1. Howard Liebman, MD Chief, Hematology Section Professor of Medicine and Pathology Keck School of Medicine of the University of Southern California Jane Anne Nohl Division of Hematology and Center for the Study of Blood Diseases Norris Cancer Hospital Los Angeles, California Future Therapy for ITP: What’s Next? This program is supported by an educational donation from

2. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm Disclosure of Unlabeled Use  This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. Postgraduate Institute for Medicine (PIM) and Clinical Care Options, LLC do not recommend the use of any agent outside of the labeled indications.  The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of PIM and Clinical Care Options, LLC. Please refer to the official prescribing information for each product for discussion of approved indication, contraindications, and warnings.

3. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm Unanswered Questions  Can we identify more triggering events for the development of adult ITP?  When does an infection-related ITP, such as ITP associated with H. pylori, become an autonomous disorder?

4. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm Time? Evolution of Antiplatelet Antibodies After H. pylori Infection Cines DB, et al. Blood. 2009;113:6511-6521. This research was originally published in Blood. © the American Society of Hematology.

5. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm Unanswered Questions  Can we identify and distinguish between a T lymphocyte or B lymphocyte dominant ITP?  Can this knowledge lead to more targeted therapies?

6. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm Chow L, et al. ASH 2008. Abstract 399. Antibody- and Cell-Mediated Immune Thrombocytopenia: Mouse Model  Lymphocytes from CD61-immunized CD61 KO mice  Depleted and transferred to SCID mice  Monitor platelets for 30 days –Non depleted lymphocytes : rapid drop in platelet numbers that does not recover –CD8+ T-cell depleted lymphocytes: rapid drop in platelet numbers that does not recover –CD4+ T-cell depleted lymphocytes: platelet numbers initially drop, but recover by Day 15 and numbers are maintained –CD19+ B-cell depleted lymphoc ytes: rapid drop in platelet numbers that does not recover

7. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm Unanswered Questions  Where have all the Tregs gone?  How does B lymphocyte–directed therapy (ie, rituximab) lead to functional and quantitative improvement in Tregs?

8. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm Treg Frequency and Function in Chronic ITP  Peripheral Tregs (CD4+CD25 hi Foxp3+) important for peripheral tolerance –Loss of tolerance in ITP possibly due to inefficient production or decreased immunosuppressive activity –Treg production similar between controls and ITP patients Yu J, et al. Blood. 2008;112:1325-1328. This research was originally published in Blood. © the American Society of Hematology.

9. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm P =.046 1:16 100 60 0 1:01:11:4 Ratio 4+25+:4+25- 80 40 20 % Inhibition Treg Frequency and Function in Chronic ITP  Decreased immunosuppressive activity in Tregs from chronic ITP patients Mean % Inhibition of Proliferative Response Autologous CD4+CD25 hi with CD4+CD25- ITP pt CD4+CD25 hi with control CD4+CD25- Control CD4+CD25 hi with ITP pt CD4+CD25- Yu J, et al. Blood. 2008;112:1325-1328. This research was originally published in Blood. © the American Society of Hematology. 100 60 0 1:01:11:41:16 Ratio 4+25+:4+25- 80 40 20 % Inhibition P =.004 P =.02 P =.006 P =.008 P =.01 P =.03 100 60 0 1:01:11:41:16 Ratio 4+25+:4+25- 80 40 20 % Inhibition Chronic ITP pts Healthy controls CD4+CD25- from healthy donors cocultured with CD4+CD25 hi cells from patients with chronic ITP CD4+CD25- from pts with chronic ITP cocultured with CD4+CD25 hi from healthy controls

10. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm Scatter Plot of Tregs Treg Changes With Rituximab Treatment  Number and function of Tregs in ITP patients restored after rituximab treatment –Particularly true for responders Stasi R, et al. Blood. 2008;112:1147-1150. This research was originally published in Blood. © the American Society of Hematology. Tregs Pre- and Post-Rituximab 80 0 Tregs (cell/μl) Before3 Mos (R) 70 60 50 40 30 20 10 Tregs (cell/μl) Tregs (%) 3 Mos (NR) 6 Mos (R) 12 Mos (R) Controls 10 0 9 8 7 6 3 2 1 5 4 Tregs (%) 16.2 3.1 35.8 6.4 20.7 3.9 41.1 6.7 43.5 6.9 56.6 7.2

11. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm The Future Management of Adult ITP  More intensive therapy of primary ITP after initial evaluation  With the early use of high-dose dexamethasone, what are the potential advantages, if any?

12. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm What Is the Potential for High-Dose Dexamethasone Therapy? CorticosteroidDose1-Yr Remission, % Prednisone [1-3] 1 mg/kg13-17 Dexamethasone [4] 40 mg/day x 4 days42 (> 13 mos) Dexamethasone [5] 40 mg/day x 4 days q 2 wks x 4 cycles 60 (15 mos) 1. Dan K, et al. Int J Hematol. 1992;55:287-292. 2. Schiavotto C, et al. Haematologica. 1993;78(suppl 2): 22-28. 3. Ben-Yehuda D, et al. Acta Haematol. 1994;91:1-6. 4. Cheng Y, et al. N Engl J Med. 2003;349:831- 836. 5. Mazzucconi MG, et al. Blood. 2007;109;1401-1407.

13. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm 1. Godeau B, et al. Blood. 2008;112:999-1004. 2. Zaja F, et al. ASH 2008. Abstract 1. TreatmentDose1-Yr Remission, % Rituximab [1] 375 mg/m 2 /wk x 4 wks40 Rituximab + dexamethasone [2] 375 mg/m 2 /wk x 4 wks + 40 mg/day x 4 days 41 (10-36 mos) Will Anti-CD20 Therapy Have a Role in the Initial Treatment of ITP?

14. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm Novel Approaches to ITP Treatment  FcR modulation –FcγIIIa blockage (3G8, GMA161) –Inhibition of Syk kinase  Inhibition of T and B lymphocyte cross-talk –Inhibition of CD40 signaling (hu5c8, toralizumab)  Expansion or upregulation of Treg lymphocytes

15. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm Response to H. pylori Treatment May Be Rapid Platelet Count (Units = K/cumm)Platelet count Normal low Normal high H. pylori Treatment Pulse Dexamethasone Platelets x 10 9 /L 0 50 100 150 200 250 300 350 400 Units 12/6 104112/7 1521 12/29 1201 1/4 0918 3/23 09563/29 0925 4/2 1034 4/12 1158 4/19 0951 6/7 09298/3 0909 8/09 09128/31 0953 11/9 0911 11/21 0956 2/8 1507 2/29 0831 5/8 09518/7 0842 Date 51 19 42 45 17 36 28 94 186 195 180 207 179 186 255 207 212 205 105

16. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm Asahi A, et al. J Clin Invest. 2008;118:2939-2949. Reprinted with permission. Monocyte Fcγ Receptor Expression After H. pylori Eradication  What are the regulatory pathways for FcR expression?

17. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm Effect of Syk Kinase Inhibition on Platelet Counts in Patients With ITP Podolanczuk, A, et al. Blood. 2009;113:3154-3160. This research was originally published in Blood. © the American Society of Hematology. Platelet Count (x 10 9 /L) 240 210 180 150 120 90 60 30 0 Maintained Responder (n = 8) Nonmaintained Responder (n = 4) Non- responder (n = 4) All Patients (n = 16) Baseline plts Max plts Med plts

18. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm Novel Approaches to ITP Treatment  FcR modulation –FcγIIIa blockage (3G8, GMA161) –Inhibition of Syk kinase  Inhibition of T and B lymphocyte cross-talk –Inhibition of CD40 signaling (hu5c8, toralizumab)  Expansion or upregulation of Treg lymphocytes

19. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm Anti-CD40 Ligand in ITP Patel VL, et al. Br J Haematol. 2008; 141: 545-548. Parameter hu5c8Toralizumab 20 mg/kg (n = 15) All Doses (n = 31) 5 mg/kg (n = 6) 10 mg/kg (n = 11) 15 mg/kg (n = 10) 20 mg/kg (n = 4) Patient characteristics  Average age, yrs 42.450.540.857.545.458.3  Sex, male/female 12/323/84/28/39/12/2  Prior ITP-associated bleeding, n (%) 7 (46.7)16 (53.3)5 (83.3)1 (9.1)7 (77.8)3 (75.0)  Average prior ITP therapies, n 7.522.31.71.92.3 Platelet response  Response, % (n/N) 43 (6/14)16 (5/31)--  Response types, CR/PR 4/21/4--  Median peak platelet response, x 1000 cells/mm 3 228.595.0--  Response onset < 2 mos, n/N 5/65/5--  Relapse prior to final anti-CD40L tx* 3/64/5--  Retreatment responders NA3/4-- *Relapse = platelet count ≤ 20,000 cells/mm 3.

20. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm Bring Back the Tregs  An optimal approach to the long-term management of ITP would be either the in vivo or extracorporeal expansion of CD4+, CD25+, Foxp3+ Tregulatory lymphocytes

21. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm Detection of Antigen Specificity of the Tolerance Induced by GP-iTreg Zhang XL, et al. Blood. 2009;113:2568-2577. This research was originally published in Blood. © the American Society of Hematology. 0 20 40 60 % of Proliferating Cells Lane GPIIb/IIIa- iTreg DCs (Loaded With)Reactive T Cells GPIIb/IIIaGPIb/IX GPIIb/IIIa + GPIb/IX GPIIb/IIIaGPIb/IX iXXX iiXXX iiiXXX ivXXX vXXXX viXX viiXX

22. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm In the Future, Where Will Thrombopoietin Receptor Agonists Be Utilized?  Only in the postsplenectomy failure?  As an early supportive treatment pending the effect of targeted therapies?

23. clinicaloptions.com/oncology Idiopathic Thrombocytopenic Purpura: Shifting the Treatment Paradigm Reduction or Discontinuation of Concurrent ITP Therapy  Will reduction in the use of immunosuppressive drugs lead to fewer infections? Kuter DJ, et al. Lancet. 2008;371:395-403. Patients With Dose Modification, % SplenectomizedNon-Splenectomized Placebo (n = 6) Romiplostim (n = 12) Placebo (n = 10) Romiplostim (n = 11) Reduced 17332036.4 Discontinued by > 25% 0673036.4

24. Remember: Treatment Is Only as Good as Your Diagnosis—Make Sure It Is ITP

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