1. Gastrointestinal Solving the Puzzle: Respiratory Psychosocial Diabetes CF Clinical Research Needs Active Studies Opportunities “Personalized” Care Undernutrition Pandora’s Box Chris Landon M.D FAAP, FCCP. Pediatric Diagnostic Center Ventura, California CF Clinical Research 2001

2. CF Clinical Research Needs “Better” Clinical Trials - Series of Cochrane Library reports - Cheng et al. Pediatr Pulmonol, 2000 Research Mandates - Adequate power - Appropriate duration - Meaningful outcome measures - Multicenter design - Account for individual variation Rapid Testing of New Treatments - Clinical trial networks

3. Modifier Genes CFTR dysfunction or absence Infection - P. aeruginosa Mucus plugging Inflammation Abnormal CF Gene Environment Pathophysiology of Cystic Fibrosis

4. CFTR dysfunction or absence Infection- P. aeruginosa Mucus plugging Inflammation Airway Microenvironment in CF

5. Inhaled tobramycin - Tobi ® (Pathogenesis/Chiron) - Compelling results from follow-up of multicenter trials RSV vaccine - (Wyeth-Lederle, P. Hiatt et al) - Multicenter trial - Potential for short and long term reduction in morbidity Dextran - (D. Speert et al) - Multiple actions including - Interference with Pseudomonas attachment to epithelium. Xylitol - (J. Zabner et al) - 5 carbon sugar, improves antimicrobial properties of airway surface liquid. Improving Antimicrobial Activity in the CF Airway

6. Airway Secretion Clearance Study (American Biosystems Inc., CFF) - Comparison of Conventional Chest Physical Therapy, Flutter Device, and High Frequency Chest Wall Oscillation - 22 centers Inhaled Hypertonic Saline - Disrupts ionic bonds in airway secretions - Multicenter trial in Australia (P. Bye et al.) Purinergic Agonists - (Inspire Pharmaceuticals Inc.) - Activate alternative chloride channel - Increase ciliary activity - Phase I trial (P. Noone et al.) Improving Mucociliary Clearance in CF

7. Dornase alfa - Pulmozyme ® (Genentech Inc.) - Does early administration of rhDnase slow the decline in lung function? - Multicenter, International trial Elastase inhibitors - Recombinant alpha-one-antitrypsin (PPL Therapeutics plc) - DMP 777 - specific intracellular inhibitor - rMNEI - Monocyte/Neutrophil Elastase Inhibitor (CBRI) Modulating Airway Inflammation in CF

8. Treatment of stop mutations - (Wilschanski et al.) - Aminoglycoside treatment (e.g. gentamicin) overcomes stop mutations e.g. G542X Correcting trafficking defects - (P. Zeitlin et al) - Short chain fatty acids can assist trafficking through endoplasmic reticulum - Aimed at  F508 mutation Correcting CFTR Dysfunction

9. Lipid abnormalities in CF (S. Freedman and J. Alvarez) - AA is increased in CF cells - DHA is decreased in CF cells - AA is pro-inflammatory - DHA treatment in murine models protects against lung infection. Lipid abnormality confirmed in: - Murine models - Tissue culture - Human epithelial cells Lumarel ® (Genzyme, Inc.) – no longer under development DHA (Docosahexanoic acid) in CF

10. Acquisition of P. aeruginosa - Early intermittent colonization with different strains - Later, one predominant strain (J. Burns et al., Multicenter BAL trial; P. Farrell, M. Rock et al. Wisconsin study D. Armstrong et al.) Early Diagnosis through Newborn Screening - Improves growth and nutrition - Avoids complications of infancy (P. Farrell et al.) Link Between Early Impaired Growth and Later Decreased Pulmonary Function. (W. Morgan, and the ESCF) Early Treatment in CF

11. CF Related Diabetes - Improved definition (A. Moran et al.) - Links to lung disease (C. Milla et al.) CF Liver Disease - Guidelines (R. Sokol et al.) - Modifier genes (K. Friedman et al.) CF Bone Disease - Diagnosis and treatment (R. Aris et al.) Adult Centers - Reproduction - Psychosocial stresses CF Clinical Research and Comprehensive Care

12. + = Genomics - Microarrays Proteomics........... Modifier Genes Pathways of Injury Individual Variation New Treatments Individual Treatment Approaches Towards “Personalized” CF Care: Genomics and Proteomics

13. New treatments are being added to the regimen ~ time ~ complexity Need to Measure Adherence ~ new electronic monitors (Doser, Nebulizer Monitor) ~ daily diary measure Include Quality of Life as Secondary Outcome Advances in CF Treatment

14. Pandemonium - All The Demons Physician Clinical Nurse Specialist Dietitian Respiratory Therapist Physical Therapist Pediatric Pulmonologist Adult Pulmonologist Pharmacist

15. TREATMENTS 1. Dietary Intake 2. Nebulizer 3. Airway Clearance 4. Overall ADHERENCE 20 - 30% (Passero,1980, Lask, 1994) 60 -70% (Quittner, 1999) 40 - 49% (Passero, 1980, Quittner, 1996, Muszynski, 1988) 50% (Gudas, 1991) Rates of Adherence

16. Pre, Post, 6, 12, & 18 Months: 1. Improved Adherence to: ~ Nebulized Treatments ~ Metered Dosed Inhalers ~ Airway Clearance ~ Enzymes 2. Reduced Morbidity (Days in hospital, IV’s) 3. Reduced Family Conflict 4. Increased Quality of Life Outcome Measures

17. Mob Action Peer Pressure in the Bacterial World

18. (N. Hoiby and J. W. Costerton) What is a Biofilm? - A structured community of bacterial cells enclosed in a self-produced polymeric matrix. - Biofilms are a protective mode of growth that allow survival in hostile environments. - Bacteria in biofilms are inherently resistant to killing. Hypothesis: P. aeruginosa infections of the CF lung are biofilm infections

19. Planktonic bacteria (free living) Attachment Flagella, adhesins Microcolonies Pili, Twitching Community Extracellular matrix Quorum sensing Mature Biofilm Biofilm Development

20. Newborn, sterile lungs Permanent colonization with P. aeruginosa Intermittent infection Bacterial adaptation Host defense defect Airway Infection in CF

21.  Basic Research  High-throughput Screening  Combinatorial Chemistry  Drug Target Identification Drug Discovery Commercialization = Rx  Therapeutics Development Grants Program  Therapeutics Development Network Drug Evaluation Drug Discovery and Pre-clinical Testing Projected Time: 7-9 years (Cost: < $75 million) Phase III Submission and Approval Phase II Phase I CFF Drug Development Process

22. Plasmin DNA Complexes Copernicus Gene System, Inc. CPX SciClone Pharmaceuticals, Inc. Moli1901 (Duramycin) Molichem Medicines Inositol induced chloride secretionInologic, Inc. Long-acting Sodium Channel blockerCYFI, Inc. Anti-Protease Therapy Center for Blood Research TyloxapolDiscovery Laboratories, Inc. P-113: antimicrobial peptidePeriodontix Pa 1806PathoGenesis Corporation Acid-stable digestive enzyme therapyAltus Biologics, Inc. Other Abnormal Gene Abnormal Protein Altered Ion Transport Abnormal Mucous Secretion Infection & Inflammation Tissue Destruction Therapeutics Development Program Grants

23. FDA Approval Phase III Phase I / II Drug Discovery Efforts Combinatorial Chemistry High-Throughput Screening New Drug Targets Therapeutics Development Program Grants Drug Development Process

24. CF Clinical Research Needs Active Studies Opportunities “Personalized” Care Clinical Research Basic Research Genomics Proteomics Center Care ? ? Solving the Puzzle