Adacolumn

Adacolumn

Device for Granulocyte and Monocyte Apheresis

Otsuka / JIMROwww.otsuka.de

www.adacolumn.com

Legal Status

• Adacolumn is indicated – for induction of remission in patients suffering from

active Ulcerative Colitis– for the treatment of objective and subjective symptoms

in patients suffering from active Rheumatoid Arthritis not responding to standard therapy

• Adacolumn is approved and reimbursable in Japan• Adacolumn is CE-certified by the „TÜV“

Adamonitor

Adacolumn +Adacircuit

Adastand

www.adacolumn.com

dacolumn

Carrier Cellulose acetate beads

Carrier weight 220g

Main Body Polycarbonate

Size 60mm Ø ×206mm

Filling solution Physiological saline

Column void volume 130mL

Sterilization method Autoclave at high vapor pressure

Granulocyte and Monocyte Apheresis Therapy

Adacolumn Apheresis System

Adacolumn

Vein

Vein

Flow rate: 30mL/minuteApheresis time: 60 minutesTotal apheresis volume: 1800mL

P

Anticoagulant port

Blood return

Blood draw

Basics

Patients with autoimmune diseases have a significant higher level of immune complexes and inflammatory factors as well as an increased number of granulocytes:

Normal: 3,4 0,4 x 103 granulocytes/µL

Ulcerative Colitis: 6,4 0,4 x 103 granulocytes/µL

Rheumatoide Arthritis: 5,5 0,3 x 103 granulocytes/µL

Carcinoma (progressed stadium): 5,2 0,7 x 103 granulocytes/µL

Rationale for using granulocyte and monocyte apheresis in autoimmune diseases (e.g. Crohn‘s disease, Ulcerative Colitis, etc.)

Granulocytes: A Double-Edged Cellular Species

Stem cell

Differentiation in different immuno-competent cells

Microorganisms

Neutrophil

Phagocytosis and degradation of infectious microorganisms

Defense of body against infection

Neutrophil Proteases, inflammatory cytokines

Active superoxide

Pro-inflammatory function

Tissue Damage Loss of Function

Tissuedamage

• Adsorption of complement fragments by cellulose acetate surfaces, for instance C5a

Neutrophils and macrophages can adhere (direct adsorption)

• Patients with autoimmune diseases have a high number of circulating immune complexes which adhere to cellulose acetate and produce C5a locally

IgG plus C5a can bind neutrophils and monocytes via Fc receptor (indirect adsorption)

• L-selectin down regulation (LECAM)• PBL produce less proinflammatory cytokines• Granulocyte apoptosis is enhanced• young granulocytes appear in the blood (not active)

Basics

Granulocyte/Monocyte adsorbed on the beads

In vitro Determination of Human Granulocyte and Lymphocyte Adsorption Efficiency

Heparinized blood was incubated with each type of beads (3mm in diameter) at 37 °C for 60 minutes

Lymphocytes

0

5

10

15

20

25

30

35

40

Co

ntr

ol

Po

lyst

yren

e

PE

TF

Gla

ss

Cel

lulo

se A

ceta

te

6-N

ylo

n

Granulocytes

% A

dso

rpti

on

Co

ntr

ol

Po

lyst

yren

e

PE

TF

Gla

ss

Cel

lulo

se A

ceta

te

6-N

ylo

n

0

5

10

15

20

25

30

35

40

Adsorption Selectivity of Adacolumn Carriers

The results show that the Adacolumn carriers

selectively adsorb granulocytes and monocytes

Data from 59 patients with active Ulcerative Colitis

Erythrocytes

Platelets

GranulocytesGranulocytes

MonocytesMonocytes

Lymphocytes

36.4±10.83

33.7±7.87

2.5±0.242.5±0.24

0.1±0.020.1±0.02

0.2±0.04

Number of cells adsorbed (×109)

0.5±0.15

5.7±1.35

24.9±1.9024.9±1.90

19.5±2.4719.5±2.47

6.6±1.27

Adsorption efficiency (%)

Preclinical

0

5

10

15

20

25

30

35

Adsorbed CD11b+

Healthy Arthritis

Ad

sorb

ed c

ells

(%

)

• Comparative trial of rabbits with induced arthritis and healthy controls

• In both groups identical apheresis was applied

• Results:

Adsorption of a significant higher number of granulocytes and monocytes during the apheresis in the rabbits with arthritis than in the controls

No significant differences in the adsorption of erythrocytes or lymphocytes

p < 0.05 Saniabadi, A.; Jpn. J. Apheresis 16 (1): 173-178, 1997

• One group of arthritic rabbits was treated with apheresis while the other group was not

• Results:

After an apheresis with Adacolumn significantly less monocytes and T-cells migrate into the arthritic joint in comparison to the control group which received no apheresis (p < 0.001)

Preclinical

0

0.5

1

1.5

2

2.5

3

3.5

Monocytes T-cells

Without apheresis Post apheresis

Saniabadi, A.; Jpn. J. Apheresis 16 (1): 173-178, 1997Infiltrated cells in the joint

Ad

sorb

ed c

ells

(%

)

• Changes in swelling of joint in 3 groups of arthritic rabbits

• 10 min. after induction of the arthritis one group received an apheresis with Adacolumn (n=6), another received a sham-column apheresis (n=6), the controls (n=7) received no apheresis

• Results:

The facts are statistically highly significant in favour of Adacolumn (p < 0.01 bzw. p< 0.001) Day 0: Induction of the arthritis

Day 0+10 min: Conduct of the apheresis

Preclinical

0

0,5

1

1,5

2

2,5

3

3,5

4

0 1 2 3 4 5 6 7

Arthritic rabbits without apheresis

Arthritic rabbits with placebo apheresis

Arthritic rabbits with Adacolumn apheresis

Sw

ellin

g o

f jo

int

(mm

)

Days after the induction of the arthritisSaniabadi, A.; Jpn. J. Apheresis 16 (1): 173-178, 1997

Production of LECAM-1-marker on arthritic rabbits before and after an apheresis with Adacolumn (p < 0.05)

Preclinical

Saniabadi, A.; Jpn. J. Apheresis 16 (1): 173-178, 1997

Decreased adhesion of granulocytes to inflammated tissue

Adacolumn Clinical Study Sites (14 Institutions)

Fukushima Medical University

Odate Municipal Hospital

Tohoku University

Hamamatsu University School of Medicine

Hirosaki University

Jichi Medical School

Gunma University

Chiba University

Niigata University

Hyogo College of Medicine

Oita Medical University

Tokyo University

Tokyo Women's Medical University

International Medical Center of Japan

Tokyo

Summary of Adacolumn Clinical Study Protocolin Patients with Active Ulcerative Colitis

Primary endpoint: To assess and evaluate the safety and efficacy of Adacolumn, patients with Ulcerative Colitis using Adacolumn were compared to patients treated with conventional drugs

Parallel controlled trial with 120 patients

Adacolumn apheresis: 60 patients

Conventional drugs: 60 patientsPrednisolon, 5-ASA, SASP

Shimoyama, T.; J. Clin. Apheresis 18:117-131, 1999

• Multicenter randomized comparative trial of standard therapy and of therapy with Adacolumn

• 14 centers in Japan

• 105 patients were enrolled and randomized whereas 53 patients received Adacolumn and 52 patients received standard therapy according to the guidelines of the national Japanese Ministry of Health

• Diagnoses were performed using clinical symptoms, endoscopy, histology and X-rays

Clinical Efficacy - Ulcerative Colitis


• Standard therapy consisted of prednisolone, salazosulphapyridine and 5-amino-salicylic acid

• Adacolumn apheresis 1x weekly for 5 weeks

• Patient age: 12-76 Years

• Exclusion criteria: Pregnancy/lactation, systolic blood pressure 80 mm Hg, anemia with < 8 g/dL Hb, increased tendency for coagulation

• Degree of the severity was classified using stool frequency, macroscopic visible blood in stool, fever, tachycardia (frequency 90), hemoglobin level and ESR (rate 30 mm)



* Expert Committee on IBD, the Ministry of Health and Welfare of Japan

Adacolumn(1 apheresis/wk × 5 wks)

Time (week)

-2 1 2 3 4 5 6 7

Overall assessment

Adacolumn Clinical Study Protocol in Patients with Ulcerative Colitis (UC)


ConventionalDrugs*

• Assessment of overall improvement

More than 50% of improvement within three items which were considered as the main items for assessing response to Adacolumn apheresis therapy according to the following standards: Clinical symptoms, endoscopic findings and inflammation markers

Significantly improved: Complete remission

Improved: Conditions improved in at least more than 2 of the 3 categories

Unchanged: Conditions did not improve or worsen

Worsened: Conditions worsened in at least 2 of the 3 categories

• Assessment of overall usefulness

The overall usefulness of treatment was assessed based on the overall improvement and safety (assessment of adverse reactions)

Assessment of the Efficacy of Adacolumn


% Usefulness (safety + efficacy)

0 10 20 30 40 50 60

Refractory cases

Severe cases

All cases n=52

n=53

n=19

n=19

n=33

n=29

Drugs

AdacolumnP=0.045

P=0.030

P=0.016

Usefulness of Adacolumn vs. Conventional Drugs



21,1%

30,3%

52,6%

51,7%

0 10 20 30 40 50 60

Severe cases

Refractory cases

Drug therapy

% Clinical usefulness(efficacy and safety of the therapy)

p = 0,016

p = 0,030

n = 29

n = 33

n = 19

n = 19

Shimoyama, T. J. Clin. Apheresis 18:117-131, 1999

Adacolumn

Usefulness (safety + efficacy) by disease background (1)

Adacolumn Clinical Study in Patients with UC

Classification based on severity

0

20

40

60

80

100

%

Drug(0)

Adacolumn(19)

Drug(19)

Adacolumn(34)

Drug(33)

Fulminant Severe Moderate

52.6

21.1

61.8 57.6

P < 0.05

Use

fuln

ess

(ver

y u

sefu

l an

d u

sefu

l)

ns ns

n

0 0

U-testAdacolumn

(0)

Classification based on disease location

Adacolumn(16)

Drug(15)

Adacolumn(37)

Drug(37)

Left-sided colitis Total colitis

75.0

33.3

51.4 48.6

Use

fuln

ess

(ver

y u

sefu

l an

d u

sefu

l)

0

20

40

60

80

100

%

ns ns

n



U-test

YA 22791-08

Adacolumn(10)

Drug(7)

Adacolumn(39)

Drug(35)

Adacolumn(4)

Drug(9)

First attack Relapsing-remitting Chronic continuous

70.0 71.4

53.8

42.9

75.0

22.2

Use

fuln

ess

(ver

y u

sefu

l an

d u

sefu

l)

0

20

40

60

80

100

(%)

n

ns ns ns

Classification based on clinical course



U-test

Adacolumn(11)

Drug(9)

Adacolumn(29)

Drug(32)

Adacolumn(13)

Drug(11)

First attack type Relapse, refractory type Relapse, non-refractory type

72.766.7

51.7

31.3

61.5 63.6P < 0.05

Use

fuln

ess

(ver

y u

sefu

l an

d u

sefu

l)

0

20

40

60

80

100

%

ns ns

n

Classification based on UC status



U-test

Adacolumn(12)

Drug(12)

Adacolumn(31)

Drug(28)

Adacolumn(10)

Drug(12)

Pseudo-polyposis type Atrophic type Mixed type

50.0

25.0

58.153.6

70.0

41.7

Use

fuln

ess

(ver

y u

sefu

l an

d u

sefu

l)

0

20

40

60

80

100

%

P < 0.05

n

ns ns

Classification based on colonoscopy



U-test

Daily Steroid Dose in the Adacolumn and Control Group during the Clinical Study

Changes in mean dosage of steroid in responder patients (results in very useful and useful cases)

Groupn mean SE

Pretreatmentmean SE

During treatment

AdacolumnContol (drug)

5352

24.426.3

3.603.05

21.555.4

3.179.95

Adacolumn vs. drug group P = 0.377 P < 0.001 U test

0 10 20 30 40 50 (day)10

20

25

30

35

40

45

Do

sag

e o

f st

ero

id

(mg

/day

)

Drug (n=22)

Adacolumn (n=31)

Shimoyama, T.; J. Clin. Apheresis 16:1-9, 2001; Shimoyama, T.; J. Clin. Apheresis 18:117-131, 1999

15

1st day of clinical study

-10

7,8

4,9

0

1

2

3

4

5

6

7

8

Mean frequency of stool

Baseline after Adacolum apheresis

Fre

qu

ency

(%

)Clinical Efficacy - Ulcerative Colitis

84,9

38,5

0

10

20

30

40

50

60

70

80

90

Blood in stool (macrosc. visible)

Pat

ien

ts (

%)

Shimoyama, T.; J. Clin. Apheresis 18:117-131, 1999(p < 0.001) (p < 0.001)

Baseline after Adacolum apheresis

2,08

1,55

0

0,5

1

1,5

2

2,5

Malaise

Baseline after Adacolumn apheresis


1,77

1,35

0

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

1,8

Ulcer



(p < 0.001) (p < 0.001)

Fre

qu

ency

Fre

qu

ency

1,8

1,3

0

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

1,8

Mucopus



1,92

1,59

0

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

1,8

2

Erosion



(p < 0.001) (p < 0.001)

Fre

qu

ency

Fre

qu

ency

Adacolumn apheresis induced suppression of LECAM-1 (CD62L, L-selectin) expression and enhanced expression of Mac-1 (CD11b/CD18) in 21 patients with

active ulcerative colitis.

0

500

1000

1500

2000

p <0.01

inflow outflow

LE

CA

M-1

[CD

62L

], %

Po

siti

ve x

MF

I

0

1000

2000

3000

4000

5000

6000

p <0.001

inflow outflow

Mac

-1[

CD

11b

], %

Po

siti

ve x

MF

I

Sixty minutes after start of apheresis, blood samples were taken at the Adacolumn inflow and outflow points and the expression of LECAM-1 and Mac-1 on blood leukocytes was investigated by flow cytometry. The expression index was calculated as % of LECAM-1 or Mac-1 positive cells x MFI (mean fluorescence intensity).

h t t p : / / w w w . a d a c o l u m n . c o m

C h a n g e s i n P r o i n f l a m m a t o r y C y t o k i n e P r o d u c t i o n b y A d a c o l u m n A p h e r e s i s ( U C p a t i e n t s , n = 1 3 )

**

* ** *

*

0

5 0 0

1 0 0 0

1 5 0 0

2 0 0 0

0

1 0 0 0

2 0 0 0

3 0 0 0

4 0 0 0

0

5 0 0 0

1 0 0 0 0

1 5 0 0 0

2 0 0 0 0

3 0 m i n 6 0 m i n 6 0 m i nb a s e l i n e i n f l o w o u t f l o w



T N F α ( p g / m L ) I L - 1 β ( p g / m L ) I L - 6 ( p g / m L )

Cyt

okin

e P

rod

uctio

n b

y P

erip

he

ral B

loo

d L

eu

kocy

te

* p < 0 . 0 5 , * * p < 0 . 0 1 , c o m p a r e d w i t h b a s e l i n e b y W i l c o x o n s i g n e d - r a n k t e s t .

http://www.adacolumn.com

0

2

4

6

8

10

12

Baseline 3 wk 5 wk post2wk

CRP (mg/dL) Stool Frequency (times/day)

0

2

4

6

8

10

12

14

16

18

20

Baseline2 3wk 4wk 5wk post2wk

** *** *** ********* *** ***

**p<0.01, ***p<0.001, Compared with baseline byWilcoxonsigned-rank test

Changes in Plasma CRP and Stool Frequency in 31 Responder Cases

0

10

20

30

40

50

60

70

80

Moderate UC Severe UC Refractory UC

Adacolumn > 1 Year Standard therapy > 1 Year

Adacolumn > 2 Years Standard therapy > 2 Years

Pat

ien

ts (

%)

Clinical Efficacy - Ulcerative ColitisPersistence of remission from ongoing follow-up-phase and post-

surveillance observation

Data on file

Adacolumn therapy: n=129 Standard therapy: n=84

Adverse Reactions

Adacolumn Drugs

8

Circulatory andrespiratory organs

• Headache• Dizziness on standing• Dizziness

111

Digestive organs• Nausea• Duodenal perforation

11

Hypersensitivity • Fever• Flushing

22

Liver disorder • Liver disorder (mild)• Liver disorder

42


Therapy

Total 40

Adverse Reactions

Adacolumn Drugs


Therapy

Musculoskeletalsymptoms

• Osteoporosis• Reduced bone mass• Compressed fracture of lumber vertebra

33

2

Lipid and protein metabolism disorders

• Moon face• Hypoproteinaemia• Hypercholesterolaemia

10 2 1

Dermatological disorders

• Acne• Pyoderma gangrenosum

51

Others 6

Safety - Ulcerative Colitis

5

24

8

40

03

0

5

10

15

20

25

30

35

40

Patients with AE Number of AE Drop out due to AE

Adacolumn (n=59) Standard therapy (n=52)(n)


Pat

ien

ts

Adacolumn Summary

Indication: Adacolumn is indicated for the treatment of UC (and potential other autoimmune diseases

which are under investigation)

Pathophysiology: 1) Reduction of granulocytes and monocytes2) Changes of granulocyte adhesion

Clinical findings: 1) Remission and improvement of clinical symptoms2) Superiority vs. standard therapy - especially

in severely affected patients3) Reduction of steroid doses

Tolerability: 1) Superior to standard therapy (less and milder side-effects)

Pyoderma Gangrenosum (UC)

Before treatment After 5th treatment

T. Kanekura, et. al., J. American Academy of Dermatology (2002 in press)

38 year old male. Duration of disease = 3 years.

Adacolumn

Documents

apheresis i

minutestotal apheresis

autoimmune diseases

direct adsorption patients

enhancedyoung granulocytes

groups identical apheresis

active ulcerative colitisfor

high number