Scientific Contribution 2017

Transcription

1 HAL Allergy Roadmap to Innovative and Registered Allergen Immunotherapy Registered Immunotherapy Phase III Phase II Pivotal Pre Clinical Phase I Dose Tolerability Dose Finding Scientific Contribution th Congress of the European Academy of Allergy and Clinical Immunology EAACI, 7-2 June 27, Helsinki, Finland

2 Dear Congress delegate, On behalf of HAL Allergy, it is our pleasure to welcome you to the EAACI 27 Congress in Helsinki. At this occasion, HAL Allergy will present the latest results of its research & development program both in the format of oral and poster presentations in the scientific program of the conference and on a company sponsored symposium. HAL Allergy symposium, entitled Roadmap of Innovative and Registered Allergen Immunotherapy will be held on Monday June 9, at 3.4h-.h in Hall 3A. Dirk-Jan Opstelten, PhD Research & Development Director Juan Gispert, MD, PhD Associate Director R&D At this year s conference we will provide an update on HAL Allergy s clinical trials to support the registration of our immunotherapies. Based on the successful Phase III trial with SUBLIVAC Birch, which has been presented at last year s EAACI Congress we will present new results from post-hoc analyses of the birch study data, including the early onset of efficacy of this therapy and on its solid effects in various sub-populations (e.g. younger and older birch pollen allergic patients). Using our SUBLIVAC Birch data, we also demonstrate a high correlation between the combined symptom and medication score (CSMS), the EAACI recommended primary endpoint measure in allergen immunotherapy trials, and the validated Rhinoconjunctivitis Quality of Life (RQLQ) score. In addition, we are also the first to evaluate the correlation between the total symptom score following pollen chamber exposure and the CSMS during natural grass pollen exposure - both were evaluated in our phase II SUBLIVAC Phleum study. In addition, we are pleased to present the design and status of a new large international Phase III trial for our PURETHAL Mites product for which 772 house dust mite allergic patients have been randomized across seven European countries. Furthermore, following the promising outcome of the First-In-Human study with our novel SCIT immunotherapy for peanut allergy, we will report on the next stage of clinical development for this therapy which has been recently initiated in the USA. Apart from the clinical research we also show the first results of a newly developed Ragweed (Ambrosia) allergoid for subcutaneous immunotherapy showing that modification of a Ragweed extract reduces its allergenicity while its immunogenicity is maintained. In addition, various abstracts will be presented on our continuous efforts to develop new methods for product characterization which confirm the manufacturing of high quality, standardized allergen products. In summary, our presented work provides an update on HAL Allergy s product development program, which is designed to enhance the wellbeing of allergic patients, by providing them high quality products with demonstrated efficacy and safety. We wish you a fruitful congress; if you require further information about our products or our R&D program, please be invited to meet us at our symposium or visit our Scientific Corner in the HAL Allergy booth in the exhibition area. Kind regards, Dirk-Jan Opstelten, PhD Research & Development Director Juan Gispert, MD, PhD Associate Director R&D

3 Scientific Contribution 27 HAL Allergy Symposium Scientific Contribution 27 Abstracts and poster presentations Contents Monday 9 June, 27, 3:4 : Hall 3A Roadmap of Innovative and Registered Allergen Immunotherapy Chairs: Oliver Pfaar, Germany Dirk-Jan Opstelten, The Netherlands Introduction Insights to AIT Clinical Study Program Dirk-Jan Opstelten, The Netherlands The TAV Program Implications for the Allergologist in Europe Ludger Klimek, Germany Grass allergen immunotherapy Where we are Moisés Calderón, United Kingdom Birch or Trees From Allergen Source to Immunological Active Compounds Krzysztof Kowal, Poland Clinical Development of Immunotherapy for Peanut Allergy Carsten Bindslev-Jensen, Denmark Clinical Sublingual immunotherapy with a liquid Birch pollen extract is similarly effective in birch pollen allergic patients with high sensitization profile compared to patients with low sensitization profile to birch allergen... 6 Early efficacy onset, already prior to the start of the birch pollen season, after sublingual immunotherapy with a liquid birch pollen extract... 8 Sublingual immunotherapy with a liquid birch pollen extract is similarly effective for younger and older patients with birch pollen induced allergic rhinitis/rhinoconjunctivitis... High correlation between validated Rhinoconjunctivitis Quality of Life (RQLQ) and EAACI recommended combined symptom medication score (CSMS) as clinical outcome measure in allergen immunotherapy trials... 2 High correlation between the Total Symptom Score measured in a pollen chamber and the Combined Symptom Medication Score measured during the grass pollen season in grass pollen allergic patients... 4 Design of the pivotal phase III study to assess the efficacy and safety of subcutaneous HDM allergoid immunotherapy in patients with HDM induced allergic rhinitis/rhinoconjunctivitis... 6 Safety and tolerability of subcutaneous immunotherapy (SCIT) with a modified peanut extract in peanut-allergic adults, adolescents and children... 8 Development Chemical modification of a ragweed extract results in an increased safety profile while immunogenicity is maintained... 2 Development of an aluminium-based Ragweed Allergoid immunotherapy using Quality-by-Design Particle size distribution of aluminium hydroxide adsorbed allergen preparation by laser diffraction Circular Dichroism as a valuable tool to characterise allergen products... 26

4 Sublingual immunotherapy with a liquid Birch pollen extract is similarly effective in birch pollen allergic patients with high sensitization profile compared to patients with low sensitization profile to birch allergen O. Pfaar,7, C. Bachert 2, P. Kuna 3, P. Panzner 4, M. Džupinová, D.Yu6, E. Mantikou6, H. Moed6, L. Klimek7, P.J. de Kam6 Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim Heidelberg University, Mannheim, Germany; 2 UZ Gent, Ear-, Nose and Throat Department, Gent, Belgium; 3 Poradnia Alergologii i Chorób Płuc Lodz, Poland; 4 Ustav imunologie a alergologie, Plzen, Czech Republic; ALIAN s.r.o. Ambulancia alergológie a klinickej imunológie, Bardejov, Slovakia; 6 HAL Allergy BV, Clinical Development & Pharmacovigilance department, Leiden, The Netherlands. 7 Center for Rhinology and Allergology Wiesbaden, Germany. Background Allergic rhinitis/rhinoconjunctivitis (ARC) is an important health problem worldwide and may significantly impair quality of life. Previously, a phase III study was conducted to establish the clinical efficacy and safety of pre- and co-seasonal sublingual immunotherapy (SLIT) with a liquid birch pollen extract for the treatment of birch pollen induced ARC. This study showed a statistically significant and clinical relevant improvement on the primary efficacy endpoint: Combined Symptoms Medication Score (CSMS) during the birch pollen season compared to placebo (Pfaar et al. Allergy (26); 7 (suppl.2): 4 (abstract 87)). The objective of this post-hoc analysis was to evaluate if birch pollen SLIT is similarly effective in patients with a high sensitization profile compared to patients with a low sensitization status. Method The study was a randomized, double-blind, placebo-controlled, parallel-group study, with treatment with 4, AUN/mL birch SLIT (ClinicalTrials.gov NCT22337), performed in 4 clinical study centers in European countries. In total, 46 patients, 8-6 years of age, suffering from moderate to severe birch pollen induced ARC were randomized. The effect of SLIT was assessed in a subgroup of patients with high sensitization profile; defined as either birch specific SPT, NPT or IgE results in the upper 7% quartile compared to patients with a low sensitization profile (below the upper 7% quartile of all three diagnostic tests). The clinical efficacy of this liquid birch pollen extract (4, AUN/mL) for both subgroups was assessed by the difference in the primary CSMS endpoint during the birch pollen season between the active vs. placebo treatment group using the Intent-to-Treat population. Results A clinically relevant and statistically significant CSMS reduction was reached for both the high and low birch sensitization subgroups compared to placebo (p=.8 and p=.48, respectively). Moreover, in absolute terms the CSMS improvement was comparable in both subgroups and exceeded the pre-defined clinical relevant CSMS effect of 23% (relative difference of 34% and 29%, respectively). Conclusion Results of this post-hoc subgroup-analysis support the hypothesis that SLIT with a liquid birch pollen extract is similarly effective in high and low birch pollen sensitized patients, indicating that patients with high and low sensitization status can benefit from this immune therapy to a similar extent. Session number, date and time: TPS7, Sunday 8 June 27; 2:-3:3 Session title: Immunotherapy - Improving the evidence base 6 EAACI, 7-2 June 27, Helsinki, Finland

5 Sublingual immunotherapy with a liquid Birch pollen extract is similarly effective in birch pollen allergic patients with high sensitization profile compared to patients with low sensitization profile to birch allergen O. Pfaar,7, C. Bachert 2, P. Kuna 3, P. Panzner 4, M. Džupinová, D.Yu 6, E. Mantikou 6, H. Moed 6, L. Klimek 7, P.J. de Kam 6 Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim Heidelberg University, Mannheim, Germany; 2 UZ Gent, Ear-, Nose and Throat Department, Gent, Belgium; 3 Poradnia Alergologii i Chorób Płuc Lodz, Poland; 4Ustav imunologie a alergologie, Plzen, Czech Republic; ALIAN s.r.o. Ambulancia alergológie a klinickej imunológie, Bardejov, Slovakia; 6 HAL Allergy BV, Clinical Development & Pharmacovigilance department, Leiden, The Netherlands; 7 Center for Rhinology and Allergology Wiesbaden, Germany. Background & Aim: Allergic rhinitis/rhinoconjunctivitis (ARC) is an important health problem worldwide and may significantly impair quality of life. Previously, a phase III study was conducted to establish the clinical efficacy and safety of preand co-seasonal sublingual immunotherapy (SLIT) with a liquid birch pollen extract for the treatment of birch pollen induced ARC. This study showed a statistically significant and clinical relevant improvement on the primary efficacy endpoint: Combined Symptoms Medication Score (CSMS) during the birch pollen season compared to placebo. Screening & ediary completion Randomization Depending on time of inclusion 3 months Preseasonal 3 months Placebo Birch pollen season 3 months 46 patients randomized Active 8Sep24 Dec24 Mar2 3May2 EOT The objective of this post-hoc analysis was to evaluate if birch pollen SLIT is similarly effective in patients with a high sensitization profile compared to patients with a low sensitization status. Methods: This pivotal Phase III study was a randomized, double-blind, placebocontrolled, parallel-group study, after treatment with a liquid birch pollen extract (4, AUN/mL) starting at least 2 weeks before the birch pollen season and continuing during the birch pollen season 2, and was performed in 4 clinical study centers in European countries. Figure : Flow chart of the double blind study. Table : Baseline characteristics of patients with high and low sensitization profile Baseline Variable High sensitization profile Low sensitization profile Placebo (N=82) Birch extract (N=9) Placebo (N=96) Birch extract (N=88) Age (years) # 33 (2-4) 34 (27-4) 38 (32-4) 37 (29-48) Female (n (%)) (62.2) 44 (48.4) (7.3) 4 (.) Birch IgE (U/mL) # 4.9 (4.3-7.) 39.7 (.-67.2) 8. ( ) 8.4 (4.-24.) Birch NPT (Lebel) # 8 (7-) 9 (7-) 8 (7-9) 8 (7-8) Birch SPT (mm) # 9 (7-2) 8 (6-) 7 (.-9) 7 (6-8) #: Median (Q-Q3) The study population consisted of 46 patients, 8-6 years of age, suffering from moderate to severe birch pollen induced ARC with or without mild to moderate controlled asthma. The effect of birch SLIT was assessed in a subgroup of patients with high sensitization profile; defined as either a birch specific SPT, NPT or IgE results in the upper 7% quartile compared to patients with a low sensitization profile (SPT, NPT and IgE below the upper 7% quartile for all three diagnostic tests). For this post-hoc analysis, the effect of birch SLIT was assessed in all patients of the Intent-to-Treat group, i.e. 73 patients with high and 84 patients with low sensitization profile. For both sensitization subgroups, the primary CSMS endpoint during the birch pollen season was compared between this liquid birch pollen extract (4, AUN/mL) and placebo. CSMS was analyzed by ANOVA and results were expressed as Least Square Means.,8,6,4,2 Mean CSMS during birch pollen season in patients with high sensitization profile -34% p =,8 Mean CSMS,8,6,4,2 Placebo Liquid Birch extract Figure 2: Analysis of mean CSMS during pollen season in patients with high sensitization profile (SPT or NPT 9 or IgE(t3) 44). Results: Baseline characteristics were comparable between the placebo and liquid Birch pollen extract groups for both the patients with low and high sensitization profile (Table ). The results of this post-hoc analysis showed a CSMS improvement from.7 (SEM.) to.4 (SEM.) (p=.8) and from.3 (SEM.) after placebo to.9 (SEM.) (p=.48) after treatment with a liquid birch extract for patients with a high and low sensitization profile, respectively. This corresponds to a clinically relevant and statistically significant CSMS reduction of 34% and 29% for patients with a high and low birch sensitization profile, respectively.,6,4,2,8,6 Mean CSMS during birch pollen season in patients with low sensitization profile -29% p =,48 Mean CSMS,4,2 Conclusion: Results of this post-hoc subgroup-analysis support the hypothesis that SLIT with a liquid birch pollen extract is similarly effective in high and low birch pollen sensitized patients, indicating that patients with high and low sensitization status can benefit from this immune therapy to a similar extent. Moreover, in absolute terms the CSMS improvement was comparable in both subgroups and exceeded the pre-defined clinical relevant CSMS effect of 2%. Placebo Liquid Birch extract Figure 3: Analysis of mean CSMS during pollen season in patients with low sensitization profile (SPT< and NPT<9 and IgE(t3)<44 U/mL). References () Pfaar et al. Allergy (26); 7 (suppl.2): 4 (abstract 87) (2) ClinicalTrials.gov NCT22337 In relation to this presentation, I declare the following, real or perceived conflict of interest. The presenter is a consultant of HAL Allergy and was contracted for the study by HAL Allergy. EAACI Congress 27

6 Early efficacy onset, already prior to the start of the birch pollen season, after sublingual immunotherapy with a liquid birch pollen extract TPS7 - Immunotherapy - Improving the evidence base Sublingual immunotherapy with a liquid Birch pollen extract is similarly effective in birch pollen allergic patients with high sensitization profile compared to patients with low sensitization profile to birch allergen O. Pfaar,7, C. Bachert 2, P. Kuna 3, P. Panzner 4, M. Džupinová, D.Yu6, E. Mantikou6, H. Moed6, L. Klimek7, P.J. de Kam6 ¹ Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim Heidelberg University, Mannheim, Germany; ² UZ Gent, Ear-, Nose and Throat Department, Gent, Belgium; ³ Poradnia Alergologii i Chorób Płuc Lodz, Poland; ⁴ Ustav imunologie a alergologie, Plzen, Czech Republic; ⁵ ALIAN s.r.o. Ambulancia alergológie a klinickej imunológie, Bardejov, Slovakia; ⁶ HAL Allergy BV, Clinical Development & Pharmacovigilance department, Leiden, The Netherlands; ⁷ Center for Rhinology and Allergology Wiesbaden, Germany. Background Allergic rhinitis/rhinoconjunctivitis (ARC) is an important problem worldwide and may significantly impair quality of life. Previously, a phase III study was conducted to establish the clinical efficacy and safety of pre- and co-seasonal sublingual immunotherapy (SLIT) for the treatment of birch pollen induced ARC. The primary analysis of this study showed a statistically significant and clinical relevant improvement on the primary efficacy endpoint: Combined Symptoms Medication Score (CSMS) during the birch pollen season after SLIT compared to placebo (Pfaar et al. Allergy (26); 7 (suppl.2): 4 (abstract 87)). Considering allergen cross-reactivity and structural homology within the birch homologous tree group, the present post-hoc analysis aimed to evaluate whether the primary CSMS endpoint would reach statistical significance prior to measurement of the first positive birch pollen count. Methods The study was a randomized, double-blind, placebo-controlled, parallel-group study, with treatment with a liquid Birch pollen extract (4, AUN/mL) starting at least 2 weeks before the birch pollen season and continuing during the birch pollen season (ClinicalTrials.gov NCT22337), performed in 4 clinical study centers in European countries. Study population consisted of 46 patients, 8-6 years of age, suffering from moderate to severe birch pollen induced ARC with or without mild to moderate, controlled asthma. CSMS was evaluated during the period March 2 until measurement of first positive birch pollen count. Results After treatment with birch SLIT, a clinically relevant and statistically significant 3.% improvement in CSMS was observed compared to placebo(p=.2), as measured in birch allergic patients prior to the appearance of the first birch pollen count. Conclusion The results of this post-hoc analysis support a beneficial effect of SLIT with a liquid birch pollen extract on allergic symptoms and medication, already visible prior to measurement of the first birch pollen count in birch allergic patients. These findings suggest an early onset of efficacy of this liquid SLIT birch pollen extract related to concomitant allergies for other early spring trees due to cross-reactivity and/or structural homology within the birch homologous tree group. Session number, date and time: TPS7, Sunday 8 June 27; 2:-3:3 Session title: Immunotherapy - Improving the evidence base EAACI, 7-2 June 27, Helsinki, Finland 7 8 EAACI, 7-2 June 27, Helsinki, Finland

7 Early efficacy onset, already prior to the start of the birch pollen season, after sublingual immunotherapy with a liquid birch pollen extract O. Pfaar,7, C. Bachert 2, P. Kuna 3, P. Panzner 4, M. Džupinová, D.Yu 6, E. Mantikou 6, H. Moed 6, L. Klimek 7, P.J. de Kam 6 Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim Heidelberg University, Mannheim, Germany; 2 UZ Gent, Ear-, Nose and Throat Department, Gent, Belgium; 3 Poradnia Alergologii i Chorób Płuc Lodz, Poland; 4 Ustav imunologie a alergologie, Plzen, Czech Republic; ALIAN s.r.o. Ambulancia alergológie a klinickej imunológie, Bardejov, Slovakia; 6 HAL Allergy BV, Clinical Development & Pharmacovigilance department, Leiden, The Netherlands; 7 Center for Rhinology and Allergology Wiesbaden, Germany. Background & Aim: Allergic rhinitis/rhinoconjunctivitis (ARC) is an important health problem worldwide and may significantly impair quality of life. Previously, a pivotal Phase III study was conducted to establish the clinical efficacy and safety of pre- and co-seasonal sublingual immunotherapy (SLIT) with a liquid birch pollen extract for the treatment of birch pollen induced ARC. This study showed a statistically significant and clinical relevant improvement on the primary efficacy endpoint: Combined Symptoms Medication Score (CSMS) during the birch pollen season compared to placebo. Screening & ediary completion Randomization Depending on time of inclusion 3 months Preseasonal 3 months Placebo Birch pollen season 3 months 46 patients randomized Active 8Sep24 Dec24 Mar2 3May2 EOT Considering allergen cross-reactivity and structural homology within the birch homologous tree group, the present post-hoc analysis aimed to evaluate whether the primary CSMS endpoint would reach already a statistically significant reduction after SLIT treatment prior to measurement of the first positive birch pollen count. Figure : Flow chart of the double blind study, birch pollen counts were collected using an e-diary starting March, 2. Methods: This pivotal Phase III study was a randomized, double-blind, placebo-controlled, parallel-group study, after treatment with a liquid birch pollen extract (4, AUN/mL) starting at least 2 weeks before the birch pollen season and continuing during the birch pollen season 2, and was performed in 4 clinical study centers in European countries. The study population consisted of 46 patients, 8-6 years of age, suffering from moderate to severe birch pollen induced ARC with or without mild to moderate, controlled asthma. The allergic symptoms and medication intake were scored using an e-diary starting on March 2. The CSMS was calculated on a daily basis as the sum of the symptom score and medication score (Figure 2). The mean CSMS was calculated during the period from March 2 until the first positive birch pollen count was measured at each of the pollen stations assigned to particular sites. The mean CSMS was analyzed using ANOVA and results were expressed as Least Square Means. Results: The results of this post-hoc analysis showed that prior to the appearance of the first birch pollen count, CSMS already improved from.67 (SEM.) after placebo to.47 (SEM.) after treatment (p=.2). This corresponds to a clinically relevant and statistically significant 3.% improvement in CSMS following preseasonal treatment with birch SLIT compared to placebo in birch allergic patients (Figure 3). Conclusion: The beneficial effect of SLIT with a liquid birch pollen extract on allergic symptoms and medication, is already visible prior to measurement of the first birch pollen count in birch allergic patients. These findings suggest an early onset of efficacy of this liquid SLIT birch pollen extract related to concomitant allergies for other early spring trees due to cross-reactivity and/or structural homology within the birch homologous tree group. Daily Symptom Score (dss) nose eyes Mild Moderate Severe itch tearing Primary endpoint: CSMS = dss + dms (range -6) Figure 2: Calculation of the primary CSMS endpoint,8,7,6,,4,3 itch sneezing runny nose obstruction Daily Medication Score (dms) Figure 3: Mean CSMS from March 2 until first positive birch pollen count References () Pfaar et al. Allergy (26); 7 (suppl.2): 4 (abstract 87) (2) ClinicalTrials.gov NCT22337 Antihistamines Nasal corticosteroids Oral corticosteroids If rescue medication of different classes used: dms = score of the highest class (maximum dss: 6 x 3 = 8/6 = 3) (maximum dms = 3) Mean CSMS prior to birch pollen season Mean CSMS,2, -3,% p =,2 Placebo Liquid Birch Extract In relation to this presentation, I declare the following, real or perceived conflict of interest. The presenter is a consultant of HAL Allergy and was contracted for the study by HAL Allergy. EAACI Congress 27

8 Sublingual immunotherapy with a liquid birch pollen extract is similarly effective for younger and older patients with birch pollen induced allergic rhinitis/rhinoconjunctivitis TPS7 - Immunotherapy - Improving the evidence base Early efficacy onset, already prior to the start of the birch pollen season, after sublingual immunotherapy with a liquid birch pollen extract O. Pfaar,7, C. Bachert2, P. Kuna³, P. Panzner⁴, M. Džupinová⁵, D.Yu⁶, E. Mantikou⁶, H. Moed⁶, L. Klimek⁷, P.J. de Kam⁶ Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim Heidelberg University, Mannheim, Germany; ² UZ Gent, Ear-, Nose and Throat Department, Gent, Belgium; ³ Poradnia Alergologii i Chorób Płuc Lodz, Poland; ⁴ Ustav imunologie a alergologie, Plzen, Czech Republic; ⁵ ALIAN s.r.o. Ambulancia alergológie a klinickej imunológie, Bardejov, Slovakia; ⁶ HAL Allergy BV, Clinical Development & Pharmacovigilance department, Leiden, The Netherlands; ⁷ Center for Rhinology and Allergology Wiesbaden, Germany. Background Allergic rhinitis/rhinoconjunctivitis (ARC) is an important problem worldwide and may significantly impair quality of life. Previously, a phase III study was conducted to establish the clinical efficacy and safety of pre- and co-seasonal sublingual immunotherapy (SLIT) with a liquid birch pollen extract for the treatment of birch pollen induced ARC. The primary analysis of this study showed a statistically significant and clinical relevant improvement on the primary efficacy endpoint: Combined Symptoms Medication Score (CSMS) during the birch pollen season after SIT compared to placebo (Pfaar et al. Allergy (26); 7 (suppl.2): 4 (abstract 87)). The objective of this post-hoc analysis was to assess whether clinical efficacy of SLIT is similar for older (4-6 yrs) and younger (8-4 yrs) birch pollen allergic patients. Method The study was a randomized, double-blind, placebo-controlled, parallel-group study, with treatment with a liquid birch pollen extract (4, AUN/mL) starting at least 2 weeks before the birch pollen season and continuing during the birch pollen season (ClinicalTrials.gov NCT22337), performed in 4 clinical study centers in European countries. Study population consisted of 46 patients, 8-6 years of age, suffering from moderate to severe birch pollen induced ARC with or without mild to moderate controlled asthma. For this post-hoc analysis, the effect of birch SLIT was assessed in all patients of the Intent-to-Treat group, i.e. 267 patients in the younger age group (age 8-4 years) and 9 patients in the older age group (age 4-6 years). Clinical efficacy of Birch SLIT 4, AUN/mL was assessed by calculation of the difference in the CSMS as assessed during the birch pollen season compared to placebo for both sub-groups separately. Results A clinically relevant and statistically significant CSMS reduction was reached for both the older and younger age subgroups compared to placebo (p=.3 and p=.22, respectively). Moreover, in absolute terms the CSMS improvement was comparable in both subgroups and exceeded the pre-defined clinical relevant CSMS effect of 23% (relative difference of 4% and 28%, respectively). Conclusion Results of this post-hoc subgroup-analysis support the hypothesis that SLIT using a liquid birch pollen extract is similarly effective in older and younger birch pollen allergic patients, indicating that both age groups can benefit from this therapy to a similar extent. Session number, date and time: PDS2, Tuesday 2 June 27; :3-2: Session title: Immunotherapy - News from the clinic EAACI, 7-2 June 27, Helsinki, Finland 9 EAACI, 7-2 June 27, Helsinki, Finland

9 Sublingual immunotherapy with a liquid birch pollen extract is similarly effective for younger and older patients with birch pollen induced allergic rhinitis/rhinoconjunctivitis O. Pfaar,7, C. Bachert 2, P. Kuna 3, P. Panzner 4, M. Džupinová, D.Yu 6, E. Mantikou 6, H. Moed 6, L. Klimek 7, P.J. de Kam 6 Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim Heidelberg University, Mannheim, Germany; 2 UZ Gent, Ear-, Nose and Throat Department, Gent, Belgium; 3 Poradnia Alergologii i Chorób Płuc Lodz, Poland; 4 Ustav imunologie a alergologie, Plzen, Czech Republic; ALIAN s.r.o. Ambulancia alergológie a klinickej imunológie, Bardejov, Slovakia; 6 HAL Allergy BV, Clinical Development & Pharmacovigilance department, Leiden, The Netherlands; 7 Center for Rhinology and Allergology Wiesbaden, Germany. Background & Aim: Allergic rhinitis/rhinoconjunctivitis (ARC) is an important health problem worldwide and may significantly impair quality of life. Previously, a pivotal Phase III study was conducted to establish the clinical efficacy and safety of pre- and co-seasonal sublingual immunotherapy (SLIT) with a liquid birch pollen extract for the treatment of birch pollen induced ARC. This study showed a statistically significant and clinical relevant improvement on the primary efficacy endpoint: Combined Symptoms Medication Score (CSMS) during the birch pollen season compared to placebo. The objective of this post-hoc analysis was to assess whether clinical efficacy of SLIT is similar for older (4-6 yrs) and younger (8-44 yrs) birch pollen allergic patients. Methods: This pivotal Phase III study was a randomized, double-blind, placebocontrolled, parallel-group study, after treatment with a liquid birch pollen extract (4, AUN/mL) starting at least 2 weeks before the birch pollen season and continuing during the birch pollen season 2, and was performed in 4 clinical study centers in European countries (Figure ). Study population consisted of 46 patients, 8-6 years of age, suffering from moderate to severe birch pollen induced ARC with or without mild to moderate controlled asthma. For this post-hoc analysis, the effect of birch SLIT was assessed in all patients of the Intent-to-Treat group, i.e. 267 patients in the younger age group (age 8-44 years) and 9 patients in the older age group (age 4-6 years) (Figure 2). Clinical efficacy of Birch SLIT 4, AUN/mL was assessed by calculation of the difference in the primary CSMS endpoint as assessed during the birch pollen season compared to placebo for both age subgroups separately. CSMS were analyzed using ANOVA and results were expressed as Least Square Means. Results: Baseline characteristics were generally comparable between the placebo and liquid Birch pollen extract groups for both the younger and older patients (Table ). Birch-specific IgE is lower in the older patients compared to younger patients. The results of this post-hoc analysis showed a CSMS improvement from.47 (SEM.4) to.88 (SEM.2) (p=.3) for older patients and from.44 (SEM.9) to.4 (SEM.9) (p=.22) for younger patients (Figure 3). This corresponds to a clinically relevant and statistically significant CSMS improvement of 4% and 28% for the older and younger age subgroups respectively, which exceeded the pre-defined clinical relevant CSMS effect of 2% for both age groups. Conclusion: Results of this post-hoc subgroup-analysis support the hypothesis that SLIT using a liquid birch pollen extract is similarly effective in older and younger birch pollen allergic patients, indicating that both age groups can benefit from this therapy to a similar extent. Screening & ediary completion Randomization Figure : Flow chart of the pivotal Phase III study. Figure 2: Flow diagram-overview of patient disposition Table : Baseline characteristics in patients below or above 4 years of age Baseline Variable Placebo (N=39) <4 years 4 years Birch extract (N=28) Placebo (N=39) Figure 3: Analysis of mean CSMS during the pollen season in patients above or below 4 years of age References () Pfaar et al. Allergy (26); 7 (suppl.2): 4 (abstract 87) (2) ClinicalTrials.gov NCT22337 Birch extract (N=) Age (years) # 33 (2-38) 32 (2-37) 3 (48-7) (48-6) Female (n (%)) 8 (7.6) 6 (46.9) 26 (66.7) 29 (6.9) Birch IgE (U/mL) # 23.3 (.-4.) 24.6 (7.8-.6) 9.3 ( ) 7.8 (4.6-2) Birch NPT (Lebel) # 8 (7-9) 8 (7-9) 8 (7-9) 8 (7-9) Birch SPT (mm) # 8 (6-) 7.3 (6-9) 8 (6-9) 8 (6-) #: Median (Q-Q3),6,4,2,,8,6 < 4 years n=39 Depending on time of inclusion 3 months Preseasonal 3 months Placebo Birch pollen season 3 months 46 patients randomized Active 8Sep24 Dec24 Mar2 3May2 Placebo - SAFETY n=98 Placebo - ITT n=78 4 years n=39 Eligibility Screening n= Treatment study medication n=46 Birch extract - SAFETY n=28 Birch extract - ITT n=79 < 4 years n=28 4 years n= Placebo EOT Liquid Birch Extract Mean CSMS,4,2,,4, Total group,47,88 Age >=4,44,4 Age < 4 In relation to this presentation, I declare the following, real or perceived conflict of interest. The presenter is a consultant of HAL Allergy and was contracted for the study by HAL Allergy. EAACI Congress 27

10 High correlation between validated Rhinoconjunctivitis Quality of Life (RQLQ) and EAACI recommended combined symptom medication score (CSMS) as clinical outcome measure in allergen immunotherapy trials PDS2 - Immunotherapy - News from the clinic Sublingual immunotherapy with a liquid birch pollen extract is similarly effective for younger and older patients with birch pollen induced allergic rhinitis/rhinoconjunctivitis O. Pfaar,7, C. Bachert 2, P. Kuna³, P. Panzner⁴, M. Džupinová⁵, D.Yu⁶, E. Mantikou⁶, H. Moed⁶, L. Klimek⁷, P.J. de Kam⁶ Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim Heidelberg University, Mannheim, Germany; ² UZ Gent, Ear-, Nose and Throat Department, Gent, Belgium; ³ Poradnia Alergologii i Chorób Płuc Lodz, Poland; ⁴ Ustav imunologie a alergologie, Plzen, Czech Republic; ⁵ ALIAN s.r.o. Ambulancia alergológie a klinickej imunológie, Bardejov, Slovakia; ⁶ HAL Allergy BV, Clinical Development & Pharmacovigilance department, Leiden, The Netherlands; ⁷ Center for Rhinology and Allergology Wiesbaden, Germany. Background EAACI recommends the combined symptom and medication score (CSMS) as standardized clinical outcome measure in allergen immunotherapy trials for allergic rhinoconjunctivitis (ARC) and calls for further validation of this score (Pfaar, Allergy 24). The first Phase III study with a sublingual immunotherapy (SLIT) in ARC with CSMS as primary outcome was recently completed. The primary results showed a clinically relevant and statistical significant 32% improvement in CSMS following SLIT with a liquid birch pollen extract compared to placebo (p<.) (Pfaar et al. Allergy (26); 7 (suppl.2): 4 (abstract 87). The validated Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ-S) assessed during the birch pollen season was correlated to the CSMS of this birch SLIT study and the minimal clinical important difference (MCID) for CSMS was estimated using the RQLQ-S as anchor. Method The data from the pivotal Phase III study were used after pre- and co-seasonal birch SLIT administration in 46 patients suffering from moderate to severe birch pollen induced ARC. Previously, a MCID of 2% in CSMS compared to placebo was justified based on clinical and statistical criteria and accepted by regulators. Pearson s correlation coefficient was calculated between the secondary RQLQ-S and CSMS and the MCID for CSMS was estimated using linear regression based on the consideration that an improvement of. points in the validated RQLQ-S score is accepted to be clinically relevant. Results A strong positive correlation was observed between the CSMS and the RQLQ-S scores during the pollen season (r=.68 and p<.). Based on regression analysis using the study results, a clinically relevant. point improvement in RQLQ-S corresponds to an MICD for CSMS of 2% (9% CI: 9-23%). Conclusion This is the first validation of the CSMS as proposed by the EAACI as primary endpoint in a Phase III field trial. Using the validated RQLQ-S score as anchor, the post-hoc results show that a 2% improvement in CSMS may be considered clinically relevant. Moreover, these results emphasize the clinical relevance of the 32% CSMS improvement realized after SLIT with a liquid birch pollen extract, the first pivotal Phase III study in ARC which used CSMS score as primary endpoint. Moreover, these results provide important guidance and support for the external validation of CSMS as primary outcome measure in allergen immunotherapy trials for ARC. Session number, date and time: OAS24, Tuesday 2 June 27; :3-2: Session title: Immunotherapy - Measures and Outcomes EAACI, 7-2 June 27, Helsinki, Finland 2 EAACI, 7-2 June 27, Helsinki, Finland

11 High correlation between validated Rhinoconjunctivitis Quality of Life (RQLQ) and EAACI recommended combined symptom medication score (CSMS) as clinical outcome measure in allergen immunotherapy trials O. Pfaar,7, C. Bachert 2, P. Kuna 3, P. Panzner 4, M. Džupinová, D.Yu 6, E. Mantikou 6, H. Moed 6, L. Klimek 7, P.J. de Kam 6 Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim Heidelberg University, Mannheim, Germany; 2 UZ Gent, Ear-, Nose and Throat Department, Gent, Belgium; 3 Poradnia Alergologii i Chorób Płuc Lodz, Poland; 4 Ustav imunologie a alergologie, Plzen, Czech Republic; ALIAN s.r.o. Ambulancia alergológie a klinickej imunológie, Bardejov, Slovakia; 6 HAL Allergy BV, Clinical Development & Pharmacovigilance department, Leiden, The Netherlands; 7 Center for Rhinology and Allergology Wiesbaden, Germany. Background & Aim: EAACI recommends the combined symptom and medication score (CSMS, Figure ) as standardized clinical outcome measure in allergen immunotherapy trials for allergic rhinoconjunctivitis (ARC) (Fig. ). However, the CSMS has not yet been formally validated. Daily Symptom Score (dss) itch tearing Daily Medication Score (dms) nose eyes Mild Moderate Severe Antihistamines Nasal corticosteroids The first Phase III study with a sublingual immunotherapy (SLIT) in ARC with CSMS as primary outcome was recently completed. 2 The validated Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ- S) assessed during the birch pollen season was correlated to the CSMS of this birch SLIT study and the change in CSMS required to achieve a clinically relevant increase of. points on RQLQ-S was calculated. Methods: A pivotal Phase III study was performed with pre- and co-seasonal administration of a liquid birch extract in 46 patients suffering from moderate to severe birch pollen induced ARC. Previously, a minimal clinical important difference (MCID) of 2% in CSMS compared to placebo was justified based on clinical and statistical criteria and justified and accepted by regulatory agencies. To further support this MCID, an anchor based analysis was performed using the validated RQLQ-S as an anchor. Firstly, the Pearson s correlation coefficient was calculated between RQLQ-S and CSMS, followed by a linear regression to estimate the change in CSMS required to achieve an improvement of. points in the validated RQLQ-S score, which is accepted to be clinically relevant. Results: The primary results showed a clinically relevant and statistical significant 32% improvement in CSMS following SLIT with this liquid birch pollen extract compared to placebo (p<., Fig. 2), while a significant RQLQ-S score reduction of.3 points (9% CI: -.7 to -.32) was observed during the birch pollen season following active treatment as compared to placebo (p<., Fig. 3). 3,4 A strong positive correlation was observed between the CSMS and the RQLQ-S scores during the pollen season (r=.68 and p<.). Based on a linear regression analysis (Fig. 4), it was calculated that. point improvement in RQLQ-S, corresponds to an CSMS improvement of 2% (9% CI: 9-23%). Primary endpoint: CSMS = dss + dms (range -6) Figure : Calculation of the primary endpoint, CSMS.,6,4,2,,8 itch sneezing runny nose obstruction Figure 2: Mean Change from Baseline (± SEM) in CSMS Figure 3: Mean Change from Baseline (± SEM) in RQLQ-S Oral corticosteroids If rescue medication of different classes used: dms = score of the highest class (maximum dss: 6 x 3 = 8/6 = 3) (maximum dms = 3) CSMS in pollen season (ITT) CSMS,6,4,2,6,4,2,,8,6,4,2 Placebo -32% P<. RQLQ (ITT) =-.3 Active Pollen Season *** Placebo Active *** p <. Conclusion: This post-hoc analysis is the first validation attempt of the CSMS, which is the EAACI recommended primary endpoint to be used in a Phase III field trial. Using the validated RQLQ-S score as anchor, the post-hoc results of this pivotal Phase III study showed that a 2% improvement in CSMSmay be consideredclinicallyrelevantfor Phase III studies in the birch ARC indication. Moreover, these results strongly support that the 32% CSMS improvement realized after SLIT with a liquid birch pollen extract in the pivotal Phase III study is clinically relevant. Importantly, these results may be considered important to support the validation of CSMS as primary outcome measure in allergenimmunotherapy trials forarc Mean CSMS during pollen season RQLQ(S) Change from baseline () Pfaar et al. Allergy. 24 Jul;69(7):84-67 (2) ClinicalTrials.gov NCT22337 (3) Pfaar et al. Allergy (26); 7 (suppl.2): 4 (abstract 87) (4) Pfaar et al. Allergy (26); 7 (suppl.2): 43 (abstract 9) RQLQ score druing pollen season Fit 9% Confidence Limits 9% Prediction Limits Figure 4: Linear regression of RQLQ-S and CSMS during the pollen season. In relation to this presentation, I declare the following, real or perceived conflict of interest. The presenter is a consultant of HAL Allergy and was contracted for the study by HAL Allergy. EAACI Congress 27

12 High correlation between the Total Symptom Score measured in a pollen chamber and the Combined Symptom Medication Score measured during the grass pollen season in grass pollen allergic patients OAS24 - Immunotherapy - Measures and Outcomes High correlation between validated Rhinoconjunctivitis Quality of Life (RQLQ) and EAACI recommended combined symptom medication score (CSMS) as clinical outcome measure in allergen immunotherapy trials P. Couroux, A.M. Salapatek¹, D. Yu², H. Moed², E. Mantikou², A. Patel¹, P.J. de Kam² Inflamax Research Inc, Mississauga, ON Canada; ² HAL Allergy BV, Clinical Development & Pharmacovigilance Department, Leiden, The Netherlands. Background The EAACI recommends the Combined Symptom Medication Score (CSMS) as standardized clinical outcome measure in allergen immunotherapy trials for allergic rhinoconjunctivitis (ARC). During early phases of clinical development it is challenging to select a surrogate parameter to be used in a phase II study, which adequately predicts the outcomes in field studies. Recently, a phase II trial was completed to investigate the efficacy and safety of different dosages of sublingual immunotherapy (SLIT) with a liquid Phleum Pratense extract for treatment of ARC due to grass pollen allergy. A post-hoc analysis was performed to assess the correlation between the primary endpoint Total Symptom Score (TSS) as measured in an environmental exposure chamber (EEC) and the CSMS assessed during the grass pollen season. Method The study was a single-center, randomized, double-blind, placebo-controlled, parallel-group study, with a treatment duration of months. In total 68 patients (8-6 years of age) suffering from grass pollen induced ARC, were randomized to treatment with one of three different dosages of a liquid Phleum Pratense extract or placebo. For this post-hoc analysis, data from the patients that completed the study were analyzed. The TSS was assessed at baseline, before the start of the grass pollen season and at the end of the study in the pollen exposure chamber. For the TSS assessment, the patients were exposed to grass pollen at an average concentration of 3 ± ppm3 in a mobile EEC for 6 hours. For this post-hoc analysis only the TSS at the end of the study was evaluated. The CSMS was assessed during the grass pollen season, which was defined based on actual pollen counts. Results The TSS score was assessed in the EEC at the end of the study between August and September 26, which was -2 months after the CSMS which was assessed during the grass pollen season (June/July 26). The results showed a strong positive and statistically significant correlation between the CSMS during the pollen season evaluated after 8-9 months of treatment and the TSS measured in the EEC after months of treatment (r=.62 and p<.). Conclusion These study results support that after pollen SLIT with a liquid Phleum Pratense extract, TSS during controlled exposure to grass pollen in an EEC is a predictive surrogate parameter for CSMS measured during the grass pollen season for patients suffering from grass pollen induced ARC. Session number, date and time: OAS8, Monday 9 June 27; 3:4-: Session title: Immunotherapy - Measures and Outcomes EAACI, 7-2 June 27, Helsinki, Finland 3 4 EAACI, 7-2 June 27, Helsinki, Finland

13 High correlation between the Total Symptom Score measured in a pollen chamber and the Combined Symptom Medication Score measured during the grass pollen season in grass pollen allergic patients P. Couroux, A.M. Salapatek, D. Yu 2, H. Moed 2, E. Mantikou 2, A. Patel, P.J. de Kam 2 Inflamax Research Inc, Mississauga, ON Canada; 2 HAL Allergy BV, Clinical Development & Pharmacovigilance Department, Leiden, The Netherlands. Background & Aim: The EAACI recommends the Combined Symptom Medication Score (CSMS) as standardized clinical outcome measure in allergen immunotherapy trials for allergic rhinoconjunctivitis (ARC, see Fig. ). During early phases of clinical development it is challenging to select an adequate surrogate efficacy parameter to be used in a Phase II dose range finding study, which is representative for a combined symptom and medication score as used in pivotal Phase III studies. Recently, a Phase II dose finding trial in an environmental exposure chamber was completed to investigate the efficacy and safety of different dosages of sublingual immunotherapy (SLIT) with a liquid Phleum Pratense extract for treatment of ARC due to grass pollen allergy. A post-hoc analysis was performed to assess the correlation between Total Symptom Score (TSS), used as (surrogate) primary endpoint as measured in an environmental exposure chamber (EEC) and the combined symptom and medication score (CSMS) as assessed during the grass pollen season. Daily Symptom Score (dss) nose eyes Mild Moderate Severe itch tearing itch sneezing runny nose obstruction Figure : Calculation of the primary endpoint, CSMS. Daily Medication Score (dms) Primary endpoint: CSMS = dss + dms (range -6) Antihistamines Nasal corticosteroids Oral corticosteroids If rescue medication of different classes used: dms = score of the highest class (maximum dss: 6 x 3 = 8/6 = 3) (maximum dms = 3) Methods: The study was a single-center, randomized, double-blind, placebocontrolled, parallel-group study, with a treatment duration of months (Fig. 2). In total 68 patients (8-6 years of age) suffering from grass pollen induced ARC, were randomized to treatment with one of three different dosages of a liquid Phleum Pratense extract or placebo. For this post-hoc analysis, data from all patients that completed the study were analyzed. TSS is the sum of four nasal symptom scores (running nose, congestion, itchy nose, and sneezing) and three ocular symptom scores (itchy/burning eyes, red eyes, watery eyes), and itchy ear/palat, each rated on a four point scale (-3). The TSS was assessed at baseline, before the start of the grass pollen season and at the end of the study (approximately months) in the pollen exposure chamber. For the TSS assessment, the patients were exposed to grass pollen at an average concentration of 3 ± ppm3 in a mobile EEC for 6 hours. For this post-hoc analysis only the TSS at the end of the study was evaluated. The CSMS was assessed approximately 8-9 months after start treatment during the grass pollen season. SEP 2 NOV 2 Screening and baseline assessment Figure 2: Mean Change from Baseline (± SEM) in RQLQ-S 2. months treatment Primary efficacy assessment OCT/NOV 26 All patients randomized End of trial Provocation in pollen chamber Observations Correlation.624 Scatter Plot With 9% Prediction Ellipse Sympton + medication score in grass pollen season Results: The TSS score was assessed in the EEC at the end of the study between August and September 26, which was -2 months after the CSMS which was assessed during the grass pollen season (June/July 26). The results of this post-hoc analysis showed a strong positive and statistically significant correlation between the CSMS during the pollen season and the TSS (r=.62 and p<., see Fig. 3) Mean CSMS during pollen season. Conclusion: These study results support that the surrogate TSS endpoint used during controlled exposure to grass pollen in an EEC is a strong predictive parameter for CSMS measured during the grass pollen season after pollen SLIT with a liquid Phleum Pratense extract, for patients suffering from grass pollen induced ARC.. 2 Mean TSS Figure 3: Scatterplot and 9% prediction ellipse between mean TSS during the end of study EEC and mean CSMS during the pollen season References () Pfaar et al. Allergy. 24 Jul;69(7):84-67 In relation to this presentation, I declare the following, real or perceived conflict of interest. The presenter was contracted for the study by HAL Allergy. EAACI Congress 27

14 Design of the pivotal phase III study to assess the efficacy and safety of subcutaneous HDM allergoid immunotherapy in patients with HDM induced allergic rhinitis/rhinoconjunctivitis OAS8 - Immunotherapy - Measures and Outcomes High correlation between the Total Symptom Score measured in a pollen chamber and the Combined Symptom Medication Score measured during the grass pollen season in grass pollen allergic patients C. Bachert, P.J. de Kam², T. Hofman³, H. Moed², D. Yu², E. Hu², M. Nell², M.J. van Nimwegen², L. Klimek⁴, O. Pfaar 4, ¹ University of Ghent, Clinical Trial Center, Upper Airways Research Laboratory, Ghent, Belgium; ² AL Allergy BV, Department of Clinical Development and Pharmacovigilance, Leiden, The Netherlands; ³ Allergy Centre, Poznan, Poland; ⁴ enter for Rhinology and Allergology Wiesbaden, Germany; ⁵ Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany. Background In order to comply with EMA guidelines on development of allergen immunotherapy products, a clinical development program was started to obtain full marketing authorization for a allergoid subcutaneous immunotherapy (SCIT) product for the treatment of house dust mite (HDM) allergy. Previously, the safety and tolerability of increasing doses of this allergoid SCIT product was evaluated in patients with HDM-induced allergic rhinitis/rhinoconjunctivitis (ARC) [EUdraCT ]. No safety or tolerability issues were identified for doses up to 4, AUeq. Subsequently, a dose-finding study to identify the optimal, i.e. effective and safe dose in HDM ARC with or without concomitant asthma was performed [EUdraCT ; Pfaar, Allergy 26]. This study demonstrated a dose response relationship with doses of, AUeq (. ml of 2, AUeq/mL) up to, AUeq (. ml of, AUeq/mL) showing significant improvements compared to placebo. The current pivotal Phase III study [EUdraCT ] aims to confirm safety and efficacy of this HDM allergoid SCIT product at a dose level of, AUeq/mL (. ml) compared to placebo after one year of treatment in patients with HDMinduced ARC. Method The current study is a multi-center (8 clinical study centers in 7 European countries) randomized, double-blind, placebocontrolled, parallel-group study in 73 adult patients, with moderate to severe HDM induced ARC with or without mild to moderate persistent asthma. The primary outcome of the study is the difference in mean Combined Symptom and Medication Score (nasal symptoms only) (CSMS(n)) between, AUeq/mL allergoid SCIT and placebo treatment, assessed during the last 8 weeks of the approximately year treatment period. Results Screening of this study has been initiated with the aim to randomize 73 patients by March 27. The primary efficacy data, expressed by CSMS(n), will be collected using an e-diary during 8 weeks in autumn 27 / winter 28. Conclusion This Phase III study was initiated to establish the efficacy and safety of, AUeq allergoid SCIT for the treatment of HDM induced ARC. This study was designed according to the EMA guidelines using CSMS as primary endpoint as recommended by EAACI (Pfaar 24). The initiation of this pivotal Phase III HDM study is an important milestone in the clinical development of a state-of-the art safe and efficacious allergoid SCIT product in patients with HDM induced ARC. Session number, date and time: PDS2, Sunday 8 June 27; :3-2: Session title: Immunotherapy - From immune response to real life treatment EAACI, 7-2 June 27, Helsinki, Finland 6 EAACI, 7-2 June 27, Helsinki, Finland

15 Design of the pivotal phase III study to assess the efficacy and safety of subcutaneous HDM allergoid immunotherapy in patients with HDM induced allergic rhinitis/rhinoconjunctivitis C. Bachert, P.J. de Kam 2, T. Hofman 3, H. Moed 2, D. Yu 2, E. Hu 2, M. Nell 2, M.J. van Nimwegen 2, L. Klimek 4, O. Pfaar 4, University of Ghent, Clinical Trial Center, Upper Airways Research Laboratory, Ghent, Belgium; 2 HAL Allergy BV, Department of Clinical Development and Pharmacovigilance, Leiden, The Netherlands; 3 Allergy Centre, Poznan, Poland; 4 Center for Rhinology and Allergology Wiesbaden, Germany; Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany. Background & Aim: Previous studies with HDM allergoid SCIT: I. Safety and tolerability Study with increasing doses in patients with HDM-induced allergic rhinitis/rhinoconjunctivitis (ARC) à No safety or tolerability issues were identified for doses up to 4, Aueq () II. Dose-finding study to identify the optimal, i.e. effective and safe dose in HDM ARC with or without concomitant asthma (2) à Dose response relationship with doses of, AUeq (. ml of 2, AUeq/mL) up to, AUeq (. ml of, AUeq/mL) showing significant improvements compared to placebo Current Phase III study: III. Pivotal Phase III study, conducted in Europe, designed to confirm safety and efficacy of this HDM allergoid SCIT product at a dose level of, AUeq/mL (. ml) compared to placebo after one year of treatment in patients with HDM-induced ARC, measured by the combined symptom and medication score-nasal (CSMS(n)) during the last 8 weeks of approximately year treatment. (3) Methods: The study is designed as a randomized, double-blind, placebo-controlled, parallel-group, multi-center (87 clinical study centers in 7 European countries) study in 73 adult patients, with moderate to severe HDM induced ARC with or without mild to moderate controlled asthma. Primary outcome: Difference in mean Combined Symptom and Medication Score (nasal symptoms only) (CSMS(n)) between, AUeq/mL allergoid SCIT and placebo treatment, assessed during the last 8 weeks of the approximately year treatment period (see Figure ). OCT 26 - MAR 27 OCT 27 - MAR 28 Period Screening 4 days Daily diary (2 weeks) randomization Period 2 Treatment Figure : Study Schedule HDM allergoid SCIT phase III trial Figure 2: contribution to randomization per country. Period 3 Treatment / Efficacy assessment months 8 weeks Daily diary (2x one week) RANDOMINZATION PER COUNTRY Slovakia 7% Portugal 4% Poland 4% Spain 8% Belgium 4% Germany 26% Hungary 6% Daily diary (8 weeks) Results: Screening of this study started October 4 th 26. A total of 8 patients have been screened, with the last patient screened on March 3 st 27. In total, 772 patients were randomized into the study. Most patients were randomized in sites in Poland (23 sites, 46% of the patients), followed by Germany (26 sites, 26% of the patients) see Figure 2. The screen failure rate was 3 % (3% anticipated), main reasons were too low CSMS(n) during the 2-week baseline e-diary period or too low HDM specific IgE see Figure 3. The primary efficacy data (expressed as CSMS(n)), will be collected using an e-diary during 8 weeks in autumn 27 / winter 28. Conclusion: This Phase III study was initiated to establish the efficacy and safety of, AUeq allergoid SCIT for the treatment of HDM induced ARC. This study was designed according to the EMA guidelines using CSMS(n) as primary endpoint as recommended by EAACI. (4) Reaching the pre-determined target for timely completion of screening and randomization of approximately 73 patients for this pivotal Phase III HDM study is an important milestone in support of registration of this state-of-the art safe and efficacious allergoid SCIT product at the, AUeq/mL dose for patients with HDM induced ARC. Figure 3 : Reasons for Screen Failure References Low IgE %. [EUdraCT ] 2. [EUdraCT ; Pfaar, Allergy. 26 Jul;7(7):967-76] 3. [EUdraCT ] REASONS FOR SCREEN FAILURE 2% % % % 4% 4. Pfaar, Allergy. 24 Jul;69(7): Low CSMS(n) 37% AE Low Compliance Inf Cons Withdrawn Low CSMS(n) Low IgE Neg SPT/NPT Other In relation to this presentation, I declare the following, real or perceived conflict of interest. The presenter was contracted for the study by HAL Allergy. EAACI Congress 27

16 Safety and tolerability of subcutaneous immunotherapy (SCIT) with a modified peanut extract in peanut-allergic adults, adolescents and children PDS2 - Immunotherapy - From immune response to real life treatment Design of the pivotal phase III study to assess the efficacy and safety of subcutaneous HDM allergoid immunotherapy in patients with HDM induced allergic rhinitis/rhinoconjunctivitis E.H. Kim¹, S.H. Sicherer², R.A. Wood³, C. Bindslev-Jensen⁴, R.G. Hamilton⁵, M.H. Shamji⁶, E. van Twuijver⁷, D.J.E. Opstelten⁷, P.J. de Kam⁷ UNC School of Medicine, Allergy and Immunology; ² The Johns Hopkins Hospital, Pediatric Allergy & Immunology, Chapel Hill, USA; ³ Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, USA; ⁴ Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark; ⁵ Johns Hopkins Asthma and Allergy Center, Baltimore, USA; ⁶ Immunomodulation and Tolerance Group, Immune Tolerance Network (ITN) Distributed Centre of Excellence for Allergy & Asthma, Imperial College London, UK; ⁷ HAL Allergy BV, Leiden, The Netherlands. Background HAL-MPE is a chemically modified, aluminum hydroxide absorbed peanut extract being developed for SCIT for treatment of peanut allergy. The first-in-human safety and tolerability study with HAL-MPE in adult patients with peanut allergy was recently successfully completed in Denmark (EudraCT ). The results of this randomized, placebo-controlled study in 7 adult patients, with dose escalation to 37 µg peanut protein during 4 weeks, showed that treatment with HAL- MPE was generally safe and well tolerated and that the immunological response was supportive of the pharmacological action of HAL-MPE. The second study is currently ongoing with primary objective to investigate the safety and tolerability of HAL-MPE in adults, adolescents and children and secondary objective to evaluate the immunological response compared to placebo. Methods This is a prospective, randomized, double blind placebo controlled, multi-centre study in 42 patients with documented peanut allergy. In order to increase the experience in the adult population, the study will start with a group of 2 adult patients (8- aged years). After completion and evaluation of the safety results in the adult population, the study is planned to continue with adolescents (2-8 years) and children (-2 years). HAL-MPE or placebo will be administered subcutaneously once weekly, using a dose titration schedule starting with. µg modified peanut protein and gradually increasing the dose to reach the maximum dose of 37 µg after 3 weeks of treatment. This maximum dose will be repeated twice, with an interval of and 2 weeks. The safety and tolerability of HAL-MPE treatment will be assessed by recording immediate, early and late local and systemic allergic reactions, and other adverse events. As a secondary outcome, the immunological response will be evaluated by determination of serum specific immunoglobulins (IgE, IgG, IgE-FAB), a basophil activation test and a histamine release test. Results This safety study with HAL-MPE was initiated at 3 academic sites in the US in Q4 26. Conclusion The described study with a modified peanut SCIT product is the next step in developing this novel immunotherapy for peanut allergy. Session number, date and time: TPS3, Tuesday 2 June 27; 2:-3:3 Session title: Risk factors and management of food allergy EAACI, 7-2 June 27, Helsinki, Finland 7 8 EAACI, 7-2 June 27, Helsinki, Finland

17 Safety and tolerability of subcutaneous immunotherapy (SCIT) with a modified peanut extract in peanut-allergic adults, adolescents and children E.H. Kim, S.H. Sicherer 2, R.A. Wood 3, C. Bindslev-Jensen 4, R.G. Hamilton, M.H. Shamji 6, E. van Twuijver 7, D.J.E. Opstelten 7, P.J. de Kam 7 UNC School of Medicine, Allergy and Immunology; 2 The Johns Hopkins Hospital, Pediatric Allergy & Immunology, Chapel Hill, USA; 3 Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, USA; 4 Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark; Johns Hopkins Asthma and Allergy Center, Baltimore, USA; 6 Immunomodulation and Tolerance Group, Immune Tolerance Network (ITN) Distributed Centre of Excellence for Allergy & Asthma, Imperial College London, UK; 7 HAL Allergy BV, Leiden, The Netherlands Background & Aim: HAL-MPE is a chemically modified, aluminum hydroxide absorbed peanut extract being developed for SCIT for treatment of peanut allergy. The first-in-human safety and tolerability study with HAL- MPE in adult patients with peanut allergy was recently successfully completed in Denmark (EudraCT ). The results of this randomized, placebo-controlled study in 7 adult patients, with dose escalation to 37 µg peanut protein during 4 weeks, showed that in adults treatment with HAL-MPE was generally safe and well tolerated and that the immunological response was supportive of the pharmacological action of HAL- MPE. The present study is currently ongoing in the US with primary objective to investigate the safety and tolerability of HAL- MPE in adults, adolescents and children and secondary objective to evaluate the immunological response compared to placebo. Part Randominization + treatment of 2 adults DSMB decision and IRB review following completion of administrations to all 2 patients DSMB decision following 4 administrations in 8 patients Ongoing DSMB safety review of all patient data Part 2 Randominization + treatment of adolescents Randominization + treatment of children Figure : Staggering groups of adults, adolescents and children. Methods: This is a prospective, randomized, double-blind, placebo controlled, multi-center study in 42 patients with documented peanut allergy. The study has started with recruitment of a group of 2 adult patients (8- aged years) Part. After completion and evaluation of the safety results in the adult population, the study is planned to continue with Part 2: The treatment of adolescents (2-8 years) and children (-2 years) (Figure ). HAL-MPE or placebo will be administered subcutaneously once weekly, using a dose titration schedule starting with. µg modified peanut protein and gradually increasing the dose to reach the maximum dose of 37 µg after 3 weeks of treatment (Table ). This maximum dose will be repeated twice, with an interval of and 2 weeks. Dosing will proceed to the next dose if asthma is well controlled and the dose level will depend on the occurrence of local and/or systemic adverse events (Figure 2). The safety and tolerability of HAL-MPE treatment will be assessed by recording immediate, early and late local and systemic allergic reactions, and other adverse events. As a secondary outcome, the immunological response will be evaluated by determination of serum specific immunoglobulins (IgE,IgG), IgE-FAB), a basophil activation test and a histamine release test. Furthermore, an elaborative evaluation of potential biomarkers is planned, including an evaluation of the effects of HAL-MPE on innate and adaptive type 2 immune response. Results: This safety study with HAL-MPE was initiated at 3 academic sites in the US in Q4 26. Screening started in January 27 and the first patient was randomized in February 27. The end of recruitment period is anticipated for December 27. Conclusion: The described study with modified (hypoallergenic) peanut extract adsorbed onto aluminium hydroxide (HAL-MPE) is the next step in developing this novel SCIT immunotherapy for peanut allergy. Table : Dosing Schedule Increase dose according to schedule Week μg of modified peanut protein Local cm Figure 2: Rules for increase/reduction of dosages. NO Grade I Systemic Administer same dose as previous ACT 2 and FEV or PEF 8% YES IMP administration Local or Systemic reaction? Local > 8 cm YES NO Postpone IMP administration for week Grade II Local Systemic > 8 cm Grade III/IV Systemic Systemic: After st administration STOP OR: Reduce dose by one/more steps STOP In relation to this presentation, I declare the following, real or perceived conflict of interest. The presenter is an employee of HAL Allergy. EAACI Congress 27

18 Chemical modification of a ragweed extract results in an increased safety profile while immunogenicity is maintained TPS3 - Risk factors and management of food allergy Hanneke van der Kleij¹, Heidi Hofer², Claudia Asam², Michael Wallner² HAL Allergy B.V., Leiden, The Netherlands, ² University of Salzburg, Dept. of Molecular Biology, Salzburg, Austria. Safety and tolerability of subcutaneous immunotherapy (SCIT) with a modified peanut extract in peanut-allergic adults, adolescents and children Background Short or common ragweed (Ambrosia artemisiifolia), belonging to the aster plant family, sheds enormous amounts of highly allergenic pollen late in the summer. Due to its high allergenic potential Ambrosia artemisiifolia is becoming a health threat in North America and Europe. HAL Allergy is developing a subcutaneous immunotherapy for patients suffering from ragweed pollen allergy. A standardized ragweed pollen extract, chemically modified and adsorbed to aluminium hydroxide (Al(OH)3), is being investigated for its potential use in immunotherapy. Methods Ragweed extract (RE) was modified by glutaraldehyde followed by adsorption to Al(OH3). In vitro, a mediator release assay (MRA) using hurbl (humanized rat basophil leukemia) cells was performed. HuRBL cells were pre-sensitized using individual sera of ragweed-allergic patients and challenged with serial dilutions of RE and modified RE starting at µg/ml followed by eight / dilutions (-. ng/ml). Antigen-specific release of ß-hexosaminidase was measured and calculated in relation to % release values. In vivo, the immunogenic potency of modified RE was evaluated by measuring the induction of REspecific IgG in mice. Female BALB/c mice (n= per group) were subcutaneously (s.c.) injected with 2. AUeq/ml RE or modified RE adsorbed to Al(OH)3 (.8 mg/ml) per mouse on days, 7, 4 and 2. Control mice (n=6) were injected with matrix only. Specific IgG titres were determined in serum obtained at days -,3 and 28. Results The potency of modified RE in MRA was drastically reduced in all patients, with a mean reduction of fold or more. Chemical modification resulted in a later onset of activation as well as a lowering of the maximum release of ß-hexosaminidase. In vivo, both RE and modified RE show comparable levels of RE-specific IgG antibodies in mice at day 28 of the immunogenicity model. Conclusions Using an in vitro and in vivo model, it has been shown that chemical modification impairs the capacity of RE to activate basophils while retaining its capability to be immunogenic. Therefore, chemical modification of RE may be a promising approach for the development of a safe and effective immunotherapy for ragweed allergy. Session number, date and time: PDS9, Sunday 8 June 27; :3-7: Session title: News in immunotherapy and varia EAACI, 7-2 June 27, Helsinki, Finland 9 2 EAACI, 7-2 June 27, Helsinki, Finland

19 m f f f m f f Table 2. Clinical characteristics of ragweed-allergic patients used for the MRA. Table. Molecular weights (MW) of the individual ragweed proteins. Figure. IgE-binding to proteins was visualized using a serum of 2 ragweed-allergic patients. Marker proteins are indicated with kda. MRE RE concentration (ng/ml).... Patient MRE RE concentration (ng/ml).... Patient x x x2 x3 x4 x x6 x7 Pre-sera MRE RE Sham ns * 2 immunizations MRE RE Sham RE 4 immunizations MRE RE Sham ** *** x x x2 x3 x4 x x6 x7 Pre-sera MRE RE Sham ns ± fold > fold > fold 2 4 immunizations Similar IgG responses to ME and MRE found indicating that IgG epitopes are still accessible after modification with GA. MRE RE Sham *** ** *** MRE RE Sham *** Female BALB/c mice, 3 groups: Mice immunized with RE ( mice per group) Mice immunized with MRE ( mice per group) Control mice received Al(OH)3 in buffer (6 mice per group) 2 immunizations ** *** MRE 28 ± fold 8 - fold fold - fold 6 ± fold > fold 3 - fold > fold 2 - fold 4 Potency reduction Potency reduction Patient Patientnr. nr. Overview of all 2 patients RE RE protein for restimulation Sham Sham IL-4 Sham protein for restimulation RE RE immunized mice RE RE Figure RE RE RE-immunized mice antigen dilution [ng/ml] MRE-immunized mice antigen dilution [ng/ml] In relation to this presentation, I declare the following, real or perceived conflict of interest. The presenter is an employee of HAL Allergy. Sham protein for restimulation Sham RE immunized mice murbl cells passively sensitized with sera of immunized mice Titration curves of β-hexosaminidase-release Measured values were calculated in relation to % release Data points are expressed as the mean release of individual mice EAACI Congress 27 The authors would like to acknowledge Dr. Christof Ebner, Allergy Clinic Reumannplatz, and Prof. Barbara Bohle, Medical University of Vienna, for providing patients sera, Prof. Fátima Ferreira, University of Salzburg, for critical review of the study and Silke Reinboth, University of Salzburg, for technical assistance with the animal experiments Sham 2 2 IFN-Ɣ protein for restimulation Sham MRE immunized mice Significantly increased amount of IL-4 and IFN-Ɣ spots in splenocytes of MRE and RE immunized mice compared to sham. IL- similar responses to IL-4 (both Th2 cytokines) No IL- responses detected in any of the immunized mice (no visible spots) No responses detected with sham immunized mice (no visible spots) 2 MRE immunized mice Biologic activity of IgE induced by immunization with either RE or MRE spots / 2*^ cells Figure 4 2x splenocytes from RE and MRE immunized mice were restimulated with 2 µg of RE or medium Splenocytes were stimulated in duplo (when enough material available) ELIspot; Splenocytes produce L-4 and IFN-Ɣ after stimulation with RE, independent of immunization Titer units Figure 3 Using an in vitro and in vivo model, it has been shown that chemical modification impairs the capacity of RE to activate basophils while retaining its capability to be immunogenic. Therefore, chemical modification of RE may be a promising approach for the development of a safe and effective immunotherapy for ragweed allergy f 4 m Total lge [ku/i] m m m RAST [PRU] Gender s.c. immunization with 2. AUeq/ml (modified) ragweed extract adsorbed to Al(OH)3 IgG induction in time measured and compared (t= -2, t=4 and t=28 days) In vitro stimulation of splenocytes to measure cytokine production (IL-4, IL-, IFN-Ɣ, and IL-) Antigen-specific release of ß-hexosaminidase was measured and calculated in relation to % release values Conclusion: 2 7 Specific IgG responses to RE and MRE Murine rat basophil leukemia (murbl) cells, incubated with sera from RE and MRE immunized mice, show similar ß-hexosaminidase release after activation with RE, indicating biologic activity of IgE induced by immunization with either RE or MRE. MRE RE Immunogenicity model IL-4, IL- and IFN-Ɣ spots identified in splenocytes stimulated with RE, independent of immunization with RE or MRE.. A significant induction of RE-specific IgG levels was observed in mice immunized with RE as well as MRE after 2 and 4 immunizations. concentration (ng/ml)..... The potency of modified RE in MRA was drastically reduced in all patients. Chemical modification resulted in a later onset of activation as well as a lowering of the maximum release of ß-hexosaminidase. 2 7 Patient. Results: Age All patients show a greatly reduced response to MRE, compared to RE Chemical modification resulted in a later onset of activation as well as in lowering the maximum release % β-hex release Figure 2 spots / 2*^ cells % release To test the biological activity of IgE induced by immunization, murbl cells were passively sensitized with the sera of immunized mice and stimulation with titrated concentrations of RE. β-hexosaminidase release of murbl cells was measured Patient nr. Table 2. Rat basophil cell line (RBL-2H3) is transfected with the human FcεR (IgE) receptor RBL cells (line 2H3) are sensitized with sera from ragweed-allergic patients and stimulated with serial dilutions of RE and MRE Figure 2 shows 3 representative examples of titration curves and an overview of potency reduction in all 2 patients The fold potency reduction is the calculated as the difference in concentration of RE versus MRE needed to induce 2% release % β-hex release Splenocytes from immunized mice were restimulated with 2 µg of RE, MRE or medium. Using the ELISpot assay, IL-4, IL-, IFN-Ɣ and IL- induction were identified to compare T-cell activation of RE and MRE. Data were expressed as the amount of spots per 2x cells. 37 kda Amb a Titer units The immunogenic potency of MRE was evaluated by measuring i.a. the induction of RE- and MRE-specific IgG in mice. Female BALB/c mice (n= per group) were subcutaneously (s.c.) injected with 2. AUeq/ml RE or MRE adsorbed to Al(OH)3 (.8 mg/ml) per mouse on days, 7, 4 and 2. Control mice (n=6) were injected with matrix (buffer and Al(OH)3). Specific IgG titres were determined in serum obtained at days -,3 and kda Amb a In vitro, a mediator release assay (MRA) using hurbl (humanized rat basophil leukemia) cells was performed. HuRBL cells were pre-sensitized using individual sera of ragweed-allergic patients and challenged with serial dilutions of RE and modified RE (MRE). kda 4 kda 2 kda kda kda 3 kda kda 38 kda 38 kda MW (SDS-PAGE) Amb a9 Amb a8 Amb a7 Amb a6 Amb a Amb a4 Amb a3 Amb a2 Amb a Allergen Table. Ragweed extract (RE) was modified by glutaraldehyde followed by adsorption to Al(OH3). 9 2 Chemical modification impairs the capacity of ragweed extract to activate basophils 8 Methods: HAL Allergy is developing a subcutaneous immunotherapy for patients suffering from ragweed pollen allergy. A standardized ragweed pollen extract, chemically modified and adsorbed to aluminium hydroxide (Al(OH)3), is being investigated for its potential use in immunotherapy. 37- patient number kda M Figure. Immunoblot of ragweed pollen extract and the 2 patients sera used for mediator release assay (MRA). Short or common ragweed (Ambrosia artemisiifolia), belonging to the aster plant family, sheds enormous amounts of highly allergenic pollen late in the summer. Due to its high allergenic potential Ambrosia artemisiifolia is becoming a health threat in North America and Europe. Immunoblot and patient characteristics. Background & Aim: Allergy BV, Leiden, The Netherlands, 2University of Salzburg, Salzburg, Austria % β-hex release spots / 2*^ cells HAL Hanneke van der Kleij, Heidi Hofer2, Claudia Asam2, Michael Wallner2 Chemical modification of a ragweed extract results in an increased safety profile while immunogenicity is maintained % release spots / 2*^ cells

20 Development of an aluminium-based Ragweed Allergoid immunotherapy using Quality-by-Design PDS9 - News in immunotherapy and varia Chemical modification of a ragweed extract results in an increased safety profile while immunogenicity is maintained Werner L. Vos, Inge Peekel, Annemarie Segaar, Dion Luykx, Jolanda Meijlis, Maurice Mannesse and Cindy Stoffelen HAL Allergy BV, Development Department, Leiden, The Netherlands. Background Development of aluminum-based allergoid vaccines is complex and multi-disciplinary. To enable an integrated approach to process and analytical development for a Ragweed immunotherapy with reduced allergenicity, the quality target product profile of a chemically modified extract coupled to aluminum hydroxide (Al(OH)3) was defined. A risk-based approach was used for the development (process development, analytical development, and protein characterization) of the immunotherapeutic product. Method The desired effect of process steps on product quality attributes was assessed using Quality-by-Design. The effect of source material, pollen concentration, time, temperature, ph, and of protease inhibitors was investigated for different extraction conditions using total protein, total allergenic activity (Relative IgE potency), Immunoblot and SDS-PAGE for testing. Mass Spectrometry (MS) was used to identify bands in the SDS-PAGE protein profile. Development of filtration and ultrafiltration was focused on the selection of the UF/DF module. Finally, the chemical modification was investigated together with coupling of the modified extract to Al(OH)3 using HP-SEC, residual allergenic activity, immunoblot (cross-linking) and quantification of unbound protein (formulation). Results Extraction of Ragweed pollen was robust across all tested conditions as assessed by Total Protein, Total allergenic activity (Relative IgE Potency), allergen profile (immunoblot) and protein profile (SDS-PAGE). UF/DF was robust across all modules tested. With MS Amb a (intact form and alpha/beta chain), Amb a 3, Amb a 4, Amb a, Amb a 6, Amb a 8 and Amb a were identified. Crosslinking was robust and reproducible as shown by HP-SEC, allergen profile and protein profiles. IgE activity was reduced as shown by residual allergenic activity assay. A robust formulation was established across a range of product strengths and concentrations of aluminium hydroxide using the concentration unbound protein as a read-out. Session number, date and time: TPS2, Tuesday 2 June 27; 2:-3:3 Session title: Miscellaneous EAACI, 7-2 June 27, Helsinki, Finland 2 22 EAACI, 7-2 June 27, Helsinki, Finland

21 DS Extraction Clarification UF/DF Modification UF/DF Sterile filtration Pre-formulation Coupling Homogenization Filling Unit operation Total protein Originate Originate Major Allergens Originate Originate Potency Remove Remove Originate Originate Originate Originate Identity Remove Remove Originate Remove Originate Critical Quality Attribute (CQA) Color Remove Originate Originate Figure. Interaction matrix between the critical quality attributes of the Ragweed immunotherapy and the manufacturing steps. The different development stages were color-coded. A positive effect of a process step is indicated by "Originate", a negative effect is indicated by "Remove". An asterisk (*) indicates that the interaction was identified as a risk a priori. Nominal Nominal hrs, condition condition rt, Phos (duplo) Time ph 8., Phos ph 8., Carb 3 hrs, 2 hrs, 24 hrs, rt, Phos rt, Carb 4 C, Carb Nominal Nominal ph 6., condition condition Phos (duplo) ph, buffer No inhibitor No inhibitor (duplo) Protease inhibitors EACA Nominal 4 C, 24 hr, Carb condition (duplo) Temperature Nominal condition Protease inhibitor cocktail 4 C, 2 hr, Phos Sample Marker IHRP Clarified extract Diafiltered extract 3 kda Diafiltered extract kda Lane Sample Marker Purified Amb a IHRP Diafiltered extract 3 kda Modified DS Purified Amb a IHRP Diafiltered extract 3 kda Modified DS kda 44 kda. 2. Time (minutes) 8 kda 7 kda 4..3 kda B A Nominal formulation 2, AUeq/mL Modified DS Lane Sample Marker IHRP Clarified extract Diafiltered extract 3 kda Modified extract (prior to UF/DF) Modified DS (after UF/DF) Formulation A: Formulation A: 2, 2, AUeq/mL AUeq/mL Buffer X Buffer X Formulation B: Formulation C:, 4, AUeq/mL AUeq/mL Buffer X Buffer X Figure. 7. SDS-PAGE (reduced) of the clarified extract, the diafiltered extract, and the modified DS. kda 2 kda 2 kda kda 37 kda kda EAACI Congress 27 Figure. 8. Percentage unbound protein after coupling. Unbound protein was measured after settling of the Al(OH)3 by centrifugation, the percentage was calculated relative to the amount of added modified DS. Stage IV: Coupling to Al(OH)3 Figure. 6. HPLC-SEC of Ragweed extract (B) before (black) and after modification (red). The protein marker is shown in the upper panel (A) Relative IgE Potency Diafiltered extract.8 (3 kda) Intermediate LOG AU/ml Linear (diafiltered extract) Linear (modified extract) 9 9 Figure. %Inhibition of unmodified diafiltered extract and modified extract. The Relative IgE potency before and after modification is shown Diafiltered extract ( kda) 9. 7 Diafiltered extract (3 kda) Recovery Recovery Total TAA (%) protein (%) Clarified extract Intermediate Table. %Recovery for UF/DF calculated based on Total protein and Total allergenic activity (TAA). 2 kda kda kda 7 kda Figure 3. SDS-PAGE of stage I lab-scale experiments before and after UF/DF with different ultrafiltration modules (3 kd, kd). The IHRP was analysed using MS/MS, the following allergens were identified: Amb a (4, 43, 3, 8, 7 kda), Amb a (4, 38 kda), Amb a 3 (7 kda), Amb a 4 (3 kda), Am b a 6 (2 kda), Amb a 8 (2 kda), and Amb a ( kda). Lane Figure 4. Non-reduced (Western IgG) blot (rabbit α Amb a ) (left, land -) and IgE blot (human serum pool Ragweed allergic patients, lanes 6-9) of different intermediates. Amb a is indicated with the black box. The Amb a - and -chains are indicated with red and purple boxes, respectively. kda 2 kda 2 kda kda 37 kda kda 2 kda kda kda 7 kda Stage III: Modification kda kda 2 kda 2 kda 37 kda kda 7 kda kda kda 2 kda Stage II: Clarification and UF/DF Figure 2. Total protein and Relative IgE Potency results of stage I experiments. Phos = sodium phosphate, Carb = ammonium carbonate. An effect of >. mg/ml was considered significant for Total protein (left axis, columns highlighted by the continuous boxes), an effect of >.3 was considered significant for Relative IgE Potency (right axis,, highlighted by the dashed boxes) Stage I: Extraction In relation to this presentation, I declare the following, real or perceived conflict of interest. The presenter is an employee of HAL Allergy. A manufacturing process for ragweed immunotherapy with reduced allergenicity coupled to Al(OH)3 was developed successfully. Conclusion: During stage I, the aim was to find an improved condition (i.e. both increased total protein and Relative IgE Potency) with respect to the nominal configuration for the extraction conditions. No meaningful improvement was found, for this reason the nominal configuration was selected for continued process development. During stage II, a Ragweed pollen extract was processed successfully on productionscale to the stage of diafiltered extract using UF/DF hollow fibers of 3 and kda NMWC. Process performance (assessed by Total protein and total allergenic activity yields) and quality of the resulting intermediate was similar for both hollow fiber modules. During stage III, the diafiltered extract was cross-linked with glutaraldehyde, the resulting DS was tested using SDS-PAGE, IgG and IgE Immunoblot, Residual IgE potency, and HPLC-SEC. It was concluded that the cross-linking and modification were successful. Finally, during stage IV, the concentration of unbound protein was measured after coupling for different product strengths using different formulations. The nominal formulation showed an increase in unbound protein, for all other tested conditions the protein concentration was low indicating that the coupling was successful. Results: - Stage IV (Coupling): Optimization of the ratio DS:Al(OH)3 using total protein as a read-out (Fig. 8). - Stage III (Modification): Testing feasibility of crosslinking. Simultaneous assay development and product characterization. - Stage II (Clarification and UF/DF): Testing of clarification and selection of hollow fibers in process scale experiments. - Stage I (Extraction): Effect of time, temperature, ph, and of protease inhibitors Figs. 2) in laboratory scale experiments and assay development. DP Glutaraldehyde The interaction between manufacturing steps and product quality attributes was defined in an interaction matrix (Fig. ). Methods: Development of aluminium-based allergoid vaccines is complex and multi-disciplinary. To enable an integrated approach to process and analytical development for a Ragweed immunotherapy with reduced allergenicity, the quality target product profile of a chemically modified extract coupled to aluminum hydroxide (Al(OH)3) was defined. A riskbased approach was used for the integrated development (process development, analytical development, and protein characterization) of the vaccine. Background & Aim: %inhibition HAL Allergy BV, Leiden, The Netherlands Werner L. Vos, Inge Peekel, Annemarie Segaar, Dion Luykx, Jolanda Meijlis, Maurice Mannesse, and Cindy Stoffelen AU AU Insolubles Relative lge Potency Relative lge Potency Development of an aluminium-based Ragweed Allergoid immunotherapy using Quality-by-Design %Unbound protein ph Total protein (Bradford) mg/ml Total protein (Bradford) mg/ml Total protein (Bradford) mg/ml Total protein (Bradford) mg/ml Relative lge Potency Relative lge Potency

22 Particle size distribution of aluminium hydroxide adsorbed allergen preparation by laser diffraction TPS2 - Miscellaneous Development of an aluminium-based Ragweed Allergoid immunotherapy using Quality-by-Design R. van den Hout¹, K. Broos², M. Laga², M. Busch¹ ¹ HAL Allergy, Leiden, The Netherlands; ² Anacura, Evergem, Belgium. Background In the manufacture of injections containing dispersed particles, measures should be taken to ensure a suitable and controlled particle size (PS) with regard to intended use (Ph. Eur. Monograph on Parenteralia, 2). Aluminium hydroxide adsorbed allergen preparations are typically polydisperse products. A method was developed to measure the particle size distribution (PSD) of an aluminium hydroxide adsorbed allergen preparation. Methods PS analysis was performed by laser diffraction according to Ph. Eur on a Mastersizer 2 equipped with a Hydro 2S sample dispersion module. Calculation of the PS is based on the Mie theory (general purpose mode). Assuming that the particles are spherical, PSD will be expressed as volume sphere equivalent. Data are reported as cumulative undersize distribution at, and 9 per cent, denoted as d, d and d9, respectively. Impact of concentration range (obscruration), dispersion procedure (stirring rate & lag time) and method duration were investigated. PS of several batches of an aluminium hydroxide adsorbed allergen preparation of different ages were measured with the developed method. Results An obscuration value between 7. and 2.% was most optimal. Sample concentration was fixed at the quantity necessary to obtain an obscuration around %. At lower stirring speed complete dispersion of the samples takes some time. At higher stirring speeds size increases at later time points suggesting early onset of aggregation. A stirring speed of rpm was found to be most optimal. The %RSD on the 6 consecutive measurements for d, d and d9 and all measurements times is well below the acceptable values ( % for d and d9, % for d). Depending on the measurement time, either a slight decrease in size (short measurement time) or an increase in size (long measurement times) is observed. Consistent PSD with a median value generally between 8 and µm, and 9% of the particles having a size around 2 µm were obtained. Comparable PSs were observed in fresh and elderly batches, which suggests particles size is not changing in time. Conclusion Laser diffraction seems to be a promising method to measure PSD of aluminium hydroxide adsorbed allergen preparations, and could be used to further characterise aluminium hydroxide adsorbed allergen preparations. Session number, date and time: TPS2, Tuesday 2 June 27; 2:-3.3 Session title: Miscellaneous EAACI, 7-2 June 27, Helsinki, Finland EAACI, 7-2 June 27, Helsinki, Finland

23 Particle size distribution of aluminium hydroxide adsorbed allergen preparation by laser diffraction R. Van den Hout, K. Broos 2, M. Laga 2, M. Busch 2 HAL Allergy BV, Leiden, The Netherlands, 2 Anacura, Evergem, Belgium Background & Aim: In the manufacture of injections containing dispersed particles, measures should be taken to ensure a suitable and controlled particle size (PS) with regard to intended use (Ph. Eur. Monograph on Parenteralia, 2). Aluminium hydroxide adsorbed allergen preparations are typically polydisperse products. A method was developed to measure the particle size distribution (PSD) of an aluminium hydroxide adsorbed allergen preparation. Methods: PS analysis was performed by laser diffraction according to Ph. Eur on a Mastersizer 2 equipped with a Hydro 2S sample dispersion module. Calculation of the PS was based on the Mie theory (general purpose mode). Assuming that the particles are spherical, PSD was expressed as volume sphere equivalent. Data were reported as cumulative undersize distribution at, and 9 per cent, denoted as d, d and d 9, respectively. The PSD of the samples was followed over time and the impact of concentration range (obscuration), dispersion procedure (stirring rate & measurement duration), and measurement time were investigated. PS of several batches of an aluminium hydroxide adsorbed allergen preparation of different ages were measured with the developed method Volume (%) 4 2,, Particle Size (µm) Figure. Overlay of PSD for obscuration optimization (3 s measurement time) Time (min) Table. Overview of the d, d and d 9 of consecutive measurements at different meaurement times A Figure 2. Size at different percentiles in function of time and at (A) and rpm (B) % Obscuration 2.% Obscuration % Obscuration 7.% Obscuration % Obscuration 2.% Obscuration.% Obscuration Size (µm) Time (min) B D D D9 Size (µm) Results: An obscuration value between 7. and 2.% was most optimal (Figure ). Sample concentration was fixed at the quantity necessary to obtain an obscuration around %. At lower stirring speed dispersion of the samples takes some time (Figure 2A) and full dispersion is not achieved, even after 4 min. At higher stirring speed size increases at later time points suggesting early onset of aggregation (Figure 2B). A stirring speed of rpm was found to be most optimal. The %RSD on the consecutive measurements for d, d and d 9 and all measurements times is well below the acceptable values ( % for d and d 9, % for d, Table ). Depending on the measurement time, either a slight decrease in size (short measurement time) or an increase in size (long measurement times) is observed. A typical trend graph under optimized conditions is shown in Figure 3. Consistent PSD with a median value generally between 8 and µm, and 9% of the particles having a size smaller than 2 µm were obtained. Comparable PSs were observed in fresh and elderly batches, which suggests particles size is not changing in time (Table 2). Time (s) d (µm) d (µm) d9 (µm) Average RSD (%) Average RSD (%) Average RSD (%) Size (µm) Time (min) Figure 3. Trend graph under optimized conditions Table 2. Results of d, d and d 9 of fresh and elderly batches D D D9 Conclusion: Laser diffraction seems to be a promising method to measure PSD of aluminium hydroxide adsorbed allergen preparations, and could be used to further characterise aluminium hydroxide adsorbed allergen preparations. Batch no. Age of batch (months) d (µm) d (µm) d9 (µm) In relation to this presentation, I declare the following, real or perceived conflict of interest. The presenter is an employee of HAL Allergy. EAACI Congress 27

24 Circular Dichroism as a valuable tool to characterise allergen products TPS2 - Miscellaneous Particle size distribution of aluminium hydroxide adsorbed allergen preparation by laser diffraction Niels Sinnige, Sandipta Acharya and Dion Luykx HAL Allergy, Leiden, The Netherlands. Background Circular Dichroism (CD) is a technique increasingly applied to study protein structures in pharmaceutical products. The value of CD has now been assessed as a tool to characterise various allergen (intermediate) products: () purified allergens, (2) allergen extracts and allergoids, (3) aluminum hydroxide adsorbed allergoids. CD was tested on these products for monitoring () chemical modifications, (2) consistency and (3) stability. Methods CD: Far-UV CD spectra (26-9 nm) were recorded on a J-8 Spectropolarimeter. A purified peanut allergen and peanut allergen extract were reduced and alkylated. CD-spectra were analysed before and after modification. Various batches of tree pollen extract and aluminum adsorbed mites allergoid were investigated via their CD-spectra and a CD-ratio. Temperature interval measurements from 2 to 9 C were performed on a purified bee venom allergen and a tree pollen extract and aluminum adsorbed mites allergoid were incubated at elevated temperatures, exposed to freeze-thawing or shaking. CDspectra and a CD-ratio were used to study the effect of stressing. Results Purified allergens: CD was applied to study the chemical modification of a peanut allergen. The CD spectra demonstrated a classical unfolding of the protein (loss of α-helix structures). Additionally, the thermal stability of a bee venom allergen was studied by monitoring its CD spectrum from 2-9 C (structural alterations occurred at 6 C). Allergen extracts and allergoids: Consistency of tree pollen extracts was established via CD and the effect of stressing a tree pollen extract was demonstrated (protein unfolding). Next, CD was also shown to be applicable to monitor the chemical modification of a peanut allergen extract (loss of α-helix structures). Aluminum hydroxide adsorbed allergoids: CD was able to characterise complex protein suspensions like aluminum adsorbed mite allergoids (mixture of α-and β-structures) for consistency and stability. The use of a CD ratio appeared to be a sensitive tool to monitor consistency and protein stability. Conclusion CD was demonstrated to be a valuable tool to characterise allergen products during the whole manufacturing process (from purified allergens up to complex aluminum adsorbed allergoids). CD was shown to be applicable for monitoring chemical modifications, consistency and stability of allergen products. Session number, date and time: TPS2, Tuesday 2 June 27; 2:-3:3 Session title: Miscellaneous EAACI, 7-2 June 27, Helsinki, Finland 2 26 EAACI, 7-2 June 27, Helsinki, Finland

25 Circular Dichroism as a valuable tool to characterise allergen products N. Sinnige, S. Acharya and D. Luykx Department of protein characterisation, HAL Allergy BV, Leiden, The Netherlands Background & Aim: Circular Dichroism (CD) is a technique increasingly applied to study protein structures in pharmaceutical products. The value of CD has now been assessed as a tool to characterise various allergen (intermediate) products: () purified allergens, (2) allergen extracts and allergoids, (3) aluminum hydroxide adsorbed allergoids (Alum-allergoids). CD was tested on these products for monitoring chemical modifications, consistency and stability. Methods: CD: Far-UV CD spectra (26-9 nm) were recorded on a J-8 Spectropolarimeter. Purified peanut allergen Ara h 6 and peanut allergen extract were reduced and alkylated. Subsequently, CDspectra were analysed before and after this modification. Various batches of tree pollen extract and aluminum adsorbed mites allergoids were investigated via their CD-spectra and the CD-ratio 27/222 nm for evaluating consistency and stability. Temperature interval measurements from 2 to 9 C were performed on purified bee venom allergen Api m. A tree pollen extract and mite Alum-allergoids were incubated at C or at elevated temperatures (4 C 2 days, C 6 days, 6 C 3 days or 9 C hour), exposed to freeze-thawing (x) or shaking. CD-spectra and the CD-ratio 27/222 nm were used to study the effect of these stressing conditions. Results: Purified allergens: CD was applied to monitor the chemical modification (reduction and alkylation) of peanut allergen Ara h 6 (Figure ). The CD spectrum demonstrated a classical unfolding of the protein (loss of α-helix) after modification. Additionally, the thermal stability of bee venom allergen Api m was studied with CD. The CD spectra started to show structural alterations for the allergen from 6 C (Figure 2). Allergen extracts and allergoids: CD spectra of a tree pollen extract showed the presence of α-helical and β-structures (not shown). Structural consistency was established for tree pollen extracts via its CD-ratio 27/222 nm of. (CV of 3%) (Figure 3). Stressing this extract resulted in (partial) protein unfolding and an increase of the CD-ratio 27/222 nm. In this way, the CD-ratio is a sensitive tool to monitor stability. CD was also shown to be applicable to monitor reduction and alkylation of a peanut allergen extract showing loss of secondary protein structures (mainly α-helix) (Figure 4). Alum-allergoids: CD spectra of mite Alum-allergoids showed the presence of α-helical and β structures (Figure A). Stressing at C (6 days) or 9 C ( hour) resulted in loss of mainly α-helical structures and an increase of the CD-ratio 27/222 nm (Figure A&B). Batch consistency was demonstrated for batches showing a CD ratio 27/222 nm of.96 (CV of 4%). Stability studies showed no change in secondary protein structures of 3 batches monitored up to 36 months at C (Figure C). Conclusion: CD was demonstrated to be a valuable tool to characterise allergen products during the whole manufacturing process (from purified allergens up to complex Alum-allergoids). CD was shown to be applicable for monitoring chemical modifications, consistency and stability of allergen products. Purified allergens 4 3 Ellipticity (mdeg) Figure : Far-UV CD spectrum of peanut allergen Ara h 6 before (blue) and after (orange) reduction and alkylation. Allergen extracts and allergoids Figure 3: CD-ratio 27/222 nm values retrieved from CD-spectra of tree pollen extract stored at C (n=) or exposed to different stressing conditions. Aluminum hydroxide adsorbed allergoids Figure : (A) Far-UV CD spectra of mite Alum-allergoids stored at C, C or 9 C. The dashed lines represent wavelengths 27 and 222 nm. (B) CD-ratio 27/222 nm values for Alumallergoids stored at C (n=), C or 9 C. (C) CD-ratio 27/222 nm values for Alum-allergoids stored at C for -36 months. Figure 2: Far-UV CD spectra of bee venom allergen Api m recorded from 2 to 9 C with a C interval. CD-ratio 27/222 nm Figure 4: Far-UV CD spectrum of a peanut allergen extract before (blue) and after (orange) reduction and alkylation. Ratio 27/222 nm Ellipticity (mdeg) CD-ratio 27/222 nm Ellipticity (mdeg) Ellipticity (mdeg) C (n= batches) 4 C 2 days 6 C 3 days Shaking native Ara h 6 modified Ara h Wavelength (nm) Wavelength (nm) Freeze-thawing 9 C hour A B 8 C 6 C 9 C Wavelength (nm).27 C C (n= batches) 2 C 3 C 4 C C 6 C 7 C 8 C 9 C Peanut extract Modified peanut extract Wavelength (nm) C Batch C Batch 2 C Batch Time (months).4 C 9 C In relation to this presentation, I declare the following, real or perceived conflict of interest. The presenter is an employee of HAL Allergy. EAACI Congress 27

26 Abbreviated leaflet texts. TPS2 - Miscellaneous Circular Dichroism as a valuable tool to characterise allergen products Basic information for PURETHAL Mites Composition: Suspension for subcutaneous injection containing 2, AUeq/ml allergenic substances chemically modified with glutaraldehyde from Dermatophagoides pteronyssinus (%) and Dermatophagoides farina (%) and absorbed onto aluminium hydroxide. Excipients: sodium chloride, phenol, aluminium hydroxide, water for injections. Indication: Treatment of immediate type allergic disorders (IgE-mediated), such as allergic rhinitis, allergic conjunctivitis and allergic bronchial asthma, which are triggered by sensitization to allergenic substances from house dust mites in adults, adolescents and children not below the age of years. Dosage and administration: Treatment starts with a subcutaneous injection of. ml, which is subsequently increased with weekly doses up to a monthly maintenance dose of. ml. Treatment should be carried out over a period of 3- successive years. Contraindications: Acute inflammatory diseases/ feverish infection at the target organ, secondary changes of the target organ (emphysema, bronchi-ectasia and others), autoimmune disorders, immune deficiencies and use of immuno-suppressants, severe uncontrolled asthma (particularly with a FEV persistently below 7% of the predicted value), cardiovascular disorders with increased risk if using adrenaline, use of ß-blockers (including ß-blocker containing eye preparations), clinical active malignant tumour, initiation of therapy during pregnancy, or hypersensitivity to any of the excipients. Undesirable effects: Reactions generally arise within 3 minutes after receiving the injection. However, even several hours after the injection side effects can be observed. After injection of PURETHAL Mites mixture, local reactions at the injection site may occur. In addition systemic reactions may occur. These can vary from mild sneezing to life-threatening anaphylactic shock. The most commonly reported local reactions after injection are swelling, erythema, warmth, paraesthesia, pain, induration, haemorrhage, and pruritus of the injection site. The most commonly reported systemic reactions are: Hypersensitivity, headache, malaise, fatigue, nausea, conjunctivitis, eye pruritus, lacrimation increased, dyspnoea, nasal congestion, sneezing, allergic rhinitis, rhinorrhoea, erythema, pruritus, swelling, atopic eczema, angioedema. The complete product information is available on request. HAL Allergy BV, Postbus 24, 232 BE Leiden, The Netherlands. Date: August 2 Note: PURETHAL Mites mixture is available as named patient prescription. Basic information for SUBLIVAC and SUBLIVAC FIX Composition: Sublingual drops, containing per ml, AU, AUN or PUN allergen extract, prepared according to the individual doctor s prescription. Excipients: glycerol, aminocaproic acid, disodium phosphate hydrate, sodium dihydrogen phosphate dihydrate, peppermint oil, purified water. Indication: Treatment of immediate type allergic disorders (IgE-mediated) such as allergic rhinitis, allergic conjunctivitis and allergic bronchial asthma, caused by allergens. Dosage and administration: The first day of the initial treatment starts with one drop. This dose is increased every day with one drop until the highest daily dose of five drops is reached. The treatment is continued with five drops. The drops have to be administered under the tongue for at least minute (preferably 2-3 minutes) before swallowing. A spoon may be used to administer the drops. It is advised to clean the dropper after use, for instance with a wet tissue. The treatment should be continued for 3 to years. Contraindications: Partly or uncontrolled bronchial asthma with a FEV below 7%, severe autoimmune diseases, immune deficiencies and immunosuppression, malign neoplastic diseases with current symptoms, initiation of treatment during pregnancy, severe inflammation of the oral mucosa, hypersensitivity to any of the excipients. Undesirable effects: Local reactions in the mouth and throat, swelling of the lips or tongue. Reappearance of the patient specific allergic symptoms such as mild systemic reactions (itching eyes, sneezing, coughing, atopic eczema). In rare cases, intensified systemic reactions, like shortness of breath, generalized urticaria, or Quincke s oedema, can occur. After intake, the patient might experience diarrhoea and abdominal pain. These symptoms generally arise within 3 minutes after intake of the drops, however can occur several hours after. In individual cases, anaphylactic shock has been reported. The complete product information is available upon request at HAL Allergy BV, P.O. Box 24, 232 BE Leiden, The Netherlands. Date: October 26 Note: SUBLIVAC and SUBLIVAC FIX are available as named patient prescriptions. EAACI, 7-2 June 27, Helsinki, Finland EAACI, 7-2 June 27, Helsinki, Finland

27 Basisinformationen PURETHAL Zusammensetzung: Suspensionen zur subkutanen Injektion, enthalten an Aluminiumhydroxid adsorbierte, mit Glutaraldehyd chemisch modifizierte allergene Substanzen aus Pollen (2. AUM/ml) oder Milben (2. AUeq/ml). Sonstige Bestandteile: NaCl, Phenol, Aluminiumhydroxid, Wasser zur Injektion. Anwendungsgebiete: Spezifische Immuntherapie allergischer Erkrankungen vom Soforttyp (IgE-vermittelt), wie Heuschnupfen (allergische Rhinitis), allergische Bindehautentzündung (Konjunktivitis) und allergisches Asthma bronchiale, ausgelöst durch eine Sensibilisierung gegenüber den enthaltenen allergenen Substanzen. Gegenanzeigen, absolute: Akute Entzündungsprozesse/Infektionskrankheiten am Reaktionsorgan; Sekundärveränderungen am Reaktionsorgan (z.b. Emphysem, Bronchiektasen); Autoimmunerkrankungen; Immundefekte; gleichzeitige Anwendung von Immunsuppressiva; schweres, unkontrollierbares Asthma bronchiale, insbesondere bei einem persistierenden FEV unter 7% Sollwert; Erkrankungen mit Kontraindikationen gegen die Anwendung von Adrenalin; gleichzeitige Behandlung mit ß-Blockern (auch ß-Blocker enthaltende Augentropfen); maligne Tumorerkrankungen mit aktuellem Krankheitswert; Einleitung der Behandlung nicht während der Schwangerschaft; Sensibilisierung gegenüber einem der sonstigen Bestandteile; relative: Schwangerschaft und Stillzeit; akute allergische Beschwerden; nicht für Kinder unter Jahren. Zum zeitlichen Intervall zu Schutzimpfungen und für weiterführende Informationen siehe Fachinformation. Nebenwirkungen: Allergische Lokal- und/ oder Allgemeinreaktionen. Überempfindlichkeit, anaphylaktischer Schock. Grippe, Otitis externa, Sinobronchitis, Sinusitis, Staphylokokkenpharyngitis. Essstörung. Kopfschmerz, Schwindelgefühl, Schläfrigkeit, Parästhesie, Geschmacksstörung, Aufmerksamkeitsstörungen. Schwellung des Auges, Konjunktivitis, Rhinokonjunktivitis, Augenreizung, Augenjucken, Tränensekretion verstärkt. Schwindel, Ohrschwellung, Ohrenjucken. Arrhythmie, Tachykardie. Kreislaufkollaps, Hitzegefühl, Hämatom. Rhinitis, Nasenverstopfung, Nasenödem, Rhinorrhoe, Niesen, Asthma, Atemnot, Husten, Bronchitis, Halstrockenheit, Rachenreizung, Rachenschmerzen, Kehlkopfirritation, Nasopharyngitis, Nasenbluten. Abdominalschmerzen, Gastritis, Übelkeit, Diarrhoe. Angioödem, Urtikaria, Erythem, Juckreiz, Ekzem, atopische Dermatitis, Ausschlag, Akne, Hautreizung. Muskuloskelettale Beschwerden. Ödem, Schwellung, Ermüdung, Schwäche, Brustschmerz, Blässe, Fieber. An der Injektionstelle: meist vorübergehende Granulome, Verhärtung, Schwellung, Urtikaria, Erythem, Überempfindlichkeit, Juckreiz, Schmerz. Patienten nach der Injektion mindestens 3 Minuten überwachen, eine Schockapotheke muss bereitgestellt sein. Nebenreaktionen können auch noch zu einem späteren Zeitpunkt auftreten. Für weiterführende Informationen und zur Behandlung von Nebenwirkungen siehe Fachinformation. In seltenen Fällen kann nach der Injektion leichte Müdigkeit auftreten, was beim Führen von Kraftfahrzeugen oder beim Bedienen von Maschinen zu berücksichtigen ist. Hinweis: Verschreibungspflichtig. (Stand: 4/27) Basisinformationen SUBLIVAC FIX / SUBLIVAC Zusammensetzung: Allergenlösungen zur sublingualen Immuntherapie. Genaue Bezeichnung und Stärke der Allergene s. Etikett. SUBLIVAC enthält Allergenextrakte nach individueller ärztlicher Rezeptur. Sonstige Bestandteile: Glycerol, Wasser, 6-Aminohexansäure (ε-amino-capronsäure/eaca), Dinatrium-hydrogenphosphat, Natrium dihydrogenphosphat, Pfefferminzöl. Anwendungs gebiete: Spezifische Immuntherapie allergischer Erkrankungen vom Soforttyp (IgE-vermittelt). Gegenanzeigen: akute Entzündungsprozesse/Infektionskrankheiten am Reaktionsorgan; Schwere Autoimmunerkrankungen; Immundefekte (auch durch Immunsuppressiva induziert); Krebserkrankungen mit aktuellem Krankheitswert; schweres oder unzureichend behandeltes Asthma (FEV < 7% vom Sollwert); Überempfindlichkeit gegenüber einem der sonstigen Bestandteile; Infektionen des Mund-/Rachenraumes; nach zahnärztlicher Behandlung (z.b. Zahnentfernung). Eine Hyposensibilisierungsbehandlung soll nicht während der Schwangerschaft begonnen werden. Zum zeitlichen Intervall zu Schutzimpfungen und für weiterführende Informationen siehe Fachinformation. Nebenwirkungen: Lokale Beschwerden, Schwellungen oder Juckreiz des Mundes, der Lippen und der Zunge, Mundtrockenheit, Geschwüre im Mund, Aphthen. Allergische Reaktionen wie Niesen, laufende oder verstopfte Nase, Nasenbeschwerden; Juckreiz oder Beschwerden des Ohrs; Juckreiz, Rötung, Tränen oder Brennen der Augen, Augenentzündung; Halsreizungen, Husten, Atemnot. Schwierigkeiten beim Schlucken, Magenbeschwerden, Erbrechen, Übelkeit, Bauchschmerzen, Appetitlosigkeit, Verdauungsstörungen. Ekzeme, Hautausschlag, Nesselsucht, schnelle oder starke Schwellung der Haut. In sehr seltenen Fällen anaphylaktische Reaktionen. Für weiterführende Informationen siehe Fachinformation. Hinweis: Verschreibungspflichtig. (Stand: /26) EAACI, 7-2 June 27, Helsinki, Finland 29

28 Notes Notes

29 Notes International Offices Headquarters The Netherlands HAL Allergy Group J.H.Oortweg CH Leiden P.O. Box BE Leiden Tel.: +3-() Offices Distributors Germany HAL Allergie GmbH Poststraße Düsseldorf Tel.: +49-() Austria HAL Allergy Handels-GmbH Johnstraße 4-6 Vienna Tel.: +43-() Poland HAL Allergy Sp. z o.o. Ul. Rumiana Warsaw Tel.: +48-() Spain HAL Allergy S.L.U Parque Empresarial Mas Blau II Avda. Les Garrigues El Prat de Llobregat Barcelona Tel.: Italy HAL Allergy s.r.l. Piazzale Asia, 2 Scala B, Piano 4, Interno 2, 44 Roma Tel: Belgium / Benelux HAL Allergy Benelux B.V. J.H. Oortweg CH Leiden The Netherlands Tel.: +32-() Estonia Balti Intermed OÜ Tartu mnt 84d 2 Tallinn Tel.: Greece Alfamedica S.A. 22 Katechaki Street 2 Athens Tel.: /9 Portugal A.M.D. Passos, Lda. Rue Cidade de Coimbra no. A, Parede, Lisbon Tel.: Hungary Hungaropharma Zrt. 6 Budapest Király u.2 Tel.: Slovenia IRIS Mednarodna Trgovina D.O.O. Cesta v Gorice 8 Ljubljana Tel.:

30 Rising to the c hal lenge of improving allergy treatments HAL Allergy 27 MAB 4893-