1. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Modeling of hypertension toxicity in response to anti-angiogenic therapy Ron Keizer, Anubha Gupta, Jantien Wanders, Mendel Jansen, Jos H Beijnen, Jan HM Schellens, Mats O Karlsson, Alwin DR Huitema Slotervaart Hospital / NKI-AvL, Amsterdam (NL) / Eisai Ltd, London (UK) / Uppsala University, Uppsala (SE)

2. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Angiogenesis inhibition in cancer treatment ●VEGF(R) is a major target ● mAbs, e.g. bevacizumab ● TKI, e.g. sorafenib ●Hypertension occurs in: ● 20-30% of patient on bevacizumab [1,2] ● 15-60% of patients on TKI [3] ●Proteinuria occurs in : ● 21-62% of patient on bevacizumab [4] ● 23–70% of patients on axitinib [5] [1] Cobleigh, Semin. Oncol. (2003) [2] Sane et al. Angiogenesis (2004) [3] Sica, J. Clin. Oncol. (2006) [4] Zhu AmJKidneyDis (2007) [5] Rugo et al. JCO (2005)

3. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Angiogenesis inhibition in cancer treatment ●Hypertension is treatable and reversible ●Hypertension is not dose-limiting in most cases ● Anti-hypertensive medication (AH) ●Proteinuria is often dose-limiting ● Limited effect AH therapy ●Treatment interruptions → reduced efficacy [1,2] ●Hypertension correlated with efficacy [3-5] [1] Harshman et al, Onkologie (2008) [2] Blay et al, ASCO (2008; #10554), [3-5] ASCO (2009; #3527,5045,8042)

4. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Aim Develop a general model for hypertension and proteinuria in patients treated with angiogenesis inhibitors ●Address clinical relevant questions ●Optimize treatment

5. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai E7080: phase I drug ●E7080: TKI of multiple receptors KDR (VEGFR-2), Flt-1 (VEGFR-1), bFGFR, PDGFR ●Data from phase I trial available (n=67) PK: 2 curves + sparse sampling BP data: weekly Proteinuria: urinanalysis weekly Available data: median 21 weeks (range 1-77 wks)

6. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai 050100150200 Days 25 mg 50 100 150 200 Blood pressure (mmHg) Example patient systolic diastolic E7080

7. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai 050100150 Days 25 mg 19 mg 13 mg 50 100 150 200 Dose reductions systolic E7080 Blood pressure (mmHg) diastolic

8. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai 050100150200 Days 16 mg 12 mg 8 mg 12.5 mg qd Amiloride 50 mg qd Hydrochlorothiazide Nifedipine Metoprolol 100 mg qd 50 100 150 200 Blood pressure (mmHg) 100 mg bid 30 mg qd 25 mg qd 2.5 mg qd E7080 systolic diastolic AH medication

9. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Model: Structure PharmacokineticsCentralPeriphDoseE7080 k in k out AH BP SystolicBP DiastolicBP Time Conc Start E7080 Time BP

10. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai ●Correlation between residuals BP sys and BP dia ●Correlation between k in for BP sys and BP dia ●No covariates Model: Structure

11. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai AH medication ●Some patients received antihypertensive meds. ●“obscures” the hypertension toxicity of E7080 ●Incorporate in model: DDD equivalents DD i = daily dose of AH-drug i DDD = defined* daily dose of AH-drug i Not enough data to assess difference in AH drugs * Defined by WHO

12. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai AH medication * Defined by WHO AH medicationDDD*DDDE Metoprolol 50 mg qd150 mg0.33 Furosemide 20 mg qd40 mg0.5 Lisinopril 10 mg qd10 mg1 1.83 + Eff AH = θ · DDDE

13. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Model: evaluation DiagnosticValue %RSE Θ < 25% %RSE Ω < 20% %RSE Σ < 5% Shrinkage η BP_bas 6% Shrinkage η k_in 45% Shrinkage η ε 33% Shrinkage ε28% Cond. Number62

14. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai 100200300400500 Time (days) 0 2 4 -4 -2 CWRES 0100200300400500 Time (days) CWRES 0 2 4 -4 -2 Model: evaluation Systolic BP Diastolic BP Time (days) CWRES 020406080 0 2 4 -4 -2 Time (days) CWRES 020406080 0 2 4 -4 -2

15. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Model: evaluation Visual predictive check Systolic BPDiastolic BP 90% 50% 10% 90% 50% 10%

16. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai 020406080 Days 50 100 150 200 Blood pressure (mmHg) 25 mg 18 mg Systolic Diastolic E7080 Model: evaluation Example patient

17. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Simulations: questions When treated at the MTD: ●% of patients experiencing dose limiting hypertension Hypertension = increase in BP dia ≥20 mmHg from baseline ●In what % of patients can BP be normalized, when: Treating with AH medication Dose reduction

18. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Simulations: summary InterventionMedian ΔBP dia (RSE) % remain on treatment (RSE) None043.3% (15%) AH: 1 DDDE-2.6 mmHg (84%) 63.7% (13%) AH: 2 DDDE-4.8 mmHg (39%) 68.8% (13%) 50% dose reduction-7.0 mmHg (29%) 82.1% (7%)

19. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Simulations: summary baseline 60 80 100 120 DBP (mmHg) After 12 weeks of treatment with E7080 None Intervention: AH: 1 DDDE AH: 2 DDDE Dose 50%

20. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Proteinurea ●Categorical data: From urinalysis, measured by `dipstick’ Converted to toxicity grades (CTC) 0-3: ObservationCTC grade ‘Negative’, ‘Trace’0 1+, 2+1 3+2 4+3

21. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Model: structure k in k out Pharmacokinetics AH BPCentralPeriphDoseE7080systolicBP diastolicBP

22. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Model: structure k in k out Pharmacokinetics AH BP Proteinurea Pr(CTC)CentralPeriphDoseE7080systolicBP diastolicBPEffect

23. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Model: evaluation 020406080100 Time (days) % patients CTC grade 0 20 40 60 80 100 Grade 0 Grade 1 Grade 2 Grade ≥ 3

24. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Model: evaluation 020406080100 Time (days) % patients CTC grade 0 20 40 60 80 100 Grade 0 Grade 1 Grade 2 Grade ≥ 3

25. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Model: evaluation 020406080100 0 20 40 60 80 100 Time (days) % patients CTC grade Grade 0 Grade 1 Grade 2 Grade ≥ 3

26. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Simulations: questions When treated at the MTD: ●What is the % of patients experiencing dose-limiting proteinuria Proteinuria = multiple occurrences of grade 2, or once grade 3 or 4 ●What is the protective effect of AH therapy on dose limiting proteinuria?

27. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai 050 100 150 0 20 40 60 80 100 Days of treatment % patient PU Grade 0 Grade 1 Grade 2 Grade 3 Simulations treated @ 25 mg qd (MTD) for 3 months continuous In 47% of patients only PU grade 0/1 In 39% of patients dose-limiting PU AH intervention: 35% dose-limiting

28. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Conclusion / Prospects ●Combined model describing hypertension and proteinuria following anti-VEGF treatment General: applicable to other VEGF inhibitors Use in phase II development of E7080 ●Update model: data from other studies / drugs Gain insight into concentration effect relationships Obtain more info on AH effect Investigate possible role of hypertension as biomarker for efficacy

29. Proprietary Eisai Information. Cannot be reproduced in whole or in part without Eisai’s express written consent – Copyright 2009 Eisai Acknowledgements Mats Karlsson Pharmacometrics group Anubha Gupta Mendel Jansen Jantien Wanders Alwin Huitema Jos Beijnen Jan Schellens Powered by Piraña and