-Stem Cell Therapy -Introduction and Practical Guide to

Use in Small Animal Practice

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What Do Stem Cells Do?

10 million cells die in your body every minute of every day.

Your own stem cells replace them so you can continue living.

This is what stem cells do for a living.

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What are Stem Cells?

Stem Cells are Primitive cells present in almost every tissue:

• Self Renewing• Able to become different tissue types• Trophic Factories – Growth Factors

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Embryonic vs Adult Stem Cells

Stem Cells from Embryos

• Intended to form whole animal - not for repair• Can form tumors – UNPREDICTABLE• Maybe someday

Adult Stem Cells – many sources

• Intended for self repair• Do not form tumors when injected• Now

Gruen L and Grabel L, Stem Cell 2006;24;2162-2169.

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Dr. Bill Futrell, et al – Univ of Pittsburgh 1998“Discovered true stem cells in fat that couldcreate new tissues like bone and cartilage”

Enabling Innovation

Stem Cells from fat Extracted can become bone Fix fractures in the lab

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Why Adipose as Stem Cell Source?

High healing cell count – No culturing required

1000X stem cell concentration as bone marrow

Family of healing cells - heterogeneous

Rapid, Easy to access

Over 1700 peer reviewed papers published

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What Cells Do We Use?1

1 Varma et al, Stem Cells and Development 2007:91-104 (freshly isolated adipose).Repeated by Collas et al and Yoshimura et al.

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Mechanisms of Repair

• Trophic support - growth factors and cytokines

• Anti-inflammatory

• Differentiation into tissue

• Homing to injury site

• Immune System Modulation

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The Injury Response Cascade

Time

Fibrosis

Inflammation

“Regeneration”

Acute InjuryAcute Injury Scar Complete

Ma

gn

itu

de

QUICK QUICK FIXFIX

Courtesy, A Caplan, Case Western Reserve

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“Regeneration”

Acute InjuryAcute Injury Scar Reduced

Time

Ma

gn

itu

de

Inflammation

Fibrosis

Stem Cells in Injury Response

Courtesy, A Caplan, Case Western Reserve

Stem CellsStem Cells

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Roles / Functions

“Stem cells are injury-specific, perfectly choreographed pharmaceutical factories”

Dr. Arnold CaplanCase Western

Reserve

Influence by injury micro-environment

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Stem Cells and Joint Therapy Mechanisms

Chondrogenesis1 - new cartilage formation

Lubricin2 - lubricate joint, improve range of motion

IRAP Secretion3 - blocks IL-1 inflammation mediator

Decrease Inflammation4 - reduce pain and swelling

1 Wei et al, Cytotherapy, 20072 Lee et al, BBRC, 20083 Ortiz et al, PNAS 20074 Tholpady, Plast Surg, 2006

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Evidence-based Cell Therapy

DATA TYPE AVAILABLECanine

OsteoarthritisCanine Tendon and Ligament

In-vitro (lab bench) X X

Lab Animal X X

Case Studies X X

Retrospective Studies X X

Non-Random, Prospective X X

Randomized, Controlled X (equine)

Human Clinical Studies X X

STATUS Supported Supported

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Rabbit Osteochondral DefectRepair Model

Nathan et al, “Cell-based therapy in the repair of osteochondral defects: A novel use for adipose tissue” Tissue Engineering, 2003.

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Elbow Dysplasia - DJD

Annie – 9 YO

Chronic elbow dysplasia – non-NSAID controlled pain

Stem Cell Therapy at Day 0 and 14.

Now able to jump in and out of car; took 2 hour run in the woods before her 90 day study exam!

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Bilateral Stifle / Hips

4 YO Rat Terrier

Bilateral stifle and hip degeneration since 6 months old

NSAIDS for 12 months and still painful

===============

Intra-articular RX with Stem cells in all four joints

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4 YO Rat Terrier

Post Treatment:

2 weeks – Dramatic pain reduction

Now NSAID free for >24 months

Bilateral Stifle / Hips

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Human Therapy

“Autologous stem cells (adipose) and fibrin glue used to treat widespread traumatic calvarial defects: case report”

A young girl with major trauma to skull cap that could not be repaired with bone graft was treated with her own adipose stem cells and re-grew the skull bones.

Journal of Cranio-Maxillofacial Surgery (2004) 32, 370–373

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• 180 Day Prospective, Non-randomized Study

• Uni or Bilateral Elbow OA

• Intra-articular stem cells 1x

• Vet and Owner assessments at pre, 30, 60, 90, 180

• 14 dog study

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1.0

1.5

2.0

2.5

3.0

3.5

0 30 60 90 180

Para

met

er S

core

(1-5

)

Days Since Intraarticular Stem Cell Injection(1=normal)

Elbow OA Pilot Study (n=12)

Lame walk

Lame trot

Pain

Range Motion

Disable

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• 180 Day Study – Blinded/Placebo

• Bilateral Hip OA – 18 dogs

• Intra-articular stem cells – 1X

• Vet/Owner assessments at pre, 30, 60, 90

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• 180 Day Pilot Study, 9 dogs

• Chronic Post-Surgical OA (>3 Mo)

• Intraarticular stem cells – 1X

• Vet and Owner assessments at pre, 30, 90, 180

• Not Blinded

Chronic Knee – Post-surgical OA Pilot Study (n=9)

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0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

0 30 90 180

Para

met

er S

core

(1-

5)

Days Post Stem Cell Treatment1=normal, 2=mild, 3=mod, 4=severe

Chronic Knee - Post-surgical OA Pilot Study (n=9)

V-Lame

V-ROM

V-Pain

O-Lame

O-Stiffness

O-Pain

O-Energy

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Tendon / Ligament Clinical Data

Equine – Blinded, placebo-controlled study1

Equine – Retrospective2 – tendonitis

Equine – Retrospective3 - ligament therapy

Canine – Clinical case studies4

Canine – Retrospective analysis5

Canine – Prospective, non-randomized6 – shoulder instability

1 Nixon et al, AJVR, 20072 Meredith et al, ACVIM, 20063 Harman, VOS, 20074 Bausman, IFATS, 20085 Harman et al, IFATS, 20076 Canapp, AVMA, 2009

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• 8 Horses – 4 treated / 4 controls

• Collagenase induced injury – Rx 10 days later

• Fully blinded histology

• Controls were treated with same volume of saline

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Stem Cell

Treated

Saline Control

Outcome: Less scar - More normal tendon Statistically improved tendon healing

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Why Use Vet-Stem?

• Began treating horses in 2003

• Global patents/licenses (over 55 issued patents)

• Over 3,000 horses and 2,000 dogs treated

• Global leader in stem cell therapy

• Peer-reviewed, published controlled studies

• High quality laboratory

• Human stem cell alliances

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Horses:7/3,359 (0.2%) Only local swelling/pain No systemic effects

Dog: 2/1,695 (0.1%) Only local swelling/pain

No systemic effects

*probable adverse events, through 6/1/09

Safety Profile*

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• Written standard operating procedures

• Independent Quality Assurance Unit

• Routine audits of all procedures

• Sample release criteria

• Formal training systems

• Environmental monitoring

• All Handling Done In Sterile Hoods

Quality Standards

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Resources from Vet-Stem

• Technical training – course & consultation• Case selection - consultation• Cell banking• Lifetime cell supply – Cell Culture Service• Marketing Kit

• Owner email support• Clinic DVD – waiting room• Brochures, posters, counter-top displays• Power Point presentations• Co-op Advertising• Newsletters

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Keys to Success

Credentialing Course (www.vet-stem.com)Complete Diagnostic Work-upRisk Assessment of Concurrent DiseasesProper Collection – close dead spaceProper use of KitProper Injection TechniqueFollow up and Rehab Program

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• Ideal Stem Cell Case• Clearly defined disease – lameness• Non-surgical candidate – surgery first, if needed• Limited intra-articular osteophytes• One or two joints• No other major systemic diseases• No major spinal disease• NSAID – non-responsive or lack of tolerance• Owner has rational expectations

Case Selection for OA

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Cruciate Ligament Diseases and the Uses of Stem Cells

• Surgery – always assess need and make appropriate surgical repairs

• At surgery – adjunct to reduce inflammation and scar tissue

• After surgery – treat the synovitis and encourage cartilage repair

• Chronic ACL inflammation and synovitis

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Current Supported IndicationsCanine/Feline

• Osteoarthritis• Polyarthritis• Tendonitis• Ligament injury

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Service Overview

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Vet-Stem Adipose Processing Lab

1. Immediate use

3. Lifetime supply by culture

2. Frozen for future

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Real World Dog OA Cases

Average Veterinary Scores of Dogs in Regards to Pain, Lameness, and Range of Motion

2008 Commercial Clinical Data*

1.0

1.5

2.0

2.5

3.0

3.5

Pain(N=141, pre-tx)

Lameness(N=146, pre-tx)

Range Of Motion(N=141, pre-tx)

Ve

teri

na

ry S

co

re

Veterinary Scale:5=Extreme (considering euthanasia)4=Severe3=Moderate2=Mild1=Normal

*Voluntary responses from commercial cases.

Day 0 30 60 90 Day 0 30 60 90 Day 0 30 60 90

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Change in NSAID Usage in Dogs Treated with Stem Cells for Osteoarthritis

90 Days Post Stem Cell Treatment 246 Days Post Stem Cell Treatment

survey range: 76 -105 days, N= 170 owner voluntary responses 10/08- 05/09

survey range: 106 - 470 days, N= 139owner voluntary responses 10/08- 05/09

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Conclusion: At 90 and 246 days after treatment

• Greater than 33% of dogs discontinued the use of NSAIDs completely

• Greater than 28% of dogs decreased their dependency on NSAIDs

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Media Coverage of Veterinary Medicine

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Additional Slides

The additional slides that follow are intended to be supplementary information and can be used to emphasize a particular area of the talk or to modify the theme or direction of the talk for the intended audience.

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Mechanisms of Repair

1. Trophic support – growth factors and cytokines

• Anti-scarring - MMPs (reduce scar tissue formation)

• Angiogenic - VEGF (induces new blood vessels)

• Anti-apoptotic (block cell death after injury)

• Stimulation of resident tissue stem cells

Caplan and Dennis, J Cell Biochem, 2006

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Mechanisms of Repair

2. Anti-inflammatory

• Decrease pro-inflammatory mediators

• Increase anti-inflammatory mediators

Tholpady et al, Clin Plastic Surg, 2006

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Mechanisms of Repair

3. Differentiation into tissue

Tholpady et al, Clin Plastic Surg, 2006

(Photo courtesy Cytori Therapeutics)

NerveNerve

BoneBone

CartilageCartilage

LiverLiver

Fat-derivedFat-derivedStem CellsStem Cells

CardiacCardiac

FatFat

Angiogensis/Angiogensis/Anti-apoptosisAnti-apoptosis

Gene TherapyGene Therapy

MuscleMuscle

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Mechanisms of Repair

Damaged cartilage

MSCs

4. Homing to injury site

Photo Courtesy Cognate Therapeutics

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5. Immune System Modulation

Mechanisms of Repair

Stem cells down-regulate the immune system attack on its own nerve sheath myelin.

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Composite Score: Lameness at walk Lameness at trot Pain on manipulation Range of motion Functional disability

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1. Sterile Collection tubes

2. Cryo-block

3. Submission form

4. Owner Consent form

Vet-Stem Adipose Collection Kit

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Adipose Tissue Harvest Falciform Fat

Most preferred collection location due to low risk of seroma and adequate fat source

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Adipose Tissue Harvest Thoracic Approach

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