1. DIAS-4-USA Study Protocol

2. Purpose of presentation
Present and discuss the DIAS-4-USA Study protocol

3. Agenda Overview of protocol Selection Criteria
Excl. & concomitant medication
Study Committees
Discussion & questions as we go along

4. Study overview - DIAS-3/4
Confirm efficacy of desmoteplase 90ug/kg vs. placebo
Two-arm, phase III, pivotal study
Neuroimaging to identify responders treated 3-9h post stroke

5. Study title
A randomised, double-blind, parallel-group placebo-controlled phase lll study to evaluate the efficacy and safety of desmoteplase in subjects with acute ischemic stroke
DIAS-3/4; Desmoteplase In Acute ischemic Stroke

6. Outline of study design
12-24h
Placebo
90 ug/kg DSPA

7. Study objectives Primary objective
To evaluate the efficacy of desmoteplase 90 μg/kg versus placebo in terms of favourable outcome at Day 90 in subjects with acute ischemic stroke
Secondary/other objectives (not exhaustive)
Favourable outcome at different time points
Favourable outcome in subgroups of patients with
“Small” core lesion (less than 25 cc)
Recanalisation (12-24 hrs)
Different mismatch volumes (optional)

8. More secondary objectives
Safety and tolerability
Mortality
Symptomatic Intracranial Haemorrhage
Immunogenicity of desmoteplase
Pharmacoeconomics
Evaluate Quality of Life & Utilisation of Resources
Population pharmacokinetics
Two blood samples at hours post-treatment

9. Key differences to DIAS-2
Dose-ranging (PBO, 90 & 125 ug/kg)
Patient selected based on penumbra imaging
Primary endpoint: mRS/NIHSS/BI
DIAS-3/4
N=400 (1:1)
Single dose (PBO & 90ug/kg)
Patients selected based on angiography
Primary endpoint:
(mRS  2)

10. Primary efficacy endpoint
Good clinical outcome at Day 90 defined as:
mRS score of 0-2
mRS
0 = No symptoms
1 = No sign. disabil., + symptoms
2 = Slight disability
3 = Moderate disability
4 = Moderately severe disability
5 = Severe disability
6 = Death

11. Effect size on primary endpoint
N = 400 patients
Post-hoc analysis showed 29% difference (mRS  2)
Power of 80%, alfa of 5%
Study is powered to detect 13% difference on mRS (mRS  2)

12. Study population overview
Patients with an occlusion or high-grade stenosis on MCA, ACA or PCA
Patients eligible for treatment within 3-9 hours
Score of 4-24 on NIHSS at baseline
Very mild and very severe strokes are excluded
Age 18-85
Exclusion of patients that:
Have an increased risk of haemorrhage
Are not expected to benefit from thrombolysis

13. Inclusion criteria (#1-3)
1. Clinical diagnosis of acute ischemic stroke
2. Informed consent/HIPAA authorisation has been obtained according to a procedure approved by the ethics committee responsible for approval of the study at this site.
3. Male or female between 18 and 85 years of age inclusive

14. Inclusion criteria (#4-6)
4. Treatment of the subject can be initiated within 3 – 9 hours after the onset of stroke symptoms. If the actual time of onset of stroke is unclear, then the onset will be considered the time that the subject was last known to be well. All measures are to be taken so treatment with alteplase within 3 hours of symptom onset is not delayed in subjects who qualified for receiving alteplase
5. The subject has a score of inclusive on the NIHSS with clinical signs of hemispheric infarction
(for example, hemiparesis)
6. The subject must receive IMP within 60 minutes after completion of diagnostic imaging screening. The time stamp on the last imaging sequence is the reference for calculating the time elapsing.

15. Inclusion criteria (#7)
7. The subject shows occlusion or high-grade stenosis as assessed by on MRA or CTA in proximal cerebral arteries that corresponds to the acute clinical deficit. Eligible vessels are the middle cerebral artery MCA M1, MCA M2, anterior cerebral artery (ACA) or posterior cerebral artery (PCA)

16. Exclusion criteria (#1,4,5)
1. The subject has a pre-stroke mRS score of >1, indicating previous disability
4. The subject has a terminal illness with a life-expectancy of less than 6 months
5. In the opinion of the investigator, the subject has any condition that could impose hazards to the subject, if study therapy is initiated, or affect the participation of the subject in the study (for example, subject with metastatic cancer or with severe microangiopathy such as hemolytic uremic syndrome or thrombotic thrombocytopenic purpura)

17. Exclusion criteria (#6-8)
6. Consciousness level >2 on question 1a of NIHSS
7. The subject has a history or clinical presentation of ICH, subarachnoid hemorrhage (SAH), arterio-venous malformation, aneurysm, or cerebral neoplasm. Subjects with incidental small intracranial aneurysm can be considered for the study if the aneurysm is < 5 mm, not thrombosed, and not visibly bleeding
8. The subject has symptomatic acute vertebral or basilar artery occlusion

18. Exclusion criteria (#13-16)
13. The subject has a baseline platelet count < 100,000/mm³
14. The subject has a baseline haematocrit of < 0.25
15. The subject has a baseline blood glucose < 50 mg/dl or > 200 mg/dl (< 3 mmol/l or > 11 mmol/l). Subjects with blood glucose value between mg/dl can be considered for the study only if the blood glucose value decreases to < 200 mg/dl after antidiabetic treatment and before administration of IMP
16. The subject has uncontrolled hypertension defined as a blood pressure > 185 mmHg systolic or >110 mmHg diastolic on at least 2 separate occasions at least 10 minutes apart, or requiring aggressive treatment to reduce the blood pressure within the limits. The definition of aggressive treatment is left to the discretion of the investigator

19. Exclusion criteria (#17-21)
17. The subject has a hereditary or acquired hemorrhagic diathesis
18. The subject has had a gastrointestinal or urinary bleeding within the past 21 day
19. The subject has had an arterial puncture at a non- compressible site within the past 7 days
20. The subject has had another stroke or a serious head injury in the past 6 weeks
21. The subject has had major surgery within the past 14 days

20. Exclusion criteria (#22-23, 25-26)
22. The subject has had seizure at the onset of stroke
23. The subject has had an acute myocardial infarction (AMI) within the past 3 weeks
25. The subject is a pregnant woman (positive serum βHCG pregnancy test, positive urine pregnancy test or clinically evident pregnancy)
26. The subject is, in the opinion of the investigator, unlikely to comply with the clinical study protocol or is unsuitable for any other reason

21. Compare with alteplase contraindications
Active internal bleeding
Severe uncontrolled hypertension
Recent intracranial or intraspinal surgery or trauma (within 3 months)
Intracranial neoplasm, arteriovenous malformation, or aneurysm
Known bleeding diathesis
History of cerebrovascular accident
Evidence of intracranial hemorrhage
Suspicion of subarachnoid hemorrhage
History of intracranial hemorrhage
Seizure at the onset of stroke
Platelet count less than 100,000/mm
Administration of heparin with 48 hours preceding the onset of stroke and have an elevated activated partial thromboplastin time at presentation (ischemic stoke)

22. Excluded medication, Excl. Criteria (#2-3)
2. The subject has previously been exposed to desmoteplase
3. The subject has participated in any investigational study in the past 30 days

23. Excluded medication, Excl. criteria (#9-11)
9. The subject is on oral anticoagulants and has a prolonged prothrombin time (INR > 1.6)
10. The subject has been treated with heparin in the past 48 hours and has a prolonged partial thromboplastin time exceeding the upper limit of the local laboratory normal range. Preventive low doses of LMWH (for example, for deep vein thrombosis (DVT) prophylaxis) do not disqualify the subject from the study
11. The subject has been treated with glycoprotein IIb - IIIa inhibitors within the past 72 hours. Use of single agent oral platelet inhibitors (e.g. clopidogrel 75 mg or low-dose aspirin < 325 mg) or the combination of low-dose-aspirin (e.g. 50 mg) and dipyridamole (e.g. 400 mg) prior to study entry is permitted

24. Excluded medication, Excl. criteria (#12, 24)
12. The subject has been treated with factor Xa inhibitors in the past 72 hours
24. The subject has been treated with a thrombolytic agent within the past 72 hours

25. Concomitant Medication
The following concomitant medications
are not allowed during the study:
Any other thrombolytic agent within the first 72 hours after IMP administration
Any antiplatelet agent within the first 24 hours after IMP administration
Any anticoagulant within the first 24 hours after IMP administration
Any endovascular/mechanical treatment of stroke within 72 hours after IMP administration

26. Reiterate imaging Baseline 12-24 hour imaging
Confirm diagnosis and ensure occlusion/high-grade stenosis
exclude ICH & other pathologies
Centres may perform imaging by either MRI or CT
MR centres may obtain Perfusion Image (not selection!)
12-24 hour imaging
To monitor for cerebral bleedings (symptomatic) by CT or MRI and before the initiation of anti-thrombotic therapy
To assess recanalisation and infarct size

27. Reiterate imaging (cont.)
Imaging selection criteria will be discussed in the imaging session
Unscheduled scans needed
In case of neurological deterioration
In case of worsening of NIHSS >4 (between baseline and Day7)
After Day 7: if NIHSS worsens >4 compared to Day 7 score and there is no reason for the worsening

28. Steering Committee Greg Albers (co-chair), US
Rüdiger von Kummer (co-chair), Germany
Markku Kaste, Finland
Antoni Davalos, Spain
Ashfaq Shuaib, Canada
Gary A Ford, UK
Hugues Chabriat, France
James Grotta, US
Lee Schwamm, US
K C Chang, Taiwan

29. Data Monitoring Committee
Kennedy Lees (chair), UK
Laurance Wechsler, US
Michael Eliasziw, Canada

30. Imaging and Adjudication Committees
Imaging Committee
Jochen Fiebach (Chair), Germany
Salva Pedraza, Spain
Karl-Olov Lövblad, Switzerland
Javier Romero, US
Adjudication Committee
Rüdiger von Kummer, Germany
Anthony Furlan, US
Howard Rowley, US

31. Summary
Post-hoc analyses of DIAS-2 and previous studies have identified a scientifically/pathophysiologically sound target population for DIAS-3/4
Selection of patients based on presence of occlusion/high-grade stenosis
Still compatible with ’penumbra concept’ (and mismatch data will be obtained)

32. Summary (cont.)
Objective of DIAS-3/4 is to confirm efficacy and safety of Desmoteplase 90ug/kg
Two pivotal, global studies planned to enrol a total of 800 patients with acute ischemic stroke
Overall purpose to fulfil a huge medical need in acute ischemic stroke in the 3-9 hr time-window

33. Questions?