DIAS-4-USA Study Protocol

Purpose of presentation Present and discuss the DIAS-4-USA Study protocol

Agenda Overview of protocol Selection Criteria Excl. & concomitant medication Study Committees Discussion & questions as we go along

Study overview - DIAS-3/4 Confirm efficacy of desmoteplase 90ug/kg vs. placebo Two-arm, phase III, pivotal study Neuroimaging to identify responders treated 3-9h post stroke

Study title A randomised, double-blind, parallel-group placebo-controlled phase lll study to evaluate the efficacy and safety of desmoteplase in subjects with acute ischemic stroke DIAS-3/4; Desmoteplase In Acute ischemic Stroke

Outline of study design 12-24h Placebo 90 ug/kg DSPA

Study objectives Primary objective To evaluate the efficacy of desmoteplase 90 μg/kg versus placebo in terms of favourable outcome at Day 90 in subjects with acute ischemic stroke Secondary/other objectives (not exhaustive) Favourable outcome at different time points Favourable outcome in subgroups of patients with “Small” core lesion (less than 25 cc) Recanalisation (12-24 hrs) Different mismatch volumes (optional)

More secondary objectives Safety and tolerability Mortality Symptomatic Intracranial Haemorrhage Immunogenicity of desmoteplase Pharmacoeconomics Evaluate Quality of Life & Utilisation of Resources Population pharmacokinetics Two blood samples at 0.5-9 hours post-treatment

Key differences to DIAS-2 Dose-ranging (PBO, 90 & 125 ug/kg) Patient selected based on penumbra imaging Primary endpoint: mRS/NIHSS/BI DIAS-3/4 N=400 (1:1) Single dose (PBO & 90ug/kg) Patients selected based on angiography Primary endpoint: (mRS  2)

Primary efficacy endpoint Good clinical outcome at Day 90 defined as: mRS score of 0-2 mRS 0 = No symptoms 1 = No sign. disabil., + symptoms 2 = Slight disability 3 = Moderate disability 4 = Moderately severe disability 5 = Severe disability 6 = Death

Effect size on primary endpoint N = 400 patients Post-hoc analysis showed 29% difference (mRS  2) Power of 80%, alfa of 5% Study is powered to detect 13% difference on mRS (mRS  2)

Study population overview Patients with an occlusion or high-grade stenosis on MCA, ACA or PCA Patients eligible for treatment within 3-9 hours Score of 4-24 on NIHSS at baseline Very mild and very severe strokes are excluded Age 18-85 Exclusion of patients that: Have an increased risk of haemorrhage Are not expected to benefit from thrombolysis

Inclusion criteria (#1-3) 1. Clinical diagnosis of acute ischemic stroke 2. Informed consent/HIPAA authorisation has been obtained according to a procedure approved by the ethics committee responsible for approval of the study at this site. 3. Male or female between 18 and 85 years of age inclusive

Inclusion criteria (#4-6) 4. Treatment of the subject can be initiated within 3 – 9 hours after the onset of stroke symptoms. If the actual time of onset of stroke is unclear, then the onset will be considered the time that the subject was last known to be well. All measures are to be taken so treatment with alteplase within 3 hours of symptom onset is not delayed in subjects who qualified for receiving alteplase 5. The subject has a score of 4 - 24 inclusive on the NIHSS with clinical signs of hemispheric infarction (for example, hemiparesis) 6. The subject must receive IMP within 60 minutes after completion of diagnostic imaging screening. The time stamp on the last imaging sequence is the reference for calculating the time elapsing.

Inclusion criteria (#7) 7. The subject shows occlusion or high-grade stenosis as assessed by on MRA or CTA in proximal cerebral arteries that corresponds to the acute clinical deficit. Eligible vessels are the middle cerebral artery MCA M1, MCA M2, anterior cerebral artery (ACA) or posterior cerebral artery (PCA)

Exclusion criteria (#1,4,5) 1. The subject has a pre-stroke mRS score of >1, indicating previous disability 4. The subject has a terminal illness with a life-expectancy of less than 6 months 5. In the opinion of the investigator, the subject has any condition that could impose hazards to the subject, if study therapy is initiated, or affect the participation of the subject in the study (for example, subject with metastatic cancer or with severe microangiopathy such as hemolytic uremic syndrome or thrombotic thrombocytopenic purpura)

Exclusion criteria (#6-8) 6. Consciousness level >2 on question 1a of NIHSS 7. The subject has a history or clinical presentation of ICH, subarachnoid hemorrhage (SAH), arterio-venous malformation, aneurysm, or cerebral neoplasm. Subjects with incidental small intracranial aneurysm can be considered for the study if the aneurysm is < 5 mm, not thrombosed, and not visibly bleeding 8. The subject has symptomatic acute vertebral or basilar artery occlusion

Exclusion criteria (#13-16) 13. The subject has a baseline platelet count < 100,000/mm³ 14. The subject has a baseline haematocrit of < 0.25 15. The subject has a baseline blood glucose < 50 mg/dl or > 200 mg/dl (< 3 mmol/l or > 11 mmol/l). Subjects with blood glucose value between 200-300 mg/dl can be considered for the study only if the blood glucose value decreases to < 200 mg/dl after antidiabetic treatment and before administration of IMP 16. The subject has uncontrolled hypertension defined as a blood pressure > 185 mmHg systolic or >110 mmHg diastolic on at least 2 separate occasions at least 10 minutes apart, or requiring aggressive treatment to reduce the blood pressure within the limits. The definition of aggressive treatment is left to the discretion of the investigator

Exclusion criteria (#17-21) 17. The subject has a hereditary or acquired hemorrhagic diathesis 18. The subject has had a gastrointestinal or urinary bleeding within the past 21 day 19. The subject has had an arterial puncture at a non- compressible site within the past 7 days 20. The subject has had another stroke or a serious head injury in the past 6 weeks 21. The subject has had major surgery within the past 14 days

Exclusion criteria (#22-23, 25-26) 22. The subject has had seizure at the onset of stroke 23. The subject has had an acute myocardial infarction (AMI) within the past 3 weeks 25. The subject is a pregnant woman (positive serum βHCG pregnancy test, positive urine pregnancy test or clinically evident pregnancy) 26. The subject is, in the opinion of the investigator, unlikely to comply with the clinical study protocol or is unsuitable for any other reason

Compare with alteplase contraindications Active internal bleeding Severe uncontrolled hypertension Recent intracranial or intraspinal surgery or trauma (within 3 months) Intracranial neoplasm, arteriovenous malformation, or aneurysm Known bleeding diathesis History of cerebrovascular accident Evidence of intracranial hemorrhage Suspicion of subarachnoid hemorrhage History of intracranial hemorrhage Seizure at the onset of stroke Platelet count less than 100,000/mm Administration of heparin with 48 hours preceding the onset of stroke and have an elevated activated partial thromboplastin time at presentation (ischemic stoke)

Excluded medication, Excl. Criteria (#2-3) 2. The subject has previously been exposed to desmoteplase 3. The subject has participated in any investigational study in the past 30 days

Excluded medication, Excl. criteria (#9-11) 9. The subject is on oral anticoagulants and has a prolonged prothrombin time (INR > 1.6) 10. The subject has been treated with heparin in the past 48 hours and has a prolonged partial thromboplastin time exceeding the upper limit of the local laboratory normal range. Preventive low doses of LMWH (for example, for deep vein thrombosis (DVT) prophylaxis) do not disqualify the subject from the study 11. The subject has been treated with glycoprotein IIb - IIIa inhibitors within the past 72 hours. Use of single agent oral platelet inhibitors (e.g. clopidogrel 75 mg or low-dose aspirin < 325 mg) or the combination of low-dose-aspirin (e.g. 50 mg) and dipyridamole (e.g. 400 mg) prior to study entry is permitted

Excluded medication, Excl. criteria (#12, 24) 12. The subject has been treated with factor Xa inhibitors in the past 72 hours 24. The subject has been treated with a thrombolytic agent within the past 72 hours

Concomitant Medication The following concomitant medications are not allowed during the study: Any other thrombolytic agent within the first 72 hours after IMP administration Any antiplatelet agent within the first 24 hours after IMP administration Any anticoagulant within the first 24 hours after IMP administration Any endovascular/mechanical treatment of stroke within 72 hours after IMP administration

Reiterate imaging Baseline 12-24 hour imaging Confirm diagnosis and ensure occlusion/high-grade stenosis exclude ICH & other pathologies Centres may perform imaging by either MRI or CT MR centres may obtain Perfusion Image (not selection!) 12-24 hour imaging To monitor for cerebral bleedings (symptomatic) by CT or MRI and before the initiation of anti-thrombotic therapy To assess recanalisation and infarct size

Reiterate imaging (cont.) Imaging selection criteria will be discussed in the imaging session Unscheduled scans needed In case of neurological deterioration In case of worsening of NIHSS >4 (between baseline and Day7) After Day 7: if NIHSS worsens >4 compared to Day 7 score and there is no reason for the worsening

Steering Committee Greg Albers (co-chair), US Rüdiger von Kummer (co-chair), Germany Markku Kaste, Finland Antoni Davalos, Spain Ashfaq Shuaib, Canada Gary A Ford, UK Hugues Chabriat, France James Grotta, US Lee Schwamm, US K C Chang, Taiwan

Data Monitoring Committee Kennedy Lees (chair), UK Laurance Wechsler, US Michael Eliasziw, Canada

Imaging and Adjudication Committees Imaging Committee Jochen Fiebach (Chair), Germany Salva Pedraza, Spain Karl-Olov Lövblad, Switzerland Javier Romero, US Adjudication Committee Rüdiger von Kummer, Germany Anthony Furlan, US Howard Rowley, US

Summary Post-hoc analyses of DIAS-2 and previous studies have identified a scientifically/pathophysiologically sound target population for DIAS-3/4 Selection of patients based on presence of occlusion/high-grade stenosis Still compatible with ’penumbra concept’ (and mismatch data will be obtained)

Summary (cont.) Objective of DIAS-3/4 is to confirm efficacy and safety of Desmoteplase 90ug/kg Two pivotal, global studies planned to enrol a total of 800 patients with acute ischemic stroke Overall purpose to fulfil a huge medical need in acute ischemic stroke in the 3-9 hr time-window

Questions?