aln-cc5 an investigational rnai therapeutic for the ... · • c5 silencing results in the...

1

ALN-CC5 An Investigational RNAI Therapeutic for the

Treatment of Complement-Mediated Diseases: Interim

Phase 1 Data in Healthy Volunteers and Efficacy in Pre-

Clinical Animal Models of MG

Anna Borodovsky, Linda L. Kusner, Jorg Taubel, Jim Bush,Noriyuki Kawahata, Helen Mclean, Angela Partisano, Jae Kim, Henry Kaminski, Nader Najafian

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ALN-CC5 and Complement-Mediated Diseases

Excessive complement activity drives disease pathophysiology in many indications

• Paroxysmal nocturnal hemoglobinuria (PNH)

• Myasthenia gravis (MG)

• Atypical hemolytic uremic syndrome (aHUS)

• Neuromyelitis optica (NMO)

• Many others

Complement C5 is a genetically validated target

• Human C5 deficiency associated with minimal complications

◦ Increased susceptibility to Neisseria infections

Complement C5 is a clinically validated target

• Eculizumab is an anti-C5 mAb

◦ Approved for use in PNH and aHUS

◦ Recently released Phase 3 data in MG

◦ Ongoing Phase 3 trial in NMO

Initiation

C3 Convertase

C5 Convertase

Terminal Pathway

Factor B

Alternative Pathway Classical Pathway Lectin Pathway

C3 C1

C3C4 and C2

C3b

C3bBb C4bC2a

C3a Opsonization

Inflammation

C3bBbC3b C4bC2aC3b

C5a

C5b

Membrane attack complex (MAC)

C5b-C9

ALN-CC5C5

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RNAi Therapeutics

Harness natural pathway

New Class of Innovative Medicines

Catalytic mechanism

Silence any gene in genome

Upstream of today’s medicines

Clinically proven approach

4

ALN-CC5: SC-Administered GalNAc-

Conjugated siRNA Targeting C5

ALN-CC5• siRNA conjugated to N-acetylgalactosamine

(GalNAc) ligand

• Efficient delivery to hepatocytes following subcutaneous (SC) administration

• Wide therapeutic index

• Utilizes enhanced stabilization chemistry (ESC)◦ Significantly improved potency and durability

Recognition of GalNAc ligand by asialoglycoprotein receptor (ASGPR)• Highly expressed in hepatocytes

• High rate of uptake

• Recycling time ~15 minutes

• Conserved across species

(GalNAc)3

ASGPR

(pH>5)

ALN-CC5

Clathrin-coated pit

Clathrin-coated

vesicle

Endosome

Recycling

ASGPR

mRNA

Nucleus

C5 protein

RISC

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Myasthenia Gravis (MG) Pathophysiology

Complement has been known to play a significant role in AChR + MG

for decades

• Multi-modal combination therapy required to achieve optimal outcomes

Conti-Fine, J Clin Invest. 2006 Nov;116(11):2843-54

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Evaluation of C5 Silencing in Rat EAMG

Passive Model

• Induced by injection of anti-AChR monoclonal antibody

• Directed at the NMJ by a complement binding antibody

◦ Treatment with anti-C5 mAb blocks disease development

• Very rapid course – animals show weakness in 24 hrs

◦ Pretreatment needed to evaluate siRNA silencing

Active Model

• Induced by immunization with AChR protein in CFA

• Rats develop an endogenous polyclonal Ab response to AChR

• Animals show weakness in 30-45 days

◦ Therapeutic siRNA treatment after symptom development can be assessed

Rodent MG models share key features of human MG

• Complement deposition, AChR loss and comparable ultrastructural at the NMJ

• Impairment of neuromuscular transmission

• MG patient IgG can transfer disease to rodents

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Protection in Passive EAMG with C5 Silencing

C5 silencing prevents disease development in a passive transfer model of MG

in the rat

• Significant reduction in disease activity for both siRNA treatment levels

◦ Decrease in disease severity seen at 40% reduction of complement activity

Collaboration with Linda Kusner and Henry Kaminski

Complement Activity Disease Activity Score

D2D-10

Anti-AChR

C5 siRNA

D-7 D-3 D1D0

-1 2 -1 0 -8 -6 -4 -2 0 2 4

0

2 0

4 0

6 0

8 0

1 0 0

1 2 0

S tu d y d a y s

% H

em

oly

sis

S aline

2 .5 m g/kg s iR N A

5 m g/kg s iR N A

S a lin e 2 .5 m g /k g 5 m g /k g

0 .0

0 .5

1 .0

1 .5

2 .0

2 .5

3 .0

cli

nic

al

dis

ea

se

sc

ore

2 4 h r s

4 8 h r s

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Reduction in MAC Deposition and AChR Preservation

• Significant reduction in MAC deposition at the NMJ and improvement in AChR

level

• Improvement in grip strength and lack of weight loss also observed

• Suggest a key role for circulating C5 at driving NMJ damage

Passive EAMG

MAC Staining AChR Staining

C o n tro l 2 .5 m g /k g 5 m g /k g

2 0

3 0

4 0

5 0

6 0

M A C

Me

an

In

ten

sit

y

**

***

C o n tro l 2 .5 m g /k g 5 m g /k g

0

1 0

2 0

3 0

4 0

5 0

A C h R

Me

an

In

ten

sit

y

*

*

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Disease Reversal in the Active EAMG Model

Treatment with C5 siRNA results in disease reversal/stabilization

• Therapeutic C5 silencing initiated on Day 36

◦ 5 mg/kg 2xweek regimen

• ~80% reduction in hemolytic activity with C5 silencing

• Improved grip strength with C5 silencing, no effect on anti-AChR antibody levels

• Evaluation of MAC deposition at NMJ ongoing

Complement Activity Disease Activity Score

5 mg/kg 2xwAChR/CFA5 mg/kg 2xwAChR/CFA

0 10 20 30 40 50 600

20

40

60

80

100

120

140

Days

%H

em

oly

sis

PBS

C5 siRNA

control siRNA

0 10 20 30 40 50 600.0

0.5

1.0

1.5

2.0

2.5

Days

Dis

ease

sco

re

PBS

C5 siRNA

control siRNA

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C5 Silencing in EAMG Models

C5 silencing prevents or reverses disease development in rat EAMG

models

• Pre-treatment with C5 siRNA in PTMG blocks disease development

◦ Near complete prevention of disease with 70% hemolysis reduction

– Effect similar to that observed with anti-C5 antibody treatment1

– Achieved with 90-93% C5 silencing (C5 mRNA and serum protein quantification)

◦ Partial effect observed when complement activity is reduced by 40%

– Suggests that complete inhibition of complement is not required to reduce complement-mediated

damage at the NMJ

• Therapeutic treatment in an active EAMG model reverses disease progression

◦ Evaluated in two studies

• C5 silencing results in the preservation of AChR levels and reduction in MAC

deposition at the NMJ

• Data suggests a key role for circulating C5 in MG pathogenesis

Summary

Zhou, 2007 JI, 179:8572

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ALN-CC5 Phase 1/2 Study DesignHealthy Volunteers and Patients with PNH

Part A: Single-Ascending Dose (SAD): Healthy VolunteersRandomized 3:1, double blind, placebo controlled, N=4/cohort

400 mg x 1 SC

600 mg x 1 SC

50 mg x 1 SC

200 mg x 1 SC

900 mg x 1 SC

Part C: Multiple Dose (MD): Patients with PNH │Open label, N = 6

Ongoing

ALN-CC5 dosed subcutaneously in 200 mg/mL solution

Part B: Multiple-Ascending Dose (MAD): Healthy VolunteersRandomized 3:1, Double blind, Placebo controlled, N=4/cohort

100 mg qW x 5 SC

: dosing completed

200 mg qW x 5, q2W x 4 SC

200 mg qW x 5 SC

400 mg qW x 5 SC

600 mg q2W x 7 SC

200 mg qW x 5, qM x 2 SC

Primary objectives• Safety, tolerability

Secondary objectives• PK, C5 reduction

• Complement activity assessment

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Materials and Methods

Pharmacodynamic (PD) assays

• Serum concentrations of C5 assayed using validated LCMS assay

• Complement activity

◦ Serum samples assessed using CAP and CCP Wieslab ELISA assays (alternative and

classical pathways, respectively)

◦ Serum samples assessed using in-house sheep erythrocyte hemolysis assay and

CH50 assay (both exploratory)

Data from Phase 1/2 Part A (SAD) and Part B (MAD)

• Part A – Double blind safety and tolerability single ascending dose (SAD) study of

ALN-CC5 in healthy volunteers (20) randomized 3:1 (ALN-CC5:placebo)

• Part B - Double blind safety and tolerability multiple ascending dose (MAD) study

of ALN-CC5 in healthy volunteers (24) randomized 3:1 (ALN-CC5:placebo)

Results preliminary as study is ongoing

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ALN-CC5 Phase 1/2: Part A – SAD*

ALN-CC5 was generally well tolerated in healthy volunteers

• No SAEs and no discontinuation due to adverse events (AE)

• 14 healthy volunteers (70%) reported at least one AE; all were mild or moderate

◦ 2 healthy volunteers (10%) reported at least one possibly related AE; all were mild

– Nasopharyngitis, injection site pain, injection site rash (N=1/each)

◦ 2 healthy volunteers (10%) reported injection site reactions (ISR); all were mild

– Injection site pain and/or rash

• No clinically significant changes in vital signs, EKG, physical exams and clinical laboratories

(hematology, biochemistry, coagulation and urinalysis)

*Data transfer: 3/2/2016

Blinded Safety and Tolerability Summary

Adverse Events (AEs) reported in ≥10% of healthy volunteers

AE by Preferred

Term

Part A: Single Ascending Dose (SAD)

N=4/cohort, randomized to ALN-CC5 or placebo (3:1)

50 mg 200 mg 400 mg 600 mg 900 mgAll dosing Cohorts

N=20

Nasopharyngitis 0 2 2 1 0 5 (25%)

Headache 0 1 0 2 2 5 (25%)

Nausea 0 0 0 3 0 3 (15%)

Influenza-like illness 0 0 0 1 1 2 (10%)

Injection site pain 0 0 0 2 0 2 (10%)

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ALN-CC5 Phase 1/2: Part B – MAD*

ALN-CC5 was generally well tolerated in healthy volunteers

• No SAEs and no discontinuation due to adverse events (AE)

• 19 healthy volunteers (79%) reported at least one AE; all were mild or moderate

◦ 10 healthy volunteers (42%) reported at least one possibly related AE; all were mild or moderate

– Nasopharyngitis (n=4); aphthous stomatitis, contusion, fatigue, headache, injection site (IS) bruising, IS edema, IS

erythema, IS pruritus, IS rash, insomnia, nausea, and vulvovaginal candidiasis (n=1/each)

◦ 4 healthy volunteers (17%) reported injection site reactions (ISR); all were mild

– Bruising, erythema, edema, pruritus and/or rash at the injection site (n=1/each)

• No clinically significant changes in vital signs, EKG, physical exams and clinical laboratories

(hematology, biochemistry, coagulation and urinalysis)


Blinded Safety and Tolerability Summary

Adverse Events (AEs) reported in ≥10% of healthy volunteers

AE by Preferred

Term

Part B: Multiple Ascending Dose (MAD)

N=4/cohort, randomized to ALN-CC5 or placebo (3:1)

100 mg

qW x 5

200 mg

qW x 5

400 mg

qW x 5

600 mg

q2W x 7

200 mg

qW x 5,

q2W x 4

200 mg

qW x 5,

qM x 2

All dosing

cohorts

N=24

Nasopharyngitis 1 3 0 3 1 1 9 (38%)

Headache 1 1 1 0 0 1 4 (17%)

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ALN-CC5 Phase 1/2: Part A – SAD*

Serum C5 knockdown following single dose of ALN-CC5• Maximum C5 knockdown relative to baseline up to 99%

• Mean maximum (± SEM) C5 knockdown: 98 ± 0.9%

• Mean (± SEM) C5 knockdown:

◦ Day 98 (600 mg): 97 ± 1.1%

◦ Day 182 (600 mg): 94 ± 1.2%


Pharmacodynamics and Clinical Activity: Serum C5

Mean

(+

/-S

EM

) C

5 k

no

ckd

ow

n

rela

tiv

e t

o b

aselin

e (

%)

100

80

60

40

20

0

-20

-40

Days since first visit

0 20 40 60 80 100 120 140 160 180 200 220 240 260 280

SAD Cohort 1: 50 mg ALN-CC5 (N=3)

SAD Cohort 2: 200 mg ALN-CC5 (N=3) SAD Cohort 5: 900 mg ALN-CC5 (N=3)

SAD Cohort 3: 400 mg ALN-CC5 (N=3) SAD: Placebo (N=5)

SAD Cohort 4: 600 mg ALN-CC5 (N=3)

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Serum C5 knockdown following multiple doses of ALN-CC5• Maximum C5 knockdown relative to baseline up to 99%• Mean maximum (± SEM) C5 knockdown: 99 ± 0.2%• Mean (± SEM) C5 knockdown: 99 ± 0.2% at Day 112 (600mg, q2W)

Pharmacodynamics and Clinical Activity: Serum C5

Mean

(+

/-S

EM

) C

5 k

no

ckd

ow

n r

ela

tiv

e t

o b

aselin

e (%

)


100

80

60

40

20

0

-20

-40

0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300

Dosing through wk 13


100 mg ALN-CC5 qW ×5 (N=3)

200 mg ALN-CC5 qW ×5 (N=3)

400 mg ALN-CC5 qW ×5 (N=3)

600 mg ALN-CC5 q2W ×7 (N=3)

Placebo (N=6)

200 mg ALN-CC5 qW ×5 then q2W ×4 (N=3)

200 mg ALN-CC5 qW ×5 then qM ×2 (N=3)

Dosing through wk 5

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Complement Classical Pathway inhibition (CCP C5b-9 ELISA)• Multiple doses of ALN-CC5

• Maximum CCP inhibition relative to baseline up to 99.4%

• Mean maximum (± SEM) CCP inhibition: 97.3 ± 1.0%

• CCP activity comparable to homozygous C5 deficient subjects1 in 200mg cohort and above

* Data transfer: 03/02/2016; 1Seelen et al. J Immunol Methods;296:187-98(2005)

Pharmacodynamics and Clinical Activity: CCP

Mean

(+

/-S

EM

) C

CP

red

ucti

on

rela

tiv

e t

o b

aselin

e (%

)


100

80

60

40

20

0

-20

0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 320

-40

100 mg ALN-CC5 qW ×5 (N=3)

200 mg ALN-CC5 qW ×5 (N=3)

400 mg ALN-CC5 qW ×5 (N=3)

600 mg ALN-CC5 q2W ×7 (N=3)

Placebo (N=6)

200 mg ALN-CC5 qW ×5 then q2W ×4 (N=3)

200 mg ALN-CC5 qW ×5 then qM ×2 (N=3)

Dosing through wk 13

Dosing through wk 5

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Reduction of CH50 activity• Multiple doses of ALN-CC5

• Maximum CH50 inhibition relative to baseline up to 100%

• Mean maximum (± SEM) CH50 inhibition: 100 ± 0.2%

* Data transfer: 03/14/2016

Pharmacodynamics and Clinical Activity: CH50

Mean

(+

/-S

EM

) C

H50 R

ed

ucti

on

rela

tiv

e t

o b

aselin

e (%

)

100

80

60

40

20

0

-20


0 10 20 30 40 50 60 70 80 90 100 110 120 130 140

200 mg ALN-CC5 qW ×5 (N=3)

400 mg ALN-CC5 qW ×5 (N=3

Placebo (N=2)

Dosing through wk 5

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ALN-CC5 Phase 1/2 Study Results*

ALN-CC5 represents a novel investigational approach for the potential

treatment of complement-mediated diseases, such as myasthenia

gravis

• In an ongoing Phase 1/2 study in healthy volunteers (N=44), single and multi-dose

subcutaneous administration of ALN-CC5 is generally well tolerated

◦ No reported SAEs; all AEs mild or moderate; no discontinuations; low incidence of mild

injection site reactions (ISRs)

◦ Part C portion of the study is ongoing

• Robust, dose-dependent and durable KD of serum C5

◦ After single dose, up to 99% C5 KD with mean max KD of 98 ± 0.9%

◦ After multiple doses, up to 99% C5 KD with mean max KD of 99 ± 0.2%

◦ Clamped lowering of C5 with very low inter-subject variability

◦ Durable KD and complement inhibition lasting months, supportive of once monthly and

potentially once quarterly SC dose regimen

• Start of two Phase 2 studies in non-PNH indications planned in 2017

*Data transfer: 03/02/2016 for safety, C5, CAP, CCP; data transfer: 03/14/2016 for hemolysis inhibition

Summary

aln-cc5 an investigational rnai therapeutic for the ... · • c5 silencing results in the...

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