5/21/2018. PNH: Understanding Your Disease and Treatment Options

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1 Patients Surviving (%) 5/2/28 PNH: What s in a Name PNH: Understanding Your Disease and Treatment Options Bart Scott, MD Associate Professor of Medicine, Division of Oncology, University of Washington Associate Member, Fred Hutchinson Cancer Research Center It is not paroxysmal Even in the absence of symptoms, destructive progression of hemolysis is ongoing It is not nocturnal Hemolysis in PNH is subtle and constant, 24 hours a day Hemoglobinuria is a less commonly seen complication ¾ patients present without hemoglobinuria 2. Rother R et al. Nature Biotechnology 27;25,: ; 2. International PNH Interest Group. Blood. 25;6: The Defect in PNH PNH clones are defined as PNH cells with a deficiency of proteins that require a GPI anchor for attachment to the cell membrane CD59 (MIRL) Forms a defensive shield for red blood cells (RBCs) from complement-mediated lysis Inhibits the assembly of the membrane attack complex CD59 GPI-anchor CD55 (DAF) Prevents formation and augments instability of the C3 convertases, attenuating the complement cascade CD55 Classic PNH Intravascular hemolysis Reticulocytosis Increased LDH Increased indirect bilirubin Low haptoglobin PNH + Bone Marrow Disorder Intravascular hemolysis + AA/MDS/Myelofibrosis Subclinical PNH No clinical/lab evidence of hemolysis Detected by very sensitive flow cytometric analysis In association with AA/MDS PNH Classification GPI = glycerophosphatidylinositol; MIRL=membrane inhibitor of reactive lysis; DAF=decay accelerating factor.. Borowitz MJ et al. Cytometry B Clin Cytom 2;78:2 23. Adapted from: Johnson RJ et al. J Clin Pathol: Mol Pathol 22;55:45 52; Brodsky R. Paroxysmal nocturnal hemoglobinuria. In: R Hoffman et al, eds. Hematology - Basic Principles and Practices. 4th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 25; Parker et al. Blood 25;6: de Latour et al. Blood 28;2: Paroxysmal Nocturnal Hemoglobinuria (PNH): A Chronic, Systemic, and Life-Threatening Disease Prevalence: 5.9 / million Diagnosed at all ages Median age early 3s 3,4 Progressive disease 2 4 Uncontrolled complement activation underlies the morbidities and mortality Despite best supportive care 5 year mortality: 35% Actuarial Survival From the Time of Diagnosis in 8 Patients With PNH Years After Diagnosis Age- and Gender- Matched Controls Patients With PNH The expected survival of an age- and gender-matched control group is shown for comparison (Hillmen et al. 995) PNH and Other BMF Syndromes PNH overlaps with BMF syndromes, and the predominant clinical characteristics can evolve over time,2 Young NS, et al. Blood. 26;8(8): Weinzierl EP, et al. Am J Clin Pathol. 23;39(): Hill A et al. Blood 26;8:29a. Abstract 985; 2. Hillmen P et al. N Engl J Med 995;333: ; 3. Nishimura JI et al. Medicine 24;83:93 27; 4. Socié G et al. Lancet 996;348: SDS DKC AA PNH Hypocellular MDS MDS AML AML, acute myelogenous leukaemia; AA, aplastic anaemia; DKC, dyskeratosis congenita; MDS, myelodysplastic syndrome; SDS, Shwachman-Diamond syndrome.

2 5/2/28 Paroxysmal Nocturnal Hemoglobinuria Pathogenesis Hypothesis: GPI-specific, CDd-restricted T cells responsible for selection of PNH cells Etn-P GlcN PIG-A glycan PIG-A nucleus Inositol-P GPI anchor X chr. + protein GPI ER PIG-A nucleus X chr. protein ER PIG-A GPI anchor T cell receptor GPI T cell Killing T cell No Killing CDd/b2m Normal cell Hematopoietic Stem Cells PNH cell 7 GPI+ ER GPI-anchored protein GPI- ER Karadimitris and Luzzatto, Leukemia 2 8 Expansion of the PNH Clone Is Necessary to Result in Clinical PNH Step Somatic Mutation of PIG-A Step 2 Immunologic Attack Selective Damage Step 3 Growth Advantage The Role of Complement GPI-Deficient Cell Selected Cells Expanded Cells Normal Hematopoietic Stem Cells GPI-Anchor Deficiency Immunologic Selection Benign Tumor- Like Expansion Expansion may be due to another somatic mutation The need for both selection and expansion may explain the rarity of PNH Adapted from: Inoue N et al. Int J Hematol 23;77:7. 9 The Complement System: Always on, Strongly Amplified, Dependent on Natural Regulators Factors That Amplify Complement Activation The complement system is a vital component of the natural (innate) protective immune system Complement is activated by three mechanisms (classical, alternative, and lectin) which allow the system to respond to inflammatory, infectious, ischemic, necrotic, as well as foreign and self antigens Always on to allow rapid immune response Rapid amplification leads to powerful and destructive immune reactions 2 Natural inhibitors of complement keep amplification in check and prevent uncontrolled complement activation 2 Infection Autoimmune Surgery Pregnancy Glovsky MM et al. Ann Allergy Asthma Immunol 24;93:53 523; Rubio MT et al. Bone Marrow Transplant 28;4(Suppl. ):S22. Abstract P766; Mastellos D et al. Immunologic Res 23;3: ; Mergenhagen STE et al. J Infect Dis. Holers VM et al. Immunol Rev 28;223:3 36; 2. Zipfel PF et al. Curr Opin Nephrol Hypertens 2;4: ;28:S86; Chenoweth DE et al. N Engl J Med 98;34:497 53; Giradi G. Am J Reprod Immunol 28;59:

3 Proximal Terminal Plasma Free Hb (µmol/l) C5 convertase C5 convertase Plasma Free Hb (µmol/l) 5/2/28 AdBoard Master_Sept 4, Chronic Uncontrolled Complement Activation Leads to Devastating Consequences in PNH Lectin pathway Classical pathway Alternative pathway Absence of CD59 Allows Terminal Complement Complex Formation Immune complex clearance Microbial Opsonization Weak anaphylatoxin C3a C3 C3b C5-convertase - C5 C3 + H 2 O: always active (chronic) Amplification ic3b C5b C6C7 C8 C9 Natural inhibitors: CD55 - Natural inhibitor: CD59 C5 C5a C5b C6 C7 C6 C7 C5b C8 C9 X C6 C5b CD59 C7 C9 x 2-5 X C6 C5b C6 C5b C7 CD59 C7 C5a Anaphylaxis Potent anaphylatoxin Inflammation Consequences Chemotaxis Pro-inflammatory Leucocyte activation Endothelial activation Pro-thrombotic C5b-9 Membrane attack complex Cell lysis Pro-inflammatory Platelet activation Leucocyte activation Endothelial activation Pro-thrombotic Cell destruction Consequences Inflammation. Zipfel PF et al. Vaccine. 28;26(Suppl 8):I67-74; 2. Figueroa JE, Densen P. Clin Microbiol Rev. 99;4:359-95; 3. Walport MJ. N Engl J Med. 2;344:58-66; 4. Rother RP et al. Nat Biotechnol. 27;25:256-64; 5. Meyers G et al. Blood. 27;:abs 3683; 6. Hill A et al. Br J Haematol. 2;49:44-25; 7. Hillmen P et al. Am J Hematol. 2;85:553-9; 8. Parker C et al. Blood. 25;6: ; 9. Hillmen P et al. N Engl J Med. 995;333:253-8;. Nishimura J et al. Medicine (Baltimore). 24;83:93-27;. Caprioli J et al. Blood. 26;8:267-79; 2. Noris M et al. Clin J Am Soc Nephrol. 2;5:844-59; 3. George JN. Blood. 2;6:46-9; 4. Loirat C et al. Pediatr Nephrol. 28;23:957-72; 5. Ståhl AL et al. Blood. 28;:537-5; 6. Hosler GA et al. Arch Pathol Lab Med. 23;27;834-9; 7. Ariceta G et al. Pediatr Nephrol.29;24: C8 C5b,6,7 C5b-8 Adapted from: Cellular and Molecular Immunology AK Abbas, AH Litchman and JS Pober, 3rd Edition. 99 WB Saunders; Philadelphia. C8 C9 C8 4 C5b-9 4 Historically Viewed as a Hemolytic Anemia Normal red blood cells (RBCs) are protected from complement attack by a shield of terminal complement inhibitors Without this protective complement inhibitor shield, PNH RBCs are destroyed Hemolysis Leads to NO Consumption in PNH Patients R=.594, P<. R=.9529, P<. NO consumption assay: NO chemiluminescence Intact RBC Complement Activation Lack of Bound CD55, CD59 Leads to Uncontrolled Complement Activation Reduced Red Cell Mass Anemia Free Hemoglobin LDH (u/l) NO Consumption (µmol/l) LDH significantly correlates with free hemoglobin (Hgb) Confirms LDH as a biomarker for hemolysis LDH.5x at diagnosis had a 4.8-fold greater mortality 2 Free Hgb significantly correlates with NO consumption Hgb is in reduced state and reactive with NO. International PNH Interest Group. Blood 25;6: Brodsky R Paroxysmal Nocturnal Hemoglobinuria. In: Hematology - Basic Principles and Practices. 4th ed. R Hoffman; EJ Benz; S Shattil et al. eds. Philadelphia, PA: Elsevier Churchill Livingstone;25; Rother RP et al. JAMA 25;293: Socie G et al. Lancet 996;348: Hill A et al. Br J Haematol 27;37: Hill A et al. Br J Haematol 2;49:44 425; 2. Lee JW et al. ASH 2. Abstract Consequences of Nitric Oxide (NO) Depletion Reduced Nitric Oxide Can Cause Smooth muscle dystonias Vascular constriction pulmonary and systemic hypertension, erectile dysfunction 2 Gastrointestinal contractions dysphagia, abdominal pain Platelet activation and aggregation 4 Platelet hyperreactivity Hypercoagulability Chronic Uncontrolled Complement Activation Leads to Devastating Consequences Complement Activation Elevated LDH Free Hemoglobin Decreased NO Renal Failure Pulmonary Hypertension Abdominal Pain Chest Pain Dyspnea Dysphagia Fatigue Hemoglobinuria Significant Impact on Survival Significant Impact on Morbidity Erectile Dysfunction LDH = lactate dehydrogenase.. International PNH Interest Group. Blood 25;6: ; 2. Brodsky R. Paroxysmal nocturnal hemoglobinuria. In: R Hoffman et al, eds. Hematology - Basic Principles and Practices. 4th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 25;49 427; 3. Rother RP et al. JAMA.. Rother R et al. JAMA 25;293: ; 2. Hill A et al. Br J Haematol 2;49:44 425; 3. Weitz I. Res 25;293: ; 4. Socie G et al. Lancet 996;348: ; 5. Hill A et al. Br J Haematol 27;37:8 92; 6. Lee JW et al. Hematologica 2;25:S6 S7; 4. Helley D et al. Haematologica 2;95: ;95(s2): Abstracts 55 and 56; 7. Hill A et al. Br J Haematol 2;49:44 425; 8. Hillmen P et al. Am J Hematol 2;85:

4 Patients With TE (%) First Ever Ischemic Stroke (per patient years) 5/2/28 Historical Management of PNH Supportive care options do not impact progression and risk for severe morbidities and mortality Transfusions risk of iron overload Anticoagulants ineffective in many patients Red cell supplements may expand clone and elevate hemolysis Steroids/androgen hormones adverse events Morbidities and Mortality in PNH Although BMT is the only potentially curative therapy for PNH, BMT is associated with significant morbidities and mortality 2,3 In a study examining PNH patients (n=23) 2 5% chronic GVHD; 42% acute GVHD 3 Transplant-related mortality was 42% BMT has a significant impact on quality of life (QoL) post-transplant 4,5. International PNH Interest Group. Blood 25;6: ; 2. Santaraone S et al. Haematologica 2;95: ; 3. de Latour PF et al. EBMT 29:Abstract 36; 4. Bieri S et al. Bone Marow Transplant 28;42:89 827; 5. Fraser CJ et al. Blood 26;8: Is the Leading Cause of Death in PNH Accounts for 4 67% of deaths 2 First thrombotic event (TE) can be fatal 2,3 First TE increases risk for death 5- to -fold 2 Up to 44% of patients experience clinical thrombotic events 2 Occurs in typical and atypical sites 4 Is not adequately managed with anticoagulation 2 All patients with PNH are at risk for thrombosis 2 Chronic Uncontrolled Complement Activation Leads to Vasoconstriction and Chronic Uncontrolled Complement Activation C5a Inflammation C5b-9 C5b-9 Leukocyte Activation Chronic Hemolysis [NO] Impaired regulation of smooth muscles Local vasoconstriction Pro-inflammatory effect on endothelial cells Platelet Activation Platelet Aggregation CLOT Chronic hemolysis Platelet activation Local vasoconstriction Inflammation Endothelial cell injury Systemic thrombosis. International PNH Group et al. Blood 25;6: ; 2. Hillmen et al. Blood 27;: ; 3. Audebert HJ et al. J Neurol 25;252: ; 4. Lee JW et al. Hematologica 2;95(s2): Abstract Adapted from: Gladwin MT et al. Free Rad Biol & Med 24;36:77 77; Rother RP et al. JAMA 25;293: The Incidence of TE is Increased in Patients with Elevated LDH at Diagnosis Risk of First Ever Ischemic Stroke (FEIS) Elevated in PNH P< Age of FEIS in PNH patients is markedly less than in the general population 5 LDH.5x ULN 3.8 LDH <.5x ULN Univariate analysis showed that the incidence of TE was significantly increased in patients with LDH.5x ULN at diagnosis (43/7; 25.%) compared with patients with LDH <.5x ULN (2/53; 3.8%; OR 8.57) PNH Population General Population PNH Population 2,3 2,3 <54 Years Old General Population Years Old Data from South Korean National Registry. Lee JW et al. Presented at the 54th Annual Meeting of the American Society of Hematology; December 8, 22; Atlanta, GA. Abstract Gostynski M et al. J Neurol 26;253:86 9; 2.Hillmen P et al. Blood 27;: ; 3. Data on file. Alexion Pharmaceuticals, Inc. 24 4

5 Rate (TE per patient years) Hazard Ratio Proportion of Patients (%) TE (%) 5/2/28 is Associated With Risk of Early Mortality TE increases risk of death 5-fold over patients with no TE (n=45) TE was an independent prognostic factor related to poor survival (HR 5.4; 95% CI ; P<.) in a large cohort of French PNH patients de Latour RP et al. Blood 28;2: French PNH Patients 25 Occurs in Both Typical and Atypical Sites* Superficial vein thrombosis 3.7 Cerebral/internal jugular thrombosis Pulmonary embolus Hepatic/portal vein thrombosis VENOUS *24 events, 63 patients Hillmen P et al. Blood 27;: Myocardial Infarction/.6 unstable angina 3.7 Cerebrovascular accident/ transient ischemic attack 33. Deep vein thrombosis* 8.5 Mesenteric/splenic vein thrombosis *Includes 8.5% lower extremity and 4.5% other (inferior vena cava, bilateral lower extremity, pelvic, ureter, axillary, subclavian, and brachiocephalic veins). ARTERIAL 26 PNH Patients are at Risk of Despite Anticoagulation or Minimal Transfusion Requirements Can Occur Regardless of Clone Size Patients Treated With Anticoagulants (n=9) 4.87 Patients With Transfusions Per Year (n=22) <2 2-5 >5 PNH Granulocyte Clone Size (%) Data from South Korean National Registry. (n=43) Hillmen P et al. Blood 27;: Lee JW et al. Hematologica 2;95(s2): Abstract Chronic Kidney Disease Chronic Kidney Disease: Morbidity and Mortality in PNH Chronic Kidney Disease 64% of PNH Patients Exhibit Clinical Chronic Kidney Disease (CKD) Kidney failure is the cause of 8 8% of PNH-related deaths 8% of PNH patients (median age of 3.5 years) had MRI evidence of significant renal hemosiderosis 2,3 Marked hemosiderin deposits in the proximal renal tubule are a common feature in all autopsy and biopsy reports dealing with PNH Demonstrable by MRI even when no overt hemoglobinuria is seen Stage 3-5 CKD (n=4) Stage -2 CKD (n=84) No CKD (n=69). Hillmen P, et al. Am J Hematol 2;85: ; 2. Brodsky R. Hematology: Paroxysmal nocturnal hemoglobinuria. In: R Hoffman et al, eds. Hematology - Basic Principles and Practices. 4th ed. Philadelphia, PA: Elsevier Churchill Livingstone 25; Hill A. et al. Blood 26;8: Abstract Hillmen P et al. Am J Hematol 2;85:

6 Patients With Response TE Odds Ratio ( = no effect on risk) Patients (%) 5/2/28 Chronic Kidney Disease Common Symptoms of PNH Kidney Disease in PNH: Conclusions Clone Size Does Not Correlate to Symptom Severity Kidney failure is the cause of 8 8% of PNH-related deaths Kidney disease in PNH is caused by complement-mediated hemolysis 2,3 64% of patients with PNH exhibit chronic kidney disease at any one time 4 Kidney disease is underappreciated in PNH 4 % 8% 6% 4% International PNH Registry Gran Clone <% Gran Clone 49% Gran Clone 5% % 6 % Abdominal Pain Shortness of Breath Chest Pain Clinical Symptoms Discolored Urine Fatigue. Nishimura JI et al. Medicine 24;83:93 27; 2. Clark DA et al. Blood 98;57:83 89; 3. McKeage K. Drugs 2;7: ; 4. Hillmen P et al. Am J Hematol 2;85: ; 5. Kim JS et al. Hematologica 2;96(s2): Abstract Urbano-Ispizua A et al. Hematologica 2;95(s2): Abstract Common PNH Symptoms are Associated With TE Common Symptoms of PNH PNH Clonal Expansion in an AA Representative Population n=75 At the Start of Follow Up PNH+ Patients At the Last of Follow Up Transitional pattern n (%) (Classic PNH) (8) (%) Expansion 3 (7%) Persistent 44 (59%) Newly developed 5 (4%) Abdominal Pain Chest Pain Dyspnea P=.4 P=.24 P=.5 Elevated LDH (.5 ULN) in combination with abdominal pain, chest pain, and dyspnea are associated with a higher risk of TE n=4 PNH- Patients Disappearance 8 (24%) 9 (96%) Study description: a retrospective analysis of the medical charts of 286 PNH patients in a South Korean National Registry. Sugimori C et al. BJH. 29;47:2-2. Lee JW et al. Hematologica 2;95(s2): Abstracts 55 and Immunosuppressive Therapy (IST) Has Increased Efficacy in AA Patients With PNH Cells % 8% * 82% PNH+ PNH- AA Management of Patients With Overlapping Signs and Symptoms Some patients may present with elements of both PNH and BMF, with the clinical picture evolving over time Targeted treatments should address both haemolysis and BMF,2 6% 4% 46% * 36% Treatment algorithm 3-5 2% % Overall Response The presence of PNH cells was the only significant predictor of response to IST in 4 AA patients (P<.) in multivariate analysis 2 *P value = complete response, P=.3; Overall response, P<... Sugimori C et al. Blood 26;7:38 34; 2. Sugimori C et al. Exp Hematol 27;35:3 2. 3% Complete Response Complete response (CR) was defined as hemoglobin normal for age, neutrophil count more than.5 9 /L, and platelet count more than 5 9 /L; Partial response (PR) was defined as transfusion independent and no longer meeting criteria for severe disease in patients with severe AA. Overall response = CR + PR 35? Eculizumab + IST or HSCT. Luzzatto L, et al. Br J Haematol. 2;53(6): Parker CJ. Hematology Am Soc Hematol Educ Program. 2;2: de Latour R, et al. Rev Med Interne. 2;3(3):2-27. Confidential For Internal Use Only. Do Not Distribute. 36 6

7 5/2/28 Evidence of PNH Cells in RA-MDS RA-MDS Patients With Unexplained Cytopenias are at High Risk for PNH Unexplained Cytopenias EXPLORE TRIAL Patient Population Description RA-MDS (n=293) Test the Following Cytopenic Patients for PNH 5,6 PNH cells/clone (Grans + RBC type III) >.% 7.6% (222 / 293) WBC PNH clone %.54% (2 / 293) Clone % and LDH > ULN 4.% (8 / 2) WBC PNH Clone size % Mean clone 32.9% (n=2) Interim Results from EXPLORE, a Multi-center Prevalence Study of PNH Clone Size in Patients with AA, MDS, and other BMF Unexplained Cytopenia After thorough work-up Cytopenia and Evidence of Hemolysis LDH Haptoglobin Reticulocyte count (with or without anemia) Cytopenia With Any of These Coexisting Findings Anemia Coombs-negative hemolytic anemia Bone marrow failure disorder Hemoglobinuria (dark colored urine) Galili N et al. Poster presentation at: American Society of Clinical Oncology 45 th Annual Meeting; May 29 June 2, 29; Orlando, FL.. 37 *.% PNH cell threshold.. Movalia MK et al. Blood 2;8: Abstract 33; 2. Barzi A, Sekeres MA. Clev Clin J Med 2;77:37 44; 3. Jordan MB et al. Blood 2;8:44 452; 4. Moreno C et al. Blood 2;6: ; 5. Borowitz MJ et al; Clinical Cytometry Society. Cytom B Clin Cytom 2;78B:2 23; 6. Brodsky RA. Blood 29;3: Standard Diagnostic Test for PNH How Do You Test for PNH? Flow cytometry performed on peripheral blood Granulocytes and at least one additional cell line should be evaluated RBCs Monocytes Quantitative results Optimal high sensitivity analysis:.% Routine analysis: % Easy to understand PNH reports Use more than one reagent against GPI-anchored proteins 39 Borowitz MJ et al.; Clinical Cytometry Society. Cytom B Clin Cytom 2;78B: Testing for PNH in RBCs Why Look Beyond RBCs for PNH? Gating on GPA+ RBCs Patient : Normal RBCs with normal CD59 expression (Type I cells) Patient 2: PNH clone with complete CD59 deficiency (Type III cells) Patient 3: PNH clone with complete CD59 deficiency (Type III cells) and partial CD59 deficiency (Type II cells) Granulocytes provide more accurate representation of PNH clone size Percentages of PNH RBCs may be affected by: Hemolysis Blood transfusion PNH reports should provide quantitative results expressing clone size on both granulocytes and RBCs GPA = glycophorin A. Data Source: Dahl-Chase Diagnostic Services.. 4. Borowitz MJ et al; Clinical Cytometry Society. Cytom B Clin Cytom 2;78B:

8 CD24- Granulocytes Proximal Terminal 5/2/28 PNH Patient With an 8% WBC Clone Size and 3% RBC Clone Size Indicating Hemolysis ICCS Recommendations for Follow-Up Testing of Patients With an Identified PNH Clone WBC RBC FLAER- GPI Anchor Binding Marker CD59 GPI Anchored Protein 8. % of Granulocytes lack GPI proteins 3.4% RBCs are Type III PNH cells Annual monitoring Stable patients Patients with aplastic anemia and small PNH clone Patients with refractory cytopenia with unilineage dysplasia (RCUD) and small PNH clone More frequent monitoring to evaluate for expanding clones Patients with changing symptoms or lab values Patients in early stages of treatment Data Source: Dahl-Chase Diagnostic Services. 43. Borowitz MJ et al.; Clinical Cytometry Society. Cytom B Clin Cytom 2;78B: Eculizumab (soliris) Humanized First in Class Anti - C5 Antibody Treatment of PNH with Complement Inhibitor Eculizumab Human Framework Regions No mutations Germline Hinge Complementarity Determining Regions (murine origin) Human IgG 2 Heavy Chain Constant Region and Hinge (Eliminates Fc receptor binding) CH2 CH3 Human IgG 4 Heavy Chain Constant Regions 2 and 3 (Eliminates complement activation) 45 Rother R et al. Nat Biotech 27;25: Eculizumab Blocks Terminal Complement,2 Clinical Trials With Eculizumab Complement Cascade 2,3 C3 C3a C3b C5 C5a C5b C5b-9 Soliris Eculizumab binds with high affinity to C5,2 Terminal complement - C5a and C5b-9 formation blocked,2 Proximal functions of complement remain intact,2 Weak anaphylatoxin 2,4 Immune complex clearance 2 Pilot Study NEJM 24 N= Primary endpoint: reduction of hemolysis TRIUMPH NEJM 26 Pivotal Phase III, Double-Blind, Placebo-Controlled Trial, N=87 SHEPHERD Blood 28 Broader patient population, including those receiving minimal transfusions or with thrombocytopenia, N = 97 Long-Term Extension Trial Hillmen Blood 27 Evaluated long-term safety, efficacy and effect on thrombosis; Placebo patients switched to eculizumab N=87 Microbial opsonization 2 Please see full prescribing information for Soliris (eculizumab).. Soliris (eculizumab) Summary of Product Characteristics. Alexion Europe SAS; 22; 2. Rother RP et al. Nature Biotech 27;25: ; 3. Walport MJ. N Engl J Med 2;344:58 66; 4. Figueroa JE, Densen P. Clin Microbiol Rev 99;4: Please see full prescribing information for Soliris (eculizumab). Soliris (eculizumab) Summary of Product Characteristics. Alexion Europe SAS;

9 Proportion of Patients (%) Thrombotic Events (#) LDH (U/L) Proportion of Patients (%) Event Rate (TE per patient-years) 5/2/28 Eculizumab is a Chronic Treatment for a Chronic Disease Dose within ±2 days. In clinical trials all patients were vaccinated against Neisseria meningitidis¹ Concomitant medications allowed: Steroids, immunosuppressant drugs, anti-clotting agents and hematinics² Eculizumab should be administered via IV infusion within minutes every 7 days during induction and every 4 days during maintenance¹ Eculizumab dose adjustment to every 2 days may be necessary for some patients to maintain LDH reduction¹ Please see full prescribing information for Soliris (eculizumab). Soliris PNH Dosing Schedule Pretreatment Induction Phase Maintenance Phase 2 weeks before induction Neisseria meningitidis vaccination Week Soliris dose, mg X 9 X 9. Soliris (eculizumab) Summary of Product Characteristics. Alexion Europe SAS; Hillmen P et al. N Engl J Med 24;35: q4d P<. at all measured time points. 86% Reduction in LDH: TRIUMPH and SHEPHERD % response after the first dose Time, Weeks TRIUMPH placebo patients switched to Eculizumab after Week 26 All TRIUMPH patients entered the long-term extension study TRIUMPH Placebo/Extension TRIUMPH Soliris/Extension SHEPHERD Eculizumab Please see full prescribing information for Soliris (eculizumab). Soliris (eculizumab) Summary of Product Characteristics. Alexion Europe SAS; 22. Hillmen P et al. Blood 27;: % Reduction in Thrombotic Events Eculizumab Reduced in Patients Treated with Anticoagulants Pre-Eculizumab Treatment 63% of patients received concomitant anticoagulants The effect of anticoagulant withdrawal was not studied 2 Events observed in both venous and arterial sites 3 There were fewer thrombotic events with Eculizumab treatment than during the same period of time prior to treatment 2 Please see full prescribing information for Soliris (eculizumab).. Brodsky R et al. Blood 28;:84 847; 2. Soliris (eculizumab) Summary of Product Characteristics. Alexion Europe SAS; 22; 3. Hillmen P et al. Blood 27;: N=95 P=. Eculizumab Treatment 5 2% % 8% 6% 4% 2% %.54 Pre-Soliris Treatment.72 Soliris Treatment 94% reduction in event rate with Eculizumab P<. N=9 *Excludes patients on antiplatelet agents. Please see full prescribing information for Soliris (eculizumab). Soliris (eculizumab) Summary of Product Characteristics. Alexion Europe SAS; 22.. Hillmen P et al. Blood 27;: % of Patients Exhibit Chronic Kidney Disease (CKD) Renal Function With Eculizumab in Different Baseline PNH Populations 8 Months 5% 4% 3% 2% % % 2.5 Stage 3-5 CKD (n=4) 43. Stage -2 CKD (n=84) 35.4 No CKD (n=69) P<. Overall (n=89) Stage 2 (n=8) P<. 2.7 Segment of PNH Population P=.5 Stage 3 5 (n=4) % of patients with minimal ( ) transfusion history had CKD (n=22) No Change Improvement Worsening Please see full prescribing information for Soliris (eculizumab). Soliris (eculizumab) Summary of Product Characteristics. Alexion Europe SAS; 22.. Hillmen P et al. Am J Hematol 2;85: Hillmen P et al. Am J Hematol 2;85:

10 Mean LDH (U/IL) Mean FACIT Fatigue Median Units Transfused Standard Effect Size (SES) Proportion of Patients With Evidence of Pulmonary Hypertension 5/2/28 73% Reduction in Mean Units Transfused Across All Subgroups: TRIUMPH Eculizumab Treatment Results in Large and Clinically Meaningful Improvements in Patient-Reported Outcomes Patients not on Ecu (n=44) Ecu (n=43) * 2 * * * (n=87) (n=3) (n=35) (n=22) Overall >25 Pre-treatment Transfusion Strata 5% of Ecu patients achieved transfusion independence vs % of patients not on Ecu FACIT-Fatigue* EORTC Fatigue* Dyspnea* Pain (P<.) (P<.) (P=.2) (P<.) Large Clinical Impact Moderate Clinical Impact Small Clinical Impact Patients with concomitant bone marrow dysfunction may continue to require transfusions 2 *P<.. Transfusion data obtained during 2 months before treatment; values were normalized for a 6-month period. Please see full prescribing information for Soliris (eculizumab). Soliris (eculizumab) Summary of Product Characteristics. Alexion Europe SAS; 22.. Hillmen P et al. N Engl J Med 26;355; ; 2. Schubert J. Br J Haematol 28;42: Please see full prescribing information for Soliris (eculizumab). Soliris (eculizumab) Summary of Product Characteristics. Alexion Europe SAS; 22.. Brodsky R et al. Blood 26;8: Abstract 377; 2. Data on file. Alexion Pharmaceuticals. 3. Weitz I, et al. Internal Medicine Journal 22. Accepted Article; doi:./j x 56 Eculizumab Reduces Hemolysis and Improves Fatigue in IST-Treated Patients IST,45, LDH * * * N= N= Months Months of of Eculizumab Eculizumab FACIT-Fatigue Months of Eculizumab IST: Severe hemolysis Ecu: Significant and sustained reduction in hemolysis IST: Severe fatigue Ecu: Significant and sustained reduction in fatigue Demonstrates effectiveness of treatment with Eculizumab to reduce hemolysis and fatigue in AA patients despite concomitant IST treatment Reduction of Pulmonary Hypertension With Eculizumab as Measured by NT-ProBNP Soliris vs Placebo (P<.) % Reduction Baseline Week 26 Baseline Week 26 Placebo Eculizumab Treatment Group - TRIUMPH (n=73) Pulmonary Hypertension Defined as NT-proBNP 6 pg/ml 2 P<.37 * P<. when prior and post months compared.. P<.5 when prior and post months compared. Please see full prescribing information for Soliris (eculizumab). Soliris (eculizumab) Summary of Product Characteristics. Alexion Europe SAS; 22. Schrezenmieier et al Blood Hill A et al. Br J Haematol 22;58: Machada et al. JAMA Recommendations for Monitoring PNH Patients on Eculizumab Monthly Complete Blood Count Reticulocyte count Serum LDH Yearly PNH Flow Cytometry If Evidence of Extravascular Hemolysis (anemia and increased retic) Direct Antiglobulin Test Summary of Clinical Efficacy 5 86% sustained reduction in hemolysis as measured by LDH Maintained over a 36 month treatment period 3 92% reduction in thrombotic events 73% reduction in transfusion requirements across all patient populations 78% clinically meaningful improvement in fatigue Sustained improvement in overall quality of life Patients treated with eculizumab experienced improvement in CKD and pulmonary hypertension Eculizumab provided a rapid and durable effect on dyspnea, a key marker of hemolysis-induced PHT Please see full prescribing information for Soliris (eculizumab).. Soliris (eculizumab) Summary of Product Characteristics. Alexion Europe SAS; Hillmen P et al. N Engl J Med 26;355: ; 3. Brodsky R et al. Blood 2;6: Abstract 4237; 4. Hillmen P et al. Blood 27;: ; 5. Socie G et al. Blood 27;: Abstract Szer J et al. In: Abstracts of the 54 Brodsky et al.. Blood 24;24: th Annual Meeting of the American Society of Hematology (ASH). December 8, 22, Atlanta, GA; Abstract # Appears in Blood 22;2(2). 6

11 Patients Surviving, % 5/2/28 Summary of Clinical Efficacy and Safety 5 In a multicenter analysis eculizumab showed a major impact on survivalin PNH; survival is comparable to age- and gendermatched controls Eculizumab significantly reduced hemolysis, the underlying cause of morbidity and mortality in PNH Significant reductions in AEs were observed suggesting good tolerability and a favorable risk/benefit ratio over the long term Paroxysmal Nocturnal Hemoglobinuria: Compelling Long Term Clinical Benefits in PNH Patients Pre-Soliris from Time of Diagnosis in 8 Patients With PNH, Age- and gendermatched controls N= Survival of PNH Patients Treated With Soliris Compared With the Normal UK Population 3 N= 53 Age- and gender-matched normal population Soliris Treated PNH Population 2 Patients with PNH 5 year mortality of 35% recently confirmed Years After Diagnosis Despite best supportive care - 5 year mortality: 35% 2 Numbers at Risk: Time (years) Please see full prescribing information for Soliris (eculizumab).. Soliris (eculizumab) Summary of Product Characteristics. Alexion Europe SAS; Hillmen P et al. N Engl J Med 26;355: ; 3. Brodsky R et al. Blood 2;6: Abstract 4237; 4. Hillmen P et al. Blood 27;: ; 5. Socie G et al. Blood 27;: Abstract Hillmen P et al. N Engl J Med. 995;333: Kelly RJ et al. Blood. 2;7: Hillmen et al. Br Jnl Haematol. 23;62: Szer J et al. In: Abstracts of the 54 th Annual Meeting of the American Society of Hematology (ASH). December 8, 22, Atlanta, GA; Abstract #26. Appears in Blood 22;2(2) Role of Complement 3 in Continued Extravascular Hemolysis Complement Cascade Regulation and Erythrocytes Lucio Luzzatto et al. Haematologica 2;95: Hemoglobin Normalization after Splenectomy = 2 units PRBCs Role of Splenectomy 65 Patient has Gilberts Disease Risitano et al. Blood 28;2:

12 5/2/28 Complement Cascade Novel Complement Inhibitors 67 Ricklin and Lambris Adv Exp Med Biol. 28;632: Complete Attack in PNH Effect of C3 inhibitors on hemolysis and C3 fragment deposition on PNH erythrocytes. Dropped from further analysis hemolysis No hemolysis Joshua M. Thurman Blood 24;23: Risitano et al. Blood 24;23: Novel Complement Inhibitors ALXN 2 C5 antibody prolonged half life administered every 8 weeks. AMY /APL-2-compstatin analog. Synthetic peptide that inhibits C3 Coversin-small molecule protein derived from a tick that inhibits C5, daily subq dosing ACH-447-oral agent. Small molecule inhibits factor D. C3 proactivator convertase. Early phase trials. Active independent of C5 inhibitor OMS-72 complement inhibitor lectin pathway, IV, monoclonal antiobdy tartes MASP-2 ALN-CC5-RNAi C5 inhibitor Transplantation for PNH

13 5/2/28 HCT for PNH Long Term Results HCT for PNH N=48 MRD 56% N=22 MRD 65% N=26 overall 57% MA 5 BM 2 RIC PBPC 6 Related 36 Unrelated 75 BM 35 PBSC 7 CBT 5 Sašo et al Br J Haematol. 999:4; Santarone et al. Haematologica 2:95; De Latour Haematologica 22;97: RIC HCT for PNH Meningitis Vaccine in PNH Farah et al. ASH 2 abstract Meningitis Vaccines Current ACIP Recommendations for Complement Deficiencies Meningitis A, C, Y, W-35 (Quadrivalent Vaccines) MenHibrix (Hib-Men CY-TT) BIVALENT children 6 weeks-8 mos Menveo (Men ACWY-CRM) 2 months-55 years of age Menactra (Men ACWWY-D) 9 months-55 years of age Menomune (MPSV4) polysaccharide allergic reactions Older than 55 No mucosal immunity Duration of immunity less than 3 years no memory T cells 77 ACIP=Advisory Committee on Immunization Practices 78 3

14 5/2/28 Distribution of Meningitis Serotype in Norway Meningitis Vaccines 79 Meningitis A, C, Y, W-35 (Quadrivalent Vaccines) MenHibrix (Hib-Men CY-TT) BIVALENT children 6 weeks-8 mos Menveo (Men ACWY-CRM) 2 months-55 years of age Menactra (Men ACWWY-D) 9 months-55 years of age Menomune (MPSV4) polysaccharide allergic reactions Older than 55 No mucosal immunity Duration of immunity less than 3 years no memory T cells Meningitis B Bexsero (Novartis) -25 years of age 2 dose series ( and -6 months) Trumenba (Pfizer) -25 years of age 3 dose series (,2, and 6 months) 8 Meningitis Vaccines Meningitis X North America, Europe, Australia and West Africa No commercially available vaccine Laboratory Analsysis in PNH 8 82 Chemistry panel in PNH Hematology panel in PNH

15 5/2/28 PNH Flow Testing LDH in PNH 78.2% 67.% =