1. XV Convegno del gruppo di studio di Dialisi Peritoneale
Bari, Marzo 2010
XV Convegno del gruppo di studio di Dialisi Peritoneale
Update sulla terapia
dell'anemia in PD
Francesco Locatelli
Dipartimento di Nefrologia, Dialisi e Trapianto di Rene
Ospedale “Alessandro Manzoni” di Lecco

2. Erythropoietin has two erythropoietin receptor binding sites
EPO receptor
EPO receptor
Main Points
• This slide shows an X-ray crystallography image of rHuEPO and the EPO receptor.1
• rHuEPO activates RBC progenitor cells by binding and activating the erythropoietin receptor on the cell surface, which is made up of a dimer of erythropoietin receptor molecules
Background Information
• The Erythropoietin receptor is a member of the superfamily of cytokine receptors. The unique crystal structure that is formed when erythropoietin is complexed to the extracellular ligand-binding domains of the erythropoietin receptor is responsible for optimal signaling through intracellular kinase pathways.1,2
• The complex formed by erythropoietin and the extracellular ligand-binding domain of the erythropoietin receptor is held together by two regions located on opposite faces of erythropoietin. These erythropoietin-receptor interfaces on erythropoietin have been identified as high-affinity and low-affinity binding sites.1
References
Syed RS, Reid SW, Culwel Li, et al. Efficiency of signaling through cytokine receptors depends critically on receptor orientation. Nature. 1998;395:
Cheung JY, Miller BA. Molecular mechanisms of erythropoietin signaling. Nephron. 2001;87:
Elliott S, Lorenzini T, Barzilay J, Chang D, Delorme E. Mapping of the active site of recombinant human erythropoietin. Blood. 1997;89:
Elliott S, et al. Blood 89: , 1997
Syed RS, et al. Nature 395: , 1998 2

3. Erythropoietin has two erythropoietin receptor binding sites
EPO receptor
EPO receptor
rHuEPO
Main Points
• This slide shows an X-ray crystallography image of rHuEPO and the EPO receptor.1
• rHuEPO activates RBC progenitor cells by binding and activating the erythropoietin receptor on the cell surface, which is made up of a dimer of erythropoietin receptor molecules
Background Information
• The Erythropoietin receptor is a member of the superfamily of cytokine receptors. The unique crystal structure that is formed when erythropoietin is complexed to the extracellular ligand-binding domains of the erythropoietin receptor is responsible for optimal signaling through intracellular kinase pathways.1,2
• The complex formed by erythropoietin and the extracellular ligand-binding domain of the erythropoietin receptor is held together by two regions located on opposite faces of erythropoietin. These erythropoietin-receptor interfaces on erythropoietin have been identified as high-affinity and low-affinity binding sites.1
References
Syed RS, Reid SW, Culwel Li, et al. Efficiency of signaling through cytokine receptors depends critically on receptor orientation. Nature. 1998;395:
Cheung JY, Miller BA. Molecular mechanisms of erythropoietin signaling. Nephron. 2001;87:
Elliott S, Lorenzini T, Barzilay J, Chang D, Delorme E. Mapping of the active site of recombinant human erythropoietin. Blood. 1997;89:
Elliott S, et al. Blood 89: , 1997
Syed RS, et al. Nature 395: , 1998 3

4. The ideal ESA Effective Safe Flexible administration route
Less frequent administration schedule
Cheap
Key points
Despite years of using erythropoiesis-stimulating agents (ESAs) there is still room to improve the pattern of practice in the treatment of anaemia
It is possible to optimize the use of ESAs by careful selection of the type of ESA used, the best route of administration and the frequency of administration
It is also posssible to consider potential cost-savings associated with the use of the different ESAs available in the market

5. Currently available ESAs
Recombinant human erythropoietin (rHuEPO)
Epoetin alfa
Epoetin beta
Long-acting ESAs
Darbepoetin alfa
Different molecular structure
Increased biological activity
Key points
Currently available erythropoiesis-stimulating agents (ESAs): epoetin alfa, epoetin beta, epoetin delta and darbepoetin alfa
Darbepoetin alfa has been engineered to contain five N-linked carbohydrate chains (two more than recombinant human erythropoietin [rHuEPO])
Compared with rHuEPO, darbepoetin alfa has a longer serum half-life (approximately three-fold) and greater in vivo potency, even though it has a lower affinity for the erythropoietin receptor
Darbepoetin alfa can, therefore, be administered less frequently to obtain the same biological response
Background
There is a direct relationship between the ESA molecule's sialic acid-containing carbohydrate content and its serum half-life and in vivo biological activity, but an inverse relationship with its receptor-binding affinity
Increasing the carbohydrate content should, therefore, lead to a molecule with enhanced biological activity
Hyperglycosylated rHuEPO analogues such as darbepoetin alfa, were, therefore, developed
Reference
Egrie JC et al. Br J Cancer 2001;84(1):3–10
CERA
Different mechanism of action
Different molecular structure
Increased biological activity

6. Biochemical and biological properties of rHuEPO and glycosylation analogs
Receptor binding
rHuEPO
3 N-linked carbohydrate chains
Up to 14 sialic acids
30,400 daltons
~40% carbohydrate
4 N-linked carbohydrate chains
Up to 18 sialic acids
33,750 daltons
~46% carbohydrate
Biological activity
Serum half-life
NESP
5 N-linked carbohydrate chains
Up to 22 sialic acids
37,100 daltons
~51% carbohydrate
The 4- and 5-N linked chain glycosylation analogs of rHuEPO are biochemically distinct from rHuEPO. They have increased molecular weight, sialic acid content and negative charge. The two extra carbohydrate chains on Aranesp® increase the molecular weight by about 22% and the maximum number of sialic acid residues from 14 to 22.
In tests of in vivo efficacy, the magnitude of the hematocrit rise correlated with the number of carbohydrate chains and the sialic acid content of the molecules.
Egrie JC, Browne JK. Nephrol Dial Transplant. 2001;16(suppl 3):3-13

7. Hb concentrations at 4-week intervals7 8 9 10 11 12 13 14 15
rHuEPO
NESP
Hb (g/dL)
Patient numbers: 37 35 35 33 34 33 31
rHuEPO
NESP
129
128
127
127
123
121
106 77 51 25 1 5 9 13 17 21 37 49
Study week
Locatelli F et al. Kidney Int 2001; 60:

9. Weeks since withheld dose
Time for Hb to return to £12 g/dL after dose withheld due to Hb >14 g/dL 16
rHuEPO (n = 13)
NESP (n = 31) 15 14 13
Hb (g/dL) 12 11 10 9 –6 –5 –4 –3 –2 –1 1 2 3 4 5 6 7 8 9 10 11
Weeks since withheld dose
Locatelli F et al. Kidney Int 2001; 60:

10. Percentage of Hb values >14 g/dL Mean % of Hb values > 14 g/dL
DA administration Q2W was not associated with an increased frequency of Hb >14 g/dL
Percentage of Hb values >14 g/dL 5 4 3 2 1
2.6
Mean % of Hb values > 14 g/dL
1.3
Key points
Patients who switched to the darbepoetin alfa once-every-2-week (Q2W) regimen were less likely to experience haemoglobin (Hb) levels above 14 g/dL, compared with the once-weekly (QW) patients:
Proportion of patients (95% CI) with Hb levels >14 g/dL was 1.3% (0.28, 2.22) for Q2W patients and 2.6% (1.33, 3.86) for QW patients
Reference
Locatelli F et al. Nephrol Dial Transplant 2006;21(Suppl 4):SP411 abstract and poster
Q2W (n=153)
QW (n=153)
Locatelli F et al. Nephrol Dial Transplant 2005;20 S.5:MP181

11. 16 (10) 2007

12. Serum half life of ESAs IV SC Agent Population
Mean (± SE) half-life (h) IV SC
Epoetin alfa
Healthy volunteers1
6.8 ± 0.6
19.4 ± 2.5
Epoetin beta
8.8 ± 0.5
24.2 ± 2.6
Darbepoetin alfa
Peritoneal dialysis patients2
25.3 ± 2.2
48.8 ± 5.2
C.E.R.A.
Healthy volunteers3
133 ± 9.8
137 ± 21.9
Peritoneal dialysis patients4
134 ± 19
139 ± 20
Pharmacokinetic properties of ESAs in healthy volunteers and peritoneal dialysis patients
In healthy volunteers and patients with chronic kidney disease (CKD) receiving peritoneal dialysis, C.E.R.A. has a prolonged and comparable half-life of approximately 130 h following IV and SC administration.
This is considerably longer than the half-lives reported for epoetin (alfa and beta) and darbepoetin alfa. C.E.R.A’.s prolonged serum half-life suggests that it can be administered at extended intervals.
1. Halstenson et al. Clin Pharmacol Ther. 1991:50:
2. Macdougall et al. J Am Soc Nephrol. 1999;10:
3. Dougherty et al. ASCO Macdougall et al. ASN 2005
Halstenson CE et al. Comparative pharmacokinetics and pharmacodynamics of epoetin alfa and epoetin beta. Clin Pharmacol Ther. 1991;50:
Macdougall IC et al. Pharmacokinetics of novel erythropoiesis stimulating protein compared with epoetin alfa in dialysis patients. J Am Soc Nephrol. 1999;10:
Dougherty FC et al. C.E.R.A. (Continuous Erythropoiesis Receptor Activator): dose-response, pharmacokinetics and tolerability in phase I multiple ascending dose studies. J Clin Oncol 2004, 22:(Suppl 15)14S (abstract 6692).
Macdougall IC et al. Pharmacologic profile of C.E.R.A. (Continuous Erythropoietin Receptor Activator) in chronic kidney disease (CKD) patients (pts) following intravenous (IV) and subcutaneous (SC) administration. Poster presented at 38th Annual Meeting of the American Society of Nephrology, November 8-13, 2005 (J Am Soc Nephrol. 2005;16:[abstract SA-PO926]).

13. Understanding how C.E.R.A. is different
Receptor binding
properties
Pharmacokinetic
properties
CERA is different to other erythropoietic stimulating agents (ESAs), having different receptor binding properties.
Different pharmacologic profile

15. Administration schedule
C.E.R.A: Dose independent of schedule Core study, PP population, n=124 (BA16286)
Mean (SE) change in Hb (g/dL) at 6 wk
n.s. QW
Q3W
Q4W
-1.5
-1.0
-0.5
0.0
0.5
1.0
1.5
Administration schedule
Locatelli et al. Curr Med Res Opin 2007;23:969–979

16. Primary efficacy analysis C. E. R. A
Primary efficacy analysis C.E.R.A. up to once-monthly as effective as epoetin TIW-QW
Non-inferiority limit: C.E.R.A. groups vs epoetin
0.004
-0.215
0.223
C.E.R.A. Q2W
ITT
-0.213
0.031
0.276
0.025
0.270
-0.220
C.E.R.A. Q2W
C.E.R.A. Q4W PP
-0.173
0.275
0.051
C.E.R.A. Q4W
eheanc11_1001 Table 20 page 84 CSR
eheanc11_4001 Table 21 page 85 CSR
For the non-inferiority test, the mean change in Hb between the baseline and evaluation periods was assessed for C.E.R.A. 1x/2 weeks and 1x/4 weeks and adjusted relative to the mean change in Hb between the baseline and evaluation periods for epoetin. The lower limits of 97.5% confidence interval for the mean difference in Hb between baseline and evaluation periods between the treatment groups for the C.E.R.A. 1x/2 weeks and 1x/4 weeks were both greater than ‑0.75 g/dL, indicating that both C.E.R.A. 1x/2 weeks and 1x/4 were clinically non-inferior to the epoetin reference group.
-1.00
-0.75
-0.50
-0.25
0.00
0.25
0.50
0.75
1.00
Difference in adjusted group mean Hb (g/dL) change between baseline and evaluation (97.5% CI)
P< for all comparisons
Levin NW et al. Lancet 2007, 370 (9596): 16

17. IV C.E.R.A. once- and twice-monthly maintains stable Hb over one year4 8 12 16 20 24 28 32 36 40 44 48 52
C.E.R.A. Q2W IV
C.E.R.A. Q4W IV
Epoetin TIW-QW IV
Mean (SD) Hb (g/dL)
Months
Weeks
ehe11p_4170
Stable Hb levels continued to be maintained with C.E.R.A. throughout the year-long study. Results are shown for the ITT population.
Reference
Levin NW, Fishbane S, Zeig S, Nassar G, Moran J, Villa G, Dougherty FC. Intravenous (IV) C.E.R.A. (Continuous Erythropoietin Receptor Activator) administered once every 2 weeks or once monthly maintains haemoglobin (Hb) levels in patients with chronic kidney disease (CKD) on dialysis. Nephrol Dial Transplant. 2006;21(Suppl 4):iv11 (abstract SO023).
Levin NW et al. Lancet 2007, 370 (9596): 17

18. SC C.E.R.A. once-monthly and twice-monthly as effective as epoetin 3x/wk PROTOS: primary efficacy analysis (PP population)
Non-inferiority lower 97.5% CI limit
0.141
0.380
C.E.R.A. 1x/2wk
0.217
C.E.R.A. 1x/4wk
eheanc11_1001 Table 20 BA16740 section efficacy CE
eheanc11_4001 Table 21 BA16740 section efficacy CE
- 1.00
- 0.75
- 0.50
- 0.25
0.00
0.25
0.50
0.75
1.00
Difference in mean adjusted Hb versus epoetin (g/dL)
P < for all comparisons
Sulowicz, Locatelli Clin J Am Soc Nephrol Jul;2(4):637-46

19. Stable Hb maintenance with once-monthly SC C. E. R. A
Stable Hb maintenance with once-monthly SC C.E.R.A. PROTOS: ITT population
Mean (SD) Hb (g/dL)
C.E.R.A. 1x/2wk
C.E.R.A. 1x/4wk
Epoetin 1-3x/wk
Conversion to IV C.E.R.A. once monthly maintains steady Hb levels
ehe11p_4170
Months
Weeks 4 8 12 16 20 24 28 32 36 40 44 48 52
Sulowicz, Locatelli Clin J Am Soc Nephrol Jul;2(4):637-46

20. IV C.E.R.A. twice-monthly as effective as darbepoetin 1x/wk STRIATA: primary efficacy analysis (PP population)
Non-inferiority lower 95.0% CI limit
0.180
-0.049
0.408
0.180
P <
0.408
eheanc11_1001
eheanc11_4001
<<Slide to be animated>>
- 1.00
- 0.75
- 0.50
- 0.25
0.00
0.25
0.50
0.75
1.00
Difference in mean adjusted Hb (g/dL)
Canaud….Locatelli et al. ERA - EDTA 2006
Canaud….Locatelli et al. Advance Access Published Nephrol Dial Transplant Jul 31

21. Stable Hb maintenance with twice-monthly IV C. E. R. A
Stable Hb maintenance with twice-monthly IV C.E.R.A. STRIATA: ITT Population
Mean (SD) Hb (g/dL)
C.E.R.A. 1x/2wk
Darbepoetin 1x/wk
Conversion to IV C.E.R.A. once monthly maintains steady Hb levels
ehe11p_4170
Months
Weeks 4 8 12 16 20 24 28 32 36 40 44 48 52
Canaud….Locatelli et al. ERA - EDTA 2006
Canaud….Locatelli et al. Advance Access Published Nephrol Dial Transplant Jul 31

22. SC C.E.R.A.: Smooth and steady Hb increase with a high response rate ARCTOS: ITT population
Mean (SD) Hb (g/dL)
Response rate (%)
95% CI
C.E.R.A. 1x/2wk
97.5
Darbepoetin alfa 1x/wk
96.3 16
C.E.R.A. 1x/2wk
Darbepoetin alfa 1x/wk 15 14 13 12 11 10 9 8 7
Months BL 1 2 3 4 5 6
Final visit
Weeks 4 8 12 16 20 24
Macdougall, … Locatelli et al. Clin J Am Soc Nephrol Mar;3(2):337-47

23. Hb concentrations during 24-week intervals
Locatelli F et al. Kidney Int 2001; 60:
Macdougall, … Locatelli et al. Clin J Am Soc Nephrol Mar;3(2):337-47
Mean (SD) Hb (g/dL) 16 15
C.E.R.A. 1x/2wk 14
Darbepoetin alfa 1x/wk 13
rHuEPO 12 11 10 9 8 7
Months BL 1 2 3 4 5 6
Final visit
Weeks 4 8 12 16 20 24

24. Fewer patients exceed Hb 13 g/dL with C. E. R. A
Fewer patients exceed Hb 13 g/dL with C.E.R.A. than with darbepoetin alfa ARCTOS: ITT population 40
P < 30
Patients (%)* 20 10
C.E.R.A. 1x/2wk
Darbepoetin alfa 1x/wk
*Patients with ≥1 Hb value >13 g/dL during first 8 weeks
Macdougall, … Locatelli et al. Clin J Am Soc Nephrol Mar;3(2):337-47

25. Weeks since treatment interruption
Decline in Hb after withholding treatment Long C.E.R.A. half-life does not affect Hb decline following dose interruption – pooled analysis of maintenance studies
Mean (SD) Hb (g/dL)
C.E.R.A. Q4W (n=59) 16
Epoetin (QW to TIW) or darbepoetin alfa (QW or Q2W) (n=126) 15 14 13 12 11 10 -3 -2 -1 1 2 3 4 5 6
Weeks since treatment interruption
(time 0)
Safety populations
Locatelli F. et al Kidney Intern. S : Heifets & Dougherty. WCN 2007

26. Half life comparison 140 120 SC IV 100 Hours 80 60 40 20
Methoxy polyethylene glycol-epoetin beta’s half-life is much longer than that of darbepoetin alfa
137 h vs 38 h when given SC
133 h vs 25 h when given IV
140
120 SC
100 IV 80
Hours 60 40
CERA’s half-life is much greater than that of darbepoetin alpha (Aranesp®):
137 hours compared to 38 hours when injected SC
133 hours compared to 25 hours when dosed IV 20
Epoetin
Epoetin
Darbepoetin
Methoxy polyethlene glycol-epoetin beta
alfa
beta
alfa
Halstenson. Clin Pharmacol Ther. 1991;50:702
Macdougall. J Am Soc Nephrol. 1999;10:23925
Reigner. Nephrol Dial Transplant. 2003;18(suppl 4):167 Abstract M527

27. Half life of epoetins t (hours) Intravenous Subcutaneous 6.8* 19.4*
*Healthy volunteers
†Peritoneal dialysis patients t
(hours)
Intravenous
Subcutaneous
Epoetin alfa
6.8*
19.4*
Epoetin beta
8.8*
24.2*
Darbepoetin alfa †
25.3
48.8
3:1
2:1
Methoxy polyethylene glycol-epoetin beta
130
133
1:1
Hematide 75
~80
Halstenson. Clin Pharmacol Ther. 1991;50:702
Macdougall. J Am Soc Nephrol. 1999;10:2392
Reigner. Nephrol Dial Transplant. 2003;18(suppl 4):167. Abstract M527
Woodburn. Blood. 2004;104:2904

28. Ht response to EPO or placebo in PD patients
Nissenson AR et al. J Am Soc Nephrol 5: , 1995

29. Cosa può influenzare la scarsa risposta agli ESAs in DP?
* ERI: EPO resistance index
Wei M, et al. Int Urol Nephrol. 2007;39(3):

30. ESAs in dialisi peritoneale
Sono stati condotti pochi trials sull'uso degli ESA's nei pazienti in dialisi peritoneale
La via di somministrazione di ESAs in dialisi peritoneale deve, per ragioni pratiche, essere SC
Le dosi di ESAs necessarie per mantenere livelli di Hb nel range suggerito dalle linee guida in dialisi peritoneale sono ridotte rispetto ai pazienti in emodialisi

31. Open-label study description* Treatment + evaluation period
Once monthly (QM) dosing of darbepoetin alfa was effective in CKD patients not on dialysis
Reference
Open-label study description*
Treatment + evaluation period
Hb study target range
Primary endpoint
Ling1
n=98
Q2W DA → QM DA
29 weeks
10-12 g/dl
% of patients within Hb study target range
Agarwal2
n=152
33 weeks
11-13 g/dl
% of patients with Hb ≥11 g/dl
Disney3
n=66
10-13 g/dl
Maintaining mean Hb ≥10 g/dl
Sousa4
n=71
18 months
Effectiveness and safety of DA QM
Hoggard5
n=442
QW/Q2W rHuEPO → QM DA
28 weeks
% of patients converting from EA QW who preferred DA QM at week 21
Ling B, Walczyk M, Agarwal A, Carroll W, Liu W, Brenner R. Darbepoetin alfa administered once monthly maintains hemoglobin concentrations in patients with chronic kidney disease. Clin Nephrol 2005;63:
Agarwal AK, Silver MR, Reed JE, et al. An open-label study of darbepoetin alfa administered once monthly for the maintenance of haemoglobin concentrations in patients with chronic kidney disease not receiving dialysis. J Intern Med 2006;260:
Disney A, Jersey PD, Kirkland G, et al. Darbepoetin alfa administered monthly maintains haemoglobin concentrations in patients with chronic kidney disease not receiving dialysis: a multicentre, open-label, Australian study. Nephrology (Carlton) 2007;12:
Sousa American Society of Nephrology 2006; Abstract SA-PO218.
Hoggard J, Crouch T, McMurray S, et al. Preference for monthly darbepoetin alfa dosing in patients with chronic kidney disease not receiving dialysis. Curr Med Res Opin 2006;22:
1Ling B et al. Clin Nephrol 2005;63:327-34; 2Agarwal AK et al. J Intern Med 2006;260:577-85; 3Disney A et al. Nephrology (Carlton) 2007;12:95-101; 4Sousa American Society of Nephrology 2006; Abstract SA-PO218; 5Hoggard J et al. Curr Med Res Opin 2006;22:

32. Limited evidence with once-monthly dosing
Drug
Administration interval (route of administration)
Target Hb (g/dL)
Population (no. patients enrolled)
Trial design
Reference
Epoetin alfa
QW, Q2W Q3W, Q4W (SC)
≥11
CKD not on dialysis (n=519)
Randomised
Provenzano et al 2005
Darbepoetin alfa
Q4W (SC)
10-12
CKD not on dialysis (n=97)
Single arm, non-randomised
Ling et al 2005
≥10
CKD not on dialysis (n=66)
Disney et al 2007
CKD not on dialysis (n=152)
Agarwal et al 2006
Q3W, Q4Wa (IV and SC)
10-13
Dialysis patients (n=54)
Jadoul et al 2004
ESAs, erythropoiesis-stimulating agents; Hb, haemoglobin; IV, intravenous; SC, subcutaneous
aDosing once a month is not indicated for darbepoetin alfa in dialysis, except in Switzerland 32

33. Limited evidence of efficacy in HD patients for once-monthly darbepoetin alfaa
Hb (g/dL)
Dose (g/wk)
Patients on darbepoetin alfa Q2W converted to Q3W dosing and, if Hb stable (10-13 g/dL), to Q4W dosinga
522 patients originally recruited
Limited conversion to Q4W dosinga: Of 54 patients entering the study, 36 patients were converted to Q4W dosing
Limited maintenance on Q4W dosinga: Of 36 patients converting to Q4W dosing, 30 patients maintained Hb >10 g/dL over 20 weeks Hb
13.0
100
Dose
12.5
Q3W dosing (n=44)
Q4W dosinga (n=30) 80
12.0
11.5 60
11.0 40
10.5
10.0 20
9.5
9.0 –2 4 8 12 16 20 26 30 34 38 42
Study week
aDosing once a month is not indicated for darbepoetin alfa in dialysis, except in Switzerland
Jadoul et al. Nephrol Dial Transplant 2004;19:

34. Labelled dosing information on maintenance therapy dosing interval
MIRCERA
Once-monthly maintenance dosing in CKD patients on dialysis and not on dialysis
Darbepoetin alfa
In HD patients
Once weekly or once every 2 weeks maintenance dosing
In Switzerland in selected HD patients, also once monthly
In CKD patients not on dialysis
Stepwise expansion from QW over Q2W to QM for those patients stable on previous dose interval and by doubling the dose
CKD, chronic kidney disease; HD, haemodialysis; QW, weekly; Q2W, every 2 weeks; QM, once monthly
ARANESP, Summary of Product Characteristics, 2006; MIRCERA, Summary of Product Characteristics, 2007

35. The PATRONUS study: a randomised comparison of the efficacy and safety of MIRCERA® with darbepoetin alfa using once-monthly dosing in haemodialysis patients 35

36. PATRONUS study objectives
Primary
To compare the efficacy of once-monthly IV MIRCERA® with that of darbepoetin alfa* in the maintenance of Hb levels in HD patients with chronic renal anaemia previously receiving IV darbepoetin alfa maintenance therapy
Secondary
To assess the safety and tolerability of IV MIRCERA® in HD patients with chronic renal anaemia previously receiving IV darbepoetin alfa maintenance treatment
* Darbepoetin alfa is not licensed for once monthly treatment in dialysis in the UK. 36

37. PATRONUS compared once-monthly MIRCERA® and darbepoetin alfa maintenance treatment
Evaluation (wk 50-53)
Screening period
MIRCERA® 1x/month (n=245)
MIRCERA® 1x/month
Primary end point
Darbepoetin alfa 1x/week R
Darbepoetin alfa 1x/2 weeks (n=245)
Darbepoetin alfa* 1x/month
4 weeks
26 weeks
26 weeks
R, randomisation
* Darbepoetin alfa is not licensed for once monthly treatment in dialysis in the UK.

38. PATRONUS primary end point
Primary end point: superiority assessment of the difference in the proportion of responders between groups
Responders are patients with an average Hb decrease from baseline of <1.0 g/dL and an average Hb >10.5 g/dL during evaluation
Study was powered to detect an absolute difference of 15% in the primary end point between the 2 treatment groups
Assumed 60% of patients would respond to MIRCERA® vs 45% to darbepoetin alfa
Target Hb range: 11–13 g/dL
* Darbepoetin alfa is not licensed for once monthly treatment in dialysis in the UK.

39. Analysis population
Primary efficacy analysis used the intent-to-treat population, defined as all randomised patients
In case of withdrawals, the last Hb value in the second treatment period was used for the Hb assessment (last value carried forward)
To correct for any increase in Hb caused by RBC transfusion, the Hb values measured within 3 weeks after a transfusion were replaced by the Hb value measured immediately before the transfusion
Safety population included all patients who received >1 dose of MIRCERA® or darbepoetin alfa
RBC, red blood cell
* Darbepoetin alfa is not licensed for once monthly treatment in dialysis in the UK.

40. Darbepoetin alfa to MIRCERA® dose conversion schedule
Weekly darbepoetin alfa dose (g/week)
MIRCERA® starting dose (g/month)
<40
120
40–80
200
>80
360
* Darbepoetin alfa is not licensed for once monthly treatment in dialysis in the UK. 40

41. Darbepoetin alfa starting doses
Two changes needed:
Double Week – 1 dose
Double Week 25 dose
Week 1
Week 27
4 week baseline period
26 weeks
26 weeks
* Darbepoetin alfa is not licensed for once monthly treatment in dialysis in the UK.

42. PATRONUS: A multicentre, multinational trial
Country
Patients enrolled
France 95
Italy 86
Spain 80
Canada 65
Germany 33
Belgium 31 UK 22
Portugal 21
Australia 15
Austria
Switzerland 11
Finland 9
Denmark 7
Total
490
* Darbepoetin alfa is not licensed for once monthly treatment in dialysis in the UK.

43. Baseline patient characteristics
MIRCERA®
n=245
Darbepoetin alfa
Male, n (%)
148 (60)
156 (64)
Race, n (%)
Caucasian
233 (95)
225 (92)
Black
5 (2)
12 (5)
Other
7 (3)
8 (3)
Mean age, years (SD)
66.2 (13.6)
65.5 (13.9)
Mean weight, kg (SD)
72.3 (15.1)
73.8 (16.9)
Mean baseline Hb, g/dL (SD)
12.09 (0.56)
12.07 (0.55)
Mean time since first dialysis, years (SD)
4.20 (5.92)
4.15 (5.55)
Dosing
Median darbepoetin alfa dose at week before randomisation, g (IQR)
30.0 (20-40)
20.0 (15-40)
Median study drug dose in month 1, g/month (IQR)
120.0 ( )
100 (60-160)
SD = standard deviation; IQR = Interquartile Range

44. Once-monthly MIRCERA® exhibited a superior response rate compared with once-monthly darbepoetin alfa*
Primary end point *
*P<0.0001
64.1%
64.1%
Response rate (%)
40.4%
40.4%
CI, confidence interval
* Darbepoetin alfa is not licensed for once monthly treatment in dialysis in the UK. 44

45. Superiority limit: MIRCERA® vs darbepoetin alfa
Once-monthly MIRCERA® shows a 59% higher likelihood of response compared with once-monthly darbepoetin alfa*
Primary end point
Superiority limit: MIRCERA® vs darbepoetin alfa
1.59*
1.33
1.90
−0.75
1.00
1.25
1.50
1.75
2.0
Relative risk of response at evaluation for MIRCERA® vs darbepoetin alfa
*P<0.0001
* Darbepoetin alfa is not licensed for once monthly treatment in dialysis in the UK. 45

46. Weeks (of trial treatment)
Only once-monthly MIRCERA® maintained Hb levels during the second 26-week treatment period
Evaluation (wk 50-53)
16.0
MIRCERA® (median, IQR)
Darbepoetin alfa (median, IQR)
15.0
14.0
13.0
12.0
Median Hb value (g/dL)
11.0
10.0
9.0
8.0
7.0
Baseline 4 8 12 16 20 24 28 32 36 40 44 48 52
Weeks (of trial treatment)

47. Darbepoetin alfa dose increased by >30% during the second 26-week treatment period
Secondary end point
Median (IQR) treatment dose, g/month
MIRCERA®
n=211
Darbepoetin alfa
n=219
Week 27
200 ( )
150 (80-280)
Months 11 and 12
196 ( )
225 ( ) 0%
+35%
The median MIRCERA® dose was virtually unchanged during the second 26-week treatment period whereas darbepoetin alfa substantially increased by 35%
* Darbepoetin alfa is not licensed for once monthly treatment in dialysis in the UK. 47

48. MIRCERA® dose was unchanged during the second 26-week treatment period
150
MIRCERA (median, IQR)
Darbepoetin alfa (median, IQR)
Secondary end point
125
100 75
Trial treatment dose change (%) 50 25
−25
−50 7 8 9 10 11 12
Months (of trial treatment)
* Darbepoetin alfa is not licensed for once monthly treatment in dialysis in the UK.

49. Most safety parameters were similar between the two PATRONUS study groups
MIRCERA®, n (%)
n=245
Darbepoetin alfa, n (%)
n=244
AEs
222 (90.6)
217 (88.9)
SAEs
99 (40.4)
94 (38.5)
AEs leading to withdrawals
3 (1.2)
7 (2.9)
Withdrawals
58 (23.7)
96 (39.3)
Withdrawals due to insufficient response
10 (4.1)
48 (19.7)
Deaths*
14 (5.7)
*includes 3 patients who died after withdrawal due to other events
AEs, adverse event; SAEs, serious adverse events
Similar incidence of AEs in both study arms
higher rate of constipation with MIRCERA®
Most common AEs in both arms were hypertension (14.7 vs 10.7%), procedural hypotension (8.6 vs 11.1%) and nasopharyngitis (10.2 vs 8.2%)
Fewer withdrawals with MIRCERA® than with darbepoetin alfa
* Darbepoetin alfa is not licensed for once monthly treatment in dialysis in the UK. 49

50. SAEs (>5% in either group) were comparable between study groups in PATRONUS
MIRCERA®
n=245 n (%)
Darbepoetin alfa
n=244 n (%)
All body systems
99 (40.4)
94 (38.5)
Infections and infestations
29 (11.8)
27 (11.1)
Injury, poisoning and procedural complications
26 (10.6)
18 (7.4)
Cardiac
16 (6.5)
16 (6.6)
Vascular
14 (5.7)
Gastrointestinal
11 (4.5)
Nervous system
7 (2.9)
13 (5.3)
Neoplasms
10 (4.1)
5 (2.0)
Metabolism and nutrition
4 (1.6)
Respiratory, thoracic and mediastinal
* Darbepoetin alfa is not licensed for once monthly treatment in dialysis in the UK. 50

51. Clinical Nephrology, Vol 73 – n 2/2010 (94-103)

52. Conclusions
MIRCERA® was shown to be superior to darbepoetin alfa as once-monthly treatment in the dialysis setting
Significantly more patients responded with MIRCERA® compared with darbepoetin alfa
MIRCERA® maintained Hb levels within a tight target range during the second 26-week treatment period
Mean Hb levels for patients receiving darbepoetin alfa fell to below the lower target (11 g/dL) over the same 26-week period, despite substantial dose increases
This is the first large, randomised, prospective head-to-head study that has shown one ESA to offer superior efficacy compared with another
Carrera F et al. WCN 2009 Milano, poster M558
* Darbepoetin alfa is not licensed for once monthly treatment in dialysis in the UK.

53. Hb (or at least high levels) vs ESA (or at least high levels)