Supporting Information Table SI. Individual rfixfc Pharmacokinetic Parameters Determined Using Compartmental Analysis (Major Surgeries)

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1 Supporting Information Table SI. Individual rfixfc Pharmacokinetic Parameters Determined Using Compartmental Analysis (Major Surgeries) Subject ID Study arm * Actual dose (iu/kg) Terminal half-life (h) Clearance (ml/h/kg) Incremental recovery (iu/dl per iu/kg) Time to 1% (d) rfixfc, recombinant factor IX Fc fusion protein; FIX, factor IX. * Subjects requiring major surgery who did not transfer from Arms 1 3 underwent a 120-hour washout period (of their pre-study FIX therapy), 4 weeks before the scheduled surgery, followed by a pharmacokinetic assessment with 50 iu/kg of rfixfc. Blood samples were collected up to 168 hours after the infusion to determine the individual pharmacokinetic profile. Subjects who intended to continue study participation in another treatment arm following surgery underwent initial pharmacokinetic testing as described for that arm. The arithmetic mean terminal half-life observed in the pharmacokinetics subgroup (n=22) of the B-LONG study was hours ( The average terminal half-life observed in the major surgery cohort (n=12) was shorter because the sampling duration for the majority of subjects was shorter than the 240 hours used in the pharmacokinetics subgroup of B-LONG. 1

2 Table SII. Individual Subjects rfixfc Surgical Dosing Regimens * Subject ID Presurgery dose 0 Day Subsequent dose ND 61 7 ND 44 8 ND 44 8 ND 44 8 ND 44 8 ND ND ND ND ND 66 0 ND ND 66 0 ND ND ND ND 68 3 ND ND ND ND 39.8 ND ND ND ND ND ND ND ND ND ND 50 4 ND 50 4 ND 50 4 ND 50 4 ND ND ND 63 2 ND 63 2 ND 63 2 ND ND ND 95 3 ND 95 3 ND 95 3 ND ND ND 47 6 ND ND ND ND ND ND ND ND ; ; ; ; 16 9; 42 4; ND ND ND 51 3 ND ND 53 6 ND ND ND ND ND ND ND 58 3 ND 58 3 ND ND ND 58 3 ND ND ND ND ND 58 3 ND ; 49 4 ** ND ND 49 4 ND 45 5 ND 45 5 ND ND ND ND ND 43 9 rfixfc, recombinant factor IX Fc fusion protein; ND, no dose. * Actual dosing of rfixfc, with doses given in units of iu/kg. 2

3 Subject received an infusion of iu/kg rfixfc the day before surgery. Two of the infusions on Day 3 were administered to treat a bleeding episode. Subject underwent 2 surgical procedures, with the second surgery occurring 3 days after the first surgery. Dosing on the day of the first surgery until the second surgery is shown in the first row; dosing beginning on the day of the second surgery and during the subsequent 14 days is shown in the second row. Dose urgently self-administered by the subject to treat bleeding from trauma site. ** Dose administered immediately prior to surgery. Unauthorised dose administered by the surgeon. Dose administered in accordance with the investigator s instructions, which were given before the investigator became aware of the unauthorised dose administered the previous evening. 3

4 Additional surgery narratives Subject 4 Subject 4, a 34-year-old male, underwent total left knee replacement. Four-hundred six days (~14 months) prior to surgery, the subject enrolled in the nonsequential pharmacokinetic subgroup of Arm 1. Medical history of note included decreased motion in both elbows, both knees, and both ankles; arthropathy of the knees, ankles, and elbows; and muscle wasting of the left arm and both upper legs. Surgical history included on-study dental extraction 151 days (~5 months) prior to surgery without incident (minor surgery subject 4 in Table IV). Prior to surgery, the subject received an initial prophylaxis regimen of ~50 iu/kg once weekly. Following 2 spontaneous bleeding episodes, the subject s prophylaxis dose was adjusted to ~60 iu/kg once weekly starting from ~2 months prior to surgery. The surgery was uneventful, and haemostatic response was evaluated as excellent. Estimated intraoperative blood loss was <100 ml, and postoperative blood loss was approximately 75 ml. The dosing regimen consisted of a presurgery dose of iu/kg, iu/kg 4 hours later, and iu/kg on postoperative Days 1 and 2. The subject received iu/kg every other day on Days 4 6 postsurgery. The subject received 39 7 iu/kg on postoperative Day 7, 61 0 iu/kg on Day 8, 62 5 iu/kg every day on Days 9 13, and 63 6 iu/kg on postoperative Day 14. The subject did not receive treatment with recombinant factor IX Fc fusion protein (rfixfc) on Days 3 and 5 postsurgery. No serious adverse events were reported during the postoperative period. Subject 5 Subject 5, a 30-year-old male, underwent total right knee arthroplasty. One-hundred three days (~3 months) prior to surgery, the subject enrolled in Arm 4. Medical history of note included 4

5 hepatitis C, broken back, epilepsy with tonic clonic seizures, and a recent staphylococcus infection. Surgical history included bilateral release of right knee, complete hip replacement, left knee arthroscopic surgery, and spinal fusion. Prior to surgery, the subject received an initial prophylaxis regimen of ~70 iu/kg once weekly. The surgery was uneventful, and haemostatic response was evaluated as excellent. Estimated intraoperative blood loss was 250 ml, and postoperative blood loss was 0 ml. The dosing regimen consisted of a presurgery dose of iu/kg and 67 8 iu/kg every day for Days 1 3 postsurgery. The subject received 61 0 iu/kg daily on postoperative Days 4 7 and 59 6 iu/kg on postoperative Day 8. On Day 3, the subject received 3 total units of red blood cells (RBCs) due to low haemoglobin levels, as stated by the attending physician. No serious adverse events were reported during the postoperative period. Subject 6 Subject 6, a 35-year-old male, underwent right knee arthroscopy. One-hundred two days (~3 months) prior to surgery, the subject enrolled in the sequential pharmacokinetic subgroup of Arm 1. Medical history of note included human immunodeficiency virus (HIV), hypertension, diabetes mellitus, haemophilic arthropathy, right knee medial/lateral meniscal tear, acute subdural haematoma of the left frontoparietal region, grand mal seizure secondary to subdural haematoma, and a recent upper respiratory tract infection. Surgical history included appendectomy, synovectomy, chondroplasty of the right knee, and left frontal craniotomy for the evacuation of subdural haematoma. Prior to surgery, the subject received an initial prophylaxis regimen of iu/kg once weekly. The surgery was uneventful, and haemostatic response was evaluated as excellent. Estimated intraoperative blood loss was 10 ml, and postoperative blood loss data were not provided. The dosing regimen consisted of a presurgery dose of

6 iu/kg, 64 8 iu/kg 5 hours later, and 50 4 iu/kg on postoperative Days 1 and 2. The subject received 50 4 iu/kg every other day on postoperative Days 3 13 and on Day 14. The subject did not receive treatment with rfixfc on Days 4, 6, 8, 10, and 12 postsurgery. No serious adverse events were reported during the postoperative period. Subject 7 Subject 7, a 50-year-old male, underwent arthroscopic subtalar fusion of the right ankle. Twohundred forty-three days (~8 months) prior to surgery, the subject enrolled in Arm 3. Medical history of note included seizure disorder and haemophilic arthropathy. Surgical history included left ankle fusion, left elbow replacement, open reduction and internal fixation for left femur spiral fracture, right ankle fusion, total left knee arthroplasty, and total left knee arthroplasty revision. Prior to surgery, the subject received episodic treatment of iu/kg for bleeding episodes as they occurred. The surgery was uneventful, and haemostatic response was evaluated as excellent. Estimated intraoperative blood loss was <5 ml, and postoperative blood loss was 0 ml. The dosing regimen consisted of a presurgery dose of iu/kg, 79 5 iu/kg 8 hours later, and 79 5 iu/kg every day for Days 1 3 postsurgery. The subject received 60 4 iu/kg on postoperative Day 5 and 63 2 iu/kg every other day on postoperative Days The subject did not receive treatment with rfixfc on Days 4, 7, 9, 11, 13, and 14 postsurgery. No serious adverse events were reported during the postoperative period. Subject 8 Subject 8, a 17-year-old male, underwent external fixation of the right knee. Ninety-eight days (~3 months) prior to surgery, the subject enrolled in Arm 4. Medical history of note included 6

7 severe arthropathy of the right knee, muscle atrophy of the right leg with flexion of the right knee, and asthma. Prior to surgery, the subject received an initial prophylaxis regimen of ~50 iu/kg once weekly. The surgery was uneventful, and haemostatic response was evaluated as excellent. Estimated intraoperative blood loss was 100 ml, and postoperative blood loss was 0 ml. The dosing regimen consisted of a presurgery dose of iu/kg, 95 3 iu/kg 12 hours later, and 95 3 iu/kg on Day 1 postsurgery. The subject received 95 3 iu/kg every other day on postoperative Days 2 8 and 47 6 iu/kg on postoperative Days 12 and 14. The subject did not receive treatment with rfixfc on Days 3, 5, 7, 9, 10, 11, and 13 postsurgery. No serious adverse events were reported during the postoperative period. Subject 9 Subject 9, a 54-year-old male, underwent right arm tendon transfer. One-hundred sixty-three days (~5 months) prior to surgery, the subject enrolled in the nonsequential pharmacokinetic subgroup of Arm 1. Medical history of note included hepatitis C, left and right elbow arthropathy, left ankle prosthesis, fixed subtalar joint right ankle, and haemophilic arthropathy. Surgical history included arthroscopic menisectomy on the right knee, extraction of subcutaneous pins, surgical fixation of the right foot, and a triple arthrodesis of the left ankle. Prior to surgery, the subject received an initial prophylaxis regimen of ~50 iu/kg once weekly. When baseline pharmacokinetic results became available, the dose was changed to ~20 iu/kg weekly. The surgery was uneventful, and haemostatic response was evaluated as excellent. Estimated intraoperative blood loss was 130 ml, and postoperative blood loss was approximately 40 ml. The dosing regimen consisted of a presurgery dose of 82 1 iu/kg, 60 7 iu/kg 6 hours later, and 41 1 iu/kg on Days 1 and 2 postsurgery. The subject received 21 2 iu/kg every day on 7

8 postoperative Days 3 7 and 42 3 iu/kg on postoperative Day 14. The subject did not receive treatment with rfixfc on Days 8 13 postsurgery. No serious adverse events were reported during the postoperative period. Subject 10 Subject 10, a 43-year-old male, underwent large intestine fistula closure. Sixty-seven days (~2 months) prior to surgery, the subject enrolled in Arm 4. Medical history of note included abdominal haematoma (evacuated 3 times), rectal/colon fistula, hepatitis B, previous surgery scars on the abdomen, right and left knee joint deformity, left knee joint ankylosis, right ankle joint limitation of motion, atrophy of the muscle of the right thigh, haematoma at left leg muscle, and infection at the left thigh fracture site. Surgical history included surgery on the abdomen (middle and lumbar area) due to fistula, plate fixation on left thigh fracture site, and right knee arthroscopic synovectomy. Prior to surgery, the subject received an initial prophylaxis regimen of ~26 iu/kg every 5 days. The surgery was uneventful, and haemostatic response was evaluated as excellent. Estimated intraoperative blood loss was 300 ml, and postoperative blood loss was approximately 500 ml. The postoperative bleeding was primarily due to diffuse oozing from the surgical wound; the incision was midline from sternum to the pubic bone and approximately the lower one-third of the wound was left open with the drain inserted, to heal by secondary intention. The subject received 7 total units of fresh frozen plasma and RBCs (2 units intraoperatively and an additional 5 units within 2 weeks of surgery). The dosing regimen consisted of iu/kg the day before surgery, a presurgery dose of 59 3 iu/kg, 50 8 iu/kg 9 hours later, 50 8 iu/kg 12 hours later, and 25 4 iu/kg on Day 2 postsurgery. The subject received 3 doses of 50 8 iu/kg each on postoperative Day 3 (2 of these were administered to treat a 8

9 bleeding episode), 2 doses of 50 8 iu/kg and 33 9 iu/kg on postoperative Day 4, and 2 doses of 42 4 iu/kg each every day on postoperative Days 5 7. On Days 8 and 9, the subject received 42 4 iu/kg. On Day 10, the subject received 2 doses of 42 4 iu/kg each and 1 dose of 16 9 iu/kg. On Days 11 13, the subject received 50 8 iu/kg twice daily. On Day 14, the subject received 1 dose of 50 8 iu/kg and a second dose of 25 4 iu/kg. The subject did not receive treatment with rfixfc on Day 1 postsurgery. No serious adverse events were reported during the postoperative period. During the postoperative period, the subject received the study-prohibited medication prothrombin complex concentrate, and was subsequently withdrawn due to noncompliance with the study protocol. As with all major surgery subjects in the study, this subject also tested negative for inhibitor development. Subject 11 Subject 11, a 24-year-old male, underwent 2 surgical procedures (incision and drainage of an abscessed pilonidal cyst; incision and drainage of a dental abscess) on 2 separate dates. Twohundred sixteen days (~7 months) prior to surgery, the subject enrolled in the nonsequential pharmacokinetic subgroup of Arm 1. Medical history of note included right elbow and right knee arthropathy and right thigh pseudo-tumour. Prior to surgery, the subject received an initial prophylaxis regimen of ~54 iu/kg (actual dose) once weekly. The first surgical procedure was incision and drainage of an abscessed pilonidal cyst. The surgery was uneventful, and haemostatic response was evaluated as excellent. Estimated intraoperative blood loss was 0 ml, and postoperative blood loss was 0 ml. The dosing regimen consisted of a presurgery dose of 51 3 iu/kg and 51 3 iu/kg on postoperative Days 2 and 4. The subject received 53 6 iu/kg on postoperative Days 7 and 14. The subject did not receive treatment with rfixfc on Days 1, 3, 5, 9

10 6, and 8 13 postsurgery. By definition, pilonidal cyst, the event which led to the surgery, was considered a serious adverse event that occurred during the initial portion of the surgical period. This event was assessed by the investigator as unrelated to the study drug. No serious adverse events were reported during the postoperative period. The subject underwent a second surgical procedure (incision and drainage of a dental abscess, with multiple dental extractions) 29 days after the first surgery. The surgery was uneventful, and haemostatic response was evaluated as excellent. Estimated intraoperative blood loss was 0 ml, and postoperative blood loss was 0 ml. The dosing regimen consisted of a presurgery dose of 58 3 iu/kg and 58 3 iu/kg on postoperative Days 1, 3, 7, and 13. The subject did not receive treatment with rfixfc on Days 2, 4 6, 8 12, and 14 postsurgery. He received antifibrinolytic treatment as systematic adjuvant therapy. By definition, dental abscess, the event which led to the surgery, was considered a serious adverse event that occurred during the initial portion of the surgical period. This event was assessed by the investigator as unrelated to the study drug. No serious adverse events were reported during the postoperative period. Subject 12 Subject 12, a 22-year-old male, underwent 2 surgical procedures (debridement, fracture dislocation, partial amputation; amputation of left middle finger) on 2 separate dates. Threehundred sixty-four days (~12 months) prior to surgery, the subject enrolled in the nonsequential pharmacokinetic subgroup of Arm 1. Medical history of note included bee sting allergy and haemophilic arthropathy. Prior to surgery, the subject received an initial prophylaxis regimen of ~54 iu/kg (actual dose) once weekly. On Day 0 (day of first surgery), the subject underwent 10

11 emergency surgery following a work-related accident of crushing injury to his finger. Surgery included debridement and fracture dislocation, and partial amputation. During the first surgery on the left middle finger, it became apparent that amputation of this finger was necessary, but consent had not been obtained for this procedure. A second major surgery, amputation of the left middle finger through proximal interphalangeal joint, was performed 3 days after the first surgery. Both surgeries were uneventful, and haemostatic response was evaluated as excellent. Estimated intraoperative blood loss was 0 ml, and postoperative blood loss was 0 ml for both surgeries. Immediately after the accidental injury on the day of the first surgery, the subject urgently self-administered iu/kg of rfixfc for bleeding from the trauma site at 15:00 hours. At 19:00 hours on the same day, the subject received an additional dose of 49 4 iu/kg immediately prior to surgery, as indicated by the subject s FIX levels and per investigator s instructions. At 21:50 hours, an unauthorised dose of 98 7 iu/kg was given by the surgeon, which was not discussed with the haematologist/investigator. At 09:15 hours on Day 1 postsurgery, the subject was dosed with 49 3 iu/kg in accordance with the investigator s instructions, as the investigator was not yet aware of the unauthorised dose given the previous evening. The dosing regimen on the subsequent days consisted of 49 3 iu/kg on postoperative Day 2, 56 3 iu/kg on Day 3, 49 4 iu/kg on Day 4, and 41 9 iu/kg on Day 5 postsurgery. The subject received 49 4 iu/kg on postoperative Day 7 and 45 5 iu/kg on Days 9 and 11 postsurgery. On Day 17 (14 days after the second surgery), the subject received 43 9 iu/kg. The subject did not receive treatment with rfixfc on Days 6, 8, 10 and postsurgery. By definition, limbcrushing injury, the event which led to the surgery, was considered a serious adverse event that occurred during the initial portion of the surgical period. This event was assessed by the 11

12 investigator as unrelated to the study drug. No serious adverse events were reported during the postoperative period. 12

Haemophilia and Orthopaedic Surgery. Brett Halliday Orthopaedic Surgeon Holy Spirit Northside and Royal Brisbane Hospitals

Haemophilia and Orthopaedic Surgery Brett Halliday Orthopaedic Surgeon Holy Spirit Northside and Royal Brisbane Hospitals Disclaimer Director of Education OTC South Pacific No funds or company support