# Presentation: 859522

## Inhaled Cyclosporine (CyIS)Clinical Evidence of Efficacy and Safety

- Sarah Noonberg, MD, PhD
- Chiron | BioPharmaceuticals

## Animal Trials of CyIS at UPMC

- Nontransplanted canine model
- High pulmonary concentrations
- No change in pulmonary function/arteriolar-alveolar gradient
- No histologic abnormalities
- Ref:  Burckart GJ, et al. *J Clin Pharmacol*. 1989;29:860
- Canine transplant model
- Dose-dependent decrease in allograft rejection
- Ref:  Dowling RD, et al. *Surgery*. 1990;108:198
- Rodent transplant model
- Dose-dependent decrease in proinflammatory cytokine production
- Decreased allograft rejection
- Ref:  Mitruka SN, et al. *J Thorac Cardiovasc Surg*. 1998;115:28

## Open-Label Trials of CyIS at UPMC

- Patients with chronic rejection:
- Improvement in chronic rejection histology
- Stabilization of pulmonary function
- Improvement in survival
- Refs: Iacono AT, et al. *Am J Respir Crit Care Med*. 1996; 153:1451   	    Iacono AT, et al. *Eur Respir J*. 2004 23:384
- Patients with refractory acute rejection:
- Improvement in acute rejection histology
- Reduction in proinflammatory cytokines
- Dose-dependent improvement in pulmonary function
- Improvement in survival
- Refs: Keenan RJ, et al. *J Thoracic Cardiovasc Surg*. 1997;113:335Iacono AT, et al. *Transplantation*. 1997;64:263Iacono AT, et al. *Am J Respir Crit Care Med*. 1997;155:1690
- Results of these trials led to unregulated compounding and use of CyIS in lung transplant recipients with chronic rejection

## The Prophylaxis Trial: ACS001

**Pivotal prospective clinical trial: 1997 through 2003**
- Randomized, double-blind, placebo-controlled trial to test the efficacy of CyIS in preventing allograft rejection and improving outcomes
- Pilot phase initiated in 1997
- 10 patients on open-label CyIS
- Designed to test safety and tolerability
- Randomized phase initiated in 1998
- 58 patients randomized, 56 treated with either CyIS or placebo
- Study endpoints:
- Primary endpoint: rate of acute rejection (AR)
- Secondary endpoints: survival, rate of chronic rejection, and pulmonary function

## Inclusion/Exclusion Criteria—Study ACS001

- Chiron Briefing Document Figure 4.1-1

**Inclusion criteria:**
- Single- or double-lung transplant recipients
- 18 years or older

**Exclusion criteria:**
- Active fungal or bacterial pneumonia or anastomotic infections prior to initiation of appropriate treatment
- Untreated bronchial stenosis > 80%
- Failure to wean from mechanical ventilation
- Women of childbearing potential unwilling to use appropriate birth control and avoid pregnancy

*All patients met study inclusion/exclusion criteria*

## ACS001 Trial Design

**Active or placebo**

**Calcineurin inhibitors**

**Anti-metabolites**

**Corticosteroids**

**Follow up for efficacy**** **

**Transplant**

**Standard-of-care systemic immunotherapy**

**Study drug**

- Days 7 - 42

- Dose escalation (10 days)

- 2 years intended treatment with 300 mg or MTD CyIS, 3 neb.s q wk

- Entered into trial

**First randomized patient enrolled ****16 NOV 98**

**Study end date ****21 AUG 03**

**No patients lost to follow-up**

## Randomization

- Developed by the Deptartment of Statistics at University of Pittsburgh
- Randomization stratified by
- CMV donor/recipient mismatch (donor+/recipient- versus other)
- ISHLT registry data demonstrate CMV mismatch is a significant risk factor for death within 1 year (relative risk = 1.32, *P* ≤ .0001)
- Enrollment period (7-21 versus 22-42 days post-transplant surgery)
- ICH guidelines caution that it is impractical to stratify by more than 2 factors

## Summary of Demographics—ACS001

|  |  | Placebon = 30 | CyIS randomn = 26 |
| --- | --- | --- | --- |
| Recipient age (years)  | Median |   55 |  55 |
| Sex, n (%) | Male | 18 (60) | 16 (62) |
| Race, n (%) | Caucasian | 28 (93) | 24 (92) |
| Weight (kg) | Median |   61.0 |   69.4 |
| Height (cm) | Median | 166.5 | 173.0 |
| CMV match/mismatch stratum, n (%) | Match | 23 (77) | 21 (81) |
|  | Mismatch |   7 (23) |   5 (19) |
| Baseline/maintenanceimmunosuppression, n (%) | Imuran |   30 (100) | 22 (85) |
|  | Tacrolimus |   30 (100) |   26 (100) |
|  | Corticosteroid |   30 (100) |   26 (100) |
|  | Mycophenolate mofetil |   5 (17) |   5 (19) |
|  | Cyclosporine | 1 (3) | 1 (4) |
| Smoking (pack years) | Mean (all diagnoses) | 37 | 36 |
| AR 2+ prior to dosing, n (%) |  | 13 (43) |   8 (31) |
| Ischemic time (mean min) |  | 265.5 | 283.6 |

## ISHLT: Predictive Value of Primary Diagnosis and Transplant Type

- _ACS001_
- COPD: 35% CyIS vs 63% Placebo
- IPF: 23% CyIS vs 3% Placebo
- Would favor Placebo

- _ACS001_
- DLT: 42% CyIS vs 20% Placebo
- SLT: 58% CyIS vs 80% Placebo
- Would favor CyIS

- Ref: ISHLT 2004

## Comparable Treatment Duration

- 63% (Placebo) and 69% (CyIS) completed ≥ 1 year of therapy;
- 43% (Placebo) and 50% (CyIS) completed the planned 2 years of therapy;
- 21/22 months median duration of dosing (Placebo/CyIS)
- No patients were lost to follow-up

|  | Patients, n (%) |  |
| --- | --- | --- |
| Primary reason for drug discontinuation | Placebon = 30 | CyIS randomn = 26 |
| Completed 2-year dosing schedule  | 13 (43) | 13 (50) |
| Adverse event | 10 (33) |   4 (15 ) |
| Withdrawal of consent | 0 |   6 (23) |
| Unsatisfactory therapeutic response | 2 (7) | 1 (4) |
| Protocol deviation/violation |   5 (17) | 2 (8) |
|  |    |  |

## Summary of Results From ACS001

- Efficacy
- Significant improvement in overall survival duration
- Significant improvement in chronic rejection-free survival
- No effect on acute rejection
- Safety
- No increase in renal toxicity
- No increase in infections, neoplasms, or other systemic toxicities
- Significant increase in mild/moderate respiratory tract irritation and bronchospasm

## CyIS Extends Survival

-    The statistically significant survival effect was observed in
- An unadjusted analysis (log-rank *P* = .007)
- Relative risk (CyIS/placebo) = 0.213

## Estimated Survival Duration 

| N at risk |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Placebo | 30 | 27 | 25 | 24 | 21 | 16 | 11 | 10 | 7 | 3 | 0 |
| CyIS | 26 | 26 | 25 | 25 | 22 | 18 | 13 | 12 | 6 | 0 | 0 |

- Time (months)

- Survival

- 0

- 6

- 12

- 18

- 24

- 30

- 36

- 42

- 48

- 54

- 60

- 0.0

- 0.1

- 0.3

- 0.4

- 0.5

- 0.6

- 0.7

- 0.8

- 0.9

- 1.0

- 0.2

- Chiron Briefing Document Figure 1.3.2-1

- Relative risk = 0.213
- Log-rank *P* = .007

- CyIS
- Placebo

## CyIS Extends Survival

**   **The statistically significant survival effect was observed in
**An unadjusted analysis (log-rank *****P***** = .007)**
**Relative risk (CyIS/Placebo) = 0.213**
- Analyses adjusting for known risk factors individually
- Relative risk (CyIS/Placebo) = 0.15 to 0.25

## Relative Risk Unchanged After Adjusting for Donor/Recipient Characteristics

- Relative risk

- 0.0

- 0.2

- 0.4

- 0.6

- 0.8

- 1.0

- 1.2

**Unadjusted analysis**

- Single LT

- Prior grade 2+ AR

- D+/R– mismatch

- Non-emphysema diagnosis

- Enrollment period

- PRA > 10%

- Recipient diabetes

- Obesity

- Recipient > 65 years

- Donor > 35 years

- Either D/R is male

- Sex mismatch

- ICU stay > 4 days

- ICU stay > 10 days

- Donor inotropic support

## CyIS Extends Survival

- 	The statistically significant survival effect was observed in
- An unadjusted analysis (log-rank *P* = .007)
- Relative risk (CyIS/Placebo) = 0.213
- Analyses adjusting for known risk factors individually
- Mean relative risk (CyIS/Placebo) = 0.15 to 0.25
- Analyses adjusting for the key known risk factors simultaneously in multivariable models (*P* _<_ .032)
- Relative risk (CyIS/Placebo) = 0.227 to 0.238

## Baseline Donor/Recipient Characteristics

**Imbalances potentially                      favoring CyIS cohort**
- Single-lung transplant (80% placebo vs 58% CyIS)
- Grade 2+ AR prior to dosing (43% placebo vs 31% CyIS)

**Balanced baseline          characteristics**
- CMV D+/R– mismatch (23% placebo vs 19% CyIS)
- Enrollment period 2 (22-42 days)  (43% placebo vs 42% CyIS)
- Sex mismatch (33% placebo vs 27% CyIS)
- Female donor/female recipient (27% placebo vs 31% CyIS)
- Donor age > 35 years
-   (60% placebo vs 62% CyIS)
- Recipient age > 35 years (87% placebo vs 88% CyIS)
- Prior grade 1+ AR prior to dosing (57% placebo vs 54% CyIS)
- Donor lung bacterial colonization (40% placebo vs 35% CyIS)
- Donor history of diabetes (0% placebo vs 0% CyIS)

**Imbalances potentially favoring placebo cohort**
- Primary diagnosis other than emphysema (37% placebo vs 65% CyIS)
- Primary diagnosis of IPF (3% placebo vs 23% CyIS)
- Donor weight > 70 kg (63% placebo vs 50% CyIS)
- Panel reactive antibodies > 10% (0% placebo vs 8% CyIS)
- Recipient diagnosis of diabetes mellitus (3% placebo vs 12% CyIS)
- Recipient diagnosis of obesity (10% placebo vs 19% CyIS)

## Relative Risk Unchanged When Controlling for Baseline Characteristics Simultaneously 

| Covariates in model in addition to treatment group |  |
| --- | --- |
| Single LT, prior grade 2+ AR | 
 |
| Single LT, prior grade 2+ AR, CMV mismatch | 
 |
| Single LT, prior grade 2+ AR, CMV mismatch, primary diagnosis (emphysema or other) | 
 |
| Single LT, prior grade 2+ AR, CMV mismatch, primary diagnosis, enrollment period  |  |

**Relative Risk Unchanged When Controlling for Baseline Characteristics Simultaneously **

- Chiron Briefing Document Table 4.3.2.1-1

- 0.0

- 0.2

- 0.4

- 0.6

- 0.8

- 1.0

- 1.2

***P***** = .026**

***P***** = .030**

***P***** = .032**

***P***** = .032**

| 95% CI for relative risk
(CyIS / Placebo) |
| --- |
|  |

-  **Unadjusted analysis**

***P***** = .007**

**Survival duration**

## Summary of Sensitivity Analyses Around the Survival Endpoint 

- Chiron Briefing Document Table 4.3.1.1-1

| Sensitivity analysis | Sample size |  | Relative risk(CyIS/Placebo) | Log-rank P value |
| --- | --- | --- | --- | --- |
|  | Placebo | CyIS |  |  |
| Analysis on full data set | 30 | 26 | 0.213 | .007 |
| Include patients randomized but not dosed | 30 | 28 | 0.200 | .005 |
| Survival relative to date of first dose | 30 | 26 | 0.216 | .008 |
| Patients (n = 3) who died within the first 
3 months removed from analysis | 27 | 26 | 0.265 | .029 |
| Patients (n = 14) who did not receive at least 80% of maximum dose study drug (adjusting for death) removed from analysis | 24 | 18 | 0.243 | .048 |
| Patients (n = 15) who developed pneumonia within 1 month of initiation of study medication removed from analysis  | 20 | 21 | 0.250 | .058 |
| Patients (n = 5) who were in the ICU more than 14 days removed from analysis | 26 | 25 | 0.275 | .036 |

## Survival Advantage Persists 10 months Poststudy

- Relative risk = 0.310
- Log-rank *P* = .017

**	****Biases introduced after study close**:
- Study unblinding
- Patients off drug for 10 months to 3.5 years
- 2 placebo patients cross over to open-label CyIS
- Expect effects to trend toward the null

- Survival probability

- 0

- 6

- 12

- 18

- 24

- 30

- 36

- 42

- 48

- 54

- 60

- 0.0

- 0.1

- 0.3

- 0.4

- 0.5

- 0.6

- 0.7

- 0.8

- 0.9

- 1.0

- 0.2

- 66

| Placebo | 30 | 27 | 25 | 24 | 23 | 21 | 17 | 11 | 10 | 7 | 3 | 0 |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| CyIS | 26 | 26 | 25 | 25 | 23 | 23 | 20 | 15 | 13 | 10 | 4 | 0 |

- Placebo

- CyIS

- _N at Risk_

- Time (months)

## Placebo Survival Is Representative 

- ACS001 subject data matched with non-UPMC subject data provided by United Network for Organ Sharing (UNOS)
- Lung transplants occurring 1998 through 2001 (ACS001 enrollment period)
- Subjects matched by
- Transplant type
- Age (18-40, 41-50, 51-60, 61+ years)
- Sex
- CMV D+/R- match or mismatch
- Primary diagnosis
- Early acute rejection
- Matching also excluded early postoperative deaths from UNOS cohort

## Placebo Survival Similar to Matched UNOS Controls

| N at risk |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Placebo | 30 | 27 | 25 | 24 | 23 | 21 | 18 | 17 | 14 | 8 | 8 |
| UNOS | 1038 | 942 | 866 | 815 | 761 | 705 | 561 | 476 | 339 | 249 | 161 |

- Time (months)

- Survival probability

- 0

- 6

- 12

- 18

- 24

- 30

- 36

- 42

- 48

- 54

- 60

- 0.0

- 0.1

- 0.3

- 0.4

- 0.5

- 0.6

- 0.7

- 0.8

- 0.9

- 1.0

- 0.2

- ACS001 placebo
- Matched UNOS controls

- Chiron Briefing Document Figure 4.3.1.2-2

## CyIS Survival Significantly Longer vs Matched UNOS Controls

**CyIS Survival Significantly Longer vs ****Matched UNOS Controls**

| N at risk |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| CyIS | 26 | 26 | 25 | 25 | 22 | 18 | 13 | 12 | 6 | 0 | 0 |
| UNOS | 1058 | 951 | 876 | 810 | 679 | 538 | 430 | 311 | 220 | 132 | 63 |

- Time (months)

- Survival probability

- 0

- 6

- 12

- 18

- 24

- 30

- 36

- 42

- 48

- 54

- 60

- 0.0

- 0.1

- 0.3

- 0.4

- 0.5

- 0.6

- 0.7

- 0.8

- 0.9

- 1.0

- 0.2

- CyIS
- Matched UNOS controls

- Chiron Briefing Document Figure 4.3.1.2-3

- Relative risk (CyIS/UNOS) = 0.252
*P *=.019

## Prevention of Chronic Rejection Leads to Improved Survival 

- Chiron Briefing Document Figure 1.3.2-1

**PNA/AR/PE**

**Sepsis**

- Time (months)

- Survival

- 0

- 6

- 12

- 18

- 24

- 30

- 36

- 42

- 48

- 54

- 60

- 0.0

- 0.1

- 0.3

- 0.4

- 0.5

- 0.6

- 0.7

- 0.8

- 0.9

- 1.0

- 0.2

**CHF/****CR**

**PNA/AR**

**Sepsis**

**PNA/PE**

**PNA/RF**

**PNA/AR**

**PNA/AR/****CR**

**CR****/AR**

**CR****/PNA**

**Sepsis/****CR**

**PE/****CR**

**Sepsis/pHTN**

**CR**

**CR****/PNA**

**CR****/AR**

- CR = Chronic rejection
- PNA = Pneumonia
- AR = Acute rejection
- PE = Pulmonary embolism
- RF = Renal failure
- pHTN = Pulmonary hypertension
- CHF = Congestive heart failure

- No unexpected deaths
- Infection most prominent early
- CR most prominent after 18 months

- CyIS
- Placebo

## CyIS Prevented Chronic Rejection

- Chronic rejection measured
- Histologically through transbronchial biopsy (OB)
- Clinically through an unexplained 20%+ sustained decrease in FEV1 (BOS)
- CyIS resulted in a 72% decrease in the risk of chronic rejection or death (log-rank *P* = .001)
- Relative risk (CyIS/placebo) = 0.279 [95% CI = 0.124, 0.630]
- Consistent results when adjusting for prognostic factors

## Kaplan-Meier Estimate of Chronic Rejection-Free Survival

**Kaplan-Meier Estimate of ****Chronic Rejection-Free Survival**

| N at risk |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Placebo | 30 | 24 | 19 | 14 | 12 | 6 | 5 | 4 | 3 | 1 | 0 |
| CyIS | 26 | 26 | 24 | 21 | 16 | 12 | 11 | 9 | 5 | 0 | 0 |

- Time (months)

- 0

- 6

- 12

- 18

- 24

- 30

- 36

- 42

- 48

- 54

- 60

- 0.0

- 0.1

- 0.3

- 0.4

- 0.5

- 0.6

- 0.7

- 0.8

- 0.9

- 1.0

- 0.2

- Chiron Briefing Document Figure 4.3. 2-1

- Chronic rejection-free survival probability

- CyIS
- Placebo

- Relative risk = 0.279
- [95% CI: 0.124, 0.630]
- Log-rank *P* = .001

## Relative Risk of Chronic Rejection or Death Is Robust

- Relative risk

- 0.0

- 0.2

- 0.4

- 0.6

- 0.8

- 1.0

- 1.2

**Unadjusted analysis**

- Single LT

- Prior grade 2+ AR

- D+/R- mismatch

- Non-emphysema diagnosis

- Enrollment period

- PRA > 10%

- Recipient diabetes

- Obesity

- Recipient > 65 years

- Donor > 35 years

- Either D/R is male

- Sex mismatch

- ICU stay > 4 days

- ICU stay > 10 days

- Donor inotropic support

## Relative Risk Unchanged When Controlling for Baseline Characteristics Simultaneously

| Covariates in model in addition to treatment group |  |
| --- | --- |
| Single LT, prior grade 2+ AR | 
 |
| Single LT, prior grade 2+ AR, CMV mismatch | 
 |
| Single LT, prior grade 2+ AR, CMV mismatch, primary diagnosis (emphysema vs. other) | 
 |
| Single LT, prior grade 2+ AR, CMV mismatch, primary diagnosis, enrollment period  |  |

**Relative Risk Unchanged When Controlling for Baseline Characteristics Simultaneously**

- Chiron Briefing Document Table 4.3.2.1-1

**0.0**

**0.2**

**0.4**

**0.6**

**0.8**

**1.0**

**1.2**

***P***** = .007**

***P***** = .007**

***P***** = .008**

***P***** = .007**

| 95% CI for relative risk
(CyIS / Placebo) |
| --- |
|  |

-  **Unadjusted analysis**

***P***** = .001**

**Chronic rejection-free survival**

## CyIS Prevents Chronic Rejection  

- The effect on chronic rejection is not driven
- solely by mortality
- Analysis of chronic rejection (deaths censored):
- Biased against CyIS due to larger number of Placebo deaths (informative censoring)
- Yet statistically significant (*P* = .015) in favor of CyIS
- Chronic rejection occurred among
- 15 (50%) of Placebo patients
- 7 (27%) of CyIS patients

## Kaplan-Meier Estimates of Time to Chronic Rejection—Deaths Censored 

**Kaplan-Meier Estimates of Time to ****Chronic Rejection—Deaths Censored **

| N at risk |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Placebo | 30 | 24 | 19 | 14 | 12 | 6 | 5 | 4 | 3 | 1 | 0 |
| CyIS | 26 | 26 | 24 | 21 | 16 | 12 | 11 | 9 | 5 | 0 | 0 |

- Time (months)

- 0

- 6

- 12

- 18

- 24

- 30

- 36

- 42

- 48

- 54

- 60

- 0.0

- 0.1

- 0.3

- 0.4

- 0.5

- 0.6

- 0.7

- 0.8

- 0.9

- 1.0

- 0.2

- Chiron Briefing Document Figure 4.3.2-3

- OB-free and BOS-free probability

- Log-rank *P* = .015

- CyIS
- Placebo

## Acute Rejection

- 71% of patients in both groups had at least 1 episode of documented grade 2+ AR prior to study termination

| Number of AR episodes after start of dosing | Placebo | CyIS |
| --- | --- | --- |
| 0 |   9 |   7 |
| 1 | 11 |   9 |
| 2 |   6 |   5 |
| 3 |   3 |   4 |
| 4 |   1 |   1 |
| Total | 36 | 35 |

**  **Estimate of ratio of ARs (CyIS/placebo) = 1.09, *P* = .73

## CyIS Results in Low Systemic Cyclosporine Levels  

|  | Dose | Population | Mean peak bloodconcentration(ng/mL) | Mean blood concentration
at 24h (ng/mL) | Mean AUC0-24h (ng·hr/mL) |
| --- | --- | --- | --- | --- | --- |
| CyIS | 300 mg | Recent lungtransplant | 206 | < 30b | 1034 |
| Neoral® | 597 mg/da | Recent renaltransplant | 1802 | 361 | 8772 |
| Neoral | 458 mg/da | Recent livertransplant | 1555 | 268 | 7187 |

- Chiron Briefing Document Table 3.2.3-1

- a Given orally as divided doses 12 hours apart.b Approximation: range was 9 to 48 ng/mL measured 24 hours postdose.

## Sources of Data for Safety Evaluation

- Animal studies
- Findings for CyIS and PG (placebo) minimal in animals and consistent with findings in ACS001 and ACS002
- ACS001:	randomized, placebo controlled trial
- N = 30 Placebo vs N = 26/36 CyIS (randomized/+pilot)
- ACS002: open-label, noncomparative trials
- N = 70 patients in patients with refractory acute or chronic rejection
- Only transplants in 1995 or later included to create a cohort with comparable immunosuppressant use
- ISS: combination of ACS001 and ACS002
- N = 102 unique patients treated with CyIS

## Summary of Clinical Safety Data

- Review of AE data in ACS001 revealed CyIS was safe
- No increased risk of nephrotoxicity, neurotoxicity, infections, malignancies, or other known toxicities of systemic cyclosporine
- CyIS was not associated with any new systemic toxicities
- CyIS was associated with respiratory tract irritation and bronchospasm
- Review of AE data in ACS002 and ISS confirmed safety findings of ACS001
- Review of SAE data in ACS001, ACS002, and ISS revealed no new safety signals

## Respiratory Adverse EventsStudy ACS001

|  |               Patients, % |  |  |
| --- | --- | --- | --- |
|  |  | Placebon = 30  | All CyISn = 36 |
| Any respiratory, thoracic or mediastinal disorder |  | 97 | 100 |
| Cough |  | 27 | 50 |
| Dyspnea exacerbated |  | 13 | 31 |
| Dyspnea |  | 60 | 53 |
| Lung consolidation |  | 13 | 31 |
| Pharyngitis |  | 17 | 39 |
| Pleural effusion |  | 50 | 47 |
| Postnasal drip |  | 37 | 28 |
| Pulmonary hemosiderosis |  | 63 | 64 |
| Wheezing |  | 20 | 33 |

- Respiratory tract irritation and bronchospasm were generally mild/moderate, occurred early, and diminished with time and did not progress to more serious respiratory complications

## Single Center Study Design  

- Study ACS001 was conducted at a single center
- No other studies/registries analyses have ever shown a survival benefit comparable with that CyIS patients
- Placebo data are comparable with UNOS data
- Single-center trials provide better estimates of treatment effect than multicenter trials of the same size
- Chiron is committed to a multicenter postapproval trial to further evaluate the generalizability of the efficacy and safety of CyIS

## Sample Size 

- The sample size of N = 56 for efficacy and N = 102 for safety is small
- The lung transplant population is small
- Despite the size, the survival data (*P* = .007) and chronic rejection data (*P* = .001) are highly statistically significant
- The safety of cyclosporine is well documented and the safety profile of CyIS is extremely favorable
- Chiron is committed to creating a larger efficacy and safety database through a postapproval trial

## Randomization and CRF Assembly

- The randomization code was susceptible to unblinding and CRF assembly was retrospective
- Actions of study team suggest they were unaware of individual treatment assignments
- Randomization was sequential with consent date
- 3 CyIS patients and 2 Placebo patients were withdrawn from the study to receive open-label CyIS
- Pathologists were not exposed to patient numbers
- Retrospective CRF assembly cannot bias assessments of death, presence of OB on a histopathology report, or > 20% decline in FEV1

## Treatment Groups

- Treatment groups were not balanced on each and every baseline characteristic
- The goal of randomization is not to eliminate imbalances but to randomly distribute imbalances between treatment groups
- Treatment groups are comparable
- For the 16 characteristics supported by evidence in the literature, 8 balanced, 2 favor CyIS, 6 and favor placebo
- Statistical models can adjust for clinically relevant imbalances
- Imbalances did not explain efficacy of CyIS

## Acute vs Chronic Rejection

- The study did not meet its primary endpoint of decreased rate of acute rejection
- Reflects evolving understanding of acute versus chronic rejection
- Lack of effect on acute rejection is consistent with low systemic exposure
- Study design does not impact the assessment of survival or chronic rejection
- Survival and chronic rejection were prospectively defined secondary endpoints
- The survival and chronic rejection data are clinically important, statistically significant, and scientifically sound

## Differences of Opinion in Statistical Analysis

- Covariates in a statistical model should be chosen based on association with clinical outcome rather than on imbalance
- ICU time posttransplant > 10 days
- Donor inotropic support
- Survival data should not be excluded from patients whose donor use of an inotrope is unknown
- Primary data set for analysis should be based on study end date
- Patients with OB need to be included in a chronic rejection analysis
- Deaths should not be censored in an analysis of chronic rejection

## Summary of Clinical Data

- CyIS was associated with a 79% decrease in risk of death
- CyIS was associated with a 72% decrease in the risk of chronic rejection or death
- CyIS efficacy results are robust
- ACS001 Placebo population is representative
- CyIS was not associated with any systemic toxicity
- CyIS was associated with local respiratory tract irritation and bronchospasm

- In the lung transplant population with no approved drugs, very few randomized clinical trials, and dismal prognosis...

## Estimated Survival Duration 

| N at risk |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Placebo | 30 | 27 | 25 | 24 | 21 | 16 | 11 | 10 | 7 | 3 | 0 |
| CyIS | 26 | 26 | 25 | 25 | 22 | 18 | 13 | 12 | 6 | 0 | 0 |

- Time (months)

- Survival

- 0

- 6

- 12

- 18

- 24

- 30

- 36

- 42

- 48

- 54

- 60

- 0.0

- 0.1

- 0.3

- 0.4

- 0.5

- 0.6

- 0.7

- 0.8

- 0.9

- 1.0

- 0.2

- Chiron Briefing Document Figure 1.3.2-1

- Relative risk = 0.213
*P* = .007

- CyIS
- Placebo