Sta Stable ble ele eleva vation tions in s in FIX ac FIX - - PowerPoint PPT Presentation

Sta Stable ble ele eleva vation tions in s in FIX ac FIX activity tivity an and d red educ uction tions in s in an annu nualiz alized ed blee bleeding ding rate te over up er up to to 2 y 2 yea ears s of

• f f

follo

• llow-up

up

• f
• f adu

adults lts wi with th se sever ere or mode e or moderate te-se sever ere e he hemop mophili hilia B B tr trea eated ted with with AMT AMT-06 060 (A 0 (AAV5 V5-hF hFIX) IX) ge gene ne the therapy y

• F. Leebeek, MD1, K. Meijer, MD2, M. Coppens, MD3, P. Kampmann, MD4, R. Klamroth, MD5, R.

Schutgens, MD6, G. Castaman, MD7, E. Seifried, MD8, J. Schwäble, MD8, H. Bonig, MD9, E. Sawyer PhD10, W. Miesbach, MD9

1

1Erasmus University Medical Center, Rotterdam, the Netherlands; 2University Medical Center

Groningen, Groningen, the Netherlands;3Academic Medical Center, Amsterdam, the Netherlands;

4Rigshospitalet, Copenhagen, Denmark; 5Vivantes Klinikum, Berlin, Germany; 6University Medical

Center, Utrecht, Netherlands; 7Azienda Ospedaliera Universitaria Careggi, Florence, Italy; 8German Red Cross Blood Service Baden-Württemberg-Hessen, Institute Frankfurt, Frankfurt, Germany;

9Universitätsklinikum Frankfurt, Frankfurt, Germany; 10uniQure biopharma, B.V., Amsterdam, the

Netherlands

2

Disclosures for F Leebeek, MD

CONFLICT DISCLOSURE — IF CONFLICT OF INTEREST EXISTS

Employment

• Erasmus University Medical Center, Rotterdam, the Netherlands

Research support

• CSL Behring, Baxalta/Shire

Travel support Consultancy

• uniQure, Shire, Novo Nordisk

Major stockholder Speakers bureau Honoraria Scientific advisory board Patents Other

Phenotype Spontaneous bleeding Prophylaxis recommended FIX activity Severe frequent yes <1% Moderate rare variable 1-5% Mild very rare no 5-40%

Goal of gene therapy in hemophilia B: Transformation of disease severity Objectives

▪

Control of bleeding with effective protection against spontaneous bleeds

▪

Elimination of the requirement for continuous prophylaxis

▪

Establish long term, multi-year benefit from a one-time procedure

▪

Improvement in quality of life

Adapted from: Srivastava A, et al. Guidelines for the management of hemophilia. Haemophilia 2013

AMT-060: AAV5 capsid with wildtype FIX cassette

1Boutin et al, Human Gen Ther 2010; 21(6):704-12. 2D’Avola et al, Journal of Hepatology 2016; doi: http://dx.doi.org/10.1016/j.jhep.2016.05.012. 3Nathwani et

• al. NEJM 2014; 371:1994-2004. 4Nathwani Oral Presentation, ESGCT October 2016

FIX, factor IX.

AAV5 Capsid

• Low prevalence of clinically-

relevant pre-existing neutralizing antibodies1, 3

• Previously tested in human clinical

trials with no safety signals or detectable immune activation2 Human wild type FIX (codon optimized) LP1 (Liver-specific promoter)

Expression cassette

• Wildtype hFIX
• Clinically demonstrated safe and

durable increases in FIX activity with meaningful improvement in clinical

• utcomes3,4

AMT-060 Phase I/II study: Study objective and trial design

*Prophylaxis was tapered and discontinued by 12 weeks if FIX activity was maintained at ≥2%

Multi-national, multi-center, open label, dose escalating Phase 1 / 2 study to investigate the safety and efficacy of AMT-060 at 2 dose levels in adults with moderate/severe or severe hemophilia B

5 –6 1 12 26 3 –58 Weeks Years

Prophylactic FIX tapering* Cohort 1 (n=5) AAV5-hFIX 5x1012 gc/kg Weekly Every two weeks Quarterly Twice yearly Cohort 2 (n=5) AAV5-hFIX 2x1013 gc/kg Twice weekly Every two weeks Quarterly Twice yearly

Retrospective analysis period Screening

(maximum 6

weeks prior to dosing)

AMT-060 Administration Follow up

FIX, factor IX.

Cohort 1: 2 years Cohort 2: 1.5 years

Study population

▪

Male patients ≥18 years with severe or moderate-severe (FIX ≤2%) hemophilia who required either:

□

Continuous exogenous FIX prophylaxis

□

On-demand exogenous FIX AND either ≥4 bleeds per year or chronic hemophilic arthropathy

▪

Exclusion criteria included:

□

Pre-existing neutralizing AAV5 antibodies measured by green fluorescent protein (GFP) bioassay

□

FIX inhibitors

□

Active Hepatitis B (s and e antigens & HBV DNA) and/or Hepatitis C (HCV RNA)

□

Uncontrolled HIV (CD4+ ≤200/μL or viral load >200 genome copies (gc)/mL)

FIX, factor IX. HBV, hepatitis B virus. HCV, hepatitis C virus. HIV, human immunodeficiency virus. 6

Baseline characteristics

Values for quantitative results are given as mean (min-max) and n for qualitative results a,1 patient received on-demand treatment and is therefore not included; b,1 patient missing historical bleed data; c, measured using a luciferase-based assay; n, number of patients with the characteristic; N, total number of patients in the cohort; HIV, human immunodeficiency virus; FIX, factor IX; IU, international units; nAb, neutralizing antibodies.

7

Variable Cohort 1 (N=5) Cohort 2 (N=5) Age (years) 60.2 (35-72) 38.2 (33-46) Race Black or African American White 5 1 4 FIX prophylaxis (IU/week) 4800 (2000-8000) 5625 (4000-10500)a Bleeds (year prior to enrolment) Total Spontaneous 14.4 9.8 4.0b 3.0 Hemophilia joint health scores 24.4 (2-49) 6.8 (0-17) HIV positive 1 Prior hepatitis C infection 4 2 AAV5 nAb+ by luciferase assayc 3

Stable dose-dependent increases in FIX activity

Values in parentheses represent FIX activity at last clean measurement. Only values at least 10 days after last FIX concentrate administration are included. The dotted line at FIX activity of 2 IU/dL indicates the threshold required for ceasing prophylaxis per protocol . FIX prophylaxis was continued after AMT-060 and tapered between Week 6 and Week 12. *Patient retrospectively tested positive for AAV5 neutralizing antibodies using the luciferase-based assay.3 patients were presumed cross-reactive matter positive. FIX, factor IX; IU, international units. Post treatment period=after end of tapering

8

2 4 6 8 10 12 14 16 18 20

4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76 80 84 88 92 96 100 104 108 112 116

Endogenous FIX activity (IU/dL) Participant 1 (7.5%) Participant 2 (5.6%) Participant 3 (1.1%)* Participant 4 (10.3%)* Participant 5 (3.9%)* 2 4 6 8 10 12 14 16 18 20

4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76 80 84

Participant 6 (11.1%) Participant 7 (8.9%) Participant 8 (8.7%) Participant 9 (4.2%) Participant 10 (7.5%)

Cohort 1

mean FIX activity 95%CI: 4.8 (1.6-8.0)

Cohort 2

mean FIX activity 95%CI 7.2 (3.5-11.0)

Weeks Weeks

FIX activity levels correlated at an approximate 1:1 ratio with FIX protein expression

0.5 1 1.5 2 2.5 3 3.5 4 4.5 Q-4 Q-3 Q-2 Q-1 Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9

Total Spontaneous Total Spontaneous Cohort 1

Sustained reductions in bleeding episodes over time

9

Cohort 2: results presented on 4 participants due to missing historical data from one participant (Participant 10; experienced 1 traumatic bleed in Q3 post-prophylaxis and no spontaneous bleeds). Bleed data were recorded by study participants using an electronic diary and reviewed by the physician at study visits. FIX, factor IX; IU, International units; Q, quarter pre- or post-AMT-060 administration

Mean number of bleeds per quarter relative to the end of prophylaxis

Cohort 2

Quarter relative to discontinuation of prophylaxis post-AMT-060 administration Pre-AMT-060

Cohort 1 (n) 5 5 5 5 5 5 5 5 5 5 5 4 1 Cohort 2 (n) 4 4 4 4 4 4 4 4 4 3 2

Marked reductions in FIX consumption

10

84% reduction in cumulative FIX consumption across all 10 patients Cohort 1 Cohort 2 Pre-AMT-060 (IU) 1,774,000 866,000 Post-AMT-060 (IU) 235,062 193,492 % decrease 87 78

Safety: Treatment Emergent Adverse Events classified as possibly / probably related to treatment (TRAE)

TEAE, treatment emergent adverse event; FIX, factor IX

11

TRAE n (E) Cohort 1 (N=5) n (E) Cohort 2 (N=5) Any TRAE 3 (4) 3 (11) Liver enzyme increased 1 (1) 2 (3a) Pyrexia 1 (1) 2 (2) Anxiety 1 (1) 1 (1) Drug ineffective 1 (1) Palpitations 1 (1) Headache 1 (1) Prostatitis 1 (1) Rash 1 (1)

n, Number of patients with events; (E), Number of events;

a2 events reported in the same patient

Treatment Related Serious Adverse Events

▪ 1 patient: short, self-limiting fever in

first 24 hours post-AMT-060

▪ 2 patients (1 in each cohort): mild,

asymptomatic elevations in liver enzymes Overall…

▪ No new TRAEs were observed during

the last 6 months of observation post- treatment

▪ No inhibitors were detected in any

patient

ALT elevations resolved without activation of capsid-specific T-cells or loss of FIX activity

Participant 7 received concomitant treatment with ciprofloxacin and reported alcohol intake at week 9 and 52.

• ---- ALT upper limit of normal (40 U/L); ALT, alanine aminotransferase; nAb, neutralizing antibody

12

20 40 60 80 20 40 60 80 10 20 30 40 50 60 70 80 90 100 110 ALT (U/L) Endogenous FIX activity (IU/L) Weeks after AMT-060 infusion FIX ALT

Cohort 1 Participant 1

20 40 60 80 20 40 60 80 10 20 30 40 50 60 70 80

Cohort 2 Participant 7 Prednisone course

20 40 60 80 20 40 60 80 10 20 30 40 50 60 70 80

Cohort 2 Participant 6

▪ ALT elevations were present in 3/10 patients:

▪ ALT elevations resolved without recurrence following a tapering course of prednisolone ▪ FIX activity remained stable

▪ No cellular immune response detected by ELISPOT

▪ No liver enzyme abnormalities in patients with AAV5 nAbs at

baseline as measured by the luciferase-based assay

Exploratory quality of life and clinical outcomes

SF-36v2

▪

At baseline, Cohort 1 generally scored lower than Cohort 2 on domains related to physical health (physical functioning, role physical, pain, and general health)

□

Mean physical component scorea (norm = 50; SD = 10)

▪ Cohort 1: 43.7 (baseline) to 44.1 (at 2 years) ▪ Cohort 2: 53.1 (baseline) to 47.0 (at 1 year)

▪

Interpret with caution due to small study size

▪

Need for more specific quality of life measurements targeted to patients with hemophilia Hemophilia Joint Health Score (HJHS)

▪

Cohort 1: Mean score of 24.4 at baseline and 20.0 at 2 years

▪

Cohort 2: Mean score of 6.8 at baseline and 9.0 at 1 year

• a. The Physical Component Score is calculated using weighted scores across 8 domains.

13

Conclusions

▪ AMT-060 continued to be generally well tolerated throughout the trial

□

No development of FIX inhibitors

□

No new adverse events of ALT elevation or capsid-specific T-cell activation observed since last report

▪ Clinical benefit endured in all patients

□

Clinically relevant FIX activity persisted for the duration (up to 2 years) of follow up

□

Continued reductions in bleeds over time in both cohorts

▪ No bleeds in Cohort 2 in last 9 months □

All patients who discontinued prophylaxis remain prophylaxis-free (8/8)

▪ Annualized FIX consumption decreased by 84% (2.64 million IU to 428,554 IU) □

Patient’s health status perception generally improved or remained stable

▪ Effects on QoL will be further explored in subsequent trials

ALT, alanine aminotransferase; FIX, factor IX; IU, International units; QoL, quality of life 14

Next steps: Phase IIb and Phase III with AMT-061

• 1. Simioni et al, NEJM 361(17) 2009

15

• AMT-061 includes a single point

mutation in the FIX gene in the AMT- 060 gene cassette resulting in R338L switch in the final protein (Padua mutation)

• Padua mutation previously reported to

increase specific activity 8-9 fold1

• Initial studies in cynomolgus macaques

demonstrate:

• Similar safety profiles
• Approximate 6-7 fold increase in

baseline-corrected clotting activity

• A pivotal Phase III study investigating

the safety and efficacy of AMT-061 in humans is scheduled for 2018 Poster #2058 Ying Poi Liu, Dec 9, 5.30-7.30pm

Nonhuman primates

Acknowledgments

We thank the participating patients and their families

▪

Academic Medical Center Amsterdam: M. Coppens, L. Landman, M. van Maarseveen, K. Nooij, M. Kemper, C. Ris – Stalpers.

▪

Azienda Ospedaliera Universitaria Careggi Florence: G. Castaman.

▪

Erasmus Medical Center: F. Leebeek, M. Kruip, A. Beishuizen, G. Mulders, E. van der Graaf, R. Van Lommel, R. Bouamar, C. Bakker.

▪

Fondazione IRCCS Cà Granda Ospedale Maggiore Milan: F. Peyvandi.

▪

Rigshospitalet Copenhagen: P. Kampmann, E. Funding, R. Duus Müller, R. Svensgaard,

• C. Nielsen, Mette Nordahl Rahbek.

▪

University Hospital Frankfurt am Main: W. Miesbach, J. Schwäble, S. Gundermann, K. Scholz, H. Bönig, E. Seifried.

▪

University Medical Center Groningen: K. Meijer, F. Yspeerd, K. Thedinga, M. Voskuilen,

• B. Molmans, M. Segers, B. Waarts.

▪

University Medical Center Utrecht: R. Schutgens, P. van der Valk, E. Beers, D. Dekker, M. van Haaften-Spoor, S. Oortwijn-De Loo, A. Braem-Enneman, M. Timmer, H. Aanstoot.

▪

Vivantes Klinikum Berlin: R. Klamroth, C. Kubicek-Hofmann, A. Orlovic, Y. Limberg.

16