The Foundation of Molecular Medicine cordially invites you to…
Speakers from Orthopedics, Dermatology and Genetic Research
Exciting Science, Exciting People, Exciting City
Orthokine® in the Treatment of
Sports Injuries, OA and Pain: what
is the evidence, what is new?
Peter Wehling
Disclosures:
Foundation for Molecular Medicine
Center for Molecular Orthopaedics and Regenerative Medicine (CEMOR)
Orthogen AG
Heinrich- Heine University, all Düsseldorf, Germany
some slides with friendly support of Chris Evans, Mayo, Rochester
and Paul Robbins and Laura Niedenhofer, Scribbs, USA
Introduction to
Osteoarthritis
4
Inflammatory Process in Osteoarthritis
4
• In addition to biomechanical factors, a cascade of biological factors are also important
• Local release of cytokines triggers destruction of the hyaline cartilage and its matrix
• Agents that inhibit the action of such cytokines have a high therapeutic potential
Interleukin-1(IL-1) is an important mediator of tissue destruction and pain in osteoarthritis
Cartilage Synthesis
Cartilage Degradation
Proteinases
IL-1
TNFα
MMPs
IL-17
IL-18
LIF
OSM
IL-6
IL-8
sTNFaR
IL-4
IL-10
IL-13
IGF-1
BMPs
TGF-β3
PGE2
IL-1Ra
� Orthokine® Animal StudiesClinical StudiesExperimental Studies SafetyOsteoarthritis �ACS Processing Comparison to PRP
© 2016 ORTHOGEN AG All rights reserved
5
Conservative
Management of Osteoarthritis
5
Pharmacological
Intra-articular
Surgical
► Education ► Exercise ► Physiotherapy
► Pain killers: ▼ COX inhibitors ▼ Non-steroidal anti-inflammatory
drugs (NSAIDs)
Experimental ► A more biological focus is being taken – gen/stem cell therapies (e.g. allogeneic
mesenchymal stem cells)
► Gives greater focus to disease modification - DMOADs targeting cartilage, bone, synovitis,
(e.g. MMP-13 inh., TIMP-3 inh)
► Arthroscopy ► Osteoscopy ► Joint replacement
► PRP injections ► Orthokine® injections► Hyaluron injections► Corticosteroid injections
...
� Orthokine® Animal StudiesClinical StudiesExperimental Studies SafetyOsteoarthritis �ACS Processing Comparison to PRP
© 2016 ORTHOGEN AG All rights reserved
6
Original Basis for Orthokine®
6
• Interleukin-1(IL-1) is an important mediator of tissue destruction and pain in
osteoarthritis
• Growth factors play an important role in healthy tissue homeostasis
• The specific conditions in the Orthokine® device lead to a strong de novo
synthesis and release of IL-1Ra and Growth Factors such as TGF-B, EGF
and IGF in blood1,2
• The combination of these proteins enhances the natural regeneration
processes in damaged tissue3,4,5
• Re-injection of this specific cell-free Autologous Conditioned Serum leads to
positive clinical effects which are confirmed by controlled clinical studies 6,7,8
• The composition of the cell-free Orthokine® Serum differs significantly from all
other autologous products
Osteoarthritis� Orthokine® Animal StudiesClinical StudiesExperimental Studies Safety �ACS Processing Comparison to PRP
© 2016 ORTHOGEN AG All rights reserved
77
• Serum filled syringes stored @
-18°C up to 7 months
• Injected locally in a series of 3
to 6 injections given once or
twice weekly always through a
sterile filter
Orthokine® Processing
Osteoarthritis� Orthokine® Animal StudiesClinical StudiesExperimental Studies Safety �ACS Processing Comparison to PRP
© 2016 ORTHOGEN AG All rights reserved
Orthokine®
Experimental and Animal
Studies
Orthokine®
Muscle Injuries
10
Wright-Carpenter et al.
10
Objective:
• To investigate the treatment of muscle injuries by local administration of
cell-free Orthokine® ACS-injection using a muscle contusion model
Study Design:
• Mice subjected to an experimental contusion injury to their
gastrocnemius muscle
• One group received Orthokine® ACS-injections (N=3) at 2 hours, 24
hours and 48 hours post injury
• Control group received saline (N=3)
Wright-Carpenter T et al. Int J Sports Med. 2004;25:582-587
Osteoarthritis� Orthokine® Animal StudiesClinical StudiesExperimental Studies Safety �ACS Processing Comparison to PRP
© 2016 ORTHOGEN AG All rights reserved
11
Wright-Carpenter et al.
11
Results:
Wright-Carpenter T et al. Int J Sports Med. 2004;25:582-587
Orthokine® Treated Control
1. Seven days post injury % of large diameter regenerating CN myofibers [2] was higher
in the ACS-treated group than the control group 87.4% vs 60.3% (p<0.05)
[1] Small diameter regenerating CN microfibers; [2] Large diameter regenerating CN microfibers; [3] normal healthy muscle fibres; [4]
granulomatous tissue; [5] necrotic muscular tissue
Osteoarthritis� Orthokine® Animal StudiesClinical StudiesExperimental Studies Safety �ACS Processing Comparison to PRP
© 2016 ORTHOGEN AG All rights reserved
Orthokine®
In Achillis Tendinopathy
13
Majewski et al.
13
Objective:
• To investigate the impact of cell-free Orthokine® ACS-injection on
the healing of transected rat Achilles tendon
Study Design:
• Achilles tendons of 80 rats were transected and sutured back
together
• One group received Orthokine® ACS-injections at 24 hours, 48
hours and 72 hours post operatively
• Control group received no injections
Majewski MT et al. Am J Sports Med. 2009;37(11)
Osteoarthritis� Orthokine® Animal StudiesClinical StudiesExperimental Studies Safety �ACS Processing Comparison to PRP
© 2016 ORTHOGEN AG All rights reserved
14
Majewski et al.
14
Results:
Majewski MT et al. Am J Sports Med. 2009;37(11)
SutureSuture with
Orthokine® ACS
Week 1
Week 2
Week 4
Week 8
Compared to control, group receiving
Orthokine® ACS-injections had:
• Enhanced expression of the
Col1A1 gene
• Thicker tendons
• More type I collagen
• Accelerated recovery
• Histology: more structured, with
a more developed crimp
pattern, bigger collagen bundles
Osteoarthritis� Orthokine® Animal StudiesClinical StudiesExperimental Studies Safety �ACS Processing Comparison to PRP
© 2016 ORTHOGEN AG All rights reserved
15
Frisbie et al.
15
Objective:
• To investigate the clinical, biochemical and histologic effects of cell-
free Orthokine® ACS-injection on experimentally induced
osteoarthritis in horses
Study Design:
• Osteoarthritis was induced arthroscopically in 1 middle carpal joint
of all horses
• 8 horses received Orthokine® ACS-injections in the osteoarthritis
joint on days 14, 21, 28 and 35
• Control group received saline (N=8)
Frisbie DD et al. American Journal of Veterinary Research. 2009;68(3):290-296
Osteoarthritis� Orthokine® Animal StudiesClinical StudiesExperimental Studies Safety �ACS Processing Comparison to PRP
© 2016 ORTHOGEN AG All rights reserved
16
Frisbie et al. (2007)
16
Results:
More favourable result in horses with cell-free Orthokine® ACS
• Lameness improvement
• Reduced synovial membrane hyperplasia
• Reduced synovial membrane haemorrhage
• Less gross cartilage fibrillation
• IL-1Ra concentrations increased until day 70
Frisbie DD et al. American Journal of Veterinary Research. 2009;68(3):290-296
Placebo Orthokine® ACS
Osteoarthritis� Orthokine® Animal StudiesClinical StudiesExperimental Studies Safety �ACS Processing Comparison to PRP
© 2016 ORTHOGEN AG All rights reserved
17
17
17
CT: Computerised tomography; GPA: Global patient assessment; HRQoL: Health-related quality of life; KOOS: Knee injury and osteoarthritis
outcome score; KSRS: Knee Society Clinical Rating System; RCT: Randomised controlled trial; VAS: Visual analogue scale; WOMAC:
Western Ontario and McMaster Universities Arthritis Index
Study Study Design Comparator(s)Study
Length
Number of
PatientsOutcomes Measured
Knee Osteoarthritis
Baselga & Hernandez,
2014Prospective observational Physiotherapy 2 years 118
WOMACGlobal; WOMACPain;
Pain VAS
Baltzer et al., 2009
(GOAT study)RCT, double-blind
Hyaluronan;
Saline
26 weeks,
2-year follow-up376
WOMACGlobal;
Pain VAS; GPA;
SF-8 (HRQoL)
Yang et al., 2008 RCT, double-blind Saline 1 year 167Pain VAS;
KOOS; KSRS
Baltzer et al., 2003 Prospective observational No comparator ≥ 3.5 years ~ 1000WOMAC; Pain VAS;
Patient satisfaction
Knee Osteoarthritis (Post-op)
Darabos et al, 2014 RCT, double-blind Saline 1 year 62CT; Lysholm Knee Questionnaire, IKDC
2000
Darabos et al, 2011 RCT, double-blind Saline 1 year 62 CT; WOMAC
Darabos et al, 2009 RCT, double-blind Saline 10 days 20Synovial cytokines;
serum cytokines
Summary of Clinical Studies- In Knee Osteoarthritis
Osteoarthritis� Orthokine® Animal StudiesClinical StudiesExperimental Studies Safety �ACS Processing Comparison to PRP
© 2016 ORTHOGEN AG All rights reserved
1818
ACS: autologous conditioned serum; MHHS: Modified Harrison Hip Score; ODI: Oswestry disability index; TRIAM: Triamcinolone; RCT:
Randomised controlled trial; rIRAP: recombinant IL-1R antagonist protein; VAS: Visual analogue scale;
Study
(Author, year)Study Design Comparator(s)
Study
Length
Number of
PatientsOutcomes Measured
Hip osteoarthritis
Baltzer et al., 2013Retrospective
observational
ACS+cortisone;
ACS+cortisone
+anakinra
14 months 119 Pain VAS
Morgenstern et al.
2013Prospective observational No comparator 6 months 23 Functional and pain VAS, MHHS
Spine
Becker et al., 2007 RCT, double-blindTRIAM 10 mg,
TRIAM 5 mg6 months 84
Lower back pain VAS;
ODI
Muscle Injuries
Wright-Carpenter, 2004 Prospective observational
Actovegin®/
Traumeel®
therapy
To recovery 29Growth factor levels;
Recovery time
Summary of Clinical Studies- In Hip Osteoarthritis, Spine and Muscle Injuries
Osteoarthritis� Orthokine® Animal StudiesClinical StudiesExperimental Studies Safety �ACS Processing Comparison to PRP
© 2016 ORTHOGEN AG All rights reserved
Orthokine® in
Knee Osteoarthritis
Baselga &
Hernández
(2015)Study of ACS with physiotherapy for the
treatment of osteoarthritis
April 2016
- pü
JOCA Febr 2009
Knee OA
376 patients
German ACS Trial - GOAT
376 SUBJECTS
KL Score 2-3
>30 years oldVAS pain 50-100mm
Autologous
Conditioned Serum
(ACS)
Hyaluronic Acid Placebo
(Saline)
Results: WOMAC (2 Years)
Results: VAS (2 Years)
Genotypes and Association in OA
in the GOAT Study Cohort depending
on Treatment Result and Modality
Back PainGCH1
IL1A/B
IL1RN
IL6
Burning Mouth Syndrome
IL1B
FibromyalgiaCOMT
HTR2A
SLC6A4
Vulvar VestibulitisIL1B
IL1RN
MC1R
Experimental PainCOMT
FAAH
GCH1
MC1R
OPRD1
OPRM1
TRPA1
TRPV1
Headache/MigraineMany
Irritable Bowel SyndromeIL10
HTR2A
SLC6A4
TNFA
Pelvic Pain
IL10
Non-steroidal anti-
inflammatory analgesiaPTGS2
Opioid analgesiaCOMT
CYP2D6
MC1R
OPRM1
Postoperative PainMAOB
Temporomandibular
DisorderADRB2
COMT
SLC6A4
o COL11A1
o PTGS2
o IL10
o MATN3
o RHOB
o APOB
o IL1R1
o IL1A
o IL1B
o FRZB
o TIMP4
o PPARG
o COL6A4 or DVWA
o TNF
o COL11A2
o VEGFA
o IL17A
o IL17F
o COL9A1
o ENPP1
o ESR1
o IL6
o TXNDC3
o WISP1
o ASPN
o LPAR1
o ADAM12
o LRP5
o MMP1
o APOA1
o VDR
o COL2A1
o IGF1
o KL
o LRCH1
o ESR2
o DIO2
o CALM1
o SERPINA3
o SMAD3
o ACAN
o IL4R
o CCL2
o COL1A1
o ACE
o COMP
o TGFB1
o GDF5
o COL9A3
o ADAMTS5
o A2BP1
o SCN9A
SNP GENE CHR BP VAS VAS (adj) WOMAC WOMAC (adj)
y1 1 23 122364958 0.00883 0.006791 0.002666 7.55E-05
y2 2 11 113312817 0.005222 0.003548 0.00152 0.0002558
y3 3 1 205011268 0.006987 0.00294 0.01821 0.001306
y4 4 20 47224258 0.07851 0.01421 0.03535 0.002322
y5 5 22 20549449 0.00339 0.00178 0.06782 0.002519
y6 6 1 205013257 0.005413 0.002768 0.04402 0.002857
y7 7 3 149897867 0.03967 0.02955 0.05565 0.003078
y8 8 3 115335421 0.05842 0.005934 0.2118 0.003109
y9 9 3 115341863 0.05842 0.005934 0.2118 0.003109
y10 10 1 11773514 0.004347 0.000883 0.141 0.003242
SNP GENE CHR BP VAS VAS (adj) WOMAC WOMAC (adj)
1
11 18 59236106 0.01208 0.01211 0.000634 0.0005152
2 12 4 1.58E+08 0.02266 0.01319 0.0005749 0.0008672
2 13 4 1.58E+08 0.02012 0.01039 0.00171 0.001005
3
14 7 1.5E+08 0.04163 0.02611 0.006617 0.001121
4 15 6 88906819 0.05123 0.03036 0.005708 0.00117
5 16 7 87068129 0.3466 0.1211 0.07796 0.001388
6 17 12 1.16E+08 0.002377 0.0009615 0.001604 0.001761
7 18 5 37876802 0.03962 0.006376 0.1726 0.002226
8 19 1 62129178 0.02686 0.01126 0.01082 0.002351
9 20 20 43158293 0.02755 0.02147 0.01839 0.00269
SNP GENE CHR BP VAS VAS (adj) WOMAC WOMAC (adj)
x21 21 3 62110395 0.02936 0.02319 0.0419 0.0007347
x22 22 7 55207473 0.04619 0.01636 0.00523 0.001153
x23 23 23 37537458 0.01414 0.02704 0.01849 0.00203
x24 24 7 55196749 0.01584 0.02009 0.002862 0.002313
x25 25 23 43487623 0.01937 0.01059 0.01105 0.003196
x26 26 23 43488335 0.01937 0.01059 0.01105 0.003196
x27 27 23 43489785 0.01937 0.01059 0.01105 0.003196
x28 28 7 142265373 0.09273 0.06894 0.00162 0.003675
x29 29 23 43475980 0.0379 0.01943 0.009545 0.003695
x30 30 22 20492126 0.0005328 0.002735 0.001443 0.004188
Conclusion
Orthokine® confers a stronger therapeutic
effect following a single treatment regiment
than HA and Placebo at 6 and 24 months as
determined by GPA, VAS and WOMAC.
Overview Effect Sizes of RCT´s
Modality ES-Pain ES-Function
Corticosteroids (1-4 w.) < 0.55 0.06
HA (24 w.) < 0.46 0.33
Orthokine®(24-104 w.) < 0.73 0.54
PRP (24-52 w.) < 0.4 0.4
Small = 0.2 Medium = 0.5 Large = 0.8
33
Darabos et al.
33
Summary:
• Orthokine® ACS injection reduced bone tunnel widening after ACL constructive surgery
• The risk-benefit ratio of Orthokine® ACS was favorable
Darabos N. et al. Knee Surgery Sports Traumatology Arthroscopy (2011) 19 (Suppl 1): S36-S46
Results:
• All adverse events were mild to moderate
• There were no differences in the adverse event profile between the 2 groups
Osteoarthritis� Orthokine® Animal StudiesClinical StudiesExperimental Studies Safety �ACS Processing Comparison to PRP
© 2016 ORTHOGEN AG All rights reserved
Orthokine®
In Meniscus Injuries
Orthokine®
In Meniscus Lesions
36
Results:
• Clinical parameter measured with Oxford Knee Score (OKS) improved significantly during the
observation over 6 months, including significant pain reduction.
• MRI findings measured with Boston Leeds Osteoarthritis Knee Score (BLOKS) improved in
the same manner significantly.
• Non of the 39 patients needed surgery during the 6 months oberservation duration
• There were no adverse events observed in this open Orthokine® ACS observational study
over 6 months
Summary:
• Orthokine® ACS significantly improved clinical signs and symptoms of meniscal lesions in an
open observational study
• Orthokine® ACS represented an effective and well-tolerated alternative to surgery
(meniscectomy).
36 © 2016 ORTHOGEN AG All rights reserved
StrümperACS Meniscus Study
Osteoarthritis� Orthokine® Animal StudiesClinical StudiesExperimental Studies Safety �ACS Processing Comparison to PRP
Orthokine®
in Shoulder Inpingement
Orthokine® (ACS)
Project Shoulder
Institute of
Rheumatology
Belgrade University,
Serbia
Nemanja Damjanov, Branko Barać, Jelena Čolić, Vladan Stevanović, Goran Tulić,
Orthokine® (ACS) Project: Shoulder
Title
The efficacy and safety of Autologous Conditioned Serum
(ACS)-Orthokine injections, compared to Betamethasone
(Diprofos) and placebo injections in the treatment of chronic
shoulder joint pain:
Prospective, randomizied,double-blind, controlled study.
Subacromial-subdeltoid bursa
Lateral shoulder
Teres minor
tendon
Infraspinatus
tendon
Supraspinatus
tendon
Humeral head
Supraspinatus
tendon trans
Full internal rotation and adductionSubacromial-subdeltoid bursa
Supraspinatus tendon
Humeral head
Antiseptic swabbing of the injection site
ACS treatment - Assessment of pain (VAS scale)
There was significant decrease in intesity of pain between week 0 and
week 4 (p<0.001), as well as between week 0 and week 24 (p<0.001) and
bewteen week 4 and week 24 (p<0.05) (Wilcoxon test)
p<0.001
p<0.001
p<0.05
70
2112,5
There was significant decrease in intesity of pain between week 0 and
week 4 (p<0.05), as well as between week 0 and week 24 (p<0.001), but
there was unsignificant deterioration bewteen week 4 and week 24
(p>0.05) (Wilcoxon test)
p<0.001
p<0.001
P>0.0565
31
Betameth/pl. treatment - Assessment of pain (VAS scale)
38
Results: CSS Score Orthokine & glucocorticoids
Poor
Poor
Excell.
Excell.
Excell.
Excell.
Poor Poor
ACS Betamethasone/pl.
Orthokine®
Lumbar Radicular
Compression
Pain: Cytokines and the Nerve Root
IL-1ra and the Nerve Root
Wehling, Schulitz et al: Spine 1996
Epidural Perineural Injection of ACS for
Lumbar Radicular Pain
A prospective, randomized, double-blind clinical study
C. Becker, S. Heidersdorf, S. Zirke de Rodriguez, J. Krämer, R. Willburger
Spine
University Hospital of Orthopedic Surgery
St. Josef Hospital Bochum, Germany
Visual analogue scale (VAS)
0
10
20
30
40
50
60
70
80
90
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 weeks
[cm
]
IRAP group
Triam 5 mg group
Triam 10 mg group
1.Injection
t 4 t 5t 3t 2t 1
2.Injection
t 6
3.Injection
Back Pain Study
• Evident pain reduction (VAS) after 3 Injections in all groups
• Pain reduction persists in Orthokine-ACS group
• Difference betweenOrthokine and Triam
• No differencebetween Triam 5 mg and 10 mg
Conclusions Lumbar Spine
• ACS is more effective as steroids in
reducing pain
• Analgesic effect is longer-lasting than that
of steroids
• Lack of side effects make ACS an
attractive local medication for lumbar
nerve root compression
Safety
53
Adverse Events Reported with Orthokine® Since 2004Safety Overview in Real Life Use
53
• Since January 2004 to present, more than 100,000* patients worldwide have been
treated with Orthokine®.
• During this time:
• A total of 45 adverse events in 27 patients treated with Orthokine® have been
reported.
• Of these, the most commonly reported adverse events were:
• There were no reported infections.
*Value estimated based on the assumption that, since January 2004, more than 400,000 EOTII® have been sold and
patients typically require treatment with 4 EOT®II syringes.†Patients may have experienced more than one adverse event.
Adverse Event Number of Reported Events†
Pain 15
Swelling 13
Haematoma 7
Osteoarthritis� Orthokine® Animal StudiesClinical StudiesExperimental Studies Safety �ACS Processing Comparison to PRP
© 2016 ORTHOGEN AG All rights reserved
Summary and Acknowledgments
The Foundation of Molecular Medicine cordially invites you to…
Speakers from Orthopedics, Dermatology and Genetic Research
Exciting Science, Exciting People, Exciting City