l(l8
`
`'l'l-ll-I I\'l:'.\\' E.Z\'GI.A.\'D _]OUR.\'Al. OF Ml-Zl)lCI.\'l'.'.
`
`Aug. 13, l987
`
`l7. Schade DS. Eaton RP. The regulation of plasma ketone body concentration
`by counterregulatory honnones in man. I. Effects of notepinephrine in dia-
`betic man. Diabetes I977: 26:989-96.
`I8. McDonald-Gibson RG. Young M. The ttse of an automatic solids injection
`system quantitative detemtination of plasma long chain non-esterilied fatty
`acids by gas-liquid chromatography. Clin Chim Acta I974: 53:l I7-26.
`19. Wolfe RR. Tracers in metabolic research: radioisotope and stable isotope
`mass spectrometry methods. New York: Alan R. Liss. l984:26l-3.
`20. Faloona GR. Unger RH. Jaffe BM. C-lucagon. In: Jaffe BM. Behmtan HR.
`eds. Methods of hormone radioimmunoassay. New York: Academic Press.
`l974:3l7-38.
`2|. Hussain MN. Benedict CR. Radioenzymatic microassay for simultaneous
`estimations of dopamine. norepinephrine. and epinephrine in plasma. urine.
`and tissues. Clin Chem I985; 3l:l86l-4.
`22. Hagenfeklt L. Wahren J. Pemow B. Rif L. Uptake of individual free
`fatty acids by skeletal muscle and liver in man. J Clin invest I972; SI:
`2324-30.
`23. Spitzer .l.l. Gold M. Studies on the metabolism of free fatty acids in diabetic
`and fasting dogs. Ann NY Acad Sci 1965; I3I:235-49.
`24. Wolfe RR. Peters El. Klein S. Holland OB. Rosenblatt ll. Gary H lr. Effect
`of short-term fasting on lipolytic responsiveness in normal and obese human
`subjects. Aml Physiol I987: 252:El89-E196.
`
`.3
`
`25. Dixon M. Webb EC. Enzymes. 3rd ed. New York: Academic Press.
`l979:842-3.
`26. Harris IA. Benedict FG. A biometric study of basal metabolism in man.
`Washington. D.C.: Camcgic institution of Washington. I919:-104.
`27. Vaugh M. The production and release of glycerol by adipose tissue incubat-
`ed in vitro. J Biochem I962: 2317:3354-8.
`N.°°
`Wilmote DW. Aulick LH. Metabolic changes in burned patients. Surg Clin
`North Am 1978; 58:1 I73-87.
`Kien CL. Young VR. Rohrbaugh DK. Burke JF. Increased rates of whole
`body protein synthesis and breakdown in children recovering front bums.
`Ann Surg I978: l8'l:383-9|.
`Jahoor F. Desai M. Hemdon DN. Wolfe RR. Dynamics of the protein
`metabolic response to burn injury. Fed Proc I987; 46:879. abstract.
`Jahoor F. Hemdon DN. Wolfe RR. The role of insulin and glucagon in the
`response of glucose and alanine kinetics in bum-injured patients. J Clin
`Invest 1986; 78:807-I4.
`32. Vaughan GM. Becker RA. Unger RH. et al. Nonthyroidal control of metab-
`olism after burn injury: possible role of glucagon. Metabolism I985:
`34:63‘I—4l.
`33. Chenoweth M. Dunn A. Fructose-6-phosphate substrate cycling and hor-
`monal regulation of glticoneogenesis in vivo. Am J Physiol 1978: 235:
`E295-E303.
`
`30.
`M!
`
`.
`
`A PILOT TRIAL OF COP 1 IN EXACERBATING—REMITTING MULTIPLE SCLEROSIS
`
`MURRAY B. BORNSTEIN, M.D., AARON MILLER, M.D., SUSAN SLAGLE, M.P.H., MURIEL WEITZMAN, M.S.W.,
`Howmzo CRYSTAL, M.D., ELLI-:N DREXLER, M.D., MARSHALL KI-:ILsoN, M.D., ARNOLD MERRIAM, M.D.,
`SYLVIA WASSERTHI-LIL-SMOLLER, Pl-l.D., VINCENT SPADA, M.Sc., WILLIAM WI-:Iss, B.A., RUTH ARNON, Pl-l.D.,
`ISRAEL JACOBSOHN, DVORA TEITELBAUM, Pl-l.D., AND MICHAEL SELA, PH.D.
`
`Abstract Cop 1 is a random polymer (molecular weight,
`14.000 to 23,000) simulating myelin basic protein.
`It is
`synthesized by polymerizing L-alanine, L-glutamic acid,
`L-lysine, and L-tyrosine. It suppresses but does not induce
`experimental allergic encephalomyelitis. an animal model
`of multiple sclerosis. It is not toxic in animals.
`In a double-blind, randomized, placebo-controlled pilot
`trial. we studied 50 patients with the exacerbating—remit-
`ting form of multiple sclerosis, who self-injected either
`20 mg of Cop 1 dissolved in 1 ml of saline or saline alone
`daily for two years.
`Six of 23 patients in the placebo group (26 percent) and
`14 of 25 patients in the Cop 1 group (56 percent) had no
`exacerbations (P = 0.045). There were 62 exacerbations
`in the placebo group and 16 in the Cop 1 group. yielding
`two-year averages 012.7 and 0.6 per patient, respectively.
`Among patients who were less disabled on entry (Kurtzke
`
`disability score, 0 to 2). there were 2.7 exacerbations in
`the placebo group and 0.3 in the Cop 1 group over two
`years. Among patients who were more affected (Kurtzke
`disability score, 3 to 6), there was an average of 2.7 exac-
`erbations in the placebo group and 1.0 in the Cop 1 group.
`Over two years, less disabled patients taking Cop 1 im-
`proved an average 010.5 Kurtzke units; those taking pla-
`cebo worsened an average of 1.2 Kurtzke units. More
`disabled patients worsened by 0.3 (Cop 1 group) and
`0.4 (placebo group) unit. Irritation at Injection sites and
`rare. transient vasomotor responses were observed as
`side effects.
`These results suggest that Cop 1 may be beneficial in
`patients with the exacerbating—remitting form of multiple
`sclerosis. but we emphasize that the study is a preliminary
`one and our data require confirmation by a more extensive
`clinical trial. (N Engl J Med 1987; 317:408-14.)
`
`is synthesized by the random polymeriza-
`OP 1
`tion of L-alanine, L-glutamic acid, L-lysine, and
`I.-tyrosine in the ratio of 6.0:l.9:4-.7:l.0 (molecular
`weight, 14,000 to 23,000). It was one of a series of
`polypeptides prepared to simulate myelin basic pro-
`tcin, a natural component of the myelin sheath.”
`Myelin basic protein in Freund’s complete adjuvant
`
`From the Saul R. Korey Department of Neurology and the Department of
`Epidemiology and Social Medicine at the Albert Einstein College of Medicine.
`Bronx. N.Y.. and the Weizmann Institute of Science. Rehovot. Israel. Address
`reprint requests to Dr. Bomstcin at the Albert Einstein College of Medicine. I300
`Morris Park Ave.. Kennedy Center 40I. Bronx. NY l046l.
`Supported by a grant (NS-I I920) from the National Institute of Neurological
`and Communicative Disorders and Stroke. and II grant (GCRC RR-50) from the
`National Institutes of Health. Bethesda. Md.
`Presented in part at the 37th Annual Meeting of the American Academy of
`Neurology in Dallas. Tex.. April 30 to May 2. l985.
`
`induces experimental allergic encephalomyelitis, an
`animal model of multiple sclerosis. In saline, it sup-
`presses the response in challenged animals.” Some of
`the polypeptides simulating myelin basic protein, par-
`ticularly Cop l, proved incapable of inducing experi-
`mental allergic enccphalomyclitis, yet suppressed the
`disease in rabbits, guinea pigs, mice, and nonhuman
`primates.‘*°'9 Studies in mice suggest
`that
`it acts
`through the production of antigen-specific suppressor
`T cells.'°’“ Cop l
`is also nontoxic during short-term
`and longer-term (three to six months) administration
`in mice, rabbits, and dogs (Mcshorer A: personal
`communication).
`In view of these characteristics and the reported
`resemblance between expcrimental_allcrgic encepha-
`lomyelitis and multiple sclerosis,”''‘’ Cop l was tested
`
`Thel
`AMNEAL EXHIBIT NO. 1016 Page 1
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`
`Vol. 3l7 No. 7
`
`COP I AND MULTIPLE SCLEROSIS — BORNSTEIN ET AL.
`
`409
`
`first on 4 severely affected patients with multiple
`sclerosis” and later on l2 patients with the chron-
`ic, progressive form of the disease and 4 patients
`with the exacerbating-remitting form. ' 7 Those studies
`led to this double-blind, randomized, matched-pair,
`placebo-controlled pilot trial of Cop l in patients with
`the exacerbating—remitting form of the disease.
`
`METHODS
`
`The trial was approved by the Committee on Clinical Investiga-
`tions of the Albert Einstein College of Medicine and by the Food
`and Drug Administration (Cop l was assigned the investigationa|-
`new-drug number l-f»,l I5).
`
`Preparation and cnaracterlzatlon of cop 1
`
`Cop l was first prepared at the Weizmann Institute of Science,
`Rehovot, Israel,‘ and later by the Bio-Yeda Company in Rehovot.
`All batches were analyzed for their amino acid composition, molec-
`ular weight, cross-reactivity with myelin basic protein, and suppres-
`sion of experimental allergic encephalomyelitis in guinea pigs. Sup-
`pression was expressed as the difference in the percentage of
`diseased animals between the group treated with Cop l and the
`controls. The 12 batches from the Weizmann Institute had a sup-
`pression rate ranging from l0 to 80 percent (average, 33.5 percent);
`the rate for I4 batches produced by Bio-Yeda ranged from I0 to 75
`percent (average, 40.6 percent). In an attempt to reduce inflamma-
`tory reactions at injection sites, we used an in vitro method to
`evaluate cell damage (basophil degranulation) by serotonin re-
`lease." All the batches in this study produced releases of less than
`30 percent.
`Cop l was dissolved in bacteriostatic saline at a concentration of
`20 mg per milliliter. Sterile single-dose vials containing I ml of
`bacteriostatic saline alone or the Cop I solution were stored at
`-20°C until they were used. Each patient received a monthly sup-
`ply of 32 vials of the appropriate solution. The preparation and
`distribution of vials and patient compliance were monitored by a
`clinical assistant under the direction of the statistician responsible
`for the randomization of patients (see Study Design below).
`
`Patient Recruitment and Enrollment
`
`To be eligible for the study, patients had to fulfill all the diagnos-
`tic criteria for definite multiple sclerosis,” be 20 to 35 years of age,
`have an abovt,~average exacerbation rate, consisting of at least two
`well-demarcated and well-documented episodes of exacerbation in
`the two years before admission, have a score no higher than 6 (am-
`bulatory with assistance) on the Kurtzke Disability Status Scale,
`and be emotionally stable as determined by psychosocial evalua-
`tion. The Kurtzke Disability Status Scale” represents degrees of
`neurologic dysfunction in units from 0 (no disability) to I0 (death
`from multiple sclerosis); a related scale measures functioning in
`eight areas: pyramidal, cerebellar, brain-stem, sensory, bowel and
`bladder, visual, mental, and other.
`Questionnaires completed by 932 volunteers were reviewed; I40
`of these candidates were evaluated in neurologic and psychosocial
`examinations. Ninety of the I40 were excluded — 23 because of
`age; 2|, low frequency of exacerbations; I9, lack of documentation;
`I5, psychosocial inadequacy; 8, transition to a chronic, progressive
`course; 3, distance from the clinic; and I, pregnancy. Fifty patients
`were accepted into the trial.
`
`Study Design and Data collection
`
`Study patients were matched according to sex, number of exacer-
`bations per year within 1| exacerbation, and degree of disability as
`measured by the Kurtzke Scale in three strata: 0 to 2, 3 to 4, and 5 to
`6. The random assignment of the first patient of a pair determined
`the assignment of both. Treatment assignments were made known
`to the clinical assistant responsible for the production, labeling, and
`distribution of medication. A second clinic visit was scheduled with-
`in a few weeks of acceptance into the study. The patient was formal-
`
`ly enrolled in the study after another explanation of the trial,
`instruction in the method of self-injection, and signing of a con-
`sent form.
`
`Eight patients who had an exacerbation between screening and
`acceptance into the study were enrolled after their conditions had
`become stable. One patient was enrolled after being weaned from
`corticosteroids over a period of a month.
`Data from a personal and disease history and a neurologic exami-
`nation and status evaluation using Kurtzke’s Disability Status Scale
`and Eight Functional Groups were recorded at the time of screening
`and on the patient’s entry into the study. Patients visited the clinic
`one month later and every three months thereafter for two years. At
`each visit, a neurologist unaware of the patient‘s treatment group
`completed a neurologic examination and status evaluation. The
`patient‘s self-evaluation of local or generalized side effects and
`changes in neurologic status were reported to the clinical assistant,
`who was not blinded to treatment.
`Patients were also seen at the times of suspected exacerbations —
`i.e., when reporting the rapid onset of new symptoms or a worsen-
`ing of preexisting symptoms that persisted for 48 hours or more.
`The neurologist verified exacerbations on the basis of study criteria.
`An event was counted as an exacerbation only when the patient’s
`symptoms were accompanied by observed objective changes on the
`neurologic examination involving an increase of at least one grade
`in the score for one of the eight functional groups or the Kurtzlte
`Scale. Sensory symptoms unaccompanied by objective findings or
`transient neurologic worsening were not considered to represent an
`exacerbation. Patients experiencing an acute exacerbation were
`evaluated at frequent intervals — usually every two weeks — until a
`new, stable neurologie base line had been established. Seventy-four
`percent of 62 exacerbations in the placebo group and 75 percent of
`16 exacerbations in the Cop I group were treated with steroids.
`Symptomatic medications, such as cholinergic and spasmolytic
`drugs, were permitted.
`
`Laboratory Tests
`
`Blood and urine samples were obtained from each patient upon
`entry into the trial and at each three-month visit. Routine urinaly-
`ses, blood chemistry (SMA 20) determinations, and complete blood
`counts were performed. Aliquots of serum and cells were stored in a
`deep freezer or in liquid nitrogen (at -90° or - l80°C, respectively)
`for future studies.
`HLA typing of HLA-A, B, C, and DR was performed by the
`tissue-typing laboratory of the Department of Surgery, Montefiore
`Medical Center, Bronx, New York.
`
`Statiettealllethods
`
`The base-line characteristics of the study population in the two
`treatment arms were compared with use of two-tailed t-tests for
`continuous variables and chi-square tests with Yates’ correction for
`discrete variables. Differences in side effects according to treatment
`arm were evaluated with a chi-square test.
`The principal end point was the proportion of exacerbation-free
`patients. The other end points were frequency of exacerbations,
`change in Kurtzke score from that at base line, and length of time
`before progression, as defined below.
`The study design included planned subgroup analyses according
`to the disability status of the patients when they were randomized
`(Kurtzlte units 0 to 2, 3 to 4-, and 5 to 6). However, only one patient
`entered with a score of 4, and three with a score of 5. Therefore, we
`combined two of the three strata (3 to 4- and 5 to 6), creating two
`strata (0 to 2 and 3 to 6) with approximately equal numbers of
`patients for subgroup analyses.
`the difference between treat-
`For the matched-pair analysis,
`ment arms was tested with use of a McNemar’s statistic for
`the 22 matched pairs. A two-tailed Fisher's exact test was used
`for other two-by-two contingency tables. The chi-square test was
`used to test two-by-three contingency tables for frequency of exacer-
`bations.
`Survival curves were calculated with life-table methods" for the
`length of time before progression, with “progression“ defined as an
`increase of at least one unit in the Kurtzke score. Progression was
`
`Thel
`AMNEAL EXHIBIT NO. 1016 Page 2
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`

`
`410
`
`THE .\'E\\' ENGLAND JOURNAL OF MEDICINE
`
`Aug. I3, 1937
`
`Table 1. Base-Line Characteristics of the Study Population.
`CIIAIM'.'l'EI|S‘l'|C
`TIEATIIEN1’ Gnour
`PLACE»
`
`COP I
`
`No. entered
`
`Average age (yr)
`Average duration of disease (yr)
`Sex
`Male
`Female
`
`randomized
`
`included In
`analysis
`
`25
`
`31.0
`6.1
`
`10
`15
`
`23
`
`3l.l
`6.4
`
`I0
`l3
`
`25
`
`30.0
`4.9
`
`ll
`l4
`
`The matched analysis of the principal end point in-
`cluded 22 pairs, or 44 patients. An unmatched analy-
`sis permitted the inclusion of an additional four pa-
`tients — two who were unmatched and two who had
`been matched to two patients who were subsequently
`excluded (Fig. I). Analyses of exacerbation data are
`reported both as matched and unmatched. Subse-
`quent analyses were performed on an unmatched
`basis.
`
`Exaoorbatlona during the Two-Your Study Period
`
`In the 22 matched pairs, there were 12 discordant
`pairs: 2 patients in the placebo group had no exacer-
`bations, whereas their matches in the Cop I group did;
`I0 patients in the Cop 1 group had no exacerbations,
`whereas their matches in the placebo group did. The
`remaining 10 pairs had concordant results. The differ-
`ence in discordant pairs between treatment groups
`was significant (P = 0.039). An unmatched analysis
`of the presence or absence of exacerbations was also
`significant (P = 0.045).
`Figure I shows the occurrence and time of exacer-
`bations in each patient during the two years of the
`trial. There were 62 exacerbations among 23 patients
`in the placebo group (average, 2.7) and 16 among the
`25 patients in the Cop I group (average, 0.6). The
`effect of treatment was also examined according to the
`base-line Kurtzke score. In the 0 to 2 stratum, there
`were 27 exacerbations in two years among 10 placebo-
`treated patients (average, 2.7) and 4- exacerbations
`among 13 Cop l—treated patients (average, 0.3). In
`the 3 to 6 stratum, there were 35 exacerbations in the
`two years among 13 placebo-treated patients (aver-
`age, 2.7) and I2 exacerbations among 12 Cop l-treat-
`ed patients (average, 1.0).
`The distributions of exacerbations among the 48
`patients are shown in Table 2. Fourteen of the 25
`patients in the Cop 1 group (56 percent) were free of
`exacerbations, as compared with 6 of the 23 patients
`in the placebo group (26 percent). By contrast, 12
`patients in the placebo group (52 percent) had three or
`more exacerbations, as compared with l in the Cop 1
`group (4 percent). Patients were grouped according to
`whether they had no exacerbations, one to two, or
`three or more. The comparison between groups was
`significant at P<0.001.
`Multiple logistic-regression analyses were carried
`out to evaluate the effect of a number of covariates.
`These included treatment, sex, duration of disease,
`prior exacerbation rate, Kurtzke score at base line,
`and various interactions of these variables. Only the
`treatment group and Kurtzke score at base line had
`a significant effect. The multiple logistic-regression
`analyses showed that treatment with Cop l independ-
`ently increased the likelihood that a patient would
`be free of exacerbations (P = 0.036), as did a lower
`disability score at base line (P = 0.003). An esti-
`mate of relative risk with adjustment for sex, disability
`score at base line, and previous exacerbation rate
`showed the risk of exacerbations to be 4.6 times
`
`23
`0
`
`23
`2
`
`Raceletbnic group
`White
`Black/Hispanic
`Disability score (Kurtzke Scale)
`I3
`10
`0-!
`5
`7
`3-4
`7
`6
`5-6
`2.9
`3.]
`Average disability score
`3.8
`3.9
`Prior exacerbation rate
`(over 2-yr period)
`
`25
`0
`
`ll
`7
`7
`
`noted at the time of the visit during which it was observed; however,
`it had to be maintained for at least three months to be counted.
`Data on patients lost
`to follow-up were censored at
`the time
`of withdrawal. The log-rank statistic was used to test for com-
`parability of the survival curves for each treatment arm. The
`curves were also tested for a difference at the discrete point of 24
`months.”
`Multiple logistic-regression analyses were undertaken to test the
`effect of treatment on the outcome, with adjustment for other varia-
`bles, including sex, the duration of disease, the previous exacerba-
`tion rate, disability at the time of entry into the study, and various
`interactions of these variables. Odds ratios were calculated from the
`regression coefficientsf”
`
`Study Population
`
`Fifty patients were enrolled: 48 in 24 matched pairs, and 2 un-
`matched patients, I randomly assigned to each study group. Table I
`shows the base-line characteristics of the total study population and
`of the 48 patients included in the analyses. The distributions of
`these characteristics were similar in the two treatment arms.
`In order to guard against any possible bias that might be intro-
`duced by subjects dropping out of the study, we tried to include all
`the randomized patients in the analyses. There were seven patients
`who did not complete the two years of the trial. Of these, two
`patients in the placebo group were excluded from all the analyses
`because of unusable data. Both had been dropped from the trial for
`psychological reasons. The partial data obtained from the other five
`patients were included in the analyses. One patient taking Cop I
`dropped out during a period of exacerbation after two months of
`treatment. This patient had a second exacerbation shortly after
`stopping medication. Both were counted as study exacerbations in
`the data analyses.
`
`Rr:sut.1's
`
`The design of the study specified the recruitment of
`patients in matched pairs, one patient randomly as-
`signed to each treatment arm, with the proportion of
`exacerbation-free patients as the principal end point.*
`
`‘See NAPS document no. 04520 for supplementary material on the subjects.
`Order from NAPS c/o Microfiche Publications. P.O. Box 3513, Grand Central
`Station. New York. NY l0l63-35l3. Remit in advance (in U.S. funds only)
`$7.75 for photocopies or $4 for microfiche. Outside the United States and Can-
`ada. add postage of $4.50 ($1.50 for microfiche postage).
`
`The!‘
`AMNEAL EXHIBIT NO. 1016 Page3
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`
` AMNEAL
`
`

`
`Vol. 317 No. 7
`
`COI’ I AND .\/IUL'I'II’LI-J S(2I.ER()SIS — B()R.‘lS'I‘El.\i I-I'l' .-\I..
`
`-ill
`
`For the end point length of time before progres-
`sion, the survival curve for each treatment group is
`shown in Figure 2. Progression was defined as an in-
`crease of at least 1 unit in the Kurtzke score that was
`maintained for at least three months. Over the two-
`
`the curves were significantly different
`year period,
`(P = 0.05), with the placebo group having progres-
`sion sooner than the Cop I group. Fifty percent of the
`
`ax2r'§Ei¥é2i'.%us
`ovenzmns Plocebo(n=23)
`3
`
`Kliliriiilis
`O
`
`1
`
`2
`
`3
`
`.
`
`.
`
`2
`
`3 4
`
`5
`
`O
`
`43
`
`2 2 3
`
`9 '
`5
`
`V,
`
`§ 4
`1L 3,
`
`35 g
`
`3 I
`
`13 6 9|2|5l82l24
`
`Copt
`
`(n=25l
`
`°
`
`3 3
`
`43 33 Z
`
`so
`
`"5'
`E
`
`«I
`
`
`
`aunt‘;00015L1%‘
`
`I 3
`
`6
`9
`l2
`l5
`Months In Study
`
`I8 2| 24
`
`Figure 1. Exacerbations Occurring during the Two Years
`oi the Trial.
`
`Each line represents a patient. and each circle an exacerbation.
`Patients are grouped according to their Kurtzke score on entry.
`The number of pretrial exacerbations are indicated to the left.
`Discontinued lines represent patients who withdrew before com-
`pletion. The open circle indicates an exacerbation occurring af-
`ter withdrawal that was included as a study event. Patients who
`were not included in the matched-pair analyses are indicated
`by an asterisk.
`
`greater for a patient taking placebo than for a patient
`taking Cop 1.
`There was a decrease in the number of exacer-
`
`bations among the patients in the placebo group, from
`41 in the first year to 2! in the second. The ratio of
`the number of exacerbations in the placebo group to
`that in the Cop I group was 4.9 for year 1 and 3.3 for
`year 2.
`Fifteen patients were treated throughout the trial
`with Cop l supplied by the Weizmann Institute, and
`10 with Cop l supplied by Bio-Yeda. Ten of the pa-
`tients receiving the Weizmann product (67 percent)
`were free of exacerbations; there were seven exacerba-
`tions among the remaining 5 patients. Of the I0 pa-
`tients receiving the Bio-Yeda product, 4 (40 percent)
`were exacerbation-free; the remaining 6 patients had
`nine exacerbations. This difference was not statistical-
`
`ly significant.
`
`Change in Disability Status
`
`Table 3 shows the distribution of the two-year
`changes in Kurtzke score according to treatment
`group for the entire study population. A negative score
`indicates improvement, a positive score worsening,
`and zero no change. Eleven patients in the placebo
`group (48 percent) and 5 in the Cop I group (20 per-
`cent) had disease progression over the two-year peri-
`od. The difference between treatment groups in the
`proportion of patients whose disability status wors-
`ened as compared with the proportion who remained
`stable or improved was of borderline significance
`(P = 0.064).
`The change in disability status in the patients treat-
`ed with the Weizmann product was similar to that in
`the patients treated with the Bio-Yeda product.
`Table 3 also shows the distribution of the changes
`in Kurtzke score according to treatment group for
`each Kurtzke-score stratum. In the 0 to 2 stratum,
`Cop I had a significantly beneficial effect on disability
`status: 84.6 percent of the patients in the Cop I group
`were stable or improved, as compared with 30 percent
`of those in the placebo group (P = 0.012). The aver-
`age change in Kurtzke score favored Cop I by l.7
`units (there was a worsening of 1.2 with placebo and
`an improvement of 0.5 with Cop I). In the 3 to 6
`stratum, the proportions of patients whose conditions
`were stable, improved, and worse were comparable in
`both treatment groups, as were the average changes in
`Kurtzke score (there was a worsening of 0.4- with pla-
`cebo and of 0.3 with Cop I).
`The effect of the previously identified covariates on
`the comparison of worsening with the absence of
`change or improvement was evaluated with use of
`multiple logistic-regression analyses. These analyses
`demonstrated a beneficial effect of Cop I on disabil-
`ity status (P = 0.033). A patient taking placebo was
`four times more likely to have progression of disease
`than a patient
`taking Cop I, after adjustment for
`sex, Kurtzke score at base line, and previous exacer-
`bation rate.
`
`Thel‘
`AMNEAL EXHIBIT NO. 1016 Page4
`DaInIondedlmrnne'pn.oqItREPRN'T5DESKlNcaIOt#aber17.2DI4.FapersauIL§eov1ly.Noaihen§esIIiihotnperrr|issnrL
`Frunih:IEIMNdI've_ Oopyriflit02D1D Mnssndtus¢ItsIi|ededSou'eIy.AIr'qMs reserved.
`
` AMNEAL
`
`

`
`4l2
`
`THE NEW ENGLANDJOURNAL OF MEDICINE
`
`Aug. 13, I987
`
`Table 2. Exaoerbations According to Treatment
` Group.
`No. or
`Encnunous
`ran Pureur
`
`hnrueur Gaour
`ruano
`
`car I
`
`no
`
`‘I:
`
`no.
`
`‘R
`
`56.0
`I4
`26.]
`6
`0
`28.0
`7
`I3.I
`3
`I
`I2.0
`3
`8.7
`2
`2
`4.0
`I
`2| 8
`5
`3
`0.0
`0
`8.7
`2
`4
`0.0
`0
`4.3
`I
`5
`0.0
`0
`8.7
`2
`6
`0.0
`0
`4.3
`I
`7
`0.0
`0
`4.3
`I
`8
`
`
`
`
`23 100.0 25Total: 100.0
`
`patients in the placebo group had progression by the
`end of I8 months, whereas only 20 percent of those in
`the Cop I group had progression by the end of 24
`months. At 24 months, there was a significant differ-
`ence (P<0.005) favoring the group treated with Cop 1.
`
`Laboratory Studies and side Enact:
`
`The HLA characteristics of the 48 patients were
`unrelated to the effects of treatment. Patient reactions
`were monitored "during each routine clinic visit by
`means of urinalysis, blood examination, and the pa-
`tient’s evaluation of symptoms. .Urinalyses and blood
`examinations revealed no apparent changes in the
`functions of the liver, spleen, kidney, bone marrow,
`gastrointestinal tract, heart, or lungs.
`Table 4 shows the percentage of patients in each
`group who reported reactions at the injection sites and
`other reactions.
`
`More patients taking Cop I reported reactions at
`thelinjection site involving soreness-(P<0.00I ), swell-
`ing (P<0.00l), and itching (P<0.0l). In addition,
`soreness was reported during at least half the visits in
`
`32 percent of the Cop I group as compared with 9
`percent of the placebo group; itching was reported in
`4-0 percent as compared with 4 percent; swelling, in 56
`percent as compared with none; and redness, in 40
`percent as compared with 9 percent.
`Other reactions were reported with comparable fre-
`quencies in each group (Table 4). No symptom was a
`persistent problem in more than 12 percent of either
`group. Dizziness, constipation, and joint pain were the
`most common symptoms in the Cop I group, whereas
`headache, dizziness, constipation, and joint pain were
`the most common in the placebo group.
`Two patients had a patterned, transient reaction to
`Cop I. It began during or immediately after an injec-
`tion and consisted of a flush, sweating, palpitations, a
`feeling of tightness around the chest, difficulty breath-
`ing, and associated anxiety. It lasted from 5 to 15
`minutes and passed with no residual difficulties. In
`one patient, the reaction occurred three times in 2]
`months, and in the other, twice in 17 months. Medica-
`tion was discontinued in these two patients, who re-
`mained under observation for the balance of the trial.
`
`The remaining patients were alerted to the possibility
`of such reactions, informed of precautionary meas-
`ures, and given a kit containing epinephrine and anti-
`histamine tablets.
`
`After the trial was completed, one of the two pa-
`tients who had had a reaction volunteered to take Cop
`I
`in an unblinded manner. This patient reported a
`hypersensitivity reaction that included urticaria, itch-
`ing, and marked discomfort and that was controlled
`with epinephrine and steroids.
`
`Blinding
`
`Considerable efforts were made to maintain the
`
`blinding of this trial. The examining neurologist and
`the patients avoided discussing side effects. Patients
`reported such effects to the unblinded clinical coor-
`dinator.
`
`After the trial, the effectiveness of the blinding was
`evaluated. The patients and the examining neurolo-
`
`Table 3. Changes in Disability Status aver Two Years According to Base-Line Kurtzke-Score Strata.
`
`Came: In
`Bass-Imus Iturrzxg Sruruu
`Kunzxs Scone
`
`0-2
`
`3-6
`
`P|.M:uo
`
`no
`
`5
`
`car I
`
`no.
`
`5
`
`rucelo
`
`cor I
`
`no.
`
`5
`
`no.
`
`I»
`
`ALL Cass
`
`r-ucauo
`
`no
`
`I
`3
`2
`5
`I I
`
`'5
`
`4.4
`l3.0
`8.7
`21.7
`47.8
`
`cor I
`
`no.
`
`%
`
`0
`I
`I
`3
`5
`
`4.0
`4.0
`I2.0
`20.0
`
`Worse
`4
`3
`2
`I
`Subtotal
`
`9
`
`39.]
`
`I2
`
`8.7
`
`48.0
`
`20.0
`12.0
`
`I
`I
`I
`4
`7
`
`2
`
`I
`
`I0.0
`I0.0
`I00
`40.0
`70.0
`20.0
`
`10.0
`
`2
`
`5
`
`4
`2
`
`l5.4
`15.4
`38.4
`
`30.8
`15.4
`
`2
`I
`I
`4
`7
`
`I
`
`ISA
`7.7
`7.7
`30.8
`53.8
`
`7.7
`
`I
`I
`I
`3
`7
`
`I
`I
`
`8.3
`8.3
`8.3
`24.9
`58.4
`
`8.3
`8.3
`
`Stable (0)
`Improved
`5
`2
`- I
`3
`0
`-2
`0
`4.4
`I
`-3
`7.7
`I
`3
`R10
`20
`52.2
`I2
`Subtotal
`75.0
`9
`69.2
`9
`84.6
`II
`30.0
`I0
`l(Xl.0
`25
`I(X).0
`23
`Total
`l(X).0
`I3
`l(XJ.0
`I3
`l(X).0
`I2
`99.9
`
`
`The!‘
`AMNEAL EXHIBIT NO. 1016 Page 5
`DaInIondedIrnmne'pnugItR?RN'TSDESKINCuIOrtabel'27.2DI4.FupersuuIL§eor1Iy.NoaIhert§esIIiIfntnpurr|issiuL
`fiun0ur£IMNdin_Oopyifln°2D1DMnssnin5¢IsMedcdSodeIy.Mr'gMsresuwd.
`
` AMNEAL
`
`

`
`Vol. 3l7 No. 7
`
`CO!’ I AND MUL'l‘ll’l.l-I SCLEROSIS — BORNSTl:‘.IN ET AL.
`
`413
`
`alf“ observed no cross-reactivity between Cop l and
`myelin basic protein nor any correlation between the
`inhibition of experimental allergic encephalomyelitis
`by Cop l and cell-mediated immunity to myelin basic
`protein.
`Three clinical trials attempting to treat multiple
`sclerosis with myelin basic protein failed to reveal any
`beneficial efTects.25'27 Perhaps the explanation for the
`difference between Cop I and myelin basic protein will
`be found in some unrecognized factor in trial design,
`such as dosage schedules, or the influence of Cop l
`on some mechanism other than immunologic cross-
`reactivity or suppressor-cell involvement. Such an ex-
`planation is supported by the lack of cross-reactivity
`between Cop l and myelin basic protein in helper
`phenotype T-cell lines isolated from human peripheral
`blood by in vitro exposure to Cop l or myelin basic
`protein.”
`Nevertheless, on the basis of previous clinical evi-
`dence of the effects of Cop l on presumed autoallergic
`disease of the human central nervous system,'°~”
`we proceeded to carry out another study. This pilot
`trial examined the effects of Cop l on a selected sam-
`ple of patients with actively exacerbating multiple
`sclerosis.
`
`The principal end point was the occurrence of exac-
`erbations. It was selected as an outcome specifically
`germane to the type of patient in this study. Changes
`in the patients’ disability status were also of‘ major
`concern and were therefore evaluated.
`
`The results show that Cop 1, administered subcuta-
`neously for two years at a daily dose of 20 mg, pro-
`duced clinically important and statistically significant
`beneficial effects, particularly in the patients who had
`less clinical involvement when treatment began.
`
`Table 4. Percentages of Patients Reporting Side
`Effects.
`
`Svurrou
`
`Local
`soreness"
`Itching?
`Swelling‘
`Redness
`Other
`Other
`Headache
`Nausea
`Vomiting
`Dizziness
`Constipation
`Sweating
`Rash
`Palpitations
`Cramps
`Faintneos
`Joint pain
`Gastrointestinal
`discomfort
`Appetite loss
`Drowsiness
`Other
`
`Pucuo
`(N = 23)
`
`Cor I
`(N - 25)
`
`35
`22
`I7
`48
`35
`
`39
`I7
`4
`30
`30
`26
`I7
`13
`9
`I3
`39
`22
`
`I3
`26
`I7
`
`92
`64
`88
`76
`36
`
`32
`24
`4
`40
`40
`28
`24
`24
`I2
`20
`40
`I2
`
`20
`20
`28
`
`’P<0.tX)I for the difference between placebo and Cup I.
`i'P<0.0l for the difference between placebo nil Cop I.
`
`\n
`
`¥I\
`
`Tlin Copt
`
`_\\\°—0 Placebo
`
`
`
`ProbabilityOfNoWorsening
`
`bobs