Targeting PCSK9 Expanding knowledge and targeting new frontiers - PowerPoint PPT Presentation

Targeting PCSK9 Expanding knowledge and targeting new frontiers John JP Kastelein, MD, PhD, FESC University of Amsterdam The Netherlands

DISCLOSURES John JP Kastelein Professor Kastelein is a consultant for Akcea, AstraZeneca, CiVi Biopharma, Corvidia, CSL Behring, Daiichi Sankyo, Draupnir, Esperion Therapeutics, Gemphire, Madrigal Pharma, Matinas Bio, The Medicines Company, NorthSea Therapeutics, Novartis, Novo, Regeneron, REGENXBIO, Staten Bio 2 ORION-3 for NLA Version 8.0

Summary of Effects of PCSK9i Evolocumab  LDL-C by 59% down to a median of 30 mg/dl •  CV outcomes in patients on statin • • Safe and well-tolerated HR 0.85 (0.79-0.92) P<0.0001 Placebo 14,6 15 HR 0.80 (0.73-0.88) 12,6 59% reduction P<0.0001 KM Rate (%) at 3 Years P<0.00001 9,9 10 7,9 Absolute  56 mg/dl 5 Evolocumab (median 30 mg/dl, IQR 19-46 mg/dl) 0 CVD death, MI, CVD death, MI, stroke stroke, UA, cor revasc An Academic Research Organization of Sabatine MS et al. NEJM 2017;376:1713-22 Brigham and Women’s Hospital and Harvard Medical School

LDL Cholesterol 2034 patients w/ baseline LDL-C<70 mg/dL 100 90 Placebo 80 (median 66 mg/dl, IQR 56-78 mg/dl) (median 1.7 mmol/L, IQR 1.4-2.0 mmol/L) LDL Cholesterol (mg/dl) 70 60 50 66% mean reduction (95%CI 62-69), P<0.00001 40 30 20 Evolocumab 10 (median 21 mg/dl, IQR 11.5-37 mg/dl) (median 0.5 mmol/L, IQR 0.3-1.0 mmol/L) 0 0 12 24 36 48 60 72 84 96 108 120 132 144 Weeks An Academic Research Organization of Giugliano RP et al. and Sabatine MS. JAMA Cardiol 2017;2:1385-91 Brigham and Women’s Hospital and Harvard Medical School

Clinical Outcomes by Baseline LDL-C CVD, MI, stroke, UA, or cor revasc HR (95% CI) P interaction 0.85 (0.79-0.92) All Patients Baseline LDL-C <70 mg/dL 0.80 (0.60-1.07) 0.65 Baseline LDL- C ≥70 mg/ dL 0.86 (0.79-0.92) 0.4 1.0 2.5 CVD, MI, or stroke 0.80 (0.73-0.88) All Patients Baseline LDL-C <70 mg/dL 0.70 (0.48-1.01) 0.44 Baseline LDL- C ≥70 mg/ dL 0.81 (0.73-0.89) 0.4 1.0 2.5 EvoMab better Pbo better An Academic Research Organization of Giugliano RP et al. and Sabatine MS. JAMA Cardiol 2017;2:1385-91 Brigham and Women’s Hospital and Harvard Medical School

Benefit of EvoMab Based on Multivessel Disease Multivessel Disease No Multivessel Disease 11% RRR 30% RRR 12.6% D 3.4% HR 0.89 HR 0.70 NNT 29 CV Death, MI, or Stroke (95% CI 0.58-0.84) (95% CI 0.79-1.00) P=0.055 P<0.001 9.2% 8.9% 7.6% Placebo D 1.3% NNT 78 Evolocumab P interaction =0.03 0 6 12 18 24 30 36 0 6 12 18 24 30 36 An Academic Research Organization of Months after Randomization Sabatine et al. Circ 2018;138:756-66 Brigham and Women’s Hospital and Harvard Medical School

CV Death, MI or Stroke in Patients w/ & w/o Peripheral Artery Disease An Academic Research Organization of Bonaca MP et al. & Sabatine MS. Circulation 2018;137:338-50 Brigham and Women’s Hospital and Harvard Medical School

Major Adverse Limb Events An Academic Research Organization of Brigham and Women’s Hospital and Harvard Medical School Bonaca MP et al. & Sabatine MS. Circulation 2018;137:338-50

Conclusions 1. Evolocumab reliably reduces LDL-C by ~60% 2. Reduces risk of major vascular events in Pts w/ ASCVD already on statin • Confirms benefit from lowering LDL-C to <1 mM • Benefit grows over time 3. Largest absolute risk reductions in Pts w/ highest baseline risk & largest amount of athero • Diabetes, CKD • Closer to MI, multiple prior MIs, multivessel CAD • PAD An Academic Research Organization of Brigham and Women’s Hospital and Harvard Medical School

BACKGROUND & RATIONALE Safety & efficacy of inclisiran not known beyond 1-year In ORION-1: • 300mg inclisiran given on day 1 & 90 demonstrated safe lowering of LDL- C by ≥50% and up to 88% ─ with minimal variability and at least 6 -months persistence 1 • Subjects were followed up to 1-year Could ORION-3 extend the treatment period for ORION-1 inclisiran subjects to enable the assessment of long-term safety and efficacy? 1. Ray KK et al. N EnglJ Med 2017; 376:1430-1440 10 ORION-3 for NLA Version 8.0

METHODS ORION-3 Group-1 baseline 1 characteristics (N = 290) Representative of a typical moderate/high-risk ASCVD population Age 63.3 (11.1) Mean years (SD) Male 188 (65%) N (%) Diabetes 70 (24%) N (%) Prior PCI 125 (43%) N (%) MI 104 (35%) N (%) CABG 47 (16%) N (%) Hypertension 193 (67%) N (%) Current statin use 232 (80%) N (%) PCSK9 Mean ng/dL( ± SD) 428.4 (128.5) LDL-C Mean mg/dL( ± SD) 130.1 (57.3) 1. Baseline for ORION-1 11 ORION-3 for NLA Version 8.0

OBJECTIVES Investigate the long-term safety and efficacy of inclisiran Safety: Incidence of adverse events and laboratory changes Efficacy: LDL-C, PCSK9 and other lipid parameters on day 210 of ORION-3 LDL-C, PCSK9 over the time course of ORION-1 & 3 combined 12 ORION-3 for NLA Version 8.0

METHODS Design of investigation Total ~3 years treatment & observation 13 ORION-3 for NLA Version 8.0

RESULTS Excellent tolerability and safety Highly consistent profile throughout ORION-1 and ORION-3 over ~3 years • Injection site reactions infrequent, mild-moderate and transient • No LFT elevations considered related to inclisiran • No myalgias or CPK elevations considered related to inclisiran • No renal adverse events or thrombocytopenia considered related to inclisiran • One cerebrovascular accident death in ORION-3 related to underlying ASCVD 14 ORION-3 for NLA Version 8.0

RESULTS Persistent and robust efficacy Group-1 primary endpoint: Percent change in LDL-C on day 210 of ORION-3 Day 210 change from baseline 1 ITT p-value - 51% < 0.001 Mean (SD) (28) All patients (N=290) - 64 mg/dL < 0.001 Mean(SD) (39) LDL-C - 56% < 0.001 Mean(SD) (18) Patients randomized to 300 mg 2 dose starting regimen (N = 61) - 73 mg/dL < 0.001 Mean (SD) (31) PCSK9 - 77% < 0.001 Mean(SD) (8) Non HDL-C - 43% < 0.001 Mean(SD) (24) HDL-C + 9% ns Mean(SD) (15) Triglycerides - 6% ns Mean(SD) (42) 1. Average 22 months from baseline at the start of ORION-1 15 ORION-3 for NLA Version 8.0

RESULTS Long-term effect of 300 mg inclisiran on LDL-C Consistent lowering of LDL-C >50% with no loss of effect over ~3 years 16 ORION-3 for NLA Version 8.0

POTENTIAL IMPLICATIONS What could this mean for ongoing blinded Phase III trials? Inclisiran expected to lower LDL- C ≥50% and MACE by ≥ 25% ORION-9 ORION-10 ORION-11 HeFH U.S.ASCVD EU ASCVD/RE N = 482 N = 1561 N = 1617 Baseline LDL-C 161 mg/dL 110 mg/dL 112 mg/dL Simulation using dose-PD response model 1 o endpoint: Day 510 % LDL reduction 54% 54% 54% Time-averaged % LDL-C reduction 51% 51% 51% LDL-C reduction calculated 82 mg/dL 56 mg/dL 57 mg/dL Estimated 5 year MACE RRR 1 44% 30% 31% 1. MACE relative risk reduction estimate assumes 50% of effect year-1; 100% of effect thereafter; based on Cholesterol Treatment Tr ialists’ (CTT) Collaboration ( Baigentat al, 2005) 17 ORION-3 for NLA Version 8.0

18 ORION-3 for NLA Version 8.0

ORAL PCSK9 INHIBITION Promises and challenges of oral PCSK9 inhibition • A small molecule oral PCSK9i is expected to reduce costs and confer convenience to patients • A cost effective pricing will significantly reduce the barriers for patient access to PCSK9i • Development of small molecule PCSK9i has proven very challenging from a medicinal chemistry perspective • Draupnir Bio is developing the first orally available PCSK9 inhibitor 19 ORION-3 for NLA Version 8.0

ORAL PCSK9 INHIBITION PCSK9 activity depends on heparan sulfate proteoglycans (HSPG) • In the absence of PCSK9, LDLR removes LDL particles by endocytosis • LDL is metabolized in lysosomes while LDLR recycles • PCSK9 binds to HSPG on hepatocytes and the PCSK9/HSPG complex hijacks LDLR for degradation 20 ORION-3 for NLA Version 8.0

ORAL PCSK9 INHIBITION Removal of HSPG/blocking PCSK9/HSPG binding protects the LDL receptor • Enzymatic removal of heparan sulfate 5 min before PCSK9 injection, results in complete LDLR protection in the liver of mice. • mAb 5E11 restores PCSK9- Evolocumab: mAb 5E11: induced reductions in LDL uptake to a similar extent as evolocumab 21 ORION-3 for NLA Version 8.0

ORAL PCSK9 INHIBITION Structure-based design of small molecule PCSK9i PCSK9/HSPG binding involves several residues known from PCSK9 LOF variants 1. PCSK9/HSPG 2. PCSK9/HSPG/LDLR complex PCSK9 LDLR HSPG Heparan sulfate Plasma R93C LOF variant confers 50% reduction in risk of CAD membrane Tang et al. Nature Commun 2017 3. LDL receptor degradation 22 ORION-3 for NLA Version 8.0

ORAL PCSK9 INHIBITION Draupnir PCSK9i increases LDL uptake and acts in synergy with statins 23 ORION-3 for NLA Version 8.0

ORAL PCSK9 INHIBITION Draupnir PCSK9i reduces cholesterol and plaque burden in mice 24 ORION-3 for NLA Version 8.0

ORAL PCSK9 INHIBITION Clinical development of oral PCSK9i • Draupnir is moving lead compound towards first in-human trials • Lead compound has unique mechanism of action and may provide therapeutic benefits by conferring additional protection of the vascular endothelium 25 ORION-3 for NLA Version 8.0

Conclusion Exciting times ahead! Acknowledgements: Thanks to the Medicines Company and Draupnir Bio for providing the data 26 ORION-3 for NLA Version 8.0