Complied studies on OctaplasLG and its clinical applications

Octaplast

1. Clinical Experience with Solvent/Detergent Treated Plasma

2. Clinical evidence on efficacy In Adults

3. Documented clinical efficacy over two decades Author/year/ therapeutic area Results Chekrizova & Murphy 2006 Republic of Ireland, Obs & Gynae Study conducted to assess the efficacy and tolerability of S/D plasma in Obs and Gynae emergenices (n=38) and critically ill neonates (n=41) in 3 large hospitals in Dublin (April 2002 – Oct 2003) Overall conclusion: octaplasLG ® in therapeutic doses has very good overall clinical tolerability and is associated with improvement of coagulopathy Williamson et al. 1999 Liver disease (LD)/ liver transplantation (LT) (coagulation) LD group (n=24) equal correction of clotting factors and PTT was seen in both groups at standard dose (12-15ml/kg) No overt haemorrhagic complications in those undergoing invasive procedures LT group (n=25) no intraoperative or post-operative deaths with 24 hrs of plasma infusion All pts completed treatment without serious side effects Hellstern et al. 1993 Complex coagulopathies Haemostatic effect accompanied by marked improvements in prothrombin time (PT), fibrinogen and antithrombin III No side effects reported Solheim et al. 1993 Open heart surgery (coagulation) Adequate correction of changes in coagulation factors Complement activation not observed, no signs of viral transmission

4. Documented clinical efficacy over two decades 1993-2018 No of studies / case reports Area Pt included 13 Liver disease / Tx 293 24 Paediatric patients 405 6 Trauma 142 8 Cardiac surgery 295 18 TTP/HUS 404 7 Coagulation disorders 39 2 Obstetrics / Gyn 47 3 Major surgery 89 1 Extracorporal circulation 3 82 Total 1663

5. Clinical evidence on efficacy In Adults – The VIPER programme

6. Vascular endothelium Endothelial cells : A single layer of cells lining the blood vessels, covering a surface area of 4-7,000 m 2 with a total weight of 1 kilogram Glycocalyx : 0.2-1 μ m e ndothelial surface layer comprising glycoproteins, heparin-like substances and plasma constituents Endothelium is anticoagulated by glycocalyx and other factors Contains a fixed non-circulating plasma volume of 0.7-1.0 L (25-30% of plasma volume) in dynamic equilibrium with the circulating plasma Johansson PI, Stensballe J, Ostrowski SR. Shock induced endotheliopathy (SHINE) in acute critical illness - a unifying pathophysiologic mechanism. Crit Care 2017; 21(1):25. Gouverneur M, Berg B, Nieuwdorp M, Stroes E, Vink H. Vasculoprotective properties of the endothelial glycocalyx : Effects of fluid shear stress. J Intern Med 2006; 259(4):393–400.

7. Tissue trauma activates the sympathoadrenal system Catecholamines influence the endothelium to induce local haemostasis (enhance thrombin generation(TG)) while in microcirculation minimizing systemic intravascular coagulation to preserve perfusion and oxygenation (tissue-type plasminogen activator ( tPA ) and activation of the protein C ( aPC )) Mild trauma: balanced system Moderate trauma: hypercoagulopathy (more TG than tPA and aPC ) Severe trauma: hypocoagulopathy : consumptive coagulopathy and release of endothelium bound anticoagulants (=destruction of glycocalyx) Massive trauma: hyperfibrinolysis Acute coagulopathy of trauma Johansson PI, Ostrowski SR. Acute coagulopathy of trauma: Balancing progressive catecholamine induced endothelial activation and damage by fluid phase anticoagulation. Med Hypotheses 2010; 75(6):564–7.

8. Shock causes glycocalyx damage More than 3000 patients suffering from different types of acute critical illness (severe trauma, sepsis, MI and PCAS) were investigated. Link between sympathoadrenal hyperactivation, endothelial cell and glycocalyx damage (endotheliopathy), and poor outcome (=SHINE) Shock causes sympatho-adrenal hyperactivation and increase in circulating levels of catecholamines Activation of natural anticoagulants directly inflicts systemic damage to the endothelium (glycocalyx), including the microcirculation. Circulating biomarkers of endothelial cell (soluble thrombomodulin (sTM)) and glycocalyx (syndecan-1) Increased risk of microvascular occlusion secondary to pro-thrombotic microcirculation, capillary leakage also hypovolemia, oedema and tissue hypoxia in these patients

9. Shock causes capillary leakage, hypovolemia, edema and tissue hypoxia

10. Damage of the glycocalyx leads to increase of syndecan-1, sTM plasmalevel Trauma, major surgery, resuscitation of crystalloids and colloids Damage of the glycocalyx Vascular leakage Oedema formation, development of hypotension, .........MOF and death Raise of syndecan-1, sTM plasmalevel Rehm M, Bruegger D, Christ F, Conzen P, Thiel M, Jacob M et al. Shedding of the endothelial glycocalyx in patients undergoing major vascular surgery with global and regional ischemia. Circulation 2007; 116(17):1896–906. Syndecan-1 correlates with the degree of endothelial breakdown

11. Plasma proteins seem to protect the glycocalyx Torres LN, Sondeen JL, Ji L, Dubick MA, Torres Filho I. Evaluation of resuscitation fluids on endothelial glycocalyx , venular blood flow, and coagulation function after hemorrhagic shock in rats. J Trauma Acute Care Surg 2013; 75(5):759–66 .

12. Proof of concept: Valve surgery, plasma transfusion and endothelial dysfunction Pilot study of the effect of Octaplas vs. FFP on endothelial integrity in patients with endocarditis undergoing valve surgery in CPB Non-randomized, non-inferiority study 22 patients screened of whom 7 received FFP and 7 received Octaplas and 8 received neither (control) Blood samples obtained at baseline, post-CPB and 24h post surgery

13. Valve surgery, plasma transfusion and endothelial dysfunction The following biomarkers where investigated: Adrenaline, Noradrenaline (toxic for the endothelium) Syndecan-1 (glycocalyx damage marker) Soluble thrombomodulin (sTM) (endothelial cell damage marker) sCD40L (endothelial activation marker)

14. Changes of biomarkers 1 2 3 4 baseline Post CPB 24h Syndecan-1 Octaplas FFP Control 1 2 3 4 baseline Post CPB 24h soluble Thrombomodulin Octaplas FFP Control 20 40 60 80 100 120 baseline Post CPB 24h Noradrenaline Octaplas FFP Control

15. Proof of concepts conclusions OctaplasLG reduces the levels of catecholamines after cardiac valve surgery, limiting the hit on the endothelium, when compared to FFP OctaplasLG treated patients have markedly reduced levels of circulating syndecan-1 and soluble thrombomodulin compared to FFP treated patients indicating improved endothelial integrity Levels of sCD40L (endothelial activator) is markedly reduced in OctaplasLG treated patients when compared to those receiving FFP

16. VIPER- Octa Trial (Dr. Stensballe) V asculopathic I njury and P lasma as E ndothelial R escue – OCTAplasLG trial Randomized, controlled, single-blinded IIT evaluating the efficacy of octaplasLG ® on endothelial integrity in patients undergoing emergency surgery for thoracic aortic dissections Endpoints Primary endpoints: Plasma levels of endothelial markers (Syndecan-1, sTM , sE -selectin, sVE -cadherin) at 24 hours postoperatively Secondary endpoints: Acute kidney injury, renal replacement therapy, sepsis-related organ failure, length of stay in ICU/hospital Number of patients Enrollment completed: n=23 octaplasLG ® , n=21 FFP

17. VIPER-OCTA: results Significant decreased endothelia glycocalyx damage Significantly reduced total transfusion requirements at 24 h (total of RBC, plasma, PLT) Significant reduced proportion of patients on ventilators on day 4 (trend on day 2+3) and improved oxygenation here Trend towards reduced Intensive Care Unit length of stay Primary endpoint met octaplasLG ® performed clinically better No safety concern Stensballe , J., Ulrich, A. G., Nilsson, J. C., Henriksen , H. H., Olsen, P. S., Ostrowski , S. R., Johansson, P. I.: Resuscitation of Endotheliopathy and Bleeding in Thoracic Aortic Dissections. Anesth . Analg . (2018).

18. VIPER-Shock trial : Dr Jakob Stensballe (DK) Randomized, controlled, open-label, pilot phase trial investigating the efficacy and safety of octaplasLG ® compared to crystalloids (standard of care) in patients with septic shock Endpoints Primary endpoint : Plasma levels of endothelial markers (Syndecan-1, soluble thrombomodulin ( sTM ), sE -selectin) Change in microvascular perfusion Secondary endpoints: mortality , acute kidney injury, renal replacement therapy, sepsis-related organ failure, length of stay in ICU/hospital Number of patients p lanned n=40 enrolled n=39 Last patient planned Q1 2019

19. S/D Plasma is Clinically Equivalent to Other Types of Plasma 19

20. 20 Solvent/Detergent Plasma Studies     Williamson (1999) Transfusion, Bindi (2013) Vox Sang , Bartelmaos (2013) Transfusion Liver disease and liver transplantation No difference in efficacy between FFP and S/D plasma 408 Haubelt (2002) Vox Sang Cardiothoracic Surgery Evidence did not demonstrate a difference in efficacy between FFP and SD plasma. Lower levels of protein S activity were observed following S/D plasma infusion. 67 Stensballe (2018) Anesth Analg Emergency surgery for thoracic aortic dissections When compared to patients receiving conventional plasma, patients transfused with S/D plasma had significantly reduced glycocalyx damage at 24 hours and significantly reduced tight junction injury at 48 hours.   57 First Author - Journal - Year Patient Population Findings Number of subjects Large Randomized Controlled Clinical Trials Evaluating the Efficacy of Solvent/Detergent Plasma Summary: no difference in efficacy; improved endothelial markers

21. LOCATION Population (n=57) E mergency surgery for thoracic aortic dissection , adults Intervention Perioperative FFP or S/D plasma Location Rigshospitalet , Copenhagen University, Denmark Primary outcomes Glycocalyx and endothelial injury @ 24 hours Secondary outcomes Bleeding, transfusion, prohemostatics , organ failure, safety

22. S/D Plasma arm had : LESS damage to the endothelial glycocalyx (syndecan-1) LESS endothelial tight junction injury ( sVE -cadherin) LESS microthrombotic endothelial adhesion ( sE selectin ) MORE anticoagulation regulation in glycocalyx (TM) S/D Plasma FFP

23. Secondary Outcomes: The use of S/D plasma was associated with: 22% lower intraoperative bleeding (median, 2150 ml vs 2750 ml; p = 0.046) 57% lower platelet transfusion volume ( 1400 ml vs 2450 ml; p = 0.027 ) 64% lower total transfusion volume ( 3975 ml vs 6220 ml; p = 0.040 ) 49% lower goal-directed use of prohemostatics (30.4% vs 61.9%; p = 0.036). 50% less days on ventilator (1 day vs 2 days in the standard FFP group, p = 0.013)

24. Clinical evidence on efficacy In TTP ( to be discussed in depth )

25. Efficacy and safety of octaplasLG ® in TTP Author/year/ therapeutic area Results Edel et al 2010 TTP All 8 patients were positive for anti-ADAMTS-13 antibody. Seven out of 8 had a severe ADAMTS-13 deficiency. The data described also indicate that octaplasLG ® might offer the benefit of reducing adverse drug reactions Scully et al 2007 PEX octaplasLG ® at least as effective as cryosupernatant when used for plasma exchange octaplasLG ® had reduced allergic and citrate reactions compared to cryosupernatant Scully et al 2014 PEX PEX with octaplasLG ® in pregnant women with TTP Mc Guckin et al. 2016 PEX for thrombotic microangiopathies PEX for thrombotic microangiopathies (TTP, HUS, a HUS)

26. Clinical evidence on efficacy In adult ( Liver transplantation or with end-stage liver disease).

27. LIVER TX CASE 50yo, 80 kg, female with diabetes, HTN, obesity, and recently diagnosed Non Alcoholic Steatohepatitis (NASH) cirrhosis who presented with acute decompensated cirrhosis who received a liver transplant During the transplant, the patient had the following ROTEM 31

28. www.aabb.org 32 CT CFT α angle A10 A20 MCF EXTEM 43-82 48-127 65-80 40-60 50-70 52-70 INTEM 122-208 45-110 70-81 40-60 51-72 51-72 FIBTEM 7-24 Reference Ranges:

29. Normal ROTEM after 4 units of OctaplasLG 10 mL/kg 33

30. Clinical evidence on efficacy In Paediatrics

31. Efficacy and safety in paediatrics Author/year/ therapeutic area Results Kalsi et al. 2018 paediatric patients with cardiac surgery FFP vs. octaplasLG ® Results showed clinically better hemostasis postoperatively in octaplasLG ® group compared with FFP group and better coagulation results Significantly lower rate of postoperative infections in the octaplasLG ® group Witt et al. 2017 TPE in children with various diseases Different replacement fluids and outcome in therapeutic plasma exchange in paediatric patients Haemostasis could be preserved in a clinically acceptable range for a variety of underlying diseases with SDP alone or in combination with human albumin. Hall et al. 2013 Primarily cardiac, liver 29 pts (aged 1 day to 15yrs) having 51 octaplasLG ® infusion episodes No adverse reactions were recorded – well tolerated in paediatric population Stanley et al. 2010 Severe sepsis (children) It was concluded that in over 3522 transfusions the use of octaplasLG ® was effective (in children with severe sepsis) The incidence of adverse events were noted to be less frequent than with standard FFP

32. Safety and tolerability of solvent/detergent-treated plasma for pediatric patients requiring therapeutic plasma exchange: An open-label, multicenter, postmarketing study 41 pediatric patients undergoing a total of 102 TPE

33. Camazine MN, et al. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 2017; 18(5):e215-e223. This is an a priori secondary analysis of a prospective, observational study. 2 Study groups were defined FFP (n=357) or octaplasLG ® (n=62). Outcomes were INR reduction and ICU mortality. Results No difference INR reduction, between FFP and S/D plasma, –0.2 (–0.4 to 0) and –0.2 (–0.3 to 0), respectively (p = 0.80). ICU mortality was lower in the octaplasLG ® versus FFP group, 14.5% versus 29.1%%, respectively (p = 0.02). Efficacy and safety in paediatrics

34. LAS-212 study in children Open-label, multicentre, Post-Marketing Requirement study investigating the safety, tolerability and efficacy of octaplasLG ® in paediatric patients with multiple coagulation factor deficiency due to liver disease Number of patients n=50 Endpoints Primary endpoint : Incidence of SAEs, ADRs (e.g., allergic reactions), TEEs and hyperfibrinolytic events Results No hperfibrinolysis , two TEEs not related to product

35. Summary — Reasons for implementing SD plasma Minimizes pathogen transmission risk through direct destruction of pathogen and by the pooled benefit of blood donor’s neutralizing antibodies Decreases transfusion reactions Including allergic reactions, TRALI and overall serious reactions Provides a more standardized product Consistent approach to pathogen inactivation and safer blood supply SD-Plasma is safe and effective to regular FFP in adults and children Added benefit of pathogen inactivation Now 405 (355 in publications and 50 in LAS-212) documented children treated with octaplasLG octaplasLG well tolerated, safe and effective in pediatrics 41