> ![](media/image1.wmf)Department of Health & Human Services [Public
> Health Service]{.smallcaps}

Food and Drug Administration

> **Memorandum** Center for Biologics Evaluation and Research
>
> 1401 Rockville Pike
>
> Rockville, MD 20852

Division of Clinical Trial Design and Analysis

HFM-576

Date: December 12, 2002

Advisory Committee Briefing Document

Genzyme Corp.

Biologics Marketing Application

STN 103979 / 0

Recombinant human α-Galactosidase

for

Fabry\'s disease

TABLE OF CONTENTS

[INTRODUCTION 5](#introduction)

[FABRY\'S DISEASE 5](#fabrys-disease)

[PRODUCT INFORMATION 6](#product-information)

[CLINICAL TRIALS CONDUCTED AND PLANNED AND DATA SUMMARIZED
6](#clinical-trials-conducted-and-planned-and-data-summarized)

[CLINICAL TRIAL DATA 8](#clinical-trial-data)

[FB9702-01: FIRST, DOSE FINDING TRIAL
8](#fb9702-01-first-dose-finding-trial)

[Treatment, concomitant medications, and length of evaluation
8](#treatment-concomitant-medications-and-length-of-evaluation)

[Procedures and evaluations 8](#procedures-and-evaluations)

[Biopsy and slide reading considerations
9](#biopsy-and-slide-reading-considerations)

[Analysis 9](#analysis)

[RESULTS: CONDUCT OF TRIAL 9](#results-conduct-of-trial)

[RESULTS: DEMOGRAPHICS AND BASELINE CHARACTERISTICS
9](#results-demographics-and-baseline-characteristics)

[RESULTS: BIOACTIVITY AND EFFICACY 9](#results-bioactivity-and-efficacy)

[Histologic GL-3 Assessments 9](#histologic-gl-3-assessments)

[GL-3 levels in tissue biopsies 11](#gl-3-levels-in-tissue-biopsies)

[Plasma GL-3 levels 11](#plasma-gl-3-levels)

[Urinary GL-3 12](#urinary-gl-3)

[Other tests reported by Genzyme 12](#other-tests-reported-by-genzyme)

[Pharmacokinetics 13](#pharmacokinetics)

[Summary comments on pharmacodynamic and clinical results
13](#summary-comments-on-pharmacodynamic-and-clinical-results)

[RESULTS: SAFETY 13](#results-safety)

[Exposure 13](#exposure)

[Deaths 13](#deaths)

[Adverse events: serious adverse events
13](#adverse-events-serious-adverse-events)

[Infusion reactions 13](#infusion-reactions)

[Other adverse events 14](#other-adverse-events)

[Concomitant medication use 14](#concomitant-medication-use)

[Summary (safety) 14](#summary-safety)

[Antibody production 14](#antibody-production)

[CONCLUSIONS REGARDING FB9702-01 14](#conclusions-regarding-fb9702-01)

[AGAL-1-002-98: CONTROLLED TRIAL 15](#agal-1-002-98-controlled-trial)

[Treatment 15](#treatment)

[Randomization and blinding 15](#randomization-and-blinding)

[Subject qualifications 15](#subject-qualifications)

[Procedures and evaluations 16](#procedures-and-evaluations-1)

[Biopsy procedure and histology slide blinding and preparation
17](#biopsy-procedure-and-histology-slide-blinding-and-preparation)

[Analysis 17](#analysis-1)

[Analytical populations 17](#analytical-populations)

[Primary endpoint 17](#primary-endpoint)

[Secondary endpoints 19](#secondary-endpoints)

[Tertiary and "other" endpoints 19](#tertiary-and-other-endpoints)

[RESULTS: CONDUCT OF TRIAL 20](#results-conduct-of-trial-1)

[Protocol changes 20](#protocol-changes)

[Enrollment by site 20](#enrollment-by-site)

[Discontinuations 20](#discontinuations)

[Protocol violations 20](#protocol-violations)

[Adherence to dosing 21](#adherence-to-dosing)

[RESULTS: DEMOGRAPHICS AND BASELINE CHARACTERISTICS
21](#results-demographics-and-baseline-characteristics-1)

[RESULTS: BIOACTIVITY AND EFFICACY
23](#results-bioactivity-and-efficacy-1)

[Analytical population 23](#analytical-population)

[Primary endpoint 23](#primary-endpoint-1)

[Genzyme's exploration of primary endpoint
24](#genzymes-exploration-of-primary-endpoint)

[CBER's exploration of the primary endpoint
25](#cbers-exploration-of-the-primary-endpoint)

[Independent pathologist's evaluation of primary endpoint
27](#independent-pathologists-evaluation-of-primary-endpoint)

[Secondary endpoint: McGill pain questionnaire
27](#secondary-endpoint-mcgill-pain-questionnaire)

[Secondary endpoint: Composite score for change in the GL-3 levels in
kidney, skin, and heart
27](#secondary-endpoint-composite-score-for-change-in-the-gl-3-levels-in-kidney-skin-and-heart)

[Secondary endpoint: urinary and kidney tissue GL-3
28](#secondary-endpoint-urinary-and-kidney-tissue-gl-3)

[Tertiary endpoints 29](#tertiary-endpoints)

["Other" endpoints 31](#other-endpoints)

[Antibody development and effect on bioactivity
32](#antibody-development-and-effect-on-bioactivity)

[Pharmacokinetics 32](#pharmacokinetics-1)

[Summary (bioactivity and efficacy)
32](#summary-bioactivity-and-efficacy)

[RESULTS: SAFETY 33](#results-safety-1)

[Exposure and population analyzed 33](#exposure-and-population-analyzed)

[Deaths 33](#deaths-1)

[Adverse events 33](#adverse-events)

[Concomitant medication use 35](#concomitant-medication-use-1)

[Antibody development and effect on safety
35](#antibody-development-and-effect-on-safety)

[Summary (safety) 35](#summary-safety-1)

[CONCLUSIONS REGARDING AGAL-1-002-98
35](#conclusions-regarding-agal-1-002-98)

[AGAL-005-99: OPEN-LABEL EXTENSION TO AGAL-1-002-98
37](#agal-005-99-open-label-extension-to-agal-1-002-98)

[Study Design 37](#study-design)

[Subject qualifications 37](#subject-qualifications-1)

[Procedures and evaluations 37](#procedures-and-evaluations-2)

[Bioactivity and efficacy measurements
38](#bioactivity-and-efficacy-measurements)

[Analysis of endpoints 38](#analysis-of-endpoints)

[RESULTS: DATA SUBMITTED 38](#results-data-submitted)

[RESULTS: CONDUCT OF TRIAL 38](#results-conduct-of-trial-2)

[Dates of the trial 39](#dates-of-the-trial)

[Formal protocol modifications 39](#formal-protocol-modifications)

[Enrollment and adherence to infusion schedule and dose
39](#enrollment-and-adherence-to-infusion-schedule-and-dose)

[Discontinuations 39](#discontinuations-1)

[Protocol violations 39](#protocol-violations-1)

[RESULTS: BASELINE CHARACTERISTICS
39](#results-baseline-characteristics)

[RESULTS: BIOACTIVITY AND EFFICACY
39](#results-bioactivity-and-efficacy-2)

[Primary endpoint: GL-3 in kidney interstitial capillaries at 6 months
39](#primary-endpoint-gl-3-in-kidney-interstitial-capillaries-at-6-months)

[Additional analyses of kidney histology (AGAL-1-002-98 and AGAL-005-99)
40](#additional-analyses-of-kidney-histology-agal-1-002-98-and-agal-005-99)

[Endpoint: McGill short form pain questionnaire
43](#endpoint-mcgill-short-form-pain-questionnaire)

[Endpoint: GL-3 in skin and heart biopsy
43](#endpoint-gl-3-in-skin-and-heart-biopsy)

[Skin 43](#skin)

[Additional cell types in the skin
44](#additional-cell-types-in-the-skin)

[Heart capillary endothelium 45](#heart-capillary-endothelium)

[Endpoint: Urinary GL-3 levels 46](#endpoint-urinary-gl-3-levels)

[Plasma GL-3 levels 46](#plasma-gl-3-levels-1)

[Other endpoints 46](#other-endpoints-1)

[Summary comments on bioactivity and efficacy from AGAL-005-99
48](#summary-comments-on-bioactivity-and-efficacy-from-agal-005-99)

[RESULTS: SAFETY 48](#results-safety-2)

[Deaths 48](#deaths-2)

[Adverse events 49](#adverse-events-1)

[IgG antibody to r-hαGal 52](#igg-antibody-to-r-hαgal)

[CONCLUSIONS REGARDING AGAL-005-99
52](#conclusions-regarding-agal-005-99)

[AGAL-007-99 52](#agal-007-99)

[Bioactivity and efficacy results 53](#bioactivity-and-efficacy-results)

[Safety 54](#safety)

[Seroconversion 54](#seroconversion)

[ADDITIONAL SAFETY INFORMATION 55](#additional-safety-information)

[Deaths 55](#deaths-3)

[Serious adverse events (excluding deaths)
56](#serious-adverse-events-excluding-deaths)

[FINANCIAL DISCLOSURE 58](#financial-disclosure)

[OVERALL SUMMARY OF BIOACTIVITY AND EFFICACY
59](#overall-summary-of-bioactivity-and-efficacy)

[OVERALL SUMMARY OF SAFETY 59](#overall-summary-of-safety)

[ONGOING CLINICAL STUDIES 60](#ongoing-clinical-studies)

[CONCLUSIONS AND CURRENT STATE OF CLINICAL ACTIVITY
61](#conclusions-and-current-state-of-clinical-activity)

[REFERENCES 61](#references)

[APPENDICES (TABLES REFERRED TO IN TEXT)
62](#appendices-tables-referred-to-in-text)

[Appendix A: Study FB9702-01 62](#appendix-a-study-fb9702-01)

[Appendix B: Study AGAL-1-002-98 66](#appendix-b-study-agal-1-002-98)

[Appendix C: Study AGAL-005-99 72](#appendix-c-study-agal-005-99)

# 

# INTRODUCTION

On June 23, 2000, Genzyme submitted an application for marketing
approval for their recombinant human α-Galactosidase (r-hαGal) for the
treatment of Fabry\'s disease. The pivotal trial that Genzyme submitted
was based on a primary endpoint of histologically determined reduction
in r-hαGal's substrate in renal interstitial capillary endothelium. This
endpoint had been discussed extensively with CBER. Genzyme requested
that their product be considered under the accelerated approval
mechanism. Under this mechanism, a product may be granted marketing
approval by showing a beneficial effect on a surrogate endpoint
reasonably likely to predict clinical benefit. However, a trial that
attempts to verify the clinical benefit must subsequently be conducted.
If such a trial were to show that the product does not confer benefit,
the product could be removed from the market. Since submission of the
BLA, Genzyme has initiated a randomized, placebo-controlled clinical
trial whose design was discussed with CBER before implementation.
Genzyme is currently proposing to change the design of this trial from
placebo-control to an open-label, single-arm trial with a control
consisting of data from a collection of medical histories of Fabry\'s
disease patients.

This briefing document contains a brief description of Fabry\'s disease
and the product. It contains a summary of the major clinical findings
presented by Genzyme. It also contains a brief summary of the progress
of Genzyme's ongoing clinical trial. A description of the natural
history data base, its analysis by Genzyme and a CBER review of these
materials are located in a separate document.

# FABRY\'S DISEASE 

Fabry\'s disease results from an X-linked recessive deficiency in the
activity of the enzyme α-galactosidase, an enzyme that catalyzes the
release of α-D-Galactose residues from oligosaccharides, galactomannans,
and galactolipids. α-Galactosidase A is targeted to its lysosomal site
of action by mannose-6-phosphate (M6P) residues on the α-galactosidase A
molecule. The M6P moiety binds to a specific M6P receptor in the Golgi
and is thus directed to prelysosomal compartments. Enzymes that escape
this routing system are secreted by the cell via the constitutive
secretory pathway and are often recaptured by cell surface M6P receptors
that return the α-galactosidase A to the lysosome by the endocytic
pathway.

Many of the clinical signs and symptoms of Fabry\'s disease are thought
to result from accumulation of the enzyme's chief substrate
(ceremidetrihexoside, also called GL-3 or Gb3) in vascular
endothelium.^1^ Glycosphingolipid deposits occur throughout the body;
other cell types in which deposition occur include perithelial and
smooth muscle cells of the vasculature, histiocytic and reticular cells
of connective tissue, epithelial cells of the cornea, glomeruli, and
tubules of the kidney, muscle fibers of the heart, and ganglion cells of
the autonomic nervous system. Most affected patients are male
hemizygotes of western European descent. The incidence of Fabry\'s
disease is approximately 1:40,000 males.^1^

Early manifestations of Fabry\'s disease include pain in the arms and
legs (acroparesthesias), vascular skin lesions (angiokeratomata),
decreased sweating (hypohidrosis), and opacities in the cornea and lens.
Acroparesthesias, which are intense burning pains, usually decrease in
frequency with age, but may also increase, and can be debilitating.
Paresthesias of the hands and feet may also be present. These forms of
pain, although considered the cardinal symptoms of Fabry\'s disease, may
be absent in 10-20% of patients. A partial list of clinical syndromes
also includes growth retardation, delay of puberty, lymphedema,
diarrhea, anemia, conjunctival and retinal vascular changes, and
skeletal deformities. With age, the principal manifestations of concern
in Fabry\'s disease are in the kidney, heart, and brain. Renal disease
is manifested by proteinuria, hypertension, and progressive azotemia;
the principal cause of death in Fabry\'s disease is renal failure.
Neurological syndromes such as transient ischemic attacks, strokes,
seizures, and hemorrhages can occur. Cardiac involvement may be
manifested by left ventricular enlargement, mitral insufficiency,
arrhythmias, and myocardial infarction. The median age of death for
hemizygous males is 50 years and that of obligate heterozygotic females
70 years.^2^

Affected males most often have the "classical" form of the disease, as
described above, with levels of circulating and cell-associated
α-galactosidase activity (hydrolysis of surrogate substrates in a
laboratory assay) nondetectable, or nearly nondetectable. Other genetic
variants have higher levels of activity, from less than 5% to 35% of
normal (normal ranges: 7.8-14.6 nmol/hr/ml (plasma) and 1.8-5.7
nmol/hr/10^6^ cells in leukocytes^3^). The deficiency of α-gal activity
may cause an increase in plasma substrate levels; the normal level is
\<1.2 ng/μl.^4^ Biochemical diagnosis in females is complicated by
random X-inactivation. This can raise the overall level of detectable
α-gal while levels in critical tissues may be low.

The most commonly described variant in the male is a so-called cardiac
variant, whose principal sign is cardiomegaly with or without
proteinuria. Patients with this variant may not have the classical early
signs of Fabry\'s disease such as hypohidrosis or pain. Rare female
heterozygotes typically have a later disease presentation and a less
severe course.

Alpha-galactosidase catabolizes blood group B-specific glycolipids.
Persons who are blood group B or AB may be more severely affected due to
additional accumulation of these glycolipids.^1^

There is no specific treatment for Fabry\'s disease. Palliative
treatments include the anticonvulsants phenytoin, diphenylhydantoin, or
carbamazepine for pain, laser for angiokeratoma, anticoagulation for
subjects prone to stroke, and dialysis and kidney transplantation for
renal failure.

# PRODUCT INFORMATION

Genzyme's alpha galactosidase is produced by recombinant DNA technology
from an established Chinese Hamster Ovary (CHO) cell line into which the
complementary DNA for natural human alpha galactosidase has been
inserted. Recombinant human alpha galactosidase is then purified through
multiple column chromatography and filtration steps. The enzyme is a
homodimer comprised of approximately 50 kDa subunits, and contains three
N-linked glycosylation sites. Formulated drug product is supplied as a
sterile, lyophilized, white to practically white powder. Each vial of
drug product contains 35 mg of Genzyme's alpha galactosidase and is
intended for single use. Lyophilized drug product is reconstituted with
Water for Injection (WFI) to a concentration of 5 mg/ml and then
delivered into sterile saline (0.9% sodium chloride) for intravenous
administration.

For preclinical acute toxicity studies and for the phase 1 trial
(FB9702-01), r-hαGal was manufactured at 30 liter and 160 liter
bioreactor scales. For the phase III pivotal clinical trial and
preclinical repeated dose toxicity studies, Genzyme used a 340 liter
bioreactor scale. The proposed commercial manufacturing process will be
conducted at the 340 liter scale. For each manufacturing scale, Genzyme
demonstrated drug substance comparability through biochemical testing
and animal study data.

# CLINICAL TRIALS CONDUCTED AND PLANNED AND DATA SUMMARIZED

**Table 1** shows completed and ongoing clinical trials by Genzyme. The
most important information regarding the safety and efficacy of r-hαGal
is from the results of AGAL-1-002-98, as it is the only controlled data
available. AGAL-005-99, the open-label extension to AGAL-1-002-98 in
which all subjects receive r-hαGal, contains important evidence on the
durability of the effects seen in the controlled trial.

This document will concentrate on the major findings of FB9702-01,
AGAL-1-002-98, and AGAL-005-99. In addition, selected results from
AGAL-007-99 and safety findings from additional trials and postmarketing
experience will be summarized.

Table 1. Genzyme clinical trials

  --------------- ------ ----------------------------------- -------------
  Trial           n      Design                              Status

  FB9702-01       15     open-label, dose finding,           completed
                         5-cohort\*                          

  AGAL-006-99     15     Single arm, open-label extension to ongoing
                         FB9702-01                           

  AGAL-1-002-98   58     randomized, double-blind,           completed
                         placebo-controlled, 5-month,        
                         histological endpoint---**pivotal** 

  AGAL-005-99     58     Single-arm, open label extension to ongoing (over
                         AGAL-1-002-98                       18 months)

  AGAL-007-99     13     Single-arm, open-label, 5-month,    Completed
                         histological endpoint               

  AGAL-012-01     13     Single arm, open-label extension to Ongoing
                         AGAL-007-99                         

  AGAL-008-00     73     Randomized, double-blind,           Ongoing
                         placebo-controlled clinical         
                         efficacy trial. First subject       
                         randomized 2/20/01. Renal, cardiac, 
                         and neurologic endpoints.           

  AGAL-019-01     5      Single-arm, open-label, rechallenge Ongoing
                         of subjects withdrawn due to IgE    
  --------------- ------ ----------------------------------- -------------

\*Only trial using other than 1 mg/kg every other week

[Special Note on Review Organization]{.underline}: Numerous tables
providing more extensive details of information discussed in this
document have been located in the Appendices of the document. All tables
from Table 41 onwards are located in the Appendices.

# CLINICAL TRIAL DATA

## **FB9702-01: FIRST, DOSE FINDING TRIAL**

The first trial that Genzyme conducted in humans was FB9702-01, called
"Pharmacokinetic and pharmacodynamic evaluation of recombinant human
α-Galactosidase A (r-hαGal) replacement in patients with Fabry disease."
It was conducted at Mt. Sinai Medical Center, New York City. It was an
open-label, nonrandomized, sequential 5-dose trial in 15 subjects with
Fabry's disease, with a duration from 22 to 70 days depending on dose
group. Its objectives were to determine the pharmacokinetics and
pharmacodynamics of various dose regimens of r-hαGal and to determine
safety.

The results of this trial, given its open-label nature and selection of
doses, are less useful than those of AGAL-1-002-98 to follow, but are
still informative.

Subjects were to meet the following entry criteria:

[Inclusion]{.underline}

-   Males with a current diagnosis of Fabry\'s disease

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-   ≥16 years old

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-   plasma α-gal activity of ≤ 1.5 nmol/hr/ml

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-   plasma GL-3 levels ≥ 5.0 ng/μl

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-   clinical presentation consistent with Fabry\'s Disease

[Exclusion]{.underline}

-   serum creatinine \> 2.5 mg/dl

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```
-   have undergone kidney transplantation or currently on dialysis

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```
-   clinically significant organic disease, including clinically
    significant cardiovascular, hepatic, pulmonary, neurologic, or renal
    disease that in the opinion of the investigator would preclude
    participation in the trial

-   participation in a study employing an investigational drug within 30
    days of the start of the trial

#### Treatment, concomitant medications, and length of evaluation

All subjects received 5 doses. Three groups of three patients each were
to receive r-hαGal at 0.3, 1.0, and 3.0 mg/kg every 14 days; two groups
of three patients each were to receive r-hαGal at 1.0 and 3.0 mg/kg
every 48 hours.

Dose levels were based on preclinical information. The every 14-day
regimen was chosen to imitate the dosing regimen for Cerezyme, Genzyme's
enzyme treatment for Gaucher's disease another inherited enzyme
deficiency; the every 48-hour treatment was meant to extend preclinical
information based on this dosing frequency and to test the hypothesis
that more frequent treatment might result in greater reductions in
substrate load.

The product was to be given at 0.83 ml/minute (over 2 hours). There was
no limitation on concomitant medications. The final evaluation was to be
2 weeks after the last dose.

#### Procedures and evaluations

Subjects were screened within 30 days of the first infusion and received
baseline enzyme levels and a liver and skin biopsy within 6 days of the
first infusion. Periodic assessments of adverse events and laboratories
were performed. All subjects were to have liver and skin biopsies at
baseline and 2-3 days after the final infusion. Optional second liver
and skin biopsies were to be after the 1^st^ infusion for subjects on
the 14-day infusion schedule and 14 days after the final infusion for
those on the 48-hour schedule.

#### Biopsy and slide reading considerations

Biopsies were to be processed for light and electron microscopy at Mt.
Sinai. Sections for light microscopy were stained with hematoxylin and
eosin (liver and kidney), periodic acid-Schiff (liver, skin, and
kidney), methylene blue/azure II (skin, heart, and kidney), and/or oil
red O (skin). Other sections were made for electron microscopy. Biopsy
samples were examined by a Mt. Sinai pathologist specialized to the
organ in question, blinded to sample sequence. The degree and extent of
glycolipid inclusions were graded on a scale from 0-3 (normal, mild,
moderate, and severe) based on an overall judgment of the entire slide.
Quantitation of the size and number of glycolipid inclusions was not
performed.

######  

#### Analysis

The final analysis of the trial (safety, pharmacokinetics, GL-3 levels,
and clinical outcomes) was to be descriptive.

###### Comments

###### FB9702's open-label design rendered it inadequate to give meaningful data on clinical effects of r-hαGal. The small cohort size rendered its ability to allow conclusions on a dose-relation of findings somewhat tenuous. 

######  Subjects in the every-48-hour spent much less time exposed to r-hαGal prior to their final evaluations than those in the every-14-day infusion groups. Thus the trial was not designed to give direct information on the durability of the response to r-hαGal given the more frequent dosing regimen.

### RESULTS: CONDUCT OF TRIAL 

With a few exceptions, dosing was complete. There were numerous
deviations from exact schedules of collection of data and incomplete
collection of data, including clinical and pharmacokinetic data.
Protocol violations of greatest importance to the outcome of the trial
were in the timing of the performance of the liver and skin biopsies,
and these were fairly common. The effect that these violations may have
had on the results is unknown, as the rate of reaccumulation of
substrate, if any, is unknown.

All 15 subjects completed the trial.

### RESULTS: DEMOGRAPHICS AND BASELINE CHARACTERISTICS 

The trial population was entirely males and mostly "White" (Table 41,
appendix). Two subjects were below the inclusionary limit for plasma
GL-3. They were in the same treatment group; the mean for all 3 subjects
in that group was clearly different from that of any other group.
Subjects were mostly in their 4^th^ decade of life. In a few cases serum
creatinine was clearly higher than others in the cohort; in most, it was
in the normal range.

###### Comments

######  The impact of the inclusion of subjects with plasma GL-3 levels below the limit of inclusion is not clear. All subjects qualified on the basis of undetectable α-gal levels. 

### RESULTS: BIOACTIVITY AND EFFICACY

#### Histologic GL-3 Assessments

Liver biopsies were obtained for nearly all subjects; collection of
biopsy data in skin, kidney, and heart was more sporadic (Table 42,
appendix). This rendered comparisons from the every 14-day to every
48-hour groups tenuous for most organs.

[Liver histology]{.underline}

Routine stains used in the liver examination failed to distinguish
glycolipid inclusions from background, and thus were uninterpretable.
Liver biopsies from several subjects were examined with antibody to
GL-3; Genzyme reports that only 2 sets of pre- and post-treatment
samples were available, and that they both showed "clearance" of GL-3
after treatment. Photomicrographs from subject 13, presented by Genzyme,
appear to show reductions.

Review of scores of transmission electron micrographs of liver
sinusoidal endothelial and Kupffer GL-3 were consistent generally with
the light microscopic appearance; reductions in hepatocytes in were
shown in 7/14 cases where both baseline and end of treatment biopsy data
were available. Data on smooth muscle, portal tract vascular
endothelium, and ducts were insufficient to make a determination of an
effect.

###### Comment

######  Liver histology was insufficient to make any conclusions.

[Skin histology]{.underline}

Not every specimen received a coded score for light microscopy due to
low vessel numbers or uncertain classification on the part of the
pathologist. All 7 of the subjects with pre- and post-treatment
superficial capillary endothelial scores had reductions to a score of 0
(Appendix Table 43).

Pericyte baseline and end-of-treatment scores were available for 5
subjects. Two of the 5 showed a reduction in GL-3 (with 3 staying the
same). Perineurium baseline and end-of-treatment scores were available
for 8 subjects. Five of the 8 showed a reduction, with 3 remaining the
same.

Electron microscopy evaluation was more consistently done. Electron
microscopic evaluations of the endothelium of skin superficial
capillaries showed reductions in all 14 subjects who had both pre- and
post-treatment scores; reductions were seen in 11/14 in endothelial
cells of larger vessels. However, pericyte scores remained the same for
12 of these 14 subjects. No effect was seen in 14/14 pairs of samples of
the muscular layer of the arterioles and 13/13 pairs of histiocytes and
fibrocytes; while reductions were noted in only 2/13 pairs of
perineurium.

###### Comment

###### Skin results show that histologically determined reductions in substrate were less robust than the capillary endothelium in some cell types.

[Heart histology]{.underline}

As for the skin, both pre- and post-treatment scores were available for
the minority of heart samples for light microscopy. Heart substrate
levels declined in vascular endothelium as measured by light microscopy
in the 7 subjects for whom biopsies at baseline and end-of-treatment
were available (Appendix Table 44).

Light microscopy data on cardiac vascular smooth muscle were too limited
to draw conclusions; only 2 paired samples were available.

Transmission electron microscopy results for the same subjects' vascular
endothelium were consistent with the light microscopy of cardiac
vascular endothelium in that for the 7 paired samples examined
reductions were seen in all. Genzyme states that histological analysis
showed that the bulk of glycolipid in the heart was in the myocytes.
Electron microscopy histological evaluation showed a reduction in 1/7
paired samples available. Genzyme performed computer-generated analysis
of the volume of cardiac myocytes occupied by lipid. This showed
variable results; the 3 subjects in the every 14-day infusion group
showed decreases, but 3 of 4 of the subjects in the every 48-hour
infusion group showed an increase. Reductions were noted in 4/7 paired
evaluations of pericytes, with no change in the others; only 3 paired
samples of cardiac smooth muscle were available.

[Kidney histology]{.underline}

Because of its importance to the pivotal trial, the results of kidney
capillary endothelium are shown in detail (Table 2).

Table 2. Trial FB9702-01: Interstitial capillary scores in kidney
(electron microscopic scores in parentheses)

+------------------+---------------+---------------+------------------+
| Dose group       | Subject       | Pre-          | Post-            |
|                  |               |               |                  |
|                  |               | treatment     | treatment        |
|                  |               |               |                  |
|                  |               | score         | score            |
+------------------+---------------+---------------+------------------+
| 3.0/14-day       | 8             | 2 (1)         | 1 (0)            |
+------------------+---------------+---------------+------------------+
|                  | 9             | 2 (1)         | 0 (1)            |
+------------------+---------------+---------------+------------------+
| 1.0/48-hour      | 10            | 2 (3)         | 1 (2)            |
+------------------+---------------+---------------+------------------+
|                  | 11            | 1 (2)         | 2 (0)            |
+------------------+---------------+---------------+------------------+
| 3.0/48-hour      | 13            | 2 (3)         | 0 (0)            |
+------------------+---------------+---------------+------------------+

There was similarly sparse collection of data on other renal cell types
(Appendix Table 45).

Pre- and post-treatment scores by electron microscopy (not shown) did
not always mirror scores by light microscopy. These scores were not
examined in detail.

###### Comments

######  There was very little data from this trial in renal interstitial capillary endothelium, but what was available was consistent with results seen in AGAL-002. The data on additional renal cell types showed variable, and sometimes no evident, effect of r-hαGal treatment.

######  Overall, available data showed a reduction in lipid in endothelium in the kidney, heart, and skin. Nonvascular cell types had variable, sometimes no evident, reduction in substrate. No dose effect could be discerned from the available data. These data are supportive of an effect in various organs, mostly demonstrated in vascular endothelial cells, but are too sparse to draw firm conclusions as to the amount of reduction one could expect with chronic treatment.

#### GL-3 levels in tissue biopsies

Total GL-3 levels were determined in biopsies where available (Appendix
Table 46). Infusion of r-hαGal reduced skin and liver total GL-3 levels
in almost all subjects. There was no differential effect of dose level
or infusion frequency. Baseline GL-3 levels in the liver were quite
variable.

Infusion of r-hαGal reduced GL-3 levels in most renal tissues examined;
effects on the heart were quite variable (Table 47).

###### Comments

######  Because of the incompleteness of the data, comparisons of the amounts of reduction in histological scores to total GL-3 reduction are difficult to make. The histological data are more useful than total GL-3 in that they detail affected and unaffected tissues in the organs. In general,

###### reduction of total GL-3 occurred for most subjects. The degree of reduction was quite variable, except for the liver.

#### Plasma GL-3 levels

Levels of plasma GL-3 were reduced on average in all groups by the last
infusion (mean reduction range 7% to 70%, without clear dose
relationship). Levels of GL-3 in both the 1 and 3 mg/kg dose groups in
the every-14-day infusion regimen appeared to drop to end-of-treatment
levels by infusion 2.

######  

#### Urinary GL-3

Genzyme reports that the volumes of urine were inconsistently recorded,
so detailed quantification of the GL-3 levels is not possible. The basis
for this observation is not detailed.

######  

#### Other tests reported by Genzyme 

The following testing was performed before and after treatment to
measure autonomic, renal, and cardiac function, and included quality of
life questionnaires. The following summaries are based on summaries and
tables in the final report. CBER did not perform an extensive review of
individual data.

-   *Thermal discrimination testing*

> Genzyme tested index finger and great toe thermal discrimination.
> There was no pattern of improvement or worsening.

-   *Sympathetic skin response*

> Subjects in the two every 48-hour groups only were tested. There was
> no consistent pattern of effect.

-   *Creatinine clearance*

> These data, like the urinary GL-3 data above, depended upon the
> collection of urine over extended periods of time. According to
> Genzyme this was not performed consistently. The data show large
> variability, with some calculated values larger than possible,
> potentially due to larger collection times than reported. The results
> are uninterpretable.

-   *Renal MRI*

> Comparisons between baseline and end of trial were not made by
> Genzyme, and data were not summarized for review.

-   *Echocardiogram*

> Mean septal thicknesses and ejection fractions were substantially
> unchanged between baseline and the 5^th^ infusion.

-   *Signal-averaged ECG*

> Of the 11 subjects who had baseline and end-of-treatment tests, 10 had
> normal ECGs that did not change, and 1 had an abnormal ECG that did
> not change.

-   *Cardiac MRI*

> Genzyme states that different imaging algorithms were used, even
> within subjects. This renders comparisons between baseline and
> end-of-treatment problematic. Comparisons between baseline and end of
> trial were not made by Genzyme. However, Genzyme noted that there were
> abnormalities in T2-weighted MRI scans consistent with
> glycosphingolipid deposition in the myocardium.

-   *Ophthalmological exams*

> Genzyme does not claim any clinically significant changes due to
> r-hαGal infusions.

-   *SF-36 Quality of Life Questionnaire (mental and physical
    separately), Beck Depression Questionnaire, Fabry Quality of Life
    Questionnaire, Fabry Questionnaire, Impact of Events Scale, McGill
    Pain Questionnaire (present pain index and number of words chosen),
    Profile of Mood states (total Mood)*

> Virtually no data were reported for the 3 mg/kg every 48-hour group.
> Genzyme tabulated the data as "better," "unchanged," or "worse"
> without qualifying these labels. Results were not examined in detail.
> The interpretability of these data is very poor due to the open label
> nature of the trial.

#### Pharmacokinetics

Samples for the determination of pharmacokinetic values were taken at
infusions 1 and 5. Results are shown in Table 3. The rate of elimination
appeared to be biphasic for all dosing regimens and doses. Dose was not
proportional to exposure as measured by AUCinfinite (AUCinf) or Cmax as
increasing doses yielded higher than proportionate increases in AUCinf
and Cmax; furthermore, clearance decreased with increasing dose within
any given frequency of dosing. There do not appear to be meaningful
differences between pharmacokinetic measures in this study that are
dependent upon the numbers of infusions within a dose and regimen:

Table 3. Pharmacokinetic parameters (mean of 1^st^ and last (5^th^)
dose)

  ---------- ----------- ----------- -------- ----------- ---------- ---------
  Dose group AUCinf,     AUC/Dose    Cmax,    Cl,         Cl/Dose    T1/2\*,
             μg-min/ml               μg/ml    ml/min/kg              min

  0.3 mg/kg  76          255         0.6      4.3         14         85
  q14d X 5                                                           

  1.0 mg/kg  481         481         4.9      2.7         3          56
  q14d X 5                                                           

  3.0 mg/kg  4247        1415        24.7     0.8         0.3        94
  q14d X 5                                                           

  1.0 mg/kg  482         482         4.5      2.4         2          58
  q48h X 5                                                           

  3.0 mg/kg  2488        829         15.3     1.3         0.4        54
  q48h X 5                                                           
  ---------- ----------- ----------- -------- ----------- ---------- ---------

\*terminal half-life. The initial elimination T1/2 for the doses 0.3, 1,
and 3 given q 14 X 5 were 15 min, 20 min and 45 min.

The development of antibodies to agalsidase occurred in 7 of 15 patients
by infusion 5, however, the pharmacokinetic data do not suggest a change
in pharmacokinetics parameters.

#### 

#### Summary comments on pharmacodynamic and clinical results

Infusion of the product reduced substrate levels measured biochemically
and histologically primarily in the vascular endothelium of various
organs---liver, skin, kidney, and heart. There was no clear evidence of
differential effect of the different infusion regimens. There were no
notable clinical beneficial effects.

### RESULTS: SAFETY

#### Exposure

Nearly all subjects completed all of their infusions.

#### Deaths

There were no deaths in this trial.

#### Adverse events: serious adverse events

There were 2 subjects with serious adverse events:

Patient 5 (1.0 mg/kg every-14-days) experienced a serious infusion
reaction at infusion 4 requiring cessation of infusion and medical
treatment (see the section on infusion reactions).

Patient 14 (3.0 mg/kg every-48-hours) had pulmonary emboli. There are no
other data to suggest thrombotic events, and the clinical data for this
case do not suggest a concern for thromboembolic events.

#### Infusion reactions

Infusion reactions were reported in 4 subjects, 3 of whom were in the
every-14-day 3 mg/kg dose group. Table 48 shows outlines of the events,
including laboratory testing. Serum anti-r-hαGal IgG was detected in all
subjects with a reaction, but serum IgE was not detected in 3/3 tested.

#### 

###### Comments

###### All infusion reactions occurred after several uncomplicated infusions had been given. For two of the subjects, a subsequent infusion had to be stopped. Genzyme slowed the rate of infusion in the subsequent trial, AGAL-1-002-98, and pretreated all subjects. For a further discussion of infusion reactions and hypertension, see the safety section of the review of AGAL-1-002-98. 

######  Although IgG was detected in all those with infusion reactions, it was also present in some subjects without significant reactions (see Table 48), so that it is not a useful prognostic feature.

#### 

#### Other adverse events

The most consistent adverse event was hypertension, occurring in 14/15
subjects, all starting on an infusion date.

Other adverse events were sporadic, showing no particular pattern among
the dose groups.

###### Comments on adverse events 

###### Hypertension was the most important adverse event other than infusion reactions in this trial. Although it was common, it was not severe. This adverse experience was not seen as an isolated event in AGAL-1-002-98 or its extension (see discussion of hypertension in the AGAL-1-002-98 review). 

#### Concomitant medication use

The pattern of this and other medication use overall was not remarkably
different from that expected in the Fabry's population.

#### Summary (safety)

The most important safety concern in this trial was the occurrence of
severe hypersensitivity-type infusion reactions and hypertension.
Although antibody to the product was found in all the subjects who had
infusion reactions, this was not a prognostic factor since several
subjects with antibody did not have reactions. Hypertension seemed
related temporally to the administration of product, but was not severe.

#### Antibody production

The majority of subjects ended the trial with antibody to the product,
consistent with results in Study AGAL-002. Ten of 15 subjects ended the
trial with serum IgG to r-hαGal by ELISA; 9/15 by Western blot (1 had a
pre-existing antibody reactivity by ELISA, and 3 had pre-existing
antibody by Western blot).

The numbers of subjects is too small to draw any conclusions about the
relationship of dose to the development of antibodies.

### CONCLUSIONS REGARDING FB9702-01

This trial was not designed to show efficacy. It showed that Genzyme's
r-hαGal can reduce GL-3 inclusions in the capillary endothelium of
various organs, but did not show reductions in some other cell types in
various organs. The largest safety concern was the presence of infusion
reactions in some of the subjects, which occurred despite premedication.

Genzyme concluded that the every 14-day regimen resulted in the most
consistent reductions in substrate levels, and chose to conduct a
controlled trial to study the 1 mg/kg dose level due to a lower
incidence of infusion reactions than shown at the 3 mg/kg level.

........................................................................................................................

## **AGAL-1-002-98: CONTROLLED TRIAL**

Genzyme's Study AGAL-1-002-98, was entitled "A multicenter,
placebo-controlled, double-blind, randomized study of the safety and
efficacy of recombinant human α-Galactosidase (r-hαGAL) replacement in
patients with Fabry Disease." It was a multinational, double-blind,
randomized, placebo-controlled, multiple-dose trial in individuals with
Fabry's disease. Its primary objectives were to determine activity in
terms of reduction of enzyme substrate from kidney, heart, and skin
tissue, and to assess safety. As mentioned in the Introduction, the
endpoint had been extensively discussed with CBER before the trial was
implemented.

This trial, because of its design, is the primary evidence of
bioactivity, efficacy, and safety.

#### Treatment

Subjects were to be randomized either to receive the product, 0.9-1.1
mg/kg, or placebo (mannitol with a phosphate buffer) every 2 weeks by
intravenous infusion for 24 weeks (a protocol amendment lowered this to
20 weeks). Due to concerns about infusion reactions seen in FB9702-01
trial agent was to be infused more slowly, at no more than 0.25 mg/min
(over 4-6 hours). In addition, all subjects were to be pretreated with
acetaminophen 975-1000 mg and hydroxyzine 25-50 mg orally. The product
and placebo were to be administered as slow IV infusions. The
composition of the placebo was the same as that of the product, without
the enzyme (3% mannitol in 50 mmol sodium phosphate buffer).

#### Randomization and blinding

Subjects were to be randomized in balanced blocks stratified by site.
Placebo and active treatments were blinded.

#### Subject qualifications

Subjects were to meet the following entry criteria:

[Inclusion]{.underline}

-   ≥16 years old

-   current diagnosis of Fabry's disease

-   clinical presentation consistent with Fabry\'s disease

-   no prior treatment with r-hαGal

-   plasma α-Gal activity of \< 1.5 nmol/hr/ml or leukocyte α-gal
    activity of \<4 nmol/hr/mg

-   negative pregnancy test (urine β-hCG) prior to dosing at each study
    visit (female patients of childbearing potential)

[Exclusion]{.underline}

-   Current evidence of kidney failure or renal insufficiency, as
    defined by a serum creatinine \> 2.2 mg/dl (194.7 μmol/l)

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-   Receipt of kidney transplantation or current dialysis

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-   Clinically significant organic disease (with the exception of
    symptoms relating to Fabry disease), including clinically
    significant cardiovascular, liver, pulmonary, neurologic, or renal
    disease, or other medical condition, serious intercurrent illness,
    or extenuating circumstance that, in the opinion of the
    investigator, would preclude participation in the trial

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-   Participation in a study employing an investigational drug within 30
    days of the start of the trial

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-   Pregnancy or lactation

#### Procedures and evaluations

The following is a synopsis of the important procedures specified in the
protocol. The first infusion was to be at Visit 1 on Day 0.

-   Baseline assessments were to be completed after enrollment and
    within 28 days prior to the first infusion:

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-   Medical and surgical history, physical examination

-   Clinical chemistry, hematology, serum cystatin C, and urinalysis

-   12-lead ECG and echocardiogram

-   Leukocyte α-gal

-   r-hαGal antibody

-   GL-3 level and plasma α-Gal activity

-   Biopsy of heart, kidney, and skin

-   Short Form McGill Pain Questionnaire, SF-36 Health Survey, Fabry
    Symptom Assessment, Neuropathy Impairment Score (U.S. patients
    only), Neuropathy Symptoms and Change Score (U.S. patients only),
    Total Symptom Score

-   Neurophysiological function testing (U.S. patients only)

-   Ophthalmic examination

-   24-hour urine GL-3

-   Glomerular filtration rate by para amino hippuric acid (PAH) and
    inulin clearance

-   Dispensing of daily patient diary

-   Adverse event and concomitant medication monitoring

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-   Randomization was to occur after the above procedures had been
    completed.

-   Visits were conducted every 2 weeks, with antibody assessments,
    infusions, reviews of diaries, adverse event and concomitant
    medication assessments.

-   Subjects received periodic routine laboratory assessments

-   At the final visit (5-months, visit 11), the following were
    performed:

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-   Trial agent infusion

-   r-hαGal antibody

-   Clinical chemistry, hematology, serum cystatin C, and urinalysis

-   Pharmacokinetics (European patients only)

-   Vital signs

-   Plasma for GL-3 (prior to study drug infusion)

-   Collection and review of patient diary

-   Short Form McGill Pain Questionnaire, SF-36 Health Survey, Total
    Symptom Score, Fabry Symptom Assessment

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-   Following the final visit, there was a followup visit, with a 28-day
    window, where the following were performed:

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-   Physical examination

-   Biopsy of heart, kidney, and skin

-   Adverse event and concomitant medication monitoring

-   12-lead ECG and echocardiogram

-   Neurophysiological function testing, Neuropathy Impairment Score,
    Neuropathy Symptoms and Change Score (U.S. patients only)

-   Ophthalmologic examination

-   24-hour urine GL-3 (This could be obtained up to 14 days prior to
    Visit 11, but after the Visit 10 infusion.)

-   Glomerular filtration rate by PAH and inulin clearance

-   Standard urea and creatinine clearance tests, including 24 hour
    urine and serum chemistries, only on patients who had not undergone
    inulin clearance testing. The protocol allowed samples to be
    collected for testing after the 28 day window.

Study sites were to attempt to reach all trial participants by telephone
approximately 2 weeks after the final follow-up procedures for a safety
call.

In summary, biopsies and most measures of efficacy were to be performed
before the first infusion and after the last infusion. Subjects
completed a daily symptom diary and were monitored for adverse events
and concomitant medications during the trial. Clinical laboratories were
measured at baseline, day 84, and the end of the trial.

######  

#### Biopsy procedure and histology slide blinding and preparation

The trial operations manual specified that the kidney biopsy site be
located by means of ultrasound to the lower pole of either kidney and
that 2 cores be obtained if possible, avoiding diseased areas. For the
heart, 8 small pieces of tissue from the right ventricular
endomyocardium were recommended; for the skin, two 3 mm punch biopsies
or the equivalent amount of tissue, avoiding angiokeratomata, were
recommended from the lower flank/upper buttock. Preserved or frozen
tissue samples were to be shipped to Genzyme, identified by subject and
collection date. Genzyme personnel masked the biopsies with respect to
subject identity and trial visit using a prespecified list and shipped
them to Mt. Sinai Medical Center's histology laboratory.

Kidney biopsy samples were sectioned and stained at Mt. Sinai with
methylene blue/azure II for light microscopy and reviewed by Mt. Sinai
histology technicians for staining and tissue quality (for example,
darkness of stain and presence of wrinkles or tears). Rejected samples
required new thin sections to be prepared. The final quality review was
performed by the Mt. Sinai Director of Pathology. A rejection by the
Director required a further thin section to be made, starting the
quality review process again. Accepted slides were returned to Genzyme.
Dr. Richard Diters, an employee of Genzyme, rendered a final judgment on
the histological readability of slides under low power microscopy.
Accepted slides were sent to reviewing pathologists. Genzyme states that
Dr. Diters was not involved in the design or management of the trial,
and had no knowledge of the trial blind or timing of sample collection.

###### Comments on blinding

######  Genzyme's detailed procedures kept slide reviewers from knowledge of subject treatment assignments and trial visit. The only members of Genzyme whom the procedure unblinded were members of Quality Assurance and the personnel who created the masking list. The procedure appears adequate to assure the integrity of the review process.

######  

#### Analysis

#### 

#### Analytical populations

Genzyme prospectively defined 3 subject populations for analysis (the
intent-to-treat, as-treated, and per protocol, populations).

###### Comment

######  Although 3 populations were defined by Genzyme, this document will concentrate on one population (the "effective" intent-to-treat, in this case similar to the as-treated group).

#### 

#### Primary endpoint

The primary endpoint was based upon quantitation of GL-3 inclusions in
the capillary endothelium (vasculature) of the kidney as determined by
light microscopy.

The primary endpoint was a comparison of the number of subjects in each
group who achieve a score of Zero on the renal capillary endothelium
histology.

[Scoring method for endothelium]{.underline}

Kidney interstitial capillary endothelium was initially evaluated by 3
pathologists using a qualitative method that had not received
concurrence from CBER. Slides received scores of 0, 1, 2, or 3 ("nearly
none" or "trace," "mild," "moderate," or "severe") based on an overall
impression of the amount of GL-3 present, and a majority score was
recorded (with a procedure for resolving discrepant scoring among
pathologists).

In discussions with Genzyme, CBER raised concern regarding the
reliability and interpretability of the global, qualitative scoring
system. Subsequent to those discussions, Genzyme had a subset of the
slides re-read by the pathologists using a well-defined quantitative
scoring procedure. The following are important aspects of the scoring:

1.  Slides from the initial, nonquantitative read that were scored as 0
    or 1 were the only ones subject to the quantitative rereading
    procedure. Since only slides with scores of zero contributed to the
    endpoint "success" category, it was assumed that any slide that had
    received an overall impression of mild (i.e., clearly present
    inclusions) or worse would not achieve a score of zero on the
    re-read.

2.  Capillary score: All capillaries on each slide were individually
    examined and received grades of 0, trace, 1, 2, or 3, based on
    imaging within the endothelium at 1000x with oil immersion:

-   "0" signified no visible inclusions

-   "trace" signified a single inclusion, or 2 inclusions for
    capillaries cut in such a way that the length of the lumen was
    greater than twice the width

-   "1" signified multiple discrete lipid granules

-   "2" signified single or multiple aggregates of lipid granules

-   "3" signified aggregates of lipid granules either large enough or
    numerous enough to cause clear distortion of the luminal surface

> The entire section was scanned field by field under the microscope.

3.  Slide score: A new slide score was generated for each slide, based
    on this complete list of capillary scores on the slide. Slides were
    given a score of 0 or 1, where 0 was interpreted as "nearly clear"
    of capillary inclusions and 1 was "not clear."

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a.  5% of the total capillaries per slide with the highest scores were
    discounted from the analysis. Thus a slide with an eventual score of
    "nearly clear" could have theoretically had 4.9% of its capillaries
    scored as high as 3.

b.  The remaining capillaries were summarized by the number with each
    capillary score

c.  A slide score of 0 would be obtained if

-   More than 50% of the remaining capillaries were free of GL-3
    inclusions (capillary score 0)

and

-   The remaining capillaries contained capillaries with no higher grade
    of inclusions than "trace."

-   Otherwise the slide reread score was "not zero."

d.  All three pathologists would generate a slide score in this manner.
    The slide would receive the score that the majority of pathologists
    gave it.

###### [Comment On Endpoint Definition and Selection:]{.underline}

######  In essence, this system classified as "success" (score of 0) slides where, after disregarding the worst 5% of capillaries on a slide, more than 50% of the capillaries had no light microscopy visible inclusions, and all the rest had no more than trace inclusions. 

######  The underlying basis for this endpoint is important to understand. This study was prospectively intended primarily as a study to provide evidence regarding a surrogate endpoint in order to seek marketing approval under the Accelerated Approval mechanism. After being unable to provide good rationale why plasma levels urinary levels of substrate alone could be justifiably regarded as "reasonably likely" to predict clinical benefit, Genzyme selected the renal capillary endothelium as the histological site to evaluate the effect of enzyme administration.

###### Genzyme sought extensive discussions with CBER regarding an endpoint based on the capillary histology that might support use of the Accelerated Approval mechanism. CBER raised concerns that any specific quantitative reduction in endothelium inclusion volume (e.g., 50%, 75%, even 90%) might not result in benefit if there was a threshold phenomenon, where the remaining volume of inclusions were still sufficient to lead to vascular injury. Genzyme was unable to locate any data that could establish a level of inclusions that did not lead to vascular injury. Consequently, Genzyme proposed that restoration of capillaries to near-normal appearance overcame the concerns regarding a threshold process, and could be regarded as "reasonably likely" to predict benefit. CBER agreed that this criterion appeared to provide a much stronger case for prediction of benefit. 

######  In addition, as a result of CBER concerns over the cell-type generalizability of the histological effect, additional cell types were examined by the same pathologists at a later time. These results are discussed in this briefing document in the review of the extension trial, AGAL-005-99.

[Analytical methods and missing values]{.underline}

Genzyme followed their prospective plan for analysis. See the results
section.

#### Secondary endpoints

Secondary endpoints were as follows:

1)  Pain as assessed on the McGill short form pain questionnaire in 5
    domains (sensory, affective, total, visual analog scale, and present
    pain intensity).

2)  Composite of capillary endothelium scores of the heart, kidney, and
    skin as determined light microscopy comparing baseline to 20 weeks

3)  Total GL-3 measured by ELISA in urine and kidney tissue

#### Tertiary and "other" endpoints

> These are mentioned in the results section of this briefing document.

###### 

###### Comments on the protocol

######  Genzyme's previous results suggested that a brief trial such as this one (6months) could demonstrate differences from placebo treatment on the chosen surrogate primary endpoint. Given the expected nature of the treatment effect, the trial's brevity and small size rendered it more problematic that subjective measures such as pain and symptom scores would show relevant, meaningful differences, despite the use of placebo controls. The final endpoint was one agreed to in discussions with CBER, based on a reasonable likelihood that it would predict a clinical benefit and that a confirmatory trial would be conducted.

######  The chief evaluations, the biopsies, were performed only at the beginning and the end of the trial, making a detailed assessment of the kinetics of a possible histological effect impossible. 

### RESULTS: CONDUCT OF TRIAL

###  

#### Protocol changes

The protocol underwent significant revisions after the trial was started
(March 14, 1999). Amendments increased enrollment from about 50 to about
60; shortened the trial by one month; changed the endpoint from a
composite of histology of skin, heart, and kidney combined to the
quantitation of GL-3 in kidney alone; and finalized the agreed-to
rereading of slides by the quantitative method as the primary analysis.

###### Comments 

###### The changes to the protocol were not prompted by review of the data, and thus do not raise suspicions as to the integrity of the results of the trial. While the changes to the analytic plan and endpoint occurred well after the trial started, and were not finalized until after data collection was completed, all revisions were made while Genzyme was fully blinded to any study outcome data.

###### It is notable that the study was shortened. Subjects received one month less of infusions than initially planned. No clear scientific rationale was provided by Genzyme for this change.

#### Enrollment by site

Fifty-eight subjects were enrolled. The Mount Sinai site had the most
subjects by a large margin; 20 subjects were enrolled there, with a
range of 2-9 at the other 7 sites (Table 49).

#### Discontinuations

No subject discontinued participation in the trial.

#### 

#### Protocol violations

[Treatment assignments]{.underline}

The most important protocol violation was the reversal of treatment
assignments for 4 subjects at site 7, and partial reversal for 2
subjects at site 5 (Table 4).

Table 4. Trial AGAL-1-002-98: Errors in treatment assignment

+----------+----------+------------------+-----------------------------+
| Site     | Subject  | Intended         | Treatment                   |
|          | ID       | treatment        |                             |
|          |          |                  | Received                    |
|          |          | assignment       |                             |
+----------+----------+------------------+-----------------------------+
| 5        | 0503     | product          | 3 infusions product, then 8 |
|          |          |                  | placebo                     |
+----------+----------+------------------+-----------------------------+
|          | 0504     | placebo          | 3 infusions placebo, then 8 |
|          |          |                  | product                     |
+----------+----------+------------------+-----------------------------+
| 7        | 0701     | product          | placebo                     |
+----------+----------+------------------+-----------------------------+
|          | 0705     | placebo          | product                     |
+----------+----------+------------------+-----------------------------+
|          | 0706     | placebo          | product                     |
+----------+----------+------------------+-----------------------------+
|          | 0708     | product          | placebo                     |
+----------+----------+------------------+-----------------------------+

Additional information was supplied by Genzyme regarding these errors in
randomization and/or administration. A contractor for Genzyme for
preparing and dispensing of study treatment kits failed to inscribe some
kits with the Genzyme-supplied subject identification numbers on the
first kit for study subjects for use at sites 5, 6 and 7 (study sites
would receive additional kits for the study subjects for the sequential
infusions). Genzyme was notified of this error and able to correct it
prior to use of kits at study sites 5 and 6.

At site 5, correct kits were used for subjects 503 and 504. However, it
was noted that Subject 504 was actually treated prior to Subject 503,
and concern that the treatment kits had been reversed for the two
subjects on the part of the site was communicated to Genzyme. This led
to a switch in treatment material supplied to the site in the
understanding that this would maintain constant treatment receipt in
these two patients. After the trial was completed it was discerned that
miscommunication and misunderstandings had occurred. The initial
treatment received had been the correct intended, and the adjustment had
caused an switch in actual treatment received.

At site 7 inadequately marked initial kits were used for subjects. Kits
were used without knowledge of kit contents, but were trackable based on
other code numbers on the kit. Consequently, the treatment assignments
at site 7 can be regarded as randomized, but not according the centrally
planned randomization scheme. Of 9 patients enrolled at this site and
subject to the problem, 5 received treatment kits other than what was
centrally planned, but containing the same material as was centrally
planned. There were 4 subjects who received an initial treatment kit
different from the centrally planned and which contained the opposite
treatment from the centrally planned ( 2 each switched in each
direction, as noted in Table 3). At this site, subsequent treatment kits
were adjusted to maintain the same material as in the original treatment
kit. Documentation supplied by Genzyme established that no unblinding
information on kits had been opened.

The most important other protocol violation concerned filtration and
centrifugation of urines at both sites in France, rendering urinary
results at those sites unevaluable.

###### Comments

###### Treatment misassignments apparently occurred due to an error that was related to contractor errors and localized to certain sites. These problems were not reflective of overall trial conduct, and they were made without unblinding treatments. There is no evidence of a systematic bias in treatment assignments. Since the subjects at site 7 can be regarded as randomized without bias, analysis of the outcomes of the subjects at site 7 can be included in an as-treated basis but considered an "intent-to-treat" analysis. Subjects 503 and 504 can be included as well, since they received a substantial majority of their infusions (8/11) with a consistent material, and toward the end of the trial. Thus, subjects 503 and 504 have been included in analyses according to the majority of their treatments. This analysis can be considered the best feasible, least biased analysis of these data.

#### Adherence to dosing

Adherence to trial drug infusion and dose amount was excellent.

### RESULTS: DEMOGRAPHICS AND BASELINE CHARACTERISTICS 

There was no evidence of screening bias.

There were no major demographic differences between treatment groups
(Table 5).

Table 5. Trial AGAL-1-002-98: Demographics

+---------------------------+-------------+-------------+-------------+
| Parameter                 | Statistic   | Placebo     | r-hαGal     |
|                           |             |             |             |
|                           |             | *n=29*      | *n=29*      |
+---------------------------+-------------+-------------+-------------+
| Age                       | Mean        | 28.4        | 32          |
|                           |             |             |             |
| (yr)                      |             |             |             |
+---------------------------+-------------+-------------+-------------+
|                           | Min., Max.  | 17,61       | 16,48       |
+---------------------------+-------------+-------------+-------------+
| Weight                    | Mean        | 69.6        | 67.3        |
|                           |             |             |             |
| (kg)                      |             |             |             |
+---------------------------+-------------+-------------+-------------+
|                           | Min., Max.  | 46,96       | 50,86       |
+---------------------------+-------------+-------------+-------------+
| Height                    | Mean        | 175.6       | 175.7       |
|                           |             |             |             |
| \(cm\)                    |             |             |             |
+---------------------------+-------------+-------------+-------------+
|                           | Min., Max.  | 156,203     | 158,196     |
+---------------------------+-------------+-------------+-------------+
| Gender:                   |             |             |             |
|                           |             |             |             |
| Male                      |             |             |             |
|                           |             |             |             |
| Female                    |             |             |             |
+---------------------------+-------------+-------------+-------------+
|                           | n (%)       | 29 (100)    | 27 (93)     |
+---------------------------+-------------+-------------+-------------+
|                           | n (%)       | 0 (0)       | 2 (7)       |
+---------------------------+-------------+-------------+-------------+
| Race:                     |             |             |             |
|                           |             |             |             |
| White                     |             |             |             |
|                           |             |             |             |
| Non-White                 |             |             |             |
+---------------------------+-------------+-------------+-------------+
|                           | n (%)       | 26(90)      | 27(93)      |
+---------------------------+-------------+-------------+-------------+
|                           | n (%)       | 3(10)       | 2 (7)       |
+---------------------------+-------------+-------------+-------------+

The only two females in the trial were in the active-treatment group and
the great majority of subjects were categorized as "White." The mean age
of the placebo group was slightly lower than that of the active group,
but there was no major difference in the shape of the age distributions
in the two groups (not shown).

Baseline characteristics of the subjects were balanced (Table 6).

Table 6. Trial AGAL-1-002-98: Baseline characteristics

  ---------------------- ---------------------- ------------ ------------
  Parameter              Statistic              Placebo      r-hαGAL

  Plasma α-Gal           *n*                    *29*         *29*

  activity               Mean                   0.49         0.65

  (nmol/hr/ml)           Min., max.             0, 1.5       0, 1.5

                         *n*                    *29*         *29*

  Plasma GL-3            Mean                   14.4         14.7

  (ng/ml)                Min., Max.             0, 36        0, 36

  Serum creatinine       *n*                    *29*         *29*

                         Mean                   0.79         0.83

  Years since onset of   *n*                    *29*         *28*

  symptoms               Mean                   21.2         23.4

                         Min., Max.             9,55         8,44

  Years since initial    *n*                    *28*         *28*

  diagnosis              Mean                   9.9          10.6

                         Min., Max.             0,46         0,28

  Blood                  *n*                    *29*         *29*

  type                   A or O                 27           27

                         B or AB                2            2
  ---------------------- ---------------------- ------------ ------------

Endogenous baseline plasma α-Gal activity was below the level of
detection in all subjects (leukocyte α-Gal activity was collected after
baseline in some subjects and is not useful for comparison). The
presence or absence of the B-specific blood group antigen was equal
between the treatment groups. Thirty-seven genotypes were identified.
Among these, only 5 were shared by a subject in both treatment groups,
none by more than one subject in either group. In addition, no genotype
was found more than 3 times in any treatment group. Baseline
characteristics were balanced, and the genotype diversity precludes any
conclusions about differences between groups.

### RESULTS: BIOACTIVITY AND EFFICACY

#### 

#### Analytical population

As discussed in the description of treatment assignment errors, the "as
treated" group (including partially treated subjects 503 and 504) can be
appropriately considered as a valid least-biased analysis grouping. This
review will focus on this "as-treated/intent-to-treat" population.
Genzyme also submitted efficacy analyses for the trial population
excluding subjects 503 and 504; review of primary, secondary, and
tertiary endpoints and plasma GL-3 data (an "other" endpoint) did not
lead to different conclusions from those presented here.

#### Primary endpoint

At baseline there was a weak trend toward greater severity in the
placebo group (Table 7).

Table 7. Trial AGAL-1-002-98: Distribution of baseline kidney slide
scores\*

  ------------------------- ---------------------- ----------------------
  Slide score               Placebo                r-hαGal

  0                         0                      1

  1                         4                      7

  2                         15                     14

  3                         10                     7

  *Total*                   *29*                   *29*
  ------------------------- ---------------------- ----------------------

\*as-treated population, considered equivalent to intent-to-treat

Table 8 shows the data and analysis of the primary endpoint:
morphological appearance of inclusions in the kidney vasculature. The
p-value is based upon the prospectively-defined χ^2^ test,

and includes an imputed nonzero score for subject 307 in the
r-hαGal-treated group.

Table 8. Trial AGAL-1-002-98: Primary endpoint results: Renal capillary
endothelium inclusions\*

+------------------------+----------------------+----------------------+
| End of trial           | Placebo              | r-hαGal              |
|                        |                      |                      |
| Score                  | *n=29*               | *n=29*               |
+------------------------+----------------------+----------------------+
| Zero                   | 0                    | 20                   |
|                        |                      |                      |
|                        | (0%)                 | (69%)                |
+------------------------+----------------------+----------------------+
| Non-zero               | 29                   | 9                    |
|                        |                      |                      |
|                        | (100%)               | (31%)                |
+------------------------+----------------------+----------------------+
| Odds ratio             | 0.008                |                      |
|                        |                      |                      |
| (C.I.)                 | (0.00, 0.14)         |                      |
+------------------------+----------------------+----------------------+
| p-value                | \<0.001              |                      |
+------------------------+----------------------+----------------------+

\*as-treated population, considered equivalent to intent-to-treat

Table 9 shows details of the end-of-trial scores used to assign "zero"
or "nonzero" status. The p-value is based on a 2x4 χ^2^ test.

Table 9. Trial AGAL-1-002-98: Distribution of end‑of‑trial slide
scores\*

+------------------------+----------------------+----------------------+
| End of trial           | Placebo              | r-hαGal              |
|                        |                      |                      |
| score                  | *n=29*               | *n=29*               |
+------------------------+----------------------+----------------------+
| 0                      | 0 (0%)               | 20 (69%)             |
+------------------------+----------------------+----------------------+
| 1                      | 7 (24%)              | 8 (28%)              |
+------------------------+----------------------+----------------------+
| 2                      | 11 (38%)             | 0 (0%)               |
+------------------------+----------------------+----------------------+
| 3                      | 11 (38%)             | 1 \*\* (3%)          |
+------------------------+----------------------+----------------------+
| p-value                | \<0.001              |                      |
+------------------------+----------------------+----------------------+

\*as-treated population, considered equivalent to intent-to-treat

\*\*Subject 307, attributed a worst-case score in the absence of an
end-of-treatment biopsy

These data show that in the active-treated group, end-of-trial nonzero
scores were only in the mild category (excepting the one purely imputed
score), but that in the placebo group scores were distributed among
mild, moderate, and severe. The results show that the effect of r-hαGal
was to diminish renal capillary endothelial GL-3 regardless of baseline
severity.

The results of Genzyme's ANOVA analysis are consistent with these
results.

[Review of transmission electron microscopy]{.underline}

During the second, quantitative reading of the kidney slides
pathologists assessed transmission electron photomicrographs. In no case
was a discrepancy noted, showing that electron microscopy evaluation was
consistent with the light microscopic appearance.

#### Genzyme's exploration of primary endpoint

The following section describes important additional analyses conducted
by Genzyme to examine the robustness of their primary results.

[Baseline scores for subjects with treatment errors]{.underline}

Baseline histological severity of the subjects with treatment assignment
reversals were distributed similarly (1 each at 1, 2, and 3). This
supports the view that there was no bias in the treatment
(mis-)assignment related to baseline severity.

[Distribution of baseline scores among those who ended trial with a "0"
score]{.underline}

The activity of the product was not limited to those with lower baseline
kidney slide scores. The majority of subjects who achieved a score of
"0" at the end of treatment had baseline scores of "2" or "3. (Table
50).

[Consistency of the pathologists in scoring]{.underline}

Genzyme tabulated the proportion of "0" scores by pathologist for both
the intent-to-treat and the as-treated population. All pathologists gave
the active-treated groups many more "0" scores.

The proportion of capillaries with a capillary score of "0" was almost
uniformly more than 90% for each pathologist (Genzyme analysis done on
the absolute-intent-to-treat group).

Dr. Rennke scored the most capillaries in a given biopsy in almost all
cases, sometimes by 100 or more. Dr. Rennke's greater number of
capillaries scored did not render his overall result discrepant from the
others; Dr. Colvin, not Dr. Rennke, was the pathologist whose number of
zero scores differed most from the rest (Dr. Rennke scored 21/29 with a
score of "0," Dr. Colvin 12/29, and Dr. Dikman 27/29).

[Sensitivity of Score to disregarded capillaries]{.underline}

Genzyme's scoring system allowed for an arbitrary 5% of the worst
capillaries to be excluded from consideration. Genzyme proposed this
procedure in the prospective design due to concerns that a small number
of aberrant capillaries might prohibit a dramatic effect on the overall
biopsy from being demonstrated. The 5% value was arbitrarily chosen.

Genzyme examined the slide score results if alternative disregard
criteria were used. When a more stringent criterion of 1% disregard was
used, there were only 10 galactosidase subjects achieving a score of 0,
vs. none in the placebo group. When a more liberal criterion of 10% was
used, overwhelming predominance of the "0" score in the galactosidase
group remained (24 vs. 3 using the absolute-intent to treat grouping).

######  Comment: While the 5% criterion is arbitrary and may be too liberal an amount of capillaries to disregard, the finding of treatment associated difference in histological outcome is a consistent finding. The fraction of subjects who achieve "success" is altered by the 1%-5%-10% criterion, and thus possibly the fraction of patients who may ultimately benefit. The observation of a treatment related effect is a highly robust finding.

[Effects of age on primary endpoint]{.underline}

Genzyme stratified the endpoint analysis at the median age of the
overall population, 30 years. The analysis of age is important since
Fabry's disease is a congenital disorder and duration of disease is the
same as age. Table 10 shows that the active treatment was effective
regardless of the age group, although there does seem to be a slightly
diminished effect in the older group (see CBER's sensitivity analyses).
Older subjects did not have a greater baseline severity (not shown).

Table 10. Trial AGAL-1-002-98: Effect of age on the primary endpoint\*

+-----------------+---------------+----------------+------------------+
| Age stratum     |               | Placebo        | r-hαGal          |
|                 |               |                |                  |
| (years)         |               |                |                  |
+-----------------+---------------+----------------+------------------+
|                 | Zero          | 0              | 9 (82%)          |
+-----------------+---------------+----------------+------------------+
| \<30            | Non-zero      | 18 (100%)      | 2 (18%)          |
+-----------------+---------------+----------------+------------------+
|                 | p-value       | \<0.001        |                  |
+-----------------+---------------+----------------+------------------+
|                 | Zero          | 0              | 11 (61%)         |
+-----------------+---------------+----------------+------------------+
| 30+             | Non-zero      | 11 (100%)      | 7 (39%)          |
+-----------------+---------------+----------------+------------------+
|                 | p-value       | 0.001          |                  |
+-----------------+---------------+----------------+------------------+

\*as-treated population, considered equivalent to intent-to-treat

[Effects of ethnicity and gender on primary endpoint]{.underline}

The number of "non-White" subjects was very small (5), and there were
only 2 women in the trial. No conclusions can be made regarding
ethnicity or gender from this small amount of data.

[Effect of trial site on endpoint]{.underline}

Results were generally consistent from site to site (Table 51). Although
center 1 had the most subjects, it did not alone produce the favorable
results. Other centers had results fully consistent with those seen at
site 1. Centers 3 and 5, with a total of only 1 slide scored as a "0" in
6 r-hαGal-treated subjects, did not contribute to the overall effect.

#### CBER's exploration of the primary endpoint

Table 11 shows the numbers of subjects with specific kidney slide score
changes from baseline, tabulated by treatment group and baseline score.
This analysis shows numbers of subjects with scores of "0" at the end of
the trial and change in score as a function of baseline score. Change
score is potentially a more sensitive indicator of the effect of
treatment than achievement of a criterion value. In addition, this
analysis, when carried out on the placebo group (which is not expected
to change appreciably on a laboratory criterion in a brief trial such as
this one), allows examination of the variability of the scoring
procedure.

Table 11. Trial AGAL-1-002-98: Numbers of subjects with specified
changes from baseline score, by baseline score, on "as-treated"
population (bold signifies numbers of subjects who achieved a score of
"0" at the end of the trial)

  ---------- ---------- ---------- -------- ------- ------- --------- ------- -------
  Group      Baseline   Change                                                
                        from                                                  
                        baseline                                              

             score      better                              worse\*           total

                        -3         -2       -1      0       1         2       

             0                                      **0**   0         0       0

             1                              **0**   1       1         2       4

  Placebo    2                     **0**    3       5       7                 15

             3          **0**      3        5       2                         10

             total      0          3        8       8       8         2       29

             0                                      **1**   0         0       1

             1                              **3**   3       0         1       7\*\*

  r-hαGal    2                     **11**   3       0       0                 14

             3          **5**      2        0       0                         7

             total      5          13       6       4       0         1       29
  ---------- ---------- ---------- -------- ------- ------- --------- ------- -------

\*There were no worsenings by greater than 2

\*\*This includes subject 307, who failed to have a biopsy at the end of
trial, and who was attributed a worst‑case score of 3 at the end of the
trial.

Among the placebo subjects the overall distribution of change scores was
centered around 0, with approximately equal numbers of slides getting
worse or better by 1 or 2 points. The fact that a moderate number of
placebo subjects changed by 1 point in either direction (and in fact
most subjects did not remain at the baseline score) shows that a change
in score by 1 point does not reliably indicate a true change. However,
more than one half of the improvement in scores in the active group were
of magnitude 2 or 3, which is reliably measured change.

[Localization of biopsy tissue]{.underline}

A small number of biopsies were of medullary tissue, not cortical
tissue. These results of these biopsies were consistent with those of
cortical tissue.

[Subgroup analysis of the primary endpoint (age)]{.underline}

The increased proportion of nonzero scores in the older age group (see
Genzyme's analysis above) is not due to a greater number of subjects
with most severe disease, as the distribution of baseline scores in the
two age groups is similar (not shown).

When the r-hαGal-treated subjects are analyzed by study quartiles of
age, there is no age-related pattern of change score from baseline
(Table 12). Note that the age distribution was not identical in the two
groups. The r-hαGal-treated subjects were slightly older, so that there
are more subjects in the 30-40 yo subset than other subsets within this
group. The apparent greater activity of the enzyme in the younger
subjects suggested by the Genzyme analysis above is not borne out by a
more subdivided analysis.

Table 12. AGAL-1-002-98: Change Score by age in r-hαGal-treated subjects

  ---------- ------------- ---------- ---------- ---------- ---------- -----------
  Age        Change Score                                              p-value\*
             ( (-)                                                     
             signifies                                                 
             improvement )                                             

             -3            -2         -1         0          +2         

  ≤ 21.5     0             3          1          1          0          0.94

  (21.5,     3             1          1          0          1          
  29.5\]                                                               

  (29.5,     1             5          2          2          0          
  40\]                                                                 

  \> 40      1             4          2          1          0          
  ---------- ------------- ---------- ---------- ---------- ---------- -----------

\* Jonckheere-Terpstra test

[Other CBER subgroup analyses of the primary endpoint]{.underline}

The CBER statistical reviewer examined the distribution of change scores
as a function of quartiles of baseline plasma GL-3 and kidney GL-3 and
when dichotomized at the median of urinary GL-3. There was no notable
pattern of change scores using any of these parameters (analyses not
shown in this document).

#### Independent pathologist's evaluation of primary endpoint

CBER requested an assessment of the kidney biopsy slides from J. Charles
Jennette, M.D. Dr. Jennette is a renal pathologist and Professor and
Chair of Pathology and Laboratory Medicine at the University of North
Carolina School of Medicine. CBER asked Dr. Jennette to examine a subset
of all the kidney slides, containing the full range of scores in each
treatment group. He concluded that the scoring of lipid inclusions was
"relatively reproducible" and that "the specimens can be accurately
grouped on the basis of the relative extent of lipid accumulation in
peritubular capillaries." Dr. Jennette's slide scores shows a good
correspondence to the scores given by the renal pathologists trained and
employed by Genzyme (Table 52).

###### Comments on primary endpoint

######  The activity of r-hαGal on renal interstitial capillaries was robustly shown in this trial. Subgroups of gender and ethnicity were too small to render useful information. Based on a small number of subjects, there may have been a small diminution of effect with increasing age, but this suggestion is not fully supported by further sensitivity analyses. The overall results were not driven by site, but occurred nearly uniformly throughout the trial. 

#### 

#### Secondary endpoint: McGill pain questionnaire

Based on a Wilcoxon signed rank test on the mean changes from baseline,
both groups showed statistically significant differences from baseline
for all measures. This may have been due to the effect of simply being
in a clinical trial. Except for the PPI question, placebo subjects
appeared to fare slightly better than their treated counterparts. Based
on the t-test on the mean change scores, however, there were no
differences between the treatment groups in the changes from baseline.

Pain medication usage is consistent with these results. They are
reviewed in the section on tertiary endpoints.

#### Secondary endpoint: Composite score for change in the GL-3 levels in kidney, skin, and heart

The composite score combined kidney, heart, and skin scores. Because the
kidney scores have already been discussed, this briefing document will
only discuss heart and skin results here.

Unlike the kidney biopsies, which were subject to special scrutiny
because of their place as the primary endpoint, the skin and heart
biopsies were not re-read using a detailed quantitative scoring
procedure. Three pathologists expert in interpreting the histology of
heart and three for skin scored slides from 0-4 based on an overall
judgment of severity. A majority score for each slide was determined.

The distribution of baseline severity for heart and skin scores was
similar between the treatment groups(Table 53).

Table 13 shows the numbers of subjects with a score of "0" at the end of
the trial. The p-value is based upon a χ^2^ test. These results
corroborate the effect of the product on reducing endothelial substrate
levels in kidney.

Table 13. Trial AGAL-1-002-98: Skin and heart biopsy results: Zero and
non‑zero status in capillary endothelium at the end of the trial\*

+-----------------+-----------------+----------------+----------------+
| Organ           | End of trial    | Placebo        | r-hαGal        |
|                 |                 |                |                |
|                 | score           | *n=29*         | *n=29*         |
+-----------------+-----------------+----------------+----------------+
|                 | Zero            | 1 (3)          | 21 (72)        |
+-----------------+-----------------+----------------+----------------+
|                 | Non-zero        | 28 (97)        | 8 (28)         |
+-----------------+-----------------+----------------+----------------+
| Heart           | Odds ratio      | 0.014          |                |
+-----------------+-----------------+----------------+----------------+
|                 | p-value         | \<0.001        |                |
+-----------------+-----------------+----------------+----------------+
|                 | Zero            | 1 (3)          | 29 (100)       |
+-----------------+-----------------+----------------+----------------+
|                 | Non-zero        | 28 (97)        | 0              |
+-----------------+-----------------+----------------+----------------+
| Skin            | Odds ratio      | 0.001          |                |
+-----------------+-----------------+----------------+----------------+
|                 | p-value         | \<0.001        |                |
+-----------------+-----------------+----------------+----------------+

\*as-treated population, considered equivalent to intent-to-treat

Based on the pathologists' judgments of heart and skin histology,
treatment with r-hαGal reduced heart and skin capillary endothelial GL-3
levels. Quantitative conclusions are hard to make due to the qualitative
method of analysis, but levels of reduction in the skin appeared
commensurate with those of the kidney, while levels of reduction in the
heart capillary endothelium appear to be not as pronounced.

#### Secondary endpoint: urinary and kidney tissue GL-3

Urinary GL-3 was determined biochemically in filtrates of urine from
24-hour urine collections and in renal biopsy tissue. Table 14 shows the
percent change from baseline for urinary GL-3 and kidney tissue GL-3,
and the rank sum score derived from these parameters. Genzyme reports a
p-value (using a Cochran-Mantel-Haenszel method) of 0.005 for the
difference in change between the treatment groups in urinary GL-3
favoring r-hαGal treatment. The p-value for kidney tissue GL-3 was
0.256, and the combined rank score p-value was 0.003.

The following points are important in review of these data:

-   While the renal tissue GL-3 levels sum the substrate from all cell
    types in the kidney, the urinary GL-3 is thought to derive only from
    shed renal tubular cells. The precise determinants of the shedding
    of tubular cells are not known.

-   Collection of urine samples for GL-3 was less complete than for the
    biopsy or pain data. At site 7 baseline urine data were compromised
    by faulty filtration procedures, and at site 8 an invalid
    centrifugation method was used; Genzyme omitted data from these
    sites in their analysis. Genzyme's analysis also omits the data from
    subject 307; this subject's end-of-treatment sample was lost.

-   The median change in urinary GL-3 for the placebo group was
    considerably positive, an unexpected finding in a placebo group that
    is expected to be stable. This makes the overall reliability of the
    urinary GL-3 data suspect.

-   Ranks for each subject for each of these determinants were given;
    the combined score for each subject was obtained as the sum of the
    ranks of each of the parameters. Since the urinary GL-3 measurement
    is from cells included in the total renal GL-3 level, the combined
    score is not based upon entirely separate measurements.

-   The reliability of the statistical difference reported by Genzyme
    for the urinary GL-3 data is compromised by its derivation from a
    nonrandomized subset of the population. The reliability of the
    kidney GL-3 statistic is higher given that the great majority of
    subjects contributed data.

Table 14. Trial AGAL-1-002-98: Urinary and kidney tissue GL‑3 and
changes from baseline

+----------+-------------+----------+----------+----------+----------+
| P        | Statistic   | Placebo  |          | r-hαGal  |          |
| arameter |             |          |          |          |          |
+----------+-------------+----------+----------+----------+----------+
|          |             | baseline | \%       | baseline | \%       |
|          |             |          | change   |          | change   |
+----------+-------------+----------+----------+----------+----------+
| Urine    | *n*         | *21*     | *21*     | *21*     | *21*     |
|          |             |          |          |          |          |
| GL-3^1^  |             |          |          |          |          |
+----------+-------------+----------+----------+----------+----------+
|          | Median      | 1353     | 42.8     | 1612     | -23.3    |
+----------+-------------+----------+----------+----------+----------+
|          | 25^th^      | 167      | -5.7     | 777      | -54.5    |
|          | Percentile  |          |          |          |          |
+----------+-------------+----------+----------+----------+----------+
|          | 75^th^      | 3716     | 420.1    | 2641     | 7.5      |
|          | Percentile  |          |          |          |          |
+----------+-------------+----------+----------+----------+----------+
| Kidney   | *n*         | *28*     | *28*     | *27*     | *27*     |
|          |             |          |          |          |          |
| Tissue   |             |          |          |          |          |
| GL-      |             |          |          |          |          |
|          |             |          |          |          |          |
| 3^2^     |             |          |          |          |          |
+----------+-------------+----------+----------+----------+----------+
|          | Median      | 6510     | -6.2     | 5262     | -34.1    |
+----------+-------------+----------+----------+----------+----------+
|          | 25^th^      | 3407     | -62.1    | 2326     | -79.6    |
|          | Percentile  |          |          |          |          |
+----------+-------------+----------+----------+----------+----------+
|          | 75^th^      | 10670    | 31       | 9104     | 19.9     |
|          | Percentile  |          |          |          |          |
+----------+-------------+----------+----------+----------+----------+
| Combined | *n*         | *21*     |          | *20*     |          |
|          |             |          |          |          |          |
| Score of |             |          |          |          |          |
|          |             |          |          |          |          |
| changes  |             |          |          |          |          |
+----------+-------------+----------+----------+----------+----------+
|          | Median      | 48       |          | 32.5     |          |
+----------+-------------+----------+----------+----------+----------+
|          | 25^th^      | 42       |          | 24.5     |          |
|          | Percentile  |          |          |          |          |
+----------+-------------+----------+----------+----------+----------+
|          | 75^th^      | 61       |          | 44       |          |
|          | Percentile  |          |          |          |          |
+----------+-------------+----------+----------+----------+----------+

> ^1^ baseline values expressed as nmol/filter

^2^ baseline values expressed as ng/mg

###### Comments on secondary endpoints

######  Scores on the McGill pain questionnaire improved in both active and placebo groups during the trial, probably from the psychological effects of being in a clinical trial, but there were no differences between the treatment groups. Other pain-related data (see section on tertiary endpoints and the section on concomitant medications in the safety review) also failed to show a reduction in pain from treatment with r-hαGal.

######  The skin and heart biopsy light microscopy data, obtained in a less rigorous manner than the kidney data, were consistent with the kidney scores in showing that r-hαGal reduces capillary endothelial substrate levels. 

######  The results for the urinary GL-3 are difficult to interpret for the reasons stated in the description of results for Table 14. The data suggest that the product reduced total renal GL-3 content. The lack of statistical difference between the treatment groups in the measurement of the total GL-3 content in the kidney may be due to a lack of effect in cell types other than the renal interstitial capillaries, as suggested in results from FB9702-01.

#### Tertiary endpoints

There were 11 protocol-specified exploratory endpoints; these are the
primary clinical data from AGAL-1-002-98. The results will be briefly
summarized. Some of the measures were assessed in U.S. subjects only
(approximately 14-16 subjects); for this population, no dispensing
errors occurred and the intent-to-treat population was the same as the
as-treated population.

1.  Vibration detection threshold, for the U.S. patients only. There was
    no difference in the change from baseline observed between treatment
    groups at Visit 11.

2.  The Neuropathy Impairment Score, done for U.S. patients only. This
    is a scoring system based on a routine neurological examination of
    finger and toe sensation, the cranial nerves, reflexes, and lower
    limb weakness and reflexes. Overall, there were few differences,
    with the slight differences observed tending to favor placebo.

3.  Neuropathy Symptom and Change Score, done for the U.S. patients
    only. This is based on subject reporting of their symptoms and the
    symptoms' changes from a previous period. Changes were similar for
    both groups for nearly all measures. Genzyme cites the fact that 2
    of the 3 autonomic scores (autonomic symptom and severity, not
    change) as well as the total symptom severity score trended toward
    greater improvement in treated subjects; however, the baseline
    scores also were higher in the active group for these measures.

4.  The Total Symptom Score (comprised of four symptoms: stabbing pain,
    burning, prickling/pins and needles, and numbness/feeling of being
    asleep). Mean scores for both groups fell by less than a point
    (range of test scores, 0-14.6) in both groups.

5.  SF-36 Health Status Survey. This questionnaire was designed to
    assess general health, not specific for Fabry\'s disease. It
    consists of 36 weighted questions falling into 8 categories
    (physical functioning, role limitations due to physical health, role
    limitations due to emotional problems, vitality, mental health,
    social functioning, pain, and general health). Baseline scores were
    similar for almost all subscales except for role limitations due to
    physical function; end-of-treatment scores for subscales were almost
    identical.

6.  Physician Assessment of Fabry Symptoms and global perception of
    subject status. The former consisted of an evaluation of better/not
    better in terms of angiokeratomas, abnormal sweating, and abdominal
    pain. There was no between-treatment group difference in the number
    of subjects rated as getting better in any of these parameters. In
    the as-treated population, physician answers to the question whether
    subjects had abnormal sweating changed from "yes" to "no" (baseline
    to end of trial) in 1 placebo and 3 r-hαGal-treated subject, a very
    small difference. Genzyme states that the global perception of
    subject status (same, improved, or worse) did not differ between the
    two treatment groups. The investigator's global perception data were
    apparently not provided in the submission.

7.  Number of symptom-free days. This measure trended toward lower
    values in the r-hαGal group, with very large variation (as-treated
    groups: placebo vs. r-hαGal mean ± standard deviation, 70 ± 57 vs.
    56 ± 56).

8.  Number of episode-free days (no pain and no medication for pain).
    This measure trended toward lower values in the placebo group
    (as-treated groups: placebo vs. r-hαGal mean ± standard deviation,
    43 ± 53 vs. 48 ± 56).

9.  Mean pain score on 0-10 scale. Mean values were slightly different
    at baseline (as-treated groups: placebo (*n=28*) vs. r-hαGal
    (*n=29*) mean ± standard deviation, 1.9 ± 1.62 vs. 2.2 ± 1.9); for
    both groups the drop in scores was 0.6 points.

> Genzyme presented an additional analysis of diary data not specified
> in the protocol: number of days in which pain medications were taken,
> measured in all subjects. This measure trended toward lower values in
> the r-hαGal group, with very large variation (as-treated groups:
> placebo vs. active mean ± s.dev., 65 ± 63 vs. 58 ± 68). These pain
> data are difficult to interpret, as the medications were not
> specified.

10. Glomerular filtration rate, planned for all subjects (see Table 32
    in the review of Study AGAL-005, with results included to 18 months
    of the extension trial AGAL-005-99). The analysis presented by
    Genzyme must be interpreted with caution: GFR was estimated from
    creatinine clearance for some subjects and directly by inulin
    clearance for others. Baseline glomerular filtration rate was not
    balanced between the treatment groups. GFR improved for the placebo
    as well as the r-hαGal-treated group (placebo and r-hαGal GFRs
    changed from 97 to 108 ml/min and from 82 to 93 ml/min,
    respectively), which is a medically unlikely result.

> Genzyme has submitted GFR results from baseline of AGAL-1-002-98 to 18
> months of AGAL-005-99, calculated with the inulin technique and
> separately as estimated with an equation that uses plasma creatinine,
> age, sex, and whether a person is "black".^5^ These results similarly
> do not show a benefit of r-hαGal treatment.
>
> In sum, the data on GFR are not reliable indicators of the true
> effect, if any, of r-hαGal on renal function due at least in part to
> the confounding factors described above.
>
> Genzyme examined serum cystatin C, whose role in the measurement of
> renal function has not been established clinically as yet.
> R-hαGal-treated subjects had a higher baseline value, but values at
> the end of the trial were similar. These results were inconclusive and
> may represent a regression toward a mean (nontreated) value.

###### Comment

###### CBER examined serum creatinines in AGAL-1-002-98 and AGAL-005-99 (the extension trial) as a measure of renal function. The results show no treatment effect (Table 33, review section of Study AGAL-005).

11. Autonomic status (also termed Global Autonomic Status), done for the
    U.S. subjects only. It was based on changes from baseline to the end
    of the trial in the Quantitative Sudomotor Axon Reflex Test (QSART,
    measuring sweat quantity), the Thermal Detection Threshold just
    noticeable difference score in the left dorsal foot, and venous
    occlusion plethysmography (measuring percent volume change in limb
    blood flow). No reliable clinical difference was shown.

###### Comments on tertiary endpoints

######  None of the tertiary endpoints, which were clinically oriented, was solidly positive. The small number of subjects overall, the fact that some of the tests were performed in an even smaller group (U.S. subjects only), the lack of established clinical validity of several of the measurements, and the very brief duration of the trial contributed to the uncertainty of the results. These results do not support a conclusion that galactosidase is ineffective, but neither do they permit concluding that direct clinical efficacy benefits have been established. 

#### "Other" endpoints 

1.  Ophthalmological examination findings. Genzyme reports that no
    differences were discerned.

2.  Urinary protein to creatinine ratio. Data were only available for
    two subjects. No analysis was performed by CBER.

3.  Renal plasma flow was not assessed due to the unavailability of a
    reagent used for the test.

4.  Plasma GL-3 levels, determined in all subjects. Baseline values were
    nearly identical (intent-to-treat population: means of 14.7 and 14.4
    ng/μl in placebo and active groups, respectively); levels at visit
    11 showed a notable reduction in the r-hαGal-treated group (11.0 and
    1.3 ng/μl respectively, p\<0.001).

Total tissue GL-3 levels in skin and heart biopsies as determined by
ELISA (not endpoints in the trial). Median percent change were not
different between treatment groups (Table 54). However, there was a
difference in the change in heart mean and median GL-3 levels at the end
of the trial between the two treatment groups. This suggests that there
was a reduction due to r-hαGal in some subjects.

The reliability of the results for skin are questionable; while mean
tissue GL-3 for the placebo group did not change appreciably from
baseline to end of trial, the median percent change was considerably
negative. It would not be expected to change.

The trial included the performance of ECGs and echocardiograms, whose
results were not endpoints in the trial. Genzyme reports that there were
no changes from the baseline in cardiac conduction and ventricular size.
In addition, Genzyme reports no differences between active and treatment
groups in echocardiographic determinations.

###### Comments on "other" endpoints

######  Plasma GL-3 levels were reduced noticeably in the actively treated population. The clinical relevance of this finding has not been established, but the result is generally supportive of the primary endpoint. Tissue GL-3 levels rendered some minimal support for the primary endpoint in showing some reductions in heart, and possibly skin, levels with treatment.

######  The ophthalmological findings, like the clinical tertiary endpoints, did not show a clinical change effected by the product. 

######  ECG and echocardiographic data as summarized by Genzyme did not lend support for a benefit of the product. 

#### Antibody development and effect on bioactivity

No subject developed IgE against r-hαGal. Nearly all of the subjects
receiving the Genzyme product (24 out of 29) developed an IgG titer
against α-Gal A at some point during the trial (Table 55). The earliest
time to development of an anti-r-hαGal IgG was visit 3, the latest,
visit 11.

A subject from the placebo group developed a persistent antibody titer
starting at visit 5. The explanation for the event is not clear.

CBER examined the proportions of subjects with scores of "0" at the end
of the trial by antibody status. Of the 23 active treatment subjects who
seroconverted, 16 (67%) achieved a "0" score at the end of treatment
(excluding subject 307, who failed to have a biopsy). Five
r-hαGal-treated subjects did not seroconvert, of whom 4 (80%) had a "0"
score at the end of treatment. These proportions suggest that
development of antibody during the trial did not have an effect on
achievement of the endpoint.

Analyses by CBER failed to show an effect of time to development of
antibody (Table 56) or peak titer (Table 57) and the change score on
renal histology.

Five treated subjects had non-0 plasma GL-3 levels at the final visit of
AGAL-1-002-98 (4/5 were noticeably reduced from baseline of
AGAL-1-002-98). The peak antibody titers of these subjects compared to
the trial population as a whole did not show a pattern suggesting a
correlation of peak titer with non-0 status.

###### Comment

######  CBER analyses did not show the effects of antibody development in this brief trial. Results from longer term exposure may suggest that there is little effect of antibody development on the ability to sustain a histological improvement. See results from the extension trial to follow.

#### Pharmacokinetics

Only 11 r-hαGal-treated subjects had data analyzed for pharmacokinetics.
The conclusions of the pharmacologist were that development of
antibodies does not appear to alter terminal elimination half-life (mean
89 ± 20.2 min, range 82-=119 min), but it appears to reduce maximal
serum concentration and the total exposure. The area under the curve of
serum concentration was reduced by the 11^th^ infusion to 27% of initial
in a subgroup of 3 subjects with the highest antibody titers (≥12,800).
The maximal concentration fell to 26% in these subjects.

###### Comment

######  The drop in exposure due to the development of antibodies raises a concern that histological and potential clinical effects might wane with chronic use in at least a subset of patients taking r-hαGal. 

### 

### Summary (bioactivity and efficacy)

The primary endpoint of change to "0" in kidney slide scores was
markedly positive, and robust to sensitivity analyses. The studied
population was nearly all male, as expected, and nearly homogenous for
ethnicity, so subgroup analyses using gender and ethnicity were not
feasible. When the results are examined dichotomized at the median age,
there is a weak suggestion that the older half of the studied population
may have not achieved as much benefit, but this statement is tenuous.
Development of antibody to r-hαGal early in the trial did not limit the
extent of reduction at the 5-month endpoint. Reductions in
histologically apparent substrate levels were noted in the vascular
endothelium of the skin and heart, consistent with the primary endpoint
results. However, total GL-3 levels in tissue did not change as
consistently, despite a marked reduction in plasma substrate in
r-hαGal-treated subjects.

In response to CBER concerns, Genzyme commissioned the same pathologists
who performed the renal histological analysis to perform analyses of
additional cell types in the kidney biopsies for this trial. These were
done at the same time as these additional biopsies were read as a part
of the analysis of the extension trial, AGAL-005-99. Please see the
"Bioactivity and efficacy" section of the review of AGAL-005-99 for
these important results.

The trial did not show or trend strongly toward any clinical benefit,
despite a large number of exploratory clinical analyses.

### RESULTS: SAFETY

Similar to the case for measures of efficacy and bioactivity,
AGAL-1-002-98 provides the only source of controlled safety data to
date. However, this is a brief trial. Longer term, uncontrolled data
will be reviewed in this document under the review of AGAL-005-99, the
open-label treatment extension to this trial.

#### 

#### Exposure and population analyzed

Twenty-eight subjects received all of their r-hαGal infusions; subject
503 received 3 infusions of product, and subject 504 received 8
infusions of product.

This analysis of safety excludes subject 503, who only received 3
infusions of r-hαGal. The omission of subject 503 from the r-hαGal group
would not affect the overall analysis of safety.

#### Deaths

There were no deaths in the trial.

#### Adverse events

[Serious adverse events]{.underline}

Nineteen serious adverse events occurred during the trial:

-   8 serious adverse events associated with a biopsy procedure (5
    placebo, 3 r-hαGal)

-   11 other serious adverse event:

placebo:

-   accidental injury (fall), convulsions, and speech disorder in a
    single subject

-   worsening of angina, coronary artery occlusion, surgical bleeding,
    and pericardial effusion in a single subject

-   paresthesia

-   intracranial hemorrhage (subdural hematoma after a fall)

r-hαGal:

-   worsening of depression in a subject on treatment for depression;
    this event responded to a change in antidepressant medication. The
    time of onset of the episode is not detailed in the BLA submission.

-   cellulitis. The episode of cellulitis occurred in the ankle of the
    subject who had a history of osteomyelitis in that ankle, about 1
    month after the first infusion. The subject required intravenous
    antibiotics, and as of this writing of the final report submitted to
    the BLA had not recovered.

###### Comment

######  Serious adverse events were rare in this brief trial. There was no discernible pattern of toxicity of r-hαGal in these serious adverse event data. 

[Adverse events: events leading to treatment
discontinuation]{.underline}

No subject discontinued participation in the trial.

[Nonserious adverse events]{.underline}

Table 58 shows the distribution of adverse events in AGAL-1-002-98.

Rigors (including chills, shaking chills, and cold flashes) and fever
were the two events with the greatest increase in frequency and severity
in the active-treatment group (Table 58). The great majority (33/40) of
adverse events coded as rigors in the active-treatment group were at
least possibly due to the infusion, and the majority ( 9/14) episodes of
fever occurred on the day of infusion.

Hypertension as an adverse experience was much less common than in trial
FB9702-01. The 3 hypertensive events were associated with infusion
reactions (see below).

The term "pain" was reported for more r-hαGal-treated subjects. It
included various events characterized as, for example, "pain," "sore
feet," "pains in hands," and "discomfort following a fall." As Table 58
shows, most of these events were mild in severity. "Fabry pain" occurred
more often in r-hαGal-treated subjects, both in mild and in severe
events.

CBER did not find evidence for serum sickness in an examination of
adverse event terms that might be associated with this syndrome.

[Infusion reactions]{.underline}

Infusion reactions were a prominent feature of the administration of the
product, occurring in 16/29 r-hαGal-treated subjects and no
placebo-treated subjects. Most infusion-related events were fever and
chills, followed by Fabry pain or myalgia. Hypersensitivity reactions,
gastrointestinal symptoms, cardiovascular signs and symptoms, and
headache accounted for the rest (Table 59).

Suspected hypersensitivity reactions occurred in 12 of these 16
subjects, at the 4^th^ infusion or later. Symptoms in some subjects
included chest tightness and shortness of breath, itchiness, flushing,
wheezing, and hypotension, as well as the more common shaking chills and
fever. (Table 60). These infusion reactions occurred in some subjects
despite the institution of steroids in addition to the routine
preinfusion medications. With pretreatment the events were mostly of
mild to moderate severity but infusion rate adjustments and medications
were instituted in most cases. With treatment, infusion reactions
resolved. All subjects completed their trial regimen of infusions.

Most, but not all subjects with suspected hypersensitivity reactions had
serum IgG to r-hαGal, consistent with the overall seroconversion rate
(Table 61). Although IgE was not tested for every reaction, serum IgE
was not found in the great majority of subjects at the last infusion
tested, indicating that serum IgE was not required for infusion
reactions. The presence or absence of leukocyte α-Gal activity or
protein did not correlate with the presence of an infusion reaction.

###### Comments on nonserious adverse events, including infusion reactions

######  The most significant adverse event was infusion reaction, which occurred despite pretreatment in many subjects, but resolved with various significant treatments or infusion rate adjustments or both. The presence of immediate hypersensitivity reactions is concerning, despite the fact that subjects continued their treatment regimens in this clinical trial. Data on leukocyte α-Gal, anti-α-Gal IgG, and anti-α-Gal IgE in serum do not allow a prediction of who will experience an infusion reaction. 

######  Hypertension as an adverse event occurred much less frequently during AGAL-1-002-98 than during FB9702-01. The reasons for this are not entirely clear, but could conceivably be due to differences in reporting or to differences in product (AGAL-1-002-98 used a larger scale production method than FB9702-01). 

######  There was no clear indication of immune complex disease, despite seroconversion in the majority of subjects treated with the product. 

*Genzyme's data do not point to a subject characteristic that will allow
prediction of the likelihood of an infusion reaction.*

######  

[Laboratory abnormalities]{.underline}

Routine hematology, serum chemistries, and urinalysis were determined at
baseline and several times during the trial (visits 4, 7, 10, and end of
trial). Mean and median values revealed no aggregate treatment-related
trend. Laboratory abnormalities listed as adverse events, submitted upon
request, did not exhibit concerning patterns. Because of the prevalence
of anemia in the Fabry\'s disease population, CBER examined the
proportions of subjects with low hemoglobins at each visit. This
analysis revealed no treatment-related trend.

###### Comment

######  The data presented on laboratory abnormalities do not suggest a safety concern.

#### Concomitant medication use

Medication usage data analysis was presented by time period, before and
after infusion 1. Although the time period before infusion 1 was not
specified, it appears that medication usage for the common symptoms of
pain and acroparesthesia was similar in the two groups.

There was an increase in the use of glucocorticoids among the active
treated subjects, primarily associated with treatment and pretreatment
of infusion reactions.

#### Antibody development and effect on safety

Comparisons of the frequency of adverse events among subjects with and
without antibody was problematic due to the small numbers of subjects in
the non-seroconversion group. However, there was no evident difference
that correlated with antibody conversion status.

### Summary (safety)

The chief concern in this trial was infusion reactions in a large number
of subjects. Infusion reactions were significant, being resistant to
pretreatment and requiring manipulations of infusion rates and
additional treatments. Hypertension, a frequent adverse experience in
FB9702-01, was noted only as a component of an infusion reaction, and in
a small minority of subjects in this trial. There was no evidence of
serum sickness, despite seroconversion in a majority of subjects.

### CONCLUSIONS REGARDING AGAL-1-002-98

AGAL-1-002-98 succeeded in its primary objective of showing that r-hαGal
reduces substrate levels in renal capillary endothelium. Although
histological analyses for the skin and heart were not as rigorously
quantitative as that for the kidney (because they were not based on a
method using quantitation of slide parameters), it appears that r-hαGal
had an effect of r-hαGal on capillary endothelium that is consistent
with that shown in the kidney. However, other secondary and tertiary
endpoints, including laboratory and clinical measures, did not show a
notable treatment benefit. Whether this lack of effect was due to an
inability of r-hαGal to affect critical pathways in the pathogenesis of
Fabry\'s disease, the severity of disease of the subject population, the
particular infusion regimen, the brevity of the trial, or some other
factor, is an open question.

The chief safety concern was the occurrence of infusion reactions, which
were sometimes severe and could occur despite pretreatment medications.
With manipulation of infusion regimes and additional administration of
medications, subjects were able to continue receiving infusions. There
was no clear evidence of antigen/antibody disease despite the prevalence
of development of anti-r-hαGal IgG, and there was no other concerning
pattern of toxicity.

Analysis of a small number of subjects suggests that antibody formation
can result in a substantial drop in exposure at a given dose. This
observation is a concern for a product that is meant to be given for the
life of a patient, as it has the potential to signal decreased effect
over time.

## **AGAL-005-99: OPEN-LABEL EXTENSION TO AGAL-1-002-98** 

After completion of AGAL-1-002-98 subjects were allowed to enter into an
open-label extension, AGAL-005-99, entitled "A multicenter, open-label
extension study of the safety and efficacy of recombinant human
α-Galactosidase A (r-hαGAL) replacement in patients with Fabry disease."

This trial is ongoing. It is a multicenter, open-label trial in which
placebo subjects from AGAL-1-002-98 are placed on active treatment and
active subjects from that trial continue on the same treatment. Both
groups receive r-hαGal at the dose and dose frequency chosen for
AGAL-1-002-98. Pretreatment for infusion reactions is to be the same as
in AGAL-1-002-98, that is, acetaminophen 975 to 1000 mg, and hydroxyzine
25 to 50 mg, orally. The trial's objectives are to determine safety and
to ascertain bioactivity primarily by means of kidney, skin, and heart
biopsies.

For this document, subjects who originally received placebo in
AGAL-1-002-98 are referred to as placebo/r-hαGal subjects, and those who
originally received r-hαGal in AGAL-1-002-98 are referred to as
r-hαGal/r-hαGal subjects.

###### Comment on the design of trial

###### This trial is most useful to determine whether the histologically observed effect of r-hαGal on the renal vasculature is a lasting one, especially considering the common development of antibodies to r-hαGal, and to observe r-hαGal-treated subjects for safety problems with continued treatment beyond that in AGAL-1-002-98. The group of subjects switched from placebo to r-hαGal affords a comparison to the r-hαGal group in AGAL-1-002-98 for objective assessments, allowing a judgment of the strength of the data from that trial on r-hαGal's effects over 5 months.

### Study Design

#### Subject qualifications

Subjects were to meet the following entry criteria:

[Inclusion]{.underline}

-   Completion of AGAL-1-002-98

[Exclusion]{.underline}

-   Having undergone kidney transplantation or being on dialysis

-   Clinically significant organic disease with the exception of
    symptoms relating to Fabry disease

#### Procedures and evaluations

Subjects were to enroll in AGAL-005-99 upon completion of AGAL-1-002-98.
The protocol calls for biopsies of skin at month 6, 12, 30, 42, and 54
(with an optional 18-month biopsy). Biopsy of the kidney and heart are
to be performed at month 6 only, but may be postponed to month 12.

The following summarizes other procedures and evaluations in relation to
the entry infusion to AGAL-005-99. Final evaluations from AGAL-1-002-98
could serve as entry evaluations if performed within specified time
limits.

-   Entry and every 2 weeks

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-   infusion of r-hαGal

-   vital signs

-   serum antibody to r-hαGal (first 24 months only, then every month)

-   adverse event assessment and concomitant medications

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```
-   Entry and month 3

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```
-   Physical examination

-   McGill short form Pain Questionnaire, SF-36 Health Survey, Fabry
    Symptom Assessment, Total Symptom Score questionnaires

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```
-   Entry and every 6 months up to month 54 except as noted:

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```
-   physical examination

-   ECG

-   echocardiogram at months 6, 18, 30, 42, and 54

-   clinical chemistry and hematology, urinalysis

-   plasma GL-3

-   24-hour urinary GL-3 up to month 18

-   renal function testing (inulin, PAH, or urea and creatinine
    clearance)

-   McGill short form Pain Questionnaire, SF-36 Health Survey

-   Fabry Symptom Assessment and Total Symptom Score questionnaires up
    to month 18

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```
-   Pain medication assessment every 3 months beginning month 21

-   Neurophysiologic Function test at entry and months 6 and 18

-   Ophthalmic examination at entry and month 12

-   In the United States only, Gastrointestinal Assessment questionnaire
    at entry and every 4 weeks up to month 18

###### Comments

######  Kidney biopsy, used for the primary endpoint in AGAL-1-002-98, allowed for a determination of the durability of effect. Other evaluations, too, were substantially the same as those in AGAL-1-002-98. 

#### Bioactivity and efficacy measurements

The histological appearance of the kidney was the primary efficacy
measurement. In addition, pain, autonomic status, GFR, GL-3 levels, skin
and heart histology, urinary protein excretion, ophthalmic changes,
vibration detection, and questionnaire data were endpoints.

#### Analysis of endpoints

Kidney biopsy slides were read by the same renal pathologists,
evaluating each capillary to assess a "0" or "non-0" score in the same
way as in AGAL-1-002-98 (scores of 1-3 were read using a slightly
different algorithm). The pathological analysis of heart and skin biopsy
slides was qualitative, as in AGAL-1-002-98, and also by the same
pathologists as in AGAL-1-002-98. The analysis of this open-label trial
was to be descriptive; in addition, a McNemar's χ^2^ test of matched
pairs was to be used to compare proportions of subjects with a score of
0 at entry and month 6 of the trial. Entry scores were the AGAL-1-002-98
end-of-trial scores.

###### Comments

###### The trial, despite its open-label nature, allows an assessment of the histological effect among those switched to r-hαGal, and possible persistence or loss of effect in those continued on r-hαGal. Its ability to determine clinical effects is severely limited. 

### RESULTS: DATA SUBMITTED

Data on important outcomes (biopsy and renal function and safety) are
available to 18 months. Some data, specified in this document, are
available only at 6 or 12 months.

### 

### RESULTS: CONDUCT OF TRIAL

#### Dates of the trial

The trial started in September, 1999 and is ongoing.

#### Formal protocol modifications

No protocol modifications have been made that would be expected to
affect the interpretation of the results.

#### Enrollment and adherence to infusion schedule and dose

All 58 subjects from AGAL-1-002-98 were enrolled.

The mean and median time to first infusion did not differ notably
between the treatment groups.

Adherence to infusion schedule was excellent.

######  

#### Discontinuations

Twenty-nine subjects started the trial from each treatment group from
AGAL-1-002-98 placebo and r-hαGal). Dropouts and reasons:

[Placebo/r-hαGal:]{.underline}

Subject 401: after infusion 41, to receive commercial product

Subject 304: after infusion 8, due to skin test reaction to r-hαGal

Subject 506: after infusion 18, due to death

[R-hαGal/r-hαGal:]{.underline}

Subject 702: after infusion 41, to receive commercial product []{.mark}

Subject 104: after infusion 23, reason not given

Subject 806: after infusion 36, due to skin test reaction to r-hαGal

Subject 705: after infusion 52; due to serum IgE to r-hαGal

###### Comment 

###### Infusion reactions due to development of IgE are discussed in the safety section for this trial.

#### Protocol violations

Information on protocol violations is available to CBER through 6 months
of AGAL-005-99. Violations of the infusion timing (or cases where
infusions were not given) occurred, and there were cases in which
biopsies were not performed. However, the frequency of these violations
was not sufficient to have a significant impact on the overall
conclusions from this trial.

### RESULTS: BASELINE CHARACTERISTICS

The subjects in AGAL-005-99 were the same subjects as participated in
AGAL-1-002-98.

### RESULTS: BIOACTIVITY AND EFFICACY

Results are shown for the as-treated grouping from AGAL-1-002-98, as was
done for the AGAL-002 data. It should be noted that data were not
available from all subjects at all time points. However, this does not
influence the overall conclusions significantly.

#### Primary endpoint: GL-3 in kidney interstitial capillaries at 6 months

Table 15 shows results expressed as zero score at 6 months (included are
two subjects with biopsies postponed to 12 months), separated by
treatment group. Most subjects had a score of 0 at the 6-month time
point of AGAL-005-99. One subject (in r-hαGal continuers) who started
with a 0 and ended a non-0, had a non-0 score at 6 months (score of 0 to
1). This subject was identified by each pathologist.

Table 15. AGAL-005-99: Score of \"0\" on kidney biopsy at 6 months

+-----------------+------------+-----------+-----------+--------------+
| Treatment       | AGA        | 6-Months  |           | Total        |
|                 | L-1-002-98 | of        |           |              |
| Group           | end of     | AG        |           |              |
|                 | trial      | AL-005-99 |           |              |
|                 |            |           |           |              |
|                 | score      |           |           |              |
+-----------------+------------+-----------+-----------+--------------+
|                 |            | Zero      | Nonzero   |              |
+-----------------+------------+-----------+-----------+--------------+
|                 |            |           |           |              |
+-----------------+------------+-----------+-----------+--------------+
| Placebo/r-hαGal | Zero       | 0 (0)     | 0 (0)     | 0 (0)        |
+-----------------+------------+-----------+-----------+--------------+
|                 | Nonzero    | 24 (100)  | 0 (0)     | 24 (100)     |
+-----------------+------------+-----------+-----------+--------------+
| R-hαGal         | Zero       | 17 (94)   | 1 (6)     | 18 (75)      |
| /r-hαGal        |            |           |           |              |
+-----------------+------------+-----------+-----------+--------------+
|                 | Nonzero    | 6 (100)   | 0 (0)     | 6 (25)       |
+-----------------+------------+-----------+-----------+--------------+

As for AGAL-1-002-98, there was good consistency among the pathologists
in the scoring of these slides.

#### Additional analyses of kidney histology (AGAL-1-002-98 and AGAL-005-99) 

In response to CBER's concerns, Genzyme performed analyses of additional
cell types from the kidney. These analyses were performed by the same
pathologists as performed the analyses in AGAL-1-002-98, but were not
based on a quantitative reading of each cell in a biopsy. Table 16 is a
summary of the scoring system for each slide, based on an overall
judgment:

Table 16. Scoring system for additional cell types (kidney)

  -------------------------------------- --------------------------------
  Cell/Tissue                            Score

  Glomerular Endothelial Cells           0 = None or Trace Accumulation

  Non-Capillary Smooth Muscle Cells      1 = Mild Accumulation

  Non-Capillary Endothelial cells        2 = Moderate Accumulation

                                         3 = Severe Accumulation

  Podocytes                              No change

  DCT/Collecting Ducts                   Decrease

                                         Increase

                                         0 = No lipid granules

  Mesangial Cells: GL-3 Accumulation     1 = Minimal lipid granules

  Interstitial Cells                     2 = Numerous lipid granules

                                         0 = Normal Mesangium

  Mesangial Matrix                       1 = Mild Expansion

                                         2 = Moderate Expansion
  -------------------------------------- --------------------------------

###### Comment

######  The slides were not fully blinded in this reading. While treatment assignment was coded and blinded, time point was partially known. Baseline slides were identified while the end-of-AGAL-1-002-98 and 6 month of AGAL-005-99 slide time points were not identified as such. 

######  The 6-month kidney results include two 12-month biopsies (postponed from 6 months).

[Glomerular capillary endothelium at 6 months]{.underline}

Glomerular capillary endothelium results paralleled those for
interstitial capillary endothelium at 6 months, showing the effect of
r-hαGal in reducing substrate levels (Table 17).

Table 17. Glomerular capillary endothelium, proportions of subjects with
0 score at time point among subjects with non-0 baseline score

+-----------------------+-------------+-------------+-----------------+
| AGAL-1-002-98 end of  |             | 6 months of |                 |
| trial                 |             | AGAL-005-99 |                 |
+-----------------------+-------------+-------------+-----------------+
| Placebo               | r-hαGal     | Placebo/    | r-hαGal/        |
|                       |             |             |                 |
|                       |             | r-hαGal     | r-hαGal         |
+-----------------------+-------------+-------------+-----------------+
| 0/16                  | 19/19       | 21/21       | 17/17           |
+-----------------------+-------------+-------------+-----------------+

##### Podocytes at 6 months

Scores of "severe" were common, and there was little effect of treatment
(Table 18). About the same number of subjects had a decrease from
baseline at the 6 month time point of AGAL-005-99 (5 in placebo/r-hαGal
and 3 in r-hαGal/r-hαGal).

Table 18. Podocytes: Proportions of subjects with no change from
baseline\*

+---------+---------+---------+---------+---------+----------------+
| AGAL-1  |         |         |         | 6       |                |
| -002-98 |         |         |         | months  |                |
|         |         |         |         | of      |                |
|         |         |         |         | AGAL    |                |
|         |         |         |         | -005-99 |                |
+---------+---------+---------+---------+---------+----------------+
| B       |         | End of  |         |         |                |
| aseline |         | trial   |         |         |                |
+---------+---------+---------+---------+---------+----------------+
| Placebo | r-hαGal | Placebo | r-hαGal | P       | r-hαGal/       |
|         |         |         |         | lacebo/ |                |
|         |         |         |         |         | r-hαGal        |
|         |         |         |         | r-hαGal |                |
+---------+---------+---------+---------+---------+----------------+
| Pro     |         | Prop    |         |         |                |
| portion |         | ortions |         |         |                |
| of      |         | of      |         |         |                |
| s       |         | s       |         |         |                |
| ubjects |         | ubjects |         |         |                |
| with    |         | with no |         |         |                |
| "       |         | change  |         |         |                |
| severe" |         | from    |         |         |                |
| score   |         | b       |         |         |                |
|         |         | aseline |         |         |                |
|         |         | of      |         |         |                |
|         |         | AGAL-1  |         |         |                |
|         |         | -002-98 |         |         |                |
+---------+---------+---------+---------+---------+----------------+
| 16/16   | 19/19   | 16/16   | 18/19   | 17/22   | 14/17          |
+---------+---------+---------+---------+---------+----------------+

> \*all subjects had non-0 score at baseline

##### Mesangial cell matrix at 6 months

There was no notable effect of treatment on the mesangial cell matrix
(Table 19).

Table 19. Mesangial cell matrix score (mean ± std. deviation)

+---------------------+-------+-------+-------+-------+-------+-------+
|                     | AGA   |       |       |       | 6     |       |
|                     | L-1-0 |       |       |       | m     |       |
|                     | 02-98 |       |       |       | onths |       |
|                     |       |       |       |       | of    |       |
|                     |       |       |       |       | A     |       |
|                     |       |       |       |       | GAL-0 |       |
|                     |       |       |       |       | 05-99 |       |
+---------------------+-------+-------+-------+-------+-------+-------+
|                     | Bas   |       | End   |       |       |       |
|                     | eline |       | of    |       |       |       |
|                     |       |       | trial |       |       |       |
+---------------------+-------+-------+-------+-------+-------+-------+
|                     | Pl    | r-    | Pl    | r-    | Pla   | r-h   |
|                     | acebo | hαGal | acebo | hαGal | cebo/ | αGal/ |
|                     |       |       |       |       |       |       |
|                     |       |       |       |       | r-    | r-    |
|                     |       |       |       |       | hαGal | hαGal |
+---------------------+-------+-------+-------+-------+-------+-------+
| Subjects with data  | 21    | 21    | 17    | 21    | 23    | 20    |
| available           |       |       |       |       |       |       |
+---------------------+-------+-------+-------+-------+-------+-------+
| Score (mean ± std.  | 0.9   | 0.8   | 0.9   | 0.7   | 0.9   | 0.7   |
| deviation)          |       |       |       |       |       |       |
|                     | ± 0.2 | ± 0.2 | ± 0.2 | ± 0.2 | ± 0.3 | ± 0.2 |
+---------------------+-------+-------+-------+-------+-------+-------+

*[Other kidney structures]{.underline}*

[Interstitial, noncapillary endothelial, and mesangial cells at 6
months]{.underline}

R-hαGal treatment was associated with a large proportion of scores of 0,
even after treatment for about a year total (Table 20).

Table 20. Interstitial, mesangial, and noncapillary endothelial cells,
proportions of subjects with 0 score at time point among subjects with
non-0 baseline score

+---------------------------+---------+---------+---------+-----------+
|                           | AGAL-1  |         | 6       |           |
|                           | -002-98 |         | months  |           |
|                           |         |         | of      |           |
|                           | End of  |         |         |           |
|                           | trial   |         | AGAL    |           |
|                           |         |         | -005-99 |           |
+---------------------------+---------+---------+---------+-----------+
|                           | Placebo | r-hαGal | P       | r-hαGal/  |
|                           |         |         | lacebo/ |           |
|                           |         |         |         | r-hαGal   |
|                           |         |         | r-hαGal |           |
+---------------------------+---------+---------+---------+-----------+
| Interstitial cells        | 0/24    | 16/23   | 19/24   | 23/23     |
+---------------------------+---------+---------+---------+-----------+
| noncapillary endothelial  | 0/22    | 16/19   | 19/22   | 19/20     |
| cells                     |         |         |         |           |
+---------------------------+---------+---------+---------+-----------+
| Mesangial cells           | 0/16    | 19/19   | 19/21   | 17/17     |
+---------------------------+---------+---------+---------+-----------+

[Noncapillary smooth muscle cells at 6 months]{.underline}

R-hαGal treatment was associated with a large proportion of decreases
from baseline, even after treatment for about a year (Table 21). The
amounts of reductions in score were maintained, and possibly increased,
with continued treatment with r-hαGal in AGAL-005-99 (not shown).

Table 21. Noncapillary smooth muscle cells, proportions of subjects with
0 score at time point among subjects with non-0 baseline score

+---------------------------+---------+---------+---------+-----------+
|                           | AGAL-1  |         | 6       |           |
|                           | -002-98 |         | months  |           |
|                           |         |         | of A    |           |
|                           | End of  |         |         |           |
|                           | trial   |         | GAL     |           |
|                           |         |         | -005-99 |           |
+---------------------------+---------+---------+---------+-----------+
|                           | Placebo | r-hαGal | P       | r-hαGal/  |
|                           |         |         | lacebo/ |           |
|                           |         |         |         | r-hαGal   |
|                           |         |         | R-hαGal |           |
+---------------------------+---------+---------+---------+-----------+
| Proportion of subjects    | 0/22    | 2/21    | 0/22    | 0/21      |
| with 0 score              |         |         |         |           |
+---------------------------+---------+---------+---------+-----------+
| Proportion of subjects    | 2/22    | 18/21   | 19/22   | 17/21     |
| with any decrease in      |         |         |         |           |
| score from baseline       |         |         |         |           |
+---------------------------+---------+---------+---------+-----------+

[Distal convoluted tubules and collecting ducts at 6 months]{.underline}

During AGAL-1-002-98 most subjects in both groups experienced no change
in score; during AGAL-005-99, decreases outnumbered stable scores and
increases in score (Table 22). With continued treatment, more subjects
had decreases in score than remained stable or had increases.

Table 22. Distal convoluted tubules and collecting ducts, proportions of
subjects with any decrease from baseline\*

+----------------------------+---------+---------+---------+---------+
|                            | AGAL-1  |         | 6       |         |
|                            | -002-98 |         | months  |         |
|                            |         |         | of      |         |
|                            | End of  |         | AGAL    |         |
|                            | trial   |         | -005-99 |         |
+----------------------------+---------+---------+---------+---------+
|                            | Placebo | r-hαGal | P       | r       |
|                            |         |         | lacebo/ | -hαGal/ |
|                            |         |         |         |         |
|                            |         |         | R-hαGal | r-hαGal |
+----------------------------+---------+---------+---------+---------+
| Proportions of subjects    | 1/24    | 6/24    | 18/24   | 12/24   |
| with any decrease from     |         |         |         |         |
| baseline                   |         |         |         |         |
+----------------------------+---------+---------+---------+---------+

\* (all subjects had non-0 score at baseline)

###### 

###### Comment 

###### Reductions in cell types other than renal interstitial capillaries occurred in many, but not all cell types. Despite the lack of full blinding, the results in several cases were quite robust. These results show that the original endpoint results from AGAL-1-002-98 were not a finding isolated to a single cell type.

#### Endpoint: McGill short form pain questionnaire

Results of a subjective questionnaire during an open label trial are
subject to bias. In addition, there was no restriction on the use of
pain medications. No remarkable differences between groups were detected
on the McGill short form pain questionnaire (Appendix C: Study
AGAL-005-99, Table 62).

#### Endpoint: GL-3 in skin and heart biopsy

#### Skin

The pathological analysis of skin biopsy slides was qualitative, on a
0-3 scale.

At 6 months, among the 23 placebo subjects who switched to r-hαGal in
AGAL-005-99 with available data, 21 had a reduction in score to 0 in
their superficial capillary endothelial scores, 1 subject had a
reduction to a non-0 score, and 1 subject remained at 0.

At 6 months, among the 24 subjects continued on r-hαGal in AGAL-005-99
with available data, 23 had no change from their 0 score at entry, and 1
had an increase in score.

Table 23 shows skin superficial capillary endothelial scores at 18
months of AGAL-005-99.

Table 23. Skin superficial capillary endothelium (18 months of
AGAL-005-99)

+-----------------+------------+-----------+-----------+--------------+
| Treatment       | AGA        | 18 months |           | Total        |
|                 | L-1-002-98 | of        |           |              |
| Group           | end of     | AG        |           |              |
|                 | trial      | AL-005-99 |           |              |
|                 |            |           |           |              |
|                 | score      |           |           |              |
+-----------------+------------+-----------+-----------+--------------+
|                 |            | Zero      | Nonzero   |              |
+-----------------+------------+-----------+-----------+--------------+
|                 |            |           |           |              |
+-----------------+------------+-----------+-----------+--------------+
| Placebo/r-hαGal | Zero       | 1 (100)   | 0 (0)     | 1            |
+-----------------+------------+-----------+-----------+--------------+
|                 | Nonzero    | 19 (90)   | 2 (10)    | 21           |
+-----------------+------------+-----------+-----------+--------------+
| R-hαGal/r-hαGal | Zero       | 21 (88)   | 3 (13)    | 24           |
+-----------------+------------+-----------+-----------+--------------+
|                 | Nonzero    | 0 (0)     | 0 (0)     | 0            |
+-----------------+------------+-----------+-----------+--------------+

Because of concerns over the possible regression exhibited by 5 subjects
(non-zero scores at 18 months), Genzyme submitted 30-months results for
these 5 subjects (Table 24).

Table 24. Skin superficial capillary endothelial cell substrate scores

+------+----------------+------+------+------+------+------+------+
|      |                | A    |      | AGA  |      |      |      |
|      |                | GAL- |      | L-00 |      |      |      |
|  Sub | Treatment      | 1-00 |      | 5-99 |      |      |      |
| ject |                | 2-98 |      |      |      |      |      |
+------+----------------+------+------+------+------+------+------+
|      |                | Base | End  | 6 mo | 12   | 18   | 30   |
|      |                | line |      |      | mo   | mo   | mo   |
+------+----------------+------+------+------+------+------+------+
| 102  | p              | 2    | 2    | 0    | 0    | 1    | 0    |
|      | lacebo/r-hαGal |      |      |      |      |      |      |
+------+----------------+------+------+------+------+------+------+
| 107  | r-hαGal        | 2    | 0    | 0    | 0    | 1    | 0    |
|      | /r-hαGal       |      |      |      |      |      |      |
+------+----------------+------+------+------+------+------+------+
| 201  | p              | 3    | 2    | 0    | 0    | 1    | 0    |
|      | lacebo/r-hαGal |      |      |      |      |      |      |
+------+----------------+------+------+------+------+------+------+
| 705  | r-hαGal        | 2    | 0    | 0    | 1    | 2    | 0\*  |
|      | /r-hαGal       |      |      |      |      |      |      |
+------+----------------+------+------+------+------+------+------+
| 806  | r-hαGal        | 2    | 0    | 0    | 0    | 1    |  Not |
|      | /r-hαGal       |      |      |      |      |      | done |
+------+----------------+------+------+------+------+------+------+

\* approximately 2-year result; subject removed due to detection of
serum IgE at 4½ months after 18 month time point

Genzyme points out that the 18-month result for subject 806 was obtained
10 weeks after the last treatment with r-hαGal. Since the kinetics of
possible re-accumulation of substrate are not known, the importance of
this observation is unclear.

###### Comment

######  The subjects with increased score at 18 months on superficial skin capillary endothelium were among the subjects with the highest anti-r-hαGal titers. The 30-month results (22 months for subject 705) suggest that the observed increases in scores at 18 months may have been due to chance. Thirty-month results are pending on additional subjects.

#### Additional cell types in the skin

Genzyme performed analyses of additional cell types from the skin as
well. These analyses were performed by the same pathologists as
performed the analyses in AGAL-1-002-98. Table 25 shows the scoring
system for each slide:

Table 25. AGAL-005-99: Scoring system for additional cell types (skin)

+-------------------------------------+--------------------------------+
| Cell/Tissue                         | Score                          |
+-------------------------------------+--------------------------------+
|                                     | 0 = None or Trace Accumulation |
|                                     |                                |
|                                     | 1 = Mild Accumulation          |
|                                     |                                |
|                                     | 2 = Moderate Accumulation      |
|                                     |                                |
|                                     | 3 = Severe Accumulation        |
+-------------------------------------+--------------------------------+
| Deep vessel endothelial cells       |                                |
+-------------------------------------+--------------------------------+
| Deep vessel smooth muscle cells     |                                |
+-------------------------------------+--------------------------------+
| Perineurium                         |                                |
+-------------------------------------+--------------------------------+

[Deep vessel endothelial cells]{.underline}

R-hαGal treatment was associated with a large proportion of decreases in
histologically determined substrate in deep vessel endothelial cells, an
effect that was maintained at 6 months (Table 26).

Table 26. AGAL-005-99: Skin deep vessel endothelial cells, proportions
of subjects with 0 score at time point among subjects with non-0
baseline score

+-----------------+-----------------+-----------------+-----------------+
| AGAL-1-002-98   |                 | 6 months of     |                 |
|                 |                 | AGAL-005-99     |                 |
| End of trial    |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| Placebo         | r-hαGal         | Placebo/        | r-hαGal/        |
|                 |                 |                 |                 |
|                 |                 | r-hαGal         | r-hαGal         |
+-----------------+-----------------+-----------------+-----------------+
| 1/24            | 19/23           | 19/22           | 23/24           |
+-----------------+-----------------+-----------------+-----------------+

Table 27 shows results at 18 months of AGAL-005-99 among subjects with
available data. Six subjects in the r-hαGal/r-hαGal group have shown an
increase in score from 0 to non-0 at 18 months of AGAL-005-99.

Table 27. AGAL-005-99: Skin deep vessel endothelial cell scores at entry
and at 18 months

+-------------------+--------------------+--------------+--------------+
| Treatment         | AGAL-1-002-98 end  | 18 Months of |              |
|                   | of trial           |              |              |
| Group             |                    | AGAL-005-99  |              |
|                   | score              |              |              |
+-------------------+--------------------+--------------+--------------+
|                   |                    | Zero         | Non-Zero     |
+-------------------+--------------------+--------------+--------------+
| Placebo/r-hαGal   | Zero               | 1 (100)      | 0            |
+-------------------+--------------------+--------------+--------------+
|                   | Non-Zero           | 16 (80)      | 4 (20)       |
+-------------------+--------------------+--------------+--------------+
| R-hαGal/r-hαGal   | Zero               | 14 (70)      | 6 (30)       |
+-------------------+--------------------+--------------+--------------+
|                   | Non-Zero           | 2 (100)      | 0            |
+-------------------+--------------------+--------------+--------------+

###### Comment

######  Three of the 6 r-hαGal continuers who showed increased deep vessel endothelial scores at 18 months were among the group with increased superficial skin capillary scores at 18 months. Among the three remaining subjects with increases in deep vessel endothelial scores, 2 were among the entire subject population with the highest maximal titers (1:51200) when determined at any point in AGAL-1-002-98 or AGAL-005-99, and 1 was among the 12 with a maximal titer of 1:12800.

######  Comments that accompany the endothelial cell biopsy scores suggest that deep structures were sometimes minimal or not available. Genzyme has stated that this could lead to mis-represented analyses. However, the data are consistent with the 18-month data from the superficial capillaries of the skin.

######  FDA has not received 30-month results for this cell type as of yet, as it has for superficial capillary endothelial cells of the skin, and so has not been able to examine the reductions in scores for their durability at this time point.

######  

[Deep vessel smooth muscle cells at 6 and 18 months]{.underline}

Far too little data (1 placebo subject and 6 r-hαGal subject) are
presented to enable any conclusions.

[Perineurium at 6 months]{.underline}

There was no notable effect of r-hαGal treatment in skin perineurium at
6 months in controlled comparison (Table 28). In AGAL-1-002-98, about
half of the subjects in both groups remained stable and a small number
showed an increase. In AGAL-005-99, about 1/3 of subjects were stable,
with 2 increases in score in the former-placebo group and none in the
former-r-hαGal group.

Table 28. AGAL-005-99: Skin perineurium, proportions of subjects with 0
score at time point among subjects with non-0 baseline score

+--------------------------+---------+---------+---------+-------------+
|                          | AGAL-1  |         | 6       |             |
|                          | -002-98 |         | months  |             |
|                          |         |         | of      |             |
|                          | End of  |         |         |             |
|                          | trial   |         | AGAL    |             |
|                          |         |         | -005-99 |             |
+--------------------------+---------+---------+---------+-------------+
|                          | Placebo | r-hαGal | P       | r-hαGal/    |
|                          |         |         | lacebo/ |             |
|                          |         |         |         | r-hαGal     |
|                          |         |         | r-hαGal |             |
+--------------------------+---------+---------+---------+-------------+
| Proportion of subjects   | 0/22    | 1/22    | 1/18    | 2/20        |
| with 0 score             |         |         |         |             |
+--------------------------+---------+---------+---------+-------------+
| Proportion of subjects   | 7/22    | 10/22   | 11/20   | 13/21       |
| with any decrease in     |         |         |         |             |
| score from baseline      |         |         |         |             |
+--------------------------+---------+---------+---------+-------------+

Table 29 shows results at 18 months of AGAL-005-99 among those with
available data. There remained little effect of r-hαGal on skin
perineurium.

Table 29. AGAL-1-002-98 end of trial and AGAL-005-99 18-month skin
perineurium results

+-------------------+--------------------+--------------+--------------+
| Treatment         | AGAL-1-002-98 end  | 18 Months of |              |
|                   | of trial           |              |              |
| Group             |                    | AGAL-005-99  |              |
|                   | score              |              |              |
+-------------------+--------------------+--------------+--------------+
|                   |                    | Zero         | Non-Zero     |
+-------------------+--------------------+--------------+--------------+
| Placebo/r-hαGal   | Zero               | 1 (100)      | 0            |
+-------------------+--------------------+--------------+--------------+
|                   | Non-Zero           | 0            | 17 (100)     |
+-------------------+--------------------+--------------+--------------+
| R-hαGal/r-hαGal   | Zero               | 0            | 1 (100)      |
+-------------------+--------------------+--------------+--------------+
|                   | Non-Zero           | 3 (17)       | 15 (83)      |
+-------------------+--------------------+--------------+--------------+

###### Comments on Additional Skin Cell Type Histology 

###### Skin endothelium, like renal endothelium, responded to treatment with r-hαGal. However, perineurium did not respond.

###### Apparent reductions at 18 months in histological effect in skin superficial capillary endothelium for several subjects (Table 23) may have been chance observations. Data on more subjects at 30 months may be helpful in determining the durability of reductions in score.

#### Heart capillary endothelium

The pathological analysis of heart biopsy slides was qualitative, on a
0-3 scale.

Table 30 shows results at baseline and end of AGAL-1-002-98, as well as
at 6 months of AGAL-005-99. Sixteen of the r-hαGal continuers who had an
AGAL-005-entry score of 0 maintained that 0 score; 1 of the 22 subjects
had an increase in score (not shown); 3 subjects lowered their scores to
0; 2 maintained a non-0 score.

Table 30. Numbers of 0 and non-0 scores in heart capillary endothelium
at time points of AGAL-1-002-98 and 6 months of AGAL-005-99

+--------------+--------+--------+--------+--------+--------+--------+
|  Treatment   | ba     |        | End of |        | 6      |        |
| group        | seline |        |        |        | months |        |
|              | of     |        | A      |        | of     |        |
|              |        |        | GAL-1- |        |        |        |
|              | A      |        | 002-98 |        | AGAL-  |        |
|              | GAL-1- |        |        |        | 005-99 |        |
|              | 002-98 |        |        |        |        |        |
+--------------+--------+--------+--------+--------+--------+--------+
|              | zero   | non-0  | zero   | non-0  | zero   | non-0  |
+--------------+--------+--------+--------+--------+--------+--------+
| pla          | 5      | 24     | 1      | 28     | 13     | 5      |
| cebo/r-hαGal |        |        |        |        |        |        |
+--------------+--------+--------+--------+--------+--------+--------+
| R-h          | 5      | 24     | 21     | 8      | 19     | 3      |
| αGal/r-hαGal |        |        |        |        |        |        |
+--------------+--------+--------+--------+--------+--------+--------+

Genzyme examined no additional cardiac cell types.

###### Comment 

###### The results of the cardiac capillary endothelium are consistent with those of other organ endothelial cells in showing a reduction with r-hαGal treatment. Long-term results are not available.

#### Endpoint: Urinary GL-3 levels

Analysis for this parameter was only done at the 6-month time point, in
22 subjects in each group (Table 64). There was a decrease in urinary
GL-3 in the group switched from placebo to active treatment, and a more
complex response among those continued on r-hαGal (mean and median
changing in opposite directions). The interpretation of these data is
complicated by the fact that this is a subgroup analysis, with a
remarkable amount of variability, making quantitative discriminations
between the groups difficult.

#### Plasma GL-3 levels

Results out to 12 months of AGAL-005-99 were summarized by Genzyme.

Plasma GL-3 dropped in placebo subjects switched to r-hαGal, and
remained low in subjects continued on r-hαGal (Table 31). Four placebo
and five r-hαgal continuers had non-0 plasma GL-3 levels at the month 12
visit (7/9 had appreciable reductions from baseline of AGAL-1-002-98).
The peak antibody titers of these subjects compared to the trial
population as a whole did not show a pattern suggesting a correlation of
peak titer with non-0 status.

Table 31. AGAL-005-99: Plasma GL‑3 levels (ng/μl) at AGAL-005 entry and
at 12 months

  ----------------- ----------------- ------------- ----------------- -------------
  Statistic         Placebo/r-hαGal                 r-hαGal/r-hαGal   

                    Entry             12 months     entry             12 months

  *n*               *28*              *26*          *28*              *26*

  Mean              15.3              0.6           2.3               1.4

  Median            10.4              0             0                 0

  Std. deviation    11.7              1.8           4.32              5.1

  Min., Max.        0,41              0, 8          0, 18             0, 26
  ----------------- ----------------- ------------- ----------------- -------------

###### Comments on plasma and urinary GL-3 observations

######  The reduction in plasma GL-3 observed with r-hαGal treatment in AGAL-1-002-98 was seen in the placebo crossovers in AGAL-005-99. Urinary GL-3 data were much more variable and based on a subset of the trial's population. However, they suggest that there is a reduction in GL-3 with treatment with r-hαGal.

#### Other endpoints

Renal outcomes, because of their importance to the overall development
plan for Genzyme's r-hαGal, will be discussed first. Data on glomerular
filtration rate and serum creatinine include results from the controlled
trial AGAL-1-002-98.

-   Glomerular filtration rate: Table 32 is extracted from table
    submitted by Genzyme. For comments on the problems with the
    interpretation of this table, see comments in the review of tertiary
    endpoints for AGAL-1-002-98. CBER's analysis out to 6 months using
    data from inulin technique only yielded similar results, but are on
    a nonrandomized subset (analysis not shown). Overall, no conclusion
    can be drawn reliably about the effect of r-hαGal on GFR from these
    data. These data do not provide evidence of any improvement with
    r-hαGal treatment.

Table 32. GFR (ml/min, mean ± st. dev.) in AGAL‑1‑002‑98 and at 6 and 18
months of AGAL‑005‑99

+---------+-----------------+---------+---------------+---------------+
| Trial   | Visit           | St      | Treatment     |               |
|         |                 | atistic | group         |               |
+---------+-----------------+---------+---------------+---------------+
|         |                 |         | placebo       | r-hαGal       |
+---------+-----------------+---------+---------------+---------------+
|         |                 | *N*     | *28*          | *29*          |
+---------+-----------------+---------+---------------+---------------+
| A       | Baseline        |         | 97 ± 35       | 82 ± 22       |
| GAL-11- |                 |         |               |               |
+---------+-----------------+---------+---------------+---------------+
| 002-98  |                 | *N*     | *23*          | *21*          |
+---------+-----------------+---------+---------------+---------------+
|         | visit 11        | Mean    | 108 ± 39      | 93 ± 34       |
+---------+-----------------+---------+---------------+---------------+
|         |                 |         | placebo/      | r-hαGal/      |
|         |                 |         |               |               |
|         |                 |         | r-hαGal       | r-hαGal       |
+---------+-----------------+---------+---------------+---------------+
| AGAL-   | 6-months        | *N*     | *26*          | *23*          |
+---------+-----------------+---------+---------------+---------------+
| 005-99  |                 | Mean    | 117 ± 41      | 82 ± 30       |
+---------+-----------------+---------+---------------+---------------+
|         | 18 months       | N       | 24            | 26            |
+---------+-----------------+---------+---------------+---------------+
|         |                 | Mean    | 108 ± 46      | 80 ± 30       |
+---------+-----------------+---------+---------------+---------------+

-   Serum creatinine, measured in all subjects. There was no notable
    effect of r-hαGal on serum creatinine out to 18 months of treatment
    (Table 33).

Table 33. AGAL-005-99: Serum creatinine (mg/dl, mean ± std error)

+------------+-----+------------+-------------+-----------+-----------+
| Treatment  | Sta | Baseline   | Entry       | 6 months  | 18 Months |
| Group      | tis |            |             |           | AG        |
|            | tic | AGA        | AGAL-005-99 | AG        | AL-005-99 |
|            |     | L-1-002-98 |             | AL-005-99 |           |
+------------+-----+------------+-------------+-----------+-----------+
| Place      | *n* | *29*       | *27*        | *27*      | *27*      |
| bo/r-hαGal |     |            |             |           |           |
+------------+-----+------------+-------------+-----------+-----------+
|            | M   | 0.8 ± 0.2  | 0.8 ± 0.2   | 0.9 ± 0.1 | 0.9 ± 0.3 |
|            | ean |            |             |           |           |
+------------+-----+------------+-------------+-----------+-----------+
| R-hαG      | *n* | *29*       | *27*        | *28*      | *28*      |
| al/r-hαGal |     |            |             |           |           |
+------------+-----+------------+-------------+-----------+-----------+
|            | M   | 0.8 ± 0.2  | 0.9 ± 0.2   | 0.9 ±     | 0.9 ± 0.3 |
|            | ean |            |             | 0.04      |           |
+------------+-----+------------+-------------+-----------+-----------+

Genzyme notes that 3 subjects have experienced deteriorations in serum
creatinine (1 in the placebo/r-hαGal group, 2 in the r-hαGal/r-hαGal
group). Genzyme postulates that these subjects were susceptible to
increases due to having "prominent glomerular sclerosis" at baseline.
The data are insufficient to draw any conclusion at this time about the
mechanism of the deterioration.

-   Urinary protein, determined in 20 and 21 subjects in the
    placebo/r-hαGal and r-hαGal/r-hαGal groups, respectively. Data were
    not collected at baseline, so do not merit a detailed discussion.
    However, it is worth noting that urinary protein excretion in this
    subgroup of subjects was greater at 6 months of AGAL-005-99 in the
    r-hαGal/r-hαGal group than in the group newly switched from placebo
    (mean ± std. deviation (mg/24 hr), placebo vs. r-hαGal, 38 ± 67
    vs.79 ± 123; normal is \<150 mg/day). Data have not been analyzed at
    later time points, but this observation merits continued
    surveillance, as increases in protein excretion may signal increased
    renal dysfunction.

###### 

###### Comment

######  The controlled experience with r-hαGal is very brief, and no effect, beneficial or detrimental was seen. The extension trial AGAL-005-99 was not designed to detect a difference between the groups in renal function, and no effect of r-hαGal was seen.

-   Vibration detection threshold (U.S. subjects only), measured at 6
    and 18 months. There was no notable effect of r-hαGal treatment.

-   The Total Symptom Score, measured in the majority of subjects at 6
    and 18 months. There was no notable effect of r-hαGal treatment. The
    overall interpretation of questionnaire data in an open-label trial
    is problematic due to the potential for subject bias.

-   Gastrointestinal Questionnaire (U.S. subjects only), out to 18
    months. The results were not examined. Genzyme states that the data
    were "unremarkable" for both groups.

-   Ophthalmic changes, out to 1 year. The results were not examined.
    Genzyme states, "No clinically significant changes in any ophthalmic
    examination parameter were observed for either treatment group
    between entry and 1 year into the Extension Study."

-   SF-36 Health Status Survey, measured in almost all subjects. During
    the 6-months of AGAL-005-99, improvements occurred in most subscales
    for both groups. At 18months, Genzyme reports that there was a
    statistically significant change for the placebo/r-hαGal group
    between entry to AGAL-005-99 and 18 months on the "physical
    component" subscale. Due to multiplicity of analysis, the
    interpretation of this result is problematic; in addition, Genzyme
    does not comment on the clinical meaning of the changes noted. The
    overall interpretation of questionnaire data in an open-label trial
    is problematic due to the potential for subject bias.

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-   Autonomic status as described in the review of AGAL-1-002-98,
    assessed in 11 subjects in the U.S.(Table 66). Genzyme states that
    for the temperature detection threshold and venous occlusion
    plethysmography neither extension baseline values nor values after 6
    months of AGAL-005-99 were abnormal for either group. Genzyme notes
    that there was a statistical difference seen in thermal detection
    threshold from entry to 18 months in the r-hαGal/r-hαGal group.
    However, Genzyme does not comment on the clinical significance of
    this observation, and the clinical significance of other results
    seen at 18 months. These analyses are limited by the small size of
    the subgroup in which they were tested; the importance of
    statistical tests is limited by the fact that multiple tests were
    applied to these data, without specification of the relative
    importance in advance.

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-   Physician assessment of Fabry symptoms. There were no notable
    changes in numbers of subjects with changes in scores (yes or no) on
    questions relating to abnormal sweating or abdominal pain. Slightly
    more subjects had abdominal pain at 18 months than had it at entry
    in both groups (Table 67).

#### 

#### Summary comments on bioactivity and efficacy from AGAL-005-99 

Histological analyses showed that reductions of substrate from capillary
endothelium of kidney, skin, and heart were sustained in subjects
continuing to receive r-hαGal, and that the reduction seen in the
r-hαGal group from AGAL-002-98 was reproduced in placebo crossovers
during the 1^st^ 6 months of subsequent open-label treatment.
Preliminary suggestions that some subjects had experienced regression in
effect may have been due to chance observations. Further data may help
to determine the durability of reductions in scores.

Clinical endpoints, as well as measures of renal function, show no
effect of treatment.

### RESULTS: SAFETY

The following is a discussion of the safety record of the AGAL-005-99.
Data have been submitted up to infusion 42.

#### Deaths

There has been one death reported up to infusion 42 of AGAL-005-99. This
was a 43 year-old man who had been on placebo during AGAL-1-002-98, who
suffered a cardiac arrest and dysrhythmia 400 days after being on
r-hαGal. His medical history is stated as "severe heart disease
associated with marked acute heart failure and findings consistent with
Fabry disease."

#### 

#### Adverse events

[Serious adverse events]{.underline}

Twenty-three of the 58 subjects experienced serious adverse events.
Counting terms that were related to each other that occurred on the same
day as the same event, the serious adverse events may be grouped as
follows:

-   Related to biopsy: 3 subjects, 3 events

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-   Related to infusion: 6 subjects, 7 events. As Table 34 shows,
    serious infusion-related events may occur late in treatment.

Table 34. Infusion-associated serious adverse events in AGAL-005-99

  ---------------- ------------------------------------ -----------------
  subject          term                                 days after
                                                        treatment

  201              tachycardia                          32

                   hypertension                         33

  304              pruritic urticaria                   98

  306              tightness in chest                   55

                   tightness in throat                  55

  705              swelling and erythema in ear, warmth 881\*
                   in face                              

                   fever                                128

  805              very intense shivering               128

                   tachycardia                          128

                   abdominal pain                       582

                   cutaneous rash                       

                   skin redness                         

  806              vomiting                             

                   pruritis                             

                   nausea                               

                   shivering                            
  ---------------- ------------------------------------ -----------------

\*post-18-month data

-   Cardiac/neurologic events: 6 subjects, 7 events. Serious cardiac and
    neurologic events occurred mostly several to many months after the
    first infusion of r-hαGal (Table 35). Two strokes occurred in
    subjects with no prior history, but stroke is a known complication
    of Fabry\'s disease. Subject 603 had an episode of chest pain during
    this trial, with no documented cardiac abnormality. An additional,
    ischemic event occurred: hand ischemia in a 41 year-old subject
    (subject 708) 175 days after the start of treatment, in a subject
    with no relevant medical history.

Table 35. Serious cardiac and neurologic adverse events in AGAL-005-99\*

  --------- --------------------- ---------- ----------- --------------------
  Subject   Term                  Age        Days after  Relevant history
                                             treatment   

  109       Stroke                37         770         no

  112       Stroke                25         870         no

  501       Stroke                42         611         yes

  502       Worsened angina       62         53          yes

  506       Bradycardia           43         242         

            Decreased cardiac                242         
            output                                       

            Cardiac arrest\*\*               400         yes

            Dysrhythmia\*\*                  400         
  --------- --------------------- ---------- ----------- --------------------

> \* See text for additional ischemic/possibly ischemic events
>
> \*\*reported as death

[]{.mark}

-   Miscellaneous: See Table 36.

Table 36. AGAL-005-99: Miscellaneous serious adverse events (one row per
subject)

+-------------------------------+--------------------------------------+
| Event                         | Medical history                      |
+-------------------------------+--------------------------------------+
| Viral pericarditis            | none related                         |
+-------------------------------+--------------------------------------+
| Hand injury                   | none related                         |
+-------------------------------+--------------------------------------+
| Suicide attempt               | none related                         |
+-------------------------------+--------------------------------------+
| Head and hand injury          | none related                         |
+-------------------------------+--------------------------------------+
| Bronchitis                    | asthma, tobacco use                  |
+-------------------------------+--------------------------------------+
| Vertigo (twice) and           | vestibulocochlear disorders,         |
|                               | tinnitus, bilateral hearing loss,    |
| hypoacousia                   | vertigo                              |
+-------------------------------+--------------------------------------+
| Carpal tunnel syndrome        | none related                         |
+-------------------------------+--------------------------------------+
| Herpes labialis of leg with   | none related                         |
| erysipelas                    |                                      |
+-------------------------------+--------------------------------------+
| Suicide attempt               | none related                         |
+-------------------------------+--------------------------------------+
| Basal cell carcinoma          | none related                         |
+-------------------------------+--------------------------------------+
| Basal cell carcinoma          | No cancer related history            |
|                               |                                      |
| Nephrotic syndrome            | Fabry related-proteinuria, extensive |
|                               | baseline glomerular scarring         |
+-------------------------------+--------------------------------------+
| Loss of visual acuity,        | inflammatory syndrome                |
| macular edema, retinal white  |                                      |
| dots syndrome                 |                                      |
+-------------------------------+--------------------------------------+
| First metatarsal osteitis     | cutaneous wound ulcer                |
+-------------------------------+--------------------------------------+

###### Comments

######  The group switched to r-hαGal experienced several serious cardiac adverse events, but serious adverse events of this nature did not occur in the r-hαGal-treated group in AGAL-1-002-98, so they do not constitute a strong pattern. There is no clear pattern of serious events other than those associated with biopsy and infusion. 

[Infusion reactions]{.underline}

[During the first 6 months of AGAL-005-99]{.underline}

The majority of subjects experienced infusion reactions in the first 6
months of AGAL-005-99. Table 37shows the numbers of subjects with any
adverse event in groups of infusion-related syndromes.

Table 37. AGAL-005-99: Subjects with infusion-related adverse events at
6 months

+-------------------------------------------+--------------------------+
| Adverse                                   | Subjects with any        |
|                                           | infusion-related event   |
| Events                                    |                          |
|                                           | *n=34*                   |
+-------------------------------------------+--------------------------+
| Febrile reactions: fever, feels warm,     | 30                       |
| feels cold, or chills                     |                          |
+-------------------------------------------+--------------------------+
| Hypersensitivity: dyspnea, throat         | 17                       |
| tightness, flushing, chest tightness,     |                          |
| pruritis, urticaria, or rhinitis,         |                          |
| bronchial constriction, tachypnea, or     |                          |
| wheezing                                  |                          |
+-------------------------------------------+--------------------------+
| Pain symptoms: Fabry pain or myalgia      | 8                        |
+-------------------------------------------+--------------------------+
| Gastrointestinal: abdominal pain, nausea, | 8                        |
| or                                        |                          |
|                                           |                          |
| vomiting                                  |                          |
+-------------------------------------------+--------------------------+
| Cardiovascular: tachycardia,              | 6                        |
| palpitations, or                          |                          |
|                                           |                          |
| hypertension                              |                          |
+-------------------------------------------+--------------------------+
| Headache                                  | 6                        |
+-------------------------------------------+--------------------------+
| Fatigue and related symptoms              | 5                        |
+-------------------------------------------+--------------------------+
| Edema                                     | 4                        |
+-------------------------------------------+--------------------------+

In addition to these events, the following events categorized as
"severe" occurred on the day of infusion.

-   Subject 501 (r-hαGal/r-hαGal) experienced severe shivering

-   Subject 505 (placebo/r-hαGal) experienced severe pains in both hands

-   Subject 804 (r-hαGal/r-hαGal) experienced severe shivering and skin
    edema

-   Subject 805 (placebo/r-hαGal) experienced severe urticaria

Treatment consisted of a reduction in infusion rate, with various
combinations of antihistamines, inhaled beta agonists, NSAIDs, or
steroids.

More infusion-related events that were suspected to be due to
hypersensitivity occurred in subjects crossed over to r-hαGal treatment
from placebo during AGAL-005-99 (15/25) than in continuers during the
first 6 months of AGAL-005-99 (Table 65). On the other hand, over half
of subjects (7/12) who had had infusion reactions while on r-hαGal
treatment during AGAL-1-002-98 had them in AGAL-005-99. Serum IgG
antibody was detected at the time of nearly all infusions; testing for
complement activation was sporadic.

[Trends relating to infusion reactions during the first 18 months of
AGAL-005-99]{.underline}

CBER examined summaries of adverse events classified as related to
treatment that occurred on the same day as infusion, divided by
approximate 6-month time periods: baseline to visit 11 (5 months) of
AGAL-1-002-98, entry to AGAL-005-99 to 6 months of the trial, 28 weeks
to 1 year after entry to AGAL-005-99, and 54 weeks to 18 months after
entry to AGAL-005-99. The incidence of infusion-related events generally
decreases over time, and there is no event with a reliable increase in
incidence. In the period from about 18-24 months after initiation of
treatment (subjects on r-hαGal in AGAL-1-002-98), 4 subjects had
infusion-associated nausea and 2 subjects each had the following events:
rigors, hypertension, and vomiting. One subject each had paresthesia,
abdominal pain, tachycardia, arthrosis, rash, ECG abnormal, hypotension,
skin discoloration, anxiety, cardiac failure, hypertonia, and myalgia
(the same subject may have had more than one event).

[IgE-mediated infusion reactions/ events leading to
withdrawal]{.underline}

With regards to the occurrence of infusion reactions that would prompt
testing for IgE, the following summary of the testing of serum samples
for IgE up to month 12 months of AGAL-005-99 is relevant:

-   12/29 (41%) r-hαGal subjects in AGAL-1-002-98 had serum tested for
    IgE (all negative)

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-   18/58 (31%, all r-hαGal) in the 1^st^ 6 months of AGAL-005-99 were
    tested for IgE (all negative)

-   3/58 (all r-hαGal) in the 2^nd^ 6 months of AGAL-005-99 were tested
    for IgE (all negative)

In trial AGAL-005-99 several subjects were withdrawn for evidence of
development of IgE to r-hαGal (see tabulation in the section on
discontinuations). It is important to note that these reactions could
occur out to infusion 52 of the trial.

###### Comment 

###### Infusion reactions to r-hαGal decrease in incidence with time. While there is evidence that suspicion for IgE-mediation for infusion reactions may go down with time, it is important to note that the development of serum IgE has been seen out to infusion 52 of an every-other-week infusion schedule. Because nearly all subjects were IgG antibody (+) during the trial (see below), testing for IgG antibody would not allow determination of subjects at risk for development of infusion reactions. 

[Other adverse events and laboratory abnormalities]{.underline}

There has been no increase in particular adverse events in the
continuers on r-hαGal compared to those who were switched from placebo
to r-hαGal (Table 68). Severities of events are generally similar (not
shown). Adverse events have been generally consistent with the course of
Fabry\'s disease. There has been no remarkable laboratory toxicity to
date.

#### IgG antibody to r-hαGal 

Data were available up to infusion 41 of AGAL-005-99. The majority of
subjects in the placebo/r-hαGal group seroconverted (25/28, with one
additional subject from the placebo group in AGAL-1-002-98 remaining
seropositive). Among the subjects who remained on r-hαGal from
AGAL-1-002-98, 27/29 seroconverted at some point before or at infusion
41, and 26/29 subjects were seropositive at infusion 41 (with 1 missing
observation).

###### 

###### Comment 

###### CBER has requested that Genzyme explore possible correlations of measures of the extent of antibody development with levels of reduction in substrate or possible regression in histological score) in AGAL-005-99. 

### CONCLUSIONS REGARDING AGAL-005-99

The results of AGAL-005-99 support the conclusion from AGAL-1-002-98
that r-hαGal causes a reduction in GL-3 deposition in capillary
endothelium of the kidney, heart, and skin. Histological reductions in
substrate persisted for most subjects, but there was some evidence that
with prolonged treatment the reductions might wane.

Nearly everyone exposed to r-hαGal has developed IgG antibody to
galactosidase.

There were no additional clinical findings or findings from other
laboratory evaluations that revealed a clinical benefit.

Infusion reactions waned with time, but late development of problematic
IgE reactions to the product remain a concern.

....................................

## **AGAL-007-99**

Genzyme conducted a trial in Japan that was not conducted under IND or
reviewed by CBER prior to its initiation. The trial, AGAL-007-99, was
entitled "A Multicenter, open-label study of the safety and efficacy of
recombinant human α-Galactosidase (r-hαGAL) replacement in patients with
Fabry Disease.

The findings of this trial have not been subject to detailed scrutiny,
but were reviewed to discern any remarkable differences in efficacy or
safety trends. A brief summary of the findings is presented here.

AGAL-007-99 was an open-label 13-subject, 5-month trial of r-hαGal at
the same dose and frequency as studied in AGAL-1-002-98 and AGAL-005-99.
Subject qualifications were the same as in AGAL-1-002-98. While the
trial was open-label, evaluation of the primary endpoint, renal
histology, was done on fully blinded slides by the same pathologists and
using the same quantitative scoring method as used for the primary
endpoint analysis of AGAL-1-002-98 and AGAL-005-99. Nonquantitative
methods were used for skin and heart, consistent with AGAL-1-002-98
(heart biopsies were to be performed only on those patients with cardiac
abnormalities demonstrated at baseline). Many of the same clinical
outcome measures were also assessed. Accumulation of substrate in
additional cell types was also assessed.

Fourteen subjects were screened; 13 met eligibility criteria and
enrolled; all completed all 11 infusions. The subjects had a slightly
lower weight and age than those enrolled in AGAL-1-002-98, and they were
all males. Other baseline characteristics were generally similar.

There were no protocol deviations that would be expected to have a major
impact on determinations of safety and efficacy.

#### Bioactivity and efficacy results

##### Histology

-   Kidney capillary endothelium: 10 subjects started with mild
    substrate accumulation; 3 with moderate. All ended with a score of 0
    except for one subject with moderate accumulation at baseline, whose
    score was 1 (mild) at the end of the trial.

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-   Additional renal cell types: Due to some biopsy samples not
    containing the cell type of interest, sample numbers were not 13 in
    all cases for all time points.

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-   Glomerular endothelial cells. Paired results for 11 subjects: 7
    subjects started with severe scores, and 4 with moderate scores; all
    ended with 0 scores.

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-   Kidney non-capillary interstitial endothelial cells. Paired results
    for 12 subjects: 10 subjects started with severe scores, and 2 with
    moderate scores; all ended with 0 scores.

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-   Kidney non-capillary interstitial smooth muscle cells. Paired
    results for 12 subjects: 8 subjects changed from severe to moderate,
    and 4 changed from severe to mild.

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-   Podocytes. Paired results for 11 subjects: 9 subjects stayed severe,
    and 2 changed from severe to moderate.

-   Kidney distal convoluted tubules and collecting ducts. 13 paired
    samples: 10 showed reductions in score.

-   Mesangial cell matrix of the kidney. There were 11 samples at
    baseline and 12 at the end of the trial. Mean and median values were
    unchanged.

-   Mesangial cells of the kidney. Paired results for 11 subjects: all
    subjects started with a score of numerous lipid granules: 2 subjects
    changed to minimal, and 9 changed to no lipid.

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-   Interstitial cells of the kidney. Paired results for 13 subjects:
    All subjects started with a score of numerous lipid granules: 1
    subject was unchanged, 2 subjects changed from numerous lipid
    granules to minimal, and 10 changed from numerous lipid granules to
    no lipid granules.

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-   Skin cells

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-   Capillary endothelium. Thirteen paired samples, all with reductions.

-   Deep vessel endothelial cells. 12 paired samples, all with
    reductions.

-   Smooth muscle cells. No paired samples were available.

-   Perineurium. 12 paired samples, 4 with reductions.

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-   Heart capillary endothelium: Only 1 subject had heart biopsies at
    baseline and end of trial. Cardiac capillary endothelial cell
    accumulation changed from mild to none.

##### Laboratory findings

-   Creatinine clearance (ml/min). Based on 13 samples at baseline and
    the end of the trial, there was an non-significant decline in mean
    creatinine clearance (126.6 ± 42 to115 ± 30). The method of
    determination of this result is not presented.

-   Serum creatinine. Mean serum creatinine did not change from baseline
    to the last visit.

-   Plasma GL-3 (ng/μl). Based on 13 samples at each time point, the
    mean value fell from 3.9± 2.7 at baseline to 0.2 ±0.8 at 11 weeks.

##### Clinical findings

-   Angiokeratomata, abnormal sweating, and abdominal pain: There was no
    significant change from baseline.

#### Safety

There were no deaths in this trial. There were two serious adverse
events: 1) fever, limb pain, malaise, and congestion of the nose
starting at an infusion 112 days after the start of treatment, and 2)
infectious gastroenteritis, severe limb pain, and a (+) reaction for
C-reactive protein 69-70 days after the start of treatment.

Infusion reactions were common in AGAL-007-99. Ten of 13 subjects
experienced reactions on the day of infusion that included events such
as fever, nasal congestion, cough, rigors, limb pain, and dyspnea.

Seven subjects had infusion reactions that raised the suspicion of
relation to development of IgE. These reactions occurred at infusions
4-10. Serum IgE against r-hαGal was not detected in any subject; skin
testing was not performed.

The most common nonserious adverse events were:

-   Albuminuria. Eleven subjects had albuminuria; 10 of the events were
    mild. Seven of the 11 subjects had a history of proteinuria

-   Bradycardia. Nine subjects, all with mild bradycardia. Three
    subjects had a history of bradycardia. The reason for bradycardia
    was not clarified in the submission, but it was noted that manual
    recording of pulse rate was performed during infusions.

-   Rhinitis: Eight subjects had mild rhinitis during the trial.

There was no notable effect of r-hαGal on means of serum chemistries or
hematologies at baseline and end of the trial.

#### Seroconversion

Eleven of 13 subjects seroconverted at a mean time of 63 days (range, 26
to 126 days).

###### Comments 

######  Histology results were consistent with results seen in AGAL-1-002-98. There was no clinical efficacy, and no notable effect on renal function. The safety results are consistent with those of the American/European trials. 

## **ADDITIONAL SAFETY INFORMATION** 

The following section summarizes additional serious adverse event and
death information received from Genzyme related to additional trials,
through February 28, 2002:

-   Ongoing open-label extension study AGAL-006-99:1 mg/kg (15
    subjects), with duration of exposure not shown.

-   Ongoing randomized, double-blind, placebo-controlled trial
    AGAL-008-00 (over 50 subjects), with duration of exposure not shown.

-   Special access and other programs in the U.S. and Europe (number of
    subjects not specified).

-   Postmarketing experience. The number of patients is not shown (there
    are approximately 176 patients worldwide who receive Genzyme's
    commercial r-hαGal as of August 14, 2002).

#### Deaths

Table 38 shows information related to deaths.

Table 38. Deaths in trials other than AGAL-005-99 to February 28, 2002

  --------------- ------ ----------- ------------ ----------- ------------- -----------------
  Study/          Age/   Treatment   Date of      Duration of Verbatim Term Medical History
                                     First                                  

  Patient         Sex    group/      Infusion/    R-hαGal                    
                                     Date                                   

                         Dose        of Onset/    treatment                  
                                                  before                    

                         q14d        Date of      SAE (days)                 
                                     Death                                  

  AGAL-008-00/    51/M   Placebo/    03OCT2001/   25          Cardiac       Hyperlipidemia,
                                                              arrest        gout, and

  18041                  R-hαGal     30OCT2001/   (blinded)                 kidney stones and
                                                                            findings

                         1.0 mg/kg   30OCT2001/                             consistent with
                                                                            history of

                         (Blinded)                                          Fabry disease

  AGAL-008-00/    55/M   Placebo/    05FEB2002/   2           Stroke        Ischemic heart
                                                                            disease,

  12041                  R-hαGal     06FEB2002/   (blinded)                 decreased left
                                                                            ventricular

                         1.0 mg/kg   13-Feb-02                              function, and
                                                                            renal impairment

                         (Blinded)                                           

  US Single       59/M   R-hαGal     18SEP2000/   1           Anasarca      Severe Fabry
                                                                            disease

  Patient                1.0 mg/kg   18SEP2000/                             associated with
                                                                            severe renal,

  Exemption                          24-Sep-00                              cardiac and
                                                                            pulmonary

  AGAL-010-00/                                                              involvement; also
                                                                            central

  Single patient                                                            nervous system
                                                                            involvement

                                                                            with a past
                                                                            cerebrovascular

                                                                            accident and
                                                                            residual

                                                                            hemiparesis.

                                                  UNK         Sepsis         

  Europe          48/M   R-hαGal     05APR2001/   5           Cardiac       Four myocardial
                                                              Arrest        infarctions

  Treatment              1.0 mg/kg   24APR2001/                             (1986, 1989,
                                                                            1997, 1998).

  Use                                24-Apr-01                               

  (Netherlands)                                                              

  Japan           63/M   R-hαGal     28DEC2000/   263         Ventricular   Extensive cardiac
                                                                            history

  Treatment              1.0 mg/kg   16SEP2001/               Tachycardia   including sick
                                                                            sinus syndrome,

  Use/                               16-Sep-01                              left ventricular
                                                                            hypertrophy,

  AGAL-011-00                                                               and congestive
                                                                            heart failure

  Europe          53/M   R-hαGal     06JUN2001/   42          Ischemic      Hemodialysis 3
                                                              colitis,      times a week,

  Treatment              1.0 mg/kg   18JUL2001/               Multiple      long history of
                                                              organ         abdominal pain

  Use (under                         18-Jul-01                failure        

  French ATU)                                                                
  --------------- ------ ----------- ------------ ----------- ------------- -----------------

\*There was one death noted in the review of AGAL-005-99.

###### Comment

###### Most of the deaths, including the death in AGAL-005-99, are consistent with vasculopathy, and possibly with the natural course of Fabry\'s disease; three of these occurred at or within 6 weeks of the start of treatment. As two of these three events were blinded, the evidence implicating treatment is weak, but is cause for being watchful.

#### Serious adverse events (excluding deaths) 

*[Trial AGAL-006-99]{.underline}*

Five subjects had serious adverse events. Times to event do not
precisely reflect time from the start of treatment, since subjects had
spent variable times on r-hαGal during the core trial, FB9702-01. These
events are of miscellaneous natures. Detailed information is available
only for the last event, as the others were not deemed related to
treatment, and the last was deemed possibly related.

1)  vomiting in a subject with a history of irritable bowel (at 8 days
    of treatment)

2)  atrial fibrillation in a subject with a history of junctional rhythm
    and SVT (at 76 days of treatment)

3)  uvula edema in a subject with family member with a "similar
    condition" (at 92 days of treatment)

4)  perforated diverticulitis and peritonitis in a subject with a
    history of cramping and diarrhea (at 1242 days of treatment)

5)  chest pain, fatigue, and dyspnea in a subject with a history of
    cardiac disease and pacemaker (at 32 days of treatment). The subject
    was discontinued from treatment.

*[AGAL-008-00]{.underline}*

The events from this trial are blinded.

Thirteen subjects experienced serious adverse events after initiating
treatment. Counting terms related to each other that occurred on the
same day as the same event, the serious adverse events may be grouped as
follows:

-   "Probable" relationship to infusion: 1 subject, 1 event: angioedema,
    flushing, wheezing, urticaria, and cough 43 days after start of
    treatment.

-   "Definite" relationship to infusion: 1 subject, 1 event:
    hypotension, at 54 days of treatment (infusion 5). This subject had
    IgE to r-hαGal and was withdrawn from the trial.

-   Miscellaneous: 4 subjects, 5 events:

> \--an acute attack of Meniere's syndrome in a subject with history of
> stroke, angina
>
> \--syncope in a subject with asthma
>
> \--mood disorder and medication adjustment in subject with
> post-traumatic stress disorder and depression
>
> \--fever in subject with "similar febrile reactions, although not in
> the past year"

-   Possibly cardiac/neurologic: 6 subjects, 6 events (Table 39). Note
    that narratives are not available to discern details of these cases,
    as the events were not deemed to be due to treatment.

Table 39. Serious possible or diagnosed cardiac and neurologic adverse
events in AGAL-008-00 (blinded treatment)

  --------- ------------------- ----- ----------- -----------------------------
  Subject   Term                Age   Days after  History
                                      treatment   

  20041     Chest pain          36    40          Cardiac disease

  20047     Atrial fibrillation 52    68          Pacemaker

  24041     Chest pain          54    105         Cardiac disease

  27041     Stroke              59    42          Cardiac disease

  34042     Auricular disease   54    43          Cardiovascular; hypertension,
                                                  left AV bundle branch block

  12041     Stroke              55    2           Ischemic heart disease;
                                                  decrease LV function; and
                                                  renal impairment
  --------- ------------------- ----- ----------- -----------------------------

\*Narratives not available to determine details of the diagnoses and
treatments

###### Comments

###### Since submission of the safety report upon which the summary of safety in the additional trials is based, Genzyme has submitted a report of the development of a (+) skin test, rash, shakes, headache, fever, and urticaria in another subject in AGAL-008-00. This subject met protocol-specified criteria for withdrawal.

###### Importantly, this trial allows enrollment of subjects with potentially moderately advanced renal disease, which may also include more advancement of cardiac and neurological manifestations of their disease. This may account for the large number of relatively early cardiac and neurological events. 

*[Serious adverse events from special access programs]{.underline}*

Subject characteristics from these programs are not presented, and
details are not available for all events.

Three subjects had 5 miscellaneous serious adverse events:

\--anemia, elevated C-reactive protein, and ileus in a subject with
end-stage renal disease and cardiovascular disease

\--musculoskeletal pain in the upper abdomen/chest in a subject with no
related medical history

\--rhabdomyolysis; subject noted to have had red discoloration of the
urine thought due to rifampicin (not clear if applicant's submission
describes event or medical history)

Possible or diagnosed cardiac or neurological events are shown in Table
40. All but the stroke were thought possibly (\-\-\-- and \-\-\--) or
probably (\-\-\-\--) to be due to r-hαGal.

Table 40. Serious possible or diagnosed cardiac and neurologic adverse
events in special access programs

  ------------------- ------------------------ ----- ----------- ----------------------
  Subject             Term                     Age   Days after  Relevant history
                                                     treatment   

  \-\-\-\-\-\-\-\--   Myocardial infarction    36    Unknown     Mild chest pain

  \-\-\-\-\-\-\--     Ataxia; urosepsis,       44    6           Cerebellar stroke
                      disorientation                             

  \-\-\-\-\-\--       Stroke                   44    264         3 left hemispheric
                                                                 strokes

  \-\-\-\-\-\-\-\--   Retrosternal chest       63    170         Cardiomyopathy,
                      pain\*\*                                   stroke, peripheral
                                                                 vascular disease
  ------------------- ------------------------ ----- ----------- ----------------------

\*Details not available in submission

\*\*Responded to nitroglycerin, but not diagnosed conclusively

*[Post-marketing serious adverse events]{.underline}*

Three serious adverse events are presented, all in subjects on the
proposed dose. Only the last was deemed due to treatment.

1)  Toe infection in a 41 year-old subject with no relevant medical
    history, 121 days after the start of treatment

2)  Umbilical hernia in a 47 year-old subject with a history of
    peritoneal dialysis, 71 days after start of treatment

3)  Infusion-related reduced blood pressure, increased sweating,
    bronchospasm, and somnolence in a 14 year-old subject 43 days after
    the start of treatment.

###### Summary comments on additional safety data

######  The largest single group of events were possibly vascular: cardiac and neurological events. Some of these events occurred shortly after treatment. However, because of the lack of a control group, the predisposition of patients with Fabry\'s disease to vascular events, and the documented history of cardiac and neurological events in some of the subjects, there is not a strong safety concern at this time. 

######  Infusion-related events were consistent with those in the clinical trial data presented earlier, and merit continued concern.

# FINANCIAL DISCLOSURE

There were two investigators with relationships to Genzyme that merited
scrutiny. Both were listed as subinvestigators on AGAL-1-002-98, the
primary source of efficacy information. Dr. Robert Desnick, who was
central to the development of Fabrazyme, and who is listed in patents
involving Fabrazyme, was a subinvestigator at the Mt. Sinai Medical
Center. Dr. Hans Aerts, was a subinvestigator at the Academisch Medisch
Centrum. CBER's review of the financial relationship of Dr. Desnick and
Dr. Aerts, and of the roles they played in the trial, show that there is
no significant concern over bias in the results of the trial.

# 

# OVERALL SUMMARY OF BIOACTIVITY AND EFFICACY

The clinical data presented provide for the following conclusions:

-   Intravenous administration of Genzyme's r-hαGal results in reduction
    of the enzyme's substrate in capillary endothelial and selected
    other cells of the kidney, heart, and skin. However, the effect of
    the product on nonvascular cell types and tissues is variable, and
    sometimes negligible to nonexistent. The pathophysiology of Fabry's
    disease does suggest that reduction of endothelium has the potential
    to decrease the microvascular pathology of the disease, however, so
    it may be reasonable to judge that the product could show clinical
    benefit.

-   There is pharmacologic evidence of a reduction in exposure to
    r-hαGal in individuals with high-titer antibody. These data open the
    question of the likelihood of continued effect in these individuals.
    More long-term skin biopsy data, up to now available in a limited
    number of subjects, may provide further insights into the
    histological effects of r-hαGal with chronic administration.

-   The clinical trials failed to show clinical benefit on a wide range
    of tests of neurologic, renal, and cardiac function. The design of
    these studies was not with objective of showing clinical efficacy,
    however. Whether a longer trial, or one with different eligibility
    criteria, could have demonstrated a benefit is an open question.

# OVERALL SUMMARY OF SAFETY

-   The chief safety problem with the administration of Genzyme's
    r-hαGal was the occurrence of infusion reactions. Reactions have
    required adjustment of infusion rates, administration of systemic
    corticosteroids and other medications, and have occurred despite
    premedication with nonsteroidal anti-inflammatory medications and
    antihistamines; and 5 subjects have met protocol requirements for
    withdrawal due to detection of anti-r-hαGal IgE. Genzyme knows of no
    predisposing factors to the development of infusion reactions.

-   Noninfusion-related toxicities appeared to be minimal, but the
    ability to discern toxicities related to chronic treatment in an ill
    population is diminished by the open-label nature of the data.

-   Antibody formation was extremely common, and persistent. The
    continued presence of antibodies poses a potential safety risk for
    the development of continued infusion reactions.

# ONGOING CLINICAL STUDIES

Besides the ongoing open label extension studies, Genzyme has Study
AGAL-008 in progress. AGAL-008 is double blind, placebo controlled study
in approximately 30 centers enrolling approximately 70 subjects and
randomizing 2:1 r-hαGal to placebo. The dose of r-hαGal is the standard
1 mg/kg IV dose. Treatment continues for 35 months or until the
prospectively determined required number events for statistical powering
occurs. Interim analyses of the aggregate data will determine the actual
study duration. The primary objective of this study is to demonstrate
the clinical efficacy of r-hαGal in preventing meaningful adverse events
or adverse progression of the disease in the renal, cardiac, or
neurological systems.

Eligibility Criteria:

Inclusion Criteria:

16 years old or greater

Diagnosis of Fabry Disease and consistent clinical presentation

No prior receipt of enzyme replacement treatments

Plasma α-Gal activity \< 1.5 nmol/hr/ml or leukocyte αGal \< 4
nmol/hr/mg

Evidence of renal impairment at baseline:

2 consecutive serum creatinine between 1.2 and 3, with less than 15%
difference

or

creatinine clearance estimate of \< 80 ml/min using Cockcroft-Gault
formula

with less than 15% difference between 2 measurements

Major Exclusion Criteria;

Renal transplant received or scheduled

Acute renal failure

Stroke or TIA within 3 prior months

Advanced cardiac disease (explicit criteria provided)

Major evaluations in the study include serum creatinine every 4 weeks,
with a broader range of assessments every 3 months.

Primary Endpoint:

> Time-to-event for any of the "events" defined in the renal, cardiac,
> or neurologic systems

Renal events are expected to be the most common, and consist of an
increase in serum creatinine by 33% from baseline or the need for
dialysis for more than 40 days. Cardiac events include MI, new
symptomatic arrhythmia, unstable angina, new or worsening heart failure.
Neurologic events include new stroke or TIA.

Secondary Endpoints include an analysis of the slope of change in
creatinine, time to renal (only) progression, pain score, and the slope
of change in estimated GFR. GFR is estimated from age, weight, and serum
creatinine. No direct measure of GFR is performed.

# CONCLUSIONS AND CURRENT STATE OF CLINICAL ACTIVITY

Based on the premise that Fabry\'s disease is primarily a vascular
disorder, Genzyme proposes that the histological data are sufficient to
conclude that there is a reasonable likelihood that r-hαGal will confer
a clinical benefit. However, no robust clinical benefit has been shown.
The reasons for this may be due to inherent lack of connection between
histological bioactivity and effect or an inability of the trials as
designed to detect clinical differences.

Genzyme has requested that they receive Accelerated Approval for their
galactosidase product. Genzyme is currently conducting a double-blind,
randomized, placebo-controlled trial intended to determine if their
r-hαGal will confer a clinical benefit in moderately severe patients
with Fabry\'s disease (AGAL-008-00). If they receive an accelerated
approval for r-hαGal, the ability of AGAL-008-00 to conclusively
determine the clinical effect of r-hαGal would become critical. This
trial is currently nearly fully enrolled. Genzyme currently has a
proposal to convert this trial into an open-label, single-arm trial,
with a comparator consisting of data from a natural historical data
base. The review of this database is the subject of another briefing
document.

# 

# REFERENCES

1.  Desnick RJ, Ioannu YA, and Eng, CM. Alpha-Galactosidase A
    deficiency: Fabry Disease. In *The Metabolic and Molecular Bases of
    Inherited Disease*, 1995 (Scriver, Beaudet, Sly, and Valle, eds.)
    McGraw-Hill, New York, NY

2.  Pastores, GM and Thadhani, R (2001) Enzyme replacement therapy for
    Anderson-Fabry disease. Lancet 358:601-603.

3.  Desnick, RJ, Allen, KY, Desnick, SJ, Raman, MK, Bernlohr, RW, and
    Krivit, W. (1973) Fabry\'s disease: Enzymatic diagnosis of
    hemizygotes and heterozygotes. α-Galactosidase activities in plasma,
    serum, urine, and leukocytes. J. Lab Clin. Med. 81:157-171

4.  Eng, CM et al. (2001) A Phase 1/2 clinical trial of enzyme
    replacement in Fabry Disease: Pharmacokinetic, substrate clearance,
    and safety studies. Am. J. Hum. Genet. 68(3): 711-722.

5.  Levey, AS et al. (2000) A simplified equation to predict glomerular
    filtration rate from serum creatinine. J. Am. Soc. Nephrol. 11:
    A0828.

# APPENDICES (TABLES REFERRED TO IN TEXT)

## **Appendix A: Study FB9702-01**

Table 41. Trial FB9702-01: Demographics and baseline characteristics

+-----------+----------+----------+----------+----------+----------+
|           | 0.       | 1.       | 3.       | 1        | 3        |
|           | 3/14-day | 0/14-day | 0/14-day | .0/48-hr | .0/48-hr |
|           |          |          |          |          |          |
|           | *n=3*    | *n=3*    | *n=3*    | *n=3*    | *n=3*    |
+-----------+----------+----------+----------+----------+----------+
| Age (yr)  | 41.0 ±   | 33.7 ±   | 34.7 ±   | 27.0 ±   | 35.7 ±   |
| mean ±    | 3.0      | 3.4      | 1.5      | 5.5      | 4.7      |
| std error |          |          |          |          |          |
|           | 35, 44,  | 27, 36,  | 32, 37,  | 37, 26,  | 45, 30,  |
| Series    | 44       | 38       | 35       | 18       | 32       |
+-----------+----------+----------+----------+----------+----------+
| Weight    | 64.7 ±   | 73.6 ±   | 69.1 ±   | 69.8 ±   | 78.0 ±   |
| (kg) mean | 4.1      | 9.1      | 7.4      | 2.4      | 8.0      |
| ± std     |          |          |          |          |          |
| error     | 66, 57,  | 88, 57,  | 56, 82,  | 73, 65,  | 74, 67,  |
|           | 71       | 76       | 69       | 72       | 93       |
| Series    |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| Gender    | 3        | 3        | 3        | 3        | 3        |
| (n) male  |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| Race (n)  | 3        |          |          |          |          |
|           |          |          |          |          |          |
| White     | 0        | 1        | 2        | 2        | 3        |
|           |          |          |          |          |          |
| Black     | 0        | 0        | 0        | 0        | 0        |
|           |          |          |          |          |          |
| Hispanic  |          | 2        | 1        | 1        | 0        |
+-----------+----------+----------+----------+----------+----------+
| Serum     | 1.3 ±    | 1.2 ±    | 1.4 ±    | 1.  ±    | 1.6 ±    |
| c         | 0.4      | 0.1      | 0.2      |     0.3  | 0.2      |
| reatinine |          |          |          |          |          |
|           | 0.6,     | 1.4,     | 1.5,     | 1.6,     | 1.9,     |
| Mean ±    | 1.3, 2.0 | 1.0, 1.1 | 1.6, 1.1 | 0.8, 0.6 | 1.7, 1.1 |
| std error |          |          |          |          |          |
|           |          |          |          |          |          |
| Series    |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| Plasma    | BDL\*    | BDL\*    | BDL\*    | BDL\*    | BDL\*    |
| α-gal     |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| Prestudy  | 22.0 ±   | 15.2 ±   | 29.5 ±   | 20.0 ±   | 3.3 ±    |
| plasma    | 3.1      | 4.3      | 10.7     | 3.2      | 1.6      |
| GL-3      |          |          |          |          |          |
| (ng/ml)   | 16.6,    | 16.7,    | 48.6,    | 20.3,    | 6.2,     |
| mean ±    | 27.4,    | 21.7,    | 28.2,    | 14.3,    | 2.6\*\*, |
| std       | 22.1     | 7.2      | 11.6     | 25.5     | 1.0\*\*  |
|           |          |          |          |          |          |
| Series    |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+

\*below 55 ng/μl

\*\*below the inclusionary limit of ≥5 ng/ml

Table 42. Trial FB9702-01: Numbers of subjects with biopsies received
and suitable for histological scoring

  --------------- ------- --------- --------- ------ ------- ------ ----- ------ -------- ------ ----- ------ ------- ------ ----- ------
  Group           Skin                               Liver                       Kidney                       Heart                
  *(n=3/group)*                                                                                                                    

                  LM\*              TEM\*\*          LM             TEM          LM              TEM          LM             TEM   

                  Pre\'   Post^2^   Pre       Post   Pre     Post   Pre   Post   Pre      Post   Pre   Post   Pre     Post   Pre   Post

  0.3 mg/kg       2       2         3         3      3       3      3     3      0        0      0     0      0       0      0     0

  every 14 d                                                                                                                       

  1.0 mg/kg       3       1         3         3      3       3      3     3      0        0      0     0      0       0      0     0

  every 14 d                                                                                                                       

  3.0 mg/kg       3       3         3         3      3       3      3     3      3        2      3     2      3       3      3     3

  every 14 d                                                                                                                       

  1.0 mg/kg       1       0         0         0      3       3      0     0      2        2      0     0      3       3      0     0

  every 48 h                                                                                                                       

  3.0 mg/kg       0       2         0         0      3       2      0     0      2        1      0     0      2       1      0     0

  every 48 h                                                                                                                       
  --------------- ------- --------- --------- ------ ------- ------ ----- ------ -------- ------ ----- ------ ------- ------ ----- ------

> \*LM is light microscopy; \*\*TEM is transmission electron microscopy
>
> ^1^ pre treatment; ^2^ post treatment

Table 43. Trial FB9702-01: Skin superficial capillary endothelial
glycolipid scores

+------------------+---------------+---------------+------------------+
| Dose group       | Subject       | Pre-          | Post-            |
|                  |               |               |                  |
|                  |               | treatment     | treatment        |
|                  |               |               |                  |
|                  |               | score         | score            |
+------------------+---------------+---------------+------------------+
| 0.3/14-day       | 2             | 3             | 0                |
+------------------+---------------+---------------+------------------+
|                  | 3             | 2             | 0                |
+------------------+---------------+---------------+------------------+
| 1.0/14-day       | 5             | 3             | 0                |
+------------------+---------------+---------------+------------------+
| 3.0/14-day       | 7             | 2             | 0                |
+------------------+---------------+---------------+------------------+
|                  | 8             | 2             | 0                |
+------------------+---------------+---------------+------------------+
|                  | 9             | 3             | 0                |
+------------------+---------------+---------------+------------------+
| 1.0/48-hour      | 12            | 2             | 0                |
+------------------+---------------+---------------+------------------+

Table 44. Trial FB9702-01: Heart vascular endothelial glycolipid scores

+------------------+-------------+---------------+-------------------+
| Dose group       | Subject     | Pre-          | Post-             |
|                  |             |               |                   |
|                  |             | treatment     | treatment         |
|                  |             |               |                   |
|                  |             | score         | score             |
+------------------+-------------+---------------+-------------------+
| 3.0/14-day       | 7           | 3             | 1                 |
+------------------+-------------+---------------+-------------------+
|                  | 8           | 3             | 2                 |
+------------------+-------------+---------------+-------------------+
|                  | 9           | 1             | 0                 |
+------------------+-------------+---------------+-------------------+
| 1.0/48-hour      | 10          | 2             | 0                 |
+------------------+-------------+---------------+-------------------+
|                  | 11          | 2             | 1                 |
+------------------+-------------+---------------+-------------------+
|                  | 12          | 1             | 0                 |
+------------------+-------------+---------------+-------------------+
| 3.0/48-hour      | 13          | 1             | 0                 |
+------------------+-------------+---------------+-------------------+

Table 45. FB9702-01: Summary of effect on renal cell types (not
including interstitial capillary endothelium)

  ----------------------- -------------- ---------------------------------
  Cell type               Subjects ID    Effect on light microscopy score

  podocyte                8,9            no effect

  mesangial cell          8,9            both fell

  glomerular endothelial  8,9            both fell
  cell                                   

  arteriolar endothelial  9,10,11,13     all fell
  cell                                   

  arterial medial cell    10,11,13       no effect

  arterial intimal cell   10,11,13       no effect (2 were 0 at baseline)

  proximal tubular cell   8,9,10,11,13   no effect (all 0 at baseline)

  distal tubular cell     8,9,10,13      2 reductions, 2 no effect

  collecting duct cell    8,9,10,13      3 reductions, 1 no reduction
  ----------------------- -------------- ---------------------------------

Table 46. Trial FB9702-01: Skin and Liver GL‑3 levels (ng/mg) and
percents reduction

  ------------- ----------- ---------- ----------- ---------- ---------- -----------
  Group/        Skin                               Liver                 

  Subject       Baseline    Infusion 5 \%          Baseline   Infusion 5 \%
                                       reduction                         reduction

  0.3/ 14-Day                                                            

  1             224         262        -17         \-         147        \-

  2             128         83         35          870        74         91

  3             198         0          100         1126       48         96

  1.0/14-Day                                                             

  4             352         42         88          832        185        78

  5             262         182        31          176        134        24

  6             451         38         92          2406       45         98

  3.0/14-Day                                                             

  7             454         320        30          371        26         93

  8             480         448        7           1776       153        91

  9             803         96         88          352        29         92

  1.0/48-Hour                                                            

  10            332         480        -45         12646      5939       53

  11            294         326        -11         1280       38         97

  12            422         102        76          1638       77         95

  3.0/48-Hour                                                            

  13            310         265        15          1690       204        88

  14            396         \-         \-          \-         \-         \-

  15            137         25         82          141        0          100
  ------------- ----------- ---------- ----------- ---------- ---------- -----------

Table 47. Trial FB9702-01: Kidney and heart GL‑3 levels (ng/mg) and
percents reduction

  ------------- ----------- ---------- ----------- ---------- ---------- -----------
  Group/        Kidney                             Heart                 

  subject       Baseline    Infusion 5 \%          Baseline   Infusion 5 \%
                                       reduction                         reduction

  3.0/14-Day                                                             

  7             3456        \-         \-          17600      15680      11

  8             12928       384        97          38080      40880      -7

  9             6912        512        93          17520      12880      26

  1.0/48-Hour                                                            

  10            1056        448        58          32480      29840      8

  11            10144       1984       80          17840      14800      17

  12            \-          \-         \-          8320       10720      -29

  3.0/48-Hour                                                            

  13            1856        5632       -203        24960      48080      -93

  14            \-          \-         \-          32960      \-         \-

  15            2336        \-         \-          \-         \-         \-
  ------------- ----------- ---------- ----------- ---------- ---------- -----------

Table 48. Trial FB9702-01: Infusion reactions

  ---------------- ------------------ -------------------- ------------------ ----------------
  Subject Number   5                  7                    8                  9

  Dose Arm         I mg/kg q14 day    3 mg/kg q14 day      3 mg/kg q14 day    3 mg/kg q14 day

  *Infusion        *4\**              *5\*\**              *4*                *4*
  Number*                                                                     

  Pretreatment     None               None                 None               lbuprofen

                   Abdominal                                                  

                   discomfort,                                                

  Symptoms         Nausea,            Flushed face,        Shaking chills     

                   Vomiting,          Palpitations,        (responded to      Chills

                   Diaphoretic,       Tachycardia          diphenhydramine)   

                   Urticaria,                              Febrile when       

                   Edema                                   infusion           

                   Pruritus,                               complete           

                   Low heart rate                                             

                   Infusion stopped,  Infusion stopped,    Infusion slowed,   Infusion slowed,

  Treatment        Diphenhydramine,   Diphenhydramine,     Diphenhydramine,   Hydrocortisone

                   Epinephrine,       Epinephrine,         Acetaminophen      

                   Hydrocortisone     Hydrocortisone                          

  Outcome          Recovered          Recovered            Recovered          Recovered

  IgG              (+)                (+)                  (+)                (+)
  antibody\*\*\*                                                              

  IgE antibody     (-)                (-)                  (-)                Not tested

  Skin Tested      (-)                (-)                  Not tested         Not tested

  *Infusion        *5\**              *Rechallenge*        *5\**              *5\**
  Number*                                                                     

                                      Prednisone,                             

  Pretreatment     Hydroxyzine        Acetaminophen,       Acetaminophen      None

                                      Diphenhydramine,                        

                                      Methylprednisolone                      

                                                           Flushed, Feeling   

  Symptoms         Light headed,      Flushed, Discomfort  warmth in face,    

                   Stomach ache,      in throat,           Febrile 20 min.    None

                   Low                Palpitations,        after infusion,    

                   heart rate         Tachycardia          Itchy eyes         

                                                           after indomethacin 

  Treatment        Infusion stopped,  Infusion stopped     Indomethacin,      N/A

                   Epinephrine                             Diphenhydramine,   

                                                           Hydrocortisone     

  Outcome          Recovered          Recovered            Recovered          N/A
  ---------------- ------------------ -------------------- ------------------ ----------------

> \* infusion reactions reported as serious adverse event
>
> \*\* infusion 5 was the last planned infusion in any subject
>
> \*\*\* see section in review on antibody development in the trial

## **Appendix B: Study AGAL-1-002-98** 

Table 49. Trial AGAL-1-002-98: Enrollment by site

+-------+------------------------------------------------+-------------+
| Site  | Center, City, and Country                      | Number of   |
|       |                                                |             |
| N     |                                                | Subjects    |
| umber |                                                | Enrolled    |
+-------+------------------------------------------------+-------------+
| 1     | Mount Sinai School of Medicine, NYC, USA       | 20          |
+-------+------------------------------------------------+-------------+
| 2     | Beth Israel-Deaconess Medical Center, Boston,  | 3           |
|       | USA                                            |             |
+-------+------------------------------------------------+-------------+
| 3     | Cedars-Sinai Medical Center, Los Angeles, USA  | 7           |
+-------+------------------------------------------------+-------------+
| 4     | Academisch Medisch Centrum, Amsterdam, The     | 2           |
|       | Netherlands                                    |             |
+-------+------------------------------------------------+-------------+
| 5     | The Middlesex Hospital, London, UK             | 6           |
+-------+------------------------------------------------+-------------+
| 6     | Hope Hospital, Manchester, UK                  | 5           |
+-------+------------------------------------------------+-------------+
| 7     | Hôpital Edouard Herriot, Lyon, France          | 9           |
+-------+------------------------------------------------+-------------+
| 8     | Hôpital Broussais, Paris, France               | 6           |
+-------+------------------------------------------------+-------------+

Table 50. Trial AGAL-1-002-98: Distribution of baseline scores among
those who ended with "0" score\*

  ------------------------------- ------------------- -------------------
  Baseline score                  r-hαGal             Placebo

  3                               5                   0

  2                               11                  0

  1                               3                   0

  0                               1                   0

  Total                           20                  0
  ------------------------------- ------------------- -------------------

\*as-treated population, considered equivalent to intent-to-treat

Table 51. Trial AGAL-1-002-98: Numbers of subjects with "0" or "non 0"
score at the end of treatment, by trial center\*

+------+---------+---------+---------+---------+------+------+-------+
|      | Tr      |         |         |         | Odds | 95%  | p-    |
|      | eatment |         |         |         |      |      | value |
|      | Group   |         |         |         | r    | C.I. |       |
|      | \[n,    |         |         |         | atio |      |       |
|      | (%)\]   |         |         |         |      |      |       |
+------+---------+---------+---------+---------+------+------+-------+
|      | Placebo |         | r-hαGal |         |      |      |       |
+------+---------+---------+---------+---------+------+------+-------+
| Site | Zero    | Non-    | Zero    | Non-    |      |      |       |
|      |         |         |         |         |      |      |       |
|      |         | zero    |         | zero    |      |      |       |
+------+---------+---------+---------+---------+------+------+-------+
| 1    | 0       | 10      | 8 (80)  | 2 (20)  |      |      |       |
|      |         | (100)   |         |         |      |      |       |
+------+---------+---------+---------+---------+------+------+-------+
| 2    | 0       | 1 (100) | 2 (100) | 0       |      |      |       |
+------+---------+---------+---------+---------+------+------+-------+
| 3    | 0       | 3 (100) | 1 (25)  | 3 (75)  |      |      |       |
+------+---------+---------+---------+---------+------+------+-------+
| 4    | 0       | 1 (100) | 1 (100) | 0       |      | (0   |       |
|      |         |         |         |         |      | .01, |       |
+------+---------+---------+---------+---------+------+------+-------+
| 5    | 0       | 4 (100) | 0       | 2 (100) | 0    | 0    | \<    |
|      |         |         |         |         | .058 | .24) | 0.001 |
+------+---------+---------+---------+---------+------+------+-------+
| 6    | 0       | 2 (100) | 3 (100) | 0       |      |      |       |
+------+---------+---------+---------+---------+------+------+-------+
| 7    | 0       | 5 (100) | 3 (75)  | 1 (25)  |      |      |       |
+------+---------+---------+---------+---------+------+------+-------+
| 8    | 0       | 3 (100) | 2 (67)  | 1 (33)  |      |      |       |
+------+---------+---------+---------+---------+------+------+-------+
| T    | 0(0)    | 29      | 20 (69) | 9(31)   |      |      |       |
| otal |         | (100)   |         |         |      |      |       |
+------+---------+---------+---------+---------+------+------+-------+

\*as-treated population, considered equivalent to intent-to-treat

The p-value is based on the Mantel-Haenszel χ^2^ test stratified by
trial center.

Table 52. AGAL-1-002-98: Independent pathologist's judgments of kidney
scores on a subset of slides

  ---------------------- ------------------ ------------ ------- ------- -------
  Genzyme slide  score   Genzyme total      Slide score                  
                                            using Dr.                    
                                            Jennette's                   
                                            scores\*                     

                                            0            1       2       3

  0                      9                  8            1        -       -

  1                      15                  -           10      5       - 

  2                      5                   -            -      4       1

  3                      6                  -                     -      6
  ---------------------- ------------------ ------------ ------- ------- -------

\*Dr. Jennette scored each slide on each of 3 days. The score in the
table represents a majority of scores where two scores were different.
No slide received scores that differed by more than 1 point on different
days.

Table 53. Trial AGAL-1-002-98: Baseline skin and heart biopsy slide
scores\*

  ------------------ ------------------ ---------------- ----------------
  Organ              Slide score        Placebo          r-hαGal

                     0                  5                5

                     1                  21               23

  Heart              2                  3                1

                     3                  \-               \-

                     **total**          **29**           **29**

                     0                  2                2

                     1                  \-               \-

  Skin               2                  15               19

                     3                  12               8

                     **total**          **29**           **29**
  ------------------ ------------------ ---------------- ----------------

\*as-treated population, considered equivalent to intent-to-treat

Table 54. Trial AGAL-1-002-98:Tissue GL-3 levels (ng/mg) at baseline and
end of trial\*

+----+-----------+--------+---------+------+--------+-------+------+
|    |           | P      |         |      | r      |       |      |
|    |           | lacebo |         |      | -hαGal |       |      |
+----+-----------+--------+---------+------+--------+-------+------+
|    |           | Ba     | Visit   | Me   | Ba     | Visit | Me   |
|    |           | seline | 11      | dian | seline | 11    | dian |
|    |           |        |         | %    |        |       | %    |
|    |           |        |         | ch   |        |       | ch   |
|    |           |        |         | ange |        |       | ange |
+----+-----------+--------+---------+------+--------+-------+------+
| H  | *n*       | *28*   | *28*    | -8   | *26*   | *26*  | -5   |
| ea |           |        |         |      |        |       |      |
| rt | median    | 8238   | 8012    |      | 10140  | 6705  |      |
|    |           |        |         |      |        |       |      |
|    | mean ±    | 10796  | 9949 ±  |      | 11024  | 8850  |      |
|    | std.      | ± 1815 | 1634    |      | ± 1740 | ±     |      |
|    | error     |        |         |      |        | 1554  |      |
+----+-----------+--------+---------+------+--------+-------+------+
| Sk | *n*       | *29*   | *28*    | -24  | *26*   | *26*  | -20  |
| in |           |        |         |      |        |       |      |
|    | median    | 385    | 343     |      | 362    | 189   |      |
|    |           |        |         |      |        |       |      |
|    | mean ±    | 453 ±  | 414 ±   |      | 413 ±  | 289 ± |      |
|    | std.      | 65     | 62      |      | 56     | 46    |      |
|    | error     |        |         |      |        |       |      |
+----+-----------+--------+---------+------+--------+-------+------+

\*as-treated population, considered equivalent to intent-to-treat

Table 55. Trial AGAL-1-002-98: Visit at which anti-α galactosidase IgG
was first observed (active, as-treated group\*)

  ---------------- ------- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- -----------
                   Visit                                                          

   Treatment       0       1    2    3    4    5    6    7    8    9    10   11   **Total**

  r-hαGAL (n=29)   0       0    0    6    9    2    0    4    0    1    1    1    **24**

  Placebo (n=29)\* 0       0    0    0    0    1    0    0    0    0    0    0    **1**
  ---------------- ------- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- -----------

\*Subject 503, who received his first 3 infusions as active treatment
and is included in the placebo group, did not develop antibody to α-Gal
A.

Table 56. Trial AGAL-1-002-98: Change from baseline as a function of
visit number at which IgG seroconversion was noted (r‑hαGal treatment,
as-treated group)\*

<table>
<colgroup>
<col style="width: 12%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 13%" />
<col style="width: 13%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="7">Visit at which anti-α-Gal A IgG first noted</td>
<td rowspan="2">Total with antibody</td>
<td rowspan="2"><p>Never</p>
<p>antibody</p></td>
</tr>
<tr class="even">
<td><p>Change</p>
<p>score</p></td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>7</td>
<td>9</td>
<td>10</td>
<td>11/13</td>
</tr>
<tr class="odd">
<td>-3</td>
<td>0</td>
<td>3</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>1</td>
<td>0</td>
<td>4</td>
<td>1</td>
</tr>
<tr class="even">
<td>-2</td>
<td>6</td>
<td>3</td>
<td>1</td>
<td>3</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>13</td>
<td>0</td>
</tr>
<tr class="odd">
<td>-1</td>
<td>0</td>
<td>2</td>
<td>1</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>1</td>
<td>4</td>
<td>2</td>
</tr>
<tr class="even">
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>1</td>
<td>1</td>
<td>0</td>
<td>0</td>
<td>2</td>
<td>2</td>
</tr>
</tbody>
</table>

\*omits subject 307, with an imputed worst case score of 3, and an
initial score of 1

Table 57. Trial AGAL-1-002-98: Change from baseline as a function of the
peak titer (r‑hαGal treatment, as-treated group)\*

+-------+------+------+------+------+------+-------+-------+-------+
| C     | Peak |      |      |      |      |       |       |       |
| hange | IgG  |      |      |      |      |       |       |       |
|       | t    |      |      |      |      |       |       |       |
| score | iter |      |      |      |      |       |       |       |
+-------+------+------+------+------+------+-------+-------+-------+
|       | 200  | 800  | 3200 | 6400 | 1    | 25600 | 51200 | 1     |
|       |      |      |      |      | 2800 |       |       | 02400 |
+-------+------+------+------+------+------+-------+-------+-------+
| -3    | 0    | 0    | 0    | 0    | 3    | 2     | 1     | 0     |
+-------+------+------+------+------+------+-------+-------+-------+
| -2    | 1    | 1    | 0    | 0    | 2    | 7     | 2     | 1     |
+-------+------+------+------+------+------+-------+-------+-------+
| -1    | 1    | 0    | 0    | 1    | 0    | 0     | 0     | 0     |
+-------+------+------+------+------+------+-------+-------+-------+
| 0     | 0    | 0    | 1    | 0    | 0    | 0     | 0     | 0     |
+-------+------+------+------+------+------+-------+-------+-------+

\*omits subject 307, with an imputed final score

Note that this analysis is tentative, since Genzyme's method for
titrating antibody was not qualified.

Table 58. Trial AGAL-1-002-98: Subjects with adverse events, among those
adverse events that occurred in at least 2 more subjects in the active
group than in placebo, with distributions of severities

+--------------------+----+-------+------+---+----+-------+----+---+
| WHOART Preferred   | P  |       |      |   | r  |       |    |   |
| Term               | la |       |      |   | -h |       |    |   |
|                    | ce |       |      |   | αG |       |    |   |
|                    | bo |       |      |   | al |       |    |   |
|                    |    |       |      |   |    |       |    |   |
|                    | *n |       |      |   | *n |       |    |   |
|                    | =2 |       |      |   | =2 |       |    |   |
|                    | 9* |       |      |   | 9* |       |    |   |
+--------------------+----+-------+------+---+----+-------+----+---+
|                    | mi | mod   | se   | * | mi | mod   | se | * |
|                    | ld | erate | vere | * | ld | erate | ve | * |
|                    |    |       |      | t |    |       | re | t |
|                    |    |       |      | o |    |       |    | o |
|                    |    |       |      | t |    |       |    | t |
|                    |    |       |      | a |    |       |    | a |
|                    |    |       |      | l |    |       |    | l |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Post-Operative     | 10 | 5     | 1    | * | 18 | 3     | 1  | * |
| Pain               |    |       |      | * |    |       |    | * |
|                    |    |       |      | 1 |    |       |    | 2 |
|                    |    |       |      | 6 |    |       |    | 2 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Rigors             | 4  | 0     | 0    | * | 9  | 4     | 2  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 4 |    |       |    | 1 |
|                    |    |       |      | * |    |       |    | 5 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      |   |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Fever              | 4  | 1     | 0    | * | 8  | 6     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 5 |    |       |    | 1 |
|                    |    |       |      | * |    |       |    | 4 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      |   |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Headache           | 9  | 1     | 1    | * | 8  | 5     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 1 |    |       |    | 1 |
|                    |    |       |      | 1 |    |       |    | 3 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Rhinitis           | 6  | 1     | 0    | * | 9  | 2     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 7 |    |       |    | 1 |
|                    |    |       |      | * |    |       |    | 1 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      |   |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Hematuria          | 3  | 3     | 1    | * | 10 | 0     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 7 |    |       |    | 1 |
|                    |    |       |      | * |    |       |    | 0 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      |   |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Anxiety            | 5  | 0     | 0    | * | 7  | 1     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 5 |    |       |    | 8 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Nausea             | 3  | 0     | 1    | * | 7  | 1     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 4 |    |       |    | 8 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Pharyngitis        | 2  | 0     | 0    | * | 7  | 1     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 2 |    |       |    | 8 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Fabry Pain         | 0  | 3     | 0    | * | 3  | 1     | 2  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 3 |    |       |    | 6 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Chest Pain         | 0  | 2     | 1    | * | 2  | 3     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 3 |    |       |    | 5 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Edema Dependent    | 0  | 1     | 0    | * | 4  | 2     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 1 |    |       |    | 6 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Pain               | 2  | 1     | 0    | * | 5  | 1     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 3 |    |       |    | 6 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Skeletal Pain      | 0  | 0     | 0    | * | 4  | 1     | 1  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 0 |    |       |    | 6 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Temperature Change | 1  | 0     | 0    | * | 4  | 0     | 1  | * |
| Sens.\*            |    |       |      | * |    |       |    | * |
|                    |    |       |      | 1 |    |       |    | 5 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Pallor             | 0  | 1     | 0    | * | 4  | 0     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 1 |    |       |    | 4 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Dizziness          | 2  | 0     | 0    | * | 4  | 0     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 2 |    |       |    | 4 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Paresthesia        | 0  | 1     | 1    | * | 3  | 0     | 1  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 2 |    |       |    | 4 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Cardiomegaly       | 1  | 0     | 0    | * | 3  | 0     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 1 |    |       |    | 3 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Dyspepsia          | 1  | 0     | 0    | * | 3  | 0     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 1 |    |       |    | 3 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Depression         | 1  | 0     | 0    | * | 1  | 2     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 1 |    |       |    | 3 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Bronchitis         | 1  | 0     | 0    | * | 1  | 2     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 1 |    |       |    | 3 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Eye Abnormality    | 1  | 0     | 0    | * | 3  | 0     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 1 |    |       |    | 3 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Arthrosis          | 0  | 0     | 0    | * | 2  | 0     | 1  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 0 |    |       |    | 3 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+
| Hypertension       | 0  | 0     | 0    | * | 0  | 3     | 0  | * |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | 0 |    |       |    | 3 |
|                    |    |       |      | * |    |       |    | * |
|                    |    |       |      | * |    |       |    | * |
+--------------------+----+-------+------+---+----+-------+----+---+

\*Temperature change sensation refers to feeling warm or cold.

> If a subject experienced an adverse event more than once, only the
> most severe event is tabulated. Remaining events, not listed, were not
> notably more severe in active than in placebo.

Table 59. Trial AGAL-1-002-98: Infusion-related adverse events
(r-hαGal-treated subjects)

+---------------------------------------------+------------------------+
| Adverse                                     | Subjects with any      |
|                                             |                        |
| Events                                      | infusion-related       |
|                                             |                        |
|                                             | event                  |
|                                             |                        |
|                                             | *n=16*                 |
+---------------------------------------------+------------------------+
| Febrile reactions: fever or chills          | 14                     |
+---------------------------------------------+------------------------+
| Pain symptoms: Fabry pain or myalgia        | 5                      |
+---------------------------------------------+------------------------+
| Hypersensitivity: dyspnea, throat           | 3                      |
| tightness, flushing, chest tightness,       |                        |
| pruritis, urticaria, or rhinitis            |                        |
+---------------------------------------------+------------------------+
| Gastrointestinal: abdominal pain, nausea,   | 3                      |
| or                                          |                        |
|                                             |                        |
| vomiting                                    |                        |
+---------------------------------------------+------------------------+
| Cardiovascular: Tachycardia, palpitations,  | 3                      |
| or                                          |                        |
|                                             |                        |
| hypertension                                |                        |
+---------------------------------------------+------------------------+
| Headache                                    | 3                      |
+---------------------------------------------+------------------------+

Table 60. Trial AGAL-1-002-98: Clinical features of infusion-related
events reported to Genzyme Pharmacovigilance as warranting complement or
IgE testing\*

  --------- ------- -------------- ---------------------- ----------- ------------------- ---------- ----------------
                                                                                          Infusion   

                    Additional                                                            rate       Time to

  Subject   Visit   pre-           Symptoms               Intensity   Treatment           adjust-    symptom

            \#      Treatment^1^                                                          ment       resolution

                                                                                          (y/n)^2^   (hr)

            4                      Shaking chills,        Mod.        Steroids,           Y          Shaking/chills
                                   hypertension, fever,                                              

                                   burning pain                       hydroxyzine,                   0.75;fever &

                                                                      ibuprofen                      burning 2.5

  101       5       ibuprofen      Chills, fever          Mod.        Codeine, ibuprofen  Y          1.5

            6       prednisone     Rigors, fever          Mod.        Unknown             Y          Not provided

            11      prednisone     Shaking chills,        Mod.        Codeine, ibuprofen  Y          Not provided
                                   hypertension, fever,                                              

                                   burning pain                                                      

  107       6       \-             Shaking chills, fever, Sev.        lbuprofen, codeine, Y          1.25
                                   pain, upset                                                       

                                   stomach                            antacids                       

  108       5       \-             Chills                 Mild        Unknown             Y          Not provided

            7       \-             Chills, extremity pain Mild        lbuprofen           Y          1

  112       7       \-             Chills, emesis         Mild        lbuprofen           Y          Chills 0.4

            8       \-             Headache, chills,      Mod.        lbuprofen, codeine, Y          Not provided
                                   extremity pain,                                                   

                                   nausea                             prochlorperazine               

            6       \-             Shaking chills,        Mod.        lbuprofen, codeine, Y          Chills 0.5;
                                   extremity pain, fever                                             

                                                                                                     pain 2

  115       9       prednisone     Chills, extremity pain Mod.        lbuprofen, codeine, Y          Not provided

            11      prednisone     Shaking chills,        Mod.        lbuprofen, codeine, Y          0.5-0.75
                                   extremity pain, fever                                             

            6,7,8   \-             Chest tightness and    Mild-       none                N          0.25-0.5
                                   shortness of                                                      

            9                      breath                 mod.                                       

  120       10      \-             Chest tightness,       Mild-       3 liter 0~2~        Y          5 min.
                                   shortness of breath,                                              

                                   and throat tightness   mod.                                       

            11      \-             Shortness of breath    mild        Albuterol inhaler   N          8 min.

            5,6     \-             Itchy, feeling warm    mild        none                N          2

  202       7       \-             Itchy, feeling warm,   unk         Benadryl            N          Itch during
                                   headaches,                                                        

                                   hot/cold flashes                                                  infusion spont

                                                                                                     resolved.

            8       \-             Itching, headaches     unk         none                N          Not provided

            5       \-             Chills, muscle         mild        None                N          0.5: bp in 2
                                   tightness, flushed                                                
                                   face,                                                             

  302                              hypertension                                                      

            7       \-             Chills, hypertension,  unk         none                Y          Not provided
                                   fever                                                             

            8       \-             Shivering, cold        Mod.        chlorpheniramine    Y          \~2
                                   feeling, hypertension,                                            

                                   fever                  or mild                                    

            9       \-             Shivering, cold        mild        chlorpheniramine    Y          0.5
                                   feeling, hypertension,                                            

  501                              fever                                                             

            10                                            Mod.        Chlorpheniramine,              

                    Chlorphenir-   Shiver, shaking,                   salbutamol,         Y          1
                                   feeling cold, wheezing                                            

                    amine                                             hydrocortisone IV              

            7       \-             Shaking, cold feeling  mild        Chlorpheniramine,   Y          0.25

                                                                      paracetamol                    

  604       8       \-             Sore throat, rigors    mild        chlorpheniramine    Y          Not provided

            9       \-             Rigors                 mild        chlorpheniramine    Y          0.25

  706       10      \-             Muscle aches, chills   mild        None                N          0.75

            11      \-             Muscle aches, chills   mild        None                N          1

                    \-             Nausea, vomiting,                                                 
                                   abdominal pain,                                                   

  806       9                      decrease in appetite,  mild        Zyrtec, polaramine, Y          \>4
                                   chills, fever,                                                    

                                   hypotension, pulse                 hydrocortisone IV              
                                   rate increased,                                                   

                                   paleness, malaise                                                 
  --------- ------- -------------- ---------------------- ----------- ------------------- ---------- ----------------

\*symptoms reported in subjects not reported to Pharmacovigilance:
chills (subjects 301 and 702), headache (subject 307), and abdominal
pain (subject 804).

^1^acetaminophen (paracetamol) and hydroxyzine given for all infusions

^2^ includes interruptions and restarting

\*ibuprofen substituted for acetaminophen

Table 61. Trial AGAL-1-002-98: Anti α-Gal IgE and IgG and complement
activation in association with the infusion reactions

+-----------+-----------+---------------+----------+-----------------+
| Subject   | Infusion  | IgE test      | IgG test | Complement      |
|           |           |               |          |                 |
|           | number    | result        | result   | activation\*    |
+-----------+-----------+---------------+----------+-----------------+
|           | 4         | \-            | \+       | \"compromised   |
|           |           |               |          |                 |
|           |           |               |          | sample\"        |
+-----------+-----------+---------------+----------+-----------------+
| 101       | 5         | Not Tested    | \+       | Not Tested      |
+-----------+-----------+---------------+----------+-----------------+
|           | 6         | Not Tested    | \+       | Not Tested      |
+-----------+-----------+---------------+----------+-----------------+
|           | 11        | \-            | \+       | \+              |
+-----------+-----------+---------------+----------+-----------------+
| 107       | 6         | \-            | \+       | \+              |
+-----------+-----------+---------------+----------+-----------------+
|           | 5         | Not Tested    | \+       | Not Tested      |
+-----------+-----------+---------------+----------+-----------------+
| 108       | 7         | \-            | \+       | \+              |
+-----------+-----------+---------------+----------+-----------------+
|           | 7         | Not Tested    | \+       | Not Tested      |
+-----------+-----------+---------------+----------+-----------------+
| 112       | 8         | \-            | \+       | \+              |
+-----------+-----------+---------------+----------+-----------------+
|           | 6         | \-            | \+       | \+              |
+-----------+-----------+---------------+----------+-----------------+
| 115       | 9         | Not Tested    | \+       | Not Tested      |
+-----------+-----------+---------------+----------+-----------------+
|           | 11        | Not Tested    | \+       | Not Tested      |
+-----------+-----------+---------------+----------+-----------------+
|           | 6,7,8,9   | \-            | \+       | \-              |
+-----------+-----------+---------------+----------+-----------------+
| 120       | 10        | Not Tested    | \+       | Not Tested      |
+-----------+-----------+---------------+----------+-----------------+
|           | 11        | Not Tested    | \+       | Not Tested      |
+-----------+-----------+---------------+----------+-----------------+
|           | 5,6       | Not Tested    | \-       | Not Tested      |
+-----------+-----------+---------------+----------+-----------------+
| 202       | 7         | \-            | \-       | \-              |
+-----------+-----------+---------------+----------+-----------------+
|           | 8         | \-            | \-       | \-              |
+-----------+-----------+---------------+----------+-----------------+
| 302       | 5         | \-            | \+       | \+              |
+-----------+-----------+---------------+----------+-----------------+
|           | 7         | Not Tested    | \+       | Not Tested      |
+-----------+-----------+---------------+----------+-----------------+
|           | 8         | \-            | \+       | \+              |
+-----------+-----------+---------------+----------+-----------------+
| 501       | 9         | Inc           | \+       | \+              |
|           |           | onclusive\*\* |          |                 |
+-----------+-----------+---------------+----------+-----------------+
|           | 10        | \-            | \+       | \+              |
+-----------+-----------+---------------+----------+-----------------+
|           | 7         | \-            | \+       | \+              |
+-----------+-----------+---------------+----------+-----------------+
| 604       | 8         | Inc           | \+       | \+              |
|           |           | onclusive\*\* |          |                 |
+-----------+-----------+---------------+----------+-----------------+
|           | 9         | \-            | \+       | \-              |
+-----------+-----------+---------------+----------+-----------------+
|           | 10        | \-            | \+       | \+              |
+-----------+-----------+---------------+----------+-----------------+
| 706       | 11        | \-            | \+       | \+              |
+-----------+-----------+---------------+----------+-----------------+
| 806       | 9         | \-            | \+       | \+              |
+-----------+-----------+---------------+----------+-----------------+

\*tested on serum drawn immediately after or during an infusion reaction

\*\*plasma instead of serum

## **Appendix C: Study AGAL-005-99** 

Table 62. AGAL-005-99: McGill short form 18-month results

+----------------+------------------+-------+----------+-------------+
| Pain           | Treatment        | Entry | 18       | Change      |
|                |                  |       | months   |             |
| Measure        | Group            |       |          | Entry to 18 |
|                |                  |       | Post     | months      |
|                |                  |       | Entry    |             |
+----------------+------------------+-------+----------+-------------+
| Sensory        | Placebo/r-hαGal  | 1.7   | 0.9      | -0.8        |
| (range: 0-33)  |                  |       |          |             |
+----------------+------------------+-------+----------+-------------+
|                | r-hαGal /        | 3.0   | 3.2      | 0.1         |
|                | r-hαGal          |       |          |             |
+----------------+------------------+-------+----------+-------------+
| Affective      | Placebo/ r-hαGal | 0.3   | 0.2      | -0.1        |
| (range: 0-12)  |                  |       |          |             |
+----------------+------------------+-------+----------+-------------+
|                | r-hαGal /        | 0.6   | 0.8      | 0.2         |
|                | r-hαGal          |       |          |             |
+----------------+------------------+-------+----------+-------------+
| Total (range:  | Placebo/ r-hαGal | 1.9   | 1.1      | -0.9        |
| 0-45)          |                  |       |          |             |
+----------------+------------------+-------+----------+-------------+
|                | r-hαGal /        | 3.6   | 4.0      | 0.3         |
|                | r-hαGal          |       |          |             |
+----------------+------------------+-------+----------+-------------+
| Present Pain   | Placebo/ r-hαGal | 0.6   | 0.4      | -0.2        |
| Intensity      |                  |       |          |             |
|                |                  |       |          |             |
| (range: 0-6)   |                  |       |          |             |
+----------------+------------------+-------+----------+-------------+
|                | r-hαGal /        | 0.8   | 0.5      | -0.3        |
|                | r-hαGal          |       |          |             |
+----------------+------------------+-------+----------+-------------+
| Visual Analog  | Placebo/ r-hαGal | 0.8   | 0.4      | -0.4        |
| Scale          |                  |       |          |             |
|                |                  |       |          |             |
| (range: 0-10)  |                  |       |          |             |
+----------------+------------------+-------+----------+-------------+
|                | r-hαGal r-hαGal  | 1.4   | 1.1      | -0.2        |
+----------------+------------------+-------+----------+-------------+

Table 63. AGAL-005-99: Change in urinary GL‑3 levels (nmol/filter) at 6
months of AGAL-005-99

+----------------+------------+------------+------------+------------+
| Statistic      | Place      |            | r-hαG      |            |
|                | bo/r-hαGal |            | al/r-hαGal |            |
|                |            |            |            |            |
|                | *n=22*     |            | *n=23*     |            |
+----------------+------------+------------+------------+------------+
|                | Entry      | \% change  | Entry      | \% change  |
+----------------+------------+------------+------------+------------+
| Mean           | 5357       | -43        | 4091       | 28         |
+----------------+------------+------------+------------+------------+
| Median         | 3539       | -56        | 3323       | -27        |
+----------------+------------+------------+------------+------------+
| Std. deviation | 3812       | 64         | 3190       | 254        |
+----------------+------------+------------+------------+------------+
| Min., Max.     | 96,12780   | -94,209    | 38,11079   | -96, 1170  |
+----------------+------------+------------+------------+------------+

Baseline data (baseline in AGAL-1-002-98) for these subjects was not
provided.

Table 64. AGAL-005-99: Urinary GL-3

+------------+---------+------------+----------------+----------------+
| Treatment  | St      | Entry      | 6-Months Post  | \% Change:     |
| Group      | atistic |            | Entry          |                |
|            |         |            |                | Entry to       |
|            |         |            |                | 6-Months Post  |
|            |         |            |                | Entry          |
+------------+---------+------------+----------------+----------------+
|            | *n*     | *22*       | *22*           | *22*           |
+------------+---------+------------+----------------+----------------+
| Place      | Mean    | 5357       | 2546           | -43            |
| bo/r-hαGal |         |            |                |                |
+------------+---------+------------+----------------+----------------+
|            | Median  | 3539       | 1761           | -56            |
+------------+---------+------------+----------------+----------------+
|            | Std.    | 3812       | 2457           | 64             |
|            | Dev.    |            |                |                |
+------------+---------+------------+----------------+----------------+
|            | Min/Max | 96, 12780  | 81, 8643       | -94, 209       |
+------------+---------+------------+----------------+----------------+
|            | *n*     | *23*       | *23*           | *23*           |
+------------+---------+------------+----------------+----------------+
| R-hαG      | Mean    | 4091       | 3050           | 28             |
| al/r-hαGal |         |            |                |                |
+------------+---------+------------+----------------+----------------+
|            | Median  | 3323       | 1966           | -27            |
+------------+---------+------------+----------------+----------------+
|            | Std.    | 3190       | 3294           | 254            |
|            | Dev.    |            |                |                |
+------------+---------+------------+----------------+----------------+
|            | Min/Max | 38, 11079  | 5.0, 14353     | -96, 1170      |
+------------+---------+------------+----------------+----------------+

Table 65. AGAL-005-99: Anti-α-gal IgG and IgE and complement activation
in infusion reactions reported to Genzyme Pharmacovigilance during the
first 6 months

+----------+----------+-----------+---------+---------+--------------+
| T        | Subject  | Infusion  | IgE     | IgG     | Complement   |
| reatment |          |           | Test    | Test    |              |
|          | Number   | Number    | Result  | Result  | Activation   |
+----------+----------+-----------+---------+---------+--------------+
| Placebo/ | 0105     | 9         | \-      | \+      | \-           |
|          |          |           |         |         |              |
| R-hαGal  |          |           |         |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          | 0110     | 7         | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 13        | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          | 0116     | 4         | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 8         | \-      | \+      | Not tested   |
+----------+----------+-----------+---------+---------+--------------+
|          | 0119     | 11        | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 12        | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 3         | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 4         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          | 0201     | 5         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 6         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          | 0304\*   | 8         | \-      | \+      | Pre = -      |
+----------+----------+-----------+---------+---------+--------------+
|          |          |           |         |         | Post = +     |
+----------+----------+-----------+---------+---------+--------------+
|          | 0306     | 5         | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 7         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          | 0502     | 8         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          | 0503     | 10        | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          | 0505     | 10        | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          | 0506     | 13        | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          | 0603     | 5         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 10        | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          | 0709     | 5         | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 7         | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 6         | Not     | \-      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 8         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          | 0802     | 10        | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 11        | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 4         | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 7         | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 8         | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          | 0805\*   | 9         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 10        | \-      | \+      | Pre = +      |
+----------+----------+-----------+---------+---------+--------------+
|          |          |           |         |         | Post = +     |
+----------+----------+-----------+---------+---------+--------------+
| R-hαGal/ | 0104     | 1         | \-      | \+      | \+           |
|          |          |           |         |         |              |
| R-hαGal  |          |           |         |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 7         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 3         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          | 0107     | 5         | \-      | \+      | \-           |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 6         | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 7         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          | 0115     | 13        | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 2         | Not     | \-      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          | 0202     | 3         | Not     | \-      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 8         | \-      | \-      | Not tested   |
+----------+----------+-----------+---------+---------+--------------+
|          | 0402     | 12        | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 4         | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 7         | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          | 0501     | 8         | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 9         | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 11        | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 1         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          | 0604     | 3         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 8         | Not     | \+      | \+           |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 1         | Not     | ND      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          | 0706     | 7         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 9         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 3         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          | 0804     | 5         | \-      | \+      | \+           |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 6         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          | 0806     | 1         | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+
|          |          | 10        | Not     | \+      | Not tested   |
|          |          |           | tested  |         |              |
+----------+----------+-----------+---------+---------+--------------+

\*Subjects 304 and 805 had skin testing for suspicion of the development
of serum IgE. Subject 304 was withdrawn because he developed a (+) skin
test; subject 805's test was (-).

Table 66. Physiological testing in AGAL-1-002-98 and AGAL-005-99 (18
months)

+------------+---------+----+------+------+------+------+------+------+
|            |         | A  |      | AGA  |      |      |      |      |
|            |         | GA |      | L-00 |      |      |      |      |
| Scale      | Tr      | L- |      | 5-99 |      |      |      |      |
|            | eatment | 1- |      |      |      |      |      |      |
|            | group   | 00 |      |      |      |      |      |      |
|            |         | 2- |      |      |      |      |      |      |
|            |         | 98 |      |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+
|            |         | Ba | Ch   | e    | Ch   |      |      |      |
|            |         | se | ange | ntry | ange |      |      |      |
|            |         | li | to   |      |      |      |      |      |
|            |         | ne | end  |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+
|            |         |    |      |      | e    | base | e    | base |
|            |         |    |      |      | ntry | line | ntry | line |
|            |         |    |      |      | to 6 | to 6 | to   | to   |
|            |         |    |      |      | mo   | mo   | 18   | 18   |
|            |         |    |      |      | nths | nths | mo   | mo   |
|            |         |    |      |      |      |      | nths | nths |
+------------+---------+----+------+------+------+------+------+------+
| TDT Mean   | P       | 19 | 3.2  | 22.4 | 1.5  | 5    | 1.1  | 4.3  |
| just       | lacebo/ | .1 |      |      |      |      |      |      |
| noticeable | r-hαGal |    |      |      |      |      |      |      |
|            |         |    |      |      |      |      |      |      |
| difference |         |    |      |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+
|            | r-hαGal | 24 | 3.8  | 27.8 | -0.3 | 0.1  | -5.5 | -5   |
|            | /       | .1 |      |      |      |      |      |      |
|            | r-hαGal |    |      |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+
| TDT Mean   | P       | 13 | 5.3  | 19   | 0.6  | 5.8  | -4.1 | 0.4  |
|            | lacebo/ | .7 |      |      |      |      |      |      |
| Threshold  | r-hαGal |    |      |      |      |      |      |      |
|            |         |    |      |      |      |      |      |      |
|            |         |    |      |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+
|            | r-hαGal | 19 | 5.1  | 24.6 | -1.6 | -0.7 | -7.5 | -6.5 |
|            | /       | .5 |      |      |      |      |      |      |
|            | r-hαGal |    |      |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+
| QSART      | P       | 65 | -    | 42.1 | 1.3  | -    | -    | -    |
| (Mean      | lacebo/ |    | 22.8 |      |      | 22.8 | 24.3 | 55.4 |
|            | r-hαGal |    |      |      |      |      |      |      |
| Sweat      |         |    |      |      |      |      |      |      |
| Volume)    |         |    |      |      |      |      |      |      |
|            |         |    |      |      |      |      |      |      |
|            |         |    |      |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+
|            | r-hαGal | 37 | 18.2 | 55.9 | -    | -12  | -    | -    |
|            | /       | .8 |      |      | 29.7 |      | 39.3 | 25.6 |
|            | r-hαGal |    |      |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+
| VOP - Mean | P       | 5  | 0.5  | 6.2  | -1   | -0.9 | -0.8 | -1.2 |
|            | lacebo/ | .6 |      |      |      |      |      |      |
| Baseline   | r-hαGal |    |      |      |      |      |      |      |
| Flow       |         |    |      |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+
|            | r-hαGal | 5  | 1.4  | 6.8  | -2   | 0    | -1.2 | 0.8  |
|            | /       | .5 |      |      |      |      |      |      |
|            | r-hαGal |    |      |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+
| VOP --     | P       | 14 | 3.3  | 18.2 | 0.1  | 2.3  | -4.3 | -2.1 |
| Mean       | lacebo/ | .9 |      |      |      |      |      |      |
|            | r-hαGal |    |      |      |      |      |      |      |
| First Peak |         |    |      |      |      |      |      |      |
|            |         |    |      |      |      |      |      |      |
|            |         |    |      |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+
|            | r-hαGal | 14 | 3.4  | 17.4 | -0.3 | 2.9  | -4.5 | -2.6 |
|            | /       |    |      |      |      |      |      |      |
|            | r-hαGal |    |      |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+
| VOP - Mean | P       | 9  | 1.8  | 11   | -0.4 | 0.9  | -4.2 | -3.1 |
|            | lacebo/ | .2 |      |      |      |      |      |      |
| Second     | r-hαGal |    |      |      |      |      |      |      |
| Peak       |         |    |      |      |      |      |      |      |
|            |         |    |      |      |      |      |      |      |
|            |         |    |      |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+
|            | r-hαGal | 8  | 2.8  | 11.5 | -3.1 | 0.1  | -4   | -0.6 |
|            | /       | .7 |      |      |      |      |      |      |
|            | r-hαGal |    |      |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+
| VOP - Mean | P       | 7  | 2    | 9.1  | -0.6 | 1    | -2.8 | -1.7 |
|            | lacebo/ | .1 |      |      |      |      |      |      |
| Third Peak | r-hαGal |    |      |      |      |      |      |      |
|            |         |    |      |      |      |      |      |      |
|            |         |    |      |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+
|            | r-hαGal | 7  | 3.1  | 10.1 | -2.7 | 0.9  | -4.3 | -0.5 |
|            | /       |    |      |      |      |      |      |      |
|            | r-hαGal |    |      |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+
| VOP --     | P       | 6  | 1.1  | 7.2  | -0.1 | 0.7  | -1.7 | -1.3 |
| Mean       | lacebo/ |    |      |      |      |      |      |      |
|            | r-hαGal |    |      |      |      |      |      |      |
| Fourth     |         |    |      |      |      |      |      |      |
| Peak       |         |    |      |      |      |      |      |      |
|            |         |    |      |      |      |      |      |      |
|            |         |    |      |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+
|            | r-hαGal | 6  | 3.1  | 9.1  | -2.9 | 0.8  | -3.5 | -0.1 |
|            | /       |    |      |      |      |      |      |      |
|            | r-hαGal |    |      |      |      |      |      |      |
+------------+---------+----+------+------+------+------+------+------+

Table 67. AGAL-005-99: Physician assessment of Fabry symptoms, numbers
(%)

  --------------- ----------------- ------- ---------- -------- -----------
                                    entry   18-month            
                                            score               

                                            yes        no       total

                  Placebo/r-hαGal   Yes     22         2        24

  Angiokeratoma                     No      0          1        1

                  R-hαGal /r-hαGal  Yes     23         0        23

                                    No      0          2        2

                  Placebo/r-hαGal   Yes     19 ( 95)   1 ( 5)   20

  Abnormal                          No      2 ( 40)    3 ( 60)  5

  Sweating        r-hαGal / r-hαGal Yes     19 ( 95)   1 ( 5)   20

                                    No      1 ( 20)    4 ( 80)  5

                  Placebo/ r-hαGal  Yes     3 ( 75)    1 ( 25)  4

  Abdominal                         No      4 ( 19)    17 ( 81) 21

  Pain            r-hαGal /a        Yes     5 ( 83)    1 ( 17)  6
                  r-hαGal                                       

                                    No      5 ( 26)    14 ( 74) 19
  --------------- ----------------- ------- ---------- -------- -----------

Table 68. AGAL-005-99: 18-month adverse events by preferred term,
occurring in ≥3 subjects overall

+--------------------------------+-----------------+-------------------+
| Preferred term                 | Placebo         | R-hαGal/r-hαGal   |
|                                | /r-hαGal        |                   |
|                                |                 | (23 months        |
|                                | (18 months      | exposure)         |
|                                | exposure)       |                   |
|                                |                 | n=29              |
|                                | n=29            |                   |
+--------------------------------+-----------------+-------------------+
| Rhinitis                       | 19              | 22                |
+--------------------------------+-----------------+-------------------+
| Rigors                         | 18              | 16                |
+--------------------------------+-----------------+-------------------+
| Albuminuria                    | 15              | 13                |
+--------------------------------+-----------------+-------------------+
| Fever                          | 15              | 12                |
+--------------------------------+-----------------+-------------------+
| Headache                       | 10              | 17                |
+--------------------------------+-----------------+-------------------+
| Coughing                       | 9               | 15                |
+--------------------------------+-----------------+-------------------+
| Renal Function Abnormal        | 14              | 9                 |
+--------------------------------+-----------------+-------------------+
| Pain                           | 13              | 9                 |
+--------------------------------+-----------------+-------------------+
| Temperature Changed            | 13              | 9                 |
| Sensation\*                    |                 |                   |
+--------------------------------+-----------------+-------------------+
| Heart Valve Disorders          | 10              | 11                |
+--------------------------------+-----------------+-------------------+
| Vomiting                       | 7               | 14                |
+--------------------------------+-----------------+-------------------+
| Nausea                         | 6               | 13                |
+--------------------------------+-----------------+-------------------+
| Cardiomegaly                   | 7               | 11                |
+--------------------------------+-----------------+-------------------+
| Pharyngitis                    | 9               | 9                 |
+--------------------------------+-----------------+-------------------+
| Upper Resp Tract Infection     | 9               | 9                 |
+--------------------------------+-----------------+-------------------+
| Anemia                         | 8               | 9                 |
+--------------------------------+-----------------+-------------------+
| Post-Operative Pain            | 8               | 9                 |
+--------------------------------+-----------------+-------------------+
| Chest Pain                     | 11              | 5                 |
+--------------------------------+-----------------+-------------------+
| Edema Dependent                | 9               | 7                 |
+--------------------------------+-----------------+-------------------+
| Abdominal Pain                 | 7               | 8                 |
+--------------------------------+-----------------+-------------------+
| Fabry Pain                     | 9               | 6                 |
+--------------------------------+-----------------+-------------------+
| Influenza-Like Symptoms        | 8               | 7                 |
+--------------------------------+-----------------+-------------------+
| Paraesthesia                   | 5               | 9                 |
+--------------------------------+-----------------+-------------------+
| Back Pain                      | 6               | 7                 |
+--------------------------------+-----------------+-------------------+
| Myalgia                        | 6               | 7                 |
+--------------------------------+-----------------+-------------------+
| Fatigue                        | 7               | 5                 |
+--------------------------------+-----------------+-------------------+
| Heart Disorder                 | 8               | 4                 |
+--------------------------------+-----------------+-------------------+
| Asthenia                       | 5               | 6                 |
+--------------------------------+-----------------+-------------------+
| Bradycardia                    | 6               | 5                 |
+--------------------------------+-----------------+-------------------+
| Bronchitis                     | 4               | 7                 |
+--------------------------------+-----------------+-------------------+
| Dyspnea                        | 6               | 5                 |
+--------------------------------+-----------------+-------------------+
| Pruritus                       | 6               | 5                 |
+--------------------------------+-----------------+-------------------+
| Diarrhea                       | 6               | 4                 |
+--------------------------------+-----------------+-------------------+
| Dizziness                      | 4               | 6                 |
+--------------------------------+-----------------+-------------------+
| ECG Abnormal                   | 3               | 7                 |
+--------------------------------+-----------------+-------------------+
| Somnolence                     | 5               | 5                 |
+--------------------------------+-----------------+-------------------+
| Anxiety                        | 6               | 3                 |
+--------------------------------+-----------------+-------------------+
| Depression                     | 3               | 6                 |
+--------------------------------+-----------------+-------------------+
| Dyspepsia                      | 6               | 3                 |
+--------------------------------+-----------------+-------------------+
| Heart Block                    | 4               | 5                 |
+--------------------------------+-----------------+-------------------+
| Bronchospasm                   | 4               | 4                 |
+--------------------------------+-----------------+-------------------+
| Flushing                       | 7               | 1                 |
+--------------------------------+-----------------+-------------------+
| Retinal Disorder               | 4               | 4                 |
+--------------------------------+-----------------+-------------------+
| Skeletal Pain                  | 4               | 4                 |
+--------------------------------+-----------------+-------------------+
| Vision Abnormal                | 3               | 5                 |
+--------------------------------+-----------------+-------------------+
| Cardiac Failure                | 4               | 3                 |
+--------------------------------+-----------------+-------------------+
| Hematuria                      | 3               | 4                 |
+--------------------------------+-----------------+-------------------+
| Hypertension                   | 3               | 4                 |
+--------------------------------+-----------------+-------------------+
| Malaise                        | 4               | 3                 |
+--------------------------------+-----------------+-------------------+
| Rash                           | 2               | 5                 |
+--------------------------------+-----------------+-------------------+
| Acne                           | 3               | 3                 |
+--------------------------------+-----------------+-------------------+
| Bundle Branch Block            | 3               | 3                 |
+--------------------------------+-----------------+-------------------+
| Hearing Decreased              | 3               | 3                 |
+--------------------------------+-----------------+-------------------+
| Infection                      | 5               | 1                 |
+--------------------------------+-----------------+-------------------+
| Injury Accident                | 3               | 3                 |
+--------------------------------+-----------------+-------------------+
| Leg Pain                       | 3               | 3                 |
+--------------------------------+-----------------+-------------------+
| Palpitation                    | 4               | 2                 |
+--------------------------------+-----------------+-------------------+
| Tremor                         | 4               | 2                 |
+--------------------------------+-----------------+-------------------+

\*Temperature changed sensation refers to feeling warm or cold.