1. Chair David S Pisetsky MD PhD Professor of Medicine and Immunology Duke University Medical Center Durham, NC Guests Ellen M Ginzler MD MPH Professor of Medicine Chief of Rheumatology SUNY-Downstate Medical Center Brooklyn, NY Jill Buyon MD Director of Lupus Clinic and Professor of Medicine Hospital for Joint Diseases Department of Rheumatology New York, NY Participants

2. Mycophenolate mofetil (CellCept ® ) Approved for prevention of transplant rejection Reversible inhibitor of inosine monophosphate dehydrogenase (rate-limiting enzyme in purine synthesis) Selective effect on lymphocytes –Blocks B- and T-cell proliferation –Inhibits antibody formation –Decreases expression of adhesion molecules Effect on neutrophils and platelets rare

3. FDA-sponsored trial: MMF vs intravenous cyclophosphamide in severe lupus nephritis Multicenter, randomized, nonblinded trial of induction therapy for SLE patients with active flare of severe Class III, IV, or V lupus nephritis Designed as an equivalence trial Hypothesis: Mycophenolate mofetil has equivalent efficacy with a superior toxicity/tolerability profile compared to IV cyclophosphamide Primary outcome measure: complete remission at 24 weeks (ie, return of serum creatinine, proteinuria, and urine sediment to normal) Secondary outcome measure: partial remission ≥50% improvement in all abnormal renal parameters without worsening of any

4. Remission rates: MMF vs IVC 16/71 4/69 21/7 1 17/69 37/71 21/69 Intent-to-treat analysis p=NS p=0.005 p=0.009 Responding (%) Ginzler et al. NEJM 2005; 353:2219.

5. Contreras study: Sequential treatment of lupus nephritis — free of renal relapse p = 0.021, MMF vs IVC p = 0.124, AZA vs IVC p = 0.222, MMF vs AZA Cumulative probability 19 15 10 6 4 3 1 17 10 4 2 2 1 1 19 17 12 8 3 2 1 0.00 0.25 0.50 0.75 1.00 0122436486072 Time (months) IVC AZA MMF Contreras, et al. NEJM 2004; 350:971.

6. Antiproliferative effect of mycophenolic acid MPA prevents proliferation of: –Smooth muscle cells –Mesangial cells –Fibroblasts –Monocytes Effect not shared by other immunosuppressive drugs

7. SELENA-SLEDAI Composite definition of flares used in SELENA trial Severe flare A. Change in SLEDAI to >12 B. New/worse: CNS SLE Vasculitis Nephritis Myositis Plt 0.5 mg/kg/d Hospitalization New cyclophosphamide, azathioprine, or methotrexate C. Increase in PGA to >2.5 Mild or moderate flare A. Change of SLEDAI >3 B. New/worse: Lupus rash Nasopharyngeal ulcers Pleuritis Pericarditis Arthritis Fever (SLE) Any  in Prednisone to <0.5 mg/kg/d Added NSAIDs or hydroxychloroquine for disease activity C. Physician global assessment (PGA) increase >1.0 and < 2.5

8. Primary endpoint: Severe flare Sample size 91 92 Number of flares 7 (7.7%) 7 (7.6%) 12-month severe flare rate 8.4% 8.7% Difference in flare rates 0.3% Upper limit 95% CI (0.83) Relative risk 0.93 Log-rank p value 0.90 OCPlacebo

9. Description of severe flares OC (N = 7) 1 nephritis/multisystem flare * 2 multisystem flare ** 1 abdominal vasculitis 1 thrombocytopenia 1 severe rash 1 fever Placebo (N = 7) 4 nephritis 1 pleural effusions 1 CNS 1 myositis *Flare after qualifying visit but before beginning study drug **In one patient, flare occurred after discontinuation of study drug

10. Secondary endpoint: Mild/moderate flare Rate of flare per person-year 1.40 1.44 OC Placebo Relative risk upper limit 95% CI 0.98 (p=0.86) (1.26)

11. Overall flares: Mild/moderate and severe Sample size 91 92 Number of subjects who had one or more flares of any type 69 (76%) 63 (69%) Difference in flare rates 7% Upper limit 95% CI (0.19) Relative risk 1.09 Log-rank p value 0.65 OCPlacebo Upper limit 95% CI (1.55)

12. Primary endpoint: Severe flare Sample size 174177 Number of flares 13 (7.5%)8 (4.9%) 12-month severe flare rate 8%4.9% Difference in flare rates 3.3% Upper limit 95% CI (0.78) Log-rank p value 0.23 HRTPlacebo

13. Secondary endpoint: Mild/moderate flare Rate of flares per person/year1.140.86 Relative risk = 1.34 (p = 0.01) HRTPlacebo 12-month overall flare rate was 64% on hormone versus 51% on placebo (p=0.03).

14. Description of severe flares HRT (N = 13) 3 nephritis 1 CNS and nephritis 2 multisystem flare 2 vasculitis 1 cranial neuropathy 1 lupus enterocolitis 1 severe arthritis 1 fever 1 severe rash Placebo (N = 8) 4 nephritis 1 peripheral neuropathy 1 episcleritis 1 bronchiolitis obliterans organizing pneumonia 1 thrombocytopenia

15. Conclusions Data from the OC-SELENA trial support the use of oral contraceptives containing estrogen as a birth control choice. Data from the SELENA-HRT trial support that adding a short course of HRT is associated with a small risk of increasing the natural rate of flares (most of which are mild/moderate). For SLE patients with current inactive or mild/moderate disease and absent antiphospholipid antibodies:

16. Chair David S Pisetsky MD PhD Professor of Medicine and Immunology Duke University Medical Center Durham, NC Guests Ellen M Ginzler MD MPH Professor of Medicine Chief of Rheumatology SUNY-Downstate Medical Center Brooklyn, NY Jill Buyon MD Director of Lupus Clinic and Professor of Medicine Hospital for Joint Diseases Department of Rheumatology New York, NY Participants

17. Antiproliferative effect of mycophenolic acid Information on mycophenolate mofetil (MMF) from kidney biopsies? –Most of the information is not from lupus nephritis patients. –Some evidence from animal studies, which looked at vascular endothelium, and from rebiopsies of transplant patients. –ALMS (Aspreva’s Lupus Management Study): maintenance study comparing CellCept to azathioprine—opportunity to see real biopsies. Ellen M Ginzler MD

18. The effect of MMF on nitric oxide synthetase MMF, unlike cyclophosphamide or azathioprine, blocks nitric oxide (NO) synthetase. Decreasing NO could have an ameliorative effect in lupus. An area worth investigating to distinguish the vasoprotective effects of MMF vs cyclophosphamide. Jill Buyon MD

19. Overall evaluation of lupus There have been no ancillary studies specifically addressing bone mineral density, or any vascular or cognitive parameters. Patients fill out an SF36 questionnaire: evaluation of a patient’s well being. Preliminary data reveal that patients feel better while taking hormones (oral contraceptive pills or hormone replacement therapy). Jill Buyon MD

20. Safety of MMF in pregnancy Currently contraindicated. Patients who get pregnant while on MMF discontinue the drug. 5-6 pregnancies were carried entirely with the drug. Has shown some teratogenic effects in animal models. Ellen M Ginzler MD

21. Safety of MMF in pregnancy Comparison with azathioprine MMF could have affect the fetus due to its antiproliferative effects. Nothing as alarming as thalidomide but should be taken into account. Azathioprine doesn't cross the placenta: –In older studies, radioactive azathioprine injected into pregnant women did not reach the fetus. –Such tests could not be carried out today. Ellen M Ginzler MD Jill Buyon MD

22. Outcome measurement tools for lupus Past trials have looked specifically at the effect of lupus on nephritis: –Serum creatinine –Protein excretion In long-term trials the goal is to keep patients out of renal failure: –Doubling of serum creatinine –Progression to renal failure Looking at other features of lupus becomes more difficult: –SLEDAI (Systemic Lupus Erythematosus Disease Activity Index) for current activity –BILAG (British Isles Lupus Assessment) looks at organ systems manifestations and grades them Ellen M Ginzler MD

23. What about nonrenal lupus? Patients in the trial were selected specifically for their renal disease. Nonrenal manifestations paralleled the success of treatment of nephritis. The numbers were too small to look at how MMF did vs cytoxan for pleuropericarditis vs nephritis; could not look at CNS disease (CNS disease patients were excluded from the trial). –Study does not shed light on specific features. Ellen M Ginzler MD

24. Would BILAG have provided the same information? “Undoubtedly” –It depends on what the trial is designed to do. –All of these instruments have important value. SELENA-SLEDAI is a safety study, not an efficacy study. Important to use the composite definition of flares and not just a scoring system: distinguishing a severe flare from a mild/moderate flare can have tremendous implications on therapy. Important to be all-inclusive in a safety trial; hemolytic anemia can be left out of SLEDAI. Jill Buyon MD

25. Steroid doses Cap on the steroid dose at the beginning. Steroid dose partly defined the severity of the flares: –Patients treated with more than 0.5 mg/kg would be considered to have a severe flare; less than that would be mild/moderate. Jill Buyon MD

26. The effects on vasculature Plan to examine the effect of therapies on vasculature in the ALMS patients. Hope that the dose of prednisone will be similar in both groups of patients at the beginning. May be other confounding variables to be controlled. Hoping to examine these issues, including the vasculature, in patients who are successful in the induction phase and move on to the maintenance phase for long-term follow-up. Ellen M Ginzler MD

27. Concluding remarks Need for a biomarker of “vasculo- atherosclerotic” risk. Aspreva affords an unparalleled opportunity to look at NO and endothelial cell function. A great new agent with the potential to replace existing treatment for lupus nephritis. Jill Buyon MD David S Pisetsky MD PhD