Hylaform P030032

1. Hylaform P030032 Herbert Lerner, M.D. General and Plastic Surgery Devices Panel November 21, 2003

2. REVIEWERS FOR FDA • Herbert Lerner, MD- Lead and Clinical • David Krause, PhD- Pre-clinical • Phyllis Silverman, MS- Statistics • David Kaplan- Pre-Clinical • Peggy Mayo- OC/GMP • Linda Godfrey- OC/BIMO • Jack McCracken & Mary Lou Pijar- Labeling

3. Hylaform Pre-Clinical Review David Krause, Ph.D. General and Plastic Surgery Devices Panel November 21, 2003

4. Pre-Clinical Biocompatibility Testing • Hylaform has successfully passed testing for: • Irritation: • Intracutaneous Toxicity • Subcutaneous Implantation • Sensitization and Immunogenicity • Immunization Subchronic Toxicity • Guinea Pig Dermal Sensitization • Delayed Contact Sensitization

5. Pre-Clinical Biocompatibility Testing (Cont.) • Cytotoxicity • Acute Systemic Toxicity • Hemocompatibility • Implantation • Muscle Implantation (7-days) • Muscle Implantation (30-days)

6. Pre-Clinical Biocompatibility Testing (Cont.) • Mutagenicity: • Ames Mutagenicity Test • Test for Induction of HGPRT Gene Mutation • Chromosome Aberrations • Test for Morphological Cell Transformation • Subchronic Toxicity • Subchronic Intraperitoneal Toxicity (2-weeks) • Immunization and Subchronic Toxicity

7. Pre-Clinical Biocompatibility Testing (Cont.) • Chronic Toxicity and Carcinogenicity: • One-year Subcutaneous Toxicity Study • Reproductive Effects Study: • Pharmacokinetics: • Intradermal Injection of Radiolabeled Hylan B • Distribution of Radiolabeled Hylan B • Pharmacodynamics: • Intradermal & Subcutaneous Injection (6-Mo.)

8. Pre-Clinical Testing • Formaldehyde Question: • Hylaform contains less than 2.3 ppm (ug/g) of formaldehyde in a 1 cc injection. • Would multiple injections of Hylaform lead to locally elevated levels of formaldehyde? • Normal tissue levels of formaldehyde are between 3 and 12 ug/g. • Multiple injections over a number of months would not lead to elevated levels of formaldehyde.

9. Objectives- Clinical • To provide a summary of Genzyme’s Hylaform Clinical Study • To highlight issues pertaining to the safety and effectiveness of the study device

10. Hylaform Study Purpose • To evaluate the safety and effectiveness of Hylaform viscoelastic gel when used for cosmetic correction of contour deformities of the dermis of the face

11. Design • Prospective, multi-center, randomized, double-blinded, parallel-group study comparing Hylaform and Zyplast in the nasolabial fold during the initial 12 week treatment, and Hylaform and Hylaform Plus during the extended treatment period.

12. Design • The sponsor has not included any efficiency data for the extended treatment phase of the study, and only 4 week safety data for possible immunological responses were presented in the PMA. The sponsor does not seek approval for Hylaform Plus at this time.

13. Inclusion Criteria • Wrinkle Severity Score of 3 or 4 on the six point grading scale • Negative skin test to Collagen Test Implant • Two fixed facial sites, fully visible nasolabial folds, which were both candidates for correction

14. Exclusion Criteria • Known, prior or present positive skin test to Collagen Test Implant • Received prior therapy (dermabrasion, facelift) during previous six months • Previous tissue augmentation or other wrinkle/fold therapies within the past six months

15. Treatment Protocol • Initial Phase • Screening • Collagen skin test x2 • Randomization • Treatment • Can have “touch-up” at 2 weeks

16. Treatment Procedures • Initial Phase • Both nasolabial folds treated • Photographs taken at all treatment sessions • Investigator Wrinkle Assessments • “Touch-up” at 2 weeks • Follow-up for 12 weeks

17. Treatment Protocol • Repeat Phase- offered to Hylaform patients only • Must have finished initial phase • Randomization • Treatment • Hylaform or Hylaform Plus

18. Treatment Procedures • Repeat Phase • Hylaform and Hylaform Plus • Investigator Assessment • Photographs at each follow-up visit • Patient global assessment at each visit

19. Follow-up Protocol • Initial Phase- after skin testing and randomization • Day 0, Day 3, Week 2,4,8, and 12 • If “touch-up” start above from date of procedure

20. Wrinkle Assessment Scale • A validated 6 point reference scale, with reference photographs, that classifies deep facial wrinkles (nasolabial folds) • Zero represents no lines/folds • 5 represents severe lines/folds

21. Clinical Endpoints • Primary Phase • Evaluate the Efficacy (non-inferiority) of Hylaform for the correction of nasolabial folds as compared to Zyplast®. This was done using serial photograpic documentation and blinded IPR scores at week 12 • Evaluate the Safety of Hylaform as compared to Zyplast- determined by rates of adverse events associated with the use of each product

22. Clinical Endpoints • Repeat Phase • Evaluate the safety of repeat treatment with hylan B gel products • In particular, the sponsor added this phase to assess the safety of the device after repeat maintenance doses by determining the presence or absence of an immunologic response by measuring serum hylan B (IgG) antibodies • Evaluate the efficacy (non-inferiority) of Hylaform Plus vs. Hylaform for the correction of nasolabial fold contour defects

23. Demographics • Both groups were comparable with respect to • Age • Male: Female • Ethnicity • Smoking History • Sun Exposure • Height/Weight • Approx. 80% of the enrolled patients were Caucasian females, with only 3 African-Americans and 16 Hispanics in the Hylaform group.

24. Patient Accounting- 12 weeks

25. Baseline Wrinkle Severity • Investigator’s Live Assessment- Day 0

26. Baseline Wrinkle Severity • Independent Panel Review- Day 0

27. Endpoint Wrinkle Severity • Investigators Live Assessment- Week 12

28. Endpoint Wrinkle Severity • Independent Panel Review- Week 12

29. Adverse Events • Initial Phase

30. Adverse Events • Initial Phase- procedure related

31. Adverse Events • Repeat treatment Phase

32. Adverse Events • Repeat Treatment Phase – Procedure Related

33. Immunologic Response • Serum IgG levels during Repeat Phase to demonstrate a response to repeat treatments of Hylaform • No immunologic response demonstrated (no patients had a 4-fold increase in IgG levels during repeat treatment)

34. Duration of Effect • Percent returning to IPR baseline- • At 2 weeks- 38.2% (control 21.9%) • At 4 weeks- 56.1% (control 26.3%) • At 8 weeks- 68.9% (control 46.7%) • At 12 weeks- 73.3% (control 65.1%)

35. Patient Assessment of Treatment Group Assignment

36. Conclusions • Adverse events were similar in both groups • The improvement of wrinkle severity at 12 weeks was comparable.

37. Panel Question-1 • 21 CFR 860.7(d)(1) states that there is a reasonable assurance that the device is safe when it can be determined that the probable benefits to health from use of the device for its intended uses, when accompanied by adequate instructions for use and warnings against unsafe use, outweigh any probable risks. Considering the data in the PMA, please comment on whether there is a reasonable assurance that the device is safe.

38. Panel Question-2 • 21 CFR 860.7(e)(1) states that there is a reasonable assurance that a device is effective when it can be determined, based on valid scientific evidence, that in a significant portion of the target population, the use of the device for its intended uses and conditions of use, when accompanied by adequate directions for use and warnings against unsafe use, will produce clinically significant results. Considering the data in the PMA, is there reasonable assurance that the device is effective?

39. Panel Question-3 • Only three African-American patients were enrolled in the Hylaform clinical study. There were 16 Hispanic, 5 Asian and 5 “Others”. If the device is approved, should the sponsor be required to conduct a post-approval study to collect safety data on specific minorities? Is specific labeling needed to address potential use in minorities that may be at a higher risk for adverse clinical outcome, e.g., African Americans?

40. Panel Question-4 • The sponsor proposes the following indications for use: “Hylaform is intended for the correction of soft tissue contour deficiencies, such as wrinkles and acne scars.” Please discuss the adequacy of these indications based on the fact that only nasolabial folds were treated in the PMA.

41. Panel Question- 5 • As shown by Genzyme, the duration of effect of this device is short, and multiple maintenance doses will be needed to maintain the desired cosmetic effects. To assess safety of these repeated doses the sponsor has provided serum hylan B IgG levels for the repeat study population. Clinically, no significant changes in adverse events were noted in this group. Does this data support the safety of the device for repeated use, or do you believe that a post-approval study is needed to address this issue?