Ory Rouvio, Tsila Zuckerman, Izhar Hardan, Moshe Yeshurun, Simcha Samuel, and Itai Levi

1. Stem Cell Mobilization Using the Combination of Plerixafor and G-CSF in Patients Previously Failed G-CSF Mobilization Alone: Preliminary Experience in Israel. Ory Rouvio, Tsila Zuckerman, Izhar Hardan, Moshe Yeshurun, Simcha Samuel, and Itai Levi ISH Spring 2009 meeting

2. Factors associated with poor mobilization: • Age>60yr • Advanced disease and/or bone marrow involvement • Previous radiation therapy and chemotherapy • Multiple chemotherapy cycles • Previous treatment with melphalan, carmustine, or fludarabine.

3. Failure Rates (cell count<2x10^6 CD34+ cells/kg) for First Mobilizers after 5 Apheresis Days* *Pusic I, et al. Impact of mobilization and remobilization strategies on achieving sufficient stem cell yields for autologous transplantation. Biol Blood Marrow Transplant. 2008; 14(9):1045-1056

4. Suboptimal mobilization can lead to: • Inability to undergo aHSCT • Increased costs to the healthcare system • Loss of quality of life • Increased number of days of apheresis • Delayed, partial, or failed stem-cell engraftment • Increased need for blood transfusions • Elevated rates of MDS* *Kalaycio M, et al. Risk factors before autologous stem-cell transplantation for lymphoma predict for secondary myelodysplasia and acute myelogenous leukemia. J Clin Oncol. 2006; 24(22):3640-3610

5. Plerixafor (AMD3100; Mozobil) • A bicyclam molecule • Reversible inhibitor of SDF-1a/CXCR4 binding • Initially developed as an inhibitor of HIV entry into CD4+ cells • Caused rapid, transient leukocytosis in patients with HIV infection and healthy volunteers, stimulating interest in capacity to mobilize CD34+ cells • Very water soluble • Low molecular weight (MW = 502)

6. Mozobil Mechanism of Action of Mozobil • Mozobil blocks the CXCR4-SDF-1a interaction, releasing stem cells from bone marrow into the circulating blood • no growth factor • release within hours • synergistic with G-CSF

7. Clinical efficacy • The efficacy and safety of Mozobil was evaluated in 2 randomized, double-blind, placebo-controlled, multicenter phase 3 studied (AMD 3100-3101-NHL, AMD 3100-3102-MM)

8. Phase 3 TrialsFDA granted SPA Dec 2004 - Primary Efficacy Endpoint 150 NHL G-CSF + MOZOBIL Primary Endpoint: > 5 million CD34+ cells/kg in 4 or fewer days of apheresis 3101: 300 NHL Patients 20% difference 150 NHL G-CSF + placebo 150 MM G-CSF + MOZOBIL Primary Endpoint: > 6 million CD34+ cells/kg in 2 or fewer days of apheresis 3102: 300 MM Patients 20% difference 150 MM G-CSF + placebo

9. Efficacy - CD34+ Cell Mobilization in NHL Patients

10. Secondary Efficacy: Number of Days to PMN and PLT Engraftment - ITT Note: Includes randomized patients receiving study drug and receiving a transplant. * p-value from Log-Rank test

11. Efficacy – CD34+ Cell Mobilization in MM Patients

12. Secondary Efficacy: Number of Days to PMN and PLT Engraftment - ITT Note: Includes randomized patients receiving study drug and receiving a transplant. * p-value from Log-Rank test stratified by baseline PLT (<200,000 dL, > 200,000 dL)

13. Indications and usage • Mozobil, a hematopoietic stem cell mobilizer, is indicated in combination with granulocyte-colony stimulating factor (G-CSF) to mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in patients with non-Hodgkin’s lymphoma and multiple myeloma

14. Dosage and administration • Initiate Mozobil treatment after the patient has received G-CSF once daily for 4 days • Repeat Mozobil dose up to 4 consecutive days • Select dose based on 0.24 mg/kg actual body weight • Administer by subcutaneous injection approximately 11 hours prior to initiation of apheresis • Renal impairment: If creatinine clearance is  50 mL/min, decrease dose by one-third to 0.16 mg/kg

15. Daily dose of G-CSF Apheresis session Mozobil dosing Stem Cell Mobilization Protocol Mobilization Collection Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8

16. Clinical Adverse Reactions • The most common AEs (>10%) reported by Mozobil clinical program regardless of cause were: diarrhea, nausea, fatigue, injection site reactions, headache, arthralgia, dizziness, and vomiting. • AEs less than 5% but were reported to be related to Mozobil during HSC mobilization and apheresis include: abdominal pain, hyperhidrosis, abdominal distention, dry mouth, erythema, stomach discomfort, malaise, oral hypoaesthesia, constipation, dyspepsia, and musculoskeletal pain. • Mild to moderate systemic AEs (less than 1%) include: urticaria, periorbital edema, dyspnea, or hypoxia. • Less than 1% experiencedvasovagal reactions, orthostatic hypotension, and/or syncope following SC injections- appropriate precautions should be taken.

17. HSC Mobilization Using Mozobil in Israel • Mozobil is FDA approved in the USA and in the European Union. • In Israel Mozobil is used through Genzyme Corporation compassionate use protocol (for NHL or MM patients only). • Currently, Mozobil was used for HSC mobilization in only 16 patients from 5 medical centers in Israel.

18. HSC Mobilization Using Mozobil in Israel (cont) • Overall 16 pts: 9 NHL, 7 MM • All failed previous one or two HSC collections (defined as cell count<2x10^6 CD34+ cells/kg) • At the time of Mozobil mobilization pts were either on CR (1/2) or PR. • One MM pt (plasma cell leukemia with PD) and one NHL pt failed collection. • One MM pt- only one aphersis for HSC back-up (pt is intended for allo-HSCT)

19. * ** ‡ Results of HSC Collection Using Mozobil *Pt is currently on 2nd day apheresis **Pt with MM (plasma cell leukemia) progressive disease ‡Pt with MM- only one apheresis for back-up (planned for allo-HSCT)

20. Amount of CD34+ Cells Collected Using Mozobil

21. Percentages of Pts Succeeded in Mobilizing ≥2x10^6/kg and ≥5x10^6/kg CD34+ HSC* *Pt with plasma cell leukemia with PD- not included

22. AEs in Israel • No significant AE were noted using Mozobil. • One MM pt died two weeks after HSC mobilization, but death was related to the pt morbid condition. • In two different aphereses from two pts we got thick aggregates in the collection bag- related to high WBC and monocytic counts.

23. Conclusions • Mozobil is indicated in combination with G-CSF to mobilize HSC to the peripheral blood for collection and subsequent aHSCT in patients with NHL and MM. • So far, 93.3% of our patients previously failed HSC collection, succeeded with Mozobil HSC mobilization. • Results of engraftment after aHSCT using HSC mobilized with Mozobil are pending.

24. Conclusion (2) • Treatment was well tolerated and no serious adverse events were noted. • This initial experience emphasizes Mozobil as an attractive agent for HSC mobilization and may have particular value in heavily pretreated patients.

25. Thanks • Dr. Lina Atlas: Apheresis unit, Institute of Hematology, Soroka Medical Center • Dr.Yizhar Hardan: Department of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer • Dr. Moshe Yeshurun: Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center • Dr. Tsila Zuckerman: Department of Hematology & Bone Marrow Transplantation, Rambam medical center • Simcha Samuel, MSc: Hadassah medical center • Yuval Levin and Dr. Ayelet Zamri: Genzyme-ISRAEL