1. ABC Advanced Bleeding Care Human Coagulation FVII Karsten Lollike

2. © TPWG May 2004 ABC Advanced Bleeding Care 2 Human Coagulation Factor VII Hagen FS et al. Proc Natl Acad Sci U S A 1986; 83: 2412 D D D D D D D D D D D D D D D D Y Y Y Y Y Y Y Y Y Y A A A A A A A A A A A A A A A D A A A D S S S S S S S S S S S S S S S S S S S S S S S S S S D Y A S L L L L L L L L L L L L L L L L L L L L L L L L L L L L L L L L L L L I I I I I I I I I I I I I I I I I K G G K G G H V E V V V V E E E G G E E E E F T T T T T T R T R R R R R V K H E G Q V V V H T E G P P P Q V R Q G Q Y G G E F P N N N K P P P N H R R R R Q Q N K F H N N K P Q G R V Q P W V G H K K W V N G G K G E F H P Q F E K P G G G V V N T Q W T V V V S T T T A P P G V P V H H G G G G G G G G T T T T TV V V V V G G G P G P V V T T G G F K T Q R G N H W Q W Q F N R P R W K K G K H W Q T Q L G P R Q K E L W E R P R R P F F M N F F M E L Q Q Q R R M M N R K Q F R F R K E W           D H S 100 80 260 140 120 200 152 160 180 220 240 280 320 360 380 340 400 406 300 20 40 C C C C C C C C C C C C C C C C C C CC C C P A NH 2 COOH C C Gamma-carboxyglutamic acid Glycosylation sites Activation site Catalytic site residues 

3. © TPWG May 2004 ABC Advanced Bleeding Care 3 Catalytic site Heavy chain EGF domains Gla domain Calcium FVII Crystal Structure Light chain Hagen FS et al. Proc Natl Acad Sci U S A 1986; 83: 2412

4. © TPWG May 2004 ABC Advanced Bleeding Care 4 Recombinant vs. Plasma-Derived FVIIa  Amino acid sequenceIdentical  Amino acid compositionIdentical  Gamma-carboxylationIdentical  Peptide mapIdentical  Biological activityIdentical  Carbohydrate compositionSimilar Lund-Hansen T, Petersen LC Thromb Haemost 1987; 58: 270; Thim L et al. Biochemistry 1988; 27: 7785

5. © TPWG May 2004 ABC Advanced Bleeding Care 5 Licensed Indications in the EU:  NovoSeven is indicated for the treatment of bleeding episodes and for the prevention of bleeding in those undergoing surgery or invasive procedures in the following patient groups: -patients with congenital haemophilia with inhibitors to coagulation factors VIII or IX > 5 BU -patients with acquired haemophilia -patients with congenital FVII deficiency -patients with Glanzmann’s thrombasthenia with antibodies to GP IIb-IIIa and/or HLA, and with past or present refractoriness to platelet transfusions NovoSeven SPC 2004

6. © TPWG May 2004 ABC Advanced Bleeding Care 6 TF-Bearing Cell Activated Platelet Platelet TF VIIa Xa X II IIa VVa II X IIa Xa Hoffman M et al. Blood Coagul Fibrinolysis 1998; 9 Suppl 1: S61 Va IX Va VIIa IXaVIIIa VIII/vWF VIIIa Normal Coagulation (Model)

7. © TPWG May 2004 ABC Advanced Bleeding Care 7 TF-Bearing Cell TF VIIa Xa X Va Normal Coagulation (Model) Hoffman M et al. Blood Coagul Fibrinolysis 1998; 9 Suppl 1: S61

8. © TPWG May 2004 ABC Advanced Bleeding Care 8 TF-Bearing Cell TF VIIa Xa X II IIa Va Normal Coagulation (Model) Hoffman M et al. Blood Coagul Fibrinolysis 1998; 9 Suppl 1: S61

9. © TPWG May 2004 ABC Advanced Bleeding Care 9 TF-Bearing Cell TF VIIa Xa X II IIa Va VIII/vWF VIIIa Normal Coagulation (Model) Hoffman M et al. Blood Coagul Fibrinolysis 1998; 9 Suppl 1: S61

10. © TPWG May 2004 ABC Advanced Bleeding Care 10 TF-Bearing Cell Platelet TF VIIa Xa X II IIa VVa VIII/vWF VIIIa Normal Coagulation (Model) Hoffman M et al. Blood Coagul Fibrinolysis 1998; 9 Suppl 1: S61

11. © TPWG May 2004 ABC Advanced Bleeding Care 11 TF-Bearing Cell Activated Platelet Platelet TF VIIa Xa X II IIa VVa VIII/vWF VIIIa Normal Coagulation (Model) Hoffman M et al. Blood Coagul Fibrinolysis 1998; 9 Suppl 1: S61

12. © TPWG May 2004 ABC Advanced Bleeding Care 12 TF-Bearing Cell Activated Platelet Platelet TF VIIa Xa X II IIa VVa IX VIIa IXa VIII/vWF VIIIa Normal Coagulation (Model) Hoffman M et al. Blood Coagul Fibrinolysis 1998; 9 Suppl 1: S61

13. © TPWG May 2004 ABC Advanced Bleeding Care 13 TF-Bearing Cell Activated Platelet Platelet TF VIIa Xa X II IIa VVa X Xa Va IX Va VIIa IXa VIIIa VIII/vWF VIIIa Normal Coagulation (Model) Hoffman M et al. Blood Coagul Fibrinolysis 1998; 9 Suppl 1: S61

14. © TPWG May 2004 ABC Advanced Bleeding Care 14 TF-Bearing Cell Activated Platelet Platelet TF VIIa Xa X II IIa VVa II X IIa Xa Va IX Va VIIa IXa VIIIa VIII/vWF VIIIa Normal Coagulation (Model) Hoffman M et al. Blood Coagul Fibrinolysis 1998; 9 Suppl 1: S61

15. © TPWG May 2004 ABC Advanced Bleeding Care 15 TF-Bearing Cell Activated Platelet Platelet TF VIIa Xa X II IIa VVa II X IIa Xa Va IX Va VIIa IXaVIIIa VIII/vWF VIIIa Fibrinogen Fibrin Fibrin cross-linked XIIIa Normal Coagulation (Model) Hoffman M et al. Blood Coagul Fibrinolysis 1998; 9 Suppl 1: S61

16. © TPWG May 2004 ABC Advanced Bleeding Care 16 Thrombin – Many Functions Thrombin activates:  Factor V  Factor VIII  Factor XI  Factor XIII  TAFI (Thrombin activatable fibrinolysis inhibitor)  Protein C  Platelets

17. © TPWG May 2004 ABC Advanced Bleeding Care 17 TF-Bearing Cell Activated Platelet Platelet TF Xa X II IIa VVa II X IIa Xa Va IX IXa (Situation in Haemophilia A) rFVIIa Mechanism of Action of rFVIIa (Model) Hoffman M et al. Blood Coagul Fibrinolysis 1998; 9 Suppl 1: S61

18. © TPWG May 2004 ABC Advanced Bleeding Care 18 Monroe DM et al. Br J Haematol 1997; 99: 542 rFVIIa Binding to Platelets [rFVIIa] (nM) Relative fluorescence 2.0 1.5 1.0 0.0 0.5 0150300450600 Activated Not activated Activated, without Ca +2

19. © TPWG May 2004 ABC Advanced Bleeding Care 19 Monroe DM et al. Blood Coagul Fibrinolysis 1998; 9 Suppl 1: S15 rFVIIa Activates FX on Platelets in the Absence of TF Time (min) [FXa] (nM) 50 nM VIIa 20 nM VIIa 10 nM VIIa 5 nM VIIa 2 nM VIIa None 0 6 5 4 3 2 1 0 10203040

20. © TPWG May 2004 ABC Advanced Bleeding Care 20 Pharmacokinetic Comparison Erhardtsen E et al. Blood Coagul Fibrinolysis 1998; 9: 741 Populationt½ (h)CL (mL/kg/h)Vss (mL/kg)N Adults with haemophilia A or B 2.72 ± 0.5432.8 ± 11.7108.9 ± 37.228 Children with haemophilia A or B 1.3267.0130.015 Anticoagulated healthy adult volunteers 2.45 ± 0.2534.5 ± 7.093.6 ± 14.56 Patients with cirrhosis2.45 ± 0.2534.9 ± 16.5Not done10