therapy was evaluated by symptom score, voiding diaries and visual analogue scales. Results An initial 56% positive (complete plus partial) response rate at week four increased to 71% by week 12 and response was maintained until week 20. Beyond week 24 there was a moderate decrease in the effectiveness of the medication. There was no significant toxicity attributable to hyaluronic acid in the bladder. Conclusions The response of patients with refractory interstitial cystitis to the intravesical administration of hyaluronic acid was gratifying. In the past many therapies for interstitial cystitis which were initially considered promising failed the test of a controlled study. Such a study to determine the activity of hyaluronic acid in patients with interstitial cystitis is currently under way. Pain (raw score) Symptom (raw score) Urgency (raw score) A O B O C O Weeks Weeks Weeks Clinical response scores before treatment (week 0) and up to 48 weeks after administration of hyaluronic acid in 25 patients (mean plus standard error). A, improvement in symptom score stabilises after week 12. B, most improvement in pain score is noted at week 12, although further decrease in pain occurs with additional treatments. C, score for urgency shows gradual improvement beyond week 20. Deterioration recorded at week 24 (also in part B) was temporary and occurred in only one patient. 17

20 Hyaluronic acid in the prevention of radiation-induced cystitis 29 Delgado JM, Samper P, Rivière M. Hyaluronic acid in the prevention of radiation-induced cystitis. Presented at the 41 st Annual Meeting of the Infectious Diseases Society of America, San Diego, Poster: #03-AB-424-IDSA. Objectives The objective of this study was to assess the efficacy of hyaluronic acid (HA) bladder instillation on bladder radiation-induced toxicity and its impact on the scheduled pelvic radiotherapy. Patients and methods Radiation-induced cystitis limits the possibility of complete treatment because of alterations to the radiation treatment schedule. We studied retrospectively 90 patients charts with cervix or uterine cancer stage FIGO 3, recruited consecutively in and treated in a single centre with the same standard ambulatory radiation protocol (external radiotherapy: 46-50Gy, brachytherapy: 20-22Gy). The first 45 patients received standard care. The last 45 patients were treated with standard care plus HA bladder instillations (40mg/50ml solution, for mins) given during the brachytherapy weekly planning, through a urethral catheter used for opacification of the bladder and kept during dose calculation. Results Evaluation was done in both cohorts at baseline, 48 hours after each brachytherapy session, and monthly for three months. The toxicity scores (RTOG/EORTC Radiation Toxicity Score) were on average at week four: 1.33 in the usual care group vs 0.71 in the HA group and at the end of the radiotherapy: 1.24 in the usual care group vs 0.71 in the HA group (p<0.0001). Two patients of the usual care group reached Grade 3 toxicity vs none in the HA group. Four patients of the usual care group had an episode of bacterial cystitis vs none in the HA group. Nine patients were still experiencing Grade 1 toxicity at two months of follow-up in the usual care group vs none in the HA group. The radiotherapy schedule needed to be delayed for two patients in the usual care group vs none in the HA group. Conclusions This retrospective study showed that weekly bladder instillations of HA protected the bladder, decreased radiationinduced toxicity and risk of infection (probably enhancing the quality of life) and allowed the completion of radiotherapy on schedule. Prospective studies are underway to confirm the protective effect in this indication. Mean toxicity grade Average radiation toxicity over time n=90 p< % reduction during treatment 42% reduction at the end of treatment Cystistat Usual care Weeks 18 ReplenishRestoreRevive

21 Prevention of recurrent bacterial cystitis by intravesical administration of hyaluronic acid: a pilot study 33 Constantinides C, Manousakas T, Nikolopoulos et.al. Prevention of recurrent bacterial cystitis by intravesical administration of hyaluronic acid: a pilot study. Br J Urol Int 2004; 93: Objectives To assess the effect of bladder instillations of hyaluronic acid (HA) on the rate of recurrence of urinary tract infection (UTI). Patients and methods Forty women (mean age 35 years) with a history of recurrent UTI received intravesical instillations of HA (40mg in 50ml phosphate-buffered saline) once weekly for four weeks then once monthly for four months. The UTI status was assessed over a prospective follow-up of 12.4 months and compared with the rates of UTI before instillation, determined by a retrospective review of patient charts covering 15.8 months. Results After HA treatment no patients had experienced a UTI during the five month treatment phase and 28 (70%) were recurrencefree at the end of the follow-up. The mean (SD) rate of UTI per patient-year was 4.3 (1.55) before treatment and 0.3 (0.55) afterward (p<0.001). The median time to recurrence after HA treatment was 498 days, compared with 96 days beforehand (p<0.001). Treatment was well tolerated, as side effects were limited to nine patients who reported mild bladder irritation; no patient interrupted the treatment. Conclusions In this preliminary study, bladder instillations of HA had a significant effect on the rate of UTI in women with a history of recurrent UTIs. The bladder instillation of HA is an acceptable and promising therapeutic alternative in patients with recurrent UTI. Probability of absence of recurrence Pre-HA Treatment (Cystistat ) Post-HA Treatment (Cystistat ) Follow-up period, days Time to recurrence of infection for the periods before (purple line) and after HA instillation (blue line); the results are expressed as the probability of no recurrence of UTI with time. The median (range) time to recurrence was 96 (40 182) and 498 ( ) days for before and after instillation, respectively. 19

22 Treatment of interstitial cystitis with Cystistat : A hyaluronic acid product 17 Kallestrup EB, Jørgensen SS, Nordling J and Hald T. Treatment of interstitial cystitis with Cystistat : A hyaluronic acid product. Scand J Urol Nephrol 2005; 39: Objectives To determine whether intravesical hyaluronic acid is effective in reducing the urinary frequency and pain associated with interstitial cystitis/painful bladder syndrome (IC/PBS). Patients and methods In a prospective, unblinded, uncontrolled pilot study, 20 patients (age range years), all suffering from IC/PBS, received weekly bladder instillations of hyaluronic acid for one month and monthly instillations for a further two months. Patients were then offered further monthly instillations and all were subsequently evaluated after three years. Patient outcomes assessed were urinary frequency, use of analgesics and pain. Results All patients completed the three months of hyaluronic acid treatment with mean decreases in nocturia and pain of 40% and 30%, respectively, and a decrease in analgesic use. Thirteen patients (65%) responded to treatment (responders) and continued therapy, while seven patients withdrew, six because of a lack of response and one due to cystectomy. In the 13 patients who continued hyaluronic acid instillations, four complete responders (30%) ceased therapy after a strong positive response (36%, 60% and 81% decreases compared to baseline in day-time voids, night-time voids and pain scores, respectively) which was maintained in the absence of continuous therapy, while after three years seven partial responders (35%) were still on therapy (25% and 43% decreases compared to baseline in day-time voids and pain scores, respectively). Two patients developed other diseases during follow-up and showed no response to long-term therapy. Hyaluronic acid was well tolerated by all patients. Conclusions Hyaluronic acid safely reduced the pain and, to a lesser degree, the urinary frequency associated with IC. Overall patient responses over the study period STUDY TIMELINE STUDY POPULATION RESPONSE At baseline 20 patients Part 1 Part 2 At 3 months 20 patients remained 13 patients requested therapy continuation 1 drop-out* 6 non-responders 13 responders 2 drop-outs 4 complete responders At 3 years 7 patients remained 7 partial responders * Patient withdrew at 3 months due to cystectomy 20 ReplenishRestoreRevive

23 Prevention of urinary tract infections in palliative radiation for vertebral metastasis and spinal compression: a pilot study in 71 patients 36 Mañas A, Glaría L, Peña C et.al. Prevention of urinary tract infections in palliative radiation for vertebral metastasis and spinal compression: a pilot study in 71 patients. Int J Radiat Oncol Biol Phys 2006; 64(3): Objectives To assess the impact of bladder instillations of hyaluronic acid (HA) on the prevalence of urinary tract infection (UTI) in patients receiving emergency radiotherapy for metastatic spinal cord compression. Patients and methods Patients were recruited consecutively at one centre and assigned to usual care (UC) (n=34, mean age 62.2 years) or UC with once-weekly HA instillation (UC+HA) (Cystistat: 40mg in 50ml phosphate-buffered saline) (n=37; mean age 63.1 years). All patients had an indwelling catheter and received radiotherapy. UTI status was assessed at baseline and during hospitalisation. Results At baseline, patient groups were comparable, except for the prevalence of UTI at baseline, which was 11.8% and 0% in the UC and UC+HA patients, respectively (p=0.0477). During hospitalisation, 76.5% (vs 11.8% at baseline, p<0.0001) of the UC patients had a UTI compared with 13.5% (vs 0% at baseline, p=0.0541) of the UC+HA patients (p<0.0001). Both groups were hospitalised for similar periods (19.8 days [UC] vs 18.5 days, p=0.4769) and received equivalent radiotherapy sessions (4.6 [UC] vs 5.8 sessions, p=0.2368). Conclusions Patients receiving UC+HA had a 5.7-fold decrease in UTI prevalence over the hospitalisation period compared to UC patients, suggesting that bladder instillations of HA effectively prevent UTI in patients with indwelling catheters receiving radiotherapy for nerve compression. % of patients Incidence of UTI requiring systemic treatment post-radiation n=71 p< % Usual care 13.5% Cystistat 21

24 Prevention of recurrent bacterial urinary tract infections by intravesical instillation of hyaluronic acid 38 Lipovac M, Kurz C, Reithmayr F et.al. Prevention of recurrent bacterial urinary tract infections by intravesical instillation of hyaluronic acid. Int J Gynecol Obstet 2007; 96(3): Objectives To evaluate the efficacy of vesical instillation of hyaluronic acid against recurrent urinary tract infections. Patients and methods Twenty women with a history of recurrent urinary tract infections each received nine intravesical instillations of hyaluronic acid over six months. Their status was assessed prospectively over 47.6 weeks and compared with a retrospective review of patient charts covering 36.2 ± 6.2 weeks. Results The total numbers of urinary tract infections were 67 before and 10 after treatment (p<0.001). Thirteen patients (65%) were free of recurrences until the end of the study. One had a recurrence during treatment, and six (30%) during follow-up. The number of infections per year per patient was reduced from 4.99 ± 0.92 to 0.56 ± 0.82 (p<0.001). In women with recurrences, time to recurrence was ± 25.5 days, compared with 76.7 ± 24.6 days before treatment (p<0.001). Conclusions Intravesical instillation of hyaluronic acid is effective in preventing recurrent urinary tract infections. Probability of absence of infection p<0.001 Pre-HA Treatment (Cystistat ) Post-HA Treatment (Cystistat ) Time (days) 22 ReplenishRestoreRevive

25 Sequential hydrodistension and intravesical instillation of hyaluronic acid under general anaesthesia for treatment of refractory interstitial cystitis: a pilot study 39 Ahmad I, Krishna NS, Meddings RN. Sequential hydrodistension and intravesical instillation of hyaluronic acid under general anaesthesia for treatment of refractory interstitial cystitis: a pilot study. Int Urogynecol J 2007; 19: Objectives Pilot study looking at the combination of general anaesthetic hydrodistension and intravesical hyaluronic acid for treatment of refractory interstitial cystitis. Patients and methods Twenty-three treatment refractory patients were recruited with an average age 53.4 years. All underwent general anaesthetic cystoscopy, hydrodistension and instillation of hyaluronic acid (40mg/50ml). The bladder was then subsequently drained with the patient awake. Two initial treatments were carried out a month apart and duration between treatments increased depending upon symptom response. Results In the responders, the average number of treatments was 6.6 (median 4.5), duration between treatments was 3.1 months (median 2.6) and follow-up 15.8 months (median 16). Seventeen patients (74%) responded with immediate improvement in symptoms. In all responders, healing of ulceration and resolution of inflammation occurred. Average anaesthetic bladder capacity increased in the responder group from an average of 492ml (median 500ml) to an average of 776ml (median 700ml) (Table 1). Conclusions Our pilot data suggests sequential hydrodistension and hyaluronic acid treatment under general anaesthesia may be considered for resistant cases of interstitial cystitis, especially those that cannot tolerate the instillation procedure under local anaesthesia. Further prospective trials are required. Table 1: Treatment responder group PATIENT NUMBER PRE-TREATMENT BLADDER CAPACITY (ml) RESPONSE TO PREVIOUS HA (LA) RESPONSE TO PREVIOUS HYDRODISTENSION AVERAGE DURATION SYMPTOM RELIEF (MONTHS) AVERAGE DURATION FOLLOW-UP (MONTHS) NUMBER OF TREATMENTS POST- TREATMENT BLADDER CAPACITY (ml) Transient Not Done , Transient Not Done Transient Transient , Transient Transient None None Not Tolerated Transient Not Done Transient Transient Transient Not Tolerated Not done Transient Transient , Transient None Transient None Not Tolerated None Transient Not Done Transient Not Done , Transient Transient Not Done None HA Hyaluronic acid, LA local anaesthesia 23

26 Efficacy of sodium hyaluronate in the management of chemical and radiation cystitis 47 Sommariva ML, Sandri SD, Ceriani V. Efficacy of sodium hyaluronate in the management of chemical and radiation cystitis. Minerva Urol Nefrol 2010; 62: Objectives Onset of cystitis in patients receiving immuno-chemotherapeutic agents by intravesical instillation for non-muscle invasive transitional cell carcinoma of the bladder or after radiotherapy for prostatic cancer is frequent and problematic, since it responds poorly and slowly to the usual symptomatic treatments. This iatrogenic complication often means that cancer therapy has to be interrupted on account of the bladder pathology symptoms and of course this has further clinical implications. The symptoms resemble those of the urgency/frequency and painful bladder syndromes, so we tested the treatment used for these disorders to see whether it helped in this difficult clinical situation. Patients and methods This prospective study therefore enrolled 69 male consecutive patients, between 54 to 81 years of age, with iatrogenic acute cystitis; in 15 the symptoms had appeared after radiotherapy for prostatic cancer, in 24 after intravesical BCG, in 30 after instillation of Mitomycin C (with Synergo thermotherapy for 12 of them). All patients were given intravesical instillations of sodium hyaluronate, 40mg/50ml, weekly for from 8 to 24 weeks, depending on how the symptoms released. In the first four weeks dexamethasone 32mg was mixed in as a cocktail, on account of its prompt and effective topical anti-inflammatory action and good mucosal penetration. Longer use of cortisone is contraindicated because of the high risk of sensitisation and it provided no evidence of any ability to overcome the severe urinary disturbances with lasting effect. In order to allow patients with marked overactive bladder to keep these drugs within the bladder, we instilled lidocaine 2% 30ml, 30 minutes before. Patients recorded their bladder capacity (BC) by filling a micturition diary. Pain was assessed using a Visual Analogue Scale (VAS) from 0 to 10 for the chemical cystitis cases at the beginning and end of treatment. Results After only four weeks BC increased in all but two patients, and urgency and pain disappeared. Treatment was continued, however, for another four weeks, even in patients with total remission of their symptoms as we had seen earlier that if it was stopped too soon the symptoms could return. In the chemical cystitis group the VAS score dropped from an initial mean of 8.6 to 0.9 at the end of treatment (p<o.ooo1). Mean BC rose from 58.4 to 283.7ml in the chemical cystitis cases (p<o.ooo1), and from 85 to 243.3ml (p<0.0001) in the radiotherapy patients. Overall 67 patients (97%) reported complete relief of dysuria and pain. Two treatment failures were due to a reduced compliance to treatment by the patients themselves. No adverse reactions were observed related to the catheters or drugs used. Patients with non-invasive bladder tumours were able to restart their cancer therapy. For cystitis induced by intravesical immuno-chemotherapy or pelvic radiotherapy this approach appears to achieve an effective and rapid cure with no adverse reactions, allowing the conclusion of treatments for non-invasive transitional cell-bladder cancer. Patients with chemical cystitis responded a little better than those who had received radiotherapy. Subsequent urinary cytology and cystoscopy ruled out bladder cancer progression in these cases after temporary postponement of the oncological treatment. Conclusions Intravesical sodium hyaluronate seems a valid and quick therapeutic solution for iatrogenic cystitis from chemo or radiotherapy. After a review of literature, this strategy does not appear to have been used before for this particular problem. VAS symptom score Visual Analogue Scale (VAS) scores before and after treatment in patients with chemical cystitis n=54 patients with chemical-induced cystitis p< Pre-treatment 0.9 After treatment (8 weeks) VAS not conducted after 8 weeks 24 ReplenishRestoreRevive

27 Long-term results of intravesical hyaluronan therapy in bladder pain syndrome/interstitial cystitis (BPS/IC) 50 Engelhardt PF, Morakis N, Daha LK et.al. Long-term results of intravesical hyaluronan therapy in bladder pain syndrome/interstitial cystitis (BPS/IC). Int Urogynecol J 2011; 22(4): Objectives While the short-term efficacy of intravesical hyaluronan for bladder pain syndrome/interstitial cystitis has been demonstrated, no data exists on the long-term outcome of this therapy. Patients and methods A questionnaire was sent to 70 patients with BPS/IC that had undergone intravesical hyaluronan therapy in the years 2001 to 2003 with a high symptom response rate of >80% to evaluate the present status of bladder symptoms on a visual analogue scale (VAS 0 to 10, 0 = no symptoms, 10 = maximal symptoms). Results 48/70 patients responded after a mean follow-up of 4.9 years. Initial VAS score had been 8.15, with a reduction to 2.71 after therapy, and a present score of 2.14 five years later. 50% of patients (24/48) were still free of bladder symptoms at five years follow-up without any additional therapy after the initial instillation series. In 41.7% (20/48) of patients symptoms recurred within the first year after instillation therapy and these patients stayed free of symptoms with hyaluronan maintenance therapy alone (12/48) or in combination with oral Pentosanpolysulfate (8/48). No change of symptoms was reported by 8.3% (4/48) patients. Conclusions Besides a high rate of acute symptom remission, intravesical hyaluronan also shows long-term efficacy in a considerable number of BPS/IC patients that suggests that some patients may be cured by this therapy. Patients with symptom recurrence after instillation therapy have a high chance for symptom remission with hyaluronan maintanance therapy. VAS symptom score (0-10) Significant reduction in VAS score at 5 years Pre-treatment End of treatment End of follow-up 25

28 Related studies Deciphering the mechanism of hyaluronic acid treatment for interstitial cystitis in an in vitro bladder model 51 Hüther H, Mahor S, Carr E, Pandit A. Deciphering the Mechanism of Hyaluronic Acid Treatment for in an In Vitro Bladder Model ESB 24 th European Conference on Biomaterials, Dublin, Objectives The overall goal of this study is to develop an in vitro bladder model and investigate the role of hyaluronic acid (HA) treatment in the inflammation in interstitial cystitis (IC). The specific objectives of this project were to investigate the effect of HA treatment on modulation of inflammatory cytokines and glycosaminoglycans (GAGs) (sulphated and total) content in IC like conditions induced by TNF-α in an in vitro model. Sulphated GAGs (mg/well) Day 1 Day 3 Day 4 Day 5 Patients and methods An in vitro bladder model of IC was developed using human bladder HTB-4 cells, grown in DMEM, 10% FBS, 1% penicillin/ streptomycin and sub-cultured using trypsin. Cells were grown at 1x10 5 cells/well in 6-well culture plates. Inflammation was induced using TNF-α at a concentration of 100ng/ml for 24 hours, and cells were further treated with hyaluronic acid treatment (0.8mg/ml) for two time points i.e. 24 hours and 48 hours. Cell supernatant was collected at regular intervals and analysed for sulphated GAGs and total GAGs by Di-methyl Methylene blue assay (DMMB) and carbazole assay respectively. The level of various cytokines such as IL-6, histamine and IGF-1 were also investigated by respective ELISA kits. Figure 4. Sulphated GAGs analysis of cell supernatant after treatment of HA (0.8mg/ml). Supernatants were collected for each time point and analyzed by DMMB assay for sulphated GAGs. Data shown as mean ± SD (n=3) and considered significant if p<0.05 a c b d Results Sulphated GAGs synthesis and amount were increased with the treatment of hyaluronic acid at concentration of 0.8mg/ml (Figure 4). Total GAGs were also estimated by carbazole assay in collected cell supernatant. There was significantly higher amount of total GAGs detected in the hyaluronic acid treated groups than the non-treated group. Fluorescent microscopy revealed that cells had a different morphology as they appeared elongated after inflammation. However, with treatment of HA the original cellular morphology was revived (Figure 5). Cellular metabolic activity was also evaluated during treatment and compared with non-treated groups. There was no significant difference seen in the cellular metabolic activity of HA treated cells when compared with non-treated group. The effect of HA treatments on various cytokines was also evaluated using specific ELISA kits. IL-6, histamine and IGF-1 levels increased after the treatment of TNF-α but reduced significantly after the treatment of HA at concentration of 0.8mg/ml. Figure 5. Fluorescent photomicrographs of in vitro bladder model system. HTB-4 cells (a) normal (without any treatment), (b) TNF-α treated, (c) hyaluronic acid treated for 24 hours, (d) hyaluronic acid treated for 48 hours. Cells were fixed with 4% paraformaldehyde fixing solution and stained with DAPI and rhodamine B for nucleus and cytoskeleton respectively (bar represents 20μm) Conclusions HA treatment enhanced GAG synthesis and reduced the level of inflammatory cytokines such as IL-6, histamine, IGF ReplenishRestoreRevive

29 Product information Proprietary name Cystistat Qualitative/quantitative information Clear, colourless, sterile aqueous solution containing 40mg sodium hyaluronate 45,58 Pharmaceutical form 50ml single-use vial 45 Use Cystistat is used as a temporary replacement of the glycosaminoglycan (GAG) layer in the bladder, for the symptomatic treatment of bladder conditions such as interstitial cystitis (IC). 45 It may also be used to treat cystitis caused by infections, trauma, urolithiasis, urinary retention, neoplasia or radiation. 45 Posology and method of administration Cystistat is administered initially once weekly, for four to twelve consecutive weeks, then monthly until symptoms resolve. 45 If symptoms recur in the future following their successful resolution, a further immediate dose is recommended. Cystistat is administered intravesically as a 50ml instillation via a catheter or bladder syringe. It should be administered after any residual urine is removed and be retained in the bladder for a minimum of 30 minutes. 45 Ideally, the patient should be rotated after Cystistat has been administered, as it allows Cystistat to coat the entire lining of the bladder, since there is usually a small air pocket at the top of the bladder. Following administration of Cystistat, the patient can leave the clinic setting and void the product at their leisure. It is not necessary to keep the patient under observation until such time as voiding occurs. Contra-indications, warnings and interactions Cystistat is contra-indicated in patients with known hypersensitivity to sodium hyaluronate. 45 No interactions are known for Cystistat with medicinal products. No studies have been undertaken on the use of Cystistat during pregnancy and lactation, nor on the use of Cystistat in children. Side effects Cystistat has a very low incidence of side effects. 33,42 Moreover, sodium hyaluronate is a naturally occurring substance with very low antigenicity. The sodium hyaluronate used in Cystistat is of fermentative origin. However, occasional cases of suspected hypersensitivity to sodium hyaluronate may still occur. Given the high molecular weight of Cystistat, absorption from the site of action is unlikely. Pharmaceutical information Cystistat contains 40mg sodium hyaluronate in 50ml sterile buffered saline 45,58 The shelf-life of Cystistat is 36 months Cystistat should be stored at room temperature (15-30 C) 45 Cystistat should not be frozen. Cystistat can be refrigerated, but should be returned to room temperature before being administered to a patient No special handling precautions are required for personnel involved with the administration of Cystistat. However, standard procedures to minimise the risks of microbial contamination should be followed Cystistat is classified as a medical device (CE 0344) The approval for CE marking is held by Mylan Institutional Cystistat is manufactured by Mylan Institutional Inverin Co. Galway Ireland Cystistat is distributed in the UK by Teva UK Limited Ridings Point, Whistler Drive, Castleford, WF10 5HX T: F: For further information on this product please contact Teva UK Limited 27

30 Material Safety information SECTION 1 Product Name/Identifier: Cystistat Trade Names and Synonyms: Hyaluronan, Hyaluronic acid Chemical Name: Sodium Hyaluronate Chemical Family: Mucopolysaccharide Chemical Formula: (C 14H 20O 11NNa)n Molecular Weight: kda MATERIAL IDENTIFICATION AND USE Product Use: Temporary replacement of the Glycosaminoglycan (GAG) layer Flammability: Not Applicable Hazardous Materials: None Manufacturer: Mylan Institutional Inverin Co. Galway, Ireland Phone: Fax: Distributor: Teva UK Limited Ridings Point, Whistler Drive, Castleford, WF10 5HX Phone: Fax: SECTION 2 Physical State: Liquid ph: Odour and Appearance: Odourless, colourless Odour Threshold (ppm): Not available PHYSICAL DATA Specific Gravity (Water = 1): 1 Vapour Pressure: Not available Vapour Density (Air = 1): Not available Evaporation Rate: 1 Boiling Point ( o C): 100 Freezing Point ( o C): Not available Co-efficient of Water/Oil Dist: Not available Aerosol Percent Volatiles (By Weight): 99 Solubility in Water (% w/w): ReplenishRestoreRevive

31 SECTION 3 Chemical Stability: Stable under normal conditions REACTIVITY DATA Conditions to Avoid: Direct sunlight. Freezing Incompatibility with Other Substances: None known Hazardous Decomposition Products: None known Hazardous Polymerisation: Will not occur SECTION 4 Gloves/Type: None Eye/Type: None Caution: Flush with water Leak/Spill: Caution - flush with water Waste Disposal: Dispose of any waste carefully in accordance with standard procedures for non-toxic liquid waste PREVENTATIVE MEASURES Respiratory/Type: None Footwear/Type: None Engineering Controls: Not applicable Handling Procedures and Equipment: For single use only. Discard after use Storage Needs: Store at room temperature (15-30 C). Do not freeze. Cystistat is exempt from the COSHH/CHIPS data sheet requirements 29

32 Appendix A: Identification of a defective GAG layer: Riedl s test 59 A defective GAG layer is indicated by a 30% or greater reduction in bladder capacity with 0.2M potassium chloride compared to saline n Explain procedure, obtain patient consent n Insert a 14F bladder transurethral catheter n Empty residual bladder volume n Fill bladder with sterile room-temperature normal saline at a rate of 50ml/min using infusion pump or gravity drainage n Patient reports first strong urge to void n Continue filling until patient says Stop filling Volume saline Volume saline - Volume KCl x 100 = % Reduction n Drain the bladder and measure the volume of saline n Repeat the procedure using 0.2M potassium chloride (ensuring filling lines are free of saline) n Calculate the % difference in maximal bladder capacity 30% or greater reduction in bladder capacity indicates a defective GAG layer. 30 ReplenishRestoreRevive