Optimized Erythropoietin (EPO) Treatment

SPECIFIC AIMS Erythropoietin (Epo) stimulates red blood cell (RBC) production. Erythropoietin
treatment of anemic, very low birth weight (VLBW) preterm infants has not been as effective
as originally anticipated in eliminating multiple RBC transfusions (RBCTX). This conclusion
is based on Epoetin Alpha dosing studies employing inconsistent RBCTX criteria, and study
designs that did not fully consider Epoetin Alpha's complex pharmacokinetics (PK) and
pharmacodynamics (PD). The hypothesis of this project challenges the conclusion that Epoetin
Alpha therapy cannot reduce RBCTX in VLBW infants to a clinically important extent. This
challenge is based on our novel comprehensive determinations of the PD of endogenous Epo in
VLBW infants, and on our recent computer Epo simulation modeling results predicting that
RBCTX can be eliminated in a select group of VLBW infants.

Study Objective To develop a pharmacodynamically-based, individualized medicine approach
capable of completely eliminating RBCTX in an identifiable group of VLBW infants by optimally
administering Epoetin Alpha.

Central Hypotheses Infants with good Epoetin Alpha responsiveness can be identified by a
mechanism-driven, individualized prediction model. Optimized Epoetin Alpha treatment of the
predicted good responders that is based on sound, evidence based PK/PD principles will
eliminate the need for RBCTX.

Epoetin Alpha responsiveness is determined by two key components: 1) RBC production, which
depends on Epoetin Alpha PD. 2) RBC lifespan. Individualized covariate-based (ie, patient
specific characteristics) prediction of these two components is critical for the development
of an individualized prediction model of Epoetin Alpha responsiveness that will be used for
testing the Central Hypothesis. These important predictors of Epoetin Alpha responsiveness
will be investigated in the following Specific Aims (SA) and Hypotheses (HY):

INFANT STUDY 1 (Years 1-3) performed in VLBW infants with birth weights from 1.0 to 1.5 kg SA
1 Determine clinical and laboratory covariates (ie, patient-specific characteristics)
controlling the large inter-subject variability in Epoetin Alpha's PD using data from Epoetin
Alpha dosing of VLBW infants HY 1 The inter-subject variability in Epoetin Alpha's PD is
predictable by several covariates that are identifiable by our PK/PD modeling approach.

SA 2 Determine the lifespan of fetal RBC in the gestational age spectrum of the study
infants.

HY 2 There exists a significant inter-subject variability in the lifespan of fetal RBCs in
VLBW infants that is predictable based on gestational age.

SA 3 Derive an individualized, optimal Epoetin Alpha dosing algorithm and an individualized
prediction model for the Epoetin Alpha responsiveness in VLBW infants from the results in
Specific Aims 1 and 2.

HY 3 Crossvalidation-type computer simulations based on individualized and optimized Epoetin
Alpha dosing in a subgroup of VLBW infants with good Epoetin Alpha responsiveness, identified
by the prediction model, will indicate that RBCTX can be avoided in a select group of VLBW
infants.

INFANT STUDY 2 (Years 3-4, to be addressed as a modification after completion of study 1)
also performed in VLBW infant with birth weights from 1.0 to 1.5 kg SA 4 Apply the optimal
Epoetin Alpha dosing algorithm and Epoetin Alpha responsiveness prediction model developed in
Infant Study 1 to an Epoetin Alpha dosing study to test the Central Hypothesis.

HY 4 The subgroup of VLBW infants with good Epoetin Alpha responsiveness will have a higher
proportion of infants that will not have any RBCTX compared to those with poor Epoetin Alpha
responsiveness.

Expected Outcomes SA 1 Among the covariates considered in Specific Aims 1 (e.g. clinical
neonatal/maternal factors, blood cell parameters, cytokines linked to erythropoiesis,
inflammation biomarkers, oxidative stress, iron status, and genetic factors), we will
identify several with statistically significant correlations to Epoetin Alpha's PD.

SA2 The lifespan of fetal RBCs will show similar relationship to gestational age as that
which was observed by us in the ovine fetus.

SA3 The model will accurately predict individual Epoetin Alpha responsiveness to optimized
Epo dosing and will provide strong support for our hypothesis that RBCTX can be completely
eliminated in a select group of VLBW infants.

SA4 Infant Study 2 will show that the select group of VLBW infants that are predicted to be
good Epoetin Alpha responders by the combined use of an individualized Epoetin Alpha
responsiveness prediction model and an optimal, individualized Epo dosing algorithm will have
a greater proportion of infants who do not require any RBCTX compared to those predicted to
have poor Epoetin Alpha responsiveness.

A successful completion of the proposed research is potentially transformative and is likely
to be applied to the care of VLBW infants, resulting in a significant overall impact.
Moreover, a successful demonstration of the utility and power of these principles will lead
to improvements in the complex pharmacotherapy of VLBW infants, who are among the most
difficult to study of any patient group.

Inclusion Criteria:

1. Post-menstrual age at birth less than 37 wk;

2. birth weight of 1,001 to 1,500 g;

3. postnatal age <48 h;

4. respiratory distress requiring ventilation;

5. signed consent by parent or guardian.

Exclusion Criteria:

1. Anticipated survival <72 h;

2. Hemolytic anemia due to alloimmune disease (including due to ABO), and other hemolytic
disease processes;

3. Major anomalies that are life-threatening during the neonatal and infant periods
(central nervous system, cardiac, metabolic chromosomal including, but not limited to,
trisomies, deletions, and trinucleotide repeats);

4. Clinical seizures;

5. Congenital thrombotic or hemorrhagic conditions including disseminated intravascular
coagulation;

6. Positive blood or spinal fluid bacterial or fungal culture, or other laboratory and/or
clinical data indicative of sepsis, including TORCH infections, prior to 48 h of age;

7. Hematocrit >50%;

8. Platelet count >400,000 per µL in first 48 h of life;

9. Hypertension with systolic blood pressure >100 mm Hg.

10. Any condition, in the opinion of the investigators, that would compromise the well
being of the subject or the study, or prevent the subject from meeting or performing
study requirements.