.,;.m-.w.-._..--"'..-.z;.:5‘5;;2.w22-'.e.'-':...u."'‘v;-.'.*::>’«;-:-*.‘».\.‘s-.rl:~.'.-.4"-".:e2};‘.'»'."'-'~
`- "'
`
`lmnsunology Letters 50 (1996) I-15
`
`BLSBVIBR
`
`The development of Cop 1 (Copaxone"), an innovative drug for
`the treatment of multiple sclerosis: personal reflections
`
`Depanesent of btnansnlogy. 11:: Welsenen Insllltttr of Science. (Morel. lsrnrl
`
`Ruth Arnon
`
`
`
`Received I5 December I995: accepted 25 Jltnry I996
`
`
`Ksyawdr: Copaaoni“. Multiple aclernsh: luunsusoipeeillc drug
`
`
`1. Introduction
`
`Thel4thol’June l995wasarnihstoneforttte~as
`on this day tlte tile on Copolymer 1 (Cup I) was
`submitted. under the nante COPAXONE‘. by the
`TBVA Pharmaceutical Company to the FDA’ for ap-
`provalasaNewDrugApplicationl'orthetreannentol"
`Multiple Sclerosis. For Prof. Michael Sela and myself.
`together with our colleague Dr. Dean Teitelbatun. this
`wasahighpoitttam.-rover27yearsot'persisteut
`research eilort. perseverance and tenacity of purpose.
`Theptu-pouoftltispaperlstodescrlbethehistoryof
`Ihedevelopment ofthiadntginterspersed withareview
`of the scientific findings along the way. all from a
`personalpexnpective.whenIam“aquarterot'acentury
`wiser”. Since multiple sclerosis is an ll'lIlll|In0l0D'¢8I
`disease and Cop I
`is an immunespecific drug. my
`perspective is that of an immunologist. and it delineates
`the course or events in a more or less chronological
`order. Beyond the story as such, the paper shows that
`studleswithcop l advancedsldebysidewiththe
`progsessol'iInmunologyasadisciplineandhence,tltat
`the increasing sophistication of the research tools and
`ntethodstlsatemu-gedfromtimetotirnepennitteda
`more in-depth study of the immune processes involved
`in activity of this innovative drug. However. the thera-
`peutic potential of this material was evident to us
`already 25 years ago.
`It all started in theesrly 1960s. I wasthena budding
`intmunologist. or. to put it more precisely, a young
`chernkt ‘corrupted’ into immunology. Immunology it
`those days was a completely different science from what
`it is today. much simpler. with more ‘yes’ or ‘no’
`answers to issues that even now are not yet completely
`understood. Antibody structure and function were just
`
`lllns-3473.-'96[Sl2.N 0 1996 Elsevler Salem: B.V. All rights reserved
`PII 80|65-2478(96Xl2506-0
`
`being revealed and elaborate studies on the structural
`aspects of antigens were conducted. under the coined
`term ‘intrnunochemistry’. to arrive at better understand-
`ing of their interaction with the antibodies. In parallel.
`information on the cellular compartment of the im-
`mune system was just starting to accumulate. with the
`fundamental discoveries of Burnet and Jeans.
`In our laboratory we were deeply involved in studies
`on the structural basis of the antigenicity of proteins.
`utilizing synthetic antigens comprising polymers and
`copolymers of amino acids [I]. Research with these
`polymers had been pioneered by Prof. Ephraim
`lcatchalslti. in whose laboratory both Michael Sets and
`myself received our training. Employing these synthetic
`protein-like molecules we (Michael Scia and l) could
`indpce immune responses of almost any desired specifi-
`city, including that of non-protein moieties. of specific
`interest was the immune response to lipid components
`which. due to solubility problems. was not easy to
`either elicit or investigate. However. conjugates in
`which synthetic lipid compounds were attached onto
`synthetic copolymers of amino acids elicited specific
`response to lipids such as cytolipin H. which is a
`tumor-associated yycolipid [2]. or sphingomyelin [3].
`Furthermore. we demonstrated that both the sugar and
`lipid components oi‘ such molecules contributed to their
`immunological specificity. The resultant anti-lipid anti-
`bodies were capable of detecting the corresponding
`lipids both in water-soluble systems and in their physio-
`logical rnilie. This was tltsctnatlng. since it gave us a
`glimpse into some disorders involving lipid-containing
`tissue and consequently led to our interest in demysti-
`noting diseases. namely disorders in which the myelin
`sheath. which constitutes the lipidvrich coating of all
`axons.
`is damaged. resulting in various neurological
`dysfunctions.
`
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`EXHIBIT NO. 1020 Page” 1
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`-r -
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`
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`
`""--‘mt.-.'
`
`2
`
`R. Ame Ilainannlogy Letters .10 (I996) I-ts
`
`Multiple scbrosis(Ms)isthentost frequent demysti-
`natingdiscaee.Nottnn_chwasknownatthetitne,or
`even to date, about
`its aetiology or nseciranisnt of
`triggering. It lsachronieinllammatorydiseaseotthe
`central nervous system (CNS),
`in which infiltrating
`lyrnphocytesleadtodarnaseofthemyelinsheathby
`meansot'innnnneprccesses.l~lence.itisconsidetedan
`autoimmune disease. In studies perforated at a later
`stage, while I was spending my sabbatical leave with
`Dr. John Fahey at'UCLA, in collaboration with Dre.
`George Ellison, Lawrence Myers and W. Tourtellotte.
`we showed that anti-xanalioeida serological activity
`tnighta1aobeinvolvedlnthisdlsease,sinceantihorlios
`aasinstseversl brainganglioeidestvcredetectedinsera
`of MS patients. but not in normal individuals. (This
`activitywasdemonstratedbythecepaeityoftheeetato
`canse complement-dependent lysis of liposcnles con-
`tainingtherespectivegangliosicleintheirlipidbilayer.)
`Moreover, an apparent correlation was indicated he-
`tweentheeeverityofdieeaeeanrltheestentofliposome
`lysis[4-1.
`SinceMSoccursonlyint.hehuntanspeciee,itwas
`necessarytodevelopanimalntodelsofthediseasefor
`thepnspoaeol'tesearch.Alr'eadyinl937Rlvere[5)had
`observedthatasingeinoculationoflahoratory animals
`withbrainorspinalcordtissueinCompleteFreund's
`adjuvant (CPA) led to an acute neurological autoim-
`mune disease resembling MS, which was designated
`Experimental Allergic Encephalontyclitis (BAB). Cell-
`ntediatedimtnnne responses wereshown tobeinvolved
`inthepath'o;enicltyol'EAE.sincethedise_esecouldbe
`transferred by a single inoculation of sensitized
`lymphoid cells [6.7]. In the early 1960: one ofthe
`myelin components. myelin basic protein (MBP). was
`identified as an eneeplralitognic agent, since when in-
`jectedinitapuriiiedl'ornsitinducedEA£ingnineapigs
`[8]. Moreover. the disease proved to be the result of
`cell-medtatedrespotIeetotheMBP,andltsspeeiflcity
`wasetnphaaizedbytheabilitytopreventorsuppms
`EAE byMBPoriesmodifiedderlvatives[9—ll].
`Onrprevio1sssnoeessesintltedeveloprnentofsyn-
`thetlc antigens and their valuable contribution to the
`understanding of several
`immunological phenomena,
`promptuedustotalteasimilarappmachwithregardto
`EAE. We actually intended tosyothesizeanencephalh
`toaen. and anticipated that if the encephalitoeenic ac-
`tivityol‘MBPcouldindeedbemimiclnedbyasysttltetic
`rnoleculc- ilrnightrmovidetsswithaneefultoolfor
`investigatingthemeehanisntofBAB.Inparenthesesl
`wonldlilretoaclcnowledgethesupportthatwereceived
`from two people already at this stage of the research.
`'l'hefirstwasProl'.OttoWestpbalwhowasexcitedhy
`ourorlglnalepproachandevenhelpedusohtainthe
`lirst grant forthese studies. tron a small private foun-
`dation - the Freudenberg Foundation. The second
`person was the late Prof. Elisabeth Robe:-Einrtein.She
`
`_
`
`wasdeep1yinvolvedinresearehonEABfromt|te
`vlewpointofaneurochernietsltewasaotakenwithonr
`reeearchapproachtbatyeataiatersltebeqneathedtous
`herentireacientlfic and reprint coibction.
`In the late I960: methods for the synthesis of se-
`quencedpolypeptideswerenotyetevailable. However,
`asgI'aduatesoi'thelaborat0ryofProl'.Bphraint
`l<atehalslti.wewereexpertsinthe synthesis of random
`copolyrners ofarnino acids. and hence we prepareda
`series of such copolyrners.withcompositiens approach-
`iagthatol'MBP.allwithahighlybasicnaturedneto
`their high lysine contents. However. elforts over the
`couraeol'rnorethaoayearledtone3ativeresults-
`none of these synthetic copolymers possessed any cn-
`eephalitogeaic activity [I2]. Furthermore, even thecoa-
`Juption of
`sphlttgolipid moiety - whid:
`could
`potentially enhance the anti-spbingomyelin response
`~andconseqnentlythedemyellnationprooeu—dldnot
`endow these polymers with any encephalitogettic activ-
`ity whatsoever. Disappointment. Was our hypothesis
`wronglnidthesynthetieapproachfailneinthiacase?
`Should we give up?
`Concomltantly. we were expanding our studies on
`EAE and its
`in collaboration with the
`lateDr. H. Hirsh£eld.wedevelopedasinrplifledprcce-
`(lure for the purification of MB)’ from myelin [13].
`basedoattheuacofanewioa-exchangeresln.
`Sulphoethyl-Sephadea, and it enabled us to prepare
`large quantities of the purified protein for more exten-
`sive investigation of EAE. 1he purified M3!’ was
`highly potent in the induction of RAE. as contrasted
`withtliecomplaelaekofsnchactivityinunyofthe
`synthetic copolyrneis. Did these polymers possess any
`other form of biological activity‘!
`I
`It is a common practice in immunology, once an
`-htteradion between antigen and antibody is established.
`to elucidate its specificity by competition. or inhibition
`studies. only substances of a similar specificity will
`evince inhibitory properties. This had he the proce-
`dtleebywhiehwehadidentifiedtltespecificityoftbe
`synthetic antigens. and the contribution of various
`parts cl‘ the macromolecules as ‘antigenic determi-
`nants‘, or epitopes. to their overall antigenic activity.
`Thistechniquehadbeenernployedtocharacteriaetlte
`specificity of blood group antigens and many other
`systems. In most cases such inhibition studies are per-
`formed with relatively short molecules - attain. or
`peptides.Woul¢lltapplytothetnacrornoleculareopoly-
`men?!’-'\trtherrnore. the isauewewereaddressingwaa
`not ts relatively simple antigen-antibody interaction. but
`rather a more complex biological process. namely the in
`vivo induction of ettcephalitogenic
`Neverthe-
`lels. the earlier findings of Elisabeth Roboa-Einstein
`andMarianKeesthatMBP.aswellassonteother
`brain basic proteins. can inhibit EAB £9.10] indicated
`that this could be a plausible approach.
`
`AMNEAL
`
`EXHlBlT No. 1020 Page.2
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`
`R. Antes/lnmnreelogy Letters Jll (I996) 145
`
`3
`
`2.sttppsesslonefEAE,thesrrlsIslssetleltortutltlple
`sclerosis
`
`The results of the inhibition experiments were over-
`whelming - not one. but several of the synthetic co-
`polyIuersshowedhigheiliescyinsuppressirtgEAEl1'he
`mostoetiventnongtheserieswascopolyrner 1 (Cop l).
`composed oi‘ L-alanine. L-lysine, L-glutsmicecid and
`Lntyrosine in a residue rnolsr rule of 6.o:4.7:l.9:l.0.
`andhenee ruostofoursubsequent resenrchwssoom
`ducted only with this substance. It had It marked
`etrpprasiveeifeetou BAEwheninjectedtogn'mes pigs
`in incomplete Freund's adjuvsnt or even in aqueous
`etI|iueso|ution,ai'tersninitialcltn|leugewithsdisesse-
`induoiugdose oi'MBP[l2]. ltredueedtheincidenosof
`EAE.i'rotn sbout15%intlreoontrolgrouptoorriy2il%
`,in the treated group. Was theeflbctrenll Could it be an
`artel‘sct?AsecondbatchofCop I wasintlnediutely
`synthesized. very similar in its composition and molecu-
`larsimtotheodginnlonqmdwssfoundtobe
`identical in its suppressive efleet on EAB. indicating
`thettheobservedsuppressiveefl’ectissreaIone.'l'his
`seentedinterestirtgindeed.Notottlydidwehaveln
`handatooli'orstudyingthemeche.nisntofEAEand
`the immune processes involved in it. but already at that
`early stage we realized that this might lead eventually to
`s therapeutic agent. We subrnitted patent applications
`in Israel and abroad and were granted them in various
`countries during 1972 to 1974.
`it was now necessary to lean! more about the etlbct
`of cop I and how it exerts it. Cynthia Webb. it Ph.D.
`student who-joined our team. showed that the suppres-
`siveuctivityofcoploonldbeexplsinedbyits
`immunological cross-reactivity with the MBP. Crossro-
`wtion was clearly manifested on the cellular level. in
`both in vitro (lymphocyte trursformation) and in vivo
`(delayed hypersensitivity) assays [M]. in studies involv-
`ing the series ofcopolymers. there was it good correla-
`tion between the level of such cross-reactivity end the
`capacity to suppress RAE. As for the burners! antibody
`response. wecouldnot detectcross-resctivitybetween
`MBPIIIG Cop l utriugtheruethodsavailnbleat the
`time. namely the pteeipitiu tat or the l’-‘err test (which
`is the ‘ancestor’ of the rsdioiunuunonseey). However.
`the more sensitive passive cutaneous snnphyluxis test
`showed that guinea pig snti-Cop I sen did cross-reset
`to e certain extent with MBP, but not vice versa [14].
`All these tests were pet-l'or-rnetl. of course, with poly-
`clonnl antibodies. the only methodology available at
`the time. Later studies. using monoclonal antibodies.
`showed a highly significant enosrreactivity between
`MBPsud Cop l - aboutnthirdofthehybridosnus
`ruisedsguinst rot MBPc-ross-reacted withcopl tothe
`some level ofreactivity as with the homologous antigen.
`and a proportion of the anti-Cop 1 antibodies reacted
`with MBP [15]. Moreover. some of the monoclonal
`
`antibodies ruisedsgninst either MBPor Cop I reacted
`ins heteroolitiemsnner sndfuvoured the cross-running
`antigen over the iruruunogen. It is of interest that the
`cross-reactivity was observed only with the monoclonal
`antibodies — antisera of the immunized mice from
`whidt these antibodies originated showed no cross-reao
`tivity. Thus. the use of monoclonal sntibodies uncov-
`eredspeoilicitiesthntwerenotevidentinlhepolyelousl
`response and revealed the pronounced crossoresctivlty
`betweeucopl sndMBP.ontheB-celllevelssweilss
`the previously observed ‘I’-cell level. This provided a.
`plausible basis for the suppressive effect of Cop l on
`MBP-induced RAE.
`.
`
`3.Specl&ilyo(EAEeII||II'eeda|hyCopl
`
`The results described above. for the suppressive eifeot
`of Cop I an EMS. were demonstrated for the disease
`induced in guinea pigs by the inoculation of bovine
`M31’. it was known. however. that the induction of
`BABisspeeiesdepeudent.inrespeettoboththespecies
`from whichtheMBPisderlvedsadthespeciesin
`whichthediseaseisinduced.1'hespecilcityisreilected
`uotsomuchintheaetuslstssceptibilitytolltedflase.
`within is relevant to most species. but in the particular
`region in the Ml!Pmoleeule which is reqsonsible for the
`eneephalitogenie activity. The encephulitosenic determi-
`nants for guinea pigs. mice. rats and primates are all
`dilferent [l6].
`ltwusthereforeinterestingtoobsctvethatcop 1 was
`efl'ectiveinsuppressionoi'EAEinguinerrpigsalso
`whenithudbeenitrducedl':yMBl’ofhtnnsnor-igin
`U7]. These results are of particular interest. since when
`EABwusinducedingrrlneupigsbythehtnnanen—
`cephalltogen.
`the histological changes observed in-
`cluded dernyelinstions and fibrosis in the guinea pig
`brain. thus resembling the symptoms of MS more than
`when the disease is induced by either bovine or rodent
`Mill’. in inter experiments we have induced BM! in
`guineapigswithMBPoi‘otherspeciesunddernon-
`strated that the suppressing etfect oi’ Cop I was lirrn
`and abiding.
`Istheefletaofcop 1 then espeeitlcone.ot-lsitdue
`to some non-specific inununosuppressive proputies?
`Thlslsanhnportant question. sinceitretlecteonthe
`mechanism of its activity in the suppression of EAE.
`Evident: for its spedllclty were provided by two exper-
`iments: The ilrst demonstrated that Cop I lacked any
`suppressive elfeet on the irnrnunc response in several
`systems —- a particulate entigsn such as bacteriophage
`1'4. soluble proteins such as BSA and IlNase. end
`carrier-hnpten
`systems
`such
`as DNP-DOG or
`polyslsnyl l-ISA. In all cases the level or the immune
`reqsonsewasnotnifectedbytlrepresenceofcop I.
`Neither wessltin gr-an rejection in rats effected by the
`
`
`
`_;_....,_...L'.___....
`
`..---__J‘‘‘.-9.’
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`AMNEAL
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`EXHIBIT NO.‘ 1020 Page 3
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` AMNEAL
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`;.;__.. . .,."/ .,.. »..:,.,,..-._.._,_.
`———-——--.-. .. ...__.. .
`
`I
`
`
`
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`- %.=.»s:-::'.w-.::c.~'..-:r::.:.*.::e:.:::::=:4:..'.v:«.a:::a::a;¢.:a:.sur:::\:.;4=c:.:9:r:::«:r:.:lJ:::;¢5;zz:éie%§zr&a.?£x?&z:$.thta2§4a?d:az.1z§'nE3:i14a%5555-W-.2._éL'-3'=:l.'r‘:'L'4'.’a’~.~I—«’.'3.=;
`
` 4
`
`R. Amenllhauorology Lenm5D(l996) I-1.1’
`
`inieetionofCopl[l1,l8).'I‘heseeondevldeneeis
`derivedfwmsnexperhnentusinascopolymeridentical
`toOopl.huteomposedofD-aminoeoideinsteadof
`thenetuxeil.A'orIn.nnddenotedD-Copi.Bothcom-
`positionundsia.-ofcoplnndb-Coplwereidentienl.
`D-Coplwndevoidofanyeuppteuiveel!'eetonEAE.
`norwn'riteroee-reaotivewithMBPateitherthehu-
`
`nrorelor theceilular level (unpublished results).
`_Bqually, or even more important is the question
`whetl|erCoplwouldheefl’eetiveinsn;:pressingBAB
`inspeeiesothertiungrdneepigs.Indee¢i.inadetailed
`'ttudyweehowedthstCopldemonstrutedefi'eetive
`suppression'ol‘BAEinrahbitr[l'l].inmiee[i9]andin
`twospecieeot'prlmstes- rhesusmonlteytlzflland
`baboons [21] (Fig. 1). It is thus apparent thst Cop I
`does not manifest species specificity, either for the
`soureeofeneephslitogenorfortheaninteltested.
`Theremltsinprimateewereverysiguificant.sinee.es
`showninFig.l.thereanimaltarehlglIlytueoeptibieto
`BABnndaIlthoeeaen¢itizedwithMBPsueeomhedto
`thedisease.'l'heexperhnentwitltRllesusmonkeysht-
`cludédlflnnitnnlnofwhiehflveserved-ateontrolsnnd
`tlIeotherilvewetetreatedwlthCopI.ThetreItment
`wasgivendatilyslartinghnmedieteiyeilertheoneetof
`thefl:ststagesofpe_relysis.Al1five_nronheysinthe
`control group deteriorated very rapidly and died within
`4-lldayeatlertheometofsymptornalncontrast.
`l'ouroutofthefive0op l-treatedlnonkeysehowed
`irn§rovementaher4—5deysoi‘ trestmentsndlinally
`reeoveredootnpletelyfrumlheparulyris.'l‘heiifthCop
`I-treated monlney continued to den:-iorate after an
`lnitinlirnprovernent. suflered a relepae 35 days later.
`andfinally'died.of.EAE.-
`Asilnilarlevelqfelieacyofcopiwasobtervedin
`the experiments with-the baboons which included a
`total of 15
`The six baboons in the control
`group developed BAB'wlth progressive paralysis and
`died within 47-11 dnys afier itial symptoms were
`
`
`
`Ffi.l.Supyresu'onofEABl:yCepllnvuioosrpeeiee.lneidsneeof
`diseaselnoopl-uestednnlnnlslseornpsredtounuestedeontrole.
`
`notedlnninebahoonsdailyuenununuwaeeurted
`immediately afler the tint paralysis symptoms were
`observed. Although initially they continued todeterio-
`rsteendmoelofthenuesehedtheeteteoffullpnuly-
`sis.theyeventuallyheg|ntotecupetate. audeevenont
`of the nine showed full recovery. I renemhu these
`expaimentsveryvividlysirtceforustheyoonstltutedn
`considerable etfonz hahoonearelnrpanitnnls. weight-
`inzahoufloltxeochandrequireepeeialeanesequipped
`with approprinteilxtureefor experimental manipulation
`oftheenh'nnls.Sincewehndonlyflvesuehea3eI.the
`above experiment was actually perfonned in three
`stay:-eeel1oneineludin.gfivehohoons.ofwbiel1two
`servednIeontrokandthreeweretreel:edwlthCopl.
`Ahertheseeondstnaeweknewwhsttoexpeannd
`heneednrlngthethirdonewefilmedoneofthecep
`l-trentedhithoonstltrougi1allthephaaeeofthetrial-
`before the BAB-inducing challenge with the MBP. durh
`inglheparIlysisperiod(2-3days)anduptoits
`eornpletereooverywhenhejumpedvivsclouslyinhis
`esge_.'l‘heflhnwesquiteelil:etiveandhelpednielnterin
`dentmnmdngtheefleetofcoplmdiuthempeutic
`powntisl. Furthermore. ithelped mein raining interest
`elnongneurologistsnndmotivatinz thenrtoeondncta
`cliniceltrielwlthcopl.
`.
`Theresulteaéhievedinthesub-humenprintatesare
`highlysignifl¢antfortworeoeom:(l):inoetheyaIethe
`sp‘eciesclosesttohununs.theell‘ectofCopIon
`prhnnteein'norereievanttomuitiplesolerosis;(2)inall
`ptimetestheueannentwithcoplwesbegunonlyafier
`synrptorneol'dineaeewereevidentandheneeilseii'eetiv-
`its: was a positive indication, since any treatment sug-
`yetedforhliswouldbefeasibleonlyafterdieeasehld
`heendiognoeed.Furtheu'nore,oneofthe0op-ltreated
`rhesus monkeys which had fully reeuperatecl after being
`paralyzed was examined and showed no histological
`darnngeinitsbrain.Ahahooneirnilnrlytestedshowed
`very minimal histological lesions. In contrast. drastic
`dantngeandrnnltipleleeionswerenotieedinthebraina
`ofsll rherusmonkeysendbnboonsofthecontrol
`groupsmswelluthosetrentedwitltcoplwhodiedof
`EAE.'l‘hisindieaten that hrainlesionswhichareirot
`ions-lastingoouldbeamembletorernyelinntion.
`Ahotherupeetoftheexperlmentslevidenoewhich
`lendssupporttothepotentialot'Coplinrelntionto
`MS.iIitebenetioialefi'eethtthechronte-relspeingronn
`ofEAE(CR-BAE).'l‘histypeoi'EAE[22]ieiudueedin
`guinea pigs by sensitizing juvenile nninnle with the
`eneephalitoaenlcchellenge. snd1schancter‘nedbyini-
`tialonsetfollowedbyatevemlstngeanduzbsequent
`relapeenbnetoits relnpeingnatureck-EAElseonsid—
`cred a more faithful experimental model for MS. In
`oollsboratien with Dr. Wisniewski and his colleagues‘
`\veetudiedlheeli'eetofCoplonthistypeoi‘dieeIee.
`Weehowedthatptetteatmenthndarnurkedeflbethoth
`in delaying the initial onset and in preventing the
`
`......_...
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`"EXHIBIT NO. 1020 Page 4 i
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`appearance ct‘ relapses. Therapeutic treatment. which
`wasgivenaltertheonsetofinitielsyInptvrns.reduced
`boththeoccurrenceandtheesverity ol'relapses{23].
`'l'he next lojcal step was to investigate whether Cop
`I was of any benefit to MS patients. We therefore
`conducted some basic toxicological studies which are
`prerequisite for any clinical trial. A full ‘toxicological
`package‘ is an extremely costly ailirir (millions of dol-
`lars), which we couldn't alford. We did. however. carry
`out 1.1),. deterrninatious and experiments of acute and
`rubaeutetoxicityhrnriceandratsaswellasinsewn
`beagle dogs. which were performed at the Weizmann
`Institute. with the expertise of Dr. Asher Meshorer
`(unpublished results).
`'I‘|teLD,,tests actuallyfailed. sincenodeathoc-
`curred at doses up to 2000 rngiltg (the highest dose that
`could hcadministered).’l'heaeuteandstrbacutetordcity
`tescrshcwedthat Cop I canbeadrninisteredbyelther
`single or several successive arhninistrationa in doses up
`to Bow-fold higher than the expected recommended
`dose for treatment. producing neither pathological
`eliects nor any other macroscopic or microscopic
`changes. Furtlrennomin rlreArnesteet.Cop I showed
`no nrutagenic effect. The conclusion was therefore that
`Cop l is a non-toxic material. and the results fulfilled
`therequiremerrtsl'oraPhaselclinicaltrial.
`
`4._IIlthlclilcaltrlah
`
`Ourl‘rstcIinicaltrialwasconductcdinlsrael,atthe
`l-ladaesah Medical School.
`in collaboration with Dr.
`Oded Abratnsky [24]. Dr. Abrarrrsky, an enthusiastic
`neurologist atlladsraah who lsncwthechalrmanot‘
`the Department of Neurology there and currently
`scrvesastheDean ofthe Medical Schoohwasattite
`time at the Weizmann Institute. working towards his
`PhD. thesis under my supervision. In this capacity he
`tooltpartinsomool'tlrcexperirnentswithCop _l.
`lrnpressedbytheeurperirrrentaldatahewasinterestedin
`tuting the elfect ol' Cop 1 in patients. This Preliminary
`Trial, according to the approval conditions of the is-
`rseli Helsinki Committee. included only four MS pa-
`tientsirt the terminal stages of the disease. They were
`treated with 2-3 mg of-Cop I. 2-3 times a week. for
`4-6 months (the initial 3 weeks were under hospitaliza-
`tion). Under these conditions no beneficial ellect was
`expected. Indeed. the patients did not show any signin-
`cant change in their motor function. Two of them
`exhibited some improvement in vision and speech ca~
`pacity. but in the absence of a control group. it was
`impossible to relate this improvement to the treatment
`However. the most important finding was that no side
`efi'ect wasobserved inanyoi'tlrepatierrts.'l‘hercwere
`nocharrgesln hloodpresure.heartraceandEC€i.or
`in liver and kidney functions. Nor were any toxic or
`
`allergic reactions observed. This infcrrnarlon paved the
`way for further clinical trials in less severe patients.
`Thedificultywastolindaclinieiantoperiorrnsuclr
`a trial. I recall this time as the ‘peddling period‘.
`I
`participatedinslrnostanyconl'erencc,Iargeorsrnall.
`which dealt with MS. I presented our experimental
`-data.whereverpossibleIecreenedthelllmonthe
`baboon and talked to everyone who was prepared to
`listen. I had success with two neurologists: Dr. Hehnut
`J. Bauer hem Gottingen in Germany and Dr. Murray
`13. Bernstein of the Albert Einstein College of Medidne
`in New York.
`I met Dr. Bauer at one of the meetings which I
`attended in Europe. He had at
`large clinic for the
`treatment of MS and was excited by the opportunity to
`test the efl‘ect of Cop I and the glimmer of hope for the
`otherwise desperate patients. The trial he conducted
`was an open-label one. involving in all 2l patients. 10
`ofwhomtwirh Dss rangez-olreecived adailydoseof
`2 rngCop I and the other II (with D83 range 5-7)
`received a daily dose ol'20 mg Cop I. for the duration
`of one month. The results were indicative of some
`improvement, particularly in the group of re|apsing-I'e-
`mining patients and those with lower DSS. Due to the
`short duration ofthetrlal and to the lack ofacontrol
`group. the siyrifinnce of the henclidnl effect is not
`clear. However. the trial was important for demonstrat-
`in3t|resal'etyofCopl — therewore onlyafewntinor
`local reactions and two cases with transient fever with-
`out any other adverse effects.
`Dr. Boinstdn. who passed away recently. was a very
`dynamic personality. whom I also met" at at conference
`in Europe. He was at renowned neurologist. who was
`also In charge of a
`MS clinic. lie was interested in
`the pathogenic rn
`anisms leading to MS and their
`association with EAE. His previous studies in tissue
`culture had indeed served to relate Ms to EAE [25].
`derrronstratlng that mammalian CNS tissue cultures
`respond with identical patterns or‘ demyelination when
`exposed to serum from EAE-afi'e:.-ted animals or from
`MS patients. Hence, the rationale for his willirgness to
`launch a trial with an agent which supprsses EMS and
`CR-EAE. looking for its ell'ect on MS patients. Alto-
`gether. Dr. Bornstein and his colleagues conducted
`three clinical trials. a preliminary one and two pilot
`double-blind controlled trials. one involving exacerbat-
`ing remitting {E-R) patients and the second involving
`, cltroniqprogressiw (C-P) patients. as sumnrorized in rr
`recent review article [26].
`The preliminary trial [27] involved to patients (four
`1-‘.~R and 12 C-1’) and was conducted as an open study.
`The iirst patients were hospitalized for the tint 3 weelrs
`to look for any significant local or systemic effects. but
`since no undesirable side eileet was observed. subse-
`
`quent patients were hospitalized for only 24-48 It. and
`continued the Cop I treatment as outpatients for the
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`durationofthetria1.Theapeelfiealnuofthiap1elimi-
`nnrytrialweretodeter1nine:(l)DidCoplproduoe
`any apparent undesirable aideteactions? (2) Did Cop 1
`produeeanyappatentdesirahleell'eets?(3)Ooulda
`dosage adtedule beertablitlted for lhrther (pilot) trials
`shouldtheyappeartohewanantedtfheresuits
`showed that: (l)ezweptl’oroeeaalonalloea1trantient
`reaetionanttheaiteofittieetion(pain.ltching.tedneta.
`etc.),nosyatenticreactionaot'anykindwerereported.
`(2)Oftltel6patlents.lldld notdetnonatrateany
`apparent
`favot-able effect. but
`live demonstrated a
`definiteimprovema1t.Themostttoticedefl'ectwasthe
`cessation otexaeubatlons In two ofthe four ER pa-
`h'ente.(3)‘l1teoptirntnndoaagewaadetertninedtohe
`20ntgIday.0nthebatitol’thoaeprelin:lnnryaeeulte,it
`wasdeeidedtoextendtheevaluationofcoplto
`rigorousdouble-hllttd.randonized,p|aeeboeontmolled
`trials.
`A double It'seaeier said than done The
`first trial involved patients with exacerbating/remitting
`(ER) MS. It took Dr. Bernstein more than a year of
`careful design and planning.
`including consultations
`vdthstntiafieiannepidemiologistrandeodalworherain
`addltlontothemedioalandnureingstatfwhowereto
`partieipateintl:etrialonadaytodayhasis.Appropti-
`ateplanningwasaprerequlsiteforsneeeeaandforthe
`intet-pretation of the results and their rignitieanee. Dr.
`Bornstelndldanexeellentjobintheentireclesisnand
`oonduetofthispilottrial.(lhaveheentoldthattltls
`trial aervedasatnodel fortltedealgnofsnheeqaent
`diniealtrialsinMSpatientrbyotherinvutiuatota.]He
`wasalsothedrivingforeehothinrecmitingthenenrol-
`ogiste.aeientisteandntnes.aewellaeineeeuringthe
`neeesearyl'undet'oroouductin3thetr'ial.Thisrequired
`mmymeetlngshteonteofwhichlparttelpatedand
`presented the experintental data which provided the
`tlIeoretiealbaaiaforthett'ial.Finally,theNIl-lagreed
`tosnpportthetrial.IIPPr0valwasobtainedfromtlte
`Committee on Clinical Investigations of the Albert
`EinsteinOollegeot'MedicineandtlteFederalFoodand
`Dru; Adnslnistration,and theball atarted rolling.
`'l'hetriaiinehtdedS0patienta,theremiitntentot'
`whomwuahonotadmpleoreaeyproeeeawhieh
`involvedthelntervlewing ofeevetal hnndredaofpa.
`tientaendlastedalmost3yeant.lwillnotdeecrlbethis
`trialindetallntneeitaresultahavebeenpuhlieltedin
`the New England Journal of Medicine [23] and unbea-
`querttlyatuumatlzedin several review artide: [26.29.3D].
`lwlll therefore giveonly the main points and comin-
`eione and emphasize only our own personal Involve-
`tnent.
`
`Ourroleinthlntrialwastosnpplytheneeded
`amounts ol'Cop l. Tlteaubetance. whiehoonaiets ofa
`copolymet-ol‘arninoacida,iaeyntheaiaecl by polymer-
`lzationofthelv-earhoxyanltydrlde derivatives offour
`antinoaeids-alanine.lyaine.slutamieaeidandty-
`
`roaine.'l’heeedetivatives.preparedhylnteuctionvvith
`pholflflflmareextrerriely aensitivetohothtetnperature
`andhnntiditymndheneehnvetobepreparedtatder‘
`very stringent condition. The polymerization stage it
`alaoaddieatept-oeesaifrtproduulailityofeontpoeition
`utdmoleculardzeistobeaehievedltinvoivestwo
`additionaletepeofdebloclringofthefunetional ear-
`hoxylesroupofthe flulatnicaoldaIIdatlflnog,rottpol'
`thelyrine.whictihavetohept-oteoteddnrlngtheentite
`syntlteslaltiearathueomplieatedprooedurewlneh
`talteeatleaatzweekainadditiontotliepdoraynthesin
`orthe monomeric N-earboxanltydridee. Using labora-
`toryscaleequipment.1‘vecouldptepnreonlygram
`amowiteatafimeandthiemeantthatoushhoretory
`wasoonverted into amlnl-factory that war constantly
`husyrorthoaeseveralyeanwlththepteparationand
`teatin;ol'Copl.lntothisp'etureentersoursupet'
`teehnicianlVlr.laraelJaeobeon.'l'ltat\veweteahleto
`lreepapatallwithdenuandisdneinnonnallmeasnre
`to his pmlltaeiottallstn and ultatlntlng devotion to the
`job.
`Mr.Jaoobeonisattniqueehatnctet'-lrefertohim
`as 'I'he last Mohican'. He received his education in
`Earopeaeaphannaoiatintheearlyl930I.butltadto
`letwehieoonntrywhenl-litlerroaetopowermndjoined
`the Weizmann Institute in 1938, shortly alter it was
`estahliahed.l-Ieinanextraordinttryperaonandatlrst
`rate technician. both knowledgeable and creative.
`highlymetiunlousinhiaperformaneaanddevetedtohis
`workahoveandheyondthecallol‘dnty.Ittl953he
`etattedtoworlt withProf. Ephraim Katchalski-Katzlr.
`andassttcltbecameanexpeninthepreparationof
`polyaminoaddsandwaeourpartnerallalongtheway.
`I-leuaedtocotnetothelahat4a.nt.—dnrlng'the
`wlntetinpitchdark-aoaatoheabletoworkwithout
`dirturhanoe and thus increase his pmduetivity. with
`Dr. Teitelhaurn, who was responsible for the final
`rtageaorthesyntheslaasweilastlteanalysisotevety
`single batch. for both chemical characteristics (compo-
`sition. size) and biological activity (lnnntntological
`propertiesandanppreasiveeIl'eetonEAE),weprepared
`a.1toytltet'tIboutl20batclteeofCopl (10-Sogeaclt),
`totallingover3t3.ltwaeaoontinuouapmdnetionline
`overapet'lodofahontl0yeans,frotnl979 to 1989.1:
`trentmdoua effort for a research laboratory in an aca-
`danicinatitution.
`lnadditiontothepatientawhohadbeenenrolledin
`the double-blind trial. Dr. Bornatein also treated with
`Cop l. on a compassionate basin. a nutnherofpatients
`whodidnotfullilthecriteriaforparticipationintlte
`uiattmtwhomneooudamdmighunttbeneatnom
`Copl.lwilloontebaektothiepointlater.butinthe
`paesenteontextitiementionedonlyeinoethistneant
`tltatevenhigherquantitieao