CF Education Day March 15, 2008

Agenda - Morning Keynote - Bob Beall, President CFF Newborn Screening - Jackie Zirbes New Treatments: VX770 - Daya Upadhyay Counseling Project - Jessica Herbold, Director, Counseling Center, Institute of Transpersonal Psychology New Treatments: MP Zoe Davies Infection Control Guidelines - Kathy Matthews New Treatments: NAC - Carol Conrad

Agenda - Afternoon New Treatments: SB Rick Moss Keynote II: Treating Exacerbations - Chris Goss Exacerbation Biology - Carol Conrad Respiratory Equipment & Meds - Colleen Dunn Chest CT Natural History - Terry Robinson Take Your Salt - Julie Matel New Treatments: KB001 - Carlos Milla New Treatments: Denufosol - Rick Moss

SB KB-001 Chest CT (Novartis/CFF-TDN) Exacerbation Biology (CFF)

Pathophysiologic Classification of CFTR Mutations Normal IIIIIIIVV Nonsense G542X Frameshift 394delTT Splice junction G A MissenseMissense G551D Missense R117H Alternative Splicing kbC T AA deletion  F508 Missense A455E No synthesis Block in processing Altered conductance Block in regulation Reduced synthesis VX770

Therapeutic Approaches to CF Keyed to Pathophysiologic Stage Abnormal Genes Abnormal CFTR Protein Altered Ion Transport Abnormal Mucus Secretion Infection & Inflammation Tissue Destruction Organ Destruction Respiratory Failure Transplantation Proper Ion Transport “Potentiation” Gene Therapy Modifier Genes Protein rescue “Correction” Anti-Inflammatories Anti-Infectives Bronchodilators X X Current: None In Development: rhDNase Hypertonic Saline Physiotherapy Anti-Inflammatories Anti-Infectives Stem Cells

Modulating Airway Inflammation in CF Dornase alfa - Pulmozyme ® - Early administration of rhDnase slows the decline in lung function - Reduces inflammation (BEAT trial) Down-regulation of inflammatory mediators -  -1 proteinase inhibitor - Glutathione repletion: N-acetylcysteine Down-regulation of neutrophil influx/activation - SB (GlaxoSmithKline ): blocking CXCR2

Elizur et al, Chest 2008;133:489 Inflamed Airways in CF Inflammation in CF starts early, is persistent, and is based on epithelial disease with exaggerated, ineffective white cell (PMN) response PMN

Chemokines RollingActivationAdhesionDiapedesis 4000µm/sec 40µm/sec secondsminutes ~10 minutes Lung Tissue Chemokines IL-8 CXCR2 PMN Epithelium Airway CXCR2 SB656933

Neutrophil Neutrophil chemotaxis Macrophage Macrophage accumulation CXCR2 T-Cells Protease, ROS Release Alveolar wall destruction, EMPHYSEMA Goblet cells CXCR2 IL-8, Gro-a release TNF-a, IL-1 GM-CSF Release Neutrophil Accumulation CXCR2 Mucus Hypersecretion CHRONIC BRONCHITIS Chronic inflammation, AIRWAYS OBSTRUCTION IL-8 & Gro-  Release Neutrophil Macrophage Epithelium Fibroblasts SB : Oral CXCR2 Antagonist

Open Label Dose Ascending Single Dose Study of SB (GlaxoSmithKline) Eligibility: Age ≥16 yr Stable, FEV1>40% Cohort mg; Cohort mg Objectives: Safety, PK (metabolism), PD (biomarker efficacy) Sites: Stanford, Pittsburgh Status: Enrolling (5 in, 3-4 more needed)

Normal Cystic Fibrosis Mucus Clearance Is a Key Component of Normal Lung Defense, Depends on Adequate Surface Liquid Volume, and Is Defective in Cystic Fibrosis ?

Improving Mucociliary Clearance in CF Airway Clearance Therapies (ACT) - Conventional Chest Physical Therapy (CPT), Flutter Device, High Frequency Chest Wall Oscillation (“Vest”), Intrapulmonary Percussive Ventilation (IPV), Exercise (Shear Stress) Inhaled Hypertonic Saline - Disrupts ionic bonds in airway secretions - Positive trials in Australia, US (NEJM 2006) Purinergic Agonists - Activate alternative chloride channel - Increase ciliary activity - Inhaled denufosol (Inspire, Phase III) ENaC Inhibitors (Gilead - Phase I completed; others)

 Depleted airway surface liquid (ASL) layer and hyper – viscous mucus  Paralyzed muco- ciliary transport Pathogenesis of cystic fibrosis lung disease Matsui et al., Cell 95;1005, 1998

Na + Activation of P2Y 2 Receptors on the Airway Surface Stimulates Chloride Secretion through an “Alternative” Chloride Channel, bypassing Defective CFTR Increases chloride and liquid secretion

Activation of P2Y 2 Receptors on the Airway Surface Na + Increases mucin secretion

Activation of P2Y 2 Receptors on the Airway Surface Na + Increases cilia beat frequency

Effects of Denufosol in CF Patients with Milder Lung Disease: Improvement in Lung Function Smiley, et al., ECFS, Copenhagen, N=33 Pts with  75% predicted normal FEV 1 at baseline *Avg. FEV 1 = 97.2% N=89 Pts with  75% predicted normal FEV 1 at baseline *Avg. FEV1 = 93.0% N=24 Pts with 75-90% predicted normal FEV 1 at baseline and no TOBI use *Avg. FEV1 = 83.0% *Average FEV 1 % predicted of normal pre-dose on Day 1 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% FEV 1 FEF 25%-75% Difference from Placebo in Percent Change from Baseline to Day 28* for FEV 1 and FEF 25%-75%

Evidence for a Reduction in Exacerbations in CF Patients Treated with Denufosol Study N=89 Study N=41 Pts with  75% predicted normal FEV 1 at baseline Pts with 75%-90% predicted normal FEV 1 at baseline

TIGER-2 (Transport of Ions to Generate Epithelial Rehydration Phase 3 International Randomized Double- blind Placebo-Controlled Denufosol 60 mg or placebo inhaled 3 times daily for 6 months ≥5 years old, FEV≥75% Stable No hypertonic saline Status: Enrolling (4-6 subjects) mid April