ENTERAGAM is a medical food as defined by the Orphan Drug Act. Physician supervision is required.

Transcription

1 HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use ENTERAGAM. See full prescribing information for ENTERAGAM. ENTERAGAM (serum-derived bovine immunoglobulin/protein isolate; SBI); SBI is a generally recognized as safe (GRAS) affirmed ingredient for enteral and/or oral administration. ENTERAGAM is a medical food as defined by the Orphan Drug Act. Physician supervision is required RECENT MAJOR CHANGES Intended Use [section (1)] [01/2015] Nutrition [section (12)] [01/2015] Nonclinical Data for the Management of Specific Intestinal Disorders [section (13)] [01/2015] Clinical Data for the Management of Specific Intestinal Disorders [section (14)] [01/2015] Dosage and Administration [section (2)] [08/2014] INTENDED USE ENTERAGAM is a prescription medical food product intended to provide for distinctive nutritional requirements that are unique for the clinical dietary management of specific intestinal disorders [e.g., in irritable bowel syndrome with diarrhea (IBS-D), inflammatory bowel disease (IBD), and HIVassociated enteropathy] DOSAGE AND ADMINISTRATION Pour packet ingredients into cup or glass Add at least 4 oz of water (or other liquid as preferred) Stir until fully mixed (do not shake) Drink all of the contents immediately Alternatively, product can be mixed with foods such as pudding or yogurt A recommended starting dose is 1 packet twice daily for two to four weeks which can be increased up to 4 packets per day as directed by the healthcare provider. After the starting dose, a maintenance dose of at least one packet per day should be used to manage the patient condition(s) [2.1,2.2,17] DOSAGE FORMS AND STRENGTHS Each packet contains 5 g of SBI, 5 g dextrose and trace amounts of sunflower lecithin (10 g Net weight). [3,16] CONTRAINDICATIONS ENTERAGAM is contraindicated for patients with a hypersensitivity (allergy) to beef or any components in ENTERAGAM. [4] WARNINGS AND PRECAUTIONS ENTERAGAM contains beef protein; therefore, patients who have an allergy to beef or any component of ENTERAGAM should not take this product. [5.1] ADVERSE REACTIONS The most commonly reported AEs in clinical studies (incidence of 2-5%) included mild nausea, constipation, stomach cramps, headache and increased urination. [6.1,6.2] To report SUSPECTED ADVERSE REACTIONS, contact Entera Health, Inc. at ENTERA ( ) or the FDA at FDA-1088 ( ) or DRUG INTERACTIONS No significant interactions of ENTERAGAM with commonly prescribed medications have been observed. [7] USE IN SPECIFIC POPULATIONS ENTERAGAM has been tested in clinical studies of pediatric (as young as 6 months of age) and adult subjects. To date, there have been no clinical studies of ENTERAGAM performed in other specific patient populations (e.g., hepatic and renal insufficiency). No significant findings were associated with patient responses by sex, race or ethnicity. ENTERAGAM has not been studied in pregnant or nursing women. The choice to administer ENTERAGAM during pregnancy is at the clinical discretion of the prescribing physician. [8.1,8.2,8.3,8.4,8.5,17] See 17 for PATIENT COUNSELING INFORMATION. Revised: [02/2015] FULL PRESCRIBING INFORMATION: CONTENTS* 1 INTENDED USE 1.1 Clinical dietary management in patients who, as a result of a condition or disease, have limited or impaired capacity to ingest, digest, absorb, or metabolize ordinary foodstuffs or certain nutrients 1.2 Clinical dietary management of specific intestinal disorders in patients with chronic loose and frequent stools [e.g., irritable bowel syndrome with diarrhea (IBS-D), inflammatory bowel disease (IBD) and HIV-associated enteropathy] 2 DOSAGE AND ADMINISTRATION 2.1 Adult patients 2.2 Pediatric patients 3 DOSAGE FORMS AND STRENGTHS 4 CONTRAINDICATIONS 5 WARNINGS AND PRECAUTIONS 6 ADVERSE REACTIONS 6.1 Clinical trial experience 6.2 Post-marketing surveillance 7 DRUG INTERACTIONS 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy 8.2 Labor and Delivery 8.3 Nursing Mothers 8.4 Pediatric Use 8.5 Geriatric Use 10 OVERDOSAGE 11 DESCRIPTION 12 NUTRITION 12.1 Distinctive nutritional requirement for oral immunoglobulins unique to specific intestinal disorders 12.2 Mechanism of Action 12.3 Digestibility/survivability of specially formulated protein 13 NONCLINICAL DATA FOR THE MANAGEMENT OF SPECIFIC INTESTINAL DISORDERS 14 CLINICAL DATA FOR THE MANAGEMENT OF SPECIFIC INTESTINAL DISORDERS 14.1 Irritable Bowel Syndrome with Diarrhea 14.2 Inflammatory Bowel Disease 14.3 HIV-associated Enteropathy 14.4 Pediatric Malnutrition 15 REFERENCES 16 HOW SUPPLIED/STORAGE AND HANDLING 17 PATIENT COUNSELING INFORMATION 17.1 Medical Foods 17.2 Instructions for Use 17.3 Pregnancy and Nursing 17.4 Warnings and Precautions *Sections or subsections omitted from the full prescribing information are not listed. 1

2 FULL PRESCRIBING INFORMATION 1 INTENDED USE 1.1 Clinical dietary management in patients who, as a result of a condition or disease, have limited or impaired capacity to ingest, digest, absorb, or metabolize ordinary foodstuffs or certain nutrients ENTERAGAM provides for distinctive nutritional requirements for the clinical dietary management of the unique nutrient needs that result from malnutrition, IBS-D, IBD and HIV-associated enteropathy, as determined by medical evaluation and which cannot be obtained from diet alone. Pediatric and adult patients with limited or impaired capacity to ingest, digest, absorb or metabolize ordinary foodstuffs or certain nutrients due to malnutrition IBS-D, IBD and HIV-associated enteropathy can utilize the specially formulated proteins in ENTERAGAM for nutritional support. 1.2 Clinical dietary management of specific intestinal disorders in patients with chronic loose and frequent stools [e.g., IBS-D, IBD and HIV-associated enteropathy] ENTERAGAM provides for distinctive nutritional requirements for the clinical dietary management of the unique nutrient needs in patients with chronic loose and frequent stools (e.g., in IBS-D, IBD and HIVassociated enteropathy) which cannot be obtained by diet alone. ENTERAGAM, as a medical food, must be used under physician supervision. ENTERAGAM is dispensed by prescription. 2 DOSAGE AND ADMINISTRATION 2.1 Adult Patients A recommended starting dose is 1 PACKET twice daily for two to four weeks which can be increased up to 4 PACKETS per day as directed by the healthcare provider. After the starting dose, a maintenance dose of at least 1 PACKET per day may be used to manage the patient condition(s). Always take ENTERAGAM according to your healthcare provider s instructions. ENTERAGAM has been safely consumed for up to one year in clinical studies in adults. ENTERAGAM powder from 1 PACKET should be dissolved in at least 4 oz (120 ml) of water or other liquids as preferred and stirred until fully mixed. The mixture should not be shaken as this process may degrade the product. The powder may also be mixed in foods such as pudding or yogurt. ENTERAGAM powder from PACKETS should not be stored as a liquid solution as the product may degrade. Consume each dose immediately after mixing. 2.2 Pediatric Patients Children 2 years and older can be administered one half (1/2) PACKET of ENTERAGAM once daily in liquids or food according to the healthcare provider s instructions. Healthcare providers may choose to increase the dose based on the response and tolerance in an individual patient. ENTERAGAM has been safely consumed for up to 8 months in clinical studies in pediatric populations as young as 6 months of age. 3 DOSAGE FORMS AND STRENGTHS ENTERAGAM PACKETS contain light-colored powder consisting of 5 g of SBI, 5 g dextrose and trace amounts of sunflower lecithin (10 g Net weight). Retail product is supplied in cartons containing 30 PACKETS. Professional sample cartons are available in two sizes: a carton of 3 PACKETS and a titration kit containing 30 PACKETS. 2

3 4 CONTRAINDICATIONS ENTERAGAM is contraindicated for patients with a hypersensitivity (allergy) to beef or any components in ENTERAGAM. 5 WARNINGS AND PRECAUTIONS ENTERAGAM contains beef protein; therefore, patients who have an allergy to beef or any component of ENTERAGAM should not take this product. 6 ADVERSE REACTIONS 6.1 Clinical Trial Experience Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a product cannot be directly compared to rates in the clinical trials of another product and may not reflect the rates observed in-market when prescribed to patients with co-morbidities or taking multiple pharmaceutical agents. The adverse reaction information from clinical trials does, however, provide a basis for identifying the adverse events (AEs) that appear to be related to product use and for approximating rates of side effects. There were no serious adverse events (SAEs) associated with or related to the use of 0.18 to 20 g of SBI per day in ENTERAGAM found in various clinical trials totaling over 300 participants. Infants ranging in age from 6 to 25 months were administered between 0.18 and 1 g of SBI per day in ENTERAGAM for up to 8 months (refer to Table 1). Adults ranging in age from 18 to 70 years were administered 5 to 20 g per day of SBI in ENTERAGAM for a duration of 2 days up to 48 weeks (Table 1). The most commonly reported AEs in clinical studies (incidence 2-5%) included mild nausea, constipation, stomach cramps, headache, and increased urination. Table 1. Clinical Safety in the Management of Intestinal Disorders Population Studied Safety Summary Healthy Adults 41 healthy adults were administered a single dose of SBI 5 g, 10 g, or 20 g, followed by SBI 2.5 g, 5.0 g or 10 g twice a day for 14 days. SBI was generally well-tolerated by the participants during the single dose and over 14 days. Adverse events that occurred at an incidence of 10% in any group were the following (presented by number of subjects for 5.0 g, 10 g or 20 g daily): abdominal cramps (3, 0, 1), constipation (2, 0, 1), diarrhea (2, 0, 0), flatulence (0, 0, 2), cold (2, 0, 0), upper respiratory tract infection (0, 2, 0), and headache (2,1, 0). IBS-D 44 adult subjects were administered either 5 or 10 g of SBI per day for 6 weeks. SBI was well-tolerated with no SAEs reported. Three subjects withdrew from the study due to nausea. No statistically significant differences between groups with respect to hematology and clinical chemistry laboratory results were observed. 10 adult patients with IBS-D and IBS with bloating and distention who were not fully managed with traditional therapies were administered 5 g of SBI per day. A retrospective chart analysis showed that SBI was well-tolerated with no reported AEs when taken up to 28 weeks. 26 adult patients previously screened for SIBO by LBT, and had been 3

4 IBD HIV-associated Enteropathy Malnutrition (Pediatric) Study 1 and 2 refractory to various therapeutics, were administered 10 g of SBI per day. A retrospective chart analysis showed that 3 patients stopped taking SBI due to AEs. 45 adults with IBD (38 diagnosed with Crohn s disease and 7 with ulcerative colitis) who were not fully managed on traditional therapies were administered 5 g of SBI per day for 12 weeks. A retrospective chart analysis showed that SBI was well-tolerated with no reports of AEs. 4 adults diagnosed with Crohn s disease and 3 with ulcerative colitis who were not fully managed on traditional therapies were administered either 5 or 10 g per day for 3 to 9 months. A retrospective chart analysis showed that SBI was well-tolerated with no reports of AEs. 2 adults diagnosed with ulcerative colitis not fully controlled on traditional therapies were administered SBI using different dosing regimens. One patient was given 5 g QID for one week followed by 5 g BID of SBI. The other patient received 5 g BID for 8 weeks followed by 5 g daily thereafter. Each patient has been maintained along with other therapies for over a year with no reported AEs. 8 HIV+ adults were administered 2.5 g SBI twice a day for 8 weeks. SBI was well-tolerated with no SAEs reported. Five patients continued on therapy for up to 48 weeks. The most commonly reported AEs included worsening or reoccurrence of diarrhea (5 AEs reported by 4 subjects), constipation (2 subjects), and worsening neuropathy (3 AEs reported by 2 subjects). AEs that were reported by 1 subject each included sinus infection, throat infection, gastroesophageal reflux disease, flatulence, worsening lower back pain, groin pain, nausea, bronchitis, acute ear infection, and infection on finger. No AEs were reported to be related to SBI and no subjects discontinued due to an AE. 10 children (9-25 months of age) were provided a diet with either 25 or 50% protein replacement of milk protein with serum-derived bovine protein containing immunoglobulins during 3 randomly-ordered, 7-day dietary periods. There were no reported AEs due to serum-derived bovine protein containing immunoglobulins. 107 infants (6-7 months of age) received serum-derived bovine protein containing immunoglobulins in an 8-month study. There were no reported AEs due to serum-derived bovine protein containing immunoglobulins. AE = adverse event; HIV = human immunodeficiency virus; IBD = inflammatory bowel disease; IBS-D = irritable bowel syndrome with diarrhea; LBT = lactulose breath test; SAEs = serious adverse events; SBI = serum-derived bovine immunoglobulin/protein isolate; SIBO = small intestinal bacterial overgrowth 6.2 Post-marketing Surveillance In an estimated population of over 225,000 people consuming SBI since 2001, the AE rate has been less than 0.1%. Common AEs are mild nausea, constipation, headache, increased urination and increased diarrhea. There has been one report of mild, itchy skin rash in a patient consuming a product containing SBI. Some patients have taken SBI for up to 4 years without experiencing AEs. No serious SAEs have been reported to the manufacturer or the FDA. 7 DRUG INTERACTIONS No significant interactions of ENTERAGAM with commonly prescribed medications or therapies have been observed. 4

5 CYP450 Interactions: Since orally-administered SBI has been shown only to be present in the gastrointestinal (GI) tract, there is no interaction with the cytochrome P450 (CYP450) enzyme system in the liver. Therefore, CYP450 polymorphisms are not a factor when administering ENTERAGAM. 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy ENTERAGAM has not been studied in pregnant women. The choice to administer ENTERAGAM during pregnancy is at the clinical discretion of the prescribing physician. 8.2 Labor and Delivery ENTERAGAM has not been studied in labor and delivery. The choice to administer ENTERAGAM during labor and delivery is at the clinical discretion of the prescribing physician. 8.3 Nursing Mothers ENTERAGAM has not been studied in nursing women. The choice to administer ENTERAGAM in nursing mothers is at the clinical discretion of the prescribing physician. 8.4 Pediatric Use Infants ranging in age from 6 to 25 months were administered between 0.18 to 1.0 g of SBI per day in ENTERAGAM for up to 8 months with no reported AEs. 8.5 Geriatric Use Clinical studies with ENTERAGAM have not included sufficient numbers of patients aged 65 and over to determine whether they respond differently than younger subjects. 10 OVERDOSAGE No specific information is available on the treatment of overdosage with ENTERAGAM. SBI in ENTERAGAM has been self-affirmed as Generally Recognized as Safe (GRAS) with no questions regarding safety from the FDA (see section 17.1). The highest level of SBI consumption has been 20 g per day in clinical studies. 11 DESCRIPTION ENTERAGAM PACKETS contain light-colored powder consisting of 5 g of SBI, 5 g dextrose and trace amounts of sunflower lecithin (10 g Net weight). SBI is composed of > 50% immunoglobulin G (IgG) as well as other proteins and peptides which reflect the composition of plasma and are similar to other serum proteins found in colostrum and milk. ENTERAGAM PACKETS do not contain any milk products such as lactose, casein, or whey. ENTERAGAM PACKETS are gluten-free, dye-free, and soy-free. ENTERAGAM PACKETS are manufactured in accordance with current Good Manufacturing Practice (cgmp) for medical foods. 12 NUTRITION 12.1 Distinctive Nutritional Requirement for Oral Immunoglobulins unique to specific intestinal disorders 5

6 Intestinal disorders are frequently found in association with several human disease conditions, including IBS-D, IBD, or HIV infection, and are caused by pathological changes in the lining of the intestinal tract. Such changes disrupt the homeostasis or balance of the GI tract, which leads to symptoms of abdominal discomfort, bloating, and abnormal bowel function (e.g., urgency, diarrhea, constipation). While the pathophysiological mechanisms that cause some of these intestinal disorders are not well understood, there is evidence to suggest the involvement of genetic predispositions, diet, stress, and exposure to external antigens (foreign substances), toxins, or other environmental insults (including infection). There are dozens of mutated genes, for example, which have been implicated in IBS and IBD. These mutations can affect intestinal permeability, metabolism of tryptophan and the synthesis and metabolism of bile acids, which can result in imbalances of neurotransmitters and alterations in motility. Modifications in tryptophan, serotonin, and bile acid metabolism have been implicated in causing or exacerbating many of the symptoms endured by patients who have IBS-D. Changes in tryptophan metabolism have also been reported in HIV and IBD patients. Besides the potential genetic contribution, alterations of the intestinal microbiota (bacteria) and gut permeability due to alterations in gut barrier function can limit or impair digestive and absorptive function, leading to changes in fluid balance, vitamin production and absorption, and maldigestion of carbohydrates and fats. Malabsorption of key micronutrients (e.g., vitamins and minerals) and macronutrients (e.g., protein, carbohydrate, fat) during chronic diarrhea can lead to malnutrition or chronic undernutrition and play a central role in patients with specific intestinal disorders. A simple dietary change does not correct the problems which occur in intestinal disorders. It is widely recognized that colostrum and breast milk, the sole source of nutrition for the neonate, contain a number of proteins including immunoglobulins which, along with early exposure to external antigens and bacteria, are critical for establishing the intestinal microbiota, normal immune function, integrity of the gut barrier, and digestive processes in the GI tract. Studies evaluating specially-formulated bovine immunoglobulin preparations have revealed a similar need or distinctive nutritional requirement for immunoglobulins to maintain gut homeostasis in specific intestinal disorders. Results from nonclinical (section 13) and clinical (section 14) studies reveal a distinctive nutritional requirement for immunoglobulins for the purpose of providing nutritional support to maintain homeostasis which cannot be met by a change in diet alone Mechanism of Action ENTERAGAM, specially formulated with SBI, has been shown to have a multi-faceted mode of action providing nutritive benefits such as increases in lean body mass, increased utilization and decreased catabolism of protein, decreased fecal fat and energy loss, as well as increased nutrient absorption (see sections 13 and 14). ENTERAGAM has been shown to bind microbial components, maintain GI immune balance, manage gut barrier function, and improve nutrient utilization to provide the distinctive nutrition required to manage specific intestinal disorders (e.g., IBS-D, IBD, or HIV infection) which cannot be achieved by a change in diet alone Digestibility/Survivability of Specially Formulated Protein Absorption Protein digestion and amino acid absorption of SBI was evaluated in 41 healthy adult subjects who consumed a single dose of SBI (5 g, 10 g, or 20 g) versus matching placebo which contained hydrolyzed collagen (HC) at the same amino acid concentration. Postprandial total amino acid profiles following consumption of SBI showed a significant increase within 30 minutes followed by a return to baseline value within 180 minutes. Total amino acid C max was 3447±657, 3742±964, and 3720±913 nmol/ml for SBI 5.0 g, 10 g and 20 g groups, respectively vs 3129±607 nmol/ml for the placebo group. Plasma levels for leucine increased at 30 minutes after administration with a C max of 149±31, 171±43, and 148±32 nmol/ml 6

7 for the 5.0 g, 10 g and 20 g groups respectively vs 126±34 nmol/ml for the placebo group. Plasma levels for tryptophan also increased around 30 minutes after administration with a mean C max of 86±17, 96±19, and 107±30 nmol/ml for the 5.0 g, 10 g and 20 g groups respectively vs 73±14 nmol/ml for the placebo group. Overall area under the curve (AUC) for tryptophan and leucine in each of the SBI groups was significantly higher (p < 0.01) compared to the placebo group. There is no evidence to suggest that metabolism of intact immunoglobulin occurs in hepatic or renal organs. No bovine IgG was detected in plasma collected following either a single dose (90 minutes) or multiple doses of SBI (5 g, 10 g, or 20 g per day for 14 days). However, bovine IgG was detected in the stool collected at Day 9 and Day 14 following multiple doses of SBI (5 g, 10 g, or 20 g per day for 14 days) demonstrating that IgG from SBI survives through the entire digestive tract (see below). This data suggests that ENTERAGAM contributes specific amino acid patterns involved in the management of barrier function and protein synthesis and only acts locally within the GI tract to manage intestinal disorders. Food Effect ENTERAGAM has been fed alone and in combination with a variety of foods. There are no known food effects on the activity of ENTERAGAM. Distribution ENTERAGAM has only been detected in the GI tract. Free amino acids representing digested protein from ENTERAGAM are absorbed into the blood stream (see above). Metabolism and Elimination Up to 50% of orally-administered immunoglobulins have been shown to survive initial digestive processes in the stomach. Transit time following oral ingestion of bovine immunoglobulins occurs between 6 and 40 hours depending on the health of the individual. In infants with diarrhea, approximately 5-12% of orallyadministered immunoglobulins are excreted in feces. Other studies in adults with compromised GI tracts show that approximately 10-20% of orally-administered immunoglobulins are excreted in the feces. Analysis of feces from healthy adults using immunological methods, however, found that only minute amounts (< 0.01%) of orally-administered immunoglobulins were excreted, indicating that most was digested as any protein source. Differences in survival through the GI tract may occur as a result of variation in transit time because of co-administration with proton pump inhibitors, GI infection, hydration state, or disease resulting in diarrhea. Resistance There are no reported incidences of resistance to orally-administered bovine-derived immunoglobulin protein isolates. Cross-Reactivity Serological studies have shown that bovine immunoglobulins, particularly IgG, contain cross-reactive antibodies to lipopolysaccharides (endotoxin) from gram-negative bacteria. Immunoglobulins in SBI have been shown to neutralize endotoxins and other microbial antigens. Special Populations There have been no transit time studies of orally-delivered immunoglobulins in geriatric patients. Several studies in infants have been performed demonstrating that immunoglobulin transit times through the GI tract of infants occur between 6 and 72 hours after ingestion. 13 NONCLINICAL DATA FOR THE MANAGEMENT OF SPECIFIC INTESTINAL DISORDERS Nonclinical studies help support the mechanism of action of ENTERAGAM through the use of animal and in vitro models (section 12.2). This research supports and corroborates clinical findings to provide for distinctive nutritional requirements that are unique for the clinical dietary management of specific intestinal disorders. 7

8 SBI has been shown in vitro to bind many different microbial components including those from multiple bacterial and viral organisms due to the polyclonal nature of the immunoglobulin content in the formulation. SBI binds to such microbial components which may activate GI immune cells if they cross through damaged tight junctions as lipopolysaccharide (LPS), peptidoglycan, zymosan, flagellin, peptidoglycan, cyclic diadenylate monophosphate, cytosine phosphate-linked guanine, muramyl dipeptide, rotaviral enterotoxin NSP4, and C.difficile toxin A and B. In a co-culture model of the intestinal epithelium, SBI was shown in the presence of a permeability enhancing compound to sterically exclude an endotoxin mimic (Pam3CSK4) from penetrating through tight junctions, which prevented activation by immune cells in an adjacent compartment. These results corroborate findings in animal models in which the immunoglobulins help maintain an immune balance in the lamina propria. Three different models have been utilized to assess the effect of SBI on managing gut barrier function. In the mdr1a-/- mouse model of spontaneous colitis, barrier alterations allow bacteria and other luminal antigens (all factors associated with GI immune cell activation) to cross the epithelium. The mdr1 gene encodes P-glycoprotein 170, a transport protein involved in the removal of drugs or xenobiotic (foreign) substances from cells. In humans, a high gene expression of mdr1 was associated with long term remission of ulcerative colitis, while mdr1 polymorphism led to decreased P-glycoprotein expression and function, which has been also associated with human Crohn s disease, highlighting the clinical relevance of this animal model in IBD. SBI in the diets of these mice helped maintain GI immune balance suggesting management of barrier function. In another animal model, altered Schaedler flora (ASF) mice with a defined bacterial microbiome were administered dextran sodium sulfate (DSS) to induce colitis along with SBI and finally an E. coli strain originally isolated from a Crohn s patient known to exacerbate the inflammatory condition. SBI significantly maintained colon mucosal height (p < 0.05), cecal stromal structure (p < 0.05), and colonic glandular tissue (p < 0.05) in DSS-treated mice compared to DSS-treated mice fed HC. Western blot analysis also demonstrated that SBI binds to multiple components of ASF and the E. coli provocateur. Finally, in an animal model of chemotherapy induced mucositis, female dark agouti rats were gavaged with 250 or 500 mg/kg of SBI twice daily for four days before intraperitoneal administration of 200 mg/kg irinotecan (gut barrier damaging agent). Twice daily gavaging of SBI continued for 6 days post-irinotecan. The overall incidence, severity and duration of diarrhea, and clinical symptoms decreased in irinotecantreated animals that had received SBI. Animals receiving 500 SBI mg/kg (equivalent to 2 PACKETS of ENTERAGAM daily in humans) also tended to lose less body weight than animals treated only with irinotecan (P > 0.10). Irinotecan-treated animals receiving SBI maintained better jejunum and colonic tissue structure compared with those not administered SBI (P < ). The mechanism of action noted above (microbial binding, maintaining GI immune balance, managing gut barrier function) all contribute to improved nutrient utilization and support the administration of ENTERAGAM to provide for distinctive nutritional requirements that are unique for the clinical dietary management of specific intestinal disorders. Nonclinical animal studies have been performed to support and corroborate the distinctive nutritional requirement for SBI. In a review of data from 75 trials in 43 publications involving over 12,000 piglets, which are known to be prone to developing intestinal dysfunction during the critical weaning period, the addition of plasma protein concentrates to normal feed provided high levels of immunoglobulins similar to levels found in SBI. Nutritional status improved by increasing nutrient ingestion, digestion, absorption, and metabolism of feed and certain nutrients when compared to a range of other proteins added to feed (i.e., from dairy, fish, soy, and other vegetable sources). Another study in a rat model using a bacterial toxin to induce intestinal inflammation and then assess the impact of SBI-containing preparations on transport of D- glucose and 3 essential amino acids through the intestinal barrier demonstrated that animals co-fed with 8

9 toxin and the immunoglobulin preparation increased D-glucose transport by 10% compared to the control group fed toxin without immunoglobulin preparation. There was also an 8-9% increase in D-glucose absorption in rats co-fed toxin and the immunoglobulin-containing preparation. This activity was correlated with increased numbers of sodium/glucose transport proteins present in the brush border membrane. There was no effect on leucine, methionine, or lysine absorption in this model. Another recent animal study supports the distinctive nutritional requirement for SBI in malnourished mice infected with Clostridia difficile. Groups of mice were either fed a 5% (low) or 20% (normal) protein diet and administered 40 mg/day SBI or HC in drinking water/oral gavage. After 5 days, a cocktail of antibiotics was given orally for 3 days followed by parenteral clindamycin. Mice were then infected with C. difficile and treated with vancomycin for 4 days. Fifty percent of mice on low protein diets that were administered SBI survived C. difficile infection compared to less than 10% in mice fed low protein with HC (P = 0.002). There was no difference between SBI or HC fed groups on the normal protein diet in terms of survival (P = 0.13). This supports a distinctive nutritional requirement for the IgG formulation in malnourished states, which are typical for C. difficile infection, especially in the elderly and critically ill patients. Finally, in the DSS-induced colitis mouse model described above, cecal biopsies from animals provided SBI compared with HC had lower kynurenine:tryptophan (K:T) ratios. The plasma K:T ratio was also unchanged suggesting SBI acted locally within the intestine to maintain tryptophan homeostasis providing for a distinctive nutritional requirement unique to specific intestinal disorders, and in this case, IBD. 14 CLINICAL DATA FOR THE MANAGEMENT OF SPECIFIC INTESTINAL DISORDERS It has been demonstrated that patients with specific, chronic intestinal disorders have a distinctive nutritional requirement for specially formulated dietary in ENTERAGAM to maintain homeostasis in the GI tract. Table 2 describes clinical findings for SBI in the management of IBS-D, IBD, HIV-associated enteropathy and malnutrition in infants and children as evidence, required to substantiate the intended use that ENTERAGAM provides nutrients unique for the clinical dietary management of specific intestinal disorders. Malnutrition typically is associated with altered barrier function. Table 2. Clinical Dietary Management of Intestinal Disorders with SBI Population Studied IBS-D (section 14.1) Randomized, doubleblind, placebo-controlled, single site, 6 week study, N = 66 patients diagnosed with IBS-D Placebo, SBI 5 g/day or SBI 10 g/day IBS-D (section 14.1) Retrospective case studies of drug refractory IBS-D administered SBI up to 10 g/day Impact of Dietary Management with SBI 10 g/day SBI group reported a reduction in days with loose stools (p = 0.01), abdominal discomfort (p < 0.01), urgency (p = 0.050), bloating (p < 0.05), flatulence (p < 0.01), and any symptom (p < 0.01). 5 g/day SBI group reported reductions in days with flatulence (p = 0.035), incomplete evacuation (p < 0.050), and any symptom (p = 0.014). A retrospective chart analysis of 10 refractory patients, 6 of which were diagnosed with IBS-D and 4 with IBS with bloating and distention. When these patients were administered 5 g of SBI per day patients reported significant IBS symptom improvement which averaged between 50% - 100% (p = 0.002) and 69% of patients reporting complete management in 2-4 weeks. A retrospective chart analysis of 35 patients who had been administered SBI were initially reviewed. Twenty-six patients met criteria for analysis of 9

10 IBD (section 14.2) Retrospective case studies of patients diagnosed with Crohn s disease and ulcerative colitis administered SBI up to 20 g/day HIV-associated Enteropathy (section 14.3), open-label pilot study, 8 HIV+ male adult patients, w/ HIVassociated enteropathy; median CD4+ cell count either being LBT positive or negative for comparison. These patients had previously been screened for SIBO using an LBT. Among patients who had a negative LBT result, 77% reported a positive response to SBI therapy (N = 13; p = 0.04), while 73% of patients with a positive LBT result reported a positive response to SBI therapy (N = 11; p = 0.117). If patients were grouped into their diagnosis, irrespective of the LBT results, response rates for IBS-D patients was 69% (N = 16; p = 0.121) and in IBS-M patients, 88% (N = 8; p = 0.015). When all patients were pooled (N = 24), the response rate to SBI therapy was 75% (p = 0.01). A retrospective chart analysis was performed on patients diagnosed with IBD (n = 45; 38 with CrD and 7 with UC) who had a variety of symptoms including abdominal discomfort, urgency, tenesmus, fatigue as well as persistent chronic loose and frequent stools and were not fully managed on traditional therapies. When these patients were administered 5 g of SBI per day, the odds ratio showed that the entire group of IBD patients were 2.8 (CI: , p < 0.011) times more likely to report satisfactory management over their overall condition at the end of 12 weeks. Retrospective chart analysis was performed on another group of IBD patients (n = 7, 4 with CrD and 3 with UC) who had been administered 5 or 10 g of SBI in addition to traditional therapies which previously had not fully managed their conditions. The patients experienced a variety of symptoms prior to SBI administration including abdominal pain, urgency, fecal incontinence, and persistent watery stools with rectal bleeding. All 4 patients with CrD reported a significant overall improvement in their symptoms with the use of SBI. Two of 3 UC patients had complete resolution of watery stools and the third experienced a severe reduction from soft stools/day to 3-4 formed stools/day. Two UC patients reported a complete reduction of urgency and one patient reported a cessation of nocturnal incontinence episodes. All three patients additionally reported a resolution of their rectal bleeding. A retrospective analysis was performed on 2 UC patients who had endoscopic evidence of colitis and experienced 5-15 watery stools per day after the co-administration of SBI with traditional therapeutics on which they were not fully managed. One patient was given 5 g QID for one week followed by 5 g BID of SBI and was previously on oral steroids. The other patient initially received 5 g BID for 8 weeks in addition to continuing oral mesalamine, adalimumab and oral steroids. After the initial SBI dosing, each was then maintained for 12 months on 5 g SBI per day. In both cases, stool frequency and consistency was restored to normal and follow-up colonoscopies demonstrated normal mucosal appearance. The patients also reported management of tenesmus, urgency, abdominal cramps, fecal incontinence, and rectal bleeding. Median bowel movements/day and stool consistency decreased at 8 weeks (p = 0.008). Improvements in median GI symptoms questionnaire scores (cramping, urgency, incontinence, and nocturnal diarrhea at 8 weeks (p = 0.008). Durable bowel movements/day, stool consistency and questionnaire responses, after a 4-week washout, were reported at 2.0 (2.0, 3.0), 2.5 (1.0, 3.8), and 6.0 (2.0, 12.8), respectively, for those that continued SBI for an 10

11 372 cells/dl, SBI 2.5 g twice a day for 48 weeks, (SBI for 8 weeks followed by 4 weeks washout and SBI for 48 weeks) Malnutrition (Pediatric) (section 14.4) Study 1: Randomized, controlled study N = 10 (9-25 months of age) recovering from severe malnutrition. Diet contained either control, or 25% or 50% milk protein replacement with serum-derived bovine protein containing immunoglobulins during 3 randomly-ordered, 7-day dietary periods Study 2: Randomized, controlled, communitybased intervention study N = 259 (6-7 months of age). Diet containing additional 48 weeks (p = compared to baseline). Marked improvement of GI-related symptoms within 3 weeks of initiating SBI in all 8 patients. Duodenal absorption of D-xylose increased in 7/8 subjects as reflected in urinary excretion. In those with improvement, absorption levels increased from 33.8 mg (28.7, 38.2) to 40.9 mg (19.8, 44.4) at week 8 (p = 0.19). Increased CD4+ T-lymphocyte density (an average of ~140 cells/mm 2 ) within lamina propria after 8 weeks of SBI from 213 to 322 cells/mm 2 (p = 0.016). MCP-1 levels were unchanged at week 8 but decreased in 5/5 subjects at week 48 (379.5 ng/ml [225, 502]) (p = 0.06). I-FABP initially rose in 7/8 subjects after 8 weeks from 3514 ng/ml to 4042 ng/ml (p = 0.039) and then fell below baseline in 4 of the 5 who continued receiving SBI to 2442 ng/ml at week 48 (p = 0.12 compared to baseline, p = 0.06 compared to week 8). MMP-9/TIMP-1 ratios in subjects were significantly lower than controls at baseline (0.13 versus 0.42 [p = 0.007]), respectively, and tended to increase at the end of study to 0.33 (p = 0.08). MCP-1 levels were negatively correlated to CD4 + lamina propria density (r = -0.59, p = 0.019) with all time points examined. MMP-9/TIMP-1 ratios were negatively correlated with CD8 + lamina propria density (r = -0.70, p = ). Baseline serum I-FABP levels were negatively correlated with subsequent rise in lamina propria CD4 + T-lymphocytes (r = -0.74, p = 0.046). Pro-inflammatory gammaproteobacteria tended to decrease and Clostridium (genus) tended to decrease. Changes in gut microbiota correlated with local lymphocyte populations that increased significantly with 8 weeks of SBI therapy. Study 1 The mean number of daily bowel movements, mean apparent absorption and retention of nitrogen, and mean apparent absorption of carbohydrate were similar for each diet. Fractional absorption of dietary lipid and of total energy increased significantly in relation to the amount of serum-derived bovine protein containing immunoglobulins in the diet. Study 2 No differences in growth or rates of morbidity were found for any group in those children who completed 8 months of observation. Children receiving MMN had lower rates of anemia, and children who 11

12 serum-derived bovine protein containing immunoglobulins, WPC, serum-derived bovine protein containing immunoglobulins + MMN or WPC + MMN daily for 8 months received WPC+MMN had less of a decline in serum ferritin. No differences in other biochemical indicators of micronutrient status were noted. Supplementation with MMN reduced anemia and iron deficiency in this population, but the MMN content and source of protein in the supplements did not affect other indicators of micronutrient status, growth, or morbidity. Trends toward increased MMN uptake and lean muscle mass in the presence of serum-derived bovine protein containing immunoglobulins but not WPC. AE = adverse event; CD = cluster of differentiation antigen; CrD = Crohn s disease; IBS-D = irritable bowel syndrome with diarrhea; HIV = human immunodeficiency virus; I-FABP = intestinal fatty acid binding protein; LBT = lactulose breath test; MCP-1 = monocyte chemotactic protein-1; MMN = multiple micronutrients; MMP = matrix metalloproteinase; SBI = serum-derived bovine immunoglobulin/protein isolate; TIMP-1 = tissue inhibitor of metalloproteinase 1; UC = ulcerative colitis; WPC = whey protein concentrate 14.1 Irritable Bowel Syndrome with Diarrhea A randomized, double-blind, placebo-controlled, single site study in which subjects with IBS-D were administered either SBI (10 g/day), SBI (5 g/day) + placebo (5 g/day soy protein isolate), or placebo (10 g/day soy protein isolate) for 6 weeks. Subjects in the 5 g/day SBI group also received 5 g/day placebo so that all 3 groups received an equivalent amount of protein. Demographic characteristics of subjects included in the study were not significantly different. There was a one week assessment period and then subjects randomized into the study at baseline. Assessments included a modified IBS-36 questionnaire, daily symptoms scores, and hematology and clinical chemistry laboratory tests. A total of 66 subjects were enrolled in this study: 22 in the placebo group, 25 in the 10 g/day SBI group, and 19 in the 5 g/day SBI group. Four subjects withdrew from the study due to nausea: 1 subject in the placebo group, 2 subjects in the 10 g/day SBI group, and 1 subject in 5 g/day SBI group. A total of 51 subjects completed the study: 16 subjects in the placebo group, 17 subjects in the 10 g/day SBI group, and 18 subjects in the 5 g/day SBI group. The rate of withdrawal was similar across groups. Within group comparison for subjects in the 10 g/day SBI cohort showed statistically significant reductions in the number of days with symptoms from week 2 to week 6 for loose stools (p < 0.01), abdominal discomfort (p = 0.01), flatulence (p < 0.01), bloating (p < 0.05), urgency (p = 0.05), and any symptom (p < 0.01). Within group comparison for subjects in the 5 g/day SBI cohort showed statistically significant reductions from week 2 to week 6 in the number of days with flatulence (p = 0.035), incomplete evacuation (p < 0.05), and any symptom (p = 0.014). The study was not powered to compare differences between groups. There were no statistically significant differences between groups with respect to hematology and clinical chemistry laboratory results. No serious AEs were reported. Administration of SBI at a dose of 10 g/day for 6 weeks significantly decreased, from baseline to end of study, the number of symptom days for loose stools, abdominal discomfort, flatulence, bloating, urgency, and any symptom. Greater improvements in hard stools, and incomplete evacuation were also achieved with SBI. Results also demonstrate the safety and tolerability of SBI when supplemented daily for 6 weeks in subjects affected by the diarrhea predominant form of IBS. In addition to the clinical trial above, two case series have recently been performed by physicians who chose to retrospectively collect the outcome of ENTERAGAM administration in difficult to treat IBS patients. The first case study utilized SBI in 10 patients: 6 IBS-D as well as 4 IBS with bloating and distention. Patients in this case study were previously refractory to a number of traditional drug treatments and met Rome III criteria. Patients were administered 5 g/day of SBI as standard-of-care nutritional support and followed for at least 4 months, assessing patient-reported improvement in symptoms from 0-100%. Patients reported significant IBS symptom improvement which averaged between 50% - 100% (p = 0.002) 12

13 with 69% of patients reporting complete management in 2-4 weeks. No side effects were reported after SBI administration even when taken for up to 28 weeks. In the second case study, 35 charts of patients who had been administered SBI were initially reviewed. Twenty-six patients met criteria for analysis of either being lactose breath test (LBT) positive or negative for comparison. Safety and clinical outcomes were analyzed for 24 of these patients (2 were lost to follow up) who had IBS-D or mixed diarrhea/constipation pattern IBS (IBS-M) were refractory to IBS therapies, and had previously been screened for small intestinal bacterial overgrowth (SIBO) using a lactose breath test (LBT). Among patients who had a negative LBT result, 77% reported a positive response to SBI therapy (N = 13; p = 0.04), while 73% of patients with a positive LBT result reported a positive response to SBI therapy (N = 11; p = 0.117). Similar results were obtained when patients were separated based on their diagnosis; IBS-D patients had a 69% response rate to SBI (N = 16; p = 0.121) and IBS-M patients had a significant response rate of 88% to SBI therapy (N = 8; p = 0.015). When all patients were pooled (N = 24), the response rate to SBI therapy was 75% (p = 0.01) Inflammatory Bowel Disease Four different case series have reported on the use of SBI in inflammatory bowel disease (IBD) including patients with either Crohn s disease or ulcerative colitis. In the first case study, a retrospective chart analysis of adult patients with IBD [n = 45, 38 with Crohn s disease, 7 with ulcerative colitis, ages (mean = 51.5 years), with 17 females and 41 identifying as Caucasian] who were utilizing SBI at 5 g/d as nutritional add-on therapy as standard-of-care supports its effect on overall disease management. The patients were not fully managed especially for chronic loose and frequent stools. As the practice s standard-of-care for change in therapeutic regimen, patients who are administered any new agent, including SBI, were contacted weekly for assessment of condition management. This practice utilizes a 5-tier scale to score overall management in response to therapy (0 = none; 1 = minimal; 2 = moderate; 3 = significant; 4 = complete). A multivariate-ordered logistical regression model that controlled for patient characteristics was used to determine the statistical significance between these standard-of-care responses that were recorded by office staff at week 1 through 12. The addition of SBI to therapy was well tolerated with no reported side effects. The odds ratio resulting from the statistical model showed that the entire group of IBD patients were 2.8 (CI: , p < 0.011) times more likely to report management continuing on therapy after the initial measurement. These results were not significantly associated with age, sex, diagnosis, or race. In the second retrospective case study, 7 adult patients with IBD (4 patients with Crohn s disease and 3 patients with ulcerative colitis), who had previously failed to respond or fully respond to conventional therapies, were administered SBI therapy at either 5 or 10 g per day. In each of these cases, patients had experienced episodes of chronic loose and frequent stools as a result of their IBD and began to experience improvement from self-evaluation within 2 weeks after consuming SBI. For those patients with Crohn s disease, they reported a significant overall improvement in their symptoms with the use of SBI. Patient 1 had a decrease in both the ileostomy output (reduced from 3.5 liters to 1.2 liters/day) and creatinine levels (3.2 to 2.6 mg/dl) while Patient 3 was able to increase his weight by approximately 10 pounds (6.3%) with a resolution of his loose, watery stools. Two patients were able to modify their treatment: Patient 2 was able to reduce his adalimumab injections administered for IBD from weekly to biweekly events and Patient 4 was able to successfully taper off steroid therapy given the resolution of his abdominal discomfort and cramps. For two of the three ulcerative colitis patients, there was a complete resolution of their loose, watery stools and one patient had a significant reduction in bowel movements from soft stools/day to 3-4 formed stools/day. All three patients additionally reported a resolution of their rectal bleeding. Two patients reported a complete reduction of urgency and one patient reported a cessation of nocturnal incontinence episodes. In addition, Patient 2 had no further exacerbation of his pouchitis while on SBI. The 13

14 ongoing use of SBI therapy has helped in the continued management of these patients chronic IBD condition for up to 15 months. All patients have now been maintained for 3-9 months on SBI therapy without relapse. Two separate cases have been reported in which ulcerative colitis patients who had follow up colonoscopies demonstrated normal mucosal appearance while on SBI. In both cases, the patients had been refractory to oral-steroids. Patient 1 had a flare precipitated by recurrent C. difficile infection secondary to long-term broad-spectrum antibiotic use secondary to a septic arthritis in her knee. The patient had a Mayo endoscopic ulcerative colitis score of 2. She refused any anti-tnf therapy and remained refractory to oral steroids, with loose stools per day. While still on 40 mg of prednisone, she was advised to include SBI 5g QID for the first week and thereafter decreased to 5 g per day. At a four week follow-up the patient reported 1-2 formed bowel movements per day and reported cessation of further rectal bleeding or cramps. Her prednisone was tapered to 5 mg over the next six weeks and a repeat flexible sigmoidoscopy illustrated an improved endoscopic ulcerative colitis score of 0. Other bloodwork normalized including: white blood cell count decreased from 12.4 to 10.9 thousand/µl; hemoglobin increased from 10.9 to 12.4 g/dl; hematocrit increased from 34.7% to 38.0% and a platelet count decreased from 482 to 248 thousand/µl. Serum albumin concentration increased from 4.1 mg/dl to 4.5 mg/dl. C. difficile toxin B remained negative by PCR. She continued to remain asymptomatic on SBI after six months, maintained on 5 g SBI daily. Patient 2 had a 3-yr history of diffuse, moderately severe pan-colitis diagnosed through colonscopy and biopsy. Patient was steroid refractory despite the inclusion of adalimumab, oral and rectal mesalamine, antibiotics (ciprofloxin and metronidazole), and probiotics. The patient was experiencing 5-10 loose stools per day. While on adalimumab, oral mesalamine, and oral steroids the patient was advised to include SBI 5 g BID into the therapeutic regime. At an 8-week follow-up the patient reported improved stool frequency and consistency, 1-2 normally formed stools per day. He also denied all other symptomology of tenesmus, urgency, and abdominal cramps. The patient was completely removed from oral steroids and decreased SBI to 5 g QD. The patient remained well maintained on adalimumab, oral mesalamine, and SBI for nearly a year at which point a colonscopy revealed quiescent colitis with no active inflammation. Patient 1 has been maintained for over 6 months and Patient 2 has been maintained for over a year without relapse HIV-associated Enteropathy A small open-label study in which HIV-infected subjects with HIV-associated enteropathy were administered SBI (5 g/day) for 8 weeks with a 4-week washout period and an optional 9-month extension study. HIV-associated enteropathy was defined as chronic GI symptoms including frequent loose or watery stools despite no identifiable, reversible cause. Assessments included GI symptoms, disaccharide gut permeability/absorption studies to test GI function, upper endoscopy for tissue immunofluorescent antibody assays to test mucosal immunity, plasma biomarkers of microbial translocation, inflammation and collagen kinetics, and intestinal microbial sequencing. Median peripheral blood CD4+ T-cell count was 372 cells/ml (193, 459) at baseline, was unchanged at 339 cells/ml (210, 468) after 8 weeks and 348 cells/ml (225, 397) after 48 weeks. Eight men (5 white, 3 African-American) with a median age of 44.5 years (38.8, 47.8) on HAART for more than 1 year were enrolled in the study. Median bowel movements/day decreased from 5.8 (range: 5.0, 8.4) to 2 (2.0, 3.8) (p = 0.008) and stool consistency [1- constipated to 6-watery] decreased from a median of 5.3 (5, 6) to 3 (2.2, 3.8) (p = 0.008) at 8 weeks. Median GI symptoms questionnaire scores (cramping, urgency, incontinence, and nocturnal diarrhea [0 to 39 with normal < 4]) decreased from 17 (15.6, 21.8) to 8.0 (3.5, 11.9) (p = 0.008) at 8 weeks compared to baseline. For those five subjects who continued SBI to week 48, durable bowel movements/day, stool consistency and questionnaire responses were reported at 2 (2.0, 3.0), 2.5 (1.0, 3.8), and 6.0 (2.0, 12.8), respectively (all p = compared to baseline). Increased GI absorption assessed by D-xylose urinary excretion increased in 7/8 subjects over the course of the 8-week intervention from a median of 33.8 mg 14

15 (28.7, 38.2) at baseline to 40.9 mg (19.8, 44.4) at week 7 (p = 0.19) demonstrated the nutritive value in SBI. These 7 patients demonstrated SBI was well-tolerated, with a reduction in HIV-associated enteropathy as noted by a decrease in stool frequency, an increase in formed stool consistencies and a decrease in GI symptoms. Immunohistochemistry enumeration of absolute lamina propria CD3+/CD4+ T-cell density revealed an increase from 213 (152, 243) to 322 cells/mm 2 (228, 433) (p = 0.016) [a median increase of cells/mm 2 of CD3+/CD4+ lamina propria lymphocytes (66.1, 216)] after 8 weeks of SBI. By contrast, previous studies showed increases of 57 cells/mm 2 (IQR: 9.0, 82) after 9 months of antiretroviral therapy. While the lamina propria CD3+/CD8+ density was unchanged [502 cells/mm 2 (416, 650) and 598 cells/mm 2 (361, 699) at baseline and week 8, respectively], the lamina propria CD4+/CD8+ ratio increased from 0.41 to 0.62 (p = 0.016). MCP-1 levels were unchanged from baseline [476.4 ng/ml (426.4, 598.1)] at week 8 but decreased in 5/5 subjects at week 48 [379.5 ng/ml (225, 502)] (p = 0.06). Intestinal fatty acid-binding protein initially rose in 7/8 subjects after 8 weeks from 3514 ng/ml (2858, 4275) to 4042 ng/ml (3233, 5613) (p = 0.039) and then fell below baseline in 4 of the 5 who continued receiving SBI to 2442 ng/ml (1267, 2875) after 48 weeks (p = 0.12 compared to baseline, p = 0.06 compared to week 8). MMP-9/TIMP-1 ratios in subjects were significantly lower than controls at baseline [0.13 (0.07, 0.33) versus 0.42 (0.23, 0.44), p = 0.007], respectively and then tended to increase at the end of study to 0.33 (0.13, 0.73) (p = 0.08). MCP-1 levels were negatively correlated to CD3+/CD4+ lamina propria density (r = -0.59, p = 0.019) with all time points examined together, suggesting that MCP-1 expression is associated with mucosal immunologic damage. Similarly, MMP-9/TIMP-1 ratios were negatively correlated with CD3+/CD8+ lamina propria density (r = -0.70, p = ) suggesting that factors promoting CD8+ T-cell infiltration into the lamina propria correlate with impaired collagen kinetics. Baseline serum I-FABP levels were negatively correlated with subsequent rise in lamina propria CD4+ T- lymphocytes (r = -0.74, p = 0.046). In addition, SBI demonstrated an effect on the composition of the gut microbiota in patients with HIVassociated enteropathy. Pro-inflammatory gammaproteobacteria tended to decrease from 0.70% to 0.12%. Clostridium (genus) and Ruminococcus (also a genus in the Clostridia family) decreased from 6.5 (2.80, 10.65) to 3.4 (2.50, 5.89) and 0.89 (0.52, 1.29) to 0.30 (0.15, 0.47), respectively. Ruminococcus decreased in all eight subjects. Decreases in Clostridium in the stool were correlated with duodenal CD3+/CD4+ density (r = -0.63; p < 0.01). Changes in gut microbiota correlated with local lymphocyte populations that increased significantly with short-term administration of SBI. A total of 20 AEs were reported by 7 subjects. Most of the reported AEs were mild (7/20) or moderate (9/20) in severity, and judged by the investigator to be not related to study product (16/20). The 4 events judged to be severe included worsening diarrhea, worsening diarrhea (due to ova/parasites), worsening lower back pain, and groin pain. Four events (reported in 3 subjects) judged to be possibly related to product included constipation (reported by 2 subjects), GERD (reported by 1 subject) and nausea (reported by 1 subject). The most common AEs included worsening or recurrence of diarrhea (5 AEs reported by 4 subjects), constipation (2 subjects), and worsening neuropathy (3 AEs reported by 2 subjects). Adverse events that were reported by 1 subject each included sinus infection, throat infection, gastroesophageal reflux disease, flatulence, worsening lower back pain, groin pain, nausea, bronchitis, acute ear infection, and infection on finger Pediatric Malnutrition Malnutrition from suboptimal food intake is known to cause intestinal dysfunction. A preliminary randomized, controlled study was conducted to assess the acceptability, safety, and digestibility of bovine serum proteins in young children. Masked study diets were provided sequentially to each of 10 young, 15

16 Peruvian children (9 25 months of age) recovering from severe protein-energy malnutrition, during 3 randomly-ordered, 7-day dietary periods. The control diet was prepared from rice, milk, vegetable oil, and sugar; the 2 study diets included serum-derived bovine protein (containing immunoglobulins) to replace either 25% or 50% of the milk protein of the control diet. All children consumed the entire amounts offered of each of the diets. The mean number of daily bowel movements, mean apparent absorption and retention of nitrogen, and mean apparent absorption of carbohydrates were similar for each diet. Fractional absorption of dietary lipid and of total energy increased significantly in relation to the amount of serumderived bovine protein in the diet. There was no difference between digestibility of the milk fat versus serum-derived bovine protein when provided in the diet. Therefore, the increase in fractional absorption is likely due to increased serum-derived bovine protein content in the diet. Numerical improvements in nitrogen retention were also noted with increased serum-derived bovine protein diet which means improved absorption was also a potential explanation for the improvement. These results demonstrate the distinct nutritive value of the serum-derived bovine immunoglobulin containing diet. Each diet was welltolerated by the children in the study, and there was no evidence of any adverse effects of serum proteins. Another randomized, controlled, community-based intervention study was conducted to evaluate the effects of serum-derived bovine protein (containing immunoglobulins) and/or multiple micronutrients on children s growth, morbidity, and micronutrient status in a low-income peri-urban Guatemalan community. A total of 259 children who were initially 6 to 7 months of age received 1 of 4 maize-based dietary products daily for 8 months: whey protein concentrate (control group), whey protein concentrate plus multiple micronutrients, or serum-derived bovine protein containing immunoglobulins, and serum-derived bovine protein containing immunoglobulins plus multiple micronutrients. Two hundred and twenty-five (225; 86.9%) children completed 60 days of observation, 184 (71.0%) completed 180 days of observation, and 132 (51.0%) finished the full 8 months of observation. All diets were well-tolerated. There were no significant differences in the number of dropouts for all groups at any time point. There were no significant differences in growth or rates of morbidity were found for any group in those children who completed 8 months of observation. Children who received multiple micronutrients had lower rates of anemia. Those who received whey protein concentrate plus multiple micronutrients showed less of a decline in serum ferritin than those who did not, but there were no differences in other biochemical indicators of micronutrient status between groups. Administration of multiple micronutrients reduced anemia and iron deficiency in this population, but the multiple micronutrients content and source of protein in the product did not affect other indicators of micronutrient status, growth, or morbidity. There was a notable trend toward increased micronutrient uptake and lean body mass in the group receiving micronutrient and serum-derived bovine protein containing immunoglobulins. 15 REFERENCES 1 21 USC Section 360ee(b)(3). 16 HOW SUPPLIED/STORAGE AND HANDLING ENTERAGAM PACKETS contain a light-colored powder available as 5 g SBI including other ingredients 5 g dextrose and trace amounts of sunflower lecithin in 10 g Net weight individual retail packets. Product # Size packets per box 16

17 ENTERAGAM PACKETS contain a light-colored powder available as 5 g SBI including other ingredients 5 g dextrose and trace amounts of sunflower lecithin in 10 g Net weight individual sample packets. (Not for resale). Product # Size packets per box ENTERAGAM PACKETS contain a light-colored powder available as 5 g SBI including other ingredients 5 g dextrose and trace amounts of sunflower lecithin in 10 g Net weight individual sample packets. (Not for resale). Product # Size packets per box Store packets at C (68-77 F): excursions permitted between C (59-86 F). [See USP Controlled Room Temperature]. Entera Health, Inc. does not represent this product code to be a National Drug Code (NDC) number. Instead, Entera Health has assigned a product code formatted according to standard industry practice to meet the formatting requirements of pharmacy and health insurance computer systems. 17 PATIENT COUNSELING INFORMATION Patients should be informed of the following information before initiating therapy with ENTERAGAM and periodically during the course of ongoing therapy: 17.1 Medical Foods ENTERAGAM is an FDA-regulated Medical Food. The term medical food, as defined by the Orphan Drug Act (21 U.S.C. 360ee(b)(3)) of 1988, is a food which is formulated to be consumed or administered enterally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation. Ingredients in medical foods must be generally recognized as safe (GRAS) and/or approved food additives for the intended use Instructions for Use Pour packet ingredients into cup or glass. Add at least 4 oz of water (or other liquid as preferred). Stir until fully mixed (do not shake). Drink all of the contents immediately. Alternatively, product can be mixed with foods such as pudding or yogurt. A recommended starting dose is 1 packet twice daily for two to four weeks which can be increased up to 4 packets per day as directed by the healthcare provider. After the starting dose, a maintenance dose of at least one packet per day should be used to manage the patient condition(s) [2.1,2.2,17] Pregnancy and Nursing ENTERAGAM has not been studied in pregnant or nursing women. The choice to administer ENTERAGAM during pregnancy or nursing is at the clinical discretion of the prescribing physician. 17

18 17.4 Warnings and Precautions ENTERAGAM contains beef protein so anyone allergic to beef should not take this product. If the patient experiences shortness of breath, immediately discontinue the product and contact your healthcare professional. Manufactured and Distributed by: Entera Health, Inc. Ankeny, Iowa ENT005F0315 Rev 03/15 18