DAS SCORES BY VISIT TO DAY 42 PRIMARY ENDPOINT CRP LEVELSDAS SCORES

AGE (yrs)

Mean, Range

GENDER

Males

Females

BMI

Mean, Range

YEARS SINCE RA DIAGNOSIS

Mean, Range

BASELINE WEEKLY MTX DOSE

mg Mean, Range

MEAN NUMBER of PRIOR DMARDS

Mean, Range

PRIOR TNF ANTAGONIST USE

RHEUMATOID FACTOR POSITIVE

ANTI-CCP ANTIBODY POSITIVE

ENROLLMENT BY COUNTRY

Bosnia and Herzegovina (Mostar, Sarajevo)

Croatia (Zagreb)

The Netherlands (Amsterdam)

55

4

4

26.3

9.9

16.25

2.75

3

7

6

3

2

3

(38 - 69)

(50%)

(50%)

(23.5-30.9)

(0.5-19)

(7.5-25)

(1-4)

(37.5%)

(87.5%)

(75%)

(37.5%)

(25%)

(37.5%)

BASELINE CHARACTERISTICS

DAS28-CRP

Mean, SD

TENDER JOINT COUNT

Mean # of 28, SD

SWOLLEN JOINT COUNT

Mean # of 28, SD

CRP (mg/L)

Mean, SD

PATIENT GLOBAL

ASSESSMENT of DISEASE

(100 pt VAS) Mean, SD

PATIENT ASSESSMENT

of PAIN

(100 pt VAS) Mean, SD

PHYSICIAN GLOBAL

ASSESSMENT of DISEASE

(100 pt VAS) Mean, SD

HAQ-DI

(0-3 SCORE) Mean, SD

6.05

18.4

12.9

17.46

57.9

68.4

70.0

1.734

(0.869)

(9.02)

(6.90)

(9.99)

(16.26)

(16.11)

(12.54)

(0.895)

ACR RESPONSE AT DAY 84:

ACR 20

ACR 50

ACR 70

5

2

1

(62.5)

(25.0)

(12.5)

BASELINE DISEASE SEVERITY

GROUP MEAN DAS IMPROVEMENT ACR AND EULAR RESPONSE AT DAY 42 PRIMARY ENDPOINT

0

5

10

15

20

25

30

35

40

45

CR

P m

g/L

Screen Visit Day 42

6.15.6

3.7

0

1

2

3

4

5

6

7

8

Screen Day 0 Day 42

DA

S 2

8

Mean DAS (SD)

Day 0 Day 42

Mean Change in DAS from Screen Visit (SD)

-0.47

-2.41

-4

-3

-2

-1

0

1

Ch

ange

in

DA

S2

8

75

50

25

0

20

40

60

80

100

ACR 20 ACR 50 ACR 70

% R

esp

on

din

g

ACR Response

25 25

0

20

40

60

80

100

75

50

Moderate+ Good

Moderate Good None

EULAR Response

0

20

40

60

80

100

25

75

No Yes

EULAR Remission

MEAN CHANGE IN DAS BY VISIT THROUGH DAY 84 STUDY CONCLUSION

Stimulation Hiatus

Active Stimulation Active Stimulation

Implant & Single in-OR Diagnostic Stimulation

-3

-2

-1

-21 -14 -7 7 14 21 28 35 42 49 56 63 70 77 840SAFETY

• No Serious Adverse Events

• No Adverse Event withdrawals

• No device-related Adverse Events

• A total of 21 Adverse Events occurred in 7 subjects: - All were mild or moderate

• Implantation procedure-related Adverse Events occurred in 3 patients:

- “Dry throat”, “hoarseness”, “dyspnea” - “Numbness of skin on neck under jaw” - “Tingling in scar area”

Anatomic Position of Implanted Device

Programming the Device in Clinic

Lead

PulseGenerator

2.5mm

53mm

0

1

2

3

4

5

6

7

8

9

-21 -14 -7 0 7 14 21 28 35 42

1

2

3

4

5

6

7

8

Screen QD Stim. QD or QID Stim.

Hiatus

Implant & in-OR Diagnostic Stim.

Patient No.

Study Day

Single Stim.

0

1

2

3

4

5

6

7

8

DA

S 2

8

Day 42Screen Visit

Conclusions

Summary & Conclusions

Pilot Study of Stimulation of the Cholinergic Anti-inflammatory Pathway with an Implantable Vagus Nerve Stimulation Device in Patients with Rheumatoid Arthritis

Frieda Koopman1, Sanda Miljko2, Simeon Grazio3, Sekib Sokolovic4, Kevin Tracey5, Yaakov Levine6, Ralph Zitnik6, Paul-Peter Tak1,7

1Academic Medical Center, Amsterdam, The Netherlands, 2University Clinical Hospital, Mostar, Bosnia and Herzegovina, 3Clinical Hospital Center Sestre Milosrdnice, Zagreb, Croatia,4Sarajevo University Clinical Center, Sarajevo, Bosnia and Herzegovina, 5Feinstein Institute for Medical Research, Manhasset, NY, USA, 6SetPoint Medical Corporation, Valencia, CA, USA, 7Currently: GlaxoSmithKline, Stevenage, U.K.

BACKGROUNDThe inflammatory reflex regulates innate and adaptive immunity (Andersson U, Tracey K, Annu. Rev. Immunol. 2012; 30:313). Activation of its efferent arm (the Cholinergic Anti-inflammatory Pathway (CAP)), by electrical vagus nerve stimulation (VNS) reduces systemic inflammation and ameliorates disease in many acute and chronic animal models. We determined whether VNS could similarly improve clinical manifestations of rheumatoid arthritis (RA).

METHODS This is an open label study of patients with active RA (>/= 4 tender and 4 swollen joints (28 joint scoring), and CRP of at least 7 mg/L) despite stable methotrexate dose for 3 months. Patients failing TNF antagonists (only for safety or tolerability reasons) could also be enrolled after washout. After a pre-implantation baseline visit, patients were surgically implanted with a Cyberonics VNS system. The device delivered the first VNS during its standard intraoperative diagnostic check sequence. Two weeks following implantation patients returned for initial in-clinic VNS. One week after the first clinic visit (day 7), patients began self-delivery of 60 second, once daily home stimulations, escalated in output current intensity as tolerated, through day 28. At day 28 patients without a EULAR good or moderate response were increased to four times daily VNS. Primary endpoint results at day 42 are reported.

RESULTS 8 patients (4 female, 7/8 RF+, 6/8 ACPA+, mean age 56 [range 39-70], mean disease duration 8 yrs [range 0.5-13]) were enrolled and implanted. Implantation and stimulation were generally well tolerated. Moderate postoperative hoarseness occurred in one patient. Pre implantation baseline values (mean, SD) were: DAS28-CRP: 6.06 (0.87), CRP: 17.5 mg/L (9.9), HAQ-DI: 1.63 (0.90). Changes at day 42 visit from pre-implantation values were: DAS28-CRP: -2.28 (1.65), CRP: -3.46 (17.95) mg/L , HAQ-DI: -0.44 (0.48). Similar levels of improvement were seen across all ACR core set assessments. ACR 20/50/70 response rates from pre-implantation baseline to day 42 were 75% (6/8), 50% (4/8), and 25% (2/8), respectively.

CONCLUSIONSIn this pilot study VNS was generally well tolerated and improved signs and symptoms of RA. This is the first demonstration in humans that stimulation of the CAP can favorably impact clinical manifestations of systemic inflammation. If efficacy and safety are confirmed in larger controlled studies, implantable medical devices may offer a feasible alternative approach to the treatment of RA and other chronic inflammatory diseases.

ResultsAbstract

• Tissue injury, inflammation and infection are sensed both centrally and by the afferent vagus nerve and signals are relayed through brainstem vagal nuclei to the efferent vagus.

• The efferent arm of the inflammatory reflex is termed the “Cholinergic Anti-inflammatory Pathway (CAP)”: Efferent neural signaling proceeds through the sub-diaphragmatic celiac ganglion to the adrenergic splenic nerve, and into the spleen.

• Within splenic white pulp, splenic nerve fibers lie in close apposition to alpha 7 nicotinic acetylcholine receptor-bearing (α7NAChR) macrophages, and a specific subpopulation of beta adrenoceptor-bearing CD4+/CD44high/CD62L low T cells which have the capacity to synthesize and release acetylcholine.

• Acetylcholine signaling induces phenotypic changes in macrophages and monocytes via α7NAChR which results in decreased sensitivity to activation by pro-inflammatory signals.

• In RA and other inflammatory disorders there is epidemiological evidence for insufficient levels of parasympathetic activity, and the extent of reduction correlates inversely with disease activity3.

• Activating the CAP is effective in rodent CIA and many other acute and chronic models of inflammation3-8.

• CAP activation using an implantable neuromodulation device in RA patients should reduce production of systemic pro-inflammatory mediators and activation of immune effector cells trafficking to the inflamed joint, thereby improving clinical signs and symptoms of RA.

Background

• Treatment resulted in significant and clinically meaningful improvement in signs and symptoms at the Day 42 primary endpoint:

- DAS28 improvement of 2.41 points - ACR 20/50/70 response rates of 75%, 50%, and 25% - EULAR good or moderate response in 75% - EULAR remission in 25%

• Loss of efficacy, as expected, following temporary treatment discontinuation after Day 42 visit

• Partial recapture of effect at Day 84 following re-institution of treatment

• Treatment was generally well tolerated, with an Adverse Event profile consistent with other studies using this device.

Summary

• This is the first clinical trial suggesting that an implantable neuromodulation device can activate the inflammatory reflex and improve clinical manifestations of RA.

• Further larger controlled studies in RA and other chronic inflammatory diseases are warranted.

• Given the relatively low one-time cost, and long expected lifespan of implantable medical devices, this approach has the potential to reduce health care expenditures in these diseases.

1. Rosas-Ballina M, et al. Science 2011; 334:98.2. Tracey K. Cell. 2012; 148:392.3. Andersson U, Tracey K. Ann Rev Immunol 2012; 30:313.4. van Maanen MA, et al. Nat Rev Rheumatol. 2009; 5:229.5. Zhang P, et al. Inflam Res 2008; 57:1.6. van Mannen M, et al. Ann Rheum Dis 2010; 69:1717.7. van Mannen M, et al. Arth Rheum 2009; 60:114.8. Levine Y, et al. Ann Rheum Dis. 2010; 69(Suppl3):191.

SPM-005 STUDY TEAMAcademic Medical Center, Amsterdam, The Netherlands

P-P Tak (PI)F A C Koopman (Sub-I)D M Gerlag (Sub-I)M Geerdink (Coordinator)R Schuurman (Neurosurgeon)I Fluri (Biomarker Technician)

University Clinical Hospital, Mostar, Bosnia and HerzegovinaS Miljko (PI)M Bevanda (Sub-I)A Bogut (Sub-I)I Kostro (Coordinator)N Petric (Device Specialist)A Kogler (Neurosurgeon)M Grle (Orthopedics/Synovial Biopsies)Z Ostojic (Orthopedics/Synovial Biopsies)K Juka (Orthopedics/Synovial Biopsies)I Mikulic (Biomarker Technician)V Barac (Biomarker Technician)

Clinical Hospital Center „Sestre Milosrdnice”, Zagreb, CroatiaS Grazio (PI)I Doko (Sub-I)M Mlinar (Coordinator)K Rotim (Neurosurgeon)M Boric (Neurosurgeon)A Matejcic (Orthopedics/Synovial Biopsies)D Vidovic (Orthopedics/Synovial Biopsies)A Tesija Kuna (Biomarker Technician)I Vukasovic (Biomarker Technician)

University Clinical Center, Sarajevo, Bosnia and Herzegovina

S Sokolovic (PI)S Mehmedagic (Sub-I)Z Hodzic (Coordinator)E Burazerovic (Neurosurgeon)F Miljanovic (Biomarker Technician)

Intraoperative Surgical ConsultantsR Bucholz, St Louis University, St Louis, MO, USA (Neurosurgery)K Novak, Medical University of Vienna, Vienna, Austria (Neurosurgery)P van Luijk, Academic Medical Center, Amsterdam, Netherlands

(Orthopedics/Synovial Biopsies)Ergomed Group (CRO)

D Cohadzic (Study Physician)M Lux (Project Manager)C Wilson (Senior Director, Regulatory Affairs)K Mirkovic Kos (Regulatory Manager)I Kmicikiewicz (Safety Manager)M Tarac (Clinical Trial Associate)A Beho (Monitor)D Barisic (Monitor)V Horvat (Site Management)S Sturlic (Data Management)A-M Supe (Data Management)W Sonbol (Data Management)H Nowak (Biometrics)V Rattemeyer (Biometrics)

SetPoint Medical, Valencia CA, USAR Zitnik (Medical Monitor)Y Levine (Biomarker Assay Design and Analysis)A Caravaca (Biomarker Technician)M Faltys (Device Engineering)D Miller (Site Device Specialist)

Author:Frieda KoopmanSanda MiljkoSimeon GrazioSekib SokolovicKevin TraceyYaakov LevineRalph ZitnikPaul-Peter Tak

Organization:NoneSetPoint MedicalSetPoint Medical SetPoint Medical SetPoint Medical SetPoint Medical SetPoint Medical SetPoint Medical

ACR Category:NoneResearch GrantResearch GrantResearch GrantStock OwnershipEmployee, Stock OwnershipEmployee, Stock OwnershipResearch Grant, Consulting

DISCLOSURES

REFERENCES

-+

Damage- and Pathogen-Associated

Molecular Pattern Molecules

TLRs

AcetylcholineRelease

NorepinephrineRelease

Efferent Vagus NerveAfferent

Brainstem Nuclei

Splenic Nerve

Choline Acetyl Transferase +T cell

2 AR

Macrophage

TNF, HMGB1IL-1, IL-6, IL-8

7 NACh R

Injury,Inflammation,

Infection

CeliacGanglion

AC6

cAMP

CREB

pCREB

cfos

Kinase TNF TNF

TLRs

7 NACh R

I BNF B

NF B

NF B

IKK

Spleen

ImplantedNerve Stimulator

EfferentVagusNerve

VagusNerve

CeliacGanglion

SplenicNerve

Choline Acetyl Transferase +

T cell

Macrophage

7 NACh R

2 AR

NorepinephrineRelease

AcetylcholineRelease

of cells which traffic to joint

Figure 1 : The inflammatory reflex modulates innate and adaptive immunity in order to maintain immunologic homeostasis1-4

Figure 2 : Neurostimulation of the Efferent Limb of the Inflammatory Reflex Enables a Means for Non-Pharmacologic Management of RA Homeostasis1-4

• The Cyberonics VNS® system has been approved for use in medically refractory epilepsy for more than 15 years, with over 60,000 patients implanted.

• Use of this device in RA is investigational: The trial was approved by the designated Ethics Committee and Competent Regulatory Authority for each site.

• Standard commercially-available devices were purchased for this study, implanted by experienced neurosurgeons as recommended by the manufacturer, and programmed according to protocol-specified algorithms by the site staff.

• At study conclusion, patients could undergo surgical removal of the

device, keep the device in place but have it permanently inactivated, or continue in a long term safety extension protocol. All patients enrolled opted to continue in the extension study.

MethodsFigure 3 : Vagus nerve stimulation was performed in this study using a commercially marketed active implantable medical device.

D28 D42 D56 D84 D21 D14 D7 D0 Implant

-

Discontinue stimulation

Baseline Synovial Biopsy Daily

stimulation

w/escalating

intensity

QID

stimulation

if clinical

response

inadequate

Restart stimulation at

same level as D42

Follow-up Synovial Biopsy

Screen

Intraoperative stimulation

during diagnostic check Single in-clinic stimulation at D0, biomarkers

pre-, and post stimulation through D7

D42D0Implant D56

Baseline Clinical Assessments Primary Endpoint

Follow-up Synovial Biopsy

STUDY POPULATION• Adult-onset rheumatoid arthritis (RA) of at least six months duration as

defined by 2010 ACR/EULAR criteria• Male or female patients 18-75 years of age• Functional status I, II, or III according to ACR 1991 criteria• Active disease defined by at least 4 tender and swollen joints and CRP

above 7 mg/L, despite at least 3 months of methotrexate at a dose of up to 25 mg orally per week

• Past TNF antagonist use acceptable, but must have failed on basis of safety, and not due to lack of efficacy

ENDPOINTS• Change in DAS28 (Primary)• ACR 20/50/70 Response Rate• EULAR Response Rate• EULAR Remission Rate• Biomarkers (FACS, serum cytokines, LPS-induced TNF release assay):

to be reported elsewhere• Synovial Biopsy (Immunohistochemistry, PCR): to be reported elsewhere

STUDY DESIGN

Implantation