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Qualitative Research Quantitative Research Profiles MedPanel, Inc., 44 Brattle St., Cambridge, MA 02138 617-661-8080 www.medpanel.com KNOWLEDGE CAPTURED.

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Presentation on theme: "Qualitative Research Quantitative Research Profiles MedPanel, Inc., 44 Brattle St., Cambridge, MA 02138 617-661-8080 www.medpanel.com KNOWLEDGE CAPTURED."— Presentation transcript:

1 Qualitative Research Quantitative Research Profiles MedPanel, Inc., 44 Brattle St., Cambridge, MA 02138 617-661-8080 www.medpanel.com KNOWLEDGE CAPTURED. INTELLIGENCE DELIVERED. Evaluation of Tysabri (EU) By MedPanel, Inc. September 19, 2006

2 1 Contents Project Objectives2 Methodology & Sample3 Respondent Practice Background4-6 Executive Summary7-11 Detailed Findings12-43 MS Treatment Patterns13-16 Tysabri17-24 PML25-35 Future Practice Patterns36-43

3 2 Study Objectives Specific Objectives: Identify current patient populations and treatments for multiple sclerosis (MS) Determine current and anticipated future use of Tysabri Distinguish the target population for Tysabri in both countries using Tysabri (Germany and the United Kingdom) and countries anticipating its future use (Italy, Spain, and France) Understand the risk of progressive multifocal leukoencephalopathy (PML) as a side effect of Tysabri use Clarify anticipated future treatment regimens for relapsing remitting MS patients

4 3 Survey Specifics: A 20-minute, self-administered survey was fielded online via MedPanels Web site from September 8-19, 2006. Sample: The total sample comprises 46 neurologists. Respondents were selected from MedPanels international database 12 neurologists from Italy, Spain, and France 34 neurologists from Germany and the United Kingdom Methodology & Sample

5 4 Respondent Practice Background Mean Number of Current Patients with Multiple Sclerosis (n=46) S3. Approximately how many years have you been in practice since completing your residency? S4. Approximately what % of your professional time is dedicated to clinical practice? S5. Approximately how many patients do you currently manage who have or have had a diagnosis of multiple sclerosis (MS)? On average, neurologists from Germany and the UK reported managing more than twice as many MS patients as did neurologists in Italy, Spain, and France. Years in Practice: IT/SP/FR: 13.6 (Range: 6-25) GE/UK: 9.7 (2-21) % Time in Clinical Practice: IT/SP/FR: 86% (70%-100%) GE/UK: 82% (60%-100%)

6 5 Mean Number of Patients Dosed with Tysabri (n=34) S6. Approximately how many patients have you, or your center dosed commercially with Tysabri to since it was approved and marketed in your country? S7. Which of the following describes your primary practice setting? Neurologists from Germany and the UK reported that they have commercially dosed an average of 23 patients with Tysabri since its approval. Almost all of the neurologists work in an urban setting. Primary Practice Setting (GE/UK) (n=34) Primary Practice Setting (IT/SP/FR) (n=12) Respondent Practice Background

7 6 S8. Please describe the practice setting in which you see the majority of your MS patients. About two-thirds of the neurologists in Italy, Spain, and France, and 88% of the neurologists in Germany the UK, work in an academic medical center. Respondent Practice Background Practice Setting (n=34) Practice Setting (n=12) GE/UK IT/SP/FR

8 7 Executive Summary

9 8 Current MS Treatment Patterns The groups differed in how many total patients and MS patients they see in a typical month Neurologists in Germany and the UK had a mean of 218 total patients and 66 MS patients in a typical month while Italian, Spanish, and French neurologists reported an average of 127 total patients and 23 MS patients seen in a typical month. Relapse remitting patients were the most frequently reported MS patients being treated by Italian, Spanish, and French neurologists Secondary progressive patients were the most frequently reported MS patients in Germany and the United Kingdom Avonex (in Italy, Spain, and France) and Rebif (in Germany and the UK) were reported as the most commonly used treatments for relapse remitting patients Tysabri Use Neurologists in Germany and the UK indicated that they have used Tysabri on an average of about 13 patients since it was approved Tysabri is currently most frequently used as a second- or third-line treatment Rebif was indicated as the treatment that neurologists have most frequently switched their patients from to Tysabri Mitoxantrone was selected most frequently as the second-line treatment that would be used after failure of a first medication if Tysabri was not available

10 9 Executive Summary Tysabri Use (contd) Neurologists reported that patients are more likely to be eligible for Tysabri use if it is used as a second line of treatment than if it is used as a first-line treatment Neurologists didnt show a preference for using Tysabri indefinitely versus using it for a specified period of time Neurologists from the UK and Germany expect typical Tysabri use to last an average of 38 months per patient, which significantly longer than the 23 months predicted by Italian, Spanish, and French neurologists More than half of the neurologists in Germany and the UK indicated that premium pricing will result in limited use of Tysabri while very few of the neurologists in Italy, Spain, and France felt that premium pricing would result in any limited use Neurologists indicated that about 30% of relapsing remitting MS patients request Tysabri and that about 20% of relapsing remitting MS patients will not receive Tysabri because of patient refusal PML Neurologists in Italy, Spain, and France reported that they require patient check-ups for MS patients every 6 months while neurologists in Germany and the UK indicated that they require these check-ups every 5 months PML monitoring: Neurologists reported that they would use other monitoring types most frequently Neurologists in Italy, Spain, and France reported that follow-up MRIs are most likely to occur 6 months after the initial infusion Neurologists in Germany and the UK indicated that these follow-up MRIs would most likely occur every 6 months thereafter.

11 10 Executive Summary PML Risk Most (68%) Italian, Spanish, and French neurologists indicated extreme concern while most (56%) neurologists in the UK and Germany only reported being somewhat concerned about the risk of PML Both groups of neurologists felt that there is more risk for PML when Tysabri is used in combination with other treatments than when it is used as a monotherapy Neurologists in the UK and Germany found it more believable that an MRI scan, CSF testing, and frequent neurological assessments would be sufficient for PML detection than did Italian, Spanish, and French neurologists. PML Education Neurologists in Germany and the UK rated Biogen Idec/Elan highly (3.3 on a 5 point scale) in how well they educate neurologists for minimizing morbidity and mortality due to PML and for distinguishing between PML and MS relapse Neurologists in Italy, Spain, and France feel that the level of education isnt as high PML Effect on Tysabri Use A little more than half neurologists in the UK and Germany indicated that 2-5 cases of PML would impact Tysabri usage while half of neurologists in Italy, Spain, and France claimed that 5-20 cases would have an impact

12 11 Executive Summary Future Practice Rebif and Avonex were reported as the treatments that currently are used most frequently and will be used the most 4 and 12 months from now for relapsing remitting MS patients Currently a very small majority of Italian, Spanish, and French neurologists indicated that they would use Tysabri only as a salvage therapy In the next 12 months, they reported that Tysabri would be more frequently used as a first- or second-line treatment Neurologists in the UK and Germany indicated that Tysabri currently is used most frequently as a third-line treatment. In 12 months, they believe it will be used mostly as a second- or third-line treatment Neurologists in Italy, Spain, and France stated that they would most likely have been using Betaseron before switching to Tysabri currently, in the next 4 months, and in 12 months Neurologists from Germany and the UK indicated that they would most likely have been using Rebif before switching to Tysabri currently, in the next 4 months, and in the next 12 months

13 12 Detailed Findings

14 13 MS Treatment Patterns

15 14 German neurologists and neurologists from the United Kingdom reported seeing an average of 218 patients a month with 66 MS patients per month. Italian, Spanish, and French neurologists report an average of 127 total patients and 23 MS patients per month. Q1. How many total patients, regardless of condition, do you see in a typical month? Q2. Of these patients you see in a typical month, how many have MS? Mean Number of Total Patients Seen in a Typical Month (n=46) Survey Details MS Treatment Patterns Mean Number of MS Patients Seen in a Typical Month (n=46)

16 15 Out of all of the MS patient classifications, relapse-remitting MS patients were reported as the most common MS patients in Italy, Spain, and France. Secondary progressive were most common in Germany and the UK. Q3. Approximately how many and what percent of your MS patients fall under the following classifications? Survey Details MS Treatment Patterns MS Patient Classifications (n=46) DiagnosisMean Number of MS PatientsMean % of MS Patients IT/SP/FRGE/UKIT/SP/FRGE/UK Relapse-Remitting 14.8 (Range: 0-45) 28.2 (Range: 2-120) 48% (Range: 0-85%) 44% (Range: 10%-75%) Secondary Progressive 11.3 (Range: 2-70) 30.4 (Range: 1-140) 26% (Range: 10%-45%) 38% (Range: 15%-70%) Primary Progressive 6.2 (Range: 1-30) 6.9 (Range: 1-30) 20% (Range: 4%-60%) 11% (Range: 5%-25% Other 5.7 (Range: 0-20) 17.0 (0-240) 6% (Range: 0-40%) 8% (Range: 0-25%)

17 16 Avonex was reported as the most frequently used treatment for relapse-remitting MS patients in Italy, Spain, and France while Rebif was reported as the most frequently used in Germany and the UK. Tysabri was reported as being used in an average of only 5% of relapse-remitting MS patients in Germany and the UK. Q4. Regarding your relapsing-remitting MS patients, what percentage of these patients currently receive the following treatments? Survey Details MS Treatment Patterns Treatment Mean % of Relapse-Remitting MS Patients (n=46) IT/SP/FRGE/UK Avonex30%17% Rebif24%22% Copaxone13%16% Betaseron11%18% No Treatment10%20% Mitoxantrone9% Methotrexate5%2% Other Immunosupressants4% Novantrone2% Cyclophosphamide2% Other1%4% Tysabri0%5%

18 17 Tysabri

19 18 Neurologists in the UK and Germany reported that they have dosed an average of 13 patients with Tysabri since it was approved. German and UK neurologists also reported that they anticipate dosing the drug more frequently than neurologists in Italy, Spain, and France in the next 4 months and the next 12 months. Q5. Approximately how many patients have you dosed commercially with Tysabri since it was approved and became available commercially in your country? Q6/Q5. Approximately how many additional patients do you expect to dose commercially with Tysabri in the next 4 months? Q7./Q6. Approximately how many additional patients do you expect to dose commercially with Tysabri in the next 12 months? Survey Details Tysabri Mean Patients Dosed with Tysabri (n=46) IT/SP/FRGE/UK Previously N/A 12.6 (Range: 0-130) Next 4 months 3.8 (Range: 0-15) 12.0 (Range: 0-60) Next 12 months 18.8 (Range: 0-100) 27.2 (Range: 3-100)

20 19 Patients who have failed one of the other MS therapies were reported as the group most frequently treated with Tysabri. MS patients who have had two or more failed treatments were reported as the highest percentage of relapse-remitting MS patients on Tysabri. Q8. Of the patients you currently treat with Tysabri, how have you distributed your use by line of therapy? MS Patients Currently Treated with Tysabri (GE/UK Only) (n=34) Treatment Mean Number of Relapsing Remitting MS Patients Mean % of Relapsing Remitting MS Patients First-Line (interferon, copaxone naïve) 0.9 (Range: 0-10) 5% (Range: 0-40%) After failure of one other MS therapy (interferon, copaxone) 11.0 (Range: 0-75) 31% (Range: 0-80%) After failure of two or more therapies (interferon, copaxone) 9.6 (Range: 0-50) 45% (Range: 0-100%) Only as salvage therapy 9.7 (Range: 0-100) 16% (Range: 0-100%) Survey Details Tysabri

21 20 Patients were most frequently switched from Rebif to Tysabri. Neurologists in Germany and the UK also reported that an average of about 3 patients on Betaseron had been switched to Tysabri. Q9. What treatment (if any treatment was being given previously) have you actively switched patients off of to put them on Tysabri? Patients Switching to Tysabri (GE/UK Only) (n=34) Treatment Mean Number of Relapsing Remitting Patients Switched From Mean % of Overall Tysabri Use Rebif 4.4 (Range: 0-20)27% (Range: 0-60%) Betaseron 2.9 (Range: 0-7)34% (Range: 0-100%) Copaxone 2.5 (Range: 0-10)24% (Range: 0-50%) Avonex 1.5 (Range: 0-5)21% (Range: 0-40%) Mitoxantrone 1.2 (Range: 0-5)10% (Range: 0-50%) Other Immunosupressants 0.9 (Range: 0-5)3% (Range: 0-10%) Methotrexate 0.7 (Range: 0-5)0% Other 0.4 (Range: 0-3)3% (Range: 0-20%) No Treatment 0.3 (Range: 0-1)20% (Range: 0-100%) Novantrone 0.2 (Range: 0-2)0% Cyclophosphamide 0.1 (Range: 0-1)1% (Range: 0-5%) Survey Details Tysabri

22 21 Mitoxantrone was the treatment identified most frequently as the therapy that would be prescribed after first- line failure if Tysabri was not available. Q10. If Tysabri were not available, which therapy would you have prescribed for non-responders after first-line failure? Second-Line Replacement Treatment for Tysabri (GE/UK Only) (n=34) TreatmentMean % of Relapsing Remitting MS Patients Mitoxantrone 30% (Range: 0-100%) Rebif 26% (Range: 0-70%) Copaxone 21% (Range: 0-50%) Avonex 16% (Range: 0-50%) Other Immunosupressants 15% (Range: 0-70%) Betaseron 11% (Range: 0-40%) Novantrone 11% (Range: 0-90%) No Treatment 9% (Range: 0-2%) Cyclophosphamide 8% (Range: 0-25%) Methotrexate 7% (Range: 0-25%) Other 5% (Range: 0-20%) Survey Details Tysabri

23 22 Neurologists in Germany, the UK, Italy, Spain, and France stated that second-line patients would more likely be eligible for Tysabri than first-line patients. Very minimal differences were reported for whether neurologists would use Tysabri indefinitely or with a pre-determined period of time. Q11/Q7. Tysabri is approved in the EU as a monotherapy in highly active relapsing remitting MS for patients with: A) highly active disease activity despite treatment with a beta-interferon or B) patients with rapidly evolving severe relapsing remitting MS. What percentage of each group would you estimate is eligible for Tysabri treatment (not immune-compromised/suppressed)? Q12/Q8. Tysabris EU label shows efficacy out to 2 years of treatment. For what percentage of patients would you plan to use Tysabri indefinitely (assuming it will work for the patient) vs. using for a pre-determined fixed time period? Mean Percent Eligible for Tysabri Treatment (n=46) Mean % of Patients for Tysabri Use (n=46) Survey Details Tysabri

24 23 Neurologists in Germany and the UK claimed that they treat patients with Tysabri for an average of 38 months while neurologists in Italy, Spain, and France treat patients with Tysabri for only 23 months. Q13/Q9. What do you expect will be the average duration you will treat a patient with Tysabri (assuming it will work for the patient)? Q14/Q10. Tysabri will likely be priced at a premium to other relapsing remitting MS treatments. Does this limit your usage of the therapy? Please comment. Mean Duration (Months) for Treating a Patient with Tysabri (n=46) Survey Details Tysabri Comments on Limited Use of Tysabri Due to Premium Pricing: IT/SP/FR:Does Limit: 8% Does not Limit: 92% No Limits: -Depends on Efficacy (5) -Reimbursed in eligible patients (1) GE/UK:Does Limit: 61% Does not Limit: 39% Limits: -There is a budget or limit in the German Healthcare system (8) -Cost (2) -No insurance coverage (2) No Limits: -Not an issue since it isnt a first-line Treatment (1) -I am working in an academic center (1)

25 24 Neurologists reported that about 30% of relapse-remitting MS patients request Tysabri and about 20% of the same patient group will not receive Tysabri due to patient refusal. Q15a/Q11a. In your best estimation, what % of the relapsing remitting MS patients request Tysabri? Q15b/Q11b. In your best estimation, what % of the relapsing remitting MS patients you recommend Tysabri to will not receive it due to patient refusal? Mean % of Relapse-Remitting MS Patients Who Request Tysabri (n=46) Survey Details Tysabri Mean % of Relapse-Remitting MS Patients Who Will Not Receive Tysabri Due to Patient Refusal (n=46)

26 25 PML (Progressive Multifocal Leukoencephalopathy)

27 26 Neurologists in Italy, Spain, and France indicated that they require patient check-ups an average of every 6 months while neurologists in Germany and the UK require these check-ups at an average of 5 months. Q16/Q12. On average, how frequently do you require patient check-up for relapsing remitting MS patients? Mean Frequency in Months for Requiring Patient Check-Up (n=46) Survey Details PML

28 27 Neurologists reported that they would use other monitoring types most frequently. In Germany and the United Kingdom, neurologists indicated that MRI monitoring would be second most frequent and in Italy, Spain, and France monitoring for opportunistic infections would be second most frequent. Q17/Q13. Please describe the frequency of your expected surveillance program for PML monitoring for patients in Tysabri? Mean Frequency (Months) of Expected Surveillance Program for PML Monitoring (n=46) FrequencyIT/SP/FRGE/UK MRI Monitoring 7.1 (Range: 2-12) 8.2 (Range: 3-36) Cerebral Spinal Fluid (CSF) Analysis 14.1 (Range: 0-60) 10.7 (Range: 0-24) Opportunistic Infections (Other than PML) 6.3 (Range: 0-36) 8.6 (Range: 0-24) Other 2.1 (Range: 0-12) 5.1 (Range: 0-12) Survey Details PML

29 28 Likelihood of Conducting a Follow-up MRI -Mean Rating Scores- (n=46) Neurologists in Italy, Spain, and France reported that follow-up MRIs are most likely to occur at 6 months after the initial infusion. Neurologists in Germany and the UK indicated that these follow-up MRIs would most likely occur every 6 months thereafter. Q18/Q14. Would you conduct a follow-up MRI during the course of treatment even without clinical signs of PML? Percentage Very Likely 30% 33% 30% 25% 15% 25% Survey Details PML

30 29 Most Italian, Spanish, and French neurologists indicated extreme concern while most neurologists in the UK and Germany reported being only somewhat concerned about the risk of PML. Q19/Q15. Given what you know about PML and the measures taken to minimize its morbidity and mortality, what is your level of concern related to the risk of PML developing in patients given Tysabri? Mean Percentage Level of Concern About Risk of PML (n=46) LevelIT/SP/FRGE/UK Extremely Concerned 68% (Range: 0-100%) 20% (Range: 0-100%) Somewhat Concerned 18% (Range: 0-60%) 56% (Range: 0-100%) Not Concerned 14% (Range: 0-100%) 24% (Range: 0-95%) Survey Details PML

31 30 Tysabri in combination with Avonex or with other interferons or Copaxone were indicated to be a lot more risky for the development of PML than Tysabri as a monotherapy. Q16. Please indicate which of the following scenarios you believe to be at risk for PML? Mean Percentage of Scenarios at Risk for PML (IT/SP/FR) (n=12) Scenario Definitely NOT at Risk Possibly at Risk Probably at Risk Definitely at Risk Tysabri as monotherapy (no previous or concurrent interferon or copaxone use) 25%50%25%0% Tysabri as monotherapy (after previous immunosuppressant use) 0%50%42%8% Tysabri in combination with Avonex 8%33%17%42% Tysabri in combination with other interferons or Copaxone 8%16%42%33% Survey Details PML

32 31 Q20. Please indicate which of the following scenarios you believe to be at risk for PML? Mean Percentage of Scenarios at Risk for PML (GE/UK) (n=34) Scenario Definitely NOT at Risk Possibly at Risk Probably at Risk Definitely at Risk Tysabri as monotherapy (no previous or concurrent interferon or copaxone use) 9%73%18%0% Tysabri as monotherapy (after previous immunosuppressant use) 0%48%52%0% Tysabri in combination with Avonex 0%27%43%30% Tysabri in combination with other interferons or Copaxone 0%30%58%12% Survey Details PML Neurologists from Germany and the UK indicated similar risk levels as the neurologists in Italy, Spain, and France for PML development.

33 32 Level of Education by Biogen Idec/Elan -Mean Rating Scores- (n=46) Neurologists in Germany and the UK reported a higher level of education by Biogen Idec/Elan for minimizing morbidity and mortality due to PML and for distinguishing between PML and MS relapse than did neurologists in Italy, Spain, and France. Q21/Q17. Do you feel you have been adequately educated by Biogen Idec/Elan to minimize morbidity and mortality due to PML? Rated on a scale where 1=Not well educated and 5=Very well educated. Q22/Q18. Do you feel Biogen Idec/Elan have adequately educated you to distinguish between PML and MS relapse? Rated on a scale where 1=Not well educated and 5=Very well educated. Percentage Well Educated 14% 17% 8% Survey Details PML

34 33 Level of Believability that an MRI Scan, CSF Testing, and Frequent Neurological Assessments Will Be Sufficient for PML Detection -Mean Rating Scores- (n=46) Neurologists in Germany and the UK found it more believable that an MRI scan, CSF testing, and frequent neurological assessments would be sufficient for PML detection than did Italian, Spanish, and French neurologists. Q23/Q19. How believable do you think it is that an MRI scan, CSF testing for JC viral DNA, and frequent neurological assessments will be sufficient to enable PML to be detected early enough to prevent any serious problems? Percentage Very Believable 14% 8% Survey Details PML

35 34 Q23/Q19. How believable do you think it is that an MRI scan, CSF testing for JC viral DNA, and frequent neurological assessments will be sufficient to enable PML to be detected early enough to prevent any serious problems? Survey Details PML Reasons for Believability Rating (n=46) Country Rating of 1 or 2 Not Believable Rating of 3 Rating of 4 or 5 Very Believable IT/SP/FR No specificity of these explorations -These tests may be refused by patients -PML is hard to diagnose -This represents all measures available to diagnose PML GE/UK -Untreatable -early diagnosis doesnt necessarily prevent serious complications -There is no reliable marker of early detection -No continuous monitoring possible -MRI and CSF testing will detect most cases -Both methods are reliable tests

36 35 Approximately half of neurologists in the UK and Germany indicated that 2-5 cases of PML would impact Tysabri usage. Half of neurologists in Italy, Spain, and France claimed that 5-20 cases would have an impact. Q24/Q20. How many reported and confirmed cases of PML would impact your Tysabri usage? Please select one. Mean Number of Reported PML Cases That Would Impact Tysabri Usage (n=46) Survey Details PML

37 36 Future Practice Patterns

38 37 Avonex would be used most frequently, followed by Rebif, as treatments for relapsing remitting MS patients in Italy, Spain, and France. Q21. Please estimate total % of relapsing-remitting patients who would receive each treatment individually regardless of whether it is a monotherapy or in combination with another drug. Mean % of Relapse-Remitting Patients Who Would Receive the Treatments (IT/SP/FR) (n=12) TreatmentCurrent Next 4 months Next 12 months Avonex32%28%25% Rebif25%22%20% Copaxone15%14% Betaseron14%13%10% No Treatment10%15%13% Tysabri7%15%25% Mitoxantrone7%8% Other Immunosuppresants6%4% Cyclophosphamide5%6%4% Methotrexate3%1% Others3% Novantrone2% Survey Details Future Practice Patterns

39 38 Neurologists in Germany and the UK stated that Rebif would be the most commonly used treatment either as monotherapy or in combination with another drug for relapsing remitting MS patients. Q25. Please estimate total % of relapsing-remitting patients who would receive each treatment individually regardless of whether it is a monotherapy or in combination with another drug. Survey Details Future Practice Patterns Mean % of Relapse-Remitting Patients Who Would Receive the Treatments (GE/UK) (n=34) TreatmentCurrent Next 4 months Next 12 months Rebif25%24%22% Avonex20%19%17% Betaseron19% 17% Copaxone16% 15% No Treatment12%11% Mitoxantrone11%10%9% Other Immunosuppresants8% Tysabri6%10%16% Methotrexate3% Novantrone3% Others3% Cyclophosphamide2%

40 39 Currently a very small majority of Italian, Spanish, and French neurologists indicated that they would use Tysabri only as a salvage therapy. In the next 12 months, they reported that Tysabri would be more frequently used as a first- or second-line treatment. Q22. Of the patients you expect to treat with Tysabri, how will you have distributed your use of Tysabri by line of therapy? Tysabri Distribution (IT/SP/FR) (n=12) TreatmentCurrent Next 4 months Next 12 months First-line (interferon, copaxone naïve) 28%31% After failure of one other MS therapy (interferon, copaxone) 21%28%32% After failure of two or more therapies (interferon, copaxone) 21%30%24% Only as Salvage therapy 30%11%13% Survey Details Future Practice Patterns

41 40 Neurologists in Germany and the UK indicated that Tysabri is currently used most frequently as a third-line treatment. In 12 months, they believe it will be used mostly as a second- or third-line treatment. Q26. Of the patients you expect to treat with Tysabri, how will you have distributed your use of Tysabri by line of therapy. Tysabri Distribution (GE/UK) (n=34) TreatmentCurrent Next 4 months Next 12 months First-line (interferon, copaxone naïve) 8%13% After failure of one other MS therapy (interferon, copaxone) 32%36% After failure of two or more therapies (interferon, copaxone) 38% Only as Salvage therapy 23%16%14% Survey Details Future Practice Patterns

42 41 Neurologists in Italy, Spain, and France stated that they would most likely have been using Betaseron before switching to Tysabri currently, in the next 4 months, and in 12 months. Q23. Of the patients you expect to treat with Tysabri in the future, what treatment (if any treatment was being given prior) will you have actively switched patients off of to put them on Tysabri? Mean % Treatments Switched to Tysabri (IT/SP/FR) (n=12) TreatmentCurrent Next 4 months Next 12 months Betaseron 35%36%38% Avonex 29% 33% Rebif 29%27%29% Copaxone 21%22%25% Mitoxantrone 20%19%21% Other Immunosuppresants 19%22%24% Novantrone 16% 17% Cyclophosphamide 16%20%23% Others 3% No Treatment 2%3% Methotrexate 0% Survey Details Future Practice Patterns

43 42 Neurologists in Germany and the UK indicated that they would most likely have been using Rebif before switching to Tysabri currently, in the next 4 months, and in 12 months. Q27. Of the patients you expect to treat with Tysabri in the future, what treatment (if any treatment was being given prior) will you have actively switched patients off of to put them on Tysabri? Mean % Treatments Switched to Tysabri (GE/UK) (n=34) TreatmentCurrent Next 4 months Next 12 months Rebif 23%22%23% Mitoxantrone 18%14%13% No Treatment 18%20% Avonex 17% 18% Betaseron 16%17%19% Copaxone 15%14% Other Immunosuppresants 11% Novantrone 8% Others 8% Methotrexate 5%6% Cyclophosphamide 4%3% Survey Details Future Practice Patterns

44 43 Q28/Q24. Please feel free to make any qualitative comments regarding the launch of Tysabri in the EU and your expectations for its future use. Survey Details Future Practice Patterns Comments on the Launch of Tysabri IT/SP/FR: It is an alternative therapeutic Very good efficacy Depends on the observed incidence of PML Hoping that the drawbacks will be low for a high level of efficiency Better control of active MS GE/UK: I am excited with regard to clinical application and long-term use data I hope for more safety data concerning the PML and early diagnosis There is the need for more information on Tysabri at European MS congresses Educational efforts have been important The take-up is likely to be slow


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