1. Integrating Proteomic Biomarkers Into Personalized Drug Dosing Jon Klein, M.D., Ph.D. University of Louisville Pharos Medicine

2. Disclosure Verification for: Name: Jon Klein, MD PhD The presenter listed above: ___ Does not have any significant financial relationships to disclose _x_ Has disclosed the following relationships: __Research Grants __Speakers Bureau Patent holder x __Consultant for fee _x_Stock/Ownership Employment x Partnership __Advisory Committee/Board ___Other _x_ Has disclosed this activity will not include discussion of unapproved/investigational uses of products or devices __ Has disclosed this activity will include discussion of unapproved/investigational uses of products or devices Was this activity Supported by an educational grant or received in-kind support? __ Yes Name of Company: _X_No

3. Goals Define the problem of anemia in end-stage renal disease (ESRD). Review the rise of recombinant erythropoietin (rEPO) as a therapy. Review the emerging doubts about rEPO and subsequent changes in dosing. Describe proteomic data of biomarkers of rEPO response. Describe the merger of biomarkers with a model predictive control tool to adjust rEPO dose.

4. The Golden Age of Anemia Treatment The WHO defines anemia as a Hgb < 13 in males and < 12 in premenopausal females By this definition > 90% of patients with kidney disease are anemic Beginning in 1989, kidney patients began receiving FDA approved rEPO. EPO use in cancer and HIV patients soon followed

5. The Golden Age of Anemia Treatment

6. The Golden Age Begins to End NlHct = 42 Low Hct = 30 N Engl J Med. 1998 Aug 27;339(9):584-90.

7. N Engl J Med 2006;355:2085-98. Conclusions The use of a target hemoglobin level of 13.5 g per deciliter (as compared with 11.3 g per deciliter) was associated with increased risk and no incremental improvement in the quality of life.

9. The Golden Age Ends WARNING: ESAs INCREASE THE RISK OF DEATH, MYOCARDIAL INFARCTION, STROKE, VENOUS THROMBOEMBOLISM, THROMBOSIS OF VASCULAR ACCESS AND TUMOR PROGRESSION OR RECURRENCE Chronic Kidney Disease: • In controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered erythropoiesis-stimulating agents (ESAs) to target a hemoglobin level of greater than 11 g/dL (5.1). • No trial has identified a hemoglobin target level, ESA dose, or dosing strategy that does not increase these risks. • Use the lowest Epogen dose sufficient to reduce the need for red blood cell (RBC) transfusions (5.1). “Clinicians should use the lowest dose of ESA sufficient to reduce the need for red blood cell transfusions”

10. Clinicians’ Response EPO weekly dose fell 12.5% in 2 years. Hgb targets are shifted from 10-13 to 10-11 g/dl

11. Discovery of EPO Response Biomarkers

12. Hypothesis The plasma proteome may distinguish between patients that are resistant and sensitive to RhEpo

13. Patient Population

14. Peptide Extraction Peptide Quantification Peptide Separation 1D RP capHPLC Robotic Fraction Collection MALDI Plate Spotting Precursor Ion Peak List Subsequent TOF/TOF MS Analytical workflow for peptide separation and identification Computer-Aided Modeling Bioinformatics Assignment of Peptide Identity

15. Results

16. Peptide and Protein Biomarkers

17. Sensitivity of the Candidate Biomarkers

18. Applying Intelligent Control to EPO Dosing

19. Standardized EPO Protocol

20. EPO DOSE VS RESPONSE

21. Model Predictive Control Model Dose Optimizer EPO Hb Pharmacodynamic Response Model EPO Dose Increment Target Range Minimization 12 10 Patient Hb 0 1 2 3 Months

22. Multiple Model Predictive Control (MMPC) System for Anemia Management

23. MMPC Results

24. Combining EPO Biomarkers and MMPC Use serum biomarker of EPO resistance to “prime” the MMPC anemia manager

25. Epo Resistance vs. OSMR

26. Biomarker Incorporation for Dosing

27. Conclusions The treatment of anemia in ESRD remains challenging. Concerns about unbridled EPO treatment have emerged. Proteomic analysis revealed serum biomarkers of EPO resistance and susceptibility The use of intelligent control methods (MMPC) provided personalized EPO dosing with results superior to standard protocols The combination of proteomic biomarkers and MMPC shows promise in guiding individualized EPO dosing.

29. NIH, DVA, DOE

30. KY Research Challenge Trust

31. The Ohio State Univ.

32. Brad Rovin