Guidance for f low cytometric testing forGPI-deficient populations and ParoxysmalNocturnal Haemoglobinuria (PNH)This guidance has been developed by the Birmingham Heartlands Hospital.

lntroduction

The name Paroxysmal Nocturnal Haemoglobinuria (PNH) itself is a misnomer, as it is not

paroxysmal or nocturnal, haemolysis is constant and only around a quarter of patients

present with haemoglobu linuria.l

PNH is an acquired haematopoietic stem cell disorder in which somatic mutation of the

X-linked phosphatidylinositol glycan complementation class A (PlG-A) gene results in a

partial or absolute deficiency of all proteins normally linked to the cell membrane by a

glycosylphosphatidylinositol (GPl) anchor.l'2 Clonal expansion of this cell population also

frequently occurs in patients with aplastic or hypoplastic anaemia in which normal

haematopoiesis has failed.

Classical clinical features of this condition are intravascular haemolysis, bone marrow

failure and a thrombotic tendency, though patients show a wide spectrum of clinical

presentation,3,a including abdominal pain, dysphagia, erectile dysfunction, renal failure and

extreme fatigue or lethargy which is disproportionaie to their anaemia and patient

presentation is highly variable. The disease is rare with a reported incidence of 1.3/million/

year and prevalence of 15.9/million.5 Median age of diagnosis is around 30 years and

median survival is around 10 years.

As PNH is a rare disease, patients may go undiagnosed for many months. Consequently,

the availability of a diagnostic flow cytometry assay means that in patients with suspected

PNH, a definitive diagnosis can be rapidly established resulting in improved patient

management and prognosis.

This publication was supported by an unrestricted educational grant from Alexion.The content of these guidelines was not influenced by Alexion.

Soliris prescribing information can be found on the back page

Test for G P I - def ic ient popu lations i n thefollowing groups:6

Requests for testing should be sent to:

Flow Cytometry Department, Specialist Testing,

Laboratory Medicine, Birmingham Heartlands Hospital,

Bordesley Green East, Birmingham, 89 5SS.

Also, suspect PNH in patients with the following:

Patients with any clone size detected are eligible for referral to the national PN H Service at St James, Leeds (pnh@leedsth.nhs.uk),

or Kings College Hospital, London (austin.kulasekararaj@nhs.net) for further assessment/evaluation. Outreach clinics are also

available at the Peterborough City Hospital, Queen Elizabeth Hospital, Birmingham and the Oxford Churchill Hospital.

Unexplained:

Indicators of haemolysis:

t LDH,1'11 J Haptoglobin,1,11 f lndirect bilirubinl

Indicators of renal dysfunction:

t Creatinine,t' J eGFR,12 t BUNIiBlood transfusions6

Gran u locytopen ia andl or th rom bocytopen ia6 Renal dysfunction6

Abnormal reticulocyte countr Abdominal pain6

t D-Dimers13 Oesophageal spasm6

J Haemoglobinl Pu I monary hypertension6,14

N-terminal pro-Btype naturetic peptide (NT-proBNP) >160pg/m114 predictive of pulmonaryhypertension and independent mortality risk

Erectile dysfunction6

Severe fatigues

Prescri bing lnformationSOLIRISo Eculizumab 300 mg concentrate for solution for infusion prescribinginformation. Presentationi 30 ml vial containing 300 mg eculizumab(10 mglml). lndication: Treatment of paroxysmal nocturnal haemoglobinuria(PNH) in adults and children. Evidence of clinical benefit is limited to patientswith history of transfusions. Treatment of atypical haemolytic uraemic syndrome(aHUS) in adults and children. Dosage and method of administration: lutde18 vears of age) PNH initial phase:600 mg weekly x 4 weeks. Adult e18veas of age) PNH maintenance phase: 900 mg week 5, followed by900 mg every 14 (! 2) days.900 mg weekly for 4 weeks.

Adult O'18 vears of age) aHUS initial phase:

phase: 12OO mg week 5, followed by 1200 mg every 14 (t2) days. aL|L|S900 mg weekly x 4

1200 mg week 5; then 1200 mg every 2 weeks. PNH paediatric oatients k18veare of ase\: >4o kq initial phase:600 mg weekly x 4. >40 kg maintenanceptaiq 900 mg week 5; then 900 mg every 2 weeks. aHUS and PNH paediatricoatients 30 - <40 kg initial ohase: 600 mg weekly x 2. aHUS and PNHpaediatric patients 30 - <40 kg maintenance phase: 90O mg week 3; then900 mg every 2 weeks. aHUS and PNH paediatric patients 20 - <30 kg initialphdss:600 mg weekly x 2. aHUS and PNH paediatric patients 20 - <30 kgmaintenance phdse;600 mg week 3; then 600 mg every 2 weeks. aHUS andPNH paediatilc patients 10 - <20 kg initial phase:600 mg weekly x 1. aA-Asand PNH paediatric patients'10 - <20 kg maintenance phase:300 mg week 2;then 30o mg every 2 weeks. aHUS and PNH paediatric patients 5 - <10 ksinitial phase:300 mg week x 1. aHUS and PNH paediatric patients 5 -

<10 kg maintenance phase:300 mg week 2; then 300 mg every 3 weeks.Supplemental dosing is required with concomitant plasma treatment, please

refer to the STPC. Administrationi Dilute to a concentration of 5 mglml.Administer via an intravenous infusion over 25 - 45 minutes in adults and 1 - 4hours in paediatric patients via gravity feed, a syringe-type pump, or an infusion

pump. Patients should be monitored for t hour post infusion. Elderly: No

evidence to suggest that special precautions are required, although experience

is limited. Renal impairment: No dose adjustmenL Hepatic impairment: Notstudied. Monitoring: aHUS patients should be monitored for thromboticmicroangiopathy (TMA). Recommended to continue Soliris treatment unlessdiscontinuation is clinically indicated. contraindications: Hypersensitivity toactive ingredient, murine proteins or other excipients. Must not initiate in PNHpatients with unresolved Neisseria meningitidis infection or patients who arenot currently vaccinated against Nelsseda meningitidis. Must not initiate inaHUs patients with unresolved Neisseria meningitidls infection, who are notcurrently vaccinated against Neisseria meningitidis or do not receiveprophylactic treatment with appropriaie antibiotics until 2 weeks aftervaccination. Special warnings and precautions: Meningococal infection,immunisation and other systemic infections: lncreased risk of meningococcalinfection. All patients must be vaccinated against meningococcal infection >2

weeks prior to starting Soliris. PNH patients must be vaccinated againstmeningococcal infection >2 weeks prior to starting Soliris. aHUS patients

treated with Soliris <2 weeks after receiving a meningococcal vaccine mustreceive treatment with appropriate prophylactic antibiotics until 2 weeks aftervaccination. Patients must be re-vaccinated according to current medicalguidelines. Tetravalent, conjugated vaccines are strongly recommended.

Vaccination may not be sufficient to prevent meninSococcal infection. Cases ofserious or fatal meningococcal infection have been reported. All Patients must

be monitored for early signs of meningococcal infection and evaluated

immediately if infection is suspected and treated with appropriate antibioiics ifnecessary. Patients should be informed of signs and symptoms of infection and

steps taken to seek medical care immediately. Physicians must discuss thebenefits and risks with patients and provide them with a patient informationbrochure and a patient safety card. Use with caution in patients with otheractive systemic infections. Patients may have increased susceptibility toinfections, especially with encapsulated bacteria. Patients <18 years must be

vaccinated against Haemophilus influenzae and pneumococcal infections.

lnfusion rcactions: Administration may result in infusion reactions orimmunogenicity that could cause allergic or hyPersensitivity reactions, includinganaphylaxis. Treatment should be interrupted in patients who experience severe

infusion reactions and appropriate medical therapy administercd. Anticoagulant

therapy: Should not be altered. Laboratory Monitoring: PNH patients should bemonitored for signs and symptoms of intravascular haemolysis, including serumLDH levels. During treatment, patients who show signs and symptoms ofintravascular haemolysis may require dose adjustment within the recommended14 (t 2) day dosing schedule during the maintenance phase. aHUS patientsshould be monitored for TMA by measuring platelet counts, serum LDH andserum creatinine and may require dose adjustment within the recommended 14(t 2) day dosing schedule during the maintenance phase. D6continuation: PNHpatients who discontinue should be monitored for serious intravascularhaemolysis for >8 weeks. lf serious haemolysis occurs, consider: bloodtransfusion, or exchange transfusion if the PNH red blood cells are >50% of thetotal red blood cells by flow cytometry; anticoagulation; corticosteroids orreinstitution of Soliris. aHUS patients who discontinue should be monitoredclosely for severe TMA complications for >12 weeks. lf severe TMAcomplications occur consider: reinstitution of Soliris treatment, supportive carewith PElPl, or appropriate organ-specific supportive measures including renalsupport with dialysis, respiratory support with mechanical ventilation oranticoagulation. SevereTMAcomplicationswereobseryedafterdiscontinuationin aHUS clinical studies. Exc?lentsr 5 mmol sodium per vial. lnteractions withother medicinal products: No studies. Pregnancy: Should be given only if clearlyneeded. Women of childbearing potential have to use effective contraceptionduring treatment and {or 5 months after treatment. Breast-feeding: Unknownwhether Soliris is excreted into human milk. Should be discontinued duringtreatment and for 5 months after treatment. Undesirable effects: The mostcommon adverse reaction was headache and the most serious adverse reactionwas meningococcal sepsis. Very common side effects (>1/10): headache.Common side effects (>1/100 to <1/10): Meningococcal sepsis, aspergillusinfection, arthritis bacterial, upper respiratory tract infection, nasopharyngitis,bronchitis, oral herpes, urinary tract infection, viral infection, thrombocytopenia,leukopenia, haemolysis, anaphylactic reaction, decreased appetite, dizziness,dysgeusia, hypotension, dyspnoea, cough, nasal congestion, pharyngolaryngealpain, rhinorrhoea, diarrhoea, vomiting, nausea, abdominal pain, constipation,dyspepsia, rash, alopecia, pruritus, arthralgia, myalgia, muscle spasms, bonepain,backpain,neckpain,paininextremity, oedema,pyrexia,chestdiscomfort,chills, {atigue, asthenia, Coombs test positive, influenza Iike illness. Please referto the SmPC for a full list of adverse events. ln PNH and aHUS clinical trials themost serious adverse event was meningococcal septicaemia. Antibodies toSoliris were detected in 2% of PNH using an ELISA assay and 3% of patientswith aHUS using the ECL bridging format assay. Cases o{ haemolysis have beenreported with missed or delayed Soliris dose in PNH clinical trials. Cases of TMAhave been reported in missed or delayed Soliris dose in aHUS clinical trials. Themost common adverse reaction in paediatric PNH patients was headache. Thesafety profile in the different paediatric subsets of age appears similan Overdose:No cases reported. MA number: EU/1/O7/393/OO1 MAH: Alexion Europe SAS,25 Boulevard de I'Amiral Wuix, 75016 Paris, France. Fudher informationavailable from Alexion Pharma UK, 3 Furzeground Way, Stockley Park,Uxbridge, Middlesex, UB11 lEZ. Tel 0800 321 3902. Date ot Authorisation:20-06-2007. Legal Category: POM. UK Cost: f3,150.00 per vial. lrish Cost:€4557.5O per vial. Preparation date: June 2014.

Adverse events should be reported. lnformationon reporting adverse events can be found at

www.imb.ie. Adverse events should also be reportedto Alexion Pharma UK Ltd on 1800 936 544

or uk.adverseevents@alxn.com

Adverse events should be reported. Reportingforms and information can be found at

www.mhra.gov.uk/yellowcard.Adverse events should also be reported toAlexion Pharma UK Ltd on 0800 321 3902

or uk.adverseevents@alxn.com.

Alo\ ol oharn " UK. 3 .rTeground Way.

Stocklev Park, Uxbridge, lViddlesex,

References: 1. Parker C et al. Blood 2OO5; 106:3699-709.2. Rother RP et al. Nat Biotechnol 2OO7;25:1256-64.3. Hillmen P et al. NEJM 1995;333:1253-8. 4. Soci6 C et al. The Lancet 1996;348:573-7. 5. Hll A et al. Blood (ASH

Abstract).2006;108. Abstract985.6. Borowitz Metal. Clinical Cytometry2OlO;78b:211-3O.7. Hill Aet al. ASH

Annual Meeting 2006: Abstract979. L Hillmen P et al. Blood 2OQ7;110:4123-28.9. NCCN Cuideline. Version 2;

2010 National Comprehensive Cancer Network. 10. Cuidelines for the Diagnosis and Management of AplasticAnaemia. British Committee for Standards in Haematology. Brit J Haematol 2OO9;'147:43-7. 11. Rother R etal. JAMA2OO5;293:1653-62.12. Hillmen P etal- Am I Hematol 2O1O;85:553-9.13. Helley D etal. Hematalogica2OlOi95(4):574-81. 14. Hill A et al. ASH Annual Meeting Abstract 2OO8; 112:486.

Soliris@ is a registered trademark of A exion Pharmaceut ca s, lncCopyright O 2014, A exion Pharmaceuticals, lnc.A I rlghts reserved.

Ul(SPNH/12l0022(3)a October 2014 Email: A exion.uk@a xn.com