EVALUATION OF THE THERAPEUTIC POTENTIAL OF PROJECT ATLAS CLINICAL CANDIDATE IN THE TREATMENT OF NEUROPATHIC PAIN AND RECOMMENDATIONS FOR

FUTURE DEVELOPMENT

FOR MALLINCKRODT, INC. HAZELWOOD, MO

February 1, 2012
BY

Bill W. Massey, Ph.D.

CONFIDENTIAL

Prepared for: Susan M. Shelby, PhD Sr. Clinical Director and Technical Lead, Atlas Covidien/Mallinckrodt Inc. 675 McDonnell Blvd Hazelwood, MO 63042 Tel: (314) 654-3486 Email: Susan.Shelby@covidien.com Prepared by: Bill W. Massey, Ph.D. 532 South 4th Street, #302 Louisville, KY 40202 Tel: (760) 443-3782 Email: bmassey@bwmassey.com

TABLE OF CONTENTS
1.0. EXECUTIVE SUMMARY...........................................................................................................................3 2.0. REVIEW OF SUPPLIED DATA ON XXXXXX.......................................................................................7 2.1. SCIENTIFIC REVIEW INTRODUCTION...............................................................................................................7 2.1.1. Purpose and Content.......................................................................................................................7 2.1.2. Brief Overview of the Neurobiology of Pain....................................................................................7 2.2. PHARMACOLOGICAL PROFILE OF XXXXXX...............................................................................................10 2.2.1. Mechanism of Action.....................................................................................................................10 2.2.2. Neurochemical Profile..................................................................................................................12 2.2.3. Analgesic Profile...........................................................................................................................15 2.2.4. Abuse Liability Assessment............................................................................................................18 2.2.5. General Pharmacological Profile.................................................................................................20 2.2.6. Pharmacokinetic Profile (Nonclinical)..........................................................................................21 2.3. COMPARATIVE ASSESSMENT OF TRAMADOL.................................................................................................22 2.3.1. Mechanism of Action and Pharmacological Profile......................................................................22 2.3.2. Analgesic Profile...........................................................................................................................23 2.3.3. Tolerance, Dependence, and Abuse Liability Profile....................................................................23 2.3.4. Adverse Effects..............................................................................................................................24 2.3.5. Pharmacokinetic Profile (Nonclinical)..........................................................................................25 2.4. COMPARATIVE ASSESSMENT OF VENLAFAXINE.............................................................................................25 2.4.1. Mechanism of Action and Pharmacological Profile......................................................................25 2.4.2. Analgesic Profile...........................................................................................................................25 2.4.3. Tolerance, Dependence, and Abuse Liability Profile....................................................................26 2.4.4. Adverse Effects..............................................................................................................................26 2.4.5. Pharmacokinetic Profile (Nonclinical)..........................................................................................26 3.0. REGULATORY REVIEW.........................................................................................................................26 3.1. REGULATORY REQUIREMENTS FOR SUPPORT OF AN INVESTIGATIONAL NEW DRUG APPLICATION (IND)...............26 3.1.1. General Principles........................................................................................................................26 3.1.2. Safety Pharmacology.....................................................................................................................27 3.1.3. Toxicokinetic and Pharmacokinetic Studies..................................................................................27 3.1.4. Single Dose Toxicity Studies.........................................................................................................27 3.1.5. Repeated Dose Toxicity Studies.....................................................................................................27 3.1.6. Local Tolerance Studies................................................................................................................27 3.1.7. Genotoxicity..................................................................................................................................27 3.2. REGULATORY ASSESSMENT OF PRECLINICAL PROGRAM AND RECOMMENDATIONS..............................................28 3.2.1. Data Summary...............................................................................................................................28 3.2.2. Assumptions..................................................................................................................................28 3.2.3. Preclinical Program Recommendations........................................................................................29 3.2.4. Formulation Development and Preclinical Manufacture..............................................................31 3.2.5. Toxicology Strategy.......................................................................................................................31 3.2.6. Pharmacology Strategy.................................................................................................................35 3.2.7. Drug Metabolism and Pharmacokinetics......................................................................................37 3.2.8. Investigational Drug Brochure......................................................................................................39 4.0. EVALUATION OF POTENTIAL INDICATIONS FOR XXXXXX....................................................39 4.1. MANAGEMENT OF MODERATE TO MODERATELY SEVERE PAIN.......................................................................39 4.2. MANAGEMENT OF CHRONIC PAIN...............................................................................................................40 4.3. MANAGEMENT OF NEUROPATHIC PAIN........................................................................................................40 5.0. EVALUATION OF POTENTIAL MARKET PENETRATION FOR XXXXXX..............................40

6.0. CLINICAL PROGRAM DESIGN ASSESSMENTS IN APPROPRIATE INDICATIONS: FDA OPINIONS...........................................................................................................................................................42 6.1. GENERAL (ACUTE) PAIN INDICATION..........................................................................................................42 6.1.1. Phase I..........................................................................................................................................42 6.1.2. Phase II.........................................................................................................................................42 6.1.3. Phase III........................................................................................................................................43 6.2. MANAGEMENT OF CHRONIC PAIN...............................................................................................................44 6.3. MANAGEMENT OF NEUROPATHIC PAIN........................................................................................................46 7.0. PRELIMINARY DEVELOPMENT PLAN OUTLINE FOR XXXXXX.............................................50 8.0. REFERENCES.............................................................................................................................................64 9.0. APPENDICES..............................................................................................................................................67 9.1. APPENDIX 1: XXXXXX, TRAMADOL, AND VENLAFAXINE COMPARISON TABLE............................................67 APPENDIX 2: XXXXXX DEVELOPMENT PROGRAM TIMELINES (GANTT CHART).................................................69

1.0.

EXECUTIVE SUMMARY XXXXXX is a centrally-acting non-opioid compound that exhibits analgesic actions in a variety of animal models of nociception. The most robust pharmacological activity produced by XXXXXX is a potent inhibition of monoamine synaptic uptake. XXXXXXs potencies in monoamine uptake inhibition are consistent with those of the tricyclic antidepressants and venlafaxine. XXXXXX, amitriptyline, and venlafaxine affect both norepinephrine and serotonin uptake with relatively similar potencies. Other tricyclics generally exhibit a greater potency difference between serotonin uptake inhibition and norepinephrine uptake inhibition. Tramadol, a currently-marketed opiate analgesic, also produces a similar monoamine uptake inhibition profile in that uptake of serotonin and norepinephrine are affected approximately equally, however, it is much less potent than XXXXXX, amitriptyline, and venlafaxine. Activation of descending noradrenergic pathways has been implicated in the analgesic actions of opiates and tricyclics. Evidence that norepinephrine uptake inhibition and subsequent increases in noradrenergic activity are involved in the analgesic actions of XXXXXX is provided by the findings that yohimbine, an 2 adrenergic receptor antagonist, reverses the analgesia produced by XXXXXX. Further evidence that noradrenergic activation is involved in XXXXXXs analgesic effects comes from the finding that depletion of central norepinephrine by pretreatment with DSP-4, a reserpinelike drug, reverses XXXXXX-produced analgesia. These findings strongly suggest that the norepinephrine uptake inhibition produced by XXXXXX is involved in mediating XXXXXXs analgesic effects. In addition to monoamine uptake inhibition, XXXXXX has exhibited weak binding affinities for dopamine D2 receptors, muscarinic M1 receptors, and and opiate receptors. The significance of these weak binding activities to the analgesic actions of XXXXXX is unknown. XXXXXXs weak binding at and opiate receptors raises the possibility of an interaction at the opiate receptor complex. There is evidence of a functionally-coupled opiate receptor complex (pharmacologically distinct from either receptor when occurring separately) through which pretreatment with agonists potentiate the antinociceptive effects of morphine. This potentiation can be blocked by antagonists. In these experiments, pretreatment with FNA, a antagonist, prevented the agonist-induced potentiation of morphine analgesia. Although there is no direct evidence that XXXXXX interacts at this opiate receptor complex, these results are consistent with effects produced by XXXXXX. There also exists evidence that enhanced release of endogenous opiates may contribute to the analgesic effects of XXXXXX. Administration of a systemically-active enkephalinase inhibitor potentiates XXXXXX-produced analgesia. This suggests that enkephalin release may be involved in XXXXXXs analgesic effects.

Outside of the inhibition of serotonin and norepinephrine uptake, XXXXXX has little activity at other physiological targets. The lack of activity at other physiological targets is consistent with a benign adverse effect profile. The overall findings from the antagonists studies suggest that opiate, noradrenergic, and serotonergic mechanisms underlie XXXXXXs analgesic activity in the PQW model of pain. It is probable that XXXXXX produces component-specific effects that interact to produce analgesia, with some actions potentiating the effects produced from other actions, all of which contribute to the final effect: analgesia. Therefore, it seems likely that XXXXXX produces its analgesia by interacting with multiple targets at multiple levels of the pain modulating system. This could explain why, although XXXXXX has low affinities for opiate receptors, the combined effects on opiate receptors and monoamine uptake result in a strong analgesic effect. The importance of determining XXXXXXs mechanism(s) of action is that it would allow a framework for predicting effectiveness in acute pain versus neuropathic pain. Monoamine uptake inhibition is a sufficient mechanistic basis for predicting efficacy in neuropathic pain, however, it is not sufficient for predicting efficacy in acute pain. The potential utility of XXXXXX in the treatment of acute pain is not strongly supported by its preclinical profile. Although XXXXXXs is effective in animal models of analgesia that intuitively resemble acute pain, these models have produced false positive results for the tricyclic antidepressants, with which XXXXXX shares biochemical mechanisms. However, the evidence suggests that there may be effects on the endogenous opiate systems that would support a mechanism for efficacy in acute pain. It is possible that the opiate-like effects of XXXXXX are the result of increased enkephalin and/or endorphin activity, interaction with the opiate receptor complex, or a combination of such effects. Additional animal studies could provide more direct evidence of endogenous opiate activity, however, the determination of efficacy in acute pain will require clinical investigation. If XXXXXX is proven effective in acute pain, then it should also be effective in chronic pain. Even if XXXXXX does not show efficacy in acute pain, its monoamine uptake inhibition properties may prove useful as an adjunctive therapy in a chronic pain treatment regimen. As monotherapy, XXXXXX would have some advantages over currently used analgesics in the treatment of chronic pain (lack of abuse liability, lack of physical dependence, lack of tolerance, potentially greater efficacy than NSAIDS and tramadol, antidepressant activity). The pharmacological profile of XXXXXX strongly supports its potential in the management of neuropathic pain. It has balanced inhibition of serotonin and norepinephrine uptake, similar to the tricyclics, as well as potential enhancement of endogenous opiate activity via direct and/or indirect mechanisms. The monoamine uptake inhibition is sufficient for predicting activity in neuropathic pain. If the enhancement of endogenous opiate activity is robust enough to contribute to XXXXXXs clinical analgesic efficacy, then it may prove to be superior to currently employed treatment regimens. The FDA is interested in the development of drugs for neuropathy

and has indicated a willingness to approve a neuropathic pain indication if certain criteria are met. XXXXXX has been thoroughly examined in animal models predictive of abuse liability. The data suggest that XXXXXX would not have significant abuse liability and has little likelihood of being scheduled under the U.S. Controlled Substances Act or being subject to similar restrictions in other countries. The need to conduct human drug discrimination studies should be discussed with FDA at a pre-IND meeting, however, such studies may not be warranted. Included in this report is a preliminary development plan for XXXXXX. The overall goal of the proposed program is to provide XXXX with sufficient clinical efficacy and safety information for the successful submission of a NDA. Obtaining a broad characterization of the efficacy and safety of XXXXXX in Phase II, including doseresponse relationships, dosing intervals, and pain model specificities, will greatly streamline the requirements for numbers of doses and indications to be evaluated in the more expensive Phase III investigations. This program design has been constructed to reduce risks for XXXX, while balancing speed of development with a logical progression of clinical investigations. The programs initial focus is on conducting the required preclinical toxicology to enable a Phase I evaluation in the U.K. The Phase I program consists of two trials, a single ascending dose study in young healthy volunteers and a multiple dose study in young healthy volunteers. Although not included in this preliminary development plan, additional pharmacokinetic evaluations in special populations will undoubtedly be conducted later in the development program if initial clinical efficacy determinations are positive. Based upon its preclinical pharmacological profile, there is potential for XXXXXX to have clinical utility in the treatment of acute pain, chronic pain, and neuropathic pain. The evidence is strongest for potential in the treatment of neuropathic pain. However, since animal models of pain provide no clear predictability for responsiveness of pain from differing etiologies, and the larger market for general pain indications, XXXXXX will be evaluated in both acute pain and neuropathic pain in Phase IIa. The results of these trials will provide a basis for deciding whether to further pursue these indications. By running these two Phase IIa trials in parallel, XXXX can evaluate efficacy in acute pain prior to completion of the initial efficacy determination in neuropathic pain. If XXXXXX is not effective in the treatment of acute pain, then it is highly doubtful that it would be effective as monotherapy in the treatment of chronic pain. However, due to its monoamine uptake blocking ability, XXXXXX may prove useful as adjunctive therapy in the treatment of chronic pain in a manner similar to the tricyclic antidepressants. This preliminary development plan does not cover chronic pain as a potential indication for XXXXXX. The reasons for this are: 1) FDA has expressed reluctance to grant an indication for chronic pain; and 2) chronic trials can be added after demonstration of efficacy in acute pain.

Following the Phase IIa trials, the program evaluates initial efficacy in additional clinical pain models in either neuropathic pain or acute pain, dependent upon the results of the Phase IIa trials. These trials will provide the information needed to optimize the design of the Phase III therapeutic confirmatory trials. By running the neuropathic pain and acute pain trials in parallel, XXXX would cut development time and maximize the potential indications and market potential of XXXXXX. If XXXXXX is not found to be efficacious in one of these indications (neuropathic or acute pain), then that component of the program can be discontinued without adversely affecting development time for the remaining indication. The strategy of running as many trials as possible in parallel is more aggressive, but will enable XXXX to make decisions regarding the viability of XXXXXX more quickly, potentially saving a significant amount of money that might otherwise be invested in fruitless investigation. After determination of initial efficacy in acute pain (Third Molar Extraction), the acute pain Phase II program would proceed to evaluate single doses of XXXXXX in two additional clinical models of acute pain: Abdominal Hysterectomy, and Arthroscopic Knee/Elbow Surgery. Also to run in parallel is a multiple dose study (3-day duration) examining XXXXXX in abdominal hysterectomy. The Phase III program in acute pain would consist of therapeutic confirmatory studies in the three clinical models explored in Phase II (abdominal hysterectomy, third molar extraction, and arthroscopic knee/elbow surgery) and an additional model, episiotomy. It is important to evaluate XXXXXX in a variety of clinical pain models since the severity of pain and responsiveness to analgesics varies between models, and since an analgesic will be used across a spectrum of clinical settings once it reaches the market. The program will expose a sufficient number of patients to XXXXXX to satisfy FDA requirements for a clinical safety database. A development program similar in strategy and structure has been included for pursuing an indication for neuropathic pain. If the initial Phase IIa investigation in diabetic neuropathy pain is positive, then an additional Phase II trial in post-herpetic neuralgia would be conducted. This patient population was selected based on the similar responsiveness of post-herpetic neuralgia to antidepressant therapy as found in diabetic neuropathy. The Phase III therapeutic confirmatory program for neuropathic pain would incorporate the neuropathic pain models employed in Phase II (diabetic neuropathy and post-herpetic neuralgia) and also a study examining radicular neuropathic pain. FDA has indicated that a general neuropathic pain indication would require proof of efficacy in radicular pain. In the plan, this is referred to as a Phase IIIb program since the acute pain NDA would be filed and approved prior to completion of the neuropathic pain confirmatory trials. As with the acute pain program, this plan provides sufficient number of patients exposed to XXXXXX to fulfill FDA requirements for a clinical safety database. Upon completion of this program, an SNDA could be filed for a neuropathic pain indication.

2.0. 2.1. 2.1.1.

REVIEW OF SUPPLIED DATA ON XXXXXX Scientific Review Introduction Purpose and Content The purpose of this report is to provide an assessment of the therapeutic potential of XXXXXX in pain management. The assessment considered the known pharmacology of XXXXXX, the basic science involved in pain processing, the pharmacology of comparative agents with relevant mechanisms of action, the potential for abuse liability, and current pain management strategies. This report also provides recommendations for additional preclinical testing (toxicological and pharmacological), potential therapeutic indications, and a preliminary clinical development plan. The assessment and recommendations for future development are based on information provided by XXXX XXXXXXXXXXXX, Inc., FDA guidelines for the development of analgesic drugs, transcripts from FDA advisory committee meetings, and information contained in the published scientific literature. Brief Overview of the Neurobiology of Pain The treatment of acute and chronic pain presents a variety of challenges for the medical profession. The multitude of neurotransmitter systems involved in pain processing, the variety of pain etiologies, and the relative paucity of therapeutic options contribute to the unmet needs of pain management. The most common classes of analgesics, the opiates and the NSAIDs, are limited in utility by serious adverse effects and abuse liability. The complexity and diversity in pain etiologies have resulted in much variability in responsiveness to therapeutic pain management and have spurred off-label use of a number of drugs with quite varied mechanisms of action. Of particular utility has been the use of antidepressant medications in the treatment of chronic pain syndromes (e.g., diabetic neuropathy) that do not respond well to traditional analgesics. Before proceeding to an assessment of the therapeutic potential of XXXXXX, a brief overview of the neurobiology of pain will be provided in order to establish a conceptual framework for potential targets for pharmacological intervention. First, a distinction should be made between pain and nociception. Pain is the perception of an aversive or unpleasant sensation that originates from a specific region of the body. Nociception refers to the reception of signals evoked by activation of specialized sensory receptors (nociceptors) that provide information about tissue damage. Not all nociception is experienced as pain. The signal evoked from nociceptor stimulation is modulated and processed via a number of mechanisms prior to perception, and these modulatory influences greatly impact the perception of pain (Jessell and Kelly, 1991). These various modulatory processes on the nociceptive signal offer multiple potential targets for therapeutic intervention. The nociceptive signals evoked as a result of noxious stimuli are conveyed to the CNS by several classes of nociceptive afferent nerve fibers. Thermal or mechanical nociceptors conduct the nociceptive stimulus via small-diameter, thinly myelinated A fibers at a speed of 5 to 30 m/s. These fibers are associated with the sensation of sharp, pricking

2.1.2.

pain. Polymodal nociceptors are activated by high-intensity mechanical, chemical, or thermal stimuli and are conveyed via small-diameter, unmyelinated C fibers that propagate the signal slowly at a rate of 0.5 to 2 m/s. Both A and C fibers are widely distributed in skin and deep tissues. Upon entering the spinal cord, both A and C fibers bifurcate and the resulting branches ascend and descend for a few segments before terminating with neurons of the spinal cord dorsal horn. At this level the afferent nociceptive fibers release the neuropeptide transmitters glutamate and substance P (Jessell and Kelly, 1991). Glutamates actions at the dorsal horn probably underlies the neuroplasticity that contributes to chronic pain through a mechanism similar to long-term potentiation, while substance P contributes to the propagation of ascending neural impulses that are perceived as pain (Rowbotham, 1995). Tissue damage can sensitize these afferent nociceptive fibers to subsequent noxious stimuli, resulting in an exaggerated response known as hyperalgesia. This sensitization is the result of the release of chemical mediators originating from the damaged tissue or nearby nerve terminals. For example, tissue injury releases bradykinin and prostaglandins, both of which activate and sensitize nociceptors. The subsequent activation of nociceptors leads to the release of substance P. Substance P acts on nearby mast cells to produce the release of histamine which directly stimulates nociceptors. Substance P also dilates peripheral blood vessels causing the further release of bradykinin. Bradykinin, in addition to directly activating nociceptors, increases the synthesis and release of prostaglandins from nearby cells. Aspirin and the NSAIDs are effective in alleviating the pain associated with tissue injury due to their ability to inhibit cyclo-oxygenase, a key enzyme in prostaglandin synthesis. Other substances that contribute to the pain associated with tissue injury are serotonin, ATP, acetylcholine, and potassium (Jessell and Kelly, 1991). In summary, there are a number of interacting modulatory mechanisms that influence nociception and the signals that are then perceived as pain. Not all pain arises from nociceptor activation. The main types of non-nociceptor-related pain are central pain and neuropathic pain of peripheral origin. Central pain results from an injury to the CNS, with roughly 90% of cases being the result of stroke (Gonzales, 1995). Due to the small market potential and refractoriness of central pain, it is not an attractive potential indication for XXXXXX. Since central pain is not a primary potential indication for XXXXXX, the specifics of this pain syndrome will not be described further in this report. However, neuropathic pain is a primary potential indication for XXXXXX and will be explored in some detail. Neuropathic pain is a term used to describe a variety of pain syndromes, which share as a common causal factor, injury to peripheral nerve(s). Various pathophysiological processes may generate and maintain the pain produced by nerve injury. No one mechanism may be disease-specific, and multiple mechanisms may be involved in any given disease. Therefore, in any individual patient, one or more mechanisms may be responsible for their pain. This heterogeneity within neuropathic syndromes may explain why only a subset of patients within each diagnostic category responds to a particular drug (Galer, 1995).

Following peripheral nerve injury, all levels of the nervous system (peripheral, central, and autonomic) can contribute to the generation and maintenance of chronic pain states. An important site for pain modulation is at the level of the spinal cord, especially the spinal cord dorsal horn. Damage to the afferent nerve fibers can result in hyperactivity of dorsal horn neurons resulting in the perception of pain. Thus, pain can arise from the level of the spinal cord dorsal horn in the absence of nociceptive afferent input (Jessell and Kelly, 1991). Regardless of whether the neural impulses arise from nociceptor stimulation or are neuropathic in origin, the signals must reach the brain for processing into the perception of pain. These impulses travel from the spinal cord dorsal horn through projection neurons that terminate in the midbrain. The most prominent of these groups of ascending projection neurons is the spinothalamic tract. These neurons terminate in the contralateral thalamus. The thalamus then directs the impulses to the cortex where they are processed and perceived as pain. It is also important to note that nociceptive impulses can be modulated at successive synaptic relays along the route to the thalamus. The cortical processing of nociceptive input is not clearly understood (Jessell and Kelly, 1991). Once the nociceptive stimulus is processed by the cortex, descending neural tracts can be activated which have modulatory actions resulting in analgesia. Opiates produce their analgesic activity by activating these descending pain modulatory pathways (Jessell and Kelly, 1991). Opiates and the endogenous opioid peptides bind to and activate specific populations of brain receptors that can be classified as , , and opiate receptors. In addition, apart from occurring as separate entities, brain and receptors have been observed to function as a receptor complex, with a different binding profile than when found individually. Opiate analgesics produce their analgesic effects through agonist actions at receptors. The endogenous opiates are classified into three families based upon their progenitor protein precursor; -endorphin, enkephalins, and dynorphins. There appears to be preferential binding to opiate receptor subtypes among the endogenous opiates with endorphin having greatest affinity for , enkephalins for , and dynorphins for . These endogenous opiates are distributed throughout brain areas and pathways involved in pain modulation (Van Ree et al., 1999). Opiate receptors are found widely distributed throughout the central nervous system, indicating that they are also involved in physiological functions other than pain modulation (Jessell and Kelly, 1991). Opiates and endogenous opiates modulate pain through the activation of descending monoaminergic pathways, a serotonergic pathway originating from the rostroventral medulla and a noradrenergic pathway originating from the pons. These monoamine pathways terminate in the spinal cord dorsal horn. Opiate activation of these monoaminergic pathways suppresses the activity of interneurons that release GABA and normally inhibit the activity of the descending tracts. Thus, opiates activate the descending monoaminergic tracts through a disinhibition mechanism (Jessell and Kelly, 1991).

The descending monoaminergic tracts synapse with dendrites of the ascending spinothalamic neurons and with enkephalin-containing interneurons in the dorsal horn. The superficial dorsal horn contains a high density of enkephalin- and dynorphincontaining interneurons located in close proximity to the terminals of nociceptive afferents and to dendrites of dorsal horn neurons that receive afferent nociceptive input, both of which express opiate receptors. Opiates and opioid peptides, through activation of opiate receptors, decrease Ca2+ entry into the presynaptic sensory nerve terminals, thereby inhibiting the release of glutamate and substance P from these presynaptic terminals. Opiates also act post-synaptically at afferent synapses to suppress the activity of nociceptive dorsal horn neurons. Thus, opiates modulate nociceptive transmission through both pre-synaptic and post-synaptic mechanisms at the level of the primary afferent synapse and reinforces the hypothesis that opiate analgesia results from actions at distinct neural locations on multiple levels within the central nervous system (Jessell and Kelly, 1991). 2.2. 2.2.1. Pharmacological Profile of XXXXXX Mechanism of Action XXXXXX is a centrally-acting non-opioid compound that exhibits analgesic actions in a variety of animal models of nociception. The most robust pharmacological activity produced by XXXXXX is a potent inhibition of synaptic monoamine uptake. In rat brain synaptosomal preparations, XXXXXX inhibited the uptake of serotonin (IC50= 120 nM) and norepinephrine (IC50= 223 nM), demonstrating a 2-fold potency difference in favor of serotonin. Dopamine uptake is not affected by XXXXXX at concentrations exceeding 10,000 nM. XXXXXXs potencies in monoamine uptake inhibition are consistent with those of the tricyclic antidepressants and venlafaxine. XXXXXX, amitriptyline, and venlafaxine affect both norepinephrine and serotonin uptake with relatively similar potencies. Other tricyclics generally exhibit a greater potency difference between serotonin uptake inhibition and norepinephrine uptake inhibition. Based upon the monoamine uptake inhibition profile, XXXXXX would have approximately equal effects (<2-fold difference in potency) on both serotonin and norepinephrine neurotransmission for a given dose. Tramadol, a currently-marketed opiate analgesic, also produces a similar monoamine uptake inhibition profile in that uptake of serotonin and norepinephrine are affected approximately equally, however, it is much less potent than XXXXXX, amitriptyline, and venlafaxine. In vivo evidence of inhibition of monoamine uptake is provided by XXXXXXs ability to reverse tetrabenezine-induced ptosis in mice. Tetrabenezine depletes central stores of norepinephrine and serotonin, and is similar to reserpine. The rank order of potency of compounds (tricyclics) that reverse ptosis correlates with their potency at inhibiting norepinephrine uptake in vitro. Further evidence of noradrenergic activation is the observation of XXXXXX-induced mydriasis in mice that can be reversed by administration of the 1 noradrenergic receptor antagonist, prazosin. The possibility that anticholinergic mechanisms underlie XXXXXX-induced mydriasis is discounted by the findings that XXXXXX doesnt bind with appreciable affinity to cholinergic muscarinic receptors and that the effect is not reversed by administration of the muscarinic agonist,

10

pilocarpine. Evidence that norepinephrine uptake inhibition and subsequent increases in noradrenergic activity are involved in the analgesic actions of XXXXXX is provided by the findings that yohimbine, an 2 adrenergic receptor antagonist, reverses the analgesia produced by XXXXXX. Additional evidence of noradrenergic involvement in XXXXXX-induced analgesia is the finding that prazosin, an 1 adrenergic antagonist, potentiates XXXXXX-induced analgesia. In a like manner, yohimbine antagonized the analgesia produced by tramadol but not the analgesia produced by morphine in a rat tailflick assay (Raffa et al., 1992). Further evidence that noradrenergic activation is involved in XXXXXXs analgesic effects comes from the finding that depletion of central norepinephrine by pretreatment with DSP-4, a reserpine-like drug, reverses XXXXXXproduced analgesia. These findings strongly suggest that the norepinephrine uptake inhibition produced by XXXXXX is involved in mediating XXXXXXs analgesic effects. In addition to monoamine uptake inhibition, XXXXXX has exhibited weak binding affinities for dopamine D2 receptors, muscarinic M1 receptors, and opiate receptors (% inhibition of binding at 10,000nM = 79%, 47%, and 60%, respectively). In a study examining the displacement of tritiated etorphine (a potent opiate receptor agonist) (XXX et al., 1992), XXXXXX weakly displaced etorphine binding (EC50= 10,303 nM). However, in other studies examining XXXXXX binding at opiate receptors, XXXXXX was determined to be inactive at and opiate receptors. There are several factors that could explain the discrepancies between laboratories with regard to XXXXXX binding at opiate receptors that are listed in the following section of this report entitled Neurochemical Profile. In concordance with XXXXXXs weak displacement of etorphine binding, XXXXXX was a weak inhibitor of electrically-induced contractions of isolated mouse vas deferens (EC50= 10,421 nM, 83.4% maximal response). XXXXXXs inhibition of electricallyinduced vas deferens contraction was reduced by addition of the receptor antagonist naltrexone, however, there was no rightward-shift of the dose-response curve, indicating that the antagonism was not of a competitive nature. Neither the receptor antagonist, ICI 174864, nor the receptor antagonist, binaltorphimine, altered responses to XXXXXX in the mouse vas deferens preparation. Likewise, XXXXXX did not antagonize the actions of , , or opiate receptor agonists (sufentanil, U-50,488, and DSLET, respectively) (XXX et al., 1992). XXXXXXs weak binding at and opiate receptors raises the possibility of an interaction at the opiate receptor complex. There is evidence of a functionallycoupled opiate receptor complex (pharmacologically distinct from either receptor when occurring separately) through which pretreatment with agonists potentiate the antinociceptive effects of morphine (Heyman et al., 1989). This potentiation can be blocked by antagonists. In these experiments, pretreatment with FNA, a antagonist, prevented the agonist-induced potentiation of morphine analgesia. Although there is no direct evidence that XXXXXX interacts at this opiate receptor complex, these results are consistent with effects produced by XXXXXX. For example, antagonists have been shown to antagonize XXXXXX-produced analgesia and peripheral administration of

11

FNA also antagonizes XXXXXX-produced analgesia. Thus, it cannot be ruled out that XXXXXX produces some of its analgesia via interaction at this opiate receptor complex. The discriminative stimulus properties of a drug in animals are indicative of its subjective effects in humans and can provide insight into its mechanism of action. In an evaluation of the potential opiate-like discriminative stimulus effects of XXXXXX in rhesus monkeys, XXXXXX (at high doses, 5.6 mg/kg and 10 mg/kg) generalized to the discriminative stimulus produced by the agonist ethylketocyclazocine. XXXXXX failed to generalize (at doses up to 10 mg/kg) to the discriminative stimulus produced by the receptor agonist, alfentanil. In morphine-treated rhesus monkeys, XXXXXX did not substitute for naltrexone. Thus, with regard to opiate-like discriminative stimulus effects, XXXXXX had no receptor agonist or antagonist activity, but did exhibit receptor agonist activity at high doses. There also exists evidence that enhanced release of endogenous opiates may contribute to the analgesic effects of XXXXXX. Administration of SCH-34,826, a systemically-active enkephalinase inhibitor, potentiates XXXXXX-produced analgesia. This suggests that enkephalin release may be involved in XXXXXXs analgesic effects since SCH-34,826 would increase the levels of released enkephalins by inhibiting the rapid degradation of enkephalins by enkephalinase. However, due to a lack of information regarding the methodology under which potentiation of XXXXXX-produced analgesia was determined and the analgesic activity of SCH-34,826, it is uncertain whether this is an actual potentiation of XXXXXX analgesia or simply an additive interaction (Chipkin et al., 1988). As there are multiple plausible mechanisms for enhancing the release of endogenous opiates, it is not possible to determine how XXXXXX may induce their release based on the currently available data. In summary, XXXXXX potently inhibits the uptake of serotonin and norepinephrine. There is also evidence of either weak direct or indirect opiate activity, however, this activity is difficult to interpret relative to known standards of reference. The importance of determining the mechanism(s) of action is that it would allow a framework for predicting effectiveness in acute pain versus neuropathic pain. Monoamine uptake inhibition is a sufficient mechanistic basis for predicting efficacy in neuropathic pain, however, it is not sufficient for predicting efficacy in acute pain. It is possible that the opiate-like effects of XXXXXX are the result of increased enkephalin and/or endorphin activity, interaction with the opiate receptor complex, or a combination of such effects. Additional animal studies could provide more direct evidence of endogenous opiate activity, however, the determination of efficacy in acute pain will require clinical investigation. 2.2.2. Neurochemical Profile As discussed in the previous section, the most prominent neurochemical actions of XXXXXX are its potent inhibition of serotonin and norepinephrine uptake. These effects result in increased serotonergic and adrenergic activity which have been implicated in the 12

modulation of pain. The possible contribution of these effects to the analgesia produced by XXXXXX will be discussed in the section profiling XXXXXXs analgesic activity. The following table lists the relative potencies for serotonin and norepinephrine uptake inhibition produced by XXXXXX and relevant comparators. RELATIVE SEROTONIN (5-HT) AND NOREPINEPHRINE (NE) UPTAKE INHIBITION COMPOUND XXXXXX Amitriptyline Chlorimipramine Desipramine Tramadol Venlafaxine 5-HT UPTAKE INHIBITION IC50 (nM) 120 140 22 900 40,500 210 NE UPTAKE INHIBITION IC50 (nM) 223 56 127 18 13,800 640 5-HT/NE INHIBITION RATIO 1.85 0.40 5.77 0.02 0.34 3.05

The 5-HT/NE ratio is a measure of relative potency for inhibiting 5-HT and NE. If the compound were equally potent at both 5-HT and NE, the ratio would equal 1. Values greater than 1 indicate a preferential potency for 5-HT uptake inhibition, whereas values less than 1 indicate a preferential inhibition of NE uptake. The magnitude of the variance from 1 is a measure of the degree of selectivity.

Of the compounds listed, XXXXXX produces the most non-selective inhibition of serotonin and norepinephrine uptake. Amitriptyline, tramadol, and venlafaxine possess similar non-selectivity, however, tramadol is much less potent. Enhancing the activity of both transmitters may be advantageous for analgesic effects since both neurotransmitter systems play a role in the modulation of pain. For example, the use of serotonin selective reuptake inhibitors (SSRIs) in pain management has not proven to be as effective as the tricyclic antidepressants. Anecdotal reports have indicated that the addition of SSRIs to the tricyclic regimen have been helpful in some cases of chronic pain. Altogether, these findings suggest that inhibition of both serotonin and norepinephrine uptake may be more effective in pain management than either alone. The table below is a composite of the receptor binding and enzyme inhibition profiles obtained for XXXXXX. The receptor binding profile of XXXXXX suggests that XXXXXX does not affect a broad range of neurochemical, inflammatory, and second messenger targets. There has been some discrepancy between the receptor binding profiles for XXXXXX obtained from different laboratories. The probable reasons for these discrepancies are different reference ligands, different cut-off points for activity determinations, and different substrate preparations.

13

COMPOSITE RECEPTOR BINDING PROFILE OF XXXXXX TARGETED BINDING SITES Opiate Receptor Opiate Receptor D2 Dopamine Receptor M1 Cholinergic Receptor Adenosine 1 Receptor Adenosine 2 Receptor 1 Adrenergic Receptor Adrenergic Receptor Glycine (Excitatory) Receptor Quisqualate Receptor Kainate Receptor NMDA Receptor PCP Receptor Glycine (Inhibitory) Receptor GABAA Receptor GABAB Receptor Benzodiazepine Receptor D1 Dopamine Receptor 5-HT1 Serotonin Receptor 5-HT2 Serotonin Receptor H1 Histamine Receptor Nitrendipine Receptor (Ca++ Channel) Diltiazem Receptor (Ca++ Channel) Omegaconotoxin Receptor (Ca++ Channel) M2 Cholinergic Receptor Nicotinic Cholinergic Receptor Opiate Receptor Receptor Leukotriene B4 Receptor Leukotriene D4 Receptor Thromboxane A2 Receptor Adenylate Cyclase Forskolin Protein Kinase C Phorbol Ester Estrogen (Estradiol) Receptor BINDING ACTIVITY Weak Activity (EC50 = 10.3 M) Weak Activity (60% inhibition at 10 M) Weak Activity (79% inhibition at 10 M) Weak Activity (47% inhibition at 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M) Inactive (IC50 > 10 M)

14

The above profile shows that outside of the inhibition of serotonin and norepinephrine uptake, XXXXXX has little activity at other physiological targets. The weak activity at D2 dopamine receptors and M1 cholinergic receptors is most probably not pharmacologically relevant. The weak activity at and opiate receptors may have some relevance since there is evidence for a opiate receptor complex that is distinct from the individual and opiate receptors. However, it is not feasible to accurately predict the clinical relevance of this weak opiate receptor binding using the currently available data. The relatively selective actions of XXXXXX would support the prediction that XXXXXX will have a benign side-effect profile at analgesic doses. 2.2.3. Analgesic Profile The analgesic efficacy of XXXXXX has been examined in a number of animal models of nociception. XXXXXX has demonstrated analgesic efficacy in the mouse, rat, dog, and rhesus monkey. Individual findings from these tests and their relevance are discussed below. In the phenylquinone writhing test (PQW), a model of chemically-induced pain, XXXXXX was moderately potent as an analgesic in both rat and mouse (ED50 = 7.9 mg/kg, p.o. and ED50 = 18 mg/kg. p.o., respectively). In the incremental dose PQW test, which evaluates the analgesic efficacy of a drug as a function of pain intensity (low PQW dose = mild pain, high PQW dose = moderately-severe pain), XXXXXX exhibited moderate to strong analgesic efficacy. These effects are similar to those observed with codeine since, like codeine, XXXXXX retained nearly full potency against the severe pain produced by the high dose of phenylquinone. The ratio of XXXXXX ED50s for mild PQW pain and moderately-severe PQW pain is quite low, indicating that the doses required for relief of severe pain are not much greater than those required for relief of mild pain (XXXXXX Ratio = 2.3, mouse). This ratio value is similar to that of the strong opiate analgesics, codeine and meperidine, whose ratio values are 1.9 and 2.0 respectively. Similar results were obtained in the rat. Less efficacious analgesics require much higher doses for relief of severe pain as compared to those required for relief of mild pain, resulting in much greater ED50 ratios in this assay. XXXXXX has a rapid onset of action and a longer duration of action than codeine in this assay in the mouse (XXXXXX single dose duration of action = 72 minutes, p.o. versus codeine = 20 minutes, p.o.) and in the rat (XXXXXX single dose duration of action = 215 minutes, p.o. versus codeine = 80 minutes, p.o.). Thus, in the PQW assay, XXXXXX exhibited a highly efficacious and long-acting analgesic profile, comparable to that of opiate receptor agonists, but with a longer duration of action. The use of selective antagonists for a multitude of neurochemical target receptors can be useful in elucidating the mechanism(s) of action of a drug. A number of antagonists at various neurochemical receptors were examined for their effect on XXXXXX-produced analgesia in the PQW assay. Low doses of naloxone (this dose should produce significant receptor blockade) produced only a weak antagonism of XXXXXX15

produced analgesia. High doses of naloxone (this dose should produce significant , , and receptor blockade) significantly antagonized XXXXXX-produced analgesia. This indicates that multiple subtypes of opiate receptors may be involved in mediating the antinociceptive effects of XXXXXX, which is consistent with other aspects of XXXXXXs profile. As stated previously, the antagonist FNA antagonizes XXXXXX-produced analgesia when administered peripherally but not when administered centrally (i.c.v.), suggesting that peripheral activation of receptors is involved in XXXXXXs analgesic actions. The non-selective receptor antagonist, naltrindol, antagonized XXXXXXs analgesic effects, suggesting that either XXXXXX binding at receptors or enkephalins are involved in mediating XXXXXXs analgesia. This is consistent with the finding, previously described, that peripheral enkephalinase inhibitors potentiate XXXXXX-produced analgesia. These findings, when taken altogether, suggest that the opiate component of XXXXXX-produced analgesia is mediated by interactions at peripheral sites. However, a central opiate mechanism cannot be ruled-out based on the existing data. The effects of noradrenergic antagonists on XXXXXX-produced analgesia in the PQW assay were interesting in that, depending upon the antagonist and its target, either potentiation or antagonism was observed. The 1 adrenergic receptor antagonist, prazosin, and the non-selective adrenergic receptor antagonist, propanolol, potentiated the analgesic effects of XXXXXX. In contrast, the 2 adrenergic receptor antagonist, yohimbine, and the norepinephrine-depleting agent, DSP-4, antagonized XXXXXXs analgesic effects. These results strongly implicate a major role for noradrenergic modulation in the production of XXXXXXs analgesic actions. The serotonergic antagonists, methylsergide (non-selective), ketanserin (5-HT2 selective), and ICS 205-930 (5-HT3 selective) were examined for their ability to modulate XXXXXX-produced analgesia in the PQW assay. Methylsergide did not affect XXXXXX-produced analgesia, however, both ketanserin and ICS 205-930 potentiated XXXXXXs analgesic effects. This is in stark contrast to the effects of serotonergic antagonists on morphine-produced analgesia. Both ketanserin and ICS 205-930 (as well as other serotonergic antagonists) have been shown to antagonize morphine-produced analgesia (Paul et al., 1988, Crisp et al., 1991). These findings suggest a role for the serotonergic system in modulating XXXXXX-produced analgesia that is different than the serotonergic role in modulating morphine-produced analgesia. The overall findings from the antagonists studies suggest that opiate, noradrenergic, and serotonergic mechanisms underlie XXXXXXs analgesic activity in the PQW model of pain. It is probable that XXXXXX produces component-specific effects that interact to produce analgesia, with some actions potentiating the effects produced from other actions, all of which contribute to the final effect: analgesia. Therefore, it seems likely that XXXXXX produces its analgesia by interacting with multiple targets at multiple levels of the pain modulating system. This could explain why, although XXXXXX is weak at binding to opiate receptors, the combined effects on opiate receptors and monoamine uptake result in a strong analgesic effect.

16

In addition to its effects in the PQW test, XXXXXX exhibited potent analgesic effects in the electrical stimulation dental pain test in the rat, the dog tooth pulp stimulation test, and in the Randall-Selitto test (ED50 = 19 mg/kg; ED50 = 1.6 mg/kg; and ED50 = 32 mg/kg, respectively). In the Randall-Selitto test, XXXXXX was equally potent on both the inflamed and non-inflamed paw. The lack of effect of XXXXXX on mediators of inflammation suggests that XXXXXXs analgesia on the inflamed paw in the RandallSelitto test is not due to inhibition of inflammatory processes, but rather due to a direct antinociceptive effect. XXXXXX is not as potent or effective in alleviating radiant heat-induced pain as it is in the PQW test. XXXXXX shows analgesic activity in the mouse tail-flick assay (ED50 = 117 mg/kg) but is inactive in the rat tail-flick assay. In studies conducted by the Drug Evaluation Committee of the College on the Problems of Drug Dependence (XXX et al., 1992), similar effects were observed: XXXXXX was inactive in the mouse tail-flick and mouse hot-plate assay and effective in the PQW assay (ED50 = 5.4 mg/kg). XXXXXX was examined for analgesic efficacy in the rhesus monkey tail-flick assay (XXX et al., 1992). In this assay, monkeys have their tails placed into 50o C and 55o C water and the latency to remove their tails from the water is an indication of analgesia. The longer the latency the greater the analgesia. This assay also allows for graded assessment of analgesic efficacy since the two water temperatures are indicative of two levels of pain. XXXXXX (10 mg/kg) produced the maximal analgesic effect possible (100%, latency > 20 seconds) in 50o C water and a substantial effect (79% of maximum effect, 32 mg/kg) in 55o C water. XXXXXX-produced analgesia in the 55o C water could be completely antagonized by high doses of quadazocine, suggesting the involvement of opiate receptors. As stated previously in the report, XXXXXX produced discriminativestimulus effects like those of the opiate receptor agonist, ethylketocyclazocine. Together these findings implicate receptor-mediated effects of XXXXXX in thermalinduced nociception. It is important to note that in the PQW chemically-induced pain model, antagonists did not antagonize XXXXXX-produced analgesia. Thus, the involvement of receptor-mediated effects in the analgesic actions of XXXXXX may be dependent upon the type of nociceptive stimulus. The development of tolerance is a challenge to the treatment of chronic pain with opiates. Development of a strong analgesic that does not result in tolerance development would be a significant improvement for the management of chronic pain. A lack of tolerance development is also indirect evidence against the development of physical dependence since tolerance and dependence result from adaptive changes caused by the same exposure. Repeated administration of 5-fold greater than analgesic ED50 doses of XXXXXX did not result in tolerance development to the analgesic actions of XXXXXX. Equi-analgesic doses of codeine in this study did result in tolerance development. XXXXXX is fully cross-tolerant to morphine in morphine-dependent mice. However, it should not be assumed that this asymmetrical cross-tolerance is evidence of direct receptor agonism, since similar cross-tolerance was observed with the monoamine uptake inhibitor, nomifensine. This suggests that monoamine uptake inhibition produces antinociception through indirect opioid mechanisms.

17

In summary, the analgesic profile of XXXXXX indicates that it is a potent and effective orally-active analgesic for moderate to moderately-severe pain. Data from mouse, rat and monkey studies indicate that XXXXXX is less effective in protecting against heatinduced pain, however, the clinical relevance of this is not known. Antagonists studies have indicated that the analgesic effects are the result of monoaminergic uptake inhibition and/or either direct or indirect opiate mechanisms. The exact mechanisms underlying these analgesic effects and their interplay in producing XXXXXXs analgesic effects has yet to be elucidated. 2.2.4. Abuse Liability Assessment The potential for drug abuse is a major obstacle in the clinical use of opiates. The social stigma surrounding the drug abuse issue has resulted in a reluctance to fully utilize the potent analgesic actions of opiates (underdosing) and the subsequent needless suffering of many pain patients (Cohen, 1980). In a study examining 12,000 patients who had received narcotics for acute pain, only 4 cases of medically-induced dependence were identified (Porter and Jick, 1980). A strong analgesic without dependence-producing properties would have a major impact on the clinical management of pain. XXXXXX has been thoroughly examined in animal models predictive of abuse liability. The data suggest that XXXXXX would not have significant abuse liability and has little likelihood of being scheduled under the U.S. Controlled Substances Act or being subject to similar restrictions in other countries. These data are summarized in the remainder of this section. Physical Dependence XXXXXX has been examined in a number of assays predictive of physical dependenceproducing properties. In a primary dependence study, mice were administered XXXXXX via 72-hour continuous infusion (34 mg/kg/hr) and observed for signs of withdrawal following cessation of XXXXXX administration. Cessation of XXXXXX administration resulted in jumping responses, but autonomic signs and weight loss characteristic of opiate withdrawal were not observed. Other monoamine uptake inhibitors examined in this study also produced similar jumping responses. It is important to note that the number of jumping responses observed following cessation of monoamine uptake inhibitor administration were much fewer than observed following cessation of opiate administration. Also, autonomic withdrawal signs were observed in mice following cessation of chronic morphine administration, whereas with XXXXXX no such signs were noted. In another study examining the primary physical dependence-producing properties of XXXXXX, rats were administered XXXXXX according to the following dosing regimen: Day 1, 25 mg/kg/day; Day 2, 50 mg/kg/day; Day 3, 100 mg/kg/day; Days 4-6, 200 mg/kg/day; Days 7-9, no drug administered (withdrawal period). Following cessation of XXXXXX administration, some opioid-like physical dependence signs were observed (XXX et al., 1992). These signs included weight loss and behavioral observations (hypersensitivity, squeaking, aggression, wet-dog shakes, rubbing and chewing), however, the signs observed were not as severe in intensity as those observed following cessation of morphine administration.

2.2.4.1.

18

In a single-dose substitution test in morphine-dependent rhesus monkeys, XXXXXX (at doses up to 24 mg/kg) did not substitute for morphine or exacerbate morphine withdrawal signs (XXX et al., 1992). The higher doses (16 and 24 mg/kg) did slightly suppress the incidence of wet-dog shakes and retching observed during morphine withdrawal. In a similar morphine substitution test in rats, XXXXXX (200 mg/kg/day) did not substitute for morphine in morphine-dependent rats as evidenced by weight loss. However, some reduction in behavioral signs of opiate withdrawal were observed in the initial 48 hours following switching from morphine to XXXXXX (XXX et al., 1992). XXXXXX was administered at high doses to beagle dogs for a 5-day period as part of the preliminary toxicology program. No signs of opiate-like withdrawal effects were observed following cessation of dosing in these dogs during a 5-day post-dosing observation period. 2.2.4.2. XXXXXX Self-Administration In a study conducted at Huntingdon Laboratories, drug-naive cynomolgus monkeys were used in an attempt to establish self-administration of XXXXXX. The propensity for an animal to self-administer a drug is predictive of its abuse potential in humans (Thompson and Young, 1978). Under fixed-ratio schedules of drug presentation, the animal must press a lever a fixed-number of times in order to receive an injection of the drug. The greater the number of times an animal will press the lever for a single injection (the higher the fixed-ratio), the greater the potential for human abuse. Only one of four monkeys initiated lever-pressing for XXXXXX. In order to facilitate the establishment of XXXXXX as a reinforcing stimulus, involuntary injections of XXXXXX were initiated. One monkey would not lever-press more than once (Fixed-Ratio 1, FR 1) despite numerous involuntary injections of XXXXXX. A second monkey extinguished XXXXXX-maintained responding at FR 3. A third monkey extinguished at FR 10 and the fourth monkey extinguished at FR 100. These results indicate that XXXXXX would maintain only very low levels of responding and as such would not be predicted to have abuse potential. For comparison, two of these monkeys were given access to codeine and did not extinguish codeine-maintained responding until the FR was raised to FR 300 in one monkey and FR 10,000 in the other. Thus, the codeine maintained responding at 30 to 100-fold greater levels than XXXXXX, indicating that XXXXXXs abuse potential is insignificant. In a more standard procedure for evaluating abuse liability, XXXXXX was evaluated for self-administration in three rhesus monkeys trained to respond for injections of alfentanil, a potent agonist (XXX et al., 1992). XXXXXX did maintain low rates of responding, however, these rates of XXXXXX-maintained responding were less than rates of responding maintained by 0.001 mg/kg/injection of alfentanil. The dose-response curve for XXXXXX in this assay flattens out at 0.1 mg/kg/injection and remains flat up to the highest dose tested (1.0 mg/kg/injection), suggesting that the maximal effect had been reached. Thus, in this assay XXXXXX produced modest rates of self-administration suggesting that it would possess low abuse liability, at least as low or lower than that of nalbuphine.

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2.2.4.3.

Discriminative-Stimulus Properties of XXXXXX The discriminative stimulus properties of XXXXXX were examined in rhesus monkeys (XXX et al., 1992). These results were presented earlier in this report under the Mechanism of Action section. At doses up to 10 mg/kg, XXXXXX did not substitute for alfentanil in monkeys trained to discriminate between alfentanil and saline. This indicates that XXXXXX does not produce subjective states similar to those produced by agonists. In morphine-treated monkeys trained to discriminate naltrexone (the withdrawal state) from saline, XXXXXX produced saline-appropriate responding. This indicates that XXXXXX does not precipitate opiate withdrawal-associated subjective effects and therefore has no antagonist properties. In a monkey trained to discriminate the agonist, ethylketocyclazocine, from saline, XXXXXX substituted fully for ethylketocyclazocine. This suggests that XXXXXX produces subjective states similar to agonists. Whether these effects are due to direct activity or indirect -like effects is undecided, although the XXXXXX receptor binding data make a direct effect unlikely. Abuse Liability Summary The above-described data indicate that XXXXXX does not possess significant abuse liability. Some evidence of withdrawal effects was observed, however, these effects were modest. The low rates of self-administration of XXXXXX provide further evidence of its low potential for abuse. The drug discrimination data indicate that XXXXXX does not produce subjective states like those produced by agonists. The like discriminative stimulus effect of XXXXXX is unusual, especially when one considers that agonists are not self-administered. This is most likely an indirect effect rather than a direct effect at receptors. The need to conduct human drug discrimination studies should be discussed with FDA at a pre-IND meeting, however, such studies may not be warranted. General Pharmacological Profile The effects of XXXXXX on organ systems and physiological functions outside of the CNS have been less extensively investigated. XXXXXXs effects on gastrointestinal function, respiratory function, cardiovascular function , and overt CNS symptomatology are discussed in this section. XXXXXX produces inhibition of gastrointestinal motility (21%) at analgesic doses. The maximum effect observed (77%) was obtained at dose 16-fold greater than the analgesic ED50. These effects are similar in magnitude and potency to the inhibition of gastrointestinal transport produced by codeine and amitriptyline. One would predict that XXXXXX may produce clinically significant constipation at analgesic doses in man. The respiratory effects of XXXXXX have been evaluated in rats, dogs, cynomolgus monkeys, and rhesus monkeys. XXXXXX produced weak but significant increases in arterial pCO2 in the rat, dog and cynomolgus monkey, however, arterial pO2 was not affected. Arterial pH also decreased slightly in the rat and dog. These effects are consistent with a weak respiratory acidosis. The highest doses tested in each species were 50-fold greater than the analgesic ED50 in the rat, 10-fold greater than the analgesic 20

2.2.4.4.

2.2.5.

ED50 in the dog, 16 mg/kg in the cynomolgus monkey, and 32 mg/kg in the rhesus monkey. Although the high doses studied in the dog and cynomolgus monkey were sedating, there were no signs of respiratory distress. In rats, an equivalent high dose of codeine produced much larger increases in arterial pCO2 and decreases in pO2, indicative of narcotic-induced respiratory depression. In the rhesus monkey, ventilatory frequency (f) and ventilatory volume (VT) were examined in a monkey breathing normal air and breathing 5% CO2 air (XXX et al., 1992). XXXXXX produced dose-dependent decreases in both f and VT under both atmospheric conditions. At the highest dose tested (32 mg/kg), XXXXXX decreased f by 20% and VT by 76% under normal air, and decreased f by 37% and VT by 37% under 5% CO2. These decreases in respiratory function were antagonized by pretreatment with 1.0 mg/kg quadazocine, implicating opiate receptor involvement in XXXXXXs respiratory effects. The effects of XXXXXX on cardiovascular function was examined in pentobarbitalanesthetized dogs. XXXXXX produced marked hypotension (56% decrease in MAP) and decreased cardiac contractility (40% to 60% decrease) after administration of 10 mg/kg, i.v., equivalent to 10-fold greater than the analgesic ED50 in the dog tooth pulp stimulation assay. These effects were minor at doses of 3 mg/kg, i.v., or lower. Arrhythmias and anticholinergic effects were not observed. In conscious dogs, no significant cardiovascular effects were observed following 16 mg/kg, p.o., which is equivalent to 10-fold greater than the oral analgesic ED50 in the dog tooth pulp stimulation assay. Based on the available data, one cannot exclude a potentiation of pentobarbital-induced cardiovascular effects. In total, these effects suggest that XXXXXX-induced cardiovascular suppression is related to Cmax and occurs at concentrations much higher than needed for analgesia. Other than mydriasis in mice and emesis in dogs, no other overt symptomatology was observed at doses that are several multiples of the analgesic dose. These observations suggest that at analgesic doses, XXXXXX produces minimal systemic effects. 2.2.6. Pharmacokinetic Profile (Nonclinical) XXXXXX is rapidly and completely absorbed in the rat following oral administration (gavage). Cmax was observed at 0.3 and 1.2 hours post-administration of 5 mg/kg and 20 mg/kg, with values being 0.94 g/ml and 2.3 g/ml, respectively. Plasma levels linearly correlated with dose. The t1/2 averaged 1.6 hours in the rat. Similar effects were observed in the dog. In the dog, dosing by gelatin capsule resulted in delayed absorption. In the monkey, the delayed absorption produced by the gelatin capsule formulation made estimates of pharmacokinetic parameters impossible in the male monkey. In the remaining female monkey, the parameters were similar to those seen in other species (t1/2 = 2.6 hours). A single metabolite, the N-desmethyl, was found in both rat and dog. This metabolite is inactive in animal models of analgesia. In a 14-day repeated dosing study in rats, plasma

21

levels increased linearly with increasing dose and there was no evidence for drug accumulation following repeated dosing. 2.3. 2.3.1. Comparative Assessment of Tramadol Mechanism of Action and Pharmacological Profile ( )-Tramadol (tramadol, Ultram ) is a centrally-acting analgesic possessing weak opiate agonist activity as well as the ability to inhibit NE and 5-HT reuptake. The IC50 of tramadol on the opiate receptor is approximately 4 M with much weaker inhibitory activities on and opiate receptors (Raffa, 1996). At concentrations of 10-100 M, tramadol does not bind to the 2-adrenergic, 5-HT1A, 5-HT2, 5-HT3, NMDA, D1/D2 dopamine, muscarinic M1 or central benzodiazepine receptors. (Raffa, 1996; Frink et al., 1996). Tramadol inhibits the reuptake of both NE and 5-HT in rat brain synaptosomal preparations with IC50 values of 14 and 40 M, respectively. Similar results for rat dorsal spinal synaptosomes were found for NE uptake (Reimann and Hennies, 1994). Tramadol also enhances 5-HT release (Driessen and Reimann, 1992). Changes in brain levels of monoamines and their metabolites are consistent with inhibition of NE and 5-HT reuptake (Frink et al., 1996). The enhanced turnover of dopamine in specific rat brain regions is similar to the effects of opiate analgesics and is blocked by naloxone (Frick et al., 1996). The (+) enantiomer of tramadol is approximately 20-fold more potent on the opiate receptor than the (-) enantiomer. In addition, (+)-tramadol is 5-fold selective for inhibition of 5-HT reuptake vs. NE reuptake while (-)-tramadol shows the reverse selectivity pattern. Following oral administration to rats or humans, tramadol undergoes extensive hepatic transformation to several metabolites mainly via N- and O-demethylation. The primary metabolite, O-desmethyl-tramadol, has a 200-fold greater affinity for the opiate receptor compared to tramadol. This metabolite, however, is slightly (2-5-fold) weaker for the inhibition of NE and 5-HT reuptake.

22

2.3.2.

Analgesic Profile As summarized below, tramadol has been evaluated for analgesic activity in several types of assays following parenteral or oral administration. Consistently, this compound induces analgesia of the same efficacy as the opiates morphine, codeine and dpropoxyphene. TRAMADOL ANALGESIC ACTIVITY IN RODENTS

ASSAY Abdom. Constrict. Hot Plate 48 Hot Plate 55 Tail Flick Tail Flick PQW Abdom. Constrict. Hot Plate 51

SPECIES Mouse Mouse Mouse Mouse Mouse Mouse Rat Rat

ROUTE i.p. s.c. s.c. s.c. p.o. p.o. p.o. i.p.

ED50 (mg/kg) 1.9 21.4 33.1 22.8 31.2 7.8 1.7 19.5

NALOXONE ANTAGONISM Partial Yes Partial Yes Yes No Partial

REFERENCE Raffa et al., 1992 Raffa et al., 1992 Raffa et al., 1992 Raffa et al., 1992 SBA SBA Raffa et al., 1992 Raffa et al., 1992

Depending upon the test employed, tramadol-induced analgesia may or may not be reversed by naloxone. The lack of effect of naloxone in the phenylquinone-induced writhing assay suggests that tramadol activity is not solely mediated through the opiate receptor. In some analgesia assays, the antinociceptive effects of tramadol can be blocked by the 2-adrenergic antagonists yohimbine and idazoxan (Kayser et al., 1992; Raffa et al., 1992) or the 5-HT antagonist, ritanserin (Raffa et al., 1992). The O-desmethyl metabolite of tramadol has also been shown to possess analgesic activity in rodent models (SBA). These include the mouse tail flick assay (ED50= 5.4 mg/kg, p.o.) and the phenylquinone-induced writhing assay (ED50=1.9 mg/kg, p.o.). As found for the parent compound, tail flick analgesia induced by the metabolite was fully blocked by naloxone. 2.3.3. Tolerance, Dependence, and Abuse Liability Profile Using the NE uptake model to study the potential for tramadol-induced tolerance, this compound was administered to rats daily for 15 days (20-125 mg/kg/day, i.p.) then challenged with an acute dose of tramadol (40 mg/kg, i.p.). The results demonstrated that the acute challenge produced a reduction in synaptosomal [3H]NE uptake suggesting that tolerance does not develop during this treatment period (Franceschini et al., 1999).

23

Using analgesia as an endpoint for tolerance development, however, mixed results have been found. In one murine study, the tramadol ED50 for inhibition of electrical stimulation-induced nociception increased 3-fold over 4 weeks of subcutaneous treatment (SBA). In another study with oral tramadol administration, however, tail-flick analgesia was not changed over 3 weeks. (SBA). Following two days of treatment with tramadol or opiates, mice were injected with naloxone and jumping behavior was quantified as an index of withdrawal (SBA). At tramadol doses of 12.5-100 mg/kg/day (route not stated), naloxone administration induced jumping behavior demonstrating that withdrawal was induced and suggesting that chronic use of tramadol may cause physical dependence. Using changes in body weight and prostaglandin-induced diarrhea as withdrawal endpoints, tramadol was concluded to produce opiate-like withdrawal but less so than typical opiates (SBA). In a chronic rat study, tramadol was provided in the drinking water (up to 2 mg/ml) for 4 weeks. At the end of that period, naloxone-induced withdrawal signs included wet-dog shakes, jumping, teeth chattering, writhing and sensitivity to touch (SBA). These signs were not qualitatively different from morphine withdrawal. Using an acute pain model (tail flick) and a chronic pain model (arthritic rat), animals made tolerant to morphine also displayed a 3-4-fold right shift in the tramadol doseresponse curve suggesting cross-tolerance to tramadol (Raffa, 1996). Monkeys trained to self-administer the stimulant lefetamine also self-administered tramadol (Yanagita, 1978). In one case, the monkey died from chronic tramadol overdose. In summary, these studies demonstrate that tramadol has weak opiate-like effects. 2.3.4. Adverse Effects Across many species, adverse effects of tramadol include nausea, dizziness, sedation, dry mouth, constipation and sweating (Dayer et al., 1994; Raffa, 1996). At high doses, respiratory depression is common. Many of these side effects including the respiratory depression are reversed by naloxone (Riedel and Stockhausen, 1984).

24

2.3.5.

Pharmacokinetic Profile (Nonclinical) In mice, rats and dogs tramadol is extensively orally absorbed (>80%). As described above, tramadol is primarily metabolized by hepatic microsomal enzymes and rapidly conjugated. With repeated administration, O-desmethyl metabolite (highly potent at the opiate receptor) concentrations exceed those of the parent in some species. Depending upon the species, the t1/2 of an oral dose ranges 1.5-6 hours. Comparative Assessment of Venlafaxine Mechanism of Action and Pharmacological Profile Venlafaxine (Effexor ) is a potent and selective inhibitor of rat synaptosomal 5-HT and NE reuptake with IC50 values of 0.21 and 0.64 M, respectively (SBA). Presumably as a result of increasing synaptic neurotransmitter, venlafaxine also suppressed the firing of both dorsal raphe 5-HT neurons (ED50=0.23 mg/kg, i.v.) and locus ceruleus NE neurons, in vivo (ED50=0.72 mg/kg, i.v.; Beique et al., 1999). Since venlafaxine was a weaker direct inhibitor of the specific 5-HT and NE transporter binding sites (labeled with [3H]cyanoimipramine and [3H]nisoxetine, respectively), it is possible that this compound inhibits monoamine reuptake by multiple mechanisms (Beique et al., 1998; Beique et al., 1999). Venlafaxine is a weaker inhibitor of rat synaptosomal dopamine reuptake (IC50=2.8 M) and does not release NE from rat hippocampal slices (SBA). This compound is inactive (IC50 values>10 M) at the M1 muscarinic, 5-HT1A, 5-HT2A, H1 histaminergic, D2 dopaminergic, opiate, NMDA, phencyclidine, benzodiazepine, 1adrenergic, 2 adrenergic and -adrenergic receptors (Muth et al., 1986; Bolden-Watson and Richelson, 1993; Owens et al., 1997, SBA). In addition, venlafaxine does not inhibit monoamine oxidases at concentrations up to 100 M (SBA). Like tramadol, venlafaxine undergoes O-desmethylation following oral administration. O-desmethylvenlafaxine is equipotent with venlafaxine for the inhibition of synaptosomal 5-HT and NE uptake as well as 5-HT and NE neuron firing rates, in vivo (Muth et al., 1991). This metabolite was also weakly active in the DA reuptake assay and inactive in the radioligand binding assays described for the parent compound (Muth et al., 1991).

2.4. 2.4.1.

2.4.2.

Analgesic Profile In most rodent studies of acute nociception, venlafaxine was not active following acute administration. At oral doses up to 60 mg/kg, venlafaxine did not possess analgesic activity in the rat tail flick or rat hot plate assays (SBA) which are considered traditional assays for acute analgesia. In the rat writhing assay, however, venlafaxine had an oral ED50 value of 39.2 mg/kg (SBA). In chronic pain that occurs after nerve injury, for example, traditional tricyclic antidepressants have been shown to be active (Rowbotham, 1995). These compounds, however, cause tachycardia, orthostatic hypotension, urinary retention, reduced gut

25

motility, visual problems, sedation and decreased gastric acid secretion. As a result, these compounds are not well-tolerated and often abandoned. Venlafaxine was tested in a rat model of chronic nerve injury where the sciatic nerve was chronically constricted resulting in a hyperalgesic response to radiant heat (Lang et al., 1996). The results demonstrated that daily oral administration of venlafaxine (22 mg/kg) prevented the development of hyperalgesia in animals where treatment was initiated immediately following nerve constriction and also relieved the hyperalgesia when administered beginning three days post-surgery. Since this oral dose of venlafaxine did not cause changes in locomotor activity, it was concluded that the compound was not causing its apparent analgesic effect as a result of sedation. These results suggest that venlafaxine or other compounds that block 5-HT and NE reuptake may be effective in neuropathic pain states. Indeed, venlafaxine has been shown to possess analgesic activity in patients with postherpetic neuralgia and painful polyneuropathy (Galer, 1995). 2.4.3. Tolerance, Dependence, and Abuse Liability Profile Based upon its mechanism of action, side effect profile and behavioral studies, there is no evidence for abuse liability or dependence by venlafaxine (Muth et al., 1991; SBA). Adverse Effects As expected based upon the lack of activity of venlafaxine and it major metabolites on CNS receptors, it was found to have few side effects in animals (SBA). In normotensive rats, low intravenous doses venlafaxine caused a small increase in blood pressure while higher doses reduced blood pressure. In dogs, oral venlafaxine caused a brief increase in mean arterial pressure and heart rate. In humans receiving chronic venlafaxine, the most common side effects were nausea and increased blood pressure (Galer, 1995). Pharmacokinetic Profile (Nonclinical) In rodents, venlafaxine is poorly absorbed or has a significant first-pass effect (SBA). Systemic availability of orally administered venlafaxine is higher in the dog with 60% of compound appearing in the circulation. In rodents and dogs, venlafaxine and its major metabolite have very short half-lives (less than one hour) following oral administration. REGULATORY REVIEW Regulatory Requirements for Support of an Investigational New Drug Application (IND) General Principles The preclinical safety evaluation should include: a characterization of toxicity with respect to target organs, dose dependence, relationship to exposure, and potential reversibility. This information is important for the estimation of an initial safe starting dose for the initial human exposure and for identification of parameters to monitor for potential adverse effects. When planning the preclinical safety program, attention should be given to potential effects on organs/physiological processes that may be compromised

2.4.4.

2.4.5.

3.0. 3.1. 3.1.1.

26

in the intended patient population. Specific recommendations are provided for each facet of the preclinical program are provided in Section 3.2. 3.1.2. Safety Pharmacology Safety pharmacology includes the assessment of effects on vital functions (cardiovascular, central nervous, and respiratory systems) and should be evaluated prior to human exposure. Depending upon the known information regarding the mechanism of action of the drug candidate, specific relevant safety studies may be required. Toxicokinetic and Pharmacokinetic Studies The relationship between dose, plasma concentration-time curves, and toxicity should be evaluated prior to human exposure. Information on metabolic pathways and metabolites appropriate for comparison to human metabolic pathways should be available by the time Phase I studies are completed. Single Dose Toxicity Studies The acute toxicity of a drug candidate should be evaluated in two mammalian species prior to the first human exposure. Repeated Dose Toxicity Studies The recommended duration of repeated dose toxicity studies is dependent upon the duration of the proposed clinical trials. The duration of these studies conducted in two mammalian species (one non-rodent) should be equal to or exceed the duration of human exposure in the proposed clinical trials. The table below summarizes the minimum duration of repeated dose toxicity studies required to support Phase I-II clinical trials of varying length in the U.S. Rodents 2 Weeks 2 Weeks 1 Month 3 Months 6 Months Non-rodents 2 Weeks 2 Weeks 1 Month 3 Months 6 Months

3.1.3.

3.1.4.

3.1.5.

Duration of Clinical Trials Single Dose Up to 2 Weeks Up to 1 Month Up to 3 Months Up to 6 Months 3.1.6.

Local Tolerance Studies Prior to first human exposure, local tolerance should be studied in animals using routes relevant to the proposed clinical administration. The assessment of local tolerance may be a part of other toxicity studies, and such examination is not required to be a separate study. Genotoxicity In vitro tests for the evaluation of mutations and chromosomal damage are needed prior to first human exposure.

3.1.7.

27

3.2.

Regulatory Assessment of Preclinical Program and Recommendations The following review of the preclinical safety program and recommendations for a preclinical safety evaluation program to supplement the existing data are based on the information supplied by XXXX XXXXXXXXXXXX. The review and recommendations include the following information: 1 A summary of available data and assumptions upon on which this document is based. XXXXXXXXXs safety evaluation strategy to support a Phase I study in the UK under local ethical review (Investigators Drug Brochure) by the oral route of administration. This strategy is based on ICH guidelines (CPMP/ICH/302/95) for a pharmaceutical NCE.
2

3.2.1.

Data Summary XXXX XXXXXXXXXXXX wishes to develop their candidate product (XXXXXX) for the management of pain. It may be that XXXXXX has greater potential in the treatment of neuropathic pain, based upon its mechanism of action. XXXXXX is a centrally acting non-opioid analgesic that exhibits analgesic activity in a variety of in vivo models of pain. XXXXXX has low affinity at opioid or muscarinic cholinergic receptors. It has been shown to block the uptake of serotonin (5-HT) and norepinepherine in brain homogenates and inhibits tetrabenazine-induced ptosis in mice. The analgesic action of XXXXXX may involve the direct enhancement of brain enkephalin or endorphin activity. A substantial database exists on CNS pharmacology of the compound including dependence studies in primates. Quality assured material suitable for the conduct of Good Laboratory Practice (GLP) compliant preclinical studies is available.

3.2.2.

Assumptions XXXX XXXXXXXXXXXX can supply a sufficient quantity of the candidate product for the execution of the program of studies outlined, with associated material safety data information, a certificate of analysis and expiry date. The safety evaluation program will need to satisfy the requirements to obtain regulatory/local ethical approval for first administration to man studies in healthy male volunteers and to enable dosing schedules in the clinic of up to 12 weeks duration to prepare for the early Phase II studies.

28

3.2.3. 3.2.3.1.

Preclinical Program Recommendations Pharmaceutical Sciences Summary (in support of early safety evaluation)

Analytical method transfer and validation for strength only (assuming simple HPLC method) Generation of early stability data on dose form to support the toxicology studies (assume 4 timepoints) Manufacture of supplies for all repeat dose toxicology studies required to enable first dose to man (drug in bottle for reconstitution). In use (Quality Control) testing of dose form on two occasions from both 28 day repeat dose toxicology studies Manufacturing and QC summary and stability reports 3.2.3.2. Toxicology Studies Summary (Initial Safety Evaluation to support Phase I)

In vitro evaluation of mutations (Ames test). In vitro evaluation of chromosomal damage (chromosome aberration in Chinese Hamster Ovary (CHO) cells In vivo evaluation of chromosomal damage (mouse micronucleus test). Systemic exposure assessment (minimal validation of bioanalytical method for mouse plasma, bioanalysis PK analysis and appendix to main report) Acute toxicity in the rat and mouse by the intravenous (if feasible) and oral routes of administration MTD confirmatory study in the rat MTD confirmatory study in the primate and in the dog 28-day repeat-dose toxicity study in the rat including satellite animals for toxicokinetics 28-day repeat-dose toxicity study in the second species including taking plasma samples for toxicokinetics.

3.2.3.3.

Toxicology Studies Summary (Safety Evaluation to support Phase II)

13-week repeat dose toxicity study in the rat including satellite animals for toxicokinetics 13-week repeat dose toxicity study in the second species including taking plasma samples for toxicokinetics.

29

3.2.3.4.

Pharmacology Studies Summary (GLP Studies)

In vitro evaluation of action potential duration using dog Purkinje fibres Effects on Central Nervous System in the rat (parameters outlined in Irwin test) by the oral route of administration Effects on Renal System in rat (pH, volume and electrolytes in saline-loaded model) by the oral route of administration ECG and hemodynamic profile in conscious telemetered dog (including respiratory rate) or ; Respiratory rate in conscious rats by the oral route Receptor/ion channel profile (30 40 targets)

3.2.3.5.

Drug Metabolism and Pharmacokinetics Studies Summary (DMPK)

Prior to first exposure to man LC-MS method transfer and minimal validation to support MTD confirmatory studies in rat and primate Comparative in vitro metabolite profiling using liver microsomes from rat, dog primate and human Bioanalytical method feasibility assessment Bioanalytical method development and validation for rat and second species plasma Bioanalysis of plasma samples collected from repeat dose toxicity studies, pharmacokinetic analysis and provision of appendices for the main toxicological reports Quantitative Whole Body Autoradiography (rat)

(DMPK) In parallel with Phase I human clinical evaluation (prior to patient studies) Intravenous and oral excretion balance studies in the rat and primate Ex vivo metabolite profiling of rat and second species plasma and excreta Comparative evaluation of plasma protein and blood cell binding Enzyme induction assessment in animal liver tissue In vitro metabolizing isozyme characterization using human liver microsomes

30

3.2.4.

Formulation Development and Preclinical Manufacture The initiation of the safety evaluation program is dependent on the availability of wellcharacterized drug substance and a controlled synthetic process. Minimal data on the physical and chemical properties of the substance are available. It is assumed that XXXXXX will be sufficiently stable during the period of the proposed preclinical and clinical studies and that XXXX XXXXXXXXXXXX can provide storage information and a certificate of analysis. Preformulation investigations can be undertaken if needed to ensure the most appropriate vehicle for use in preclinical development and to underwrite the physical and chemical characteristics of the material for potential clinical use. Specific discussions will be required regarding the pharmaceutical sciences support necessary for the proposed initial safety evaluation and the support required to prepare for the clinical trials.

3.2.4.1.

Pharmaceutical Sciences Summary (in support of early safety evaluation)

Analytical method transfer and validation for strength only (assuming simple HPLC method) Generation of early stability data on dose form to support the toxicology studies (assume 4 timepoints) Manufacture of supplies for all repeat dose toxicology studies required to enable first dose to man (drug in bottle for reconstitution). In use (Quality Control) testing of dose form on two occasions from both 28 day repeat dose toxicology studies Manufacturing and QC summary and stability reports 3.2.5. Toxicology Strategy Regulatory Authorities have established guidelines that provide a framework for the content of toxicology studies. The non-clinical safety studies must be of suitable design to characterize the potential toxic effects of the candidate product in the clinical trial that they are intended to support. Pre-development studies have been conducted with XXXXXX, an Ames test has been completed to GLP using 5 strains of Salmonella typhimurium (plus and minus activation). It may be necessary to repeat this study using both S. typhimurium (histamine dependent) and E. coli (tryptophan dependent), particularly if there have been any changes in the routes or sites of manufacture of XXXXXX. Maximum tolerated dose levels have been determined in the rat, dog and primate and the therapeutic indices between effective dose in pain models and maximum tolerated doses have also been determined. The available data suggest that XXXXXX is tolerated at higher dose levels in the primate than in the dog following oral administration, however 31

due to the incomplete data set with regards to systemic exposure in the primate study we consider the data to be inconclusive at this time. It is therefore recommended that a 14day repeat dose study is conducted in a pair of primates and a pair of dogs using the maximum tolerated dose of 32 and 20 mg/kg respectively. Plasma samples will be collected on day 1 and day 14 at six time points post dose. This information can then be used to confirm the reproducibility of data and to compare potential toxicity and systemic exposure in each species. This comparative study will be used as a basis of the selection of the most appropriate second species for the formal repeat-dose toxicology studies. A comparative in vitro metabolism study is recommended between the rat, dog, primate and man. This study requires radiolabelled XXXXXX. Reversibility of toxicology findings should also be assessed during the safety evaluation, further discussion is required regarding the extent of recovery assessment on the chronic repeat-dose studies (ie., top dose and control groups only or all dose groups).

3.2.5.1.

Genetic Toxicity Studies The genetic toxicity battery of studies for registration of human pharmaceuticals has been agreed by the International Conference on Harmonization. Three tests are required for registration: gene mutation in bacteria (Ames test); gene mutation in eukaryotes (in vitro) or chromosomal aberrations in mammalian cells (in vitro); and chromosome aberrations (in vivo). If the chromosome aberrations (in vivo) study is negative, proof of systemic exposure is required. These studies should normally be completed prior to initiating patient studies. The absolute requirement regarding study type is dependent on the class of compound. Cytotoxins, anti-bacterials, or compounds with known genotoxic activities are investigated on a case-by-case basis. Clinical guidelines in the UK state that an Ames test and Chromosome aberrations study should be performed prior to Phase I. The chromosome aberrations study usually performed at this stage is the in vitro study. On ethical grounds, XXXXXXXXXs also request that the in vivo study be performed prior to human administration. If the outcome of this study is negative, proof of systemic exposure is required.

3.2.5.2.

Acute Toxicity Studies The acute (single dose) toxicity should be evaluated in two mammalian species. The studies should be conducted using two routes of administration, intravenous and the proposed clinical route. These studies provide an indication of the estimated lethal dose of the candidate product. Repeat Dose Toxicity Studies The duration of repeat dose toxicity studies is related to the duration of proposed clinical trials and the therapeutic indication. Repeat-dose toxicity studies should be conducted in two mammalian species (rodent and non-rodent) and be equal to or exceed the proposed

3.2.5.3.

32

duration of the clinical trial up to a maximum recommended duration for the relevant phase of clinical trial. Maximum tolerated dose confirmatory studies have been proposed to precede the repeat dose toxicity studies. 3.2.5.4. MTD Confirmatory Study in the Rat Two groups of 5 male and 5 female rats receive either the maximum tolerated dose (MTD) or vehicle for a period of 14 days. MTD Confirmatory Study in the Non-Rodent Species The MTD is administered to a pair of primates or dogs for a period of 14 days. Plasma samples will be collected at 6 time points post-dose on day 1 and day 14 of each study. Repeat-Dose Toxicology Studies Repeat-dose toxicology studies in two species, rodent and non-rodent with a minimum duration of 14 days are required to support Phase I (Human Pharmacology) and Phase II (Therapeutic Exploratory) studies. Studies of 14 or 28 days duration will support Phase II studies of equivalent duration. XXXXXXXXXs recommends the 28-day repeat-dose study option, allowing for greater flexibility in the clinical situation for a minimal additional cost. In order to conduct clinical studies in Phase II of 10 12 weeks in duration, repeat dose toxicology studies of equivalent duration (13 weeks) would be required to support those clinical studies. Data from the initial 28-day repeat-dose toxicology studies, in addition to supporting the safety evaluation for Phase I clinical administration, will be used to determine dose levels for the 13-week repeat-dose toxicology studies required in support of the longer term dosing schedule in the clinic.

3.2.5.5.

3.2.5.6.

28-Day Repeat-Dose Toxicology Studies in the Rat

These studies require 10 male and 10 female rats per dose group, vehicle control and three active dose levels of XXXXXX. The rats receive the candidate product by the oral dose route daily for 28 days. Body weight, food consumption, clinical chemistry, urinalysis and ophthalmoscopic observations are included. All animals undergo full necropsy and the high dose group and control group animals are subject to full histopathological examination. If any target organ toxicities are identified, they will also be examined in the lower dose groups (costs are additional). Toxicokinetics: Systemic exposure data should be evaluated prior to Phase I clinical trials. XXXXXXXXXs recommends that three groups of 24 satellite animals, two male and two female animals per active dose group, be bled at each of six time points postdose on the first and last day of dosing (resulting in a total of 144 plasma samples for bioanalysis). Bioanalytical data can then be subject to full pharmacokinetic analysis and data presented as an appendix to the main toxicological report.

33

28-Day Repeat-Dose Toxicology Studies in the Non-Rodent Species

Three male and three female animals per dose group, vehicle control and three active dose levels receive the candidate product by the oral route daily for 28 days. Body weight, food consumption, clinical chemistry, urinalysis and ophthalmoscopic investigations are included. All animals undergo full necropsy. All animals are subject to full histopathological evaluation. Toxicokinetics: Systemic exposure data should be evaluated prior to Phase I clinical trials. XXXXXXXXXs recommends that plasma samples be collected from three male and three female animals per active dose group, at six timepoints post-dose on the first and last day of dosing (resulting in a total of 216 plasma samples for bioanalysis). Bioanalytical data can then be subject to full pharmacokinetic analysis and data presented as an appendix to the main toxicological report. 3.2.5.7. Reproduction Toxicology Appropriate reproduction toxicity investigations for the population that is to be exposed should be performed. Men and/or women not of child-bearing potential (permanently sterilized or post-menopausal) may be included in Phase I and Phase II clinical trials prior to the conduct of reproduction toxicity studies, provided that an evaluation of the male, and/or female reproductive organs is performed in the repeat-dose toxicology studies. Carcinogenicity Studies Carcinogenicity studies are not usually required in advance of early clinical studies unless there is a known cause for concern.

3.2.5.8.

34

3.2.5.9.

Toxicology Studies Summary (Initial Safety Evaluation to support Phase I)

In vitro evaluation of mutations (Ames test). In vitro evaluation of chromosomal damage (chromosome aberration in Chinese Hamster Ovary (CHO) cells In vivo evaluation of chromosomal damage (mouse micronucleus test). Systemic exposure assessment (minimal validation of bioanalytical method for mouse plasma, bioanalysis PK analysis and appendix to main report) Acute toxicity in the rat and mouse by the intravenous (if feasible) and oral routes of administration MTD confirmatory study in the rat MTD confirmatory study in the primate and in the dog 28-day repeat-dose toxicity study in the rat including satellite animals for toxicokinetics 28-day repeat-dose toxicity study in the second species including taking plasma samples for toxicokinetics.

3.2.5.10.

Toxicology Studies Summary (Safety Evaluation to support Phase II)

13-week repeat dose toxicity study in the rat including satellite animals for toxicokinetics 13-week repeat dose toxicity study in the second species including taking plasma samples for toxicokinetics.

3.2.6. 3.2.6.1.

Pharmacology Strategy Mechanism of Action XXXX XXXXXXXXXXXX has data available which demonstrate the therapeutic potential of XXXXXX. Direct measurement of cerebrospinal fluid levels of endogenous opioid peptides following a range of doses of XXXXXX may provide some insight into any effects on release of endogenous opiates. The relative contribution of 1 and 2 opiate receptors can be elucidated by examining the effects of pretreatment with subtypeselective receptor antagonists (naltriben, 2 antagonist; BNTX, 1 antagonist) on the analgesic actions of XXXXXX. Evaluation of XXXXXX in a model of neuropathic pain in the rat (Bennett and Xie) is recommended to enhance the available database. Additional in vitro functional assays in paced vas deferens may elucidate further mechanism of action information related to both opioid- and enkephalin-mediated actions.

35

3.2.6.2.

Safety Pharmacology A package of safety pharmacology studies conducted in accordance with GLP guidelines is required for registration of drugs in the EEC and Japan. Currently GLP safety pharmacology studies are not a requirement for the FDA, however ICH 4 guidelines (July 1997) now recommend that appropriate safety pharmacology is performed prior to first dose-to-man studies (CNS, cardiovascular and respiratory function). A comprehensive package of exploratory research studies (non-GLP) has been reported in rats and dogs, together with a pilot behavioral study in conscious primates. These studies have broadly defined acute tolerability levels in these species. With these data it may not be necessary to conduct additional CNS studies prior to first to man dosing. However, XXXX XXXXXXXXXXXX may wish to conduct a simple formal GLP behavioral study in the rodent (Irwin test in the rat) to support Regulatory submission. A formal GLP renal function study is recommended in saline-loaded rats. Two cardiovascular studies have been conducted, a pilot anaesthetized (ventilated) dog protocol (i.v. dose route) and a conscious dog protocol (oral dose route to MTD). These studies appear to satisfy general hemodynamic safety up to 3 mg/kg by the intravenous route, however no formal measurement of ECG intervals was conducted in this study, although ECG morphology was scrutinized. No formal measurement of respiratory function was assessed, apart from blood gas measurements (pO2 and pCO2) in the conscious primate study. Of particular importance, in the light of a recent Points To Consider Document from the European Agency for the evaluation of medicinal products (EMA, 17 December 1997: CPMP /986/96), the assessment of the potential for QT-interval prolongation by noncardiovascular medicinal products and a comprehensive ECG evaluation of the test article in vivo is recommended. This would be best conducted in conscious telemetered dogs. The requirement for data on respiratory function can be met by the conduct of an additional study in the rodent or as part of the telemetry study in dogs. In addition to the above in vivo cardiovascular study, CPMP 986 recommends an in vitro study of test article effects on the action potential duration, upstroke velocity (Vmax ) and amplitude and resting membrane potential (Em). XXXXXXXXXs would conduct this study in dog Purkinje fibre using intracellular recordings over a wide concentration range. At present, the conduct of the in vitro cardiac studies is still at the discretion of the review board in the Phase I unit conducting the first-dose-to man studies and based on the assessment of risk. However, prior to CTX, the CPMP are recommending that this study be undertaken. New ICH guidance currently at Stage 2 concerning a full complement of safety pharmacology studies is under review with regulatory authorities. This document will

36

impact future drug development strategy and may alter XXXXXXXXXs recommendations in the future. 3.2.6.3. Drug Interactions No interaction studies are proposed prior to Phase I, unless particular concerns are identified. Pharmacology Studies Summary (GLP Studies)

3.2.6.4.

In vitro evaluation of action potential duration using dog Purkinje fibres Effects on Central Nervous System in the rat (parameters outlined in Irwin test) by the oral route of administration Effects on Renal System in rat (pH, volume and electrolytes in saline-loaded model) by the oral route of administration ECG and hemodynamic profile in conscious telemetered dog (including respiratory rate) or ; Respiratory rate in conscious rats by the oral route Receptor/ion channel profile (30 40 targets)

3.2.7.

Drug Metabolism and Pharmacokinetics Exposure data in animals should be evaluated prior to human clinical trials. Bioanalytical Method Evaluation An LC-MS method needs to be established and subject to minimal validation for XXXXXX in dog and primate plasma to support the MTD confirmatory studies. XXXXXXXXXs recommends the conduct of a bioanalytical method feasibility assessment and development and validation of the most appropriate methodology for quantitation of the candidate product and its main metabolite (N-desmethyl XXXXXX) in rat and second species plasma. The validated method will be used to analyze the plasma samples generated from the repeat dose toxicology studies. Full validation for human plasma and urine should be undertaken just prior to the Phase I clinical trial. The cost estimate provided assumes the use of LC-MS/MS technology for the formal GLP bioanalytical support.

3.2.7.1.

3.2.7.2.

Absorption, Distribution, Metabolism and Excretion (ADME) Studies to assess the extent of absorption, tissue distribution and retention, plasma protein binding and the rates and routes of metabolism and elimination should be considered. In addition, the potential interaction of XXXXXX with other compounds relevant to

37

therapeutic use should be examined. An in vitro investigation of potential routes of metabolism and enzyme systems involved should also provide useful information on potential interactions in the clinical situation. ADME data should be available to compare human and animal metabolic pathways by the time Phase I clinical trials have been completed. Some of these studies will require a radiolabelled version of XXXXXX. XXXXXXXXXs recommends the following ADME studies: Studies to be conducted prior to first administration to man i. Rat quantitative tissue distribution by quantitative whole body autoradiography following oral administration of radiolabelled candidate product to evaluate the extent of distribution and any target tissues. Conventional tissue distribution techniques are also available. ii. In vitro metabolic profiling using metabolism of radiolabelled drug by animal and human liver microsomes may be used to assist in selection of repeat dose toxicology species and will provide preliminary information on the identity of any major oxidative metabolites. This study may be of particular importance in supporting the choice of the most appropriate second species for toxicology studies. Studies to be conducted in parallel with Phase I clinical studies iii. Single oral and intravenous administration of radiolabelled candidate product excretion balance studies including evaluation of plasma radioactivity pharmacokinetics (PK) in the rat and the second species. Residual excreta and plasma samples can be stored for metabolite profiling and identification. iv. Ex vivo metabolite profiling of rat and the second species plasma and excreta from the above study (iii) to provide comparative metabolism data and allow major metabolic fractions to be collected for further possible identification (not included in the cost estimate) by LC-MS, LC-MS/MS. The identification of potentially active metabolites should be evaluated as a priority to ensure accurate interpretation of pharmacological, toxicological, and metabolism data. v. Evaluation of plasma protein and blood cell binding in the two species and humans using radiolabelled compound. vi. Enzyme induction assessment in animal liver tissue collected following multiple dose exposure to the candidate product or harvested from the formal repeat dose toxicology studies (if identified as a requirement prior to authorization of the study protocol). vii. In vitro metabolizing isozyme characterization. Conducted with human liver microsomes to allow identification of potential clinical drug interactions prior to patient studies.

38

3.2.7.3.

Drug Metabolism and Pharmacokinetics Studies Summary

Prior to first exposure to man LC-MS method transfer and minimal validation to support MTD confirmatory studies in rat and primate Comparative in vitro metabolite profiling using liver microsomes from rat, dog, primate and human Bioanalytical method feasibility assessment Bioanalytical method development and validation for rat and second species plasma Bioanalysis of plasma samples collected from repeat dose toxicity studies, pharmacokinetic analysis and provision of appendices for the main toxicological reports Quantitative Whole Body Autoradiography (rat)

In parallel with Phase I human clinical evaluation (prior to patient studies) Intravenous and oral excretion balance studies in the rat and primate Ex vivo metabolite profiling of rat and second species plasma and excreta Comparative evaluation of plasma protein and blood cell binding Enzyme induction assessment in animal liver tissue In vitro metabolizing isozyme characterization using human liver microsomes 3.2.8. Investigational Drug Brochure Prior to initiating human trials, it will be necessary to compile and submit an application to the appropriate Ethics Committee, investigational review board or regulatory authority as appropriate, to enable the Phase I clinical study. The timelines and costs for preparation of this document are included in the Preliminary Development Plan. EVALUATION OF POTENTIAL INDICATIONS FOR XXXXXX Management of Moderate to Moderately Severe Pain The potential utility of XXXXXX in the treatment of acute pain is not strongly supported by its preclinical profile. However, the evidence suggests that there may be effects on the endogenous opiate systems that would support a mechanism for efficacy in acute pain. Although XXXXXX is effective in animal models of analgesia that intuitively resemble acute pain, these models have produced false positive results for the tricyclic antidepressants, with which XXXXXX shares biochemical mechanisms. Therefore, the only way that acute analgesic efficacy can be determined is by clinical investigation. Clinical investigation is warranted since XXXXXX would have potential advantages over currently used analgesics (lack of abuse liability, lack of tolerance, potentially greater efficacy than NSAIDS and tramadol, etc.). The market for an analgesic with a general

4.0. 4.1.

39

pain indication is much larger than that for neuropathic pain. Thus, it seems warranted to examine XXXXXX in a proof of concept clinical study. The preliminary development plan (see Section 7.0) includes this type of study as the initial Phase IIa study. 4.2. Management of Chronic Pain If XXXXXX is proven effective in acute pain, then it should also be effective in chronic pain. Even if XXXXXX does not show efficacy in acute pain, its monoamine uptake inhibition properties may prove useful as an adjunctive therapy in a chronic pain treatment regimen. In chronic pain as monotherapy, XXXXXX would have some advantages over currently used analgesics in the treatment of chronic pain (lack of abuse liability, lack of physical dependence, lack of tolerance, potentially greater efficacy than NSAIDS and tramadol, antidepressant activity, etc.). The current preliminary development plan does not address the clinical evaluation of efficacy in chronic pain. It is unlikely that the FDA will approve an indication for chronic pain (see Section 6.2), however, if chronic studies are performed in a controlled manner, it is likely that statements regarding XXXXXXs effectiveness in chronic pain can be introduced into the labeling (as was done for tramadol). 4.3. Management of Neuropathic Pain The pharmacological profile of XXXXXX strongly supports its potential in the management of neuropathic pain. It has balanced inhibition of serotonin and norepinephrine uptake, similar to the tricyclics, as well as potential enhancement of endogenous opiate activity via direct and/or indirect mechanisms. The monoamine uptake inhibition is sufficient for predicting activity in neuropathic pain. If the enhancement of endogenous opiate activity is robust enough to contribute to XXXXXXs clinical analgesic efficacy, then it may prove to be superior to currently treatment regimens. The FDA is interested in the development of drugs for neuropathy and has indicated a willingness to approve a neuropathic pain indication if certain criteria are met (see Section 6.3). 5.0. EVALUATION OF POTENTIAL MARKET PENETRATION FOR XXXXXX Pain management remains a major healthcare problem and presents a considerable therapeutic challenge. Among the types of pain patients in the US, are 20 million patients with arthritis, 40 million patients with chronic recurrent headache, 8 million cancer patients, and 15% of the adult population who have persistent back pain. An estimated 45% of Americans seek treatment for persistent pain at least once during their lifetime. Approximately 45% of the 16 million Americans with diabetes (7 million) will suffer from neuropathic pain during their lifetime. The estimated societal cost in the US is $100 billion annually. The worldwide market for analgesics is $7.7 billion and is growing at a rate of 7% per year. New medications for pain are expected to add $1.5 billion by the year 2001. Prescription analgesics accounted for $4.4 billion in sales in 1996, with about 20% of those sales being for opiates (Drug & Market Development, Volume 10, August, 1999).

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There are considerable efforts underway with regard to new analgesic development. As of March 1998, there were 311 preclinical compounds in development, 32 compounds in Phase I, 60 compounds in Phase II, and 26 in Phase III (Pharmaprojects CD-ROM, March 1998). Unfortunately these numbers represent both analgesics and anti-inflammatory agents, and cannot be analyzed separately. However, it is evident that a considerable effort has been initiated with regard to analgesic development. This implies that XXXXXX will most likely be competing with a number of new analgesics upon market introduction. The extent of market penetration by XXXXXX is largely dependent upon its performance in clinical development. If XXXXXX is effective in acute pain, then there is great potential for XXXXXX to capture a large share of the analgesic market. Also, if effective in acute pain, XXXXXX would be used in chronic pain. The advantages that would differentiate it from the competition include: strong analgesic efficacy, lack of tolerance development (especially important for chronic pain), potentially better tolerability, greater safety than the opiates, and lack of physical dependence. These advantages would provide marketing with outstanding opportunities to differentiate XXXXXX from its competitors. The pharmacological profile of XXXXXX predicts that it will have great potential in the treatment of neuropathic pain. If XXXXXXs effects on endogenous opiate systems prove to be clinically relevant, then there is the potential for XXXXXX to show greater efficacy and/or safety/tolerability than the tricyclics, tramadol, or opiates in neuropathic pain. If a general neuropathic pain indication is obtained for XXXXXX (requires efficacy in radicular and non-radicular pain), it would be the first drug to carry such an indication and would provide marketing with a clear message for differentiating XXXXXX from the off-label medications currently employed. The fact that XXXXXX can be given orally will also provide an advantage over the transdermal preparations being developed for peripheral neuropathies. Based upon these potential advantages and dependent upon demonstration of clinical efficacy, XXXXXX has a good chance of becoming the market leader in neuropathic pain. American Home Products recently announced positive results with venlafaxine in neuropathic pain (diabetic neuropathy and post-herpetic neuralgia) from a Phase III trial conducted in the US. AHP is currently conducting a similar trial in Europe. AHP expects to begin marketing of venlafaxine for neuropathic pain by the second quarter of 2000.

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6.0. 6.1.

CLINICAL PROGRAM DESIGN ASSESSMENTS IN APPROPRIATE INDICATIONS: FDA OPINIONS General (Acute) Pain Indication The following recommendations are derived from the FDA Guidance Document Guideline for the Clinical Evaluation of Analgesic Drugs and statements made by FDA Advisory Board members contained in the Summary Basis for Approval documentation for tramadol, ketorolac, and buprenorphine. The preliminary development plan strategy reflects these recommendations.

6.1.1.

Phase I Preferable to use normal adults in an institutional setting. Dose range should be appropriate for proposed Phase II trials. Duration of exposure should be appropriate for the Phase II Trials. A concurrent placebo-treated group should be used. Route of administration should encompass all intended routes for Phase II. After initial single-dose Phase II studies demonstrate efficacy, repeated-dose Phase I studies should be conducted. Renal-impaired and hepatic-impaired individuals should be evaluated.

6.1.2.

Phase II Phase II trials should utilize a wide enough range of doses to enable proper dose selection for Phase III. Early Phase II trials should provide for the patient to be under the investigators surveillance throughout the anticipated course of action of the drug candidate. Pain models differ in their ability to detect differences between weak and strong analgesics. Several models should be employed with selection based upon the pharmacology of the drug candidate. The use of patients with pain of mixed etiology is not recommended in Phase II due to differences in sensitivity among pain of differing etiologies. Unless there are specific safety concerns uncovered during Phase I studies, laboratory studies need not be routinely performed in single-dose or short term Phase II trials.

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Double-blind, placebo-controlled studies utilizing multiple doses of the test drug and an appropriate active control are recommended. It is important that the doses of test drug are at least two-fold different and that the pharmacokinetic variability indicates that there will be little overlap in peak levels or bioavailability. Incorporating two comparator drugs (mild and strong) into the study design allows assessment of the assay sensitivity of the study (both downside and upside). If placebo-control is not possible, it may be useful to perform a relative potency assay to establish equi-efficacious doses of the standard and test drug. When technically feasible, it is advisable to obtain plasma levels to further stratify drug response. The comparator drug should possess a similar MOA as the test drug. Most parallel study designs should employ 30 to 50 patients per treatment arm (we assumed 40 for the preliminary development plan). The development program should collect data to describe the onset of effect, peak effect, and duration of effect. The double-blind technique must be employed in controlled trials of analgesics. (Bolded for emphasis) Provision must be made to allow patients to receive effective pain treatment (escape) if adequate pain relief is not obtained from the assigned study drug/placebo. 6.1.3. Phase III Test drug should be evaluated in a variety of disease states and therapeutic regimens. Dosages and dosing interval should be those intended for the package insert and should provide analgesia comparable to that provided by approved standard analgesics. The study design should mimic the intended clinical use (and labeling) of the drug. Tolerance, dependence, and abuse liability should be scrutinized (including animal studies).

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6.2.

Management of Chronic Pain The FDA has expressed awareness of the need for more research into the management of chronic pain. Of concern is the relative lack of data with non-opioid analgesics in chronic pain (notwithstanding the use of NSAIDs in arthritis or other inflammatory diseases), as well as a lack of data with opioid analgesics in chronic non-cancer-related pain. The latter issue is hampered by societal prejudices regarding the abuse liability of opiates. A strong non-opioid analgesic would probably be more acceptable in the treatment of chronic non-cancer-related pain. The following quotes from FDA Advisory meetings illustrate these concerns. Chairman Michelle Petri, M.D., MPH: Im a splitter (in favor of approving a general chronic pain indication), for the basic science reasons, and Im willing to keep on splitting every time basic science teaches us something more about chronic pain. Im also a splitter, because I want to encourage industry to develop drugs in this area. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Mitchell B. Max: There are essentially no clinical trials aside from dysmenorrhea published in chronic visceral pain. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. John Farrar: With regards to the chronic pain population as a whole which is a much larger group we are less clear about the role of opioids in that population. (FDA Anesthetic and Life Support Drugs Advisory Committee Meeting, September 17, 1997) Dr. Russell K. Portnenoy: I think the perspective here is that the role of opioid therapy in chronic, non-cancer-related pain is evolving, and it is a growing therapy. And in fact, during the last year the Boards of Directors of both the American Pain Society and the American Academy of Medicine have approved a consensus statement that recognizes for the first time in history, that chronic opioid therapy for non-cancer-related pain may be appropriate. (FDA Anesthetic and Life Support Drugs Advisory Committee Meeting, September 17, 1997) Dr. Curtis Wright: Ill try to be brief. In the past we have not, as a Division, differentiated between cancer pain and other forms of severe, chronic pain requiring opioid therapy, except as pertains to occasional matters of safety as have already been brought up and discussed by the committee. Usually in testing we require that the drug be tested in a suitable, chronic pain model, and that is usually cancer pain for a chronic opioid, although not exclusively. We had not entertained the notion of marketing an oncology-only analgesic, simply desiring not to make other classes of patients therapeutic orphans. (FDA Anesthetic and Life Support Drugs Advisory Committee Meeting, September 17, 1997)

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The Advisory Committee members also recognize the difficulties in clinically evaluating analgesic in the chronic pain scenario. Difficulties include: inability to distinguish between drugs having different levels of efficacy, high drop-out rates, and inability to compare to placebo. The following statements illustrate these problems. Dr. Eugene Laska: -but in the studies of chronic pain we heard one thing this morning from Dr. Brandt where failures occur, they tend to occur more often in the chronic pain situations where you cant tell drugs apart that you thought you were going to be able to distinguish. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Eugene Laska: But in the studies I have seen of chronic pain where the models have been consistent with acute pain, the parameter values tend to look the same. Things get to have an effect difference of around the same size, but the level of failures goes way up when you compare drugs of chronic pain levels. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Eugene Laska: Its curious for pain that lasts for a long time what you really end up studying are the compliers, and among the compliers the response rate is high. You cant tell anything from anything else. You cant get the effect of a drug against placebo, because of the early dropouts. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) The Advisory Committee members generally do not support approving a general chronic pain indication. The following statements illustrate this stance. Dr. Patricia McGrath: I just wanted to say that I think that at the present we dont have the information to support the term chronic pain as meaningful. I would say its meaningless in terms of a category for pain claims. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Felix Fernandez-Madrid: I would be inclined not to split (approve a general chronic pain indication) at this time and to approve drugs or continue to using drugs in an unrestricted form, letting the medical profession and the patients, the consumer, to decide what drugs are good for what conditions. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. John E. Hyde: currently, the sentiment then is that most would not really grant a general chronic pain. It would have to be for specific entities. (FDA Arthritis Advisory Committee Meeting, March 25, 1998)

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6.3.

Management of Neuropathic Pain The FDA has expressed interest in the development of drugs for neuropathic pain. They understand that neuropathic pain responds to different classes of drugs than those used in other pain states and that the current claim structure doesnt differentiate between pain of different etiologies. The following statements illustrate these perceptions. Dr. John E. Hyde: One case in point would be neuropathic pain, and we sort of generally recognize that the things we approve for pain dont generally work for neuropathic pain, and what should we do about this. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. John E. Hyde: Under the current situation, as long as you get a pain claim, you could still do the dental studies, do a few post-operative studies, and then go and sell yourself as the low back pain drug. Theres currently nothing really to stop that approach. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Mitchell B. Max: Certainly neuropathic pain is different in mechanisms than other kinds of pain, because theres a distinct anatomy. Once you injure a nerve, you have sprouting of the neuroma at the injury site which has ectopic discharges. You have discharge from the dorsal root ganglia, and you have changes in the central wiring. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Mitchell B. Max: In many kinds of pain, there is central sensitization, which is a central counterpart of peripheral inflammation where the neurons the gain is turned up, and there are some drugs being introduced that may relieve that. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) The Advisory Committee members are in favor of granting a general neuropathic pain indication provided the drug is effective in both radicular and non-radicular neuropathic pain. Dr. Mitchell B. Max: So I would propose using a claim structure as an incentive to get industry, particularly small companies, to study to get a bit of a niche with good research. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Mitchell B. Max: You know, I would go for general neuropathic pain category, if you included one radicular and one other. That sounds reasonable to me. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Mitchell B. Max: I would add, I thinkI would say I would give a general neuropathic claim if they did one study in spinal radicular pain and one study showing efficacy in something else, in peripheral diabetic neuropathy, post-herpetic neuralgia. (FDA Arthritis Advisory Committee Meeting, March 25, 1998)

46

Dr. Mitchell B. Max: As I said, if one wants a general neuropathic pain category, I would include a radicular pain, because that would be new territory, and it would encompass the largest group of patients. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Mitchell B. Max: -completed a couple of large trials in AIDS related neuropathy where tricyclics didnt work at all. The biggest group of all with neuropathic pain are thoseprobably ten times as many people have neuropathic pain from spinal root compression, cervical or lumber, than with diabetic neuropathy; but there are almost no clinical trials whatsoever, and I would hate to give someone give a company an indication for general neuropathic pain. They ought to be studying neuropathic spinal pain if they want a general indication. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Mitchell B. Max: I mean, to give you an example of a danger in even a smaller category: If I were advising a company for a study on neuropathic pain and you let them do, say, one diabetic study and one-post-herpetic study and get a general neuropathic pain category, I would advise them to send their detail men out and try to market the drug for radiating pain from spinal disease; because there are ten times as many or 20 times as many patients. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Chairman Michelle Petri, M.D., MPH: Im in favor of a separate indication for neuropathic pain. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Chairman Michelle Petri, M.D., MPH: which we had subdivided into radicular and other neuropathic. I think where we left it was we would only require one study for each of these subcategories. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) The Advisory Committee members noted that even within neuropathic pain there are multiple etiologies and that there is a difference in response to drugs between them. However, post-herpetic neuralgia and diabetic neuropathy pain respond to the same agents, whereas radicular pain is more refractory. The following statements illustrate these points. Dr. Mitchell B. Max: If it is myofascial I mean, all weve got are tricyclics and Flexeril, you know, pretty much. Visceral pain, theres very little. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Mitchell B. Max: The tricyclic antidepressants work for several kinds of neuropathic pain, but have been completely ineffective in six studies of low back pain thats not radicular. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Mitchell B. Max: If you take even neuropathic pain thats been a main focus of my research for 15 years theres a very nice correlation with a few drugs, with tricyclic antidepressants work and have similar efficacies and similar individual drugs correlate

47

well between diabetic neuropathy and post-herpetic neuralgia. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Mitchell B. Max: Post-herpetic As I said, post-herpetic neuralgia has shown exactly the same responses to tricyclics as diabetic neuropathy, but we dont know anything about radicular pain, and general back pain has been negative. So I would view post-herpetic as analogous to diabetic, that those are two other conditions that are rather small, that have a few hundred thousand people in the country, and you go in and get an indication for post-herpetic neuralgia alone or you could do a study in each diabetic and post-herpetic and get an indication for post-herpetic and diabetic, or you could do postherpetic plus radicular and then get a general neuropathic. The post-herpetic studies are about as well trodden as diabetics, and maybe theyre about 50 percent the number of patients around. The patients are older, and there are, you know, more safety concerns. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Ms. Celia Winchell (Member of the Audience): One of the things I hope that we will not miss the opportunity to mine from the committees experience is this issue of the amount of evidence and were not asking would one trial be sufficient, but in your experience within some of these subcategories such as myofascial pain, neuropathic pain, inflammatory pain, would there be some specific diagnoses so similar to one another that one trial in each could be regarded as confirmatory for both. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Ms, Celia Winchell (Member of the Audience): When Dr. Max said in his experience you cant even extrapolate from one viscera to another, those are the questions that the agency needs help with. Are there two conditions so similar that one trial in each could be confirmatory of both? (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Mitchell B. Max: As I said, there are probably five studies of tricyclics in postherpetic neuralgia and a dozen in diabetic neuropathy showing very similar responses comparing, say, the way SSRIs and mixed serotonin reuptake blockers line up. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Mitchell B. Max: but so far from the published data it looks like opioids relieve neuropathic pain. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Mitchell B. Max: other hand, there have been just two studies with gabapentin in diabetic neuropathy and post-herpetic neuralgia worked again about 20-25 percent reduction in pain compared to placebo, and there is some evidence that has some general action at the spinal cord gate. (FDA Arthritis Advisory Committee Meeting, March 25, 1998)

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The Advisory Committee also suggested that if a drug was not effective in neuropathic pain of radicular origin but was effective in non-radicular neuropathic pain, then FDA would grant indications for only those populations which showed a response. This sentiment is reflected in the following statement. Dr. John E. Hyde: I mean, if you did two diabetic neuropathy studies, you know, we would have to say it works for that. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) The Advisory Committee members also suggested components of clinical trial design that they feel are necessary for a successful trial. These include proper evaluation of dose-response, 12-week trial length, use of active comparators, placebo-control and dropout, and Quality of Life assessment. These sentiments are illustrated in the following statements. Dr. Mitchell B. Max: So I would require, whether its in the same study as efficacy or another study, that you look at least two, three doses, you know, so you really know what the curve looks like. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Chairman Michelle Petri, M.D., MPH: We really only felt comfortable about expanding the neuropathic indication, and there seems to be some concerns that three months might be optimal for efficacy; but again, its just for this one specific example and not based on a lot of data. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Chairman Michelle Petri, M.D., MPH: But for your primary efficacy trial, we sort of came to a consensus about three months for neuropathic pain. As we get to chronic pain subcategories, does three months again seem (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Mitchell B. Max: Yes. Again for efficacy, I think three months is twice as long as anybody has ever done a neuropathic pain study. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Mitchell B. Max: So you might want to make a requirement that you include a standard, say desipramine or amitriptyline in diabetic neuropathy; and if that doesnt show efficacy, you wont count a negative result against you, but if its just a clearcut negative result without then you may need extra evidence to overcome the negative result. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Mitchell B. Max: Theres a lot of evidence thus far in the literature that patients with lots of care in an academic center where they put a lot of effort into it will put up with three weeks of a placebo up to I mean we lost about ten percent of patients on every six-week study period. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Dr. Lee S. Simon: Im pretty struck by the length of time that still remains of placebo response, even out of six weeks. So I would actually be much more encouraged by three

49

month study for efficacy, and I think that that also raises the issue of eliminating the issue of placebo and giving you more understanding about the durability of the response and also the toxicity issue. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) Chairman Michelle Petri, M.D., MPH: A final issue is I think there should be some quality of life measures incorporated besides pain, not that a drug should have to show that peoples activities improve. Its hard enough to show that pain is better. However, we want to know that the drug dose does not intoxicate people so much that the improvement in pain isnt worth it. (FDA Arthritis Advisory Committee Meeting, March 25, 1998) 7.0. PRELIMINARY DEVELOPMENT PLAN OUTLINE FOR XXXXXX The preliminary development program plan is based upon information provided by XXXX XXXXXXXXXXXX regarding XXXXXXs pharmacological profile, the current FDA Guideline for the Clinical Evaluation of Analgesic Drugs, comments from FDA Advisory Committee members, as well as internal expertise and experience within XXXXXXXXXs CNS Therapeutics. The overall goal of the proposed program is to provide XXXX with sufficient clinical efficacy and safety information for the successful submission of a NDA. Obtaining a broad characterization of the efficacy and safety of XXXXXX in Phase II, including dose-response relationships, dosing intervals, and pain model specificities, will greatly streamline the requirements for numbers of doses and indications to be evaluated in the more expensive Phase III investigations. This program design has been constructed to reduce risks for XXXX, while balancing speed of development with a logical progression of clinical investigations. The programs initial focus is on conducting the required preclinical toxicology to enable a Phase I evaluation in the U.K. The preclinical program and the rationale behind its design are discussed in detail in Section 3 of this report under Regulatory Assessment of Nonclinical Program and will not be discussed further here. The Phase I program consists of two trials, a single ascending dose study in young healthy volunteers and a multiple dose study in young healthy volunteers. Although they are not included in this preliminary development plan, additional pharmacokinetic evaluations will undoubtedly be conducted later in the development program if initial clinical efficacy determinations are positive. Examples of the types of pharmacokinetic studies would include: evaluation in the elderly, pediatric profiling, evaluation of potential sex differences, evaluation in hepatically-impaired patients, evaluation in renally-impaired patients, and drug-drug interaction studies. The selection of drugs to study in drug-drug interaction studies will depend upon the indications that are selected for further pursuit. Based upon the preclinical pharmacological profile of XXXXXX, there is potential for XXXXXX to have clinical utility in the treatment of acute pain, chronic pain, and neuropathic pain. The evidence is strongest for potential in the treatment of neuropathic pain. However, since animal models of pain provide no clear predictability for responsiveness of pain from differing etiologies, and due to the larger market for general pain indications, XXXXXX will be evaluated in both acute pain and neuropathic pain in

50

Phase IIa. The results of these trials will provide a basis for deciding whether to further pursue each of these indications. By running these two Phase IIa trials in parallel, XXXX can evaluate efficacy in acute pain prior to completion of the initial efficacy determination in neuropathic pain. If XXXXXX is not effective in the treatment of acute pain, then it is highly doubtful that it would be effective as monotherapy in the treatment of chronic pain. However, due to its monoamine uptake blocking ability, XXXXXX may prove useful as adjunctive therapy in the treatment of chronic pain in a manner similar to the tricyclic antidepressants. This preliminary development plan does not cover chronic pain as a potential indication for XXXXXX. The reasons for this are: 1) FDA has expressed reluctance to grant an indication for chronic pain; and 2) chronic trials can be added after demonstration of efficacy in acute pain. Following the Phase IIa trials, the program evaluates initial efficacy in additional clinical pain models in either neuropathic pain or acute pain, dependent upon the results of the Phase IIa trials. These trials will provide the information needed to optimize the design of the Phase III therapeutic confirmatory trials. By running the neuropathic pain and acute pain trials in parallel, XXXX would cut development time and maximize the potential indications and market potential of XXXXXX. If XXXXXX is not found to be efficacious in one of these indications (neuropathic or acute pain), then that component of the program can be discontinued without adversely affecting development time for the remaining indication. The strategy of running as many trials as possible in parallel is more aggressive, but will enable XXXX to make decisions regarding the viability of XXXXXX more quickly, potentially saving a significant amount of money that might otherwise be invested in fruitless investigation. After determination of initial efficacy in acute pain (Third Molar Extraction), the acute pain Phase II program would proceed to evaluate single doses of XXXXXX in two additional clinical models of acute pain: Abdominal Hysterectomy, and Arthroscopic Knee/Elbow Surgery. Also to run in parallel is a multiple dose study (3-day duration) examining XXXXXX in abdominal hysterectomy. The abdominal hysterectomy model is recommended for the initial multiple dose evaluation based on the following: 1.Homogeneity in pain response (standard procedures, same degree of tissue injury). 2.Study can begin on post-operative Day 1; pain is moderate to severe for at least 2 days; however, there are no residual effects of the general anesthesia on post-operative Day 1. 3.Patients are generally healthy, easily accessible, and younger when compared with patients in other pain models. There is minimal dependence on pre-operative opioids that could otherwise compromise interpretation of study results. However, due to patient reluctance to participate in early phase II studies (in general), the screen-to-enrollment ratio has been observed to be as high as to 2.5 to 1. 4.Good model for opioid-induced nausea and vomiting since this is commonly seen in this patient population. 5.All patients are surgically sterile.

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The Phase III program in acute pain would consist of therapeutic confirmatory studies in the three clinical models explored in Phase II (abdominal hysterectomy, third molar extraction, and arthroscopic knee/elbow surgery) and an additional model, episiotomy. It is important to evaluate XXXXXX in a variety of clinical pain models since the severity of pain and responsiveness to analgesics varies between models, and since an analgesic will be used across a spectrum of clinical settings once it reaches the market. The program will expose a sufficient number of patients to XXXXXX to satisfy FDA requirements for a clinical safety database. A development program similar in strategy and structure has been included for pursuing an indication for neuropathic pain. If the initial Phase IIa investigation in diabetic neuropathy pain is positive, then an additional Phase II trial in post-herpetic neuralgia would be conducted. This patient population was selected based on the similar responsiveness of post-herpetic neuralgia to antidepressant therapy as found in diabetic neuropathy. The Phase III therapeutic confirmatory program for neuropathic pain would incorporate the neuropathic pain models employed in Phase II (diabetic neuropathy and post-herpetic neuralgia) and also a study examining radicular neuropathic pain. FDA has indicated that a general neuropathic pain indication would require proof of efficacy in radicular pain (see Section 6). In the plan, this is referred to as a Phase IIIb program since the acute pain NDA would be filed and approved prior to completion of the neuropathic pain confirmatory trials. As with the acute pain program, this plan provides sufficient number of patients exposed to XXXXXX to fulfill FDA requirements for a clinical safety database. Upon completion of this program, an SNDA could be filed for a neuropathic pain indication.

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XXXX XXXXXXXXXXXX XXXXXX Development Program, Estimated Timelines and Costs

The timeframes and costs referenced are for typical for drug development program of this type. More accurate estimates could be provided following discussions with FDA and/or other regulatory agencies and finalization of protocols.

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Task Complete Non-Clinical Studies to Support IND for Pain Management

Estimated Timeframe 6 months to 1 year, overlap with clinical program

Estimated Cost Range (in US$)

Formulation Development Toxicity Studies HPLC method transfer, QC release and supplies Preclinical Studies Pharmacology Safety Pharmacology: CNS, Renal, Respiratory rate (rodents), Cardiovascular, ECG, in vivo (telemetered dog) Cardiac Electrophysiology (dog) in vitro Toxicology Acute Toxicity Studies (rat and mouse i.v. and oral administration) Subacute Toxicity Studies Repeat Dose Toxicology Rat MTD Confirmatory Study Dog/Primate MTD Confirmatory Study Rat 28-Day Repeat-Dose Toxicity Study Dog/Primate 28-Day Repeat-Dose Toxicity Study Rat 13-Week Repeat-Dose Toxicity Study Dog/Primate 13-Week Repeat-Dose Toxicity Study Reproductive Toxicity Studies (full requirements to be reviewed) Genetic Toxicity (3 studies) Drug Metabolism and Pharmacokinetics (non-clinical, rat and dog/primate) Bioanalytical LC-MS Establishment and Validation Bioanalytical Method Feasibility, Establishment, and Validation Bioanalysis 28-Day Rat and Dog/Primate Samples (including report writing) $16,100 $40,200 $59,900 Need TBD $46,000 $15,100 $12,900 to $25,800 $78,100 $109,000 to $185,500 $109,400 $140,000 to $263,200 $31,200 $100,200 $32,000 $48,300

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Task Bioanalysis 13-Week Rat and Dog/Primate Samples (including report writing) Quantitative Tissue Distribution and in vitro Metabolite Profiling Preparation and Submission of IND DECISION POINT 1 (DP1): INITIATE PHASE I CLINICAL INVESTIGATIONS
1 2

Estimated Timeframe

Estimated Cost Range (in US$) $86,600 $68,000

3 months (+30 days) 12 to 18 months total1

$150,000 to $225,000 $1,143,000 to $1,355,6002

This duration represents the time interval from initiation of Development Plan preparation to submission of a IND application. This cost is the cumulative sum of development costs to be incurred up to this decision point.

55

Task Clinical Safety Studies: Phase I Clinical Trial A: Protocol Design Clinical Trial A: Execution of a single ascending dose study in young healthy volunteers Clinical Trial B: Protocol Design Clinical Trial B: Execution of a multiple dose study in young healthy volunteers (3 dosages) DECISION POINT 2 (DP2): PRELIMINARY SAFETY, TOLERABILITY, AND PK BASED ON RESULTS OF PHASE I STUDIES A AND B. Initial Efficacy Exploratory Studies: Phase IIa Clinical Trial C: Protocol Design Clinical Trial C: Execution of Safety, Tolerability and Efficacy Study to Determine the Preliminary Efficacy of XXXXXX in Pain Management Following Third Molar Extraction (Double-Blind, Placebo- and Active-controlled (tramadol), single dose, comparison of 3 fixed doses of XXXXXX) Clinical Trial D: Protocol Design Clinical Trial D: Execution of Safety, Tolerability and Efficacy Study to Determine the Preliminary Efficacy of XXXXXX in Pain Management in Patients with Diabetic Neuropathy (Double-Blind, Placebo- and Active-controlled (tramadol and amitriptyline), comparison of 3 fixed doses of XXXXXX and clinically relevant doses of active comparators, 6-arm study, 40 patients per arm, 6-week duration,10 to 20 sites) IND Amendment that includes new clinical study protocols, updated Investigators Brochure, IND Annual Report (must be submitted within 60 days of anniversary of IND initiation) and any new information regarding the product safety DECISION POINT 3 (DP3): SAFETY, TOLERABILITY AND PRELIMINARY EFFICACY DATA IN PATIENTS BASED ON RESULTS OF CLINICAL TRIALS C and D (PHASE II GENERAL PAIN / NEUROPATHIC PAIN GO-NO GO DECISION).
3 This duration represents the time interval from IND initiation to completion of the Phase I studies A and B. 4 This cost is the total cumulative costs to be incurred after IND initiation to completion of the Phase I studies A and B. 5 This duration represents the time interval from Decision Point 2 to Decision Point 3. 6 This cost is the total cumulative costs for development from Decision Point 2 to Decision Point 3.

Estimated Timeframe

Estimated Cost Range (in US$)

1 month 3 months 1 month 3 months 8 months total

3

$10,000 to $25,000 $500,000 to $600,000 $10,000 to $25,000 $700,000 to $800,000 $1,220,000 to $1,460,0004

2 months 3 months

$20,000 to $30,000 $900,000 to $1,000,000

2 months 12 to 18 months (depending upon # of sites)

$10,000 to $25,000 $1,440,000 to $1,800,000

4 to 6 weeks

$35,000 to $40,000

6 months total5

$2,405,000 to $2,895,0006

56

Task Therapeutic Exploratory Studies (Phase II) Clinical Trial E: Protocol Design Clinical Trial E: Execution of Safety, Tolerability and Efficacy Study to Determine the Preliminary Efficacy of XXXXXX in Pain Management Following Abdominal Hysterectomy (Double-Blind, Placebo- and Active-controlled (tramadol, and oxycodone), single dose, comparison of 3 fixed doses of XXXXXX and clinically relevant doses of active comparators, 6-arm study, 40 patients per arm, 10 to 20 sites) Clinical Trial F: Protocol Design Clinical Trial F: Execution of Safety, Tolerability and Efficacy Study to Determine the Preliminary Efficacy of XXXXXX in Pain Management Following Arthroscopic Knee/Elbow Surgery (DoubleBlind, Placebo- and Active-controlled (tramadol, and oxycodone), single dose, comparison of 3 fixed doses of XXXXXX and clinically relevant doses of active comparators, 6-arm study, 40 patients per arm, 10 to 20 sites) Clinical Trial G: Protocol Design Clinical Trial G: Execution of Safety, Tolerability and Efficacy Study to Determine the Preliminary Efficacy of XXXXXX in Pain Management Following Abdominal Hysterectomy (Double-Blind, Placebo- and Active-controlled (tramadol and oxycodone), multiple dose (3 days), comparison of 3 fixed doses of XXXXXX and clinically relevant doses of active comparators, 6-arm study, 40 patients per arm, 10 to 20 sites) Human Pharmacokinetics (including renal and hepatic impairment), Disposition, and Drug Interaction Studies DECISION POINT 4 (DP4): EFFICACY AND DOSE-RANGING BASED ON RESULTS OF EXPLORATORY CLINICAL TRIALS E, F, and G (GENERAL PAIN PHASE III GO-NO GO DECISION)

Estimated Timeframe 2 months 3 to 6 months (depending upon # of sites)

Estimated Cost Range (in US$) $20,000 to $30,000 $960,000 to $1,100,000

2 months 3 to 6 months (depending upon the # of sites)

$20,000 to $30,000 $960,000 to $1,100,000

2 months 3 to 6 months (depending upon the # of sites)

$20,000 to $30,000 $1,450,000 to $1,600,000

9 months 1 to 1.5 years7

TBD $3,430,000 to $3,890,0008

7 This duration represents the time interval from Decision Point 3 to completion of Clinical Trials E, F, and G. The Human Pharmacokinetics Studies are not included in this time estimate as they can be either initiated in parallel or delayed depending upon the Sponsors strategy. 8 The costs for Clinical Trials ,E, F, and G depend upon the final study parameters and intricacies of the protocols.

57

Task Product Optimization Planning Patient Outcomes, Quality of Life, and Health Economics: Consultation Report profiling competitor products outcomes compared to effects of XXXXXX. Recommended action for research strategies to build advantageous patient outcome profile Strategic Design: Incorporate Quality of Life and Health Economic research outcomes into planned trials: Pain-specific issues, caregiver burden, and patient quality-of-life issues, cost of care and cost savings

Estimated Timeframe 2 months

Estimated Cost Range (in US$) $15,000 to 20,000

Ongoing in clinical program

$75,000 to 150,000

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Task Therapeutic Confirmatory Studies (Phase III) Clinical Trial H: Protocol Design Clinical Trial H: : Execution of Comparative Evaluation of Efficacy and Safety of XXXXXX in Pain Management Following Lower-Abdominal Surgery (Double-Blind, Placebo- and Activecontrolled (tramadol), multiple dose (5 days), comparison of a fixed dose of XXXXXX and a clinically-relevant dose of tramadol, 3-arm study, 100 patients per arm, 30 sites) Clinical Trial I: Protocol Design Clinical Trial I: Execution of Comparative Evaluation of Efficacy and Safety of XXXXXX in Pain Management Following Third Molar Extraction (Double-Blind, Placebo- and Active-controlled (tramadol), multiple dose (5 days), comparison of a fixed dose of XXXXXX and a clinicallyrelevant dose of tramadol, 3-arm study, 100 patients per arm, 30 sites) Clinical Trial J: Protocol Design Clinical Trial J: Execution of Comparative Evaluation of Efficacy and Safety of XXXXXX in Pain Management Following Episiotomy (Double-Blind, Placebo- and Active-controlled (tramadol), multiple dose (5 days), comparison of a fixed dose of XXXXXX and a clinically-relevant dose of tramadol, 3-arm study, 100 patients per arm, 30 sites) Clinical Trial K: Protocol Design Clinical Trial K: Execution of Comparative Evaluation of Efficacy and Safety of XXXXXX in Pain Management Following Arthroscopic Knee/Elbow Surgery (Double-Blind, Placebo- and Activecontrolled (tramadol), multiple dose (5 days), comparison of a fixed dose of XXXXXX and a clinically-relevant dose of tramadol, 3-arm study, 100 patients per arm, 30 sites) DECISION POINT 5 (DP5): NDA GO-NO GO DECISION BASED ON RESULTS OF CONFIRMATORY PHASE III TRIALS
9 10

Estimated Timeframe

Estimated Cost Range (in US$)

2 to 3 months 16 to 18 months

$20,000 to $30,000 $1,800,000 to $2,100,000

2 months 16 to 18 months

$20,000 to $30,000 $1,600,000 to $2,000,000

2 months 16 to 18 months

$20,000 to $30,000 $1,800,000 to $2,100,000

2 months 16 to 18 months

$20,000 to $30,000 $1,800,000 to $2,100,000

2 to 2.5 years9

$7,080,000 to $8,420,00010

This duration represents the time interval from initiation of Phase III clinical studies to their completion. The actual time required is dependent upon a number of study parameters and operational strategies (e.g., number of patients, number of sites, duration of observational period, enrollment rates). A more accurate estimate can be made upon finalization of the protocols and determination of the amount of concurrent analgesic development activity. The costs for the Phase III program depend upon the final study parameters and intricacies of the protocols.

59

Task Routine IND maintenance, which includes safety surveillance and submission of IND Safety Reports, IND Annual Report preparation, and other regulatory submissions FDA liaison support: preparation of documents for regulatory meetings, rehearsal and attendance (includes pre-IND, end of phase II, advisory committee meetings, pre-NDA, etc., depending on program needs) Packaging, labeling, storage and distribution of clinical trial materials anywhere in the world.

Estimated Timeframe Ongoing through IND program Throughout development program Duration of clinical studies

Estimated Cost Range (in US$) $30,000 to $50,000 per year $200,000 to $500,000 depending upon number and complexity of meetings $250,000 to $750,000 Costs of this service depend on the extent of manufacturing, testing, labeling and distribution required $1,000,000 to $2,000,000 for U.S. only $10,000 to $20,000 each

Preparation and submission of the Product Marketing Application (NDA) for [DRUG] Pre-approval Audit Inspections

6 to 9 months 1 to 2 weeks

60

Task Neuropathy Indication Program (Phase IIIb) Therapeutic Exploratory Studies Clinical Trial L: Protocol Design Clinical Trial L: Execution of Safety, Tolerability and Efficacy Study to Determine the Preliminary Efficacy of XXXXXX in Pain Management in Patients with Post-Herpetic Neuralgia (DoubleBlind, Placebo- and Active-controlled (tramadol, and oxycodone), single dose, comparison of 3 fixed doses of XXXXXX and clinically relevant doses of active comparators, 6-arm study, 40 patients per arm, 6-week duration, 10 to 20 sites) DECISION POINT 6 (DP6): EFFICACY AND DOSE-RANGING BASED ON RESULTS OF EXPLORATORY CLINICAL TRIALS D and L (NEUROPATHIC PAIN THERAPEUTIC CONFIRMATORY PROGRAM GO-NO GO DECISION)
9 10

Estimated Timeframe

Estimated Cost Range (in US$)

2 months 12 to 18 months (depending upon the # of sites)

$20,000 to $30,000 $1,440,000 to $1,800,000

1.5 to 2 years9

$1,460,000 to $1,830,00010

This duration represents the time interval from initiation of Phase III clinical studies to their completion. The actual time required is dependent upon a number of study parameters and operational strategies (e.g., number of patients, number of sites, duration of observational period, enrollment rates). A more accurate estimate can be made upon finalization of the protocols and determination of the amount of concurrent analgesic development activity. The costs for the Phase III program depend upon the final study parameters and intricacies of the protocols.

61

Task Neuropathy Indication Program (Phase IIIb) Therapeutic Confirmatory Studies Clinical Trial M: Protocol Design Clinical Trial M: Execution of Safety, Tolerability and Efficacy Study to Determine the Preliminary Efficacy of XXXXXX in Pain Management in Patients with Diabetic Neuropathy (Double-Blind, Placebo- and Active-controlled (tramadol and oxycodone), multiple dose (3 days), comparison of 2 fixed doses of XXXXXX and clinically relevant doses of active comparators, 5-arm study, 100 patients per arm, 8-week duration, 10 to 20 sites) Clinical Trial N: Protocol Design Clinical Trial N: Execution of Safety, Tolerability and Efficacy Study to Determine the Preliminary Efficacy of XXXXXX in Pain Management in Patients with Post-Herpetic Neuralgia (DoubleBlind, Placebo- and Active-controlled (tramadol and amitriptyline), comparison of 2 fixed doses of XXXXXX and clinically relevant doses of active comparators, 5-arm study, 100 patients per arm, 8-week duration,10 to 20 sites) Clinical Trial O: Protocol Design Clinical Trial O: Execution of Safety, Tolerability and Efficacy Study to Determine the Preliminary Efficacy of XXXXXX in Pain Management in Patients with Radiculopathy (Double-Blind, Placebo- and Active-controlled (tramadol, and oxycodone), single dose, comparison of 2 fixed doses of XXXXXX and clinically relevant doses of active comparators, 5-arm study, 100 patients per arm, 8-week duration, 10 to 20 sites) DECISION POINT 7 (DP7): SNDA GO-NO GO DECISION BASED ON RESULTS OF CONFIRMATORY PHASE IIIb TRIALS
9 10

Estimated Timeframe

Estimated Cost Range (in US$)

2 months 16 to 18 months (depending upon the # of sites)

$20,000 to $30,000 $3,000,000 to $3,500,000

2 months 16 to 18 months (depending upon # of sites)

$20,000 to $30,000 $3,000,000 to $3,500,000

2 months 18 to 24 months (depending upon the # of sites)

$20,000 to $30,000 $3,000,000 to $3,500,000

2 to 2.5 years9

$9.060,000 to $10,560,00010

This duration represents the time interval from initiation of Phase III clinical studies to their completion. The actual time required is dependent upon a number of study parameters and operational strategies (e.g., number of patients, number of sites, duration of observational period, enrollment rates). A more accurate estimate can be made upon finalization of the protocols and determination of the amount of concurrent analgesic development activity. The costs for the Phase III program depend upon the final study parameters and intricacies of the protocols.

62

Task Complete Non-Clinical Studies to Support NDA (to be conducted in parallel to Phase III) Six Month Chronic Toxicity Study in the Rat One Year Chronic Toxicity Study in Dog / Primate Comprehensive Reproductive Toxicity Program Two Year Carcinogenicity Study in the Rat Two Year Carcinogenicity Study in the Mouse TOTAL COSTS AND TIME FOR CONDUCT OF THE NON-CLINICAL NDA SUPPORT PROGRAM

Estimated Timeframe

Estimated Cost Range (in US$)

9 months 16 to 18 months 12 months 30 months 30 months 2 to 2.5 years

$346,150 $434,700 to $515,200 $322,000 $901,600 $644,000 $2,648,450 to $2,728,950

63

8.0.

REFERENCES XXX, M.D., et al. (1992) xxxxxxxxxxxxxxxxxxxxxxxxx in XXXXXXXXXXXX U.S. Department of Health and Human Services, Rockville, MD. Beique, J.-C., Lavoie, N., de Montigny C. and Debonnel, G. (1998) Affinities of venlafaxine and various reuptake inhibitors for the serotonin and norepinephrine transporters. Eur. J. Pharmacol. 349, 129-132. Beique, J.-C., de Montigny, C., Blier, P. and Debonnel, G. (1999) Venlafaxine: discrepancy between in vivo 5-HT and NE reuptake blockade and affinity for reuptake sites. Synapse 32, 198-211. Bolden-Watson, C. and Richelson, E.(1993) Blockade by newly-developed antidepressants of biogenic amine uptake into rat brain synaptosomes. Life Sci. 52, 10231029. Chipkin, R.E., Berger, J.G., Billard, W., Iorio, L.C., Chapman, R. and Barnett, A. (1988) Pharmacology of SCH 34826, an orally active enkephalinase inhibitor analgesic. J. Pharmacol. Exp. Ther. 245 (3), 829-38. Cohen, F.L. (1980) Postsurgical pain relief: Patients status and nurses medication choices. Pain 9, 265-74. Crisp, T., Stafinsky, J.L., Uram, M., Perni, V.C., Weaver, M.F. and Spanos, L.J. (1991) Serotonin contributes to the spinal antinociceptive effects of morphine. Pharmacol. Biochem. Behav. 39 (3), 591-5. Dayer, P., Collart, L. and Desmeules, J. (1994) The pharmacology of tramadol. Drugs 47 (Suppl. 1) 3-7. Driessen, B. and Reimann, W. (1992) Interaction of the central analgesic, tramadol, with the uptake and release of 5-hydroxytryptamine in the rat brain in vitro. Br. J. Pharmacol. 105, 147-151. Franceschini, D., Lipartiti, M. and Giusti, P. (1999) Effect of acute and chronic tramadol on [3H]-norepinephrine-uptake in rat cortical synaptosomes. Prog Neuropsychopharmacol. Biol. Psychiatry 23, 485-496. Frink, M.C., Hennies, H.H., Engleberger, W., Haurand, M. and Wilffert, B. (1996) Influence of tramadol on neurotransmitter systems of the rat brain. Arzneimittelforschung 46, 1029-1036. Galer, B.S. (1995) Neuropathic pain of peripheral origin: Advances in pharmacologic treatment. Neurology 45 (Suppl. 9) S17-S25.

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Gonzales, G.R. (1995) Central Pain: Diagnosis and Treatment Strategies. Neurology 45 (Suppl. 9), S11-S16. Heyman, J.S., Jiang, Q., Rothman, R.B., Mosberg, H.I. and Porreca, F. (1989) Modulation of mu-mediated antinociception by delta agonists: characterization with antagonists. Eur. J. Pharmacol. 169 (1), 43-52. Jessell, T.M. and Kelly, D.D. (1991) Pain and Analgesia in Principles of Neural Science 3rd Edition, Elsevier Science Publishing Co., Inc., New York. Kayser, V. Besson, J.M. and Guilbaud, G. (1992) Evidence for noradrenergic component in the antinociceptive effect of the analgesic agent tramadol in an animal model of clinical pain. Eur. J. Pharmacol. 224, 83-88. Lang, E., Hord, A.H. and Denson, D. (1996) Venlafaxine hydrochloride (Effexor ) relieves thermal hyperalgesia in rats with an experimental mononeuropathy. Pain 68, 151155. Muth, E.A., Haskins, J.T., Moyer, J.A., Husbands, G.E.M., Nielsen, S.T. and Sigg, E.B. (1986) Antidepressant biochemical profile of the novel bycyclic compound Wy-45,030, an ethanol cyclohexanol derivative. Biochem. Pharmacol. 35, 4493-4497. Muth, E.A., Moyer, J.A., Haskins, J.T., Andree, T.H. and Husbands, G.E.M. (1991) Biochemical, neurophysiological, and behavioral effects of Wy-45,233 and other metabolites of the antidepressant venlafaxine. Drug Dev. Res. 23, 191-199. Owens, M.J., Morgan, W.N., Plott, S.J. and Nemeroff, C.B. (1997) Neurotransmitter receptor and transporter binding profile of antidepressants and their metabolites. J. Pharmacol. Exp. Ther. 283, 1305-1322. Paul, D., Mana, M.J., Pfaus, J.G. and Pinel, J.P. (1988) Attenuation of morphine analgesia by the S2 antagonists, pirenperone and ketanserin. Pharmacol. Biochem. Behav. 31 (3), 641-7. Porter, J. and Jick, H. (1980) Addiction is rare in patients treated with narcotics. N. Engl. J. Med. 302, 123. Raffa, R.B. (1996) A novel approach to the pharmacology of analgesics. Am. J. Med. 101 (Suppl. 1A) 40S-46S. Raffa, R.B., Friderichs, E., Reimann, W., Shank, R.P., Codd, E.E. and Vaught, J.L. (1992) Opioid and nonopioid components independently contribute to the mechanism of action of tramadol, an atypical opioid analgesic. J. Pharmacol. Exp. Ther. 260, 275-285. Reimann, W. and Hennies H.-H. (1994) Inhibition of spinal noradrenaline uptake in rats by the centrally acting analgesic tramadol. Biochem. Pharmacol. 47, 2289-2293.

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Riedel, F. and von Stockhausen, H.B. (1984) Severe cerebral depression after intoxication with tramadol in a 6-month-old infant. Eur. J. Clin. Pharmacol. 26, 631-632. Rowbotham, M.C. (1995) Chronic pain: From theory to practical management. Neurology 45 (Suppl. 9), S5-S10. Thompson, T and Young, A.M. (1978) Relevance of animal models for human addiction. The Bases of Addiction, 119-32. XXX, et al. (1992) xxxxxxxxxxxxxxxxxxxxxxx in XXXXXXXX U.S. Department of Health and Human Services, Rockville, MD. Van Ree, J.M., Gerrits, M.A., and Vanderschuren, L.J. (1999) Opioids, Reward and Addiction: An Encounter of Biology, Psychology, and Medicine. Pharmacological Reviews 51 (2), 341-396. Yanagita, T. (1978) Drug dependence potential of 1-(m-methoxyphenyl)-2dimethylaminomethyl)- cyclohexan-1-ol hydrochloride (tramadol) tested in monkeys. Arzneimittelforschung 28 (1a), 158-163.

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9.0. 9.1.

APPENDICES Appendix 1: XXXXXX, Tramadol, and Venlafaxine Comparison Table

67

XXXXX PHARMACOLOGICAL ACTIVITY (MECHANISTIC) Weak binding (10 M) to: opiate, opiate, dopamine 2, and muscarinic 1 receptors. Potent uptake inhibition of: NE (IC50= 223 nM) and 5-HT (IC50= 120 nM).

TRAMADOL Low-affinity agonist at opiate receptors (2 M). O-demethylated metabolite is more potent. Uptake inhibition of: NE (IC50= 13,800 nM) and 5-HT (IC50= 40,500 nM).

VENLAFAXINE Weak binding (10 M) to histamine 1 receptors. Potent uptake inhibition of: 5-HT (IC50= 210 nM) Moderate uptake inhibition of: NE (IC50= 640 nM). In vivo activity is greater than predicted from binding affinities, but similar in that 5-HT is more affected than NE. Rat Writhing (PQW?): ED50= 39.2 mg/kg

ANALGESIC ACTIVITY

Mouse PQW: ED50= 18 mg/kg Rat PQW: ED50= 7.9 mg/kg Mouse Tail-Flick: ED50= 117 mg/kg Rat Tail-Flick: Inactive Rat Randall-Selitto: ED50= 32 mg/kg Rat Tooth Pulp: ED50= 19 mg/kg Dog Tooth Pulp: ED50= 1.6 mg/kg Lack of tolerance. Low or no abuse liability. Moderately-Strong analgesia. Data to support efficacy in acute pain is lacking in that there is no proven mechanistic basis for acute analgesic actions. (POTENTIAL) Expected low incidence of side effects like venlafaxine (POTENTIAL) Chronic pain syndromes, including neuropathic pain. Possibly for acute pain/general pain, although mechanistic basis for prediction is weak.

Mouse PQW ED50= 7.8 mg/kg Mouse Tail-Flick ED50= 31.2 Rat Hot Plate: ED50= 40 mg/kg Rat Tail Flick: Inactive Rat Hot Plate: Inactive

ADVANTAGES

Low abuse liability. Moderate analgesia.

Lack of tolerance. No abuse liability.

DISADVANTAGES

3-Fold tolerance development to analgesic actions. Nausea, dizziness, sedation, dry mouth, constipation, sweating Acute and chronic pain of mild to moderate severity.

No utility in acute pain.

ADVERSE EFFECTS

Small potential for nausea, headache, weight loss, constipation Chronic pain syndromes, including neuropathic pain. Usually as an adjuvant to other analgesic therapy.

CLINICAL UTILITY

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Appendix 2: XXXXXX Development Program Timelines (Gantt Chart)

ID 1 2 3 4 5 6 7 8 9 10 Task Name Non-Clinical IND Support Studies Phase I Clinical Safety Studies Phase IIa Studies (Gen. Pain) Phase IIa Studies (Neuropathic Pain) Phase II Efficacy Studies (Gen. Pain) Phase II Efficacy Studies (Neuro. Pain) Non-Clinical NDA Support Studies Complete & Analyze Phase III (Gen. Pain) NDA Submission (Gen. Pain) Complete/Analyze Phase III/IIIb (Neuro. Pain) 0 2002 2004 2006 20 Qtr 1 Qtr 3 Qtr 1 Qtr 3 Qtr 1 Qtr 3 Qtr 1 Qtr 3 Qtr 1 Qtr 3 Qtr 1 Qtr 3 Qtr 1 Qtr 3 Qtr 1 Qtr 3

69