During the past decade, great progress has been

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1 Combining Therapies With Interferon Beta for Relapsing and Early Progressive MS: A Review Michael Kaufman, MD Interferon beta-la and interferon beta-lb are approved treatments for relapsing-remitting multiple sclerosis (MS). However, many patients experience disease activity despite appropriate use of these biologic therapies. When disease activity occurs during treatment with one of these agents, physicians can consider adding one or more treatments. Therapies that could be combined with interferon beta are reviewed, and practical issues in their use are discussed. None of the agents discussed have been rigorously tested in combination with interferon beta, and physicians are reminded that combination therapy may aggravate MS or cause delayed injury to other organ systems. Multicentered, scientifically valid clinical trials are needed to assess the efficacy and safety ofinterferon beta combined with other therapies for the treatment of MS. Whenever possible, patients needing combined therapy should be referred to a site conducting clinical trials of such therapy, (hit] MS Care. 2002;4:50-65,) During the past decade, great progress has been made in the treatment of multiple sclerosis (MS). Four immunomodulatory agents have been approved by the US Food and Drug Administration (FDA) for the treatment of relapsing forms of MS or relapsing-remitting MS (RRMS). Interferon beta-la may be given intramuscularly or subcutaneously, interferon beta-lb is given subcutaneously, and glatiramer acetate also is given subcutaneously. Mitoxantrone, a cytotoxic immunosuppressant, also has been approved for worsening forms of relapsing and secondary progressive MS (SPMS). Other therapies are being used for the treatment of MS without FDA approval or established efficacy. This review will focus on the use of interferon beta and currently available approved and unapproved therapies in combination. Interferon beta preparations have demonstrated varying degrees of reductions in sustained disability progression,1,2 relapse rate,1"3 brain atrophy,4 and cognitive dysfunction.5 They have repeatedly demonstrated dramatic suppression of new lesions detected by magnetic resonance imaging (MRI).6"11 Interferon beta induces more than 100 genes that affect the immune system,12 thereby reducing mitogen-induced proliferation of T cells,13 inhibiting migration of T cells into the central nervous system (CNS),14'15 inhibiting nitric oxide synthase,16 inducing regulatory cytokines,17 inducing the production of nerve growth factor,18 and decreasing interferon-y-induced major histocompatibility complex type II expression.19 The mechanisms of action of interferon beta do not primarily depend upon activation of T cells, and thus, it should be possible to use interferon beta with cytotoxic agents. Review of a number of studies using interferon beta-la intramuscularly3'20'21 or subcutaneously2'22"24 to treat patients with clinically isolated symptoms, RRMS, and SPMS suggests that interferon beta therapy administered at the earliest stages of MS is more successful in delaying relapses, reducing accumulation of MRI lesions, and preventing progression than is delayed treatment. Delayed therapy also appears illadvised when glatiramer acetate is used as primary treatment.25 A quantitative examination of axonal injury in MS has shown that axonal transsection is corn- Michael Kaufman is Director of the MS Center, Carolinas Healthcare System, Charlotte, North Carolina. 50

2 mon in acute MS lesions,26 presumably leading to irreversible injury; this injury most probably contributes to physical and cognitive impairment. Cognitive impairment is common in early MS, involving up to 6 of patients with Expanded Disability Status Scale (EDSS) scores between 1.0 and 3.5. Its progression can be slowed by treatment.5 Despite appropriate use of immunomodulatory agents, many patients with RRMS experience exacerbations and/or progression (Table l).1"3,27 The results of phase III studies of currently available preparations of interferon beta are similar. A dose effect has been suggested by some studies23'28"30 but not others.31 Two recently completed comparative studies of interferon preparations have suggested that more frequent administration of interferon beta results in improved MRI outcomes and a higher proportion of relapse-free patients; however, neither study followed patients long enough to determine the full impact of significantly higher rates of neutralizing antibodies in the cohort receiving more frequent injections.32'33'34 Because interferon beta treatment is only partially effective for many patients, early supplementary therapy is appropriate for those whose MS is not controlled with single immunomodulators. A personal definition of disease activity is presented in Table 2. The author believes that combination therapy with the agents that are now available should be tested in patients with RRMS and SPMS with relapses. Epidemiologie data35 and one trial using interferon beta-lb24 support aggressive treatment of the latter. This paper discusses agents that Table I Incidence of Relapse and Disease Progression From Phase III Trials of Immunomodulatory Agents During Two Years oftreatment for Patients With RRMS INFß-la (AVONEX )3 Weekly dosage 6 MIU IM % patients with a relapse 6 % patients with progression 21% INFß-lb (Betaseron )' 28MIUSC 7 2 Glati ramer Acetate (Copaxone )27!40mgSC 6 INFß-la 2 27% MIU = million international units; IM = intramuscular; SC = subcutaneous. have been combined with interferon beta, particularly with interferon beta-la injected intramuscularly, in small safety studies and the rationale for the use of some combinations of therapies that have not been examined in such trials. The efficacy of many of these agents has also been recently reviewed elsewhere.36 Two views of how inflammatory cells arrive in the CNS have attracted considerable attention. One view proposes that immune activation occurs in peripheral immune organs, where T cells recognizing CNS autoantigens are stimulated by exogenous antigens.37'38 The other hypothesizes that a chronic infection within the CNS leads to activation of microglia39 that then attract T cells to the CNS. Four distinct pathological patterns have been identified in MS lesions obtained by biopsy and autopsy. Pathologies from different areas of an individual patient affected with MS have appeared uniform. Patterns I and II resemble experimental allergic encephalomyelitis, an animal model of MS with an immune pathophysiology. Patterns III and IV are most consistent with a primary injury, perhaps by a virus, to the myelin sheath and to the oligodendroglial cell body, respectively.40,41 Different mechanisms of injury to CNS tissue could help to explain the marked variability of clinical course and the inconsistent response to therapy in patients with MS. Combinations of agents are likely to be more effective than a single agent for the control of diverse MS pathologies. Indeed, combinations of agents are frequently more effective for the control of some diseases, such as AIDS and tuberculosis, for which the pathogen is precisely known. Principles for optimizing combination therapy in MS are listed in Table 3. Patients taking interferon beta should be tested for the presence of neutralizing antibodies before considering combination therapy. Four studies have shown that the development of neutralizing antibodies reduces (Rebif )2 36 MIU SC 68% the effectiveness of interferon beta.1'3'28'42 Therefore, finding a high titer of neutralizing antibodies in the serum of a patient with disease activity may be sufficient reason to discontinue interferon beta rather than to add agents to it. Two studies43,44 have shown that more neutralizing antibodies to interferon beta form when it is given subcutaneously rather than intramuscularly, when it is given more rather than less frequently, continued on page 56 51

3 NOVANTRONE: A Breakthrough in MS The first therapy indicated to reduce neurologic disability in secondary progressive MS. NOVANTRONE is also indicated to reduce neurologic disability in progressive relapsing and worsening relapsing-remitting MS, NOVANTRONE is not indicated for primary progressive MS. Clinical benefits demonstrated in a trial of NOVANTRONE 12 mg/m2 Significantly reduced relapse rate Prolonged time to first treated relapse; median not reached at 24 months with NOVANTRONE vs 14.2 months for placebo (p=.0004) 67% reduction in the number of treated relapses Significantly reduced neurologic disability Significantly improved change in EDSS* from baseline compared to placebo (p=.019) 61% reduction in deterioration in Ambulation Index1 *Expanded Disability Status Scale (EDSS). ambulation Index (AI) rates a patient's mobility from 0 (asymptomatic or fully active) to 9 (restricted to wheelchair and unable to transfer independently). fmri was performed for a subgroup of 110 patients at predefined centers based on their ability to perform MRI scans according to protocol. Demographics of the MRI subgroup were similar to the overall study population. Please see brief summary of prescribing information at the end of this advertisement for a more complete listing of indications, contraindications, warnings, precautions, adverse reactions, and dosage and administration guidelines.

4 once every 3 months for 24 months...1 " Clinical efficacy confirmed by MRP Significantly decreased new gadolinium-enhancing (Gd+) lesions Generally manageable side effects The most common adverse events associated with NOVANTRONE in the Phase 3 trial were nausea, alopecia, menstrual disorder, amenorrhea, urinary tract infection, stomatitis, arrhythmia, diarrhea, and constipation Please see important treatment considerations on next page immunex Novantrone mitoxantrone for injection concentrate Changing the Course of MS

5 z$ Bringing Optimsism to MS treatment Novantrone mitoxantrone Changin ;. Changing the Course of MS Convenient, quarterly Short 5- to 15-miriute infusion evei^llriiä ; mmm INRJSION 000M SBm;m V y/a.-'.' :* ; '&*&'& -:'& $; Important administration guidelines NOVANTRONE should be administered under the supervision of a physician experienced in the use of cytotoxic chemotherapy agents. NOVANTRONE should be given into a freely flowing intravenous infusion. NOVANTRONE should not be given by subcutaneous, intramuscular, intrathecal, or intra-arterial injection. Severe permanent injury can result from these forms of administration. Generally manageable side effects The most common side effects with NOVANTRONE in the Phase 3 clinical trial in patients with MS were nausea, alopecia, menstrual disorder, amenorrhea, urinary tract infection, stomatitis, arrhythmia, diarrhea, and constipation Important treatment considerations Serious myocardial toxicity can occur with NOVANTRONE and should be monitored Cardiac monitoring of LVEF should be conducted at baseline, at a cumulative dose of 100 mg/m* and prior to alt subsequent doses. Treatment should be discontinued if LVEF is less than 5 or there is a clinically significant reduction in LVEF. Ordinarily, NOVANTRONE should not be administered beyond a cumulative lifetime dose of 140 mg/m2. In cancer patients, the risk of clinical congestive heart failure was estimated to be 2. for patients who received a cumulative dose of up to 140 mg/m2 either alone or in combination with other chemotherapeutic agents. Risk increases in patients with prior anthracycline treatment, prior mediastinal radiotherapy, or preexisting cardiovascular disease. Neutropenia may occur with NOVANTRONE and should be monitored; patients should be advised of the signs of myeiosuppression. In MS patients, hematologic monitoring (a complete blood count including platelets) should occur prior to each course of NOVANTRONE and if signs of infection develop A liver function test should occur prior to each course of NOVANTRONE. NOVANTRONE is not recommended for patients with abnormal liver function tests Other important information Secondary ieukemias have been reported infrequently in cancer patients treated with NOVANTRONE in combination with other cytotoxic agents Women who are pregnant, breast feeding, or attempting to get pregnant should not use NOVANTRONE. It is recommended that women who are biologically capable of becoming pregnant, even if they are using birth control, should have a pregnancy test prior to each dose For more information about NOVANTRONE, pleg^e contact iMMUNEX or visit our Web site at Reference: 1. Immunex Corporation. NOVANTRONE (mitoxantrone for injection concentrate) package insert Seattle, WA October. Please see adjacent page of this advertisement for a brief summary of prescribing information, which includes a $toe complete listing of contraindications, warnings, precautions, and adverse reactions. immunex» 2001 Immunex Corporation, Seattle, WA JA APR 4/01

6 Novantrone mitoxantrone for injection concentrate BRIEF SUMMARY Please see package insert for full Prescribing Information. NOVANTRONE (mitoxantrone for injection concentrate) should be administered under the supervision of a physician experienced in the use of cytotoxic chemotherapy agents. NOVANTRONE should be given slowly into a freely flowing intravenous infusion. It must never be given subcutaneously, intramuscularly, or intra-arterially. Severe local tissue damage may occur if there is extravasation during administration. (See ADVERSE REACTIONS, General, Cutaneous) NOT FOR INTRATHECAL USE Severe injury with permanent sequelae can result from intrathecal administration. (See WARNINGS, General) Except for the treatment of acute nonlymphocytic leukemia, NOVANTRONE therapy generally should not be given to patients with baseline neutrophil counts of less than 1,500 cells/mm 3. In order to monitor the occurrence of bone marrow suppression, primarily neutropenia, which may be severe and result in infection, it is recommended that frequent peripheral blood cell counts be performed on all patients receiving NOVANTRONE Myocardial toxicity, manifested in its most severe form by potentially fatal congestive heart failure (CHF), may occur either during therapy with NOVANTRONE or months to years after termination of therapy. Use of NOVANTRONE has been associated with cardiotoxicity, this risk increases with cumulative dose. In cancer patients, the risk of symptomatic congestive heart failure (CHF) was estimated to be 2. for patients receiving up to a cumulative dose of 140 mg/m 2. For this reason, patients should be monitored for evidence of cardiac toxicity and questioned about symptoms of heart failure prior to initiation of treatment. Patients with multiple sclerosis who reach a cumulative dose of 100 mg/m 2 should be monitored for evidence of cardiac toxicity prior to each subsequent dose. Ordinarily, patients with multiple sclerosis should not receive a cumulative dose greater than 140 mg/m 2. Active or dormant cardiovascular disease, prior or concomitant radiotherapy to the mediastinal/pericardial area, previous therapy with other anthracyclines or anthracenediones, or concomitant use of other cardiotoxic drugs may increase the risk of cardiac toxicity. Cardiac toxicity with NOVANTRONE may occur at lower cumulative doses whether or not cardiac risk factors are present. For additional information, see WARNINGS, Cardiac Effects, and DOSAGE AND ADMINISTRATION. Secondary acute myelogenous leukemia (AML) has been reported in cancer patients treated with anthracyclines. NOVANTRONE is an anthracenedione, a related drug. The occurrence of refractory secondary leukemia is more common when anthracyclines are given in combination with DNA-damaging antineoplastic agents, when patients have been heavily pretreated with cytotoxic drugs, or when doses of anthracyclines have been escalated. Secondary leukemias have been reported in cancer patients treated with NOVANTRONE in combination with other cytotoxic agents; the incidence of these events has not been quantified. CLINICAL PHARMACOLOGY Hepatic Impairment - Mitoxantrone clearance is reduced by hepatic impairment. Patients with severe hepatic dysfunction (bilirubin > 3.4 mg/dl) have an AUC more than three times greater than that of patients with normal hepatic function receiving the same dose. Patients with multiple sclerosis who have hepatic impairment should ordinarily not be treated with NOVANTRONE Other patients with hepatic impairment should be treated with caution and dosage adjustment may be required. Drug Interactions - Pharmacokinetic studies of the interaction of NOVANTRONE with concomitantly administered medications have not been performed.the pathways leading to the metabolism of NOVANTRONE have not been elucidated.to date, post-marketing experience has not revealed any significant drug interactions in patients who have received NOVANTRONE for treatment of cancer. Information on drug interactions in patients with multiple sclerosis is limited. INDICATIONS AND USAGE - NOVANTRONE is indicated for reducing neurologic disability and/or the frequency of clinical relapses in patients with secondary (chronic) progressive, progressive relapsing, or worsening relapsing-remitting multiple sclerosis (i.e., patients whose neurologic status is significantly abnormal between relapses). NOVANTRONE is not indicated in the treatment of patients with primary progressive multiple sclerosis. The clinical patterns of multiple sclerosis in the studies were characterized as follows: secondary progressive and progressive relapsing disease were characterized by gradual increasing disability with or without superimposed clinical relapses, and worsening relapsing-remitting disease was characterized by clinical relapses resulting in a stepwise worsening of disability. CONTRAINDICATIONS - NOVANTRONE is contraindicated in patients who have demonstrated prior hypersensitivity to it. WARNINGS -WHEN NOVANTRONE IS USED IN HIGH DOSES (> 14 mg/m 2 /d X 3 DAYS) SUCH AS INDICATED FOR THE TREATMENT OF LEUKEMIA, SEVERE MYELOSUPPRESSION WILL OCCUR. THEREFORE ΓΤ IS RECOMMENDED THAT NOVANTRONE BE ADMINISTERED ONLY BY PHYSICIANS EXPERIENCED IN THE CHEMOTHERAPY OF THIS DISEASE LABORATORY AND SUPPORTIVE SERVICES MUST BE AVAILABLE FOR HEMATOLOGICAND CHEMISTRY MONITORING AND ADJUNCTS THERAPIES, INCLUDING ANTIBIOTICS. BLOOD AND BLOOD PROD- UCTS MUST BEAVAILABLETO SUPPORT PATIENTS DURING THE EXPECTED PERIOD OF MEDULLARY HYPOPLASIAAND SEVERE MYELOSUP- PRESSION. PARTICULAR CARE SHOULD BE GIVEN TO ASSURING FULL HEMATOLOGIC RECOVERY BEFORE UNDERTAKING CONSOLIDATION THERAPY (IFTHIS TREATMENT IS USED) AND PATIENTS SHOULD BE MONiTORED CLOSELY DURING THIS PHASE NOVANTRONE ADMINIS- TERED AT ANY DOSE CAN CAUSE MYELOSUPPRESSION. General - Patients with preexisting myelosuppression as the result of prior drug therapy should not receive NOVANTRONE unless it is felt that the possible benefit from such treatment warrants the risk of further medullary suppression. The safety of NOVANTRONE in patients with hepatic insufficiency is not established (see CLINICAL PHARMACOLOGY). Safety for use by routes other than intravenous administration has not been established. NOVANTRONE is not indicated for subcutaneous, intramuscular, or intra-arterial injection.there have been reports of local/regional neuropathy, some irreversible, following intra-arterial injection. NOVANTRONE must not be given by intrathecal injection. There have been reports of neuropathy and neurotoxicity, both central and peripheral, following intrathecal injection. These reports have included seizures leading to coma and severe neurologic sequelae, and paralysis with bowel and bladder dysfunction. Topoisomerase II inhibitors, including NOVANTRONE in combination with other antineoplastic agents, have been associated with the development of acute leukemia. Cardiac Effects - Because of the possible danger of cardiac effects in patients previously treated with daunorubicin or doxorubicin, the benefit-to-risk ratio of NOVANTRONE therapy in such patients should be determined before starting therapy. Functional cardiac changes including decreases in left ventricular ejection fraction (LVEF) and irreversible congestive heart failure can occur with NOVANTRONE Cardiac toxicity may be more common in patients with prior treatment with anthracyclines, prior mediastinal radiotherapy, or with preexisting cardiovascular disease. Such patients should have regular cardiac monitoring of LVEF from the initiation of therapy. Cancer patients who received cumulative doses of 140 mg/m 2 either alone or in combination with other chemotherapeutic agents had a cumulative 2. probability of clinical congestive heart failure. In comparative oncology trials, the overall cumulative probability rate of moderate or severe decreases in LVEF at this dose was 1. Multiple Sclerosis - Functional cardiac changes may occur in patients with multiple sclerosis treated with NOVANTRONE In one controlled trial, two patients () of 127 receiving NOVANTRONE one receiving a 5 mg/m 2 dose and the other receiving the 12 mg/m 2 dose, had LVEF values that decreased to below 5. An additional patient receiving 12 mg/m 2, who did not have LVEF measured, had a decrease in another echocardiographic measurement of ventricular function (fractional shortening) that led to discontinuation from the trial (see ADVERSE REACTIONS, Multiple Sclerosis). There were no reports of congestive heart failure in either controlled trial. Evaluation of LVEF (by echocardiogram or MUGA) is recommended prior to administration of the initial dose of NOVANTRONE Ordinarily, multiple sclerosis patients with a baseline LVEF of < 5 should not be treated with NOVANTRONE Subsequent LVEF evaluations are recommended if signs or symptoms of congestive heart failure develop, and prior to all doses administered to patients who have received a cumulative dose of > 100 mg/m 2. NOVANTRONE should not ordinarily be administered to multiple sclerosis patients who have received a cumulative lifetime dose of > 140 mg/m 2, or those with either LVEF of < 5 or a clinically significant reduction in LVEF. Pregnancy NOVANTRONE may cause fetal harm when administered to a pregnant woman. Women of childbearing potential should be advised to avoid becoming pregnant Mitoxantrone is considered a potential human teratogen because of its mechanism of action and the developmental effects demonstrated by related agents. Treatment of pregnant rats during the organogenesis period of gestation was associated with fetal growth retardation at doses > 0.1 mg/kg/day (0.01 times the recommended human dose on a mg/m 2 basis). When pregnant rabbits were treated during organogenesis, an increased incidence of premature delivery was observed at doses > 0.1 mg/kg/day (0.01 times the recommended human dose on a mg/m 2 basis). No teratogenic effects were observed in these studies, but the maximum doses tested were well below the recommended human dose (0.02 and 0.05 times in rats and rabbits, respectively, on a mg/m 2 basis). There are no adequate and well-controlled studies in pregnant women. Women with multiple sclerosis who are biologically capable of becoming pregnant should have a pregnancy test prior to each dose, and the results should be known prior to administration of the drug. If this drug is used during pregnancy or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential risk to the fetus. PRECAUTIONS General - Therapy with NOVANTRONE should be accompanied by close and frequent monitoring of hematologic and chemical laboratory parameters, as well as frequent patient observation. Systemic infections should be treated concomitantly with or just prior to commencing therapy with NOVANTRONE Information for Patients - NOVANTRONE may impart a blue-green color to the urine for 24 hours after administration, and patients should be advised to expect this during therapy. Bluish discoloration of the sclera may also occur. Patients should be advised of the signs and symptoms of myelosuppression. Patients with multiple sclerosis should be provided with the Patient Package Insert at the time that the decision is made to treat with NOVANTRONE and prior to and in close temporal proximity to each treatment. In addition, the physician should discuss the issues addressed in the Patient Package Insert with the patient. Laboratory Tests -A complete blood count, including platelets, should be obtained prior to each course of NOVANTRONE and in the event that signs and symptoms of infection develop. Liver function tests should also be performed prior to each course of therapy. NOVANTRONE therapy in multiple sclerosis patients with abnormal liver function tests is not recommended because NOVANTRONE clearance is reduced by hepatic impairment and no laboratory measurement can predict drug clearance and dose adjustments. Women with multiple sclerosis who are biologically capable of becoming pregnant even if they are using birth control, should have a pregnancy test, and the results should be known, before receiving each dose of NOVANTRONE (see WARNINGS, Pregnancy). Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenesis - Intravenous treatment of rats and mice, once every 21 days for 24 months, with NOVANTRONE resulted in an increased incidence of fibroma and external auditory canal tumors in rats at a dose of 0.03 mg/kg (0.02 fold the recommended human dose, on a mg/m 2 basis), and hepatocellular adenoma in male mice at a dose of 0.1 mg/kg (0.03 fold the recommended human dose, on a mg/m 2 basis). Intravenous treatment of rats, once every 21 days for 12 months with NOVANTRONE resulted in an increased incidence of external auditory canal tumors in rats at a dose of 0.3 mg/kg (0.15 fold the recommended human dose, on a mg/m 2 basis). Mutagenesis - NOVANTRONE was clastogenic in the in vivo rat bone marrow assay. NOVANTRONE was also clastogenic in two in vitro assays; it induced DNA damage in primary rat hepatocytes and sister chromatid exchanges in Chinese hamster ovary cells. NOVANTRONE was mutagenic in bacterial and mammalian test systems (Ames/Salmonella and E coli and L5178Y TK +/- mouse lymphoma). Drug Interactions - Mitoxantrone and its metabolites are excreted in bile and urine, but it is not known whether the metabolic or excretory pathways are saturable, may be inhibited or induced, or if mitoxantrone and its metabolites undergo enterohepatic circulation.to date, post-marketing experience has not revealed any significant drug interactions in patients who have received NOVANTRONE for treatment of cancer. Information on drug interactions in patients with multiple sclerosis is limited. Following concurrent administration of NOVANTRONE with corticosteroids, no evidence of drug interactions has been observed. Special Population Hepatic Impairment - Patients with multiple sclerosis who have hepatic impairment should ordinarily not be treated with NOVANTRONE. NOVANTRONE should be administered with caution to other patients with hepatic impairment. In patients with severe hepatic impairment, the AUC is more than three times greater than the value observed in patients with normal hepatic function. Pregnancy - Pregnancy Category D (see WARNINGS). Nursing Mothers - NOVANTRONE is excreted in human milk and significant concentrations (18 ng/ml) have been reported for 28 days after the last administration. Because of the potential for serious adverse reactions in infants from NOVANTRONE, breast feeding should be discontinued before starting treatment Pediatric Use - Safety and effectiveness in pediatric patients have not been established. ADVERSE REACTIONS Multiple Sclerosis - NOVANTRONE has been administered to 149 patients with multiple sclerosis in two randomized clinical trials, including 21 patients who received NOVANTRONE in combination with corticosteroids. In Study 1, the proportion of patients who discontinued treatment due to an adverse event was 9.7% (n - 6) in the 12 mg/m 2 NOVANTRONE arm (leukopenia, depression, decreased LV function, bone pain and emesis, renal failure, and one discontinuation to prevent future complications from repeated urinary tract infections) compared to 3.1% (n - 2) in the placebo arm (hepatitis and myocardial infarction). The following clinical adverse experiences were significantly more frequent in the NOVANTRONE groups: nausea, alopecia, urinary tract infection, and menstrual disorders, including amenorrhea.table la summarizes clinical adverse events of all intensities occurring in > of patients in either dose group of NOVANTRONE and that were numerically greater on drug than on placebo in Study 1. The majority of these events were of mild to moderate intensity, and nausea was the only adverse event that occurred with severe intensity in more than one patient (three patients (J in the 12 mg/m 2 group). Of note, alopecia consisted of mild hair thinning. Two of the 127 patients treated with NOVANTRONE in Study 1 had decreased LVEF to below 5 at some point during the 2 years of treatment. An additional patient receiving 12 mg/m 2 did not have LVEF measured, but had another echocardiographic measure of ventricular function (fractional shortening) that led to discontinuation from the study. Table la Adverse Events of Any Intensity Occurring in > of Patients on Any Dose of NOVANTRONE and That Were Numerically Greater Than in the Placebo Group Study 1 Percent of Patients Preferred Term Nausea Alopecia Menstrual disorder* Amenorrhea* Upper respiratory tract infection Urinary tract infection Stomatitis Arrhythmia Diarrhea Urine abnormal ECG abnormal Constipation Back pain Sinusitis Headache Placebo (N-64) mg/m 2 NOVANTRONE (N - 65) mg/m 2 NOVANTRONE (N-62) Percentage of female patients. The proportion of patients experiencing any infection during Study 1 was 67% for the placebo group, 8 for the 5 mg/m 2 group, and 81% for the 12 mg/m 2 group. However, few of these infections required hospitalization: one placebo patient (tonsillitis), three 5 mg/m 2 patients (enteritis, urinary tract infection, viral infection), and four 12 mg/m 2 patients (tonsillitis, urinary tract infection [two], endometritis). Table lb summarizes laboratory abnormalities that occurred in > of patients in either NOVANTRONE dose group, and that were numerically more frequent than in the placebo group. Table lb Laboratory Abnormalities Occurring in > of Patients* on Either Dose of NOVANTRONE and That Were More Frequent Than in the Placebo Group Study 1 Percent of Patients Event Leukopenia' Gamma-GT SGOT Granulocytopenia" Anemia SGPT Assessed using World Health Organization (WHO) toxicity criteria. a. < 4000 cells/mm? b. < 2000 cells/mm? 5 mg/m 2 NOVANTRONE (N-65) mg/m 2 NOVANTRONE (N - 62)

7 There was no difference among treatment groups in the incidence or severity of hemorrhagic events. In Study 2, NOVANTRONE* (mitoxantrone for injection concentrate) was administered once a month. Clinical adverse events most frequently reported in the NOVANTRONE group included amenorrhea (5 of female patients), alopecia (3 of patients), nausea (29% of patients), and asthenia (2 of patients). Tables 2a and 2b respectively summarize adverse events and laboratory abnormalities occurring in > of patients in the NOVANTRONE group and numerically more frequent than in the control group. Table 2a Adverse Events of Any Intensity Occurring in > of Patients* In the NOVANTRONE Group and Numerically More Frequent Than in the Control Group Study 2 Percent of Patients Phayngtttytrra* «ifcctton Gastnrifls/stofflich bunv epigastric pi N NOVANTRONE, MP methyiprednisoione. Assessed usine National Cancer Institute (NO) common tudcfy criteria. a. P*wnta s of female patients. (n - 21) (Π-21) Table 2b Laboratory Abnormalities Occurring In > of Patients* In the NOVANTRONE Group and Numerically n Frequent Than in the Control Group Study 2 Percent of Patients MP N*MP Event (n-21) (n-21) WBClow' ANCiow* Lymphocytes low Henoftobin low Platelets lowc SGOThitfi SOT high Glucose high Potassium low N - NOVANTRONE, MP - methylprednisolone. Assessed using National Cancer Institute (NO) common taxiert* criteria. a.<4000cellvmnrl b.<1500cehs/rnm> c< 100,000 cefc/mm; Leukopenia and neutropenia were reported in the N+MP group (see Table 2b). Neutropenia occurred within 3 weeks after NOVANTRONE administration and was always reversible. Only mild to moderate intensity Infections were reported in 9 of 21 patients in the N + MP group and in 3 of 21 patients in the MP group; none of these required hospitalization. There was no difference among treatment groups in the incidence or severity of hemorrhage events. There were no withdrawals from Study 2 for safety reasons. Allergic Reaction Hypotension, urticaria, dyspnea, and rashes have been reported occasionally. Cutaneous - Extravasation at the infusion site has been reported, which may result in erythema, swelling, pain, burning, and/or blue discoloration of the skin. Extravasation can result in tissue necrosis with resultant need for debridernent and skin grafting. Phlebitis has also been reported at the site of the infusion. Hematologic Topoisomerase II inhibitors, including NOVANTRONE, in combination with other antineoplastic agents, have been associated wfth the development of acute leukemia. Gastrointestinal - Nausea and vomiting occurred acutely in most patients and may have contributed to reports of dehydration, but were generally mild to moderate and could be controlled through the use of arrtiemetics. Stomatitis/mucositis occurred wfthin 1 week of therapy. Cardiovascular - Congestive heart failure, tachycardia, EKG changes including arrhythmias, chest pain, and asymptomatic decreases in left ventricular ejection fraction have occurred. (See WARNINGS) Pulmonary Interstitial pneumonias has been reported in cancer patients receiving combination chemotherapy that included NOVANTRONE OVERDOSAGE - There is no known specific antidote for NOVANTRONE Accidental overdoses have been reported. Four patients receiving mg/m1 as a single bolus Injection died as a result of severe leukopenia with infection. Hematologic support and antimicrobial therapy may be required during prolonged periods of severe myelosuppression. Although patients with severe renal failure have not been studied, NOVANTRONE is extensively tissue bound and it is unlikely that the therapeutic effect or toxicity would be mitigated by peritoneal or hemodialysis. DOSAGE AND ADMINISTRATION (See also WARNINGS) Multiple Sclerosis The recommended dosage of NOVANTRONE is 12 mg/m3 given as a short (approximately 5 to 15 minutes) intravenous infusion every 3 months. Evaluation of LVEF (by echocardiogram or MUGA) is recommended prior to administration of the initial dose of NOVANTRONE Subsequent LVEF evaluations are recommended if signs or symptoms of congestive heart failure develop, and prior to ad doses administered to patients who have received a cumulative dose of mg/m1. NOVANTRONE should not ordinarily be administered to multiple sclerosis patients who have received a cumulative lifetime dose of 140 mg/m2, or those with either LVEF of < 5 or a clinically-significant reduction in LVEF. Complete blood counts, including platelets, should be monitored prior to each course of NOVANTRONE and in the event that signs or symptoms of infection develop. NOVANTRONE generally should not be administered to multiple sclerosis patients with neutrophil counts less than'1500 cefts/mm3. Liver function should also be monitored prior to each course. NOVANTRONE therapy in multiple sclerosis patients with abnormal liver function tests is not recommended because NOVANTRONE clearance is reduced by hepatic impairment and no laboratory measurement can predict drug clearance and dose adjustments. Women with multiple sclerosis who are biologically capable of becoming pregnant, even if they are using birth control, should have a pregnancy test, and the results should be known, before receiving each dose of NOVANTRONE (see WARNINGS, Pregnancy). Rev Cl Issue Date 10/2000 Manufactured for IMMUNEX CORPORATION, Seattle, WA by LEDERLE PARENTERALS, INC. Carolina, Puerto Rico irnrnunex 2000 Irnrnunex Corporation, Seattle, WA IS JA N0V 1/01 continued from page 51 and when interferon beta-lb is used rather than Interferon beta-la. CORTICOSTEROIDS Corticosteroids also have broad effects upon the immune system that include lymphocytotoxicity,45 diminished trafficking of cells into the CNS,46 increased production of regulatory cytokines,47 and suppression of lipid peroxidation.48 A high degree of protein binding of corticosteroids and the relative impermeability of the blood-brain barrier to their bound form necessitate administration of large doses for entry of unbound drug into the CNS. Administration of methylprednisolone 250 mg intravenously (IV) every six hours on three consecutive days to patients with isolated optic neuritis has been shown to reduce the incidence of clinically definite MS for two years49 but not for longer.50 Following the publication of these results, methylprednisolone typically has been given IV at a dose of 1 g over one hour, to allow for outpatient administration, for three to five days during acute exacerbations of MS. In my experience, the equivalent dose of an oral corticosteroid is easily tolerated. Whether serum corticosteroid binding sites on serum proteins are saturated as well by an oral corticosteroid as by IV administration has not been studied. IV-pulsed methylprednisolone, 500 mg/d for three days every other month in SPMS with relapses,51 or 1,000 mg/d for three days every third month in RRMS52 appears to be beneficial for patients with MS. An open-label study using interferon beta-la intramuscularly and prednisone (7.5 to 15 mg/kg/d) has demonstrated the safety of this combination.53 CYTOTOXIC IMMUNOSUPPRESSANTS Cytotoxic immunosuppressants have demonstrated efficacy in human immune-mediated diseases, in experimental allergic encephalomyelitis, and, to varying degrees, in MS. While the development of less toxic agents is highly desirable, the severe physical and cognitive disability that can result from MS may justify the exploratory use of cytotoxic agents in combination with interferon beta. The safe use of cytotoxic immunosuppression requires careful screening and close follow-up of patients. A battery of appropriate serum tests, a chest x-ray, possibly dental x-rays, and a careful physical examination should be performed prior to 56

8 Table 2 A Personal View of Evidence of Disease Activity Two or more gadolinium-positive lesions in the absence of a relapse Significant new persistent T2-weighted activity Significant new cerebral atrophy A relapse resulting in a Kurtzke Functional Scale (KFS) change of 2 or more points in pyramidal, cerebellar, or visual function Three relapses within two years resulting in a KFS change of less than 2 points or that are not associated with any KFS change in the absence of fever and somatization Demonstration of new cognitive impairment in the absence of depression and somatization beginning treatment. The dose-limiting side effects of many agents are bone marrow suppression, hepatic toxicity, and gastrointestinal mucosal injury. Routine monitoring of the complete blood count and hepatic enzymes is usually necessary. I generally increase the dose of cytotoxic agents that produce continuous immunosuppression until the lymphocyte count is higher than 1,000 cells/mm3, so long as the neutrophil count remains higher than 1,500 cells/mm3. Induction of gonadal failure limits the lifetime dose of some therapies in young patients who wish to have children. Concurrent administration of gonadotropinreleasing hormone agonist analogues is a potential remedy to this treatment complication.54 Patients taking cytotoxic therapies must be instructed to follow adequate contraception measures, and a pregnancy test should be administered prior to the start of therapy. For optimal treatment of MS, it is unclear whether one should attempt to reduce the number of leukocytes within the CNS. A cautious approach is warranted, since entry of cytotoxic agents into the CNS could destroy mitotically active precursor cells that are responsible for remyelination within the brain.55'56 Table 3 Principles for Optimizing Combination Therapy in MS Mitoxantrone is the only cytotoxic immunosuppressant approved by the FDA for the treatment of patients with MS. Azathioprine, cyclophosphamide, and methotrexate are among the agents that are used off-label for the treatment of MS. These agents are discussed below, and safety issues that should be considered when using these and other drugs are outlined in Table 4. AZATHIOPRINE Choose treatments that - Are administered easily - Have different, complementary mechanisms of action - Have non-overlapping toxicities - Are well tolerated over long periods - Address multiple pathological processes relevant to MS Treatment must be appropriate for the population, eg, a patient of childbearing age may wish to avoid gonadotoxic therapy Follow patients taking combination therapies closely with sensitive clinical scales, laboratory tests, and MRI so that ineffective or toxic therapy can be changed Limit total doses of agents with cumulative toxicity When possible, refer patients to centers conducting clinical trials of combination therapy, so the effectiveness of therapeutic combinations can be determined Azathioprine is widely used in Europe for the treatment of MS. Therapeutic effects of azathioprine in MS are presumably mediated by disruption of T-cell activation and differentiation. As commonly prescribed, azathioprine is administrated orally beginning at a dosage of 50 mg/d and increasing by 50 mg/mo until the mean red blood cell corpuscular volume is higher than 100 fl57 and/or the absolute lymphocyte count is lower than 1,000 cells/mm3. The usual dosage of azathioprine is 2 to 3 mg/kg per day, but both its full therapeutic effect and its acute side effects may be delayed for months.58 Two meta-analyses of MS trials suggest that azathioprine moderately reduces relapse rate and disability.59,60 The safety of azathioprine in combination with interferon beta has been supported by several small pilot studies.61"64 CYCLOPHOSPHAMIDE Cyclophosphamide has potentially beneficial effects upon immune dysfunction in MS patients.65"67 The combination of pulsed IV cyclophosphamide and IV methylprednisone has provided inconsistent results in clinical trials for progressive MS.68'69 Two small studies have suggested that the combination of cyclophosphamide and interferon beta may be beneficial for patients with rapidly 57

9 worsening MS.70'71 An ongoing trial is evaluating intramuscular interferon beta-la in combination with either IV methylprednisolone (1 g/mo) or with IV methylprednisolone plus IV cyclophosphamide (800 mg/m2/mo). A preliminary report of this trial suggests this combination is safe and well tolerated.72 A small, blinded, placebo-controlled trial has suggested that oral cyclophosphamide (up to 500 mg/m2/wk, orally) can be used safely with intramuscular interferon beta-la.73 METHOTREXATE Methotrexate is an antimetabolite that inhibits dihydrofolate reductase, impairing the synthesis of purine nucleotides and thymidylate. The absorption of oral doses is highly unpredictable.74 In progressive MS, methotrexate 7.5 mg orally per week has been reported to modestly slow impairment of upper limb dexterity.75 I initiate methotrexate therapy at a dosage of 7.5 mg/wk and then increase the dosage by 2.5 mg/mo, up to a once-weekly dosage of 30 mg, if tolerated. A small open-label trial of intramuscular interferon betala and oral methotrexate (20 mg/wk) has shown that this combination appears to be safe and to reduce the number of gadolinium-enhanced lesions on MRI at three to six months after initiation of therapy.76 Theoretically, methotrexate can be used to purge the CNS of the immunologically active cells. To reach cytocidal concentrations in the CNS, methotrexate must be administered IV at doses greater than 0.5 g/m2 77 and the administration of folinic acid (leucovorin), adequate hydration, and urinary alkalinization are required. High-dose IV methotrexate therapy (2.5 g/m2) followed by leucovorin rescue therapy administered every two months has been reported to ameliorate disease in eight of 11 patients with primary progressive MS or SPMS.78 MlTOXANTRONE Mitoxantrone is a synthetic anthracenedione that damages deoxyribonucleic acid. A large, randomized, double-blind, placebo-controlled study of MS has demonstrated efficacy for mitoxantrone at a dosage of 12 mg/m2 given IV once every three months.79 The combination of mitoxantrone and pulse IV methylprednisolone may be beneficial for the treatment of MS.80 Induction therapy is being considered in a trial in which mitoxantrone is to be given in monthly 20-mg IV boluses for six months followed by treatment with interferon beta-lb.81 In breast cancer patients, mitoxantrone in combination with radiation therapy or other mutagenic agents has been associated with a high risk of secondary malignancies.82 However, in three studies of mitoxantrone without other mutagenic therapies, no secondary leukemia has occurred during a mean follow-up period of 3.5 years.79>81>83 Mitoxantrone can cause cardiomyopathy, with a rapid rise in incidence at cumulative doses higher than 140 mg/m2. The author uses a multi-gated acquisition or MUGA scan of the heart to assess ejection fraction at baseline and before each administration above a cumulative dose of 100 mg/m2. A baseline ejection fraction of more than 5 is required to initiate mitoxantrone treatment, and if an 8% drop in ejection fraction from baseline is observed subsequently, it is discontinued. Dexrazoxane is an agent that reduces the cardiotoxicity of a related antracenedione, doxorubicin, independently ameliorates experimental allergic encephalomyelitis, and works in synergy with mitoxantrone to reduce the severity of experimental allergic encephalomyelitis.84 The combination of mitoxantrone and dexrazoxane may be useful in the treatment of MS. The use of mitoxantrone is associated with a 4 rate of infertility in women.80 GLATIRAMER ACETATE Glatiramer acetate is a mixture of random synthetic polypeptides originally developed to mimic myelin basic protein in the induction of experimental allergic encephalomyelitis. The proposed mechanisms of action of glatiramer acetate in MS are deletion of high-affinity TH1 cells and induction of T-cell clones that recognize glatiramer acetate with low affinity. These glatiramer acetate-specific T cells produce predominantly TH2 cytokines and may cross-react with multiple myelin antigens.85 Other actions of glatiramer acetate may also ameliorate MS.86 Glatiramer acetate has an effect similar to mitoxantrone upon MS relapses but has a more delayed and less robust effect upon MRI lesions.87"91 In a small in vitro study, enhanced suppression of mitogen-induced T-cell activation was demonstrated with the combination of glatiramer acetate and interferon beta as compared with either agent alone.90 58

10 Table 4 Treatment Consideration for Agents Used in Combination With Interferon Beta Drug AZA* Side Effects Acute: Allergic response with fever, nausea, vomiting, and anorexia; hepatitis; skin rash; bone marrow suppression58 Longterm: Risk of a secondary lymphoma low,'' occurring: after 10 years of continuous treatment"!' Laboratory Monitoring CBC weekly until maintenance dose is reached, then monthly For neutrophil count < 1,000 cells/mm3 or platelet count < 50,000 cells/mm3, discontinue AZA; restart at lower dose when counts recover Hepatic enzymes monthly Special Considerations Onset of action and side effects may be delayed If taking allopurinol.dose should be reduced by 7109 Low activity of thiopurine methyltransferase increases risk of leukocytosis and mucositis.1,2 CYP* Acute: Nausea, vomiting, mucositis, skin rash, thinning of the hair, darkening and dryness of the skin, and weight gain are common; hepatitis, hemorrhagic cystitis, inappropriate antidiuretic hormone secretion and cardiotoxicity occur rarely Long-term: Premature menopause; sterility; rare secondary leukemia, lymphoma, and bladder cancer; activation of varicella virus IV dose: CBCs, urinalysis, and hepatic enzymes monthly; check for nadir for WBC eight to 11 days Oral dose: CBC and urinalysis monthly and bimonthly hepatic enzyme tests Yearly chest x-rays and urine cytologies Keep maximum lifetime dose < 50 g Alopecia and gonadal failure make use in young patients problematic Good hydration and administration of NaHC03 during the day of CYP protects against bladder toxicity Very large doses of CYP may require mesna (Mesnex ) for bladder protection 113 MTX* Acute: Bone marrow and gastrointestinal toxicity occur five to 14 days after treatment High doses: Renal failure, elevations of hepatic enzymes, and pneumonitis; rarely progressive encephalopathy with doses of 8 to 15 g/m2 ',4 Long-term: Hepatic, retroperitoneal, pulmonary, and renal fibrosis; infertility in 1 to 2 at low doses CBCs monthly, hepatic enzymes and creatinine bimonthly Creatinine clearance and chest x-ray yearly Continuous and prolonged exposure produces toxicity due to high intracellular levels of MTX Urge extravascular reservoirs such as ascitis, pleural effusion, or significant edema can enhance toxicity Nausea can be reduced by administration of intramuscular MTX Concurrent use of aspirin, tetracycline, phenytoin,and trimethoprim-sulfamethoxazole can increase toxicity1,5 MITOX* Acute: Nausea, vomiting, blue sclera and urine; bone marrow toxicity seven to 14 days after treatment; locally corrosive to tissues Long-term: Cardiotoxicity; secondary cancers in patients taking other mutagenic agents82 CBC, hepatic enzymes, and physical examination before each administration Cardiac ejection fraction at baseline and before each administration after total dose of 100 mg/m2 baseline should be > 5 Check WBC and platelet nadir so that next dose can be reduced if necessary Administered over 20 to 60 minutes IV Do not administer if neutrophil count < 1,500 or platelet count < 75,000 Do not administer to patients with abnormalities of hepatic enzymes since impairment of liver function makes metabolism unpredictable IVIg Acute: Fever, malaise, myalgia, rashes, nausea, and headache may occur within minutes to hours of treatment; less common are aseptic meningitis, renal failure (more common in preparations containing sucrose), and deep vein thrombosis"6 Chronic Renal disease,alopecia,'l7 and eczema"6 Check immunoelectrophoresis to find patients with absence of immunoglobulin alpha Check creatinine at institution and prior to each treatment Anaphylaxis (more common with preparations containing immunoglobulin alpha) Nonrecombinant human protein CS Acute: Agitation, mania, gastrointestinal bleeding, glucose intolerance, acne, hypokalemia, candidiasis Chronic Cataracts, bruising, cushingpid appearance, osteopenia, gastric ulcer, hypertension, activation of tuberculosis, aseptic necrosis of bone, hirsutism Baseline chest x-ray, electrolytes, CBC Rarely, rapid administration can lead to intense flushing, burning genital pain, and circulatory collapse Aseptic necrosis on bone can occasionally occur after a single administration AZA, azathioprine; CBC, complete blood count; CYP, cyclophosphamide;wbc, white blood count; MTX, methotrexate; MITOX, mitoxantrone; IVIg, intravenous immunoglobulin; CS, corticosteroids. *See text for common precautions when using cytotoxic immunosuppressants. 59

11 A small trial investigating intramuscular interferon beta-la and glatiramer acetate in relapsing MS has suggested that this combination has no adverse effects upon MRI scan activity.91 Glatiramer acetate is administered daily by subcutaneous injection in a dose of 20 mg. Side effects are mild and easy to manage. Injection site pain, erythema, and subcutaneous scarring occur to a variable degree in nearly all patients. An infrequent, intermittent systemic reaction (dyspnea, chest pain, hives, palpitations, anxiety, or flushing) occurs in 1 to 38% of patients.29,87 Rarely, chronic lymphadenopathy and eosinophilia are seen in response to therapy. INTRAVENOUS HUMAN IMMUNOGLOBULIN Commercially available IV human immunoglobulin (IVIg) contains antibodies and small amounts of impurities, including cytokines derived from pools of 3,000 to 10,000 donors. IVIg does not suppress bone marrow, has multiple mechanisms of action, has an 18- to 32-day half-life, and enters the CNS when given in high concentrations.92 Unfortunately, it is expensive, available in limited quantities, and nonrecombinantly derived. Studies have suggested a benefit of IVIg for RRMS,93"95 but no benefit has been found for patients with SPMS.96 The dosage of IVIg used in MS trials has ranged from to 2 g/kg/mo.96 An open-label trial of intramuscular interferon beta-la and IVIg is being conducted.97 Prior to infusion of IVIg, I prescribe diphenhydramine 50 mg orally and acetaminophen 1,000 mg orally. Infusion of IVIg can be initiated at a rate of 2.5 g/h and titrated every 15 minutes in 2.5-g/h steps to a rate of 10 g/h. BLOCKERS OF LEUKOCYTE TRAFFICKING INTO THE CNS Entry of leukocytes into the CNS is an active process that can be inhibited by several strategies. Natalizumab is a humanized monoclonal antibody to oc4ßl integrin, an adhesion molecule that promotes the entry of monocytes, B cells, and T cells into the CNS.98 A phase II trial has shown approximately an 88% to 91% reduction in gadolinium-enhanced MRI lesions and a 43 % to 49% reduction in relapse rate for patients treated with monthly IV infusions of natalizumab." Inhibition of matrix metalloproteases, a family of enzymes that promote the entry of peripheral leukocytes into the CNS, ameliorates experimental allergic encephalomyelitis.100'101 Minocycline, a readily available and well-tolerated tetracycline antibiotic that is a potent inhibitor of matrix metalloproteases, is being considered for the treatment of MS.102 ANTIOXIDANTS MACROPHAGE AND INHIBITORS Patients with MS show evidence of significant oxidative stress.103,104 Nitric oxide synthetase, which elaborates nitric oxide radicals, can be induced in macrophages by interferon-γ.105 Simvastatin, an inhibitor of nitric oxide synthetase, is now undergoing testing for the treatment of MS. Experimental allergic encephalomyelitis can be ameliorated by angiotensinconverting enzyme inhibitors, such as captopril,106 presumably by down-regulating macrophage activity. Beta-2 adrenergic agonists ameliorate experimental allergic encephalomyelitis by inhibiting macrophage interleukin-12 production.107 A trial of the beta-2 adrenergic agonist albuterol sulfate administered to patients with MS is using IL-12 production as an outcome measure. In one small study, the combination of retinoic acid and interferon beta-lb significantly increased suppressor function as compared with interferon beta-lb alone.108 SUMMARY Despite the observed benefits of interferon beta, it is only partially effective in controlling clinically apparent breakthrough symptoms and MRI changes in MS. If patients displaying disease activity while taking interferon beta have high titers of neutralizing antibodies, then interferon beta may be discontinued and alternative treatment initiated. For patients without neutralizing antibodies, interferon beta may be continued and consideration may be given to adding additional therapy. Interferon beta has broad mechanisms of action, many of which do not involve T cell activation, allowing it to be used with cytotoxic and lymphotoxic drugs. In rapidly deteriorating situations, one may consider induction therapy with cytotoxic immunosuppressants to deplete activated T cells. This may be followed by long-term combination therapy I with less toxic agents, including interferon beta. continued on page 63 60

12 Response.Results.Rebif Introducing Your P Lifeline to Answers & More MS lifelines TM The Comprehensive Support Program for Your Patients Caü REBIF or visit Please see the following brief summary ofthefullrebifpreatibmgliilonmtion, mdudingimportantsafetyriiiformation. Rebif8 is a registered trademark of Serono, Inc. MS LifeLines is a trademark of Serono, Inc Serono /02 All rights reserved. Printed in USA. ^Rebif (interfefxxi beta-la) sc injection Response. Results. Rebif.

13 & Rebif sc injection BRIEF SUMMARY Please see package insert for full prescribing information. Indications and Usage Rebif* (interferon-beta-1a) is indicated for the treatment of patients with relapsing forms of multiple sclerosis to decrease the frequency of clinical exacerbations and delay the accumulation of physical disability. Efficacy of Rebif* in chronic progressive multiple sclerosis has not been established. Clinical Studies Two multicenter studies evaluated the safety and efficacy of Rebif* in patients with relapsing-remitting multiple sclerosis. Study 1 demonstrated that Rebif* significantly reduced the number of relapses per patient compared to placebo at 2 years. Study 2 was a comparative trial comparing the recommended doses of Rebif* and Avonex*. The results of this trial demonstrated that patients treated with Rebif* 44 meg sc tiw were more likely to remain relapse-free during the 24-week treatment period than patients treated with Avonex* 30 meg im qw. Adverse reactions were generally similar between the two treatment groups. Exceptions included injection site disorders (8 of patients on Rebif* vs. 2 of patients on Avonex*), hepatic function disorders (1 on Rebif vs. 7% on Avonex*), leukopenia ( on Rebif* vs. <1% on Avonex*), which were observed with greater frequency in the Rebif* group compared to the Avonex* group. Contraindications Rebif* (interferon beta-1a) is contraindicated in patients with a history of hypersensitivity to natural or recombinant interferon, human albumin, mannitol USP, sodium acetate, or Water for Injection USP. WARNINGS Rebif* (interferon beta-1a) should be used with caution in patients with depression, a condition that is common in people with multiple sclerosis. Depression, suicidal ideation, and suicide attempts have been reported to occur with increased frequency in patients receiving interferon compounds, including Rebif". Patients should be advised to report immediately any symptoms of depression and/or suicidal ideation to the"'prescribing physician. If a patient develops depression, cessation of treatment with Rebif* should be considered. A case of fulminant hepatic failure requiring liver transplantation in a patient who initiated Rebif* therapy while taking another potentially hepato-toxic medication has been reported from a non-u.s. postmarketing source. Symptomatic hepatic dysfunction, primarily presenting as jaundice, has been reported as a rare complication of Rebif use. Asymptomatic elevation of hepatic transaminases (particularly SGPT) is common with interferon therapy (see ADVERSE REACTIONS). Rebif* should be initiated with caution in patients with active liver disease, alcohol abuse, increased serum SGPT (> 2.5 times ULN), or a history of significant liver disease. Dose reduction should be considered if SGPT rises above 5 times the upper limit of normal. The dose may be gradually re-escalated when enzyme levels have normalized. Treatment with Rebif* should be stopped if jaundice or other clinical symptoms of liver dysfunction appear. Anaphylaxis has been reported as a rare complication of Rebif* use. Other allergic reactions have included skin rash and urticaria, and have ranged from mild to severe without a clear relationship to dose or duration of exposure. Several allergic reactions, some severe, have occurred after prolonged use. PRECAUTIONS General: Caution should be exercised when administering Rebif* to patients with pre-existing seizure disorders. Seizures have been associated with the use of beta interferons. A relationship between occurrence of seizures and the use of Rebif* has not been established. Leukopenia and new or worsening thyroid abnormalities have developed in some patients treated with Rebif*. Regular monitoring for these conditions is recommended. Information for Patients All patients should be instructed to read the Rebif Medication Guide supplied to them. Patients should be cautioned not to change the dosage or the schedule of administration without medical consultation. Patients should be informed of the most common and the most severe adverse reactions associated with the use of Rebif*. Patients should be advised of the symptoms associated with these conditions, and to report them to their physician. Female patients should be cautioned about the abortifacient potential of Rebif*. Patients should be instructed in the use of aseptic technique when administering Rebif*. Appropriate instruction for self-injection or injection by another person should be provided, including careful review of the Rebif* Medication Guide. If a patient is to self-administer Rebif*, the physical and cognitive ability of that patient to self-administer and properly dispose of syringes should be assessed. The initial injection should be performed under the supervision of an appropriately qualified health care professional. Patients should be advised of the importance of rotating sites of injection with each dose, to minimize the likelihood of severe injection site reactions or necrosis. Laboratory Tests: In addition to those laboratory tests normally required for monitoring patients with multiple sclerosis, blood cell counts and liver function tests are recommended at regular intervals (1, 3, and 6 months) following introduction of Rebif* therapy and then periodically thereafter in the absence of clinical symptoms. Thyroid function tests are recommended every 6 months in patients with a history of thyroid dysfunction or as clinically indicated. Patients with myelosuppression may require more intensive monitoring of complete blood cell counts, with differential and platelet counts. Drug Interactions: Drug interaction studies have not been conducted with Rebif*. Due to its potential to cause neutropenia and lymphopenia, proper monitoring of patients is required if Rebif* is given in combination with myelosuppressive agents. Carcinogenesis, Mutagenesis, Impairment of Fertility: No carcinogenicity data for Rebif*are available in animals or humans. Rebif* was not mutagenic when tested in the Ames bacterial test and in an in vitro cytogenetic assay in human lymphocytes in the presence and absence of metabolic activation. No studies have been conducted to evaluate the effects of Rebif* on fertility in humans. In studies in normally cycling female cynomolgus monkeys given daily sc injections of Rebif* for six months at doses of up to 9 times the recommended weekly human dose (based on body surface area), no effects were observed on either menstrual cycling or serum estradiol levels. The validity of extrapolating doses used in animal studies to human doses is not established. In male monkeys, the same doses of Rebif* had no demonstrable adverse effects on sperm count, motility, morphology, or function. Pregnancy Category C: Rebif* treatment has been associated with significant increases in embryolethal or abortifacient effects in cynomolgus monkeys administered doses approximately 2 times the cumulative weekly human dose (based on either body weight or surface area) either during the period of organogenesis (gestation day 21-89) or later in pregnancy. There were no fetal malformations or other evidence of teratogenesis noted in these studies. These effects are consistent with the abortifacient effects of other type I interferons. There are no adequate and well-controlled studies of Rebif* in pregnant women. However, in Studies 1 and 2, there were 2 spontaneous abortions observed and 5 fetuses carried to term among 7 women in the Rebif* groups. If a woman becomes pregnant or plans to become pregnant while taking Rebif*, she should be informed about the potential hazards to the fetus and discontinuation of Rebif* should be considered. Nursing Mothers: It is not known whether Rebif* is excreted in human milk. Pediatric Use: The safety and effectiveness of Rebif* in pediatric patients have not been studied. Geriatric Use: Clinical studies of Rebif* did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently than younger subjects. ADVERSE REACTIONS The most frequently reported serious adverse reactions with Rebif* were psychiatric disorders including depression and suicidal ideation or attempt (See WARNINGS). The incidence of depression of any severity in the Rebif*-treated groups and placebo-treated group was approximately 2. The most commonly reported adverse reactions were injection site disorders, influenza-like symptoms (headache, fatigue, fever, rigors, chest pain, back pain, myalgia), abdominal pain, depression, elevation of liver enzymes and hematologic abnormalities. The most frequently reported adverse reactions resulting in clinical intervention (e.g., discontinuation of Rebif*, adjustment in dosage, or the need for concomitant medication to treat an adverse reaction symptom) were injection site disorders, Table 1. Adverse Reactions and Laboratory Abnormalities in Study 1 influenza-like symptoms, BODY SYSTEM Preferred Term BODY AS A WHOLE Influenza-like symptoms Headache Fatigue Fever Rigors Chest Pain Malaise INJECTION SITE DISORDERS Injection Site Reaction Injection Site Necrosis CENTRAL & PERIPH NERVOUS SYSTEM DISORDERS Hyperion ia Coordination Abnormal Convulsions ENDOCRINE DISORDERS Thyroid Disorder GASTROINTESTINAL SYSTEM DISORDERS Abdominal Pain Dry Mouth LIVER AND BILIARY SYSTEM DISORDERS SGPT Increased SG0T Increased Hepatic Function Abnormal Bilirubinaemia MUSCULO-SKELETAL SYSTEM DISORDERS Myalgia Back Pain Skeletal Pain HEMATOLOGIC DISORDERS Leukopenia Lymphadenopathy Thrombocytopenia Anemia PSYCHIATRIC DISORDERS Somnolence SKIN DISORDERS Rash Erythematous Rash Maculo-Papular URINARY SYSTEM DISORDERS Micturition Frequency Urinary Incontinence VISION DISORDERS Vision Abnormal Xerophthalmia Placebo tiw (n=187) 51% % 39% 17% 1% 1% % 1% 7% Rebif 22 meg tiw (n=189) depression and elevation of liver enzymes (See WARNINGS). Injection site necrosis was rare. The safety of Rebif» (22 meg and 44 meg) vs placebo was studied in 560 patients with RRMS who were treated for 24 months (Study 1). Table 1 enumerates adverse events and laboratory abnormalities that occurred at an incidence that was at least more in either Rebif*-treated group than was observed in the placebo group. Immunogenicity: As with all therapeutic proteins, there is a potential for immunogenicity. Serum NAb were detected in 45/184 (2) of Rebif*- treated patients at the 44 meg tiw dose at one or more times during Study 1. The clinical significance of the presence of NAb to Rebif* is unknown. Comparison of the incidence of antibodies to other products may be misleading. DOSAGE AND ADMINISTRATION The recommended dosage of Rebif* is 44 meg injected sc tiw. Rebif* should be administered, if possible, at the same time (preferably in the late afternoon or evening) on the same three days (e.g. Monday, Wednesday, and Friday) at least 48 hours apart each week. Generally, patients should be started at 8.8 meg sc tiw and increased over a 4- week period to 44 meg sc tiw (see Table 2). A Rebif "Starter Pack" containing 22 meg syringes is available for use in titrating the dose during the first four weeks of treatment. Leukopenia or elevated liver function tests may necessitate dose reductions of 20-5 until toxicity is resolved. Table 2: Schedule for Patient Titration Weeks 1-2 Weeks 3-4 Weeks 5+ Recommended Titration % 1% 7% 2 1% % 11% 7% 7% Rebif* Dose 8.8 meg 22 meg 44 meg Rebif 44 meg tiw (n=184) 59% 7 41% 28% 1 8% % 17% 9% % 7% 1 1% Volume 0.2 ml 0.5 ml 0.5 ml Syringe Strength (per 0.5 ml) 22 meg 22 meg 44 meg Rebif* is intended for use under the guidance and supervision of a physician. It is recommended that physicians or qualified medical personnel train patients in the proper technique for self-administering subcutaneous injections using the pre-filled syringe. Patients should be advised to rotate sites for sc injections. Concurrent use of analgesics and/or antipyretics may help ameliorate flu-like symptoms on treatment days. Rebif* should be inspected visually for paniculate matter and discoloration prior to administration. Rx only. Manufactured by: Serono, Inc. Randolph, MA Issued: April Rebif* is a registered trademark of Serono, Inc. \. serono biotech & beyond

14 continued from page 60 Table 5 Considerations in Planning Combination Therapy Trials Should multiple therapies, both toxic and nontoxic, be given together in order to determine if suppression of MS disease activity can be achieved, or should combinations be limited to two agents so that a clear assessment of the effects of each combination can be made? Since we currently do not have the ability to clearly predict the course of MS, what parameters should be measured and followed in order to gain insight about predicting future responsiveness to therapy? Should combination treatment be offered to patients in the earliest stages of MS, or should combination therapy trials be initiated only for patients with breakthrough disease activity white taking an immunomodulator? What steps should be taken to assess the effects of treatment upon patients with possible different pathologies of MS? What are the best ways to measure treatment outcomes? How long should patients be followed to assess efficacy and possible long-term toxicities of combination therapy? Pulsed corticosteroids also have broad immune effects, are well tolerated, and could be useful as adjunctive therapy in MS. Glatiramer acetate has efficacy in MS, and it may be advisable to administer it with interferon beta, but it may be less useful in combination with lymphocytotoxic agents, and therapies that block entry of leukocytes into the CNS. Until the efficacy of combination therapy can be established in large, well-controlled clinical trials, such therapy should be restricted to patients that have been refractory to interferon beta or to patients with patterns of disease indicating a rapidly progressive course. Physicians wishing to use combination therapy must follow patients closely. Although none of the trials to date show clear treatment efficacy, many combinations appear safe in the hands of experts. In choosing treatment, clinicians should consider patients' age, childbearing expectations, and tolerance of side effects. If the treatment of severe MS can be shown to improve with combination therapy, such therapy will be extended to patients with milder and earlier disease. A mechanism to conduct these important investigations exists in only a rudimentary form, and a study group analogous to oncologic study groups is needed. Important issues in planning trials of combination therapy are listed in Table 5. Solutions for the questions that I have proposed will require careful consideration and consensus among leaders in clinical research before an MS research study group can move forward. MS REFERENCES 1. IFNB Multiple Sclerosis Study Group. Interferon beta-1 b is effective in relapsing-remitting multiple sclerosis: I. Clinical results of a multicenter, randomized, double-blind, placebo-controlled trial. Neurology. 1993;43: PRISMS (Prevention of Relapses and Disability by Interferon b-la Subcutaneously in Multiple Sclerosis) Study Group. Randomised double-blind, placebo-controlled study of interferon b-1 a in relapsing/remitting multiple sclerosis. Lancet 1998;352: Jacobs LD, Cookfair DL, Rudick RA, et al. Intramuscular interferon beta-1 a for disease progression in relapsing multiple sclerosis. Ann Neuroi 1996;39: Rudick RA, Fisher E, Lee J-C, et al, for the Multiple Sclerosis Collaborative Research Group. Use of brain parenchymal fraction to measure whole brain atrophy in relapsing-remitting MS. Neurology. 1999;53: Fischer J, Priore R, Jacobs LD, et al. Neuropsychological effects of interferon beta-1 a in relapsing multiple sclerosis. Ann Neuroi 2000;48: IFNB Multiple Sclerosis Study Group and the University of British Columbia MS/MRI Analysis Group. Interferon beta-lb in the treatment of multiple sclerosis: final outcome of the randomized controlled trial. Neurology. 1995;45: Jacobs LD, Beck RW, Simon JH, et al. Intramuscular interferon beta-1 a therapy initiated during a first demyelinating event in multiple sclerosis. N Engl J Med. 2000;343: Li DK, Paty DW. Magnetic resonance imaging results of the PRISMS trial: a randomized, double-blind, placebo-controlled study of interferon-bla in relapsing-remitting multiple sclerosis.ann Neuroi 1999;46: Paty DW, Li DK, for the UBC MS/MRI Study Group, the IFNB Multiple Sclerosis Study Group. Interferon beta-lb is effective in relapsing-remitting multiple sclerosis: II. MRI analysis of a multicenter, randomized, double-blind, placebo-controlled trial. Neurology. I993;43: Simon JH, Lull JJacobs LD, et al. A longitudinal study oft I hypointense lesions in relapsing MS:MSCRG trial of interferon ß I a. Neurology. 2000;55: Stone LA, Frank JA, Albert PS, et al. Characterization of MRI response to treatment with interferon beta-1 b: contrast-enhancing MRI lesion frequency as a primary outcome measure. Neurology. 1997;49: I lyongvw. Chabot S, Stiive O,Williams G. Interferon beta in the treatment of multiple sclerosis: mechanisms of action. Neurology. 1998;51: Noronha AJoscas A,Jensen MA. Interferon beta decreases T cell activation and interferon gamma production in multiple sclerosis.) Neuroimmunol. 1993;46: Leppert D,Waubant E, Bürk MR, et al. Interferon beta-1 b inhibits gelatinase secretion and in vitro migration of human T cells: a possible mechanism for treatment efficacy in multiple sclerosis.annneuro/. 1996;40: Stiive O, Dooley NP, Uhm JH, et al. Interferon beta-1 b decreases the migration of T lymphocytes in vitro: effects on matrix metalloproteinase-9. Ann Neuroi. 1996;40: Hua LL, Liu JS, Brosnan CF, Lee SC Selective inhibition of human glial inducible nitric oxide synthase by interferon-beta: implications for multiple sclerosis. Ann Neuroi. 1998;43: Rudick RA, Ransohoff RM, Lee JC, et al. In vivo effects of interferon beta-1 a on immunosuppressive cytokines in multiple sclerosis. Neurology. 1998;50: BoutrosT, Croze E,YongVW. Interferon-beta is a potent promoter of nerve growth factor production by astrocytesj Neurochem. 1997;69: Barna BP, Chou SM, Jacobs B, et al. Interferon-b impairs induction of HLA-DR antigen expression in cultured adult human astrocytes.j Neuroimmunol. 1989;23: Jacobs LD, Beck RW, Simon JH, et al. Intramuscular interferon beta-1 a therapy initiated during a first demyelinating event in multiple sclerosis. N Eng/J Med. 2000;343: Cohen JA, Cutter GR, Fischer JS, et al. Benefit of intramuscular interferon beta-1 a on disability progression and quality of life in secondary progressive MS. N Eng/J Med. In press. 22. Comi G, Filippi M, Barkhof F, et al. Effect of early interferon treatment on conversion to definite multiple sclerosis: a randomised study. Lancet 2001 ;357: OWIMS Study Group. Evidence of interferon b-la dose response in relapsing-remitting MS: the OWIMS study. Neurology. 1999;53: SPECTRIMS Study Group. Randomized controlled trial of interferon beta-1 a in secondary progressive MS: clinical results. Neurology ;56:

15 25. Johnson KP, Brooks BR, Ford CC, et al. Sustained clinical benefits of glatiramer acetate in relapsing multiple sclerosis patients observed for 6 years. Mu/t Sc/er. 2000;6: Trapp BD, Peterson J, Ransohoff RM, et al. Axonal transection in the lesions of multiple sclerosis. N Engl] Med. 1998;338: Johnson KP, Brooks BR, Cohen JA, et al. Copolymer I reduces relapse rate and improves disability in relapsing-remitting multiple sclerosis: results of a phase III multicenter, doubleblind placebo-controlled trial. Neurology. 1995;45: PRISMS Study Group. PRISMS-4: Long-term efficacy of interferon-b-la in relapsing MS. Neuro/ogy. 2001;56: Durelli L Presented at American Academy of Neurology Annual Meeting; May 7,2001; Philadelphia, Pa. 30. Coyle R Results of Comparative Efficacy Trial Using Two Formulaions of Interferon Beta- I a in RRMS. Presented at XVII World Conference of Neurology;June 22,2001; London, England. 31. Cohen JA. Presented at American Academy of Neurology Annual Meeting; May 7,2001; Philadelphia, Pa. 32. Sharief MK,for the EVIDENCE Study Group. Evidence of dose response: effects of two Interferon beta-1 a products on relapse-related parameters in multiple sclerosis. Presented at the American Academy of Neurology 54th Annual Meeting; April 13-20,2002; Denver, Colorado. 33. Panitch H,for the EVIDENCE Study Group.The evidence of interferon dose-response: European-North American comparative efficacy (EVIDENCE) Study: 48 week data. Presented at the American Academy of Neurology 54th Annual Meeting; April 13-20,2002, Denver, Colorado. 34. Durelli UVerdun E, Barbero P, et al. Every-other-day interferon beta-1 b versus once-weekly interferon beta-1 a for multiple sclerosis: results of a 2-year prospective randomised multicentre study (INCOMIN). Loncet 2002;359: Confavreux C.Vukusic S, Moreau T, Adeleine R Relapses and progression of disability in multiple sclerosis. N Engl] Med. 2000;343: Bryant J, Clegg A, Milne R. Systematic review of immunomodulatory drugs for the treatment of people with multiple sclerosis: is there good quality evidence on effectiveness and cost? J Neurol Neurosurg Psychiatry ;70: Kaufman MD. Do microbes with peptides mimicking myelin cause multiple sclerosis if the T cell response to their unique peptides is limited?jfheor Biol. 1998; 193: Wucherpfennig KW, Strominger JL Molecular mimicry int cell-mediated autoimmunity: viral peptides activate human T cell clones specific for myelin basic protein. Cell. 1995:80: Sriram S, Rodriguez M. Indictment of the microglia as the villain in multiple sclerosis. Neurology. 1997;48: Lucchinetti C, Brück W, Parisi J, et al. Heterogeneity of multiple sclerosis lesions: implications for the pathogenesis of demyelination. Ann Neurol. 2000;47: Ozawa K, Suchanek G, Breitschopf H, et al. Patterns of oligodendroglia pathology in multiple sclerosis. Brain. 1994; 117: European Study Group. Placebo-controlled multicentre randomised trial of interferon b- I b in treatment of secondary progressive multiple sclerosis, lancet 1998;352: Cook SD, Quinless JR, Jotkowitz A, and the NAB Study Group. Neutralizing antibodies (Nab's) to beta Interferons in patients with multiple sclerosis (MS) [abstraaj.taken from: Neuro/ogy. 2000;54(suppl 3): A Ross C.CIemmesen KM.Svenson M,etal.lmmunogenicity of interferon-b in multiple sclerosis patients: influence of preparation, dosage, dose frequency, and route of administration. Ann Neurol. 2000;48: Crockard A, Droogan AJreacy M, Hawkins S. Effea of intravenous methylprednisolone therapy ont cell apoptosis in multiple sclerosis [abstractj.taken from: Neuro/ogy. I996;46 (suppl2)a252-a Rosenberg GA, Dencoff JE, Correa N Jr, et al. Effects of steroids on CSF matrix metalloproteinases in multiple sclerosis: relation to blood-brain barrier injury. Neurology. 1996;46: Almawi WY, Beyhum HN, Rahme AA, Rieder MJ. Regulation of cytokine and cytokine receptor expression by glucocorticoids [review].] Leukoc Biol. 1996;60: Hall ED. Neuroprotective actions of glucocorticoid and nonglucocorticoid steroids in acute neuronal injury [Review]. Cell Mo/ Neurobbl. 1993; 13: Beck RW, Cleary PAJrobe JD, et al.the effea of corticosteroids for acute optic neuritis on the subsequent development of multiple sclerosis. N Eng/J Med. 1993;329: Beck RWThe optic neuritis treatment trial: three-year follow-up results. Arch Ophthalmol. 1995;113: Goodkin DE, Kinkel RP, Weinstock-Guttman B, et al. A phase II study of i.v. methylprednisolone in secondary-progressive multiple sclerosis. Neuro/ogy. 1998;51: Zivadinov R, Rudick RA, De Masi R, et al. Effea of intravenous methylprednisolone on brain atrophy in relapsing-remitting multiple sclerosis [abstraa]. Taken from:neuro/ogy, 200l:56(suppl3):AI Kolar O, Hau W, Huler KKH, et al. Combined treatment of relapsing multiple sclerosis (MS) with interferon-beta I-a and prednisone. Poster presented at Consortium of Multiple Sclerosis Centers Annual Meeting-June ; Halifax, Nova Scotia, Canada. 54. Blumenfeld Z, Shapiro D, Shteinberg M, et al. Preservation of fertility and ovarian function and minimizing gonadotoxicity in young women with systemic lupus erythematosus treated by chemotherapy. Lupus. 2000;9: Gensert JM, Goldman JE. Endogenous progenitors remyelinate demyelinated axons in the adult CNS. Neuron. 1997; 19: Keirstead HS, Levine JM, Blakemore WF. Response of the oligodendrocyte progenitor population (defined by NG2 labelling) to demyelination of the adult spinal cord. Glia. 1998;22: Witte AS, Cornblath DR, Schatz NJ, Lisak RR Monitoring azathioprine therapy in myasthenia gravis. Neurology. 1986;36: Kissel JT, Levy RJ, Mendell JR, Griggs RC. Azathioprine toxicity in neuromuscular disease. Neurology. 1986;36: Palace J, Rothwell R New treatments and azathioprine in multiple sclerosis. Lancet. I997;350:26l. 60.Yudkin PL, Ellison GW, Ghezzi A, et al. Overview of azathioprine treatment in MS. Lancet. 1991;338: Fernandez O, Guerrero M, Mayorga L, et al. Combined therapy with interferon beta-lb and azathioprine in multiple sclerosis: a pilot trial of 2 years duration [abstraaj.taken from: Rev Neurol (Paris). 2000;suppl 3:3S Kolar O, Hau W, Huler KKH, et al. Continuous, simultaneous treatment with interferonbeta I-a, prednisone and azathioprine in multiple sclerosis (MS). Poster presented at Consortium of Multiple Sclerosis Centers Annual Meeting; June 22-25,2000; Halifax, Nova Scotia, Canada. 63. Moreau T, Blanc S, Riche G, et al. A pilot safety and tolerability study of interferon beta I a in combination with azathioprine in multiple sclerosis [abstractj.taken from:neuro/ogy. 200l;56(suppl3):A TichaV, Havrdova E, Novakova I. Tolerability and safety of betaferon combined with azathioprine in relapsing-remitting multiple sclerosis (RRMS) [abstraa]. Taken from:rev Neurol (Paris).2000;Suppl3:3SI Comabella M, Balashov K, Issazadeh S, et al. Elevated interleukin-12 in progressive multiple sclerosis correlates with disease activity and is normalized by pulse cyclophosphamide therapy.j On invest 1998; 102: Moody DJ, Kagan J, Liao D, et al. Administration of monthly-pulse cyclophosphamide in multiple sclerosis patients: effects of long-term treatment on immunologic parameters.] Neuro/mmuno/. 1987;14: Smith DR, Balashov KE, Hafler DA, et al. Immune deviation following pulse cyclophosphamide/methylprednisolone treatment of multiple sclerosis: increased interleukin-4 production and associated eosinophilia. Ann Neurol. 1997;42: Canadian Cooperative Multiple Sclerosis Study GroupThe Canadian cooperative trial of cyclophosphamide and plasma exchange in progressive multiple sclerosis. Lancet. 1991;337: Weiner HL, Mackin GA, Orav EJ, et al. Intermittent cyclophosphamide pulse therapy in progressive multiple sclerosis: final report of the Northeast Cooperative Multiple Sclerosis Treatment Group. Neurology. 1993;43: Patti F, Cataldi ML, Ciancio MR, et al. Possible association of cyclophosphamide and interferon-b for the treatment of rapidly transitional multiple sclerosis patients [abstraa].taken from:rev Neurol (Paris). 2000;Suppl 3:3S Weinstock-Guttman B, Kinkel RP, Cohen JA, et al.treatment of "transitional MS" with cyclophosphamide and methylprednisolone (CTX/MP) followed by interferon b [ abstraa].taken from:neuro/ogy. I997;48(suppl 2):A34I. 72. Smith DR,Weinstock-Guttmann B, Cohen JA, et al. Design of a randomized, blinded, MRI trial of pulse cyclophosphamide rescue therapy in B-IFN resistant aaive MS [abstraaj.taken from:neuro/ogy.200l;56(suppl 3):A Kaufman MD, Norton J, Sonnenfeld G. Safety and tolerability of the combination of interferon beta-1 a and oral cyclophosphamide for patients with multiple sclerosis [abstraaj.taken from:neuro/ogy.200l;56(suppl 3):A Chungi VS, Bourne DWA, Dittert LW Drug absorption VIII: kinetics of Gl absorption of methotrexate.j Pharm So. 1978;67: Goodkin DE, Rudick RA, VanderBrug Medendorp S, et al. Low-dose (7.5 mg) oral methotrexate reduces the rate of progression in chronic progressive multiple sclerosis. Ann Neurol. 1995;37:30-40.

16 76.Whartenby KA, Mills PC, Rogg J, et al. An open-label trial of combination MS therapy using IFN bla and oral methotrexate 20 mg weekly [abstract].taken from:neuro/ogy. 2000;54(suppl 3):A Bertino JR, Kamen B, Romanini A. Folate antagonists. In: Holland, Bast, Morton Frei, et al, eds. Cancer Mediane. 4th ed. Baltimore, Md:Williams & Wilkins; 1997: Conrad CA, RoweVD.Treatment of primary and secondary progressive multiple sclerosis with high dose methotrexate and leucovorin rescue [abstract]. Taken from:neuro/ogy. I998(suppl4);50:l Härtung H-R Gonsette R,and the MIMS Study Group. Mitoxantrone in progressive multiple sclerosis: a placebo-controlled, randomised, observer-blind phase III trial: clinical results and three-year follow-up [abstractj.taken from:neuro/ogy. I999;52(suppl 2):A Edan G, Miller D, Clanet M, et al. Therapeutic effect of mitoxantrone combined with methylprednisolone in multiple sclerosis: a randomised multicentre study of active disease using MRI and clinical criteria.] Neurol Neurosurg Psychiatry. 1997;62: Edan G. Is there a role of intensive immunosuppression in MS? Prospects of combinations [abstractj.taken from:mu/t Scler. 1999;5(suppl I ):S Chaplain G, Milan C, Sgro C, et al. Increased risk of acute leukemia after adjuvant chemotherapy for breast cancer: a population-based study. J Qin Oncol. 2000; 18: Mauch E, Eisenmann S, Hahn A, et al. Mitoxantrone (MITOX) in the treatment of patients with multiple sclerosis (MS): a large single center experience [abstractj.taken from: Mu/t Scler. I999;5: Weilbach FX,Toyka KV, Gold R. Combination therapy with the cardioprotector dexrazoxane augments therapeutic efficacy of mitoxantrone in experimental autoimmune encephalomyelitis in Lewis rat [abstractj.taken from:neuro/ogy.2000;54(suppl 3):A60-A6I. 85. Duda PW, Schmied MC, Cook SL, et al. Glatiramer acetate (Copaxone) induces degenerate, Th2-polarized immune responses in patients with multiple sclerosis.) din Invest. 2000;105: Neuhaus O, Farina C,Wekerle H, Hohlfeld R. Mechanisms of action of glatiramer acetate in multiple sclerosis. Neurology ;56: Comi G, Filippi M, Wolinsky JS and the European/Canadian Glatiramer Acetate Study Group. The European/Canadian multicenter, double-blind, randomized, placebo-controlled study of the effects of glatiramer acetate on magnetic resonance imaging measured disease activity and burden in patients with relapsing multiple sclerosis. Ann Neurol. 2001;49: Stone LA, Frank JA, Albert PS, et al. Characterization of MRI response to treatment with interferon beta-1 b: contrast-enhancing MRI lesion frequency as a primary outcome measure. Neuro/ogy. 1997;49: Waubant E, Goodkin DE, Sloan R, Andersson P-B. A pilot study of MRI activity before and during interferon beta-1 a therapy. Neuro/ogy. 1999;53: Milo R, Panitch H. Additive effects of copolymer-1 and interferon beta-1 b on the immune response to myelin basic protein.] Neuroimmunol. 1995;61: Lublin F, Cutter G, Elfont R, et al. A trial to assess the safety of combining therapy with interferon beta-1 a and glatiramer acetate in patients with relapsing MS [abstractj.taken from: Neuro/ogy ;56(suppl 3):A Fazekas F, Strasser-Fuchs S, Gold R, Härtung H-R Intravenous immunoglobulin. In: Rudick RA, Goodkin DE, eds. Multiple Sc/eros/s Therapeutics. London: Martin Dunitz,Ltd; 1999: Achiron A, Gabbay U, Gilad R, et al. Intravenous immunoglobulin treatment in multiple sclerosis: effect on relapses. Neuro/ogy. 1998;50: Fazekas F, Deisenhammer F, Strasser-Fuchs S, et al, for the Austrian Immunoglobulin in Multiple Sclerosis Study Group. Randomised placebo-controlled trial of monthly intravenous immunoglobulin therapy in relapsing-remitting multiple sclerosis. Lancet 1997;349: Sorensen PS,Wanscher B,Jensen CV,et al. Intravenous immunoglobulin G reduces MRI activity in relapsing multiple sclerosis. Neurology. 1998;50: Francis GS, Freedman MS, Antel JR Failure of intravenous immunoglobulin to arrest progression of multiple sclerosis: a clinical and MRI based study. Muk Scler. 1997;3: Sadiq SThe Role of Combination Therapies. Presented at Consortium of Multiple Sclerosis Centers Annual Meeting;June 22-25,2000; Halifax, Nova Scotia, Canada. 98.Tubridy N, Behan PO, Capildeo R, et al, and the UK Antegren Study GroupThe effect of anti-a4 integrin antibody on brain lesion activity in MS. Neuro/ogy. 1999;53: Presented at ECTRIMS Annual Meeting; September 12-14,2001; Dublin, Ireland Gijbels K, Galardy RE, Steinman L Reversal of experimental autoimmune encephalomyelitis with a hydroxamate inhibitor of matrix metalloproteases. ] din Invest. 1994;94: Liedtke W, Cannella B, Mazzaccaro RJ, et al. Effective treatment of models of multiple sclerosis by matrix metalloproteinase inhibitors. Ann Neurol. 1998;44: BrundulaV, Rewcasde B, Metz UYongVW.Targeting matrixmetalloproteinases in multiple sclerosis: minocycline as a novel therapeutic strategy [abstract]. Taken from:mu/t Scler. 2000;6:4II Greco A, Minghetti L, Sette G, et al. Cerebrospinal fluid isoprostane shows oxidative stress in patients with multiple sclerosis. Neuro/ogy. 1999;53: Svenningsson A, Petersson A-S, Andersen O, Hansson GK. Nitric oxide metabolites in CSF of patients with MS are related to clinical disease course. Neurology. 1999;53: MiskoTRTrotter JL, Cross AH. Mediation of inflammation by encephalitogenic cells: interferon gamma induction of nitric oxide synthase and cyclooxygenase 2. j Neuroimmunol. 1995;61: Constantinescu CS,Ventura E, Hilliard B, Rostami A Effects of the angiotensin converting enzyme inhibitor captopril on experimental autoimmune encephalomyelitis. Immunopharmacol Immunotoxicol. 1995; 17: Bolton C. 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17 For all patients starting multiple sclerosis (MS) therapy or those currently being treated for MS... MS Pathways the only MS Well Along the Way... M U L T I P L E j S C L E R O S I S PATH ^WAYS. 800*788* Betaseron is indicated for ambulatory patients with relapsing-remitting MS to treat clinical exacerbations.

18 support Your patients get 24/7 side-effect management and support MS-specialist registered nurses, available 24 hours a day, 7 days a week Personal Patient Assistants answer questions and guide patients to helpful resources Personalized injection training for patients New teleconferences for patients starting Betaseron (Interferon beta-1 b) therapy Plus many more services, including convenient home delivery of Betaseron MS Pathways is the MS support program rated "best" by patients f New Web site visit Or, call MS Pathways at * In a market research study conducted by TDR. Please see brief summary of prescribing information, including important safety information, on adjacent page Bertex Laboratories, Inc. All rights reserved. Manufactured by CHIRON Corporation, Emeryville, CA Distributed by BERLEX Laboratories, Inc., Montville, NJ Printed in USA September 2001 BERyEJC

19 Betaseron Interferon beta-1b DESCRIPTION Betaseron (Interferon beta-1b) is a purified, sterile, lyophilized protein product produced by recombinant DNA techniques and formulated for use by injection. Interferon beta-lb is manufactured by bacterial fermentation of a strain of Escherichia co//that bears a genetically engineered plasmid containing the gene for human interferon betaserl7. The native gene was obtained from human fibroblasts and altered in a way that substitutes serine for the cysteine residue found at position 17. Interferon beta-1b is a highly purified protein that has 165 amino acids and an approximate molecular might of 18,500 daltons. It does not include the carbohydrate side chains found in the natural material. The specific activity of Betaseron is approximately 32 million international units (IU)/mg Interferon beta-lb. Each vial contains 0.3 mg of Interferon beta-lb. The unit measurement is derived by comparing the antiviral activity of the product to the World Health Organization (WHO) reference standard of recombinant human interferon beta. Mannitol USP and Albumin Human USP (15 mg each/vial) are added as stabilizers. Prior to 1993, a different analytical standard was used to determine potency. It assigned 54 million IU to 0.3 mg Interferon beta-1 b. Lyophilized Betaseron is a sterile, white to off-white powder intended for subcutaneous injection after teconstitution with the diluent supplied (Sodium Chloride, 0.5 Solution). CLINICAL PHARMACOLOGY General: Interferons are a family of naturally occurring proteins, which have molecular weights ranging from 15,000 to 21,000 daltons. Three major classes of interferons have been identified: alfa, beta, and gamma. Interferon beta-1 b, interferon alfa, and interferon gamma have overlapping yet distinct biologic activities.1'5 The activities of Interferon beta-1 b are species-restricted and, therefore, the most pertinent pharmacologic information on Betaseron is derived from studies of human cells in culture and in humans. Biologic Activities: Interferon beta-1b has been shown to possess both antiviral and immunoregulatory activities. The mechanisms by which Betaseron exerts its actions in multiple sclerosis (MS) are not clearly understood. However, it is known that the biologic responsemodifying properties of Interferon beta-lb are mediated through its interactions with specific cell receptors found on the surface of human cells. The binding of Interferon beta-1 b to these receptors induces the expression of a number of interferon-induced gene products (e.g., 2',5'-oligoadenylate synthetase, protein kinase, and indoleamine 2,3-dioxygenase) that are believed to be the mediators of the biological actions of Interferon beta-lb.'3610 A number of these interferon-induced products have been readily measured in the serum and cellular fractions of blood collected from patients treated with Interferon beta-1b.'"2 Pharaiacokinetics: Because serum concentrations of Interferon beta-lb are low or not detectable following subcutaneous administration of 0.25 mg or less of Betaseron, pharmacokinetic information in patients with MS receiving the recommended dose of Betaseron is not available. Following single and multiple daily subcutaneous administrations of 0.5 mg Betaseron to healthy volunteers (N=12), serum Interferon beta-1b concentrations were generally below 100 Ili/mL. Peak serum Interferon beta-lb concentrations occurred between 1 to 8 hours, with a mean peak serum interferon concentration of 40 lu/ml. Bioavailability, based on a total dose of 0.5 mg Betaseron given as two subcutaneous injections at different sites, was approximately 5. After intravenous administration of Betaseron (0.006 mg to 2.0 mg), similar pharmacokinetic profiles were obtained from healthy volunteers (N=12) and from patients with diseases other than MS (N=142). In patients receiving single intravenous doses up to 2.0 mg, increases in serum concentrations were dose proportional. Mean serum clearance values ranged from 9.4 ml/minkg' to 28.9 ml/minkg"' and were independent of dose. Mean terminal elimination half-life values ranged from 8.0 minutes to 4.3 hours and mean steady-state volume of distribution values ranged from 0.25 L/kg to 2.88 L/kg. Three-times-a-week intravenous dosing for 2 weeks resulted in no accumulation of Interferon beta-1 b in the serum of patients. Pharmacokinetic parameters after single and multiple intravenous doses of Betaseron were comparable. Clinical Trials: The effectiveness of Betaseron in relapsing-remitting MS was evaluated in a double-blind, multiclinic (11 sites: 4 Canadian and 7 United States), randomized, parallel, placebo-controlled clinical investigation of 2 years duration. The study enrolled MS patients, aged 18 to 50, who were ambulatory (Kurtzke expanded disability status scale [EDSS] of < 5.5), exhibited a relapsing-remitting clinical course, met Poser's criteria'3 for clinically definite and/or laboratory supported definite MS and had experienced at least two exacerbations over 2 years preceding the trial without exacerbation in the preceding month. Patients who had received prior immunosuppressant therapy were excluded. An exacerbation was defined, per protocol, as the appearance of a new clinical sign/symptom or the clinical worsening of a previous sign/symptom (one that had been stable for at least 30 days) that persisted for a minimum of 24 hours. Patients selected for study were randomized to treatment with either placebo (N=123), 0.05 mg of Betaseron (N=125), or 0.25 mg of Betaseron (N=124) self-administered subcutaneously every other day. Outcome based on the 372 randomized patients was evaluated after 2 years. Patients who required more than three 28-day courses of corticosteroids were removed from the study. Minor analgesics (acetaminophen, codeine), antidepressants, and oral baclofen were allowed ad libitum but chronic nonsteroidal anti-inflammatory drug (NSAID) use was not allowed. The primary, protocol defined, outcome assessment measures were 1) frequency of exacerbations per patient and 2) proportion of exacerbation free patients. A number of secondary outcome measures were also employed as described in TABLE 1. In addition to clinical measures, annual magnetic resonance imaging (MRI) was performed and quantitated for extent of disease as determined by changes in total area of lesions. In a substudy of patients (N=52) at one site, MRIs were performed every 6 weeks and quantitated for disease activity as determined by changes in size and number of lesions. Results at the protocol designated endpoint of 2 years (see TABLE 1): In the 2-year analysis, there was a 31% reduction in annual exacerbation rate, from 1.31 in the placebo group to 0.9 in the 0.25 mg group. The p-value for this difference was The proportion of patients free of exacerbations was 1 in the placebo group, compared with 2 in the Betaseron (Interferon beta-1b) 0.25 mg group. Of the 372 patients randomized, 72 (19%) failed to complete 2 full years on their assigned treatments. The reasons given for withdrawal varied with treatment assignment. Excessive use of steroids accounted for 11 of the 26 placebo withdrawals, but only 2 of the 21 withdrawals from the 0.05 mg assigned group and 1 of the 25 withdrawals from the 0.25 mg assigned group. Withdrawals for adverse events attributed to study article, however, were more common among Betaseron-treated patients: 1,5, and 10 withdrew from the placebo, 0.05 mg, and 0.25 mg groups, respectively. Over the 2-year period, there were 25 MS-related hospitalizations in the 0.25 mg Betaseron-treated group compared to 48 hospitalizations in the placebo group. In comparison, non-ms hospitalizations were evenly distributed among the groups, with 16 in the 0.25 mg Betaseron group and 15 in the placebo group. The average number of days of MS-related steroid use was 41 days in the 0.25 mg Betaseron group and 55 days in the placebo group (p=0.004). TABLE 1 2 Year Study Results Primary and Secondary Clinical Endpoints Statistical Comparisons Efficacy Parameters Treatment Groups p-value Placebo 0.05 mg 0.25 mg Placebo vs 0.05 mg vs Placebo vs Primary Endpoints 0.05 mg 025 mg 0.25 mg Annual exacerbation rate Proportion of exacerbation-free patientst (N=123) (N=125) % (N=124) Exacerbation Ot frequency per patient > Secondary Endpointstt Median number of months to first on-study exacerbation Rate of moderate or severe exacerbations per year Mean number of moderate or severe exacerbation days per patient Mean change in EDSS scoret at endpoint Mean change in Scripps scorett at endpoint I Median duration in days per exacerbation I % change in mean MRI lesion area at endpoint % % ND ND ND ND - Not done t 14 exacerbation-free patients (0 from placebo, 6 from 0.05 mg, and 8 from 0.25 mg) dropped out of the study before completing 6 months of therapy. These patients are excluded from this analysis, tt Sequelae and Functional Neurologic Status, both required by protocol, were not analyzed individually but are included as a function of the EDSS. t EDSS scores range from 0-10, with higher scores reflecting greater disability. tt Scripps neurologic rating scores range from 0-100, with smaller scores reflecting greater disability. MRI data were also analyzed for patients in this study. A frequency distribution of the observed percent changes in MRI area at the end of 2 years was obtained by grouping the percentages in successive intervals of equal width. Figure 1 displays a histogram of the proportions of patients who fell into each of these intervals. The median percent change in MRI area for the 0.25 mg group was -1.1% which was significantly smaller than the 16. observed for the placebo group (p=0.0001). Figure 1 Distribution of Change in MRI Area Betaseron 0.25 mg From O To <-40 <-20 <0 <20 <40 <60 <80 <100 < Percent Change in MRI Area In an evaluation of frequent MRI scans (every 6 weeks) on 52 patients at one site, the percent of scans with new or expanding lesions was 29% in the placebo group and in the 0.25 mg treatment group (p=0.006). MRI scanning is viewed as a useful means to visualize changes in white matter that are believed to be a reflection of the pathologic changes that, appropriately located within the central nervous system (CNS), account for some of the signs and symptoms that typify relapsing-remitting MS. The exact relationship between MRI findings and the clinical status of patients is unknown. Changes in lesion area often do not correlate with clinical exacerbations probably because many lesions affect so-called "silent" regions of the CNS. Moreover, it is not clear what fraction of the lesions seen on MRI become foci of irreversible demyelinization (i.e., classic white matter plaques). The prognostic significance of the MRI findings in this study has not been evaluated. At the end of 2 years on assigned treatment, patients in the study had the option of continuing on treatment under blinded conditions. Approximately 8 of patients under each treatment accepted. Although there was a trend toward patient benefit in the Betaseron (Interferon beta-1b) groups during the third year, particularly in the 0.25 mg group, there was no statistically significant difference between the Betaseron-treated vs. placebo-treated patients in exacerbation rate, or in any of the secondary endpoints described in Table 1. As noted above, in the 2-year analysis, there was a 31 % reduction in exacerbation rate in the 0.25 mg group, compared with placebo. The p-value for this difference was In the analysis of the third year alone, the difference between treatment groups was 28%. The p-value was The lower number of patients may account for the loss of statistical significance, and lack of direct comparability among the patient groups in this extension study makes the interpretation of these results difficult. The third year MRI data did not show a trend toward additional benefit in the Betaseron arm compared with the placebo arm. Throughout the clinical trial, serum samples from patients were monitored for the development of antibodies to Interferon beta-1b. In patients receiving 0.25 mg of Betaseron (N=124) every other day in the clinical trial, 4 were found to have serum neutralizing activity at one or more of the time points tested. The relationship between antibody formation and clinical efficacy is not known. INDICATIONS AND USAGE Betaseron is indicated for use in ambulatory patients with relapsing-remitting multiple sclerosis to reduce the frequency of clinical exacerbations. (See CLINICAL PHARMACOLOGY, Clinical Trials section.) Relapsing-remitting MS is characterized by recurrent attacks of neurologic dysfunction followed by complete or incomplete recovery. The safety and efficacy of Betaseron in chronic-progressive MS has not been evaluated. CONTRAINDICATIONS Betaseron is contraindicated in patients with a history of hypersensitivity to natural or recombinant interferon beta, Albumin Human USP, or any other component of the formulation. WARNINGS One suicide and 4 attempted suicides were observed among 372 study patients during a 3-year period. All five patients received Betaseron (three in the 0.05 mg group and two in the 0.25 mg group). There were no attempted suicides in patients on study who did not receive Betaseron. Depression and suicide have been reported to occur in patients receiving interferon alfa, a related compound. Patients to be treated with Betaseron should be informed that depression and suicidal ideation may be a side effect of the treatment and should report these symptoms immediately to the prescribing physician. Patients exhibiting depression should be monitored closely and cessation of therapy should be considered. Injection site necrosis (ISN) has been reported in of patients in controlled clinical trials (see ADVERSE REACTIONS section). Typically, injection site necrosis occurs within the first 4 months of therapy, although post-marketing reports have been received of ISN occurring over 1 year after initiation of therapy. Necrosis may occur at single or multiple injection sites. The necrotic lesions are typically 3 cm or less in diameter, but larger areas have been reported. While necrosis has commonly extended only to subcutaneous fat, there are also reports of necrosis extending to and including fascia overlaying muscle. In some lesions where biopsy results are available, vasculitis has been reported. For some lesions debridement and, infrequently, skin grafting has been required. As with any open lesion, it is important to avoid infection and, if it occurs, to treat the infection. Time to healing has varied depending on the severity of the necrosis at the time treatment was begun. In most cases healing was associated with scarring. Some patients have experienced healing of necrotic skin lesions while Betaseron (Interferon beta-1 b) therapy continued; others have not. Whether to discontinue therapy following a single site of necrosis is dependent on the extent of necrosis. For patients who continue therapy with Betaseron after injection site necrosis has occurred, Betaseron should not be administered into the affected area until it is fully healed. If multiple lesions occur, therapy should be discontinued until healing occurs. Patient understanding and use of aseptic self-injection techniques and procedures should be periodically reevaluated, particularly if injection site necrosis has occurred. PRECAUTIONS General: Patients should be instructed in injection techniques to assure the safe self-administration of Betaseron. (See PRECAUTIONS, Information to patients, and Betaseron Patient Information sheet.) Information to patients: Instruction on self-injection technique and procedures. Patients should be instructed in the use of aseptic technique when administering Betaseron. Appropriate instruction for reconstitution of Betaseron and self-injection should be given including careful review of the Betaseron Patient Information sheet. If possible, the first injection should be performed under the supervision of an appropriately qualified health care professional. Patients should be cautioned against the re-use of needles or syringes and instructed in safe disposal procedures. A puncture resistant container for disposal of used needles and syringes should be supplied to the patient along with instructions for safe disposal of full containers. Patients should be advised of the importance of rotating areas of injection with each dose, to minimize the likelihood of severe injection site reactions or necrosis (see Rotating Injection Sites section of Patient Information sheet). Patients should be cautioned not to change the dosage or the schedule of administration without medical consultation. Awareness of adverse reactions. Serious adverse reactions associated with the use of Betaseron have been reported including depression and injection site necrosis (see WARNINGS section). Patients should immediately report symptoms of depression or suicidal ideation to their physician. The symptoms of depression should be closely monitored by a physician. Injection site necrosis was reported in of patients in a controlled MS trial. If the patient experiences any break in the skin, which may be associated with blue-black discoloration, swelling, or drainage of fluid from the injection site, the patient should be advised to promptly contact their physician prior to continuing their Betaseron therapy. Other injection site reactions occurred in eighty-five percent of patients in the controlled MS trial, at one or more times during therapy. There was redness, pain, swelling and discoloration. In general, these were transient and did not require discontinuation of therapy, but the nature and severity of all reported reactions should be carefully assessed (see ADVERSE REACTIONS section). Flu-like symptoms are common following initiation of therapy with Betaseron. In the controlled MS clinical trial, acetaminophen was permitted for relief of fever or myalgia (see ADVERSE REACTIONS section). Patients should be cautioned about the abortifacient potential of Betaseron (see PRECAUTIONS, Pregnancy Teratogenic effects). Laboratory tests: The following laboratory tests are recommended prior to initiating Betaseron therapy and at periodic intervals thereafter: hemoglobin, complete and differential white blood cell counts, platelet counts and blood chemistries including liver function tests. In the controlled MS trial, patients were monitored every 3 months. The study protocol stipulated that Betaseron therapy be discontinued in the event the absolute neutrophil count fell below 750/mm3. When the absolute neutrophil count had returned to a value greater than 750/mm3, therapy could be restarted at a 5 reduced dose. No patients were withdrawn or dose reduced for neutropenia or lymphopenia. Similarly, if hepatic transaminase (SGOT/SGPT) levels exceeded 10 times the upper limit of normal, or if the serum bilirubin exceeded 5 times the upper limit of normal, therapy was discontinued. In each instance during the controlled MS trial, hepatic enzyme abnormalities returned to normal following discontinuation of therapy. When measurements had decreased to below these levels, therapy could be restarted at a 5 dose reduction, if clinically appropriate. Two patients were dose reduced for increased liver enzymes; one continued on treatment and one was ultimately withdrawn. Drug interactions: Interactions between Betaseron and other drugs have not been fully evaluated. Although studies designed to examine drug interactions have not been done, it was noted that corticosteroid or ACTH treatment of relapses for periods of up to 28 days has been administered to patients (N=180) receiving Betaseron. Betaseron administration to three cancer patients over a dose range of mg to 2.2 mg led to a dose-dependent inhibition of antipyrine elimination.14 The effect of alternate-day administration of 0.25 mg of Betaseron on drug metabolism in MS patients is unknown. Carcinogenesis: The carcinogenic potential of Betaseron was evaluated by studying its effect on the morphological transformation of the mammalian cell line BALBc-3T3. No significant increases in transformation frequency were noted. No carcinogenicity data are available in animals or humans.

20 Betaseron (Interferon beta-lb) was not mutagenic when assayed for genotoxicity in the Ames bacterial test in the presence or absence of metabolic activation. Impairment of fertility: Studies in rhesus monkeys at doses up to 0.33 mg/kg/day (32 times the recommended human dose based on body surface area comparison*) in normally cycling rhesus female monkeys had no apparent adverse effects on the menstrual cycle or on associated hormonal profiles (progesterone and estradiol) when administered over 3 consecutive menstrual cycles. The extrapoiability of animal doses to human doses is not known. Effects of Betaseron on normal cycling human females are not known. *body surface dose based on 70 kg female Pregnancy Teratogenic effects: Pregnancy Category C: Betaseron was not teratogenic at doses up to 0.42 mg/kg/day in rhesus monkeys, but demonstrated a dose-related abortifacient activity when administered at doses ranging from mg/kg/day (2.8 times the recommended human dose based on body surface area comparison) to 0.42 mg/kg/day (40 times the recommended human dose based on body surface area comparison). The extrapoiability of animal doses to human doses is not known. Lower doses were not studied in monkeys. Spontaneous abortions while on treatment were reported in patients (n=4) who participated in the Betaseron MS clinical trial. Betaseron given to rhesus monkeys on gestation days 20 to 70 did not cause teratogenic effects, however, it is not known if teratogenic effects exist in humans. There are no adequate and well-controlled studies in pregnant women. If the patient becomes pregnant or plans to become pregnant while taking Betaseron, the patient should be apprised of the potential hazard to the fetus and it should be recommended that the patient discontinues therapy. Nursing mothers: It is not known whether Betaseron is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from Betaseron, a decision should be made as to whether either to discontinue nursing or discontinue the drug, taking into account the importance of drug to the mother. Pediatric use: Safety and efficacy in children under 18 years of age have not been established. ADVERSE REACTIONS Experience with Betaseron in patients with MS is limited to a total of 147 patients at the recommended dose of 0.25 mg every other day or more (see CUNICAL PHARMACOLOGY, Clinical Trials section). Consequently, adverse events that are associated with the use of Betaseron in MS patients at a low incidence may not have been observed in premarketing studies. Clinical experience with Betaseron in other populations (patients with cancer, HIV positive patients, etc.) provides additional data regarding adverse reactions; however, experience in non-ms populations may not be fully applicable to the MS population. Injection site reactions (8) and injection site necrosis () occurred after administration of Betaseron. Inflammation, pain, hypersensitivity, necrosis, and non-specific reactions were significantly associated (p<0.05) with the 0.25 mg Betaseron-treated group. Only inflammation, pain, and necrosis were reported as severe events (see WARNINGS and PRECAUTIONS sections). The incidence rate for injection site reactions Body as a Whole Injection site reaction* Headache Fever* Flu-like symptom complex* Pain Asthenia* Chills* Abdominal pain Malaise* Generalized edema Pelvic pain Injection site necrosis* Cyst Necrosis Suicide attempt Cardiovascular System Migraine Palpitation* Hypertension Tachycardia Peripheral vascular disorder Hemorrhage Digestive System Diarrhea Constipation Vomiting Gastrointestinal disorder Endocrine System Goiter Hemic and Lymphatic System Lymphocytes less thanl 500/mm 3 ANC<1500/mm 3 * WBC<3000/mm 3 * Lymphadenopathy Adverse Reaction Metabolic and Nutritional Disorders SGPT> 5 times baseline* Glucose < 55 mg/dl Total bilirubin > 2.5 times baseline Urine protein > 1+ SG0T> 5 times baseline* Weight gain Weight loss Musculoskeletal System Myalgia* Myasthenia Nervous System Dizziness Hypertonia Anxiety Nervousness Somnolence Confusion Speech disorder Convulsion Hyperkinesia Amnesia I Respiratory System Sinusitis Dyspnea* Laryngitis Skin and Appendages Sweating* Alopecia I Special Senses Conjunctivitis Abnormal vision I Urogenital System Dysmenorrhea Menstrual disorder* Metrorrhagia Cystitis Breast pain Menorrhagia Urinary urgency Fibrocystic breast Breast neoplasm * Significantly associated with Betaseron treatment. TABLE 2 I Adverse Reactions and Laboratory Abnormalities Placebo N=123 37% 77% 41% 5 48% 3 19% 2 7% 1% 29% 18% 19% 67% 11% 1 28% 1 28% 2 1 1% 2 11% 1 11% 8% 8% 1% 0.25 mg I N= % % % 1 8% 7% % 8 18% % % 3 8% 2 1 7% 18% 17% 1 8% 7% was calculated over the course of 3 years. This incidence rate decreased over time, with 79% of patients experiencing the event during the first 3 months of treatment compared to 47% during the last 6 months. The median time to the first occurrence of an injection site reaction was 7 days. Patients with injection site reactions reported these events days per year. Three patients withdrew from the 0.25 mg Betaserontreated group for injection site pain. Flu-like symptom complex was reported in 7 of the patients treated with 0.25 mg Betaseron. A patient was defined as having a flu-like symptom complex if flu-like symptoms or at least two of the following symptoms were concurrently reported: fever, chills, myalgia, malaise, or sweating. Only myalgia, fever, and chills were reported as severe in more than of the patients. The incidence rate for flu-like symptom complex was also calculated over the course of 3 years. The incidence rate of these events decreased over time, with 6 of patients experiencing the event during the first 3 months of treatment compared to 1 during the last 6 months. The median time to the first occurrence of flu-like symptom complex was 3.5 days and the median duration per patient was 7.5 days per year. Laboratory abnormalities included absolute neutrophil count less than 1500/mm 3 (18%) (no patients had absolute neutrophil counts less than 500/mm 3 ), WBC less than 3000/mnf (1), SGPT greater than 5 times baseline value (19%), and total bilirubin greater than 2.5 times baseline value (). Three patients were withdrawn from treatment with 0.25 mg Betaseron for abnormal liver enzymes including one following dose reduction (see PRECAUTIONS, Laboratory Tests) Twenty-one (28%) of the 76 premenopausal females treated at 0.25 mg Betaseron and 10 (1) of the 76 premenopausal females treated with placebo reported menstrual disorders. All of these reports were of mild to moderate severity and included: intermenstrual bleeding and spotting, early or delayed menses, decreased days of menstrual flow, and clotting and spotting during menstruation. Mental disorders have been observed in patients in this study. Symptoms included depression, anxiety, emotional lability, depersonalization, suicide attempts, confusion, etc. In the treatment group, two patients withdrew for confusion. One suicide and four attempted suicides were also reported. It is not known whether these symptoms may be related to the underlying neurological basis of MS, to Betaseron treatment, or to a combination of both. Some similar symptoms have been noted in patients receiving interferon alfa and both Interferons are thought to act through the same receptor. Patients who experience these symptoms should be closely monitored and cessation of therapy considered. Additional common adverse clinical and laboratory events associated with the use of Betaseron (Interferon beta-1b) are listed in the following paragraphs. These events occurred at an incidence of or more in the 124 MS patients treated with 0.25 mg of Betaseron every other day for periods of up to 3 years in the controlled trial, and at an incidence that was at least twice that observed in the 123 placebo patients. Common adverse clinical and laboratory events associated with the use of Betaseron were: injection site reaction (8), injection site necrosis (), palpitation (8%), hypertension (7%), tachycardia (), peripheral vascular disorders (), gastrointestinal disorders (), absolute neutrophil count <1500/mnf (18%), WBC <3000/mnf (1), SGPT >5 times baseline value (19%), total bilirubin >2.5 times baseline value (), somnolence (), dyspnea (8%), laryngitis (), menstrual disorder (17%), cystitis (8%), breast pain (7%), pelvic pain (), and menorrhagia (). A total of 277 MS patients have been treated with Betaseron (Interferon beta-lb) in doses ranging from mg to 0.5 mg. During the first 3 years of treatment, withdrawals due to clinical adverse events or laboratory abnormalities not mentioned above included: fatigue (, 6 patients), cardiac arrhythmia (<1%, 1 patient), allergic urticarial skin reaction to injections (<1%, 1 patient), headache (<1%, 1 patient), unspecified adverse events (<1 %, 1 patient), and "felt sick" (<1 %, 1 patient). TABLE 2 enumerates adverse events and laboratory abnormalities that occurred at an incidence of or more among the 124 MS patients treated with 0.25 mg Betaseron every other day for periods of up to 3 years in the controlled trial and at an incidence that was at least more than that observed in the 123 placebo patients. Reported adverse events have been reclassified using the standard COSTART glossary to reduce the total number of terms employed in the table. In TABLE 2, terms so general as to be uninformative, and those events where a drug cause was remote have been excluded. It should be noted that the figures cited in the table cannot be used to predict the incidence of side effects in the course of usual medical practice where patient characteristics and other factors differ from those that prevailed in the clinical trials. The cited figures do provide the prescribing physician with some basis for estimating the relative contribution of drug and nondrug factors to the side effect incidence rate in the population studied. Other events observed during premarketing evaluation of various doses of Betaseron in 1440 patients are listed in the paragraph that follows. Because most of the events were observed in open and uncontrolled studies, the role of Betaseron in their causation cannot be reliably determined. Body as a Whole: abscess, adenoma, anaphylactoid reaction, ascites, cellulitis, hernia, hydrocephalus, hypothermia, infection, peritonitis, photosensitivity, sarcoma, sepsis, and shock; Cardiovascular System: angina pectoris, arrhythmia, atrial fibrillation, cardiomegaly, cardiac arrest, cerebral hemorrhage, cerebral ischemia, endocarditis, heart failure, hypotension, myocardial infarct, pericardial effusion, postural hypotension, pulmonary embolus, spider angioma, subarachnoid hemorrhage, syncope, thrombophlebitis, thrombosis, varicose vein, vasospasm, venous pressure increased, ventricular extrasystoles, and ventricular fibrillation; Digestive System: aphthous stomatitis, cardiospasm, cheilitis, cholecystitis, cholelithiasis, duodenal ulcer, dry mouth, enteritis, esophagitis, fecal impaction, fecal incontinence, flatulence, gastritis, gastrointestinal hemorrhage, gingivitis, glossitis, hematemesis, hepatic neoplasia, hepatitis, hepatomegaly, ileus, increased salivation, intestinal obstruction, melena, nausea, oral leukoplakia, oral moniliasis, pancreatitis, periodontal abscess, proctitis, rectal hemorrhage, salivary gland enlargement, stomach ulcer, and tenesmus; Endocrine System: Cushing's Syndrome, diabetes insipidus, diabetes mellitus, hypothyroidism, and inappropriate ADH; Hemic and Lymphatic System: chronic lymphocytic leukemia, hemoglobin less than 9.4 g/100 ml, petechia, platelets less than 75,000/mm 3, and splenomegaly; Metabolic and Nutritional Disorders: alcohol intolerance, alkaline phosphatase greater than 5 times baseline value, BUN greater than 40 mg/dl, calcium greater than 11.5 mg/dl, cyanosis, edema, glucose greater than 160 mg/dl, glycosuria, hypoglycemic reaction, hypoxia, ketosis, and thirst; Musculoskeletal System: arthritis, arthrosis, bursitis, leg cramps, muscle atrophy, myopathy, myositis, ptosis, and tenosynovitis; Nervous System: abnormal gait, acute brain syndrome, agitation, apathy, aphasia, ataxia, brain edema, chronic brain syndrome, coma, delirium, delusions, dementia, depersonalization, diplopia, dystonia, encephalopathy, euphoria, facial paralysis, foot drop, hallucinations, hemiplegia, hypalgesia, hyperesthesia, incoordination, intracranial hypertension, libido decreased, manic reaction, meningitis, neuralgia, neuropathy, neurosis, nystagmus, oculogyric crisis, ophthalmoplegia, papilledema, paralysis, paranoid reaction, psychosis, reflexes decreased, stupor, subdural hematoma, torticollis, tremor, and urinary retention; Respiratory System: apnea, asthma, atelectasis, carcinoma of lung, hemoptysis, hiccup, hyperventilation, hypoventilation, interstitial pneumonia, lung edema, pleural effusion, pneumonia, and Pneumothorax; Skin and Appendages: contact dermatitis, erythema nodosum, exfoliative dermatitis, furunculosis, hirsutism, leukoderma, lichenoid dermatitis, maculopapular rash, psoriasis, seborrhea, skin benign neoplasm, skin carcinoma, skin hypertrophy, skin necrosis, skin ulcer, urticaria, and vesiculobullous rash; Special Senses: blepharitis, blindness, deafness, dry eyes, ear pain, iritis, keratoconjunctivitis, mydriasis, otitis externa, otitis media, parosmia, photophobia, retinitis, taste loss, taste perversion, and visual field defect; Urogenital System: anuria, balanitis, breast engorgement, cervicitis, epididymitis, gynecomastia, hematuria, impotence, kidney calculus, kidney failure, kidney tubular disorder, leukorrhea, nephritis, nocturia, oliguria, polyuria, salpingitis, urethritis, urinary incontinence, uterine fibroids enlarged, uterine neoplasm, and vaginal hemorrhage. DRUG ABUSE AND DEPENDENCE No evidence or experience suggests that abuse or dependence occurs with Betaseron (Interferon beta-1b) therapy; however, the risk of dependence has not been systematically evaluated. DOSAGE AND ADMINISTRATION The recommended dose of Betaseron for the treatment of ambulatory relapsing-remitting MS is 0.25 mg injected subcutaneously every other day. Limited data regarding the activity of a lower dose are presented above (see CLINICAL PHARMACOLOGY, Clinical Trials). Evidence of efficacy beyond 2 years is not known since the primary evidence of efficacy derives from a 2-year, double-blind, placebo-controlled clinical trial (see CLINICAL PHARMACOLOGY, Clinical Trials). Safety data are not available beyond the third year. Patients were discontinued from this trial due to unremitting disease progression of 6 months or greater. To reconstitute lyophilized Betaseron for injection, use a sterile syringe and needle to inject 1.2 ml of the diluent supplied, Sodium Chloride, 0.5 Solution, into the Betaseron vial. Gently swirl the vial of Betaseron to dissolve the drug completely; do not shake. Inspect the reconstituted product visually and discard the product before use if it contains paniculate matter or is discolored. After reconstitution with accompanying diluent, Betaseron vials contain 0.25 mg Interferon beta-1b/ml of solution. Withdraw 1 ml of reconstituted solution from the vial into a sterile syringe fitted with a 27-gauge needle and inject the solution subcutaneously. Sites for self-injection include arms, abdomen, hips, and thighs. A vial is suitable for single use only; unused portions should be discarded. (See BETASERON PATIENT INFORMATION sheet for SELF-INJECTION PROCEDURE.) Stability: The reconstituted product contains no preservative. Store at room temperature 25 C (77 F), excursions permitted to C (59-86 F). After reconstitution, if not used immediately, the product should be refrigerated and used within 3 hours. Avoid freezing. HOWSUPPUED Betaseron is supplied as a lyophilized powder containing 0.3 mg of Interferon beta-lb, 15 mg Albumin Human USP, and 15 mg mannitol USP. Drug is packaged in a clear glass, single-use vial (3 ml capacity); a separate vial containing 2 ml of diluent (Sodium Chloride, 0.5 solution) is included for each vial of drug. Store at room temperature. NDC mg/vial NDC vials, 0.3 mg/vial Caution: Federal law prohibits dispensing without prescription. REFERENCES 1. Ruzicka FJ, et al. J Biol Chem, 1987; 262: Uze G, et al. Cell, 1990; 60: DeMaeyer E, et al. In: Interferons and other regulatory cytokines, NY, Wiley Colby CB, et al. J Immunol 1984; 133: Pestka S, et al. Annu Rev Biochem 1987; 56: Lengyel P Annu Rev Biochem 1982; 51: Witt PL, et al. J Interferon Res 1990; 10: Schiller JH, et al. J Biol Resp Mod 1990; 9: Rosenblum MG, et al. J Interferon Res 1990; 10: Carlin JM, et al. J Immuno 1987; 130(7): Witt PL, et al. J Immunotherapy 1993; 13: Goldstein D, et al. J Natl Cancer Inst 1989; 81: Poser CM, et al. Ann Neural 1983; 13(3): BlaschkeTF, etal. Clinical Research 1985; 33(1): 19A. Manufactured by: CHIRON Corporation Emeryville, CA U.S. License No Distributed by: BERLEX Laboratories Richmond, CA U.S. Patent No. 4,588,585; 4,959,314; 4,737,462; 4,450, Berlex Laboratories All rights reserved. Printed in U.S.A. Part Number Revision date 1/02