endocrinologic

1

Endocrinologic & Metabolic Drugs Endocrinologic & Metabolic Drugs Advisory CommitteeAdvisory Committee

Replagal BLA 103977 Replagal BLA 103977

Endocrinologic & Metabolic Drugs Endocrinologic & Metabolic Drugs Advisory CommitteeAdvisory Committee

Replagal BLA 103977 Replagal BLA 103977

Transkaryotic Therapies, Inc.Transkaryotic Therapies, Inc.

January 14, 2003January 14, 2003

Transkaryotic Therapies, Inc.Transkaryotic Therapies, Inc.

January 14, 2003January 14, 2003

4000.01

2

REPLAGAL: REPLAGAL: agalsidase alfaagalsidase alfaREPLAGAL: REPLAGAL: agalsidase alfaagalsidase alfa

Human Human -galactosidase A-galactosidase A

Homodimer comprised of two Homodimer comprised of two ~~50kDa subunits50kDa subunits

Produced in continuous human cell lineProduced in continuous human cell line

Identical amino acid sequence to endogenous proteinIdentical amino acid sequence to endogenous protein

Human Human -galactosidase A-galactosidase A

Homodimer comprised of two Homodimer comprised of two ~~50kDa subunits50kDa subunits

Produced in continuous human cell lineProduced in continuous human cell line

Identical amino acid sequence to endogenous proteinIdentical amino acid sequence to endogenous protein

4002.03

3

Clinical Summary: ReplagalClinical Summary: ReplagalClinical Summary: ReplagalClinical Summary: Replagal

Improves standard glomerular pathologyImproves standard glomerular pathology Correlates with renal functionCorrelates with renal function

Stabilizes renal function over 30 monthsStabilizes renal function over 30 months

Reduces LV massReduces LV mass

Improves cardiac conduction system functionImproves cardiac conduction system function

Safe and well-tolerated after 2Safe and well-tolerated after 2½ years of therapy½ years of therapy

Improves standard glomerular pathologyImproves standard glomerular pathology Correlates with renal functionCorrelates with renal function




Safe and well-tolerated after 2Safe and well-tolerated after 2½ years of therapy½ years of therapy

4001.06

4

TKT PresentationsTKT PresentationsTKT PresentationsTKT Presentations

4778.05

IntroductionIntroduction Neil Kirby, Ph.D.Neil Kirby, Ph.D.Vice President, Global Regulatory Affairs, Vice President, Global Regulatory Affairs, TKTTKT

Fabry DiseaseFabry Disease Ravi Thadhani, M.D., M.P.H.Ravi Thadhani, M.D., M.P.H.Assistant Professor of Medicine, Harvard Assistant Professor of Medicine, Harvard Medical SchoolMedical SchoolDirector of Clinical Research in NephrologyDirector of Clinical Research in NephrologyMassachusetts General Hospital, BostonMassachusetts General Hospital, Boston

Renal Pathology of Renal Pathology of Fabry DiseaseFabry Disease

Thomas J. Schuetz, M.D., Ph.D. Thomas J. Schuetz, M.D., Ph.D. Vice President, Clinical Affairs, TKTVice President, Clinical Affairs, TKT

Replagal Clinical Replagal Clinical DataData

Thomas J. Schuetz, M.D., Ph.D. Thomas J. Schuetz, M.D., Ph.D.

5

ExpertsExpertsExpertsExperts

Dr. Wilson ColucciDr. Wilson ColucciChief of Cardiovascular Medicine, Boston Medical Center.Chief of Cardiovascular Medicine, Boston Medical Center.

Director, Myocardial Biology Unit, Boston University School of Medicine.Director, Myocardial Biology Unit, Boston University School of Medicine.

Dr. Dr. Christoph KampmannChristoph KampmannProfessor of Pediatrics, Pediatric Cardiology and Neonatology, Director Professor of Pediatrics, Pediatric Cardiology and Neonatology, Director

of the Dept. of Pediatric Cardiology, Children’s Heart Center, of the Dept. of Pediatric Cardiology, Children’s Heart Center, University Children’s Hospital, Johannes Gutenberg University, University Children’s Hospital, Johannes Gutenberg University, Mainz, Germany.Mainz, Germany.

Dr. Dr. Edwin KolodnyEdwin KolodnyChairman, Department of Neurology, New York University School of Chairman, Department of Neurology, New York University School of

Medicine, New York.Medicine, New York.

Dr. Kathleen LambornDr. Kathleen LambornProfessor of Neurological Surgery (Biostatistics), University of Professor of Neurological Surgery (Biostatistics), University of

California, San Francisco.California, San Francisco.

Dr. Wilson ColucciDr. Wilson ColucciChief of Cardiovascular Medicine, Boston Medical Center.Chief of Cardiovascular Medicine, Boston Medical Center.

Director, Myocardial Biology Unit, Boston University School of Medicine.Director, Myocardial Biology Unit, Boston University School of Medicine.

Dr. Dr. Christoph KampmannChristoph KampmannProfessor of Pediatrics, Pediatric Cardiology and Neonatology, Director Professor of Pediatrics, Pediatric Cardiology and Neonatology, Director

of the Dept. of Pediatric Cardiology, Children’s Heart Center, of the Dept. of Pediatric Cardiology, Children’s Heart Center, University Children’s Hospital, Johannes Gutenberg University, University Children’s Hospital, Johannes Gutenberg University, Mainz, Germany.Mainz, Germany.

Dr. Dr. Edwin KolodnyEdwin KolodnyChairman, Department of Neurology, New York University School of Chairman, Department of Neurology, New York University School of

Medicine, New York.Medicine, New York.

Dr. Kathleen LambornDr. Kathleen LambornProfessor of Neurological Surgery (Biostatistics), University of Professor of Neurological Surgery (Biostatistics), University of

California, San Francisco.California, San Francisco.

4780.06

6

Experts (cont)Experts (cont)Experts (cont)Experts (cont)

Dr. Atul MehtaDr. Atul MehtaConsultant Hematologist, Royal Free Hospital, London, UK.Consultant Hematologist, Royal Free Hospital, London, UK.

Dr. Ronald PerroneDr. Ronald PerroneProfessor of Medicine, Tufts University School of Medicine.Professor of Medicine, Tufts University School of Medicine.

Associate Chief of New England Medical Center Division of Nephrology. Associate Chief of New England Medical Center Division of Nephrology.

Medical Director of Renal Transplantation, Tufts New England Medical Medical Director of Renal Transplantation, Tufts New England Medical Center, Boston.Center, Boston.

Dr. Melvin SchwartzDr. Melvin SchwartzProfessor, Department of Pathology at Rush-Presbyterian-St Luke’s Professor, Department of Pathology at Rush-Presbyterian-St Luke’s

Medical Center, Chicago.Medical Center, Chicago.

Dr. Atul MehtaDr. Atul MehtaConsultant Hematologist, Royal Free Hospital, London, UK.Consultant Hematologist, Royal Free Hospital, London, UK.

Dr. Ronald PerroneDr. Ronald PerroneProfessor of Medicine, Tufts University School of Medicine.Professor of Medicine, Tufts University School of Medicine.

Associate Chief of New England Medical Center Division of Nephrology. Associate Chief of New England Medical Center Division of Nephrology.

Medical Director of Renal Transplantation, Tufts New England Medical Medical Director of Renal Transplantation, Tufts New England Medical Center, Boston.Center, Boston.

Dr. Melvin SchwartzDr. Melvin SchwartzProfessor, Department of Pathology at Rush-Presbyterian-St Luke’s Professor, Department of Pathology at Rush-Presbyterian-St Luke’s

Medical Center, Chicago.Medical Center, Chicago.

4784.04

7


4546.05







8

Fabry DiseaseFabry DiseaseFabry DiseaseFabry Disease

X-linked glycosphingolipid lysosomal storage disorderX-linked glycosphingolipid lysosomal storage disorder

Deficiency of Deficiency of -galactosidase A leading to -galactosidase A leading to accumulation of Gbaccumulation of Gb33

Rare: Approximately 1500-2000 patients in USARare: Approximately 1500-2000 patients in USA

Progressive, multisystem disease Progressive, multisystem disease RenalRenal CardiacCardiac CerebrovascularCerebrovascular NeurologicNeurologic GastrointestinalGastrointestinal MetabolicMetabolic

Death in 4th or 5th decade of lifeDeath in 4th or 5th decade of life

X-linked glycosphingolipid lysosomal storage disorderX-linked glycosphingolipid lysosomal storage disorder

Deficiency of Deficiency of -galactosidase A leading to -galactosidase A leading to accumulation of Gbaccumulation of Gb33

Rare: Approximately 1500-2000 patients in USARare: Approximately 1500-2000 patients in USA

Progressive, multisystem disease Progressive, multisystem disease RenalRenal CardiacCardiac CerebrovascularCerebrovascular NeurologicNeurologic GastrointestinalGastrointestinal MetabolicMetabolic

Death in 4th or 5th decade of lifeDeath in 4th or 5th decade of life4003.04

9

Disease ManagementDisease ManagementDisease ManagementDisease Management

No specific treatmentNo specific treatment

Patient care generally restricted to palliation:Patient care generally restricted to palliation: Renal failure: dialysis/transplantationRenal failure: dialysis/transplantation Heart disease/stroke: standard treatmentHeart disease/stroke: standard treatment GI disease: antidiarrhealsGI disease: antidiarrheals Neuropathic pain: Neuropathic pain:

– generally refractory to analgesics and opioidsgenerally refractory to analgesics and opioids– empiric use of anticonvulsants has been useful for pain empiric use of anticonvulsants has been useful for pain

control in some patients control in some patients

No specific treatmentNo specific treatment

Patient care generally restricted to palliation:Patient care generally restricted to palliation: Renal failure: dialysis/transplantationRenal failure: dialysis/transplantation Heart disease/stroke: standard treatmentHeart disease/stroke: standard treatment GI disease: antidiarrhealsGI disease: antidiarrheals Neuropathic pain: Neuropathic pain:

– generally refractory to analgesics and opioidsgenerally refractory to analgesics and opioids– empiric use of anticonvulsants has been useful for pain empiric use of anticonvulsants has been useful for pain

control in some patients control in some patients

4004.01

10

PathophysiologyPathophysiologyPathophysiologyPathophysiology

4005.06

Parenchymal cell deposition of GbParenchymal cell deposition of Gb33 leads to multisystem leads to multisystem

pathologypathology

Kidney: Kidney: Glomerular epithelial cells (podocytes)Glomerular epithelial cells (podocytes)Glomerular mesangial cells Glomerular mesangial cells

Tubular epithelial cellsTubular epithelial cells

Kidney: Kidney: Glomerular epithelial cells (podocytes)Glomerular epithelial cells (podocytes)Glomerular mesangial cells Glomerular mesangial cells

Tubular epithelial cellsTubular epithelial cells

Renal failureRenal failureRenal failureRenal failure

Concentrating defectsConcentrating defectsConcentrating defectsConcentrating defects

Cardiomyopathy and cardiac hypertrophyCardiomyopathy and cardiac hypertrophyQRS complex wideningQRS complex widening

Cardiomyopathy and cardiac hypertrophyCardiomyopathy and cardiac hypertrophyQRS complex wideningQRS complex widening

Heart:Heart:MyocytesMyocytesConduction systemConduction system

Heart:Heart:MyocytesMyocytesConduction systemConduction system

PainPainPainPainNerves: Nerves:

Autonomic gangliaAutonomic gangliaNerves: Nerves:

Autonomic gangliaAutonomic ganglia

11

Fabry Disease: Renal Natural History Fabry Disease: Renal Natural History Fabry Disease: Renal Natural History Fabry Disease: Renal Natural History

Early manifestationsEarly manifestations

ProteinuriaProteinuria

Renal concentrating defectsRenal concentrating defects

Progressive decline in renal Progressive decline in renal functionfunction

Early manifestationsEarly manifestations

ProteinuriaProteinuria

Renal concentrating defectsRenal concentrating defects

Progressive decline in renal Progressive decline in renal functionfunction

Late manifestationsLate manifestations

Nephrotic syndromeNephrotic syndrome

Diabetes insipidusDiabetes insipidus

ESRDESRD

Late manifestationsLate manifestations

Nephrotic syndromeNephrotic syndrome

Diabetes insipidusDiabetes insipidus

ESRDESRD

4006.04

Progression of Renal DiseaseProgression of Renal Disease

12

Fabry Disease: Renal Natural HistoryFabry Disease: Renal Natural HistoryFabry Disease: Renal Natural HistoryFabry Disease: Renal Natural History

4782.05

SummarySummary

0

10

20

30

40

50

60

70

80

90

100

110

120

Ren

al F

un

ctio

n (

mL

/min

)R

enal

Fu

nct

ion

(m

L/m

in)

Ren

al F

un

ctio

n (

mL

/min

)R

enal

Fu

nct

ion

(m

L/m

in)

Time (years)Time (years)Time (years)Time (years)

Chronic Renal Insufficiency

Normal

ESRD

Impaired Renal Function

13


All patients (n=116)All patients (n=116) Age: 33.6 ± 10.4 yearsAge: 33.6 ± 10.4 years Renal function: 48.9 ± 44.9 mL/minRenal function: 48.9 ± 44.9 mL/min

Patients not in ESRD (n=54)Patients not in ESRD (n=54) Age: 30.7 ± 9.8 yearsAge: 30.7 ± 9.8 years Renal function: 85.1 ± 33.8 mL/minRenal function: 85.1 ± 33.8 mL/min

Patients in ESRD (n=62)Patients in ESRD (n=62) Age of onset: 36.7 ± 10.1 yearsAge of onset: 36.7 ± 10.1 years

All patients (n=116)All patients (n=116) Age: 33.6 ± 10.4 yearsAge: 33.6 ± 10.4 years Renal function: 48.9 ± 44.9 mL/minRenal function: 48.9 ± 44.9 mL/min

Patients not in ESRD (n=54)Patients not in ESRD (n=54) Age: 30.7 ± 9.8 yearsAge: 30.7 ± 9.8 years Renal function: 85.1 ± 33.8 mL/minRenal function: 85.1 ± 33.8 mL/min

Patients in ESRD (n=62)Patients in ESRD (n=62) Age of onset: 36.7 ± 10.1 yearsAge of onset: 36.7 ± 10.1 years

4007.03

Age and Renal FunctionAge and Renal Function

14


4008.08

Decline of Renal Function Over TimeDecline of Renal Function Over Time

Patient PopulationPatient PopulationPatients Patients

(Number)(Number) Age*Age*

Rate of Decline of Rate of Decline of Renal Function Renal Function

(mL/min/yr)(mL/min/yr)

Individual literature Individual literature patientspatients

1111 28.8 → 32.128.8 → 32.1 2121

Branton, Branton, et alet al 1414 39.8 → 43.139.8 → 43.1 12.212.2

TKT003, TKT005, and TKT003, TKT005, and TKT010 placebo patients TKT010 placebo patients

5959 35.7 → 36.235.7 → 36.2 8.38.3

Mean Mean 8484 35.5 → 36.835.5 → 36.8 10.610.6

* Mean patient age range over the period of the decline of renal function* Mean patient age range over the period of the decline of renal function

15


4741.04

Predicted Rate of DeclinePredicted Rate of Decline

6 18

Month

Cre

atin

ine

Cle

aran

ce(m

L/m

in)

120

100

80

60

400 12 24 30

10.6mL/min/yr

21.0mL/min/yr

Month

(

Predicted Rate of Decline

8.3 mL/min/yr

16


4679.06

Age at End Stage Renal DiseaseAge at End Stage Renal DiseaseReferencesReferences Patients (n)Patients (n) Age of ESRD Age of ESRD

(yrs)(yrs)Barnes (1975)Barnes (1975) 99 41*41*Maizel (1981)Maizel (1981) 7 7 43.343.3Nissenson (1989)Nissenson (1989) 17 17 Median ~40Median ~40Tsakiris (1996)Tsakiris (1996) 8383 3838Ojo (2000)Ojo (2000) 9393 38±838±8MacDermot (2001)MacDermot (2001) 26 26 36.736.7Thadhani (2002)Thadhani (2002) 4242 39-4239-42Branton (2002)Branton (2002) 24 24 39±10 39±10 Individual case reports in Individual case reports in the literaturethe literature††

6262 36.7±10.136.7±10.1

SummarySummary 363 363 patientspatients

~38 ~38

* * age at kidney transplantage at kidney transplant†† among the 116 patients identified in the literature search there are 62 among the 116 patients identified in the literature search there are 62

individual case reports of patients who progressed to ESRD, and the mean individual case reports of patients who progressed to ESRD, and the mean age of these patients is 36.7 ± 10.1 years.age of these patients is 36.7 ± 10.1 years.

17


Fabry ESRD Patients

0

20

40

60

80

100

0 10 20 30 40 50 60 70

Age (years)

Per

cen

t o

f P

atie

nts

w/o

ES

RD

4742.02

Progression to ESRDProgression to ESRD

*

All USRDS Patients*

18


4009.07

SummarySummary

0

10

20

30

40

50

60

70

80

90

100

110

120

Ren

al F

un

ctio

n (

mL

/min

)R

enal

Fu

nct

ion

(m

L/m

in)

Ren

al F

un

ctio

n (

mL

/min

)R

enal

Fu

nct

ion

(m

L/m

in)

Time (years)Time (years)Time (years)Time (years)

Chronic Renal Insufficiency

Normal

ESRD

~10.6 mL/min/yr~10.6 mL/min/yr~10.6 mL/min/yr~10.6 mL/min/yr

mean agemean ageof ESRDof ESRD~38 yrs~38 yrs

mean agemean ageof ESRDof ESRD~38 yrs~38 yrs

Early to mid 30’sEarly to mid 30’sEarly to mid 30’sEarly to mid 30’s

~ 4.3 yrs~ 4.3 yrs~ 4.3 yrs~ 4.3 yrs

Impaired Renal Function

19


Beginning at Beginning at approximately approximately age 30-35 years the rate of age 30-35 years the rate of decline of renal function is decline of renal function is ~~10.6 mL/min/year10.6 mL/min/year

The mean age at which patients with Fabry disease The mean age at which patients with Fabry disease progress to ESRD is progress to ESRD is ~38 years~38 years

Beginning at Beginning at approximately approximately age 30-35 years the rate of age 30-35 years the rate of decline of renal function is decline of renal function is ~~10.6 mL/min/year10.6 mL/min/year

The mean age at which patients with Fabry disease The mean age at which patients with Fabry disease progress to ESRD is progress to ESRD is ~38 years~38 years

4011.04

Two Major ConclusionsTwo Major Conclusions

20

Fabry Disease: Heart DiseaseFabry Disease: Heart DiseaseFabry Disease: Heart DiseaseFabry Disease: Heart Disease

Accumulation of GbAccumulation of Gb33 in myocytes and conduction in myocytes and conduction

systemsystem

Cardiomyopathy with LV hypertrophyCardiomyopathy with LV hypertrophy Progressive increase in LV mass Progressive increase in LV mass Significant age-related progression in males and femalesSignificant age-related progression in males and females

Conduction system dysfunctionConduction system dysfunction Widening of QRS complex leading to bundle branch blocksWidening of QRS complex leading to bundle branch blocks

20% incidence of cardiac death20% incidence of cardiac death

Accumulation of GbAccumulation of Gb33 in myocytes and conduction in myocytes and conduction

systemsystem

Cardiomyopathy with LV hypertrophyCardiomyopathy with LV hypertrophy Progressive increase in LV mass Progressive increase in LV mass Significant age-related progression in males and femalesSignificant age-related progression in males and females

Conduction system dysfunctionConduction system dysfunction Widening of QRS complex leading to bundle branch blocksWidening of QRS complex leading to bundle branch blocks

20% incidence of cardiac death20% incidence of cardiac death

4012.07

21

Other ManifestationsOther ManifestationsOther ManifestationsOther Manifestations

Cerebrovascular systemCerebrovascular system StrokeStroke Altered cerebrovascular blood flowAltered cerebrovascular blood flow

Neuropathic painNeuropathic pain Chronic painChronic pain Refractory to pain medicationsRefractory to pain medications

Gastrointestinal systemGastrointestinal system Abdominal pain; diarrheaAbdominal pain; diarrhea Chronic weight lossChronic weight loss

Progressive hearing lossProgressive hearing loss

Angiokeratoma; hypohydrosisAngiokeratoma; hypohydrosis

Cerebrovascular systemCerebrovascular system StrokeStroke Altered cerebrovascular blood flowAltered cerebrovascular blood flow

Neuropathic painNeuropathic pain Chronic painChronic pain Refractory to pain medicationsRefractory to pain medications

Gastrointestinal systemGastrointestinal system Abdominal pain; diarrheaAbdominal pain; diarrhea Chronic weight lossChronic weight loss

Progressive hearing lossProgressive hearing loss

Angiokeratoma; hypohydrosisAngiokeratoma; hypohydrosis

4015.02

22

Fabry Disease: ConclusionsFabry Disease: ConclusionsFabry Disease: ConclusionsFabry Disease: Conclusions

Complex, multisystem disorderComplex, multisystem disorder

Progressive deterioration of renal functionProgressive deterioration of renal function

Progressive increase in LV massProgressive increase in LV mass

Major causes of mortalityMajor causes of mortality Progressive renal failureProgressive renal failure Progressive cardiac failureProgressive cardiac failure

Complex, multisystem disorderComplex, multisystem disorder

Progressive deterioration of renal functionProgressive deterioration of renal function

Progressive increase in LV massProgressive increase in LV mass

Major causes of mortalityMajor causes of mortality Progressive renal failureProgressive renal failure Progressive cardiac failureProgressive cardiac failure

4520.04

23


4547.05







24

Kidney Pathology: IntroductionKidney Pathology: IntroductionKidney Pathology: IntroductionKidney Pathology: Introduction

Glomerular epithelial cell GbGlomerular epithelial cell Gb33 deposition deposition

Glomerular mesangial wideningGlomerular mesangial widening

Segmental glomerular sclerosisSegmental glomerular sclerosis

Obsolescent glomeruliObsolescent glomeruli

Tubular epithelial cell depositionTubular epithelial cell deposition

Capillary endothelial cells relatively sparedCapillary endothelial cells relatively spared

Glomerular epithelial cell GbGlomerular epithelial cell Gb33 deposition deposition

Glomerular mesangial wideningGlomerular mesangial widening

Segmental glomerular sclerosisSegmental glomerular sclerosis

Obsolescent glomeruliObsolescent glomeruli

Tubular epithelial cell depositionTubular epithelial cell deposition

Capillary endothelial cells relatively sparedCapillary endothelial cells relatively spared

Intracellular Deposition Disease of the Nephron:Intracellular Deposition Disease of the Nephron:Intracellular Deposition Disease of the Nephron:Intracellular Deposition Disease of the Nephron:

4016.03

25

Kidney: Normal GlomeruliKidney: Normal GlomeruliKidney: Normal GlomeruliKidney: Normal Glomeruli

4540.04

PAS Stain Toluidine Blue Stain

26

Kidney: Early Glomerular DiseaseKidney: Early Glomerular DiseaseKidney: Early Glomerular DiseaseKidney: Early Glomerular Disease

4017.06

Toluidine Blue StainPAS Stain

27

Kidney: Mesangial WideningKidney: Mesangial WideningKidney: Mesangial WideningKidney: Mesangial Widening

4018.04


28

Kidney: Segmental SclerosisKidney: Segmental SclerosisKidney: Segmental SclerosisKidney: Segmental Sclerosis

4019.07


29

Kidney: ObsolescenceKidney: ObsolescenceKidney: ObsolescenceKidney: Obsolescence

4020.03


30

Histopathological Spectrum of DiseaseHistopathological Spectrum of DiseaseHistopathological Spectrum of DiseaseHistopathological Spectrum of Disease

Histopathological Progression

4021.03

Early Deposition

Mesangial Widening

Segmental Sclerosis

Obsolescence

31

Replagal Clinical DataReplagal Clinical DataReplagal Clinical DataReplagal Clinical Data

4867.02

32

Replagal Clinical StudiesReplagal Clinical StudiesReplagal Clinical StudiesReplagal Clinical Studies

Study Design # Pts Duration

NIH Clinical Study

TKT001 Open label, dose escalationscalation safety study 10 single dose

TKT003 Randomized, double blind, placebo controlled 26 6 months

TKT006 Open label maintenance study for patients completing TKT003

25 1 yr

TKT011 Open label maintenance study for patients completing TKT006

24 1 yr interim analysis

RFH Clinical Study

TKT005 Randomized, double blind, placebo controlled 15 6 months

University of Mainz Clinical Study

TKT014 Open label safety and efficacy trial in females 15 3 – 12 months

TOTAL Multidose Studies 56 > 2½ yrs

4026.02

33

Replagal: NIH Clinical StudiesReplagal: NIH Clinical StudiesReplagal: NIH Clinical StudiesReplagal: NIH Clinical Studies

4027.05

0

10

20

30

40

0 1 2 3

Total Time of Studies (years)

Pat

ien

ts E

nro

lled

Replagal

(n=24)

Replagal

(n=25)

Replagal 6 months

(n=14)

placebo 6 months

(n=12)

TKT003 TKT011 (1 year analysis)

TKT006

34

TKT003: TKT003: Creatinine ClearanceCreatinine ClearanceTKT003: TKT003: Creatinine ClearanceCreatinine Clearance

4028.03

p=0.051 (Replagal vs placebo)

60

70

80

90

100

110

120

130

0 6

TKT003 Replagal (n=14 : mean age = 34.0)TKT003 placebo (n=11 : mean age = 34.4)C

reat

inin

e C

lear

ance

(m

L/m

in)

Treatment Period (months)

35

60

70

80

90

100

110

120

130

0 5 10 15 20 25

ReplagalPlacebo

Cre

atin

ine

Cle

aran

ce (

mL

/min

)

Treatment Period (weeks)

TKT003: Creatinine ClearanceTKT003: Creatinine ClearanceTKT003: Creatinine ClearanceTKT003: Creatinine Clearance

0 9 17 23/24

4683b.04


36

TKT003: TKT003: Glomerular Filtration Rate (GFR)Glomerular Filtration Rate (GFR)TKT003: TKT003: Glomerular Filtration Rate (GFR)Glomerular Filtration Rate (GFR)

60

70

80

90

100

110

120

130

Replagal (n=14)Placebo (n=11)

GF

R (

mL

/min

/1.7

3m

2)

Treatment Period (weeks)0 23/24

4683c.05

p=0.25(Replagal vs placebo)

37

60

70

80

90

100

110

120

130

Baseline 6 Months

TKT010 Replagal (n=40)TKT010 Placebo (n=40)

GF

R (

mL

/min

/1.7

3m

2)

Treatment Period

TKT010: TKT010: Glomerular Filtration Rate (GFR)Glomerular Filtration Rate (GFR)TKT010: TKT010: Glomerular Filtration Rate (GFR)Glomerular Filtration Rate (GFR)

4869.01


38

NIH Clinical Trials: Creatinine ClearanceNIH Clinical Trials: Creatinine ClearanceNIH Clinical Trials: Creatinine ClearanceNIH Clinical Trials: Creatinine Clearance

4029.05

60

70

80

90

100

110

120

130

0 6 12 18 24 30

Cre

atin

ine

Cle

aran

ce (

mL

/min

)


Study TKT003 Replagal – Study TKT006/TKT011 Replagal (n=13) Study TKT003 placebo – Study TKT006/TKT011 Replagal (n=12)

TKT011TKT003 TKT006

39

NIH Clinical Trials: GFRNIH Clinical Trials: GFRNIH Clinical Trials: GFRNIH Clinical Trials: GFR

4744.02

60

70

80

90

100

110

120

130

0 6 12 18 24 30

GF

R (

mL

/min

/ 1.

73m

2 )


Study TKT003 Replagal – Study TKT006/TKT011 Replagal Study TKT003 placebo – Study TKT006/TKT011 Replagal

TKT011TKT003 TKT006

40

Renal Function: 2 years of ReplagalRenal Function: 2 years of ReplagalRenal Function: 2 years of ReplagalRenal Function: 2 years of Replagal

60

70

80

90

100

110

120

130

0 6 12 18 24

Cre

atin

ine

Cle

ara

nce

(m

L/m

in)

GF

R (

mL

/min

/1.7

3m2)

Month

TKT011TKT006

4031.02

GFR

Creatinine clearance

41

6 18

TKT003, TKT006, TKT011 Patients

Month

Cre

atin

ine

Cle

aran

ce(m

L/m

in)

120

100

80

60

400 12 24 30

10.6 mL/min/yr

21.0 mL/min/yr

Month

(

Predicted Rate of Decline

8.3 mL/min/yr

TKT003, TKT006, TKT011 Patients

Progression of Renal Disease: NIH Replagal Progression of Renal Disease: NIH Replagal Patients vs. Historical ControlsPatients vs. Historical ControlsProgression of Renal Disease: NIH Replagal Progression of Renal Disease: NIH Replagal Patients vs. Historical ControlsPatients vs. Historical Controls

4034.03

42Patients

72.5

59

47

38.532.5

28.5

21.516

10.5 9.5 8 6 6

-7 -8-11

-14 -16-20 -20 -22.5-22.5

-31

-70

-50

-30

-10

10

30

50

70

Ch

ang

e in

Cre

atin

ine

Cle

aran

ce (

mL

/min

)Individual Patient Data: Creatinine Individual Patient Data: Creatinine ClearanceClearanceIndividual Patient Data: Creatinine Individual Patient Data: Creatinine ClearanceClearance

4777.04

43

Progression to ESRD: Age Range of Progression to ESRD: Age Range of Replagal-Treated Patients vs. LiteratureReplagal-Treated Patients vs. LiteratureProgression to ESRD: Age Range of Progression to ESRD: Age Range of Replagal-Treated Patients vs. LiteratureReplagal-Treated Patients vs. Literature

4032.06

Age (years)0 10 20 30 40 50 60 70

100

80

60

40

20

0

Source: Literature Patients TKT003/006/011 Replagal Patients

Pe

rce

nt

of

Pa

tien

ts n

ot

in E

SR

D

44

Histopathological Spectrum of DiseaseHistopathological Spectrum of DiseaseHistopathological Spectrum of DiseaseHistopathological Spectrum of Disease

Histopathological Progression

4868.01

Early Deposition

Mesangial Widening

Segmental Sclerosis

Obsolescence

45

TKT003: Kidney PathologyTKT003: Kidney PathologyTKT003: Kidney PathologyTKT003: Kidney Pathology

Patients underwent Baseline and Month 6 renal Patients underwent Baseline and Month 6 renal biopsiesbiopsies

OutcomesOutcomes Lipid deposition (ALDS)Lipid deposition (ALDS) Chronic damage (CDS)Chronic damage (CDS) Standard histopathologyStandard histopathology

– Normal glomeruliNormal glomeruli– Mesangial wideningMesangial widening– Segmental sclerosisSegmental sclerosis– ObsolescenceObsolescence

Mean of 24.3 glomeruli examined per biopsyMean of 24.3 glomeruli examined per biopsy

Patients underwent Baseline and Month 6 renal Patients underwent Baseline and Month 6 renal biopsiesbiopsies

OutcomesOutcomes Lipid deposition (ALDS)Lipid deposition (ALDS) Chronic damage (CDS)Chronic damage (CDS) Standard histopathologyStandard histopathology

– Normal glomeruliNormal glomeruli– Mesangial wideningMesangial widening– Segmental sclerosisSegmental sclerosis– ObsolescenceObsolescence

Mean of 24.3 glomeruli examined per biopsyMean of 24.3 glomeruli examined per biopsy

4035.02

46

TKT003: Kidney Pathology ProceduresTKT003: Kidney Pathology ProceduresTKT003: Kidney Pathology ProceduresTKT003: Kidney Pathology Procedures

Biopsies performed at baseline and week 24Biopsies performed at baseline and week 24

Biopsy cores fixed and embeddedBiopsy cores fixed and embedded

All blocks assigned random numbersAll blocks assigned random numbers

Blocks sectioned and stainedBlocks sectioned and stained

Investigators amended planned analysis to include Investigators amended planned analysis to include assessment of standard glomerular histopathology assessment of standard glomerular histopathology

Slides read in one batch by 2 AFIP pathologists – Slides read in one batch by 2 AFIP pathologists – consensus reachedconsensus reached

Biopsies performed at baseline and week 24Biopsies performed at baseline and week 24

Biopsy cores fixed and embeddedBiopsy cores fixed and embedded

All blocks assigned random numbersAll blocks assigned random numbers

Blocks sectioned and stainedBlocks sectioned and stained

Investigators amended planned analysis to include Investigators amended planned analysis to include assessment of standard glomerular histopathology assessment of standard glomerular histopathology

Slides read in one batch by 2 AFIP pathologists – Slides read in one batch by 2 AFIP pathologists – consensus reachedconsensus reached

4922.01

47

TKT003: Kidney PathologyTKT003: Kidney PathologyTKT003: Kidney PathologyTKT003: Kidney Pathology

4036.03

Normal glomeruli Mesangial widening Segmental sclerosis Obsolescence

p=0.012 p=0.010 p=0.048 p=0.870

0

10

20

30

40

50

60

70

80

Pe

rcen

t

Replagal placebo Replagal placebo Replagal placebo Replagal placebo 0 6 m 0 6 m 0 6 m 0 6 m 0 6 m 0 6 m 0 6 m 0 6 m

48

Mean Baseline Creatinine Clearance vs Mean Baseline Creatinine Clearance vs Normal Glomeruli (%)Normal Glomeruli (%)Mean Baseline Creatinine Clearance vs Mean Baseline Creatinine Clearance vs Normal Glomeruli (%)Normal Glomeruli (%)

4748.01

T r a n s k a r y o t i c T h e r a p i e s , I n c . P a g e 1 o f 1 P r o t o c o l N o . T K T 0 0 3

F I G U R E 2 . 1

M e a n B a s e l i n e C r C l v s N o r m a l ( % ) P e a r s o n C o r r e l a t i o n C o e f f i c i e n t r = 0 . 7 6 3 8 6 , p < 0 . 0 0 0 1

P r o g r a m: p : \ t k t 0 0 3 \ p o s t b l a \ f d a _ 2 0 0 2 _ 0 9 \ 2 0 0 2 _ 0 9 _ 0 9 \ f _ g f r _ p a t h 3 . s a s O u t p u t : f _ g f r _ p a t h 3 . d o c N o v e mb e r 1 5 , 2 0 0 2 0 7 : 0

cc

0

2 0

4 0

6 0

8 0

1 0 0

1 2 0

1 4 0

1 6 0

1 8 0

2 0 0

N o r m a l ( % )

0 2 0 4 0 6 0 8 0 1 0 0

R e g r e s s i o n E q u a t i o n : C C = 5 2 . 3 4 3 0 3 + 1 . 1 5 3 9 5 4 * N L

Normal Glomeruli (%)

100806040200

0

20

40

60

80

100

120

140

180

200

160

Cre

atin

ine

Cle

aran

ce

r = 0.76

49

Mean Baseline Creatinine Clearance vs Segmental Mean Baseline Creatinine Clearance vs Segmental Sclerosis and Obsolescent Glomeruli (%)Sclerosis and Obsolescent Glomeruli (%)Mean Baseline Creatinine Clearance vs Segmental Mean Baseline Creatinine Clearance vs Segmental Sclerosis and Obsolescent Glomeruli (%)Sclerosis and Obsolescent Glomeruli (%)

4749.01


F I G U R E 2 . 3

M e a n B a s e l i n e C r C l v s S e g m e n t a l S c l e r o s i s a n d O b s c e l e s c e n t G l o m e r u l i ( % ) P e a r s o n C o r r e l a t i o n C o e f f i c i e n t r = - 0 . 6 8 1 4 4 , p = 0 . 0 0 0 2


cc

0

2 0

4 0

6 0

8 0

1 0 0

1 2 0

1 4 0

1 6 0

1 8 0

2 0 0

S e g m e n t a l S c l e r o s i s a n d O b s c e l e s c e n t G l o m e r u l i ( % )

0 2 0 4 0 6 0 8 0 1 0 0

R e g r e s s i o n E q u a t i o n : C C = 1 3 0 . 8 4 6 5 - 1 . 0 2 6 1 9 7 * S E G _ O B

Segmental Sclerosis and Obsolescent Glomeruli (%)

100806040200

0

20

40

60

80

100

120

140

180

200

160

Cre

atin

ine

Cle

aran

ce

r = -0.68

50

Renal Efficacy of Replagal: ConclusionsRenal Efficacy of Replagal: ConclusionsRenal Efficacy of Replagal: ConclusionsRenal Efficacy of Replagal: Conclusions

Replagal stabilizes renal functionReplagal stabilizes renal function

Replagal may delay progression to ESRD compared Replagal may delay progression to ESRD compared with historical controlswith historical controls

Replagal therapy significantly improves the renal Replagal therapy significantly improves the renal pathology of Fabry Diseasepathology of Fabry Disease

Standard renal glomerular histopathology is Standard renal glomerular histopathology is reasonably likely to predict clinical benefitreasonably likely to predict clinical benefit

Replagal stabilizes renal functionReplagal stabilizes renal function

Replagal may delay progression to ESRD compared Replagal may delay progression to ESRD compared with historical controlswith historical controls

Replagal therapy significantly improves the renal Replagal therapy significantly improves the renal pathology of Fabry Diseasepathology of Fabry Disease

Standard renal glomerular histopathology is Standard renal glomerular histopathology is reasonably likely to predict clinical benefitreasonably likely to predict clinical benefit

4039.08

51

Effect of Replagal on Cardiomyopathy: Effect of Replagal on Cardiomyopathy: Study TKT005Study TKT005Effect of Replagal on Cardiomyopathy: Effect of Replagal on Cardiomyopathy: Study TKT005Study TKT005

Randomized, double-blind, placebo controlled study of Randomized, double-blind, placebo controlled study of 15 patients over six months15 patients over six months

Males with LVH by Echo (mean LV mass = 262 g)Males with LVH by Echo (mean LV mass = 262 g)

Reduction in cardiac GbReduction in cardiac Gb33 favoring Replagal, but not favoring Replagal, but not

statistically significantstatistically significant

Statistically significant reduction in LV mass (MRI)Statistically significant reduction in LV mass (MRI) Placebo: 8.8% LV mass increasePlacebo: 8.8% LV mass increase Replagal: 4.2% LV mass decreaseReplagal: 4.2% LV mass decrease p-value = 0.041p-value = 0.041

Randomized, double-blind, placebo controlled study of Randomized, double-blind, placebo controlled study of 15 patients over six months15 patients over six months

Males with LVH by Echo (mean LV mass = 262 g)Males with LVH by Echo (mean LV mass = 262 g)

Reduction in cardiac GbReduction in cardiac Gb33 favoring Replagal, but not favoring Replagal, but not

statistically significantstatistically significant

Statistically significant reduction in LV mass (MRI)Statistically significant reduction in LV mass (MRI) Placebo: 8.8% LV mass increasePlacebo: 8.8% LV mass increase Replagal: 4.2% LV mass decreaseReplagal: 4.2% LV mass decrease p-value = 0.041p-value = 0.041

4040.03

52

TKT005: LV Mass by MRITKT005: LV Mass by MRITKT005: LV Mass by MRITKT005: LV Mass by MRI

p=0.041

4750.02

240

250

260

270

280

290

300

Baseline Week 24 Baseline Week 24

LV

Mas

s (g

)

Placebo Replagal

53

Effect of Replagal on Cardiomyopathy: Effect of Replagal on Cardiomyopathy: NIH Studies (TKT003/TKT006)NIH Studies (TKT003/TKT006)Effect of Replagal on Cardiomyopathy: Effect of Replagal on Cardiomyopathy: NIH Studies (TKT003/TKT006)NIH Studies (TKT003/TKT006)

No selection criteria for cardiomyopathy No selection criteria for cardiomyopathy (mean cardiac mass = 219 g)(mean cardiac mass = 219 g)

Statistically significant decline in LV mass compared Statistically significant decline in LV mass compared to baselineto baseline

LV mass declined in 13 of the 16 patients with elevated LV LV mass declined in 13 of the 16 patients with elevated LV massmass

LV mass declined to the normal range after 12 to 18 months LV mass declined to the normal range after 12 to 18 months in 8 of the 16 patientsin 8 of the 16 patients

Significant decline in QRS complex duration in Significant decline in QRS complex duration in Replagal treated patients compared with placebo Replagal treated patients compared with placebo (p = 0.047) (p = 0.047)

Replagal: 94.1 – 91.7 msecReplagal: 94.1 – 91.7 msec Placebo: 94.0 – 97.6 msecPlacebo: 94.0 – 97.6 msec

No selection criteria for cardiomyopathy No selection criteria for cardiomyopathy (mean cardiac mass = 219 g)(mean cardiac mass = 219 g)

Statistically significant decline in LV mass compared Statistically significant decline in LV mass compared to baselineto baseline

LV mass declined in 13 of the 16 patients with elevated LV LV mass declined in 13 of the 16 patients with elevated LV massmass

LV mass declined to the normal range after 12 to 18 months LV mass declined to the normal range after 12 to 18 months in 8 of the 16 patientsin 8 of the 16 patients

Significant decline in QRS complex duration in Significant decline in QRS complex duration in Replagal treated patients compared with placebo Replagal treated patients compared with placebo (p = 0.047) (p = 0.047)

Replagal: 94.1 – 91.7 msecReplagal: 94.1 – 91.7 msec Placebo: 94.0 – 97.6 msecPlacebo: 94.0 – 97.6 msec

4041.08

54

LV Mass: TKT003/TKT006LV Mass: TKT003/TKT006LV Mass: TKT003/TKT006LV Mass: TKT003/TKT006

4751.03

180

200

220

240

260

0 6 12 18

LV

Mas

s (g

)

(month)TKT003 Placebo/TKT006 Replagal

180

200

220

240

260

0 6 12 18(month)

TKT003 Replagal/TKT006 Replagal

p=0.006

p=0.023

55

Replagal Reduces LV Mass in Female Replagal Reduces LV Mass in Female Patients (Study TKT014)Patients (Study TKT014)Replagal Reduces LV Mass in Female Replagal Reduces LV Mass in Female Patients (Study TKT014)Patients (Study TKT014)

Mean LV mass at Baseline: 254 g Mean LV mass at Baseline: 254 g 38.5 g decline from baseline at Week 27 (p = 0.003)38.5 g decline from baseline at Week 27 (p = 0.003) 42.7 g decline from baseline at Week 41 (p = 0.039) 42.7 g decline from baseline at Week 41 (p = 0.039)

Statistically significant declines in cardiac mass index Statistically significant declines in cardiac mass index and wall thicknessesand wall thicknesses

LV mass declined in all 12 patients with elevated LV mass, LV mass declined in all 12 patients with elevated LV mass, and normalized in 4 of the 12 patientsand normalized in 4 of the 12 patients

Statistically significant improvement in QRS complex Statistically significant improvement in QRS complex duration (p = 0.007)duration (p = 0.007)

Mean LV mass at Baseline: 254 g Mean LV mass at Baseline: 254 g 38.5 g decline from baseline at Week 27 (p = 0.003)38.5 g decline from baseline at Week 27 (p = 0.003) 42.7 g decline from baseline at Week 41 (p = 0.039) 42.7 g decline from baseline at Week 41 (p = 0.039)

Statistically significant declines in cardiac mass index Statistically significant declines in cardiac mass index and wall thicknessesand wall thicknesses

LV mass declined in all 12 patients with elevated LV mass, LV mass declined in all 12 patients with elevated LV mass, and normalized in 4 of the 12 patientsand normalized in 4 of the 12 patients

Statistically significant improvement in QRS complex Statistically significant improvement in QRS complex duration (p = 0.007)duration (p = 0.007)

4042.05

56

TKT014: LV Mass Response to Replagal TKT014: LV Mass Response to Replagal TKT014: LV Mass Response to Replagal TKT014: LV Mass Response to Replagal

4752.03

200

210

220

230

240

250

260

270

280

0 13 27 41

LV

Mas

s (g

)

Week

(n=7)(n=11)(n=15)(n=15)

p=0.29

p=0.04

p=0.003

57

TKT014: LV Mass Index – Long Term TKT014: LV Mass Index – Long Term Therapy with Replagal Therapy with Replagal TKT014: LV Mass Index – Long Term TKT014: LV Mass Index – Long Term Therapy with Replagal Therapy with Replagal

4753.05

p=0.025

Upper limit of Normal

100

120

140

160

180

200

0 6 12

LV

MI

(g/m

2)

Month

(n=13)

(n=13)(n=13)

58

Cardiac Efficacy of Replagal: ConclusionsCardiac Efficacy of Replagal: ConclusionsCardiac Efficacy of Replagal: ConclusionsCardiac Efficacy of Replagal: Conclusions

Initiation of the reversal of cardiomyopathyInitiation of the reversal of cardiomyopathy Regression of LVHRegression of LVH Normalization of LV mass in many patients Normalization of LV mass in many patients

Improved cardiac conduction system function with Improved cardiac conduction system function with significantly decreased QRS durationsignificantly decreased QRS duration

Initiation of the reversal of cardiomyopathyInitiation of the reversal of cardiomyopathy Regression of LVHRegression of LVH Normalization of LV mass in many patients Normalization of LV mass in many patients

Improved cardiac conduction system function with Improved cardiac conduction system function with significantly decreased QRS durationsignificantly decreased QRS duration

4043.03

59

Replagal: Metabolic EffectsReplagal: Metabolic EffectsReplagal: Metabolic EffectsReplagal: Metabolic Effects

Statistically significant change in body weight in Study Statistically significant change in body weight in Study TKT003TKT003

Placebo patients: 1.85 kg weight lossPlacebo patients: 1.85 kg weight loss Replagal patients: 1.55 kg weight gainReplagal patients: 1.55 kg weight gain

Long term effects confirmed in study TKT006Long term effects confirmed in study TKT006

GbGb33 declines declines Plasma: Plasma: ~ 50% statistically significant decline in Studies ~ 50% statistically significant decline in Studies

TKT003 and TKT005 TKT003 and TKT005 Urine Sediment: 40-60% statistically significant decline in Urine Sediment: 40-60% statistically significant decline in

Studies TKT003 and TKT005Studies TKT003 and TKT005 Tissue: Trends favoring Replagal in kidney and heart tissueTissue: Trends favoring Replagal in kidney and heart tissue

Statistically significant change in body weight in Study Statistically significant change in body weight in Study TKT003TKT003

Placebo patients: 1.85 kg weight lossPlacebo patients: 1.85 kg weight loss Replagal patients: 1.55 kg weight gainReplagal patients: 1.55 kg weight gain

Long term effects confirmed in study TKT006Long term effects confirmed in study TKT006

GbGb33 declines declines Plasma: Plasma: ~ 50% statistically significant decline in Studies ~ 50% statistically significant decline in Studies

TKT003 and TKT005 TKT003 and TKT005 Urine Sediment: 40-60% statistically significant decline in Urine Sediment: 40-60% statistically significant decline in

Studies TKT003 and TKT005Studies TKT003 and TKT005 Tissue: Trends favoring Replagal in kidney and heart tissueTissue: Trends favoring Replagal in kidney and heart tissue

4047.05

p = 0.025p = 0.025

60

Safety Experience: Adverse EventsSafety Experience: Adverse EventsSafety Experience: Adverse EventsSafety Experience: Adverse Events

Over 300 patients treated with Replagal Over 300 patients treated with Replagal

The most common adverse events were consistent The most common adverse events were consistent with the natural history of Fabry Diseasewith the natural history of Fabry Disease

No withdrawals due to adverse events No withdrawals due to adverse events

Most events mild to moderate in severityMost events mild to moderate in severity

Most assessed as ‘not related’ to study drugMost assessed as ‘not related’ to study drug

Over 300 patients treated with Replagal Over 300 patients treated with Replagal

The most common adverse events were consistent The most common adverse events were consistent with the natural history of Fabry Diseasewith the natural history of Fabry Disease

No withdrawals due to adverse events No withdrawals due to adverse events

Most events mild to moderate in severityMost events mild to moderate in severity

Most assessed as ‘not related’ to study drugMost assessed as ‘not related’ to study drug

4049.03

61

Safety Experience: Infusion ReactionsSafety Experience: Infusion ReactionsSafety Experience: Infusion ReactionsSafety Experience: Infusion Reactions

Routine use of premedications not requiredRoutine use of premedications not required

Mild infusion reactions (~10% patients) with Mild infusion reactions (~10% patients) with recommended infusion over 40 minutesrecommended infusion over 40 minutes

ChillsChills Facial flushingFacial flushing No apparent association with antibodiesNo apparent association with antibodies

Infusion reactions easily managed Infusion reactions easily managed

Infusion reactions generally disappear over timeInfusion reactions generally disappear over time

Routine use of premedications not requiredRoutine use of premedications not required

Mild infusion reactions (~10% patients) with Mild infusion reactions (~10% patients) with recommended infusion over 40 minutesrecommended infusion over 40 minutes

ChillsChills Facial flushingFacial flushing No apparent association with antibodiesNo apparent association with antibodies

Infusion reactions easily managed Infusion reactions easily managed

Infusion reactions generally disappear over timeInfusion reactions generally disappear over time

4050.03

62

TKT003/TKT006: Infusion Reactions and TKT003/TKT006: Infusion Reactions and IgG AntibodiesIgG AntibodiesTKT003/TKT006: Infusion Reactions and TKT003/TKT006: Infusion Reactions and IgG AntibodiesIgG Antibodies

Infusion ReactionInfusion Reaction

++ ––

AntibodyAntibody++ 66 44 1010

–– 44 1111 1515

1010 1515 2525

4754.01

63

Antibody Response to Replagal TherapyAntibody Response to Replagal TherapyAntibody Response to Replagal TherapyAntibody Response to Replagal Therapy

Patients originally enrolled in Studies TKT003 and Patients originally enrolled in Studies TKT003 and TKT005TKT005

40 male patients followed for up to 2.5 years40 male patients followed for up to 2.5 years Persistent IgG antibodies observed in 12/40 patients (30%)Persistent IgG antibodies observed in 12/40 patients (30%) No patients were positive for IgE, IgA, or IgM antibodiesNo patients were positive for IgE, IgA, or IgM antibodies Most patients positive at 1:50 or 1:100 dilution; 1 positive at Most patients positive at 1:50 or 1:100 dilution; 1 positive at

1:2,5001:2,500

Patients enrolled in Study TKT014Patients enrolled in Study TKT014 15 female patients followed for 3 to 12 months15 female patients followed for 3 to 12 months No patients positive for IgG, IgE, IgA or IgM antibodies No patients positive for IgG, IgE, IgA or IgM antibodies

Patients originally enrolled in Studies TKT003 and Patients originally enrolled in Studies TKT003 and TKT005TKT005

40 male patients followed for up to 2.5 years40 male patients followed for up to 2.5 years Persistent IgG antibodies observed in 12/40 patients (30%)Persistent IgG antibodies observed in 12/40 patients (30%) No patients were positive for IgE, IgA, or IgM antibodiesNo patients were positive for IgE, IgA, or IgM antibodies Most patients positive at 1:50 or 1:100 dilution; 1 positive at Most patients positive at 1:50 or 1:100 dilution; 1 positive at

1:2,5001:2,500

Patients enrolled in Study TKT014Patients enrolled in Study TKT014 15 female patients followed for 3 to 12 months15 female patients followed for 3 to 12 months No patients positive for IgG, IgE, IgA or IgM antibodies No patients positive for IgG, IgE, IgA or IgM antibodies

4791.03

64

Study TKT011: Plasma GbStudy TKT011: Plasma Gb33 Results ResultsStudy TKT011: Plasma GbStudy TKT011: Plasma Gb33 Results Results

4793.04

4

5

6

7

8

9

10

11

12

13

14

0 6 12 18 24 30

Months

Pla

sm

a G

b3

nm

ol/m

L

No Ab Persistent Ab Transient Ab

65

Study TKT011: Creatinine Clearance Study TKT011: Creatinine Clearance ResultsResultsStudy TKT011: Creatinine Clearance Study TKT011: Creatinine Clearance ResultsResults

4796.03

70

80

90

100

110

120

130

140

150

0 6 12 18 24 30

Months

Cre

atin

ine

Cle

aran

ce

(mL

/min

)

No Ab, Transient Ab Persistent Ab

66

Study TKT011: LV Mass ResultsStudy TKT011: LV Mass ResultsStudy TKT011: LV Mass ResultsStudy TKT011: LV Mass Results

4800.03

160

180

200

220

240

260

280

0 6 12 18Months

LV M

ass

(g)

No Ab, Transient Ab Persistent Ab

67

Antibody Response to Replagal Therapy: Antibody Response to Replagal Therapy: ConclusionsConclusionsAntibody Response to Replagal Therapy: Antibody Response to Replagal Therapy: ConclusionsConclusions

Persistent IgG antibodies may occur in approximately 30% of Persistent IgG antibodies may occur in approximately 30% of treated patientstreated patients

No IgE antibodies or hypersensitivityNo IgE antibodies or hypersensitivity Fully human glycosylation patternFully human glycosylation pattern

No clear correlation of IgG antibody with infusion reactionsNo clear correlation of IgG antibody with infusion reactions

Mean reductions in plasma and urine GbMean reductions in plasma and urine Gb33 are lower for subset of are lower for subset of

patients with persistent antibodiespatients with persistent antibodies GbGb33 levels remain below baseline after 2-2.5 years of therapy levels remain below baseline after 2-2.5 years of therapy

No effect of IgG antibody formation on renal function or cardiac No effect of IgG antibody formation on renal function or cardiac massmass

No evidence of immune complex depositionNo evidence of immune complex deposition

Persistent IgG antibodies may occur in approximately 30% of Persistent IgG antibodies may occur in approximately 30% of treated patientstreated patients

No IgE antibodies or hypersensitivityNo IgE antibodies or hypersensitivity Fully human glycosylation patternFully human glycosylation pattern

No clear correlation of IgG antibody with infusion reactionsNo clear correlation of IgG antibody with infusion reactions

Mean reductions in plasma and urine GbMean reductions in plasma and urine Gb33 are lower for subset of are lower for subset of

patients with persistent antibodiespatients with persistent antibodies GbGb33 levels remain below baseline after 2-2.5 years of therapy levels remain below baseline after 2-2.5 years of therapy

No effect of IgG antibody formation on renal function or cardiac No effect of IgG antibody formation on renal function or cardiac massmass

No evidence of immune complex depositionNo evidence of immune complex deposition

4051.03

68

Conclusions: ReplagalConclusions: ReplagalConclusions: ReplagalConclusions: Replagal

Improves glomerular pathologyImproves glomerular pathology


Delay in time to ESRD Delay in time to ESRD



Concomitant metabolic improvementsConcomitant metabolic improvements

Safe and well-toleratedSafe and well-tolerated

Improves glomerular pathologyImproves glomerular pathology


Delay in time to ESRD Delay in time to ESRD



Concomitant metabolic improvementsConcomitant metabolic improvements

Safe and well-toleratedSafe and well-tolerated

4052.04

69

TKT Q&A Slides TKT Q&A Slides TKT Q&A Slides TKT Q&A Slides

704532.02

Figure 12A: GFR vs the Fraction of Glomeruli Figure 12A: GFR vs the Fraction of Glomeruli with Mesangial Widening (%): Scatter Plotwith Mesangial Widening (%): Scatter PlotFigure 12A: GFR vs the Fraction of Glomeruli Figure 12A: GFR vs the Fraction of Glomeruli with Mesangial Widening (%): Scatter Plotwith Mesangial Widening (%): Scatter Plot


F I G U R E 1 . 2

B a s e l i n e G F R v s M e s a n g i a l W i d e n i n g ( % ) P e a r s o n C o r r e l a t i o n C o e f f i c i e n t r = - 0 . 1 4 5 6 , p = 0 . 4 8 7 4


GFR

0

2 0

4 0

6 0

8 0

1 0 0

1 2 0

1 4 0

1 6 0

1 8 0

2 0 0

M e s a n g i a l W i d e n i n g ( % )

0 2 0 4 0 6 0 8 0 1 0 0

Mesangial Widening (%)

100806040200

0

20

40

60

80

100

120

140

180

200

160

GF

R

71

Reversal of ProteinuriaReversal of ProteinuriaReversal of ProteinuriaReversal of Proteinuria

4280.03

0

100

200

300

400

0 6 12 18 24

mg

/24

Ho

urs


Upper Limit Normal

Albuminuria (mg/d) Proteinuria (mg/d)

72

Effect of Replagal on Glomerular Effect of Replagal on Glomerular Endocapillary GbEndocapillary Gb33 Deposition DepositionEffect of Replagal on Glomerular Effect of Replagal on Glomerular Endocapillary GbEndocapillary Gb33 Deposition Deposition

Replagal Placebo

Baseline 1.2 ± 0.1 1.1 ± 0.2

Change to Week 24 -0.7 ± 0.2 0.0 ± 0.3

p-value 0.04

4787.02

73

Change of Creatinine Clearance vs Change Change of Creatinine Clearance vs Change of Normal (%) and Mesangial Wideningof Normal (%) and Mesangial WideningChange of Creatinine Clearance vs Change Change of Creatinine Clearance vs Change of Normal (%) and Mesangial Wideningof Normal (%) and Mesangial Widening

4815.01

T r a n s k a r y o t i c T h e r a p i e s , I n c .P r o t o c o l N o . T K T 0 0 3

F I G U R E 4 .

C h a n g e o f C r C l v s C h a n g e o f N o r m a l ( % ) a n d M e s a n g i a l W i d e n i n g ( % ) R e p l a g a l P a t i e n t s O n l y

C o r r e l a t i o n C o e f f i c i e n t : C h a n g e o f C r C l v s C h a n g e o f N o r ma l r = 0 . 2 4 8 8 p = 0 . 4 3 5 5 C o r r e l a t i o n C o e f f i c i e n t : C h a n g e o f C r C l v s C h a n g e o f Me s a n g i a l Wi d e n i n g r = - 0 . 5 4 9 1 8 p = 0 . 0 6 4 4

P r o g r a m: p : \ t k t 0 0 3 \ p o s t b l a \ f d a _ 2 0 0 2 _ 0 9 \ 2 0 0 2 _ 0 9 _ 1 7 \ f _ c c _ p a t h . s a s O u t p u t : f _ c c _ p a t h . d o c S e p t e mb e r 1 7 , 2 0 0 2 1 0 : 5 8

N o r ma l Me s a n g i a l Wi d e n i n g

Chan

ge o

f Cr

Cl

- 5 0

- 4 0

- 3 0

- 2 0

- 1 0

0

1 0

2 0

3 0

C h a n g e o f N o r m a l ( % ) a n d M e s a n g i a l W i d e n i n g ( % )

- 4 0 - 3 0 - 2 0 - 1 0 0 1 0 2 0 3 0 4 0 5 0

Replagal Patients OnlyReplagal Patients Only

Baseline Normal (%) and Mesangial Widening (%)Normal Mesangial Widening

-40 -30 -20 -10 0 10

20

30

40

50

Ch

ang

e o

f C

reat

inin

e C

lear

ance 30

20

10

0

-10

-20

-30

-40

-50

74

TKT003 – Creatinine Clearance Over/Under TKT003 – Creatinine Clearance Over/Under CollectionsCollectionsTKT003 – Creatinine Clearance Over/Under TKT003 – Creatinine Clearance Over/Under CollectionsCollections

4808.03

VisitVisit

Mean Urine Mean Urine Creatinine (g) Creatinine (g)

(n=5)(n=5)

Urine CreatinineUrine CreatinineBody WeightBody Weight

(mg/kg)(mg/kg)

Visit Urine Visit Urine Creatinine Creatinine

(g)(g)

Urine CreatinineUrine CreatinineBody WeightBody Weight

(mg/kg)(mg/kg)

PlaceboPlacebo W23W23 1.321.32 22.222.2 0.850.85 14.114.1



ReplagalReplagal W9W9 1.671.67 19.419.4 3.193.19 36.536.5

TKT003 creatinine clearance (6 collections)TKT003 creatinine clearance (6 collections) Over/under collections defined by 35% differenceOver/under collections defined by 35% difference 2.7% of creatinine clearance measurements were 2.7% of creatinine clearance measurements were

over/under collectionsover/under collections

TKT003 creatinine clearance (6 collections)TKT003 creatinine clearance (6 collections) Over/under collections defined by 35% differenceOver/under collections defined by 35% difference 2.7% of creatinine clearance measurements were 2.7% of creatinine clearance measurements were

over/under collectionsover/under collections

75

GFR in Study TKT003GFR in Study TKT003GFR in Study TKT003GFR in Study TKT003

GFR (MDRD Estimate)

Replagal (n = 14)

Placebo (n = 11)

Baseline 96.6 ± 8.5 98.0 ± 11.3

Week 24 93.7 ± 8.3 89.6 ± 11.7

Change to Week 24 -2.9 ± 5.3 -8.5 ± 2.9

p-value 0.098

Mean ± SE

4939.01

76

Replagal Liver Biodistribution vs. Dose in Replagal Liver Biodistribution vs. Dose in Humans (75 Kg patient, 2 hours after infusion)Humans (75 Kg patient, 2 hours after infusion)Replagal Liver Biodistribution vs. Dose in Replagal Liver Biodistribution vs. Dose in Humans (75 Kg patient, 2 hours after infusion)Humans (75 Kg patient, 2 hours after infusion)

4823.01

0

1

2

3

0 0.05 0.1 0.15 0.2 0.25

Dose (mg/kg)

mg

/liv

er

77

Choice of Recommended Human Dose Choice of Recommended Human Dose (0.2 mg/kg)(0.2 mg/kg)Choice of Recommended Human Dose Choice of Recommended Human Dose (0.2 mg/kg)(0.2 mg/kg)

Phase I single (escalating) dose studyPhase I single (escalating) dose study

Rodent biodistribution dataRodent biodistribution data

GbGb33 clearance in a knockout mouse model for Fabry clearance in a knockout mouse model for Fabry

diseasedisease

Comparative pharmacokineticsComparative pharmacokinetics

Phase I single (escalating) dose studyPhase I single (escalating) dose study

Rodent biodistribution dataRodent biodistribution data

GbGb33 clearance in a knockout mouse model for Fabry clearance in a knockout mouse model for Fabry

diseasedisease

Comparative pharmacokineticsComparative pharmacokinetics

4816.01

78

TKT003: Two Interpretations of Placebo TKT003: Two Interpretations of Placebo ArmArmTKT003: Two Interpretations of Placebo TKT003: Two Interpretations of Placebo ArmArm

60

70

80

90

100

110

120

130

0 5 10 15 20 25

Cre

atin

ine

Cle

aran

ce (

mL

/min

)

Treatment Period (weeks)

4783.02

79

Figure 23A: GFR vs Plasma GbFigure 23A: GFR vs Plasma Gb33Figure 23A: GFR vs Plasma GbFigure 23A: GFR vs Plasma Gb33


F I G U R E 1 . 1

B a s e l i n e G F R v s P l a s m a C T HP e a r s o n C o r r e l a t i o n C o e f i c i e n t r = - 0 . 1 6 6 7 7 p = 0 . 4 1 5

P r o g r a m: p : \ t k t 0 0 3 \ p o s t b l a \ f d a _ 2 0 0 2 _ 0 9 \ 2 0 0 2 _ 1 2 _ 0 9 \ f _ g f r _ c t h _ b a s e . s a s O u t p u t : f _ g f r _ c t h _ b a s e . d o c D e c e mb e r 9 , 2 0 0 2

GFR

0

2 0

4 0

6 0

8 0

1 0 0

1 2 0

1 4 0

1 6 0

1 8 0

2 0 0

P l a s m a C T H

4 . 0 0 5 . 0 0 6 . 0 0 7 . 0 0 8 . 0 0 9 . 0 0 1 0 . 0 0 1 1 . 0 0 1 2 . 0 0 1 3 . 0 0 1 4 . 0 0 1 5 . 0 0 1 6 . 0 0 1 7 . 0 0 1 8 . 0 0 1 9 . 0 0 2 0 . 0

Plasma Gb3

2015105

0

20

40

60

80

100

120

140

180

200

160

GF

R

r = -0.17

4854.02

80

Table 20: Effect of Replagal on Interstitial Table 20: Effect of Replagal on Interstitial Vascular Endothelial GbVascular Endothelial Gb33 Deposition DepositionTable 20: Effect of Replagal on Interstitial Table 20: Effect of Replagal on Interstitial Vascular Endothelial GbVascular Endothelial Gb33 Deposition Deposition

Vascular Endothelium Replagal (n=12)

Placebo (n=9)

Baseline 2.0 ± 0.23 1.6 ± 0.29

Change to Week 24 -1.2 ± 0.26 0.2 ± 0.28

p-value 0.003

4570.01

81

Figure 9: TKT003 Kidney Pathology Figure 9: TKT003 Kidney Pathology ResultsResultsFigure 9: TKT003 Kidney Pathology Figure 9: TKT003 Kidney Pathology ResultsResults

4712.01

Normal glomeruli Mesangial widening Segmental sclerosis Obsolescence

p=0.012 p=0.010 p=0.048 p=0.870

0

10

20

30

40

50

60

70

80

Pe

rcen

t

Replagal placebo Replagal placebo Replagal placebo Replagal placebo 0 6 m 0 6 m 0 6 m 0 6 m 0 6 m 0 6 m 0 6 m 0 6 m

82

Branton et al, Medicine 2002

4916.01

Branton, Branton, et alet al – Decline in Renal Function – Decline in Renal FunctionBranton, Branton, et alet al – Decline in Renal Function – Decline in Renal Function

83

Table 21: Reduction of Interstitial Capillary Table 21: Reduction of Interstitial Capillary Endothelial Cell GbEndothelial Cell Gb33 by Agalsidase Beta by Agalsidase Beta (Fabrazyme™, Genzyme Corporation)(Fabrazyme™, Genzyme Corporation)

Table 21: Reduction of Interstitial Capillary Table 21: Reduction of Interstitial Capillary Endothelial Cell GbEndothelial Cell Gb33 by Agalsidase Beta by Agalsidase Beta (Fabrazyme™, Genzyme Corporation)(Fabrazyme™, Genzyme Corporation)

Interstitial Capillary Endothelial Gb3 Content

Agalsidase Beta (n=29)

Placebo (n=29)

Baseline 1.9 ± 0.8 2.2 ± 0.7

Change to Week 20 -1.6 ± 1.2 0.1 ± 1.1

p-value <0.001

4571.01

84

Effect of Replagal on GbEffect of Replagal on Gb33 Storage in the Storage in the Kidney: Peritubular CapillariesKidney: Peritubular CapillariesEffect of Replagal on GbEffect of Replagal on Gb33 Storage in the Storage in the Kidney: Peritubular CapillariesKidney: Peritubular Capillaries

TC4000TC4000TC4000TC4000

Baseline Week 24

330x

4914.02

85

Figure 6: Fabry Disease: Heart Biopsy Figure 6: Fabry Disease: Heart Biopsy (Toluidine Blue Stain: 40x)(Toluidine Blue Stain: 40x)Figure 6: Fabry Disease: Heart Biopsy Figure 6: Fabry Disease: Heart Biopsy (Toluidine Blue Stain: 40x)(Toluidine Blue Stain: 40x)

4581.01

86

FOS - Fabry Outcome SurveyFOS - Fabry Outcome Survey A database on medical outcomesA database on medical outcomes

of patients with Fabry diseaseof patients with Fabry disease

FOS - Fabry Outcome SurveyFOS - Fabry Outcome Survey A database on medical outcomesA database on medical outcomes

of patients with Fabry diseaseof patients with Fabry disease

Dr. Atul MehtaDr. Atul MehtaConsultant Hematologist, Royal Free Consultant Hematologist, Royal Free

Hospital, London, UKHospital, London, UK

Dr. Atul MehtaDr. Atul MehtaConsultant Hematologist, Royal Free Consultant Hematologist, Royal Free

Hospital, London, UKHospital, London, UK

5001.02

87

Number of Patients on Agalsidase AlfaNumber of Patients on Agalsidase AlfaNumber of Patients on Agalsidase AlfaNumber of Patients on Agalsidase Alfa

65.8 %n=217

34.2%n=119

Untreated

Treated

5005.02

88

Number of Involved Organ SystemsNumber of Involved Organ SystemsNumber of Involved Organ SystemsNumber of Involved Organ Systems

0123456789

10

<10 10-20 20-30 30-40 40-50 50-60 60+

Females

Males

Nu

mb

er o

f o

rgan

sys

tem

s

Age at FOS entry

5008.01

89

Clinical Manifestations in Obligate Carrier Clinical Manifestations in Obligate Carrier Females: MacDermot, 2001Females: MacDermot, 2001Clinical Manifestations in Obligate Carrier Clinical Manifestations in Obligate Carrier Females: MacDermot, 2001Females: MacDermot, 2001

Most frequent symptoms included:Most frequent symptoms included: Neuropathic pain (70%); fatigue (66%)Neuropathic pain (70%); fatigue (66%) GI symptoms (58%); chest pain/palpitations (53%)GI symptoms (58%); chest pain/palpitations (53%) Heart valve abnormalities (48%)Heart valve abnormalities (48%) Angiokeratoma and abnormal renal function (35%)Angiokeratoma and abnormal renal function (35%) Arrhythmia and hypohidrosis (33%); Arrhythmia and hypohidrosis (33%); Tinnitus (25%); hearing loss (23%);Tinnitus (25%); hearing loss (23%); TIA or CVA (22%)TIA or CVA (22%) LVH (19%)LVH (19%)

Most frequent symptoms included:Most frequent symptoms included: Neuropathic pain (70%); fatigue (66%)Neuropathic pain (70%); fatigue (66%) GI symptoms (58%); chest pain/palpitations (53%)GI symptoms (58%); chest pain/palpitations (53%) Heart valve abnormalities (48%)Heart valve abnormalities (48%) Angiokeratoma and abnormal renal function (35%)Angiokeratoma and abnormal renal function (35%) Arrhythmia and hypohidrosis (33%); Arrhythmia and hypohidrosis (33%); Tinnitus (25%); hearing loss (23%);Tinnitus (25%); hearing loss (23%); TIA or CVA (22%)TIA or CVA (22%) LVH (19%)LVH (19%)

4669.02

endocrinologic

Documents

decline of renal function

years renal function

progression of renal

renal function mlminyr

end stage renal disease

disease management

boston medical center

clinical affairs