`
`Selected important Safety Information
` Tyvaso is breathed in (inhalabie) through your mouth into yourlungs.
`Tyvaso should only be used with the Tyvase Inhalation System
`& The effects of Tyvaso are unknownin patients with lung disease (such as asthma
`or chronic obstructive pulmonary disease) and in patients under 18 years of age
`
`Please see complete important Safety Information and Indication on page 18.
`
` TRMALATION
`
`SEUTIGM
`
`oF
`
`Page 70 of 113
`
`Page 70 of 113
`
`

`

`71 of 113
`
`Page 71 of 113
`
`

`

`°
`ase
`
`
`
`tfuouoneisastyA
`
`Baye
`
`si]
`ORPHE
`IG
`
`AqaResye2
`
`2HauOes
`
`Rey
`
`seaig)
`
`5:
`
`vedpeD
`af
`ofp
`ae}
`Dap
`ott,
`28Bq
`
`AAG
`©——ra°N-
`
`Page 72 of 113
`
`
`
`
`
`
`
`

`

`SPLHAG
`
`AAD3OYY
`
`"QioBeduovonmuoguyAyoyesWarptce
`
`iMNHES
`
`
`Papeicduonaesaszapy
`
`LOTpeULDHeAGe,
`
`STEMEETRe
`
`LOSWAAS
`
`Page 73 of 113
`
`Page 73 of 113
`
`
`
`

`

` :
`
`op
`
`“gtabdUoLorpuLazy
`
`{A325Wend
`
`APIAwWO?BasBSPafy
`
`4
`
`
`
`BtCLANJOAJeyAsOLLrin
`
`PS
`
`scePea
`
`£u
`
`wosiNEA
`
`BND
`x
`
`pPwMiae)
`
`Page74 of 113
`
`
`pvoynnoaFfna?1G.
`
`Page 74 of 113
`
`
`
`
`

`

`aySUeaay
`ap SSIS
` ADDU
`
`LUPUSBLBe:
`
`nols
`
`
`
`
`
`‘Safed!roUGuosasAtalesqumod
`
`Mt
`
`Page 75 of 113
`
`Page 75 of 113
`
`
`
`

`

`3
`
`4 a
`
`p
`Se
`
`HOt
`
`ANSOREAAL
`
`Ay
`
`AISIAHO
`
`st
`ia
`
`ae
`DEOS
`
`ifjiodd
`nSOS¥
`
`
`i.
`AA.
`
`epg
`rag
`é
`
`eeeA
`fLine
`
`o t
`
`{oO
`A
`
`sod
`'
`Ag
`EEE
`
`LED
`3m
`
`©——ra°©-
`
`Page 76 of 113
`
`
`
`
`
`
`
`
`
`
`
`
`

`

`
` POYE-PRiLrgen|
`
`Page 77 of 113
`
`Page 77 of 113
`
`

`

` B78 of 113
`
`Page 78 of 113
`
`

`

`
`
`FullPrescribing
`
`Neaccompanyiny}
`
`
`ee
`
`i,&
`
`
`
`aticiy
`
`Y
`
`additionali information,PPleaseseet
`
`
`
`yisitwww.tyvase.comorcall+-B77-864-8.437.
`ahoutTyvaso,
`
`ndthtionsforUse
`
`tPackageinser
`
`
`
`halationSysteminstru
`
`Ormatio
`TyvasetrmanualFor
`
`
`
`
`9
`a
`S
`a
`=
`a
`
`
`=
`2
`s
`a
`é
`
`
`2
`=
`oH2
`
`eety
`wv
`z,
`of
`Ea
`
`
`&ie
`3
`
`gad
`
`g
`g
`be
`g
`Y
`Bo
`a0
`8
`io
`
`
`
`cy
`oe
`
`
`e
`a
`°
`5D
`2
`v
`a
`a
`A
`3
`2
`
`
`
`“
`
`3pers
`°%
`w
`Seg
`2
`
`
`
`2
`a
`a
`3
`a
`z
`‘.
`
`ae
`E
`=
`=
`e
`3
`2
`2
`2
`
`
`voiYage 79 of 113
`
`Page 79 of 113
`
`

`

`
`
`ro learn more about Tyvaso,
`visit tyvaso.comor call 1-877-UNITHER (1-877-864-8437).
`
`United
`
`Therapeutics
`
`Page 80 of 113
`
`Page 80 of 113
`
`

`

`PATIENT PACKAGE INSERT
`
`Tyvaso (Ti-vas6)
`
`(treprostinil)
`
`Inhalation Solution
`
`Read this Patient Package Insert before you start taking Tyvaso and each time you geta refill.
`There may be new information. This leaflet does not take the place of talking with your
`healthcare provider about your medical condition or your treatment.
`
`Whatis Tyvaso?
`
`Tyvasois a prescription medicine used in adults to treat pulmonary arterial hypertension (PAH),
`which is high blood pressure in the arteries of your lungs. Tyvaso can improvethe ability to do
`exercise in people who also take bosentan (an endothelin receptor antagonist (ERA)) or
`sildenafil (a phosphodiesterase-5 (PDE-5) inhibitor). Your ability to do exercise decreases 4
`hours after taking Tyvaso.
`
`It is not known if Tyvaso is safe or effective in people under 18 years of age.
`
`Whatshould I tell my healthcare provider before taking Tyvaso?
`
`Before taking Tyvaso, tell your healthcare provider about all of your medical conditions,
`including if you:
`e
`have lung disease, such as asthma or chronic obstructive pulmonary disease (COPD)
`have a lung infection
`have liver problems or kidney problems
`have low blood pressure
`are pregnantor plan to become pregnant.It is not known if Tyvaso will harm your
`unborn baby. Women who can become pregnantshould use effective birth contro! while
`taking Tyvaso.
`are breast-feeding or plan to breast-feed. It is not knownif Tyvaso passes into your
`breast milk. Talk to your healthcare provider about the best way to feed your baby while
`taking Tyvaso.
`
`e
`
`Tell your healthcare provider aboutall the medicines you take, including prescription
`and non-prescription medicines, vitamins, and herbal supplements. Tyvaso and other medicines
`may affect each other.
`
`Especially tell your healthcare provider if you take any of these medicines:
`e medicines that decrease blood clotting
`waterpills (diuretics)
`medicines used to treat high blood pressure or heart disease
`gemfibrozil (Lopid) (for high cholesterol)
`rifampin (Rimactane, Rifadin, Rifamate, Rifater) (for infection)
`
`Know the medicines you take. Keep a list of them and show it to your healthcare provider and
`specialty pharmacist when you get a new medicine.
`
`Page 81 of 113
`
`Page 81 of 113
`
`

`

`e
`
`How should I take Tyvaso?
`e Take Tyvaso each day exactly as your healthcare providertells you.
`e
`See the detailed Tyvaso Inhalation System Instructions for Use.
`e Tyvaso is breathed in (inhaled) through your mouth into your lungs. Tyvaso should only
`be used with the Tyvaso Inhalation System.
`Tyvasois taken in 4 treatment sessions each day during waking hours. The sessions
`should be at about 4 hours apart.
`e At the beginning of each day, it will take about 5 minutes to prepare the Tyvaso
`Inhalation System. Each treatment session will take 2 to 3 minutes.
`e Take your first Tyvaso treatment session in the morning and take your last treatment
`session before bedtime.
`e Your healthcare provider may change your doseif needed.
`e
`If you miss a dose of Tyvaso take it as soon as you remember.
`e Do not let Tyvaso solution get into your eyes or onto your skin. If it does, rinse your skin
`or eyes right away with water.
`e Using the Treatment Tracker, record the numberof breaths you inhale during each
`treatment session (4 times a day). You should bring your Treatment Tracker to your
`medical appointments, as your doctor may wantto reviewit with you.
`
`Whatare the possible side effects of Tyvaso?
`
`Tyvaso can cause serious side effects, including:
`e Tyvaso mayincrease the risk of bleeding in people who take blood thinners
`(anticoagulants).
`If you have low blood pressure, Tyvaso may loweryour blood pressure further.
`
`e
`
`Ask your healthcare provider if you are not sure if this applies to you.
`The most commonside effects of Tyvaso include:
`coughing
`headache
`nausea
`reddening of your face and neck (flushing)
`throatirritation and pain
`fainting or loss of consciousness
`
`Tell your healthcare provider if you have any side effect that bothers you or that does not go
`away. Theseare notail the possible side effects of Tyvaso. For more information, ask your
`healthcare provider or specialty pharmacist.
`
`Cail your healthcare provider for medical advice about side effects. You may report side effects
`to FDA at 1-800-FDA-1088.
`
`Page 82 of 113
`
`Page 82 of 113
`
`

`

`How should I store Tyvaso?
`e
`Store Tyvaso ampules in the unopenedfoil pack between 59°F to 86°F (15°C to 30°C)
`until ready to use.
`e« Whenthefoil pouch is opened, Tyvaso ampules should be used within 7 days.
`e
`Tyvasois sensitive to light. The unopened Tyvaso ampules should be stored in the foil
`pouch.
`e After a Tyvaso ampule is opened and put into the medicine cup in the Tyvaso Inhalation
`System, Tyvaso can be kept in the medicine cup for no more than 1 day (24 hours).
`e Tyvaso thatis left in the medicine cup at the end of the day must be thrown away.
`e The Tyvaso Inhalation System can be stored in the carrying case when notin use
`(Example: between treatment sessions or overnight).
`If storing between treatment
`sessions, ensure that the plugs arefirmly in place in the dome assembly to prevent
`spillage of Tyvaso. See the Instructions for Use for additional information regarding
`storage of your Tyvaso Inhalation System.
`
`Keep Tyvasoandall medicines out of the reach of children.
`
`General information about the safe and effective use of Tyvaso.
`
`Medicines are sometimes prescribed for conditions that are not mentioned in a patient
`information leaflet. Do not use Tyvaso for a condition for which it was not prescribed. Do not
`give Tyvaso to other people, even if they have the same symptomsyou have. It may harm
`them.
`
`This patient information leaflet summarizes the most important information about Tyvaso. You
`can ask your healthcare provider or specialty pharmacist for information about Tyvaso thatis
`written for health professionals.
`
`For more information, go to www.tyvaso.com or call 1-877-UNITHER (1-877-864-8437).
`
`Whatarethe ingredients in Tyvaso?
`Active ingredient: treprostinil
`Inactive ingredients: sodium chloride, sodium citrate, sodium hydroxide, hydrochloric acid, and
`waterfor injection.
`
`Tyvaso is a registered trademark of United Therapeutics Corporation.
`
`Literature issued May 2013.
`
`United Therapeutics Corp.
`Research Triangle Park, NC 27709 USA
`Copyright © 2013, United Therapeutics Corp. All rights reserved.
`
`Page 83 of 113
`
`Page 83 of 113
`
`

`

`
`WSYSTEM
` a ghee
`
`a=
`And:
`3g
`——
`
`
`
`
`
`Page 84 of 113
`
`Page 84 of 113
`
`

`

`
`
`
`
`‘i210suolsanbAueseynodjiJaplaoldAseuueydAyepads
`
`
`
`
`
`
`
`ybne;asenokGurpAuefoainsun
`
`
`
`
`
`Bodansaye"WaISASUOHSCULYOSPAALOU}aS0}Pauley
`
`
`
`
`
`JO10}20pINOAySeSAOMIY“SUOLIBHDayJOWePuersiopuN
`
`
`
`
`
`aedancyHod(AUNOSYAALIUiMJuaaRaTLeysJOUOg+
`
`
`
`
`
`
`
`UsdDONEPIAYOSUALLauBinjonysepgnag,
`
`SuSTRoeS
`
`
`
`
`
` ysarsdsLOETRNOLOSWAR]DOSBinbiens
`
`
`
`
`
`sieYd:SutSGeypUSURAL
`
`PuyJOSouBUATAepueGuuEer
`
`
`
`
`
`Pz~iiaysdgwoeUL,OSYAAL
`
`
`
`
`
`orosauensazoyaineeBunuwars£bG3ow
`
`
`
`usamiegwuaységUOTEUYOSYALLog}Gul015,
`
`
`
`
`
`
`
`
`
`“OASHAAL)Bumipayy1no,Buegue
`
`
`
`
`
`
`
`USUNESI,10)LUAWUORAUAaspayyBupedaig
`
`
`
`POWARLMUAMioiealltopansedeig
`
`
`
`LORSIDCyEEBLOTASHFEIQUAYSUUBPVIOT1OHEL
`
`Mom
`
`7
`
`<7
`
`ahanségul
`
`LAUD]BySUNOSIJOMONSuy
`
`SUDHDRSUREIR
`
`sea10Aigiedarg
`
`BOSIAPEHE
`
`
`
`
`
`"dH3}SA5UOREFEYU]OSYAALOY]UTMAjUOBSA10351OSYAALeonetutayeyAQueUPA
`
`
`
`
`
`Aressoyy
`
`
`
`Page 85 of 113
`
`Page 85 of 113
`
`
`
`
`
`
`
`
`
`

`

`
`
`SBHupeuiaaaag
`
`
`
`BIAspUOReTOYLY
`
`ONBIEYU40)
`
`
`
`
`
`=tyase@/HyBySERjonuoy_/°.
`
`Agua
`
`
`
`
`
`sobessayAgjdsiqaHAaq
`
`Page 86 of 113
`
`
`
`
`
`
`
`STOBUASpanesuoproyy‘shunwe
`
`Page 86 of 113
`
`
`
`
`
`

`

`Sanaa:
`
`SBNOSSEIYG
`
`ws
`eo
`
`ine
`
`aidhFAA]SFOZ
`
`S{P30PUoy
`
`
`
`sayddngfupeuyeg
`
`
`
`SNAPUOHTLEBN“f
`
`Page 87 of 113
`
`Page 87 of 113
`
`
`
`
`
`
`
`

`

`
`
`anapneaZEANNS
`
`jodyeqn)
`
`or
`
`
`
`prersiq“suigeyeyaned|Ajucuadg,
`
`
`
`
`
`
`‘shep/JayesagndwepasnunAue
`
`
`
`
`
`SPUeYINGAyse@s‘spueywokUo“ypredHoyBuruadojosystsandweayyoyautpauAuefySAvD/UIUUMpasnagjsiidsaindury
`
`‘Aayeipawury
`
`
`
`
`
`
`
`
`
`—_AdyNon
`
`
`
`doyanaivay
`
`sindyodyaioyog
`
`
`
`indaHEMOSH
`
`
`
`au0Aluoasutnod
`
`orempayne
`
`qWwegy
`
`
`
`aydyinwBunsasuy‘desauiipau
`
`
`
`
`
`
`
`JOMO}ayyWsAasdfissda
`
`“aupypaU
`
`Page 88 of 113
`
`
`
`dngaulipaypuesequueyadiAagLoreyequyayyBurts
`
`
`
`
`
`
`
`
`
`
`
`masdguoHMEUYOSvALLwna,deyGunes
`
`Page 88 of 113
`
`
`
`
`
`
`
`
`
`
`
`
`

`

`
`
`ays22083,
`
`'.62
`
`
`BLDIPAU!34}0}S}9BULO3YIBLUYSUiy
`
`ayyAjuosya,aul
`
`awOpaiUdyeSsalynesJ)“dno
`
`
`
`asaichynosy
`
`aid
`eTYY
`
`weauuubgy
`
`SAUD
`
`
`
`eyerdaen
`
`ARRIA215
`
`
`
`JBY}OUR2eaYYoUPALNOKAywisee
`
`“yy
`
`
`
`SHARUONePEYLyainSuyquassy
`
`Page 89 of 113
`
`Page 89 of 113
`
`
`
`
`
`
`
`
`
`
`
`

`

`SqSms
`
`peep
`
`Bradyeoy
`
`ayysoedypur
`
`BORERPU
`
`HSHSPREISg,
`
`apaedars
`
`iosAoetsigy
`
`
`
`Heys2943
`
`Page 90 of 113
`
`daaLOReRYLYay3UgGunny
`
`
`
`
`
`{panunuer)arinequonejeyuyaigBuyquassy
`
`Page 90 of 113
`
`
`
`
`
`
`
`

`

` UOISSRS
`
`|MAWIESILWUESERA4OJaqUIANolFaeg
`
`iESROSEY
`
`
`
`‘OpseSaSTEBEONWoesBANEAusGadeRutan
`
`
`
`
`
` ASGSaMora4HSERRINJOSSSR1BateHe
`
`5:-see|;o609062=i
`
`:aei|“passeues
`
`i:
`
`TAAARIEOPOByardayRNCet
`
`eeee
`
`WOaryBICgUdSIO
`
`
`
`CEOSSASGOGHNPSURUPOle
`
`SHPO)(6GSURUINOEBEEN.
`
`eAebny
`
`
`
`
`
`
`
`saquunuasearnysaquunuasra33g
`
`S3897930smenigyo
`
`Page 91 of 113
`
`Page 91 of 113
`
`
`
`
`
`
`
`
`

`

`
`
`spbry
`
`uaaiasKepsig
`
`USSRAL
`
`TOSSa
`
`ae
`
`RGmiedo
`
`
`
`
`
`paqiasaydayySayszOW}BinsaYBUI07LABIISABydsip
`
`
`
`
`
`
`
`
`
`
`
`Lanesusaepepnefnascilan)newss)ouminewinesSuneyur
`
`
`
`sdb)Hongpeay)
`
`
`
`A,
`
`Sueulion2 OSEco
`
`
`
`
`SHPlO2Sy“UOISSasJUBUNL|N1eY}40)syzeasgjoJoquUITU
`
`
`
`‘yaypetfquatjees|mdAuianpeA
`
`
`
`
`
`3g)yajewyouopAgpdsipainuesyyeaigfozaquinuautJ}
`
`aUlO{SS3§JUSiUPRals0UtSIeaigjoFeqUUAYay)Dunas,
`
`
`>}abed6)08uogdissaudsoduyssnbaigfosequanu
`
`
`
`“go,sayswadalpue
`
`ae
`
`Page 92 of 113
`
`
`
`
`
`
`
`
`
`Page 92 of 113
`
`
`
`
`
`
`
`
`
`
`
`

`

`
`
`
`
`yasoqyUBRuWiayssau}ApadodBuymaiyaq0)weaddejoltsappasipadtyy
`
`
`
`
`
`
`
`NOUNS
`
`
`
`
`
`
`“sueiap40]‘g¢-ogsabed‘vonoasGunooysayqnoyyaas‘Apaauosutdn
`
`
`
`
`
`
`
`
`
`
`
`
`
`ipanuyuos}wonnjosuoRepeyuy(uNsosdaly}-OSYAAL‘auIpayino,Guyeyuy
`
`
`
`
`
`
`
`
`
`
`
`Page 93 of 113
`
`Page 93 of 113
`
`
`
`

`

`
`
`Page 94 of 113
`
`aaaiduynow
`
`
`
`WeuSJaan.
`
`g
`
`AP
`
`om:
`
`
`
`HaysJoan!
`
`
`
`
`
` SUDISSAYLUMLEYUSSOgDSSMONEPIUEOGwARLan}Supers
`
`Page 94 of 113
`
`
`
`
`
`
`
`

`

`
`
`%
`
`asaidwold
`
`shryg
`
`
`
`Apquiasseawog
`
`“
`
`
`
`SromceeGRDSUITED
`
`
`
`podsuenpueabezoysjruoyIppe20)OFabedaag“uoIssaspuaUREE
`
`
`
`
`peustyHunuogisodyyBudnueUyariAapLopeyeyy34391035
`
`“UOPLOFU)
`
`
`
`
`idsAeiuauripawayy‘aserduryouageshnydau)ay
`
`
`-agndwesaul8UpiaJ9A0YEYS‘auDEpaieAueFi
`
`
`
`Page 95 of 113
`
`
`
`
`
`
`
`{panunuos}sudissasJUsWIeaE,HeAMIagWaIshsVOHZIEUL]OSYAALJULSuLaIg
`
`
`
`
`
`
`
`Page 95 of 113
`
`
`
`
`
`
`
`
`
`

`

`
`
`
`
`
`“AjayIpaUAUEspuayYsera‘spueyINGAINCASS
`NOLLAVDV7Q:
`‘woREA||:<
`
`
`
`
`
`
`
`WazshsUOREIEULEOSYAALOUI4GSoMaPUeDinUnOTS
`
`,.sous
`
`
`
`aoaidUORPyeULE
`
`uadg
`
`ways2amnousLyd
`
`
`
`savossaqzyau}yoBuiuearyAeqyopug
`
`
`
`
`
`uosyidsdnosuioipausayyWo}ainoipauAue4aneiquuau
`
`
`
`a5n02Ue?USa4;YMewesaupipapy|:-
`
`ve
`
`Page 96 of 113
`
`Page 96 of 113
`
`
`
`
`
`
`
`
`
`

`

`geen
`
`
`adtkapay)433320}BuydwayysaimpeynuewagyXqpautopad
`
`“HORDUNeWBasriesABWpusAUPUEMayyspioaAemAue
`
`
`
`BqSTUWassUOTEOSYAALBU)JOS31NaS[ry
`
`
`
`
`
`
`
`aseBude
`
`
`
`
`
`BACMOINEL©USaOSSaIIeSHJOSHASPHOREPBYLBY}a2EYdTOUOG‘UDAJBUOHUBAUOD410
`
`
`
`daysemysipBUf40JayeMUlBdtAapUO]EPEYUYayyd2e]dJouOG
`
`
`
`
`
`
`molu]‘apeydaca)aysemayenidosddeueulvoKnEs‘dn>aurtpatuayyasne:youog“dnssupipaw23sefdayAbsae
`
`
`
`
`
`
`
`
`voneeua](juyscidag)-OSWAALBuriemaraigprersiq
`
`
`‘dndauiipewayyapéoayyouog
`
`
`
`Page 97 of 113
`
`
`
` \AIGUGESSEatdog
`
`
`
`{panunuos)savossazsyayyjoBunuealAggjopuy
`
`Page 97 of 113
`
`
`
`
`
`
`
`
`
`

`

`
`
`
`
`@dNOPVORRIEGUS24)OFPAYSUUODyOuStALaHeau;BUMSBOW
`
`
`
`noAusyMpebiey?Aypny
`
`oyu:pabbnydyabiesAyn}aysunsaBuoyeasnbaspueApmoys
`
`
`asow367249HimAapegayy“buiGiey>siuayegag]any
`
`
`
`
`
`
`4814NOAaugzagAzayeqMaueafieyosAeAtpy‘ylaAT900)
`
`
`
`"SsA|pUONRIEUUEBuy
`
`yesn
`
`
`
`
`Page 98 of 113
`
`oepronpunssoug
`
`
`
`_—aGsey?ayeg
`
`wytora
`
`ulisdgUOMpeppUnycs
`
`
`SPALLino,Susi)
`
`
`
`Arnegaqeaiieway
`
`Page 98 of 113
`
`
`
`
`
`
`

`

` OHO}
`
`
`
`RIDICASHOTIRIRCOAATaun
`
`NQOUSaEQNOEE
`
`Page 99 of 113
`
`Page 99 of 113
`
`
`
`

`

`
`
`aeOURftTLE
`
`3
`
`omywin
`
`
`
`SACD?SPSS
`
`BUROEDRUELEBA
`
`assay
`
`
`
`SHIRLON
`
`efupnp
`
`suppZ
`
`sd
`
`Page 100 of 113
`
`Page 100 of 113
`
`
`
`
`
`
`

`

`pruayreay8
`
`HaipOSEOy
`
`WBRIGLE
`
`
`
`SFACIS
`
`
`
`Agpuesseauunpo42Sunpage
`
`
`
`LIDARGEDDYSEMHAD.ON,
`
`fpenuquesdwnyedgUCHRBRE
`
`
`
`SUAALOutBineousoparenss
`
`SOS,
`
`Page 101 of 113
`
`Page 101 of 113
`
`
`
`
`
`
`
`

`

`
`
`
`
`a5sidWORBENGLSENDe908(ouyesseo}mafia99°0-O50
`
`
`
`
`
`
`
`
`
`ayeg!auguniAotaasseauiogOEeseeeGenin)Te
`
`
`
`
`
`
`
`
`
`PeasouhySPEND:fnwe.tonSUPAUDFRELHEARSE
`
`
`
`
`
`
`
`gpAuenninsauzipagHPRSIGGHpTUOHPIBWIAISSEN]D|PUPSSOOSYAALBradpenay
`
`
`
`
`
`
`
`RAVEIGUISU!IBYune7sueaeadnveulene90me
`
`
`
`
`
`oOOPSEEROEE
`
`
`
`Faeoningabeisnwept
`
`saydepe30AZLwhLEVOXBEitdSOEX99XBG
`
`
`
`findgonoyisanunaea)Boge
`
`SMUIOSTIYOMALONBRYYW\yy
`
`suatraesds
`
`
`
`
`
`astnowyaseBnofp-ueaejuloosAyapdesitescus
`
`
`
`
`
`
`
`
`
`diJOAALESLERSEGgeegs
`
`
`
`BODAREALBSBISIG
`
`APESea
`
`
`
`AYpIUNGBANNIOALOROTOP04G-
`
`
`
`‘AUBINOANIOT©G2-OF)9.5291.SL
`
`founueuSwop
`
`gackey
`
`Page 102 of 113
`
`Page 102 of 113
`
`
`
`
`
`
`
`

`

`SUD)USESSMARESLE
`
`RAGS2m
`
`
`
`dnoaUniney
`
`euSysnag
`
`apaupnEpeyyy
`
`say2oauyeg
`
`
`
`HSYORIDUMLLogugIon
`
`
`
`Hycereydapjeg
`
`Page 103 of 113
`
`Page 103 of 113
`
`
`
`
`
`
`
`
`
`

`

`
`
`CECAHUTHAPOEL
`
`
`
`HOUPOULIONNLARUDLNIAS
`
`
`
`
`
`sinad(7)errtagookAgueniemsedaliojeumeomda:Wty©peyueilsrwatsdsUGTOPPYULOSWAALHIOA
`
`
`
`
`
`
`
`
`
`
`
`20S70paintousieved[g)oAanTOYJoeywueysdgUORTPULEOSUAALOMI40FiscaljoayenINSAwody
`
`
`
`
`
`
`
`“AjuOIASPWIaISAGUORPIRUY]OSYAALay)oFsagenAquelipsaStL,Js4uSOtO3JaaSyya“OuNpRINUEUE
`
`
`
`
`
`
`
`
`
`
`
`APRIELLDA2
`
`pe
`
`ae
`
`OSUAAL
`
`
`
`Page 104 of 113
`
`
`
`
`
`QUEUEJ8PUnPaIoan?IOLeBIBSyuBUDdinE?Arassanny
`
`
`
`
`
`Page 104 of 113
`
`
`
`
`
`
`

`

`
`
`FIJISASNOUVTIVHN]
`
`SSP10.SLOSrasuE
`
`OSVAAL
`
`
`
`
`
`Aaoornumadissaedsoy5)GOESHONOROSYARL
`
`
`
`
`
`PROT0410Ut
`
`ELPTRSPDIB
`
`qsoRmiensAyo)nae
`
`osrug
`
`sapnndeiagyegPMY
`
`Page 105 of 113
`
`Page 105 of 113
`
`
`
`
`
`
`

`

`EXHIBIT 7
`Biochemical Pharmacology 84 (2012) 68-75
`
`
`
`
`Contents lists available at SciVarse ScienceDirect
`
`Biochemical Pharmacology
`
`
`
`journal homepage: www.elsevier.com/locate/biochempharm
`
`
`Binding and activity of the prostacyclin receptor (IP) agonists, treprostinil
`and iloprost, at human prostanoid receptors: Treprostinil is a potent
`DP, and EP agonist
`
`Brendan J. Whittle *, Adam M.Silverstein, David M. Mottola”, Lucie H. Clapp “*
`? William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, Charterhouse Square, London ECIM 6BQ, UK
`> United Therapeutics Corporation, 55 T.W. Alexander Drive, Research Triangle Park, NC 27709, USA
`“Centre for Clinical Pharmacology, Division of Medicine, University College London, Rayne Building, London WCTE 6JF, UK
`
`
`ARTICLE INFO
`
`ABSTRACT
`
`Keywords:
`Prostacyctin analogues
`Radioligand binding
`Cyclic AMP
`Calcium influx
`Prostanoid receptors
`
`Article history:
`Received 24 january 2012
`Accepted 19 March 2012
`Available online 27 March 2012
`
`
`iloprost and treprostinil are extensively used in treating pulmonary
`The prostacyclin analogues,
`hypertension.Their binding profile and corresponding biochemicalcellular responses on human prostanoid
`receptors expressedin cell lines, have now been compared. Hoprost had high bindingaffinity for EP, and IP
`receptors (K; 1.1 and 3.9 nM, respectively), low affinity for FP, EP; or EP, receptors, and very lowaffinity for
`EP2, DP; or TP receptors. By contrast, treprostinil had highaffinity for the DP;, EPs and IP receptors(Kj 4.4, 3.6
`and 32 nM, respectively), low affinity for EP, and EP, receptors and even loweraffinity for EP3, FP and TP
`receptors. In functional assays, iloprost had similar high activity in elevating cyclic AMP levels in cells
`expressing the human !P receptor and stimulating calcium influx in cells expressing EP; receptors (EC59 0.37
`and 0.3 nM, respectively) with the rank orderof activity on the other receptors comparable to the binding
`assays. As with binding studies, treprostinil elevated cyclic AMP with a similar high potency in cells
`expressing DP, IP and EP2 receptors (ECs9 0.6, 1.9 and 6.2 nM, respectively), but had low activity at the other
`receptors. Activation of IP, DP, and EP2 receptors, as with treprostinil, can all result in vasodilatation of
`human pulmonary arteries. However,activation of EP; receptors can provoke vasoconstriction, and hence
`mayoffset the [P-receptor mediated vasodilator effects of iloprost. Treprostinil may therefore differ from
`iloprost
`in its overall beneficial pulmonary vasorelaxant profile and other pharmacological actions,
`especially in diseases where the IP receptor is down-regulated.
`© 2012 Elsevier Inc. Openaccess under CC BY-NC-ND license,
`
`1. Introduction
`
`is of substantial
`The endogenous prostanoid, prostacyclin,
`therapeutic benefit
`in the treatment of the highly debilitating
`disease, pulmonary hypertension {1~4]. Prostacyclin itself is however
`chemically unstable at physiological
`temperatures and pH, and
`rapidly decomposesto a relatively inactive breakdown product as
`reviewed by Whittle and colleagues [5,6]. Therefore, the early clinical
`use of prostacyclin, as the chemically synthesised material epopros-
`tenol, necessitated the use of a high pH formulation andice packs for
`its prolonged intravenoususe. The developmentof chemically stable
`prostacyclin analogues such asiloprost, treprostinil and beraprost
`obviated the requirementfor such a formulation [6]. These agents
`have been used clinically for different
`indications,
`including
`
`* Corresponding author at: Centre for Clinical Pharmacology, Division of
`Medicine, Floor 3, Rayne Building, University College, 5 University Street, London
`WCIE 6JF, UK. Tel.: +44 020 7679 6180; fax: +44 20 7679 6212.
`E-mail addresses: b.j.whittle@qmul.ac.uk (BJ. Whittle), asilverstein@unither.-
`com {A.M. Silverstein}, dmottola@ltunglic.com (D.M. Mottola),
`|.clapp@ucl.ac.uk
`(LH. Clapp).
`
`0006-2952 © 2012 Elsevier Inc. Open access under CC BY-NC-ND license.
`http: //dx.doi.org/10.1016/j.bep.2012.03.012
`
`pulmonary hypertension, peripheral vascular disease as well as
`Raynaud’s phenomenonanddigital ulcers associated with scleroder-
`ma [7-13]. In particular, iloprost and treprostinil are currently used
`extensively in Europe and the US for the treatment of pulmonary
`arterial hypertension {14-18}.
`As with most other mediators, prostaglandins such as prostacy-
`clin elicit their molecular, pharmacological and biochemical effects
`through binding and activation of specific receptor sites [19]. It was
`initially established by pharmacological techniques that there was a
`range of specific receptors for the naturally occurring prostanoids
`(see [20]) and these receptors have been subsequently cloned and
`expressed [19,21]. The original classification of the different
`prostanoid receptors {20,22,23] has remained essentially intact
`since the early proposals [24]. Thus, the receptors are identified as
`the IP, EP;, EP2, EP3, EP4, DP (now DP,, see below), FP and TP receptor
`{23-25]. The IP, EP2, EP, and DP; receptors are classically known to
`be G,-coupled receptors linked to cyclic AMP (cAMP) generation,
`while EP;, FP and TP receptors couple to calcium mobilisation
`pathways through G,, Gand asyet unidentified G proteins { 19,25].
`Thereare several splice variants of EP; which can couple negatively
`or positively to G; or G., respectively [19].
`
`Page 106 of 113
`
`Page 106 of 113
`
`

`

`BJ. Whittle et al. / Biochemical Pharmacology 84 (2012) 68-75
`
`69
`
`The natural ligand for the IP receptor is prostacyclin (PGI,), with
`previously described [21,34,35]. Briefly, cells from each cell line
`prostaglandin Ez (PGE) for the EP receptors, PCF2, for the FP
`stably expressing the recombinant human prostanoid receptor
`receptors and thromboxane Ag; for the TP receptor [24]. A recent
`were spun downat 4 °C and the cell pellet suspended in a 50 mM
`pharmacological study has suggested evidence for a second [IP
`Tris/HCl (pH 7.4) buffer containing 5 mM EDTA, 20 mm NaCl, 5 mM
`receptor on human airway epithelial cells that mediates the
`KCl, 5 mM MgCl, 1.5 mM CaClo, 10 g/ml trypsin inhibitor, 1 wg/
`inhibition of cytokine release | 26]. This is not thoughtto beasplice
`ml leupeptin and 75 jzg/mi phenylmethylsulphonylfluoride.
`variant although its occurrence elsewhere has not been described.
`Cell
`lysis was performed by ultra sonication (3 min at 4 °C)
`The original classification of the DP receptor with prostaglandin Dz
`using a Vibro cell 72405, followed by centrifugation (Beckman
`(PGD2) as the natural ligand has now been designated as DP, [24].
`Avanti J301) of the resulting homogenate at 4°C (50,000 ~ g for
`This takes into account the more recently identified DP2 receptor or
`15 min). The membranepellet was resuspendedin fresh Tris buffer
`CRTh2 receptor,
`that while recognising PGD2,
`is more closely
`containing 10% glycerol and stored as aliquots at ~70 °C until used
`associated with chemo-attractant molecules and has no significant
`in the binding studies. Proteins levels were determined using the
`homology with the other prostanoid receptors [24].
`Bradford method and the optimised quantity of protein used in the
`Despite their extensive clinical use over the past decade, there is
`binding studies was 16 jg for the TP receptor, 20 xg for the EP»,
`relatively little direct comparative pharmacology of iloprost and
`EP3, EP4 and FP receptors, 40 wg for the IP receptor and 60 j1g per
`treprostinil in experimental systems and models. It is generally
`samplefor the EP; and DP, receptors. Incubations werecarried out
`using nanomolar concentrations of the appropriate [*H] radioli-
`assumed that both are potent agonists at the prostacyclin IP receptor
`and that such agonist activity predominantly underlies their
`gand (Table 1) in the absence or presenceof various concentrations
`respective responses, including their potent vasodilator effects in
`of the prostacyclin analogue(final solvent concentration was kept
`the pulmonary vasculature, at least under physiological conditions
`constant). Total binding was determinedin the presenceofvehicle.
`|27~29]. Indeed, based on this premise, novel agents that are highly
`Non-specific binding was determined in the presence of 650-
`selective agonists at the IP receptor such as the non-prostanoid
`5000-fold excess of
`the corresponding non-labelled ligand.
`moiety, selexipag, are being developedforclinicalutilities including
`Following a 60-120 min incubation of ligands at room tempera-
`pulmonary hypertension [30,31]. However, the situation is more
`ture (Table 1), samples were filtered rapidly under vacuum
`complex, since the prostacyclins appear to have functionally
`throughglass fibre filters, dried, and then countedfor radioactivity
`in a scintillation counter.
`relevanteffects at other prostanoid receptors as reviewed by Clapp
`and Patel [32].
`The specific ligand binding was calculated as the difference
`Although the receptor binding profile of iloprost, including its
`between total binding measured in the presence of radioligand
`high affinity for the IP as well as the EP;, and EP receptor, has been
`alone and nonspecific binding determined in the presence of an
`reported for both murine and human prostanoid receptors [21,33],
`excess of unlabelled ligand, as performedin the laboratory at Cerep
`there has been no reported comparable evaluation of treprostinil.
`(Le bois l’'Evéque, France). Specific binding for ligands reached
`Because of the multiple pathophysiological processes involved in
`equilibrium after 30-40 min of incubation at reom temperature,
`pulmonaryhypertension,there is a need to understand more about
`wasstable for greater than 2 h and was determinedto be saturable.
`the respective pharmacology of these two extensively used
`Results are expressed as a percent of the control specific binding
`obtained.
`prostacyclins. Thus, the current study investigates the binding
`profile of treprostinil on humanprostanoid receptors, individually
`Competition curves for each data-set were generated by non-
`expressed in separate cell lines, and has directly compared this
`linear regression analysis of the data (Prism 4.03; GraphPad, San
`profile to that of iloprost in the same studies. In addition, the
`Diego, USA) using a four parameter logistic (Hill) equation:
`cellular responsesofeither an elevation of intracellular cyclic AMP
`or calcium levels as appropriate, as a consequenceof activation of
`the individual human prostanoid receptors by either iloprost or
`treprostinil, have also been evaluated.
`
`(A ~D)
`r al a 19%leg 1Csq) xn)
`
`(1)
`
`2. Methods and materials
`
`2.1, In vitro radio-ligand binding assays
`
`Evaluation of the affinities of treprostinil and iloprost for each
`prostanoid receptor was determinedin radioligand binding assays
`using standard techniques. Cell
`lines, conditions and materials
`used are documented in Table 1 and broadly follow protocols
`
`binding,
`where Y=specific binding, D=minimum specific
`A=maximum specific binding,
`ICs53=the concentration that
`inhibits half of the control specific binding and nH = Hill factor.
`The inhibition constants (K;) were calculated using the Cheng
`Prusoff equation:
`
`ICso
`TSU)
`
`o
`
`Table 1
`Experimental conditions for prostanoid receptor radioligand binding assays. h= human; K,4= dissociation constant; RT=room temperature; HEK-293 =human embryonic
`kidney 293 cells; CHO=Chinese hamster ovary; 1321N1=human glial brain astrocytoma.
` Prostanoid receptor Expression system/accession no.
`
`IP (h)
`HEK-293/NM_000960
`EP, (h)
`HEK-293/NM_000955
`EP(h)
`HEK-293/NM_000956
`EP; (h}
`HEK-293/NM_198714
`EP, (h)
`CHO/NM_.000958
`
`Nonspecific (j4M)
`Hoprost (10)
`PGE, (10)
`PGE, (10)
`PGE2 (1)
`PGE(10)
`
`Incubation time @RT (min)
`60
`120
`120
`120
`120
`
`Ligand
`CH] iloprost
`[7H] PGE,
`{PH} PGE2
`PH] PGE,
`PH} PGE2
`
`Concentration (nM)
`10
`15
`3.0
`0.5
`0.5
`
`Ka (0M)
`8
`1.5
`3.0
`0.8
`03
`
`DP, (h)
`
`1321N1/NM_000953.1
`
`(?H} PGD
`
`1.5
`
`1.2
`
`BW245C (1)
`
`60
`
`60
`Cloprostenol (10)
`3.8
`2
`[(PH} PGF2,,
`HEK-293/NM_000959
`FP (h)
`
`TP (h) (TXA2) 60 HEK-293/U11271 PH] SQ 29548 5 4 U44069 (10)
`
`
`
`
`
`
`Page 107 of 113
`
`Page 107 of 113
`
`

`

`70
`
`BJ. Whittle et al./ Biochemical Pharmacology 84 (2012) 68-75
`
`where L = concentration of radioligand in the assay, and Kp = affi-
`nity of the radioligand for the receptor. Scatchard analysis was
`used to determine Kp from a plot of specific binding/free
`radioligand concentration versus specific binding giving a slope
`equivalent to —1/Kp and are given in Table 1 (see Figure Si of
`Supplementary Information for examples of Scatchard plots).
`
`CHO-K1, EP, (GenBank Accession Number NM_000958; Cat#
`C1204) in HEK293T, FP (GenBank Accession Number NM_000959;
`Cat# C1205)
`in HEK293T,
`IP (GenBank Accession Number
`NM_000960; Cat# C120G6-1) in CHO-K1, DP; (GenBank Accession
`Number NM_000953; Cat# C1200) in HEK293T and TP (TXAsR;
`GenBank Accession Number NM_001060.4; Cat# C1365)
`in
`HEK293T were from Multispan.
`
`2.2. Receptor activation assays
`
`2.2.1. Cyclic AMP assay
`HEK 293 (expressing EP2, EP4) CHO (EPs, IP) or 1321N1 (DP;)
`cells were lifted with a non-enzymatic cell stripper and re-
`suspended in assay buffer at the desired cell density for each cell-
`line. Cyclic AMP wasassayed in suspensionof cells using a CisBio
`HTRE cAMPHiRangeKit (Cisbio US, Bedford, MA, USA) according to
`the manufacturer's protocol. Cells were incubated with the
`prostacyclin analogues for 20min at 37°C. The reaction was
`terminated by sequentially adding D2-labelled cyclic AMP and
`cryptate-labelled anti-cyclic AMP antibody contained in lysis
`buffer. The plate was incubated at room temperature for 60 min
`before reading of fluorescent emissions at 620nm and 668 nm
`with excitation at 314mm were made on a microplate reader
`(Molecular Devices, Sunnyvale, CA, USA). These experiments were
`performed in the laboratory at Multispan (Hayward, CA, USA). Data
`were converted from a cyclic AMP standard curve and expressed as
`cyclic AMP (nM).
`
`2.2.2. Calcium mobilization
`HEK293cells expressing FP, TP or EP; receptors were seededin
`384-well plates at appropriate densities and cultured overnight.
`The calcium flux assay was conducted according to the manu-
`facturer’s protocol using the FLIPR Calcium 4 Assay Kit (R8142;
`Molecular Devices). Loading buffer, containing the calcium-
`sensitive dye, was added to the cells and incubated for 60 min
`at 37°C. The plate was then transferred to a FlexStation™ 3
`benchtop multi-mode microplate reader (Molecular Devices),
`where compounds were automatically injected into each well.
`IntraceHular calcium, monitored as changes in fluorescent, was
`recorded for 90s with a single compound application occurring
`after 19 s, These experiments were performedin the laboratory at
`Multispan (Hayward,CA, USA). Assay results (5~10 determinations
`per analogue concentration) wereplotted as relative fluorescence
`units (RFU).
`
`2.3. Materials
`
`Treprostinil was provided in powder form by United Therapeu-
`tics Corporation (Research Triangle Park, NC, USA). floprost (50:50
`R/S isomer), BW245C, prostaglandin E, (PGE2) and PGDz were
`purchased from Cayman Chemical Company (Ann Arbor, MI, USA).
`Cloprostenol, U-44069 and buffer reagents and materials were
`purchased from Sigma-Aldrich (Lyon, France). Treprostinil was
`dissolved in DMSO at a stock concentration of 10 mM andiloprost
`was dissolved in methylacetate at a concentration 13.9 mM.For
`concentration—response experiments, the highest agonist concen-
`tration used was 10 4M with serial 1:10 dilutions.
`In binding assays, stable cells expressing respective human
`prostanoid receptors were used by Cerep (Table 1). The radi-
`oligands used in these studies (Table 1) were obtained from Perkin
`Elmer NEN (Courtaboeuf, Cedex 191945, France), or for iloprost,
`from Isobio (Fleurus, Belgium), Likewise for functional assays
`conducted in the laboratories of Multispan, stable cell
`lines
`expressing human receptors were: EP;
`(GenBank accession
`number NM_000955.2; Cat# C1201a) in HEK293T, EP2 (GenBank
`Accession Number NM_000956.3; Cat# C1202) in HEK293T, EP3
`(GenBank Accession Number NM_000957; Cat# C1203-1a),
`in
`
`2.4, Data analysis
`
`ICs9 values were obtained from each
`In binding studies,
`individual concentration-response curve for specific binding
`(n= 6) and used to determine the affinity constant, K;.
`Concentration-dependent relationships for each prostacyclin
`analogue stimulating elevations in either intracellular cyclic AMP
`or calcium (mean + S.E.M. of n determinants per concentration as
`indicated) as appropriate, were constructed using a variable slope
`sigmoidal fitting routine in GraphPad Prism 4.03 (San Diego, CA, USA).
`The ECsq value, the concentration of agonist causing 50% of the
`maximal response (Emax), Was determined from individualfits to each
`data-set and expressed as mean+ S.E.M.Statistical analysis was
`performed using GraphPad with significance assessed using a
`Student's t-test or ANOVA with correction for multiple comparisons.
`A P value <0.05 was considered significant.
`