Insights from the First Trials in Epigenetics in Humans: What is the - - PowerPoint PPT Presentation

Insights from the First Trials in Epigenetics in Humans: What is the Way Forward?

Stephen Nicholls MBBS PhD @SAHMRI_Heart

Residual Clinical Risk in Statin Trials

20 40 60 80 100

4S JUPITER WOS AF/Tex LIPID CARE HPS 2o PREVENTION 1o PREVENTION HIGH RISK

Percent of Events

Residual Events Prevented Events

BET

BD1 BD2 ET

Ac Ac Ac

Increased ApoA-I mRNA

bromodomain Extraterminal Domain (ET) Other transcriptional proteins RVX-208

Ac Ac BET Ac

An Epigenetic Approach to CVD?

Stimulate ApoA-I Synthesis

SR-BI ABCA1 ABCG1 10 20 30 40

Vehicle RVX-208

Percent Cholesterol Efflux Efflux Capacity of Serum Isolated Following 28 Days of Treatment

Bailey JACC 2010; 55:2580-9

Potential Mechanistic Effects Linking Apabetalone to CV Risk Reduction

Vascular Inflammation Reverse Cholesterol Pathway Metabolism Vascular

Calcification

Coagulation Pathway Complement Pathway

Epigenetic Regulation

Apabetalone in the Clinic

• 985 participants in completed trials
• 706 received treatment with apabetalone, including

576 patients with CAD and/or dyslipidemia on top of standard of care

• Three phase 2 studies completed in CAD patients

– ASSERT: 12 weeks in 299 patients – SUSTAIN: 24 weeks in 176 patients – ASSURE: 26 weeks in 323 patients

• Ongoing phase 3 CVOT (BETonMACE) recruiting

Early Effects of Apabetalone in CAD Patients

Parameter Placebo (n=74) RVX-208 P Value 100 mg (n=76) 200 mg (n=75) 300 mg (n=74) ApoA-I 0.9 0.1 3.8 5.6 0.02 HDL-C 3.2 6.3* 8.3** 0.02 Large HDL

• 0.5

11.1 20.2** 21.1*** 0.003 Small HDL 2.6

• 0.4
• 2.6
• 4.0

0.07 α1 HDL

• 2.3

3.7 8.0* 8.8* 0.12

* P<0.05, ** P<0.01 and *** P<0.001compared with placebo

Nicholls JACC 2010; 57:1111-9

Placebo RVX-208

• 0.50
• 0.25

0.00

P=0.81†

• 0.30

P=0.23*

• 0.40

P=0.08*

Change Percent Atheroma Volume

ASSURE: Change in Percent Atheroma Volume

* Primary endpoint: comparison from baseline † comparison between groups.

• 6
• 3

3

Percentage Change

Fibrous Calcific Necrotic Fibro-fatty

P=0.002 P=0.34 P=0.007 P=0.37 P=0.84 P<0.001 P=0.04 P=0.27 P=0.04* P=0.09* P=0.37* P=0.46*

ASSURE: VH Measures of Plaque Composition

Placebo RVX-208

Expressed as LS mean change P values for comparison with baseline *P value for comparison with placebo

Attenuated Plaque as a Measure

• f Vulnerability

J Pu et al. J Am Coll Cardiol 2014;63:2220-33

Percent Change in Biochemical Parameters

Characteristic No Attenuated Plaque (n=216) Attenuated Plaque (n=27) P Value

Age (years) 58.5 62.0 0.06 Males (%) 76.4 88.9 0.22 BMI (kg/m2) 29.4 28.7 0.80 Hypertension (%) 79.6 77.8 0.80 Diabetes (%) 30.6 37.0 0.51 LDL-C (mg/dL) 96.0 85.0 0.07 HDL-C (mg/dL) 39.0 39.0 0.55 hsCRP (mg/L) 2.2 2.5 0.63 PAV (%) 37.5 43.8 0.007 TAV (mm3) 193.6 245.0 0.005

Apabetalone Reduces ALP Activity in Phase 2 Clinical Trials

Apabetalone Reduces Osteoprotegerin Levels

7,8

• 6,2
• 10
• 5

5 10 15

Placebo (n=47) Apabetalone 200mg daily (n=47) 6-months treatment

Median Percentage Change From Baseline

**

Plasma Osteoprotegerin: ASSURE trial

1 2 3 4 5 6

• DMSO

5µM 208 25µM 208 DMSO 5µM 208 25µM 208 DMSO 5µM 208 25µM 208 DMSO 5µM 208 25µM 208 Day 0 Day 3 Day 7 Day 14 Day 21

Fold Change mRNA relative to Day 0 Osteoprotegerin Expression in Human Coronary Artery Smooth Muscle Cells: Time Course

Apabetalone Reduces Expression

• f Factors Involved in Calcification

Apabetalone downregulates expression of genes related to vascular calcification in microarrays from whole blood treated ex-vivo (fold change) Apabetalone downregulates expression of genes related to vascular calcification in primary human hepatocytes microarrays (fold change) Apabetalone downregulates expression of calcification related genes in LPS stimulated U937 macrophages

Apabetalone Downregulates Pathways Associated with Vascular Calcification in CKD

Phase I, Safety & PK Study: Healthy Control Subjects (n=8) versus CKD (stage IV) Patients (n=8) treated with single 100 mg dose of Apabetalone, 12 hours post dose

(Ingenuity Pathway Analysis of SOMAscan proteomic assessment) Bioinformatics (IPA) Analysis of the Plasma Proteome (SOMAscan™)

Pathway Upregulated in CKD vs controls P-value

BMP signaling pathway

IPA z-score: 2.12 (predicted upregulation in CKD) 0.0000062

RANK signaling in osteoclasts

IPA z-score: 1.89 (predicted upregulation in CKD) 0.00033

Pathways associated with VC are elevated in CKD vs controls AT BASELINE Apabetalone downregulates pathways associated with VC in CKD patients AT 12 Hours

Bioinformatics (IPA) Analysis of the Plasma Proteome (SOMAscan™)

Pathway Response to apabetalone P-value

BMP signaling pathway

IPA z-score: -2.45 (predicted downregulation) 0.00027

RANK signaling in osteoclasts

IPA z-score: -2.65 (predicted downregulation) 0.00018

*no modulation of either pathway in controls

Apabetalone has Favorable Effects on Vascular Inflammation

Apabetalone reduces expression of PARC (CCL18), MCP-1,

• steopontin (SPP1), IL-6 and VCAM-1 in blood and endothelial cells

(PBMCs, HAECs, U937 – resting and stimulated)

0,2 0,4 0,6 0,8 1 1,2 1,4 1,6 0,1 1 10 100 Fold Change (relative to DMSO) Apabetalone (uM) PARC MCP-1 SPP1 0,2 0,4 0,6 0,8 1 1,2 1,4 1,6 0,01 0,1 1 10 100 Fold Change (relative to DMSO) Apabetalone (uM) MCP-1 VCAM 0,2 0,4 0,6 0,8 1 1,2 1,4 1,6 1 10 100 Fold Change (relative to DMSO) Apabetalone (uM) SPP1, 24h LPS SPP1, Naive MCP-1, 24h LPS MCP-1, Naive 0,2 0,4 0,6 0,8 1 1,2 1,4 1,6 0,01 0,1 1 10 100 Fold Change (relative to DMSO) Apabetalone (uM) IL-6

Apabetalone Treatment of PBMC (3h) Apabetalone Treatment of HAEC (TNFα 3h) Apabetalone Treatment of Macrophage Cell Line (LPS 24h) Apabetalone Treatment of Macrophage Cell Line (LPS 3h)

Apabetalone Reduces Atheroma in Aorta of ApoE-/- Mice

4

Protein Name Placebo N=30 p-value vs baseline apabetalone 200mg daily N=25 p-value vs baseline Δ treated vs. placebo p-value vs placebo Metalloproteinase inhibitor 2 (TIMP2) * * * Metalloproteinase inhibitor 1 (TIMP1) * * Protein Name Placebo N=30 p-value vs baseline apabetalone 200mg daily N=25 p-value vs baseline Δ treated vs. placebo p-value vs placebo C-reactive protein (CRP) * * RANTES (CCL5) * sTWEAK (TNFSF12) * * Osteopontin (SPP1) * * PARC (CCL18) * * Epiregulin (EREG) * * TNFSF14 * * Pappalysin-1 (PAPPA) * *

ASSERT Clinical Data : anti-inflammatory and plaque-stabilizing effects

Apabetalone Reduces Levels of Vascular Inflammation Proteins in CVD Patients

* = p<0.05 †p<0.10

Apabetalone Reduces Levels of Vascular Inflammation Proteins in CVD Patients

Protein Name Placebo N=47 p-value vs baseline apabetalone 200mg daily N=47 p-value vs baseline Δ treated vs. placebo p-value vs placebo C-reactive protein (CRP) * * * Pappalysin-1 (PAPPA) * * Vascular cell adhesion protein 1 (VCAM1) * * Serum amyloid P-component (APCS) * * Protein Name Placebo N=47 p-value vs baseline apabetalone 200mg daily N=47 p-value vs baseline Δ treated vs. placebo p-value vs placebo Stromelysin-1 (MMP3) * * Macrophage metalloelastase (MMP12) * *

ASSURE clinical data: anti-inflammatory and plaque- stabilizing effects

18

* = p<0.05 †p<0.10

Clinical Characteristics and Medication Use

Characteristic Placebo (n=242) Apabetalone (n=556) P Value

Age (years) 59.7 61.4 0.03 Male (%) 69.0 75.5 0.05 BMI (kg/m2) 30.7 30.2 0.25 Hypertension (%) 82.6 82.4 0.93 Dyslipidemia (%) 46.7 64.4 <0.001 Prior CVD (%) 91.3 94.2 0.13 Diabetes (%) 35.1 35.1 0.99 Smoker (%) 25.2 23.6 0.62

Percent Change in Biochemical Parameters

Characteristic Placebo (n=242) Apabetalone (n=556) P Value

ApoA-I +2.7%*** +6.7%*** <0.001 ApoB

• 3.9%***
• 4.6%***

0.19 HDL-C 0% +6.5%*** <0.001 LDL-C

• 3.6%***
• 5.0%**

0.33 Triglycerides

• 1.4%

+3.9%* 0.54 Total HDL particles +0.5% +4.8%*** <0.001 Large HDL particles +1.7%* +23.3%*** <0.001 Total LDL particles 0%

• 2.2%

0.77 hsCRP

• 13.3%**
• 21.1%***

0.04

* P<0.05, ** P<0.01 and *** P<0.001 compared with baseline

Less CV Events with Apabetalone in Pooled Phase 2 Studies

44% RRR p=0.0232 0% 3% 6% 9% 12% 20 40 60 80 100 120 140 160 180 200 220 Days Since Randomization Apabetalone (n=556) Placebo (n=242) 15%

Less CV Events with Apabetalone in Patients with Diabetes

Diabetic Patients 57% RRR p=0.0181 Non-Diabetic Patients 31% RRR p=0.3037 0% 3% 6% 9% 12% 15% 20 40 60 80 100 120 140 160 180 200 220 Days Since Randomization Apabetalone Diabetics (n=195) Apabetalone Nondiabetics (n=361) Placebo Diabetics (n=85) Placebo Nondiabetics (n=157)

Less CV Events with Apabetalone in Patients with Elevated CRP Levels

Elevated CRP Patients 62% RRR p=0.0166 Normal CRP Patients

• 46% RRR

p=0.7932 0% 3% 6% 9% 12% 15% 20 40 60 80 100 120 140 160 180 200 220 Days Since Randomization Apabetalone Elevated CRP (n=290) Apabetalone Normal CRP (n=264) Placebo Elevated CRP (n=133) Placebo Normal CRP (n=108)

Apabetalone Adverse Events

24

• Across the three studies (ASSERT/SUSTAIN/ASSURE)

most common AEs were similar to placebo:

– gastrointestinal disorders (nausea, diarrhea, and constipation)

– infections (upper respiratory tract infection, sinusitis, and bronchitis)

• With few exceptions these findings were mild and moderate

in severity

• Most clinically significant adverse event is raised hepatic

transaminases

Confidential 28 Aug 2016

Hepatic Adverse Events

25

• Hepatic profile of apabetalone evaluated in detail
• Incidence of transaminases >3X ULN 7-8%
• No cases of Hy’s law or serious hepatic injury to date in

>1000 subjects

• Raised transaminases resolve rapidly (approx 15 days for 5X

to <ULN)

• More data to be obtained from BETonMACE study to further

delineate both early and long term hepatic safety

Confidential 28 Aug 2016

BETonMACE

2,400 + subjects

• double blinded
• 1-2 week statin run-in

atorvastatin and rosuvastatin run-in apabetalone 200mg daily + standard of care placebo + standard of care safety follow-up safety follow-up standard of care includes 20-80 mg atorvastatin

• r 10-40 mg rosuvastatin

screening 1-2 weeks treatment duration up to 104 weeks 4-16 weeks randomization (1:1) end of treatment The study is an event-based trial and continues until 250 events have occurred.

Key inclusion criteria

• T2DM
• HbA1c > 6.5% or history of diabetes

medications

• CAD event 7 days - 90 days prior to Visit 1
• MI, UA or PCI
• HDL < 1.04 for males and < 1.17 for females

Primary Objective To evaluate if treatment with apabetalone as compared to placebo increases time to the first

• ccurrence of triple MACE. Triple MACE is defined

as a single composite endpoint of CV death or non-fatal MI or stroke. Primary Endpoint Time from randomization to the first

• ccurrence of adjudication-confirmed triple

MACE defined as a single composite endpoint of CV Death or Non-fatal MI or Stroke. Secondary Endpoint Time from randomization to the first

• ccurrence of adjudication-confirmed MACE

including revascularization and UA Changes in apoA-I, apoB, LDL-C, HDL-C, and TG Changes in HbA1c, fasting glucose, and fasting insulin Changes in ALP and eGFR

BETonMACE CV Outcomes Study

27 28 Aug 2016

Summary

• Apabetalone is a first in class BET-inhibitor that regulates

genes and pathways that underlie development of CVD

• In phase 2 clinical trials, CVD event reductions were found

which were most pronounced in patients with diabetes mellitus or increased inflammation

• BETonMACE is an ongoing pivotal phase 3 trial designed to

confirm if apabetalone can prevent CVD events in post-ACS patients with T2DM and low HDL cholesterol

28 Aug 2016