Drugs in Development to Treat Lp(a): Risk Reduction vs. Lowering a Number—

What Can We Expect?

Christie M. Ballantyne, MDCenter for Cardiovascular Disease PreventionMethodist DeBakey Heart & Vascular Center

Baylor College of MedicineHouston, Texas

• Grant/Research Support: Abbott Diagnostic, Amarin, Amgen, Eli Lilly, Esperion, Novartis, Pfizer, Otsuka, Regeneron, Roche Diagnostic, Sanofi-Synthelabo, Takeda, NIH, AHA, ADA (all paid to institution, not individual)

• Consultant: Abbott Diagnostics, Amarin, Amgen, Astra Zeneca, Eli Lilly, Esperion, Genzyme, Ionis, MatinasBioPharma Inc, Merck, Novartis, Pfizer, Regeneron, Roche Diagnostic, Sanofi-Synthelabo

Christie M. Ballantyne, MDFinancial Disclosure

Drugs in Development to Treat Lp(a): Risk Reduction vs. Lowering a Number—

What Can We Expect1. Are high levels of Lp(a) associated with increased risk

for CV events (MI, stroke, aortic stenosis, and HF)?2. Are high levels of Lp(a) a risk factor for atherosclerotic

CVD?3. Are high levels of Lp(a) associated with increased risk

for CV events even after statin therapy?4. What therapies are available or in development to lower

Lp(a)?5. What studies will be needed to examine if therapies that

lower Lp(a) are beneficial to treat individuals with high Lp(a) and established CVD or at high risk for CVD?

Drugs in Development to Treat Lp(a): Risk Reduction vs. Lowering a Number—

What Can We Expect1. Are high levels of Lp(a) associated with increased risk

for CV events (MI, stroke, aortic stenosis, and HF)? YES2. Are high levels of Lp(a) a risk factor for atherosclerotic

CVD? YES3. Are high levels of Lp(a) associated with increased risk

for CV events even after statin therapy?4. What therapies are available or in development to lower

Lp(a)?5. What studies will be needed to examine if therapies that

lower Lp(a) are beneficial to treat individuals with high Lp(a) and established CVD or at high risk for CVD?

JLR Cover March 2016

Is Lp(a) a Risk Factor for CV events In Patients On Long-Term Statin Therapy?

Major landmark RCTs show Lp(a) is associated with increased risk for CV events:

At baseline• 4S• LIPID• HPS

• After effective treatment with statins• JUPITER• AIM HIGH

Lp(a) Thresholds for CVD in High Risk Primary Care Patients or in Patients with Established CAD

Tsimikas CVEndo 2016 In Press

JUPITER: Lp(a) and Residual Risk with Rosuvastatin

• Median change in Lp(a) with rosuvastatin was 0 but rosuvastatin resulted in small statistically significant positive shift in overall Lp(a) distribution (P<0.0001) in whites

• Baseline Lp(a) associated with incident CVD (adjusted HR 1.18 per 1-SD increment in Ln[Lp(a)]; 95% CI 1.03–1.34; P=0.02) in whites

• On-statin Lp(a) associated with residual risk of CVD (adjusted HR 1.27; 95% CI 1.01–1.59; P=0.04), independent of LDL-C and other factors in whites

• Rosuvastatin significantly reduced incident CVD in whites with baseline Lp(a) ≥median (HR 0.62; 95% CI 0.43–0.90) and Lp(a) <median (HR 0.46; 95% CI 0.30–0.72), with no evidence of interaction

Khera AV et al. Circulation 2014;129:635-642.

JUPITER: Lp(a) and Residual Risk with Rosuvastatin

Khera AV et al. Circulation 2014;129:635-642.

AIM-HIGH: Baseline and On-Study Lp(a) and CVD Risk

• In the 3196 participants with baseline statin therapy, baseline and on-study Lp(a) were predictive of CV events in both simvastatin–placebo (baseline HR: 1.24 [p = 0.002] and on-study HR: 1.21 [p = 0.017]) and simvastatin–ERN (baseline HR: 1.25 [p ¼ 0.001] and on-study HR: 1.18 [p = 0.028]) groups

• ERN decreased Lp(a) 21%, but did not reduce CV events

• Conclusions: Lp(a) was associated with increased CV risk in both treatment groups, indicating that it contributes to residual CV risk. However, there was no evidence that ERN reduced CV risk, despite favorable lipoprotein changes.

Albers JJ et al. J Am Coll Cardiol 2013;62:1575–9.

Lp(a) remains a predictor of CVD events in patients with treated LDL-C of 54 mg/dLAIM-HIGH Trial

Albers et al JACC 2013

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Statin + placebo Statin plus niacin

Q4 of Lp(a): >125 nmol/L (50 mg/dL)

Proposed Pathogenic Mechanisms for Lp(a)

Spence and Koschinsky (2012) ATVB 32:1550-1551; Koschinsky & Marcovina (2004) Curr. Opin. Lipidol. 15: 167-74

Do levels of Lp(a) predict progression of atherosclerosis in patients with statins?

Angiographic trial: FATS suggested that after effective LDL-c lowering therapy, increased Lp(a) was not associated with progression by QCA

IVUS data from SATURN to be presented at ESC re high Lp(a) in patients treated with high dose atorvastatin and rosuvastatin

Change in Lp(a) with therapeutic agents

Tsimikas CV Endo Diab Obes 2016

Change in Lp(a) and OxPL-apoB with therapeutic agents

Yeang J Clin Lipidol 2016

AntisenseSingle-Strand

Multiple Mechanisms

DNAPhosphorothioate (PS)

2’-MOE, 2’-OMe, cEt, LNA

siRNADouble-strandRISC Mechanism

RNAPhosphodiester

2’-OMe, 2’-FAliphatic substituents

AptamerStructured

DNA or RNA Mixed modifications

Pegylation(REG1 system for factor IX)

Distinct Chemical Classes of Oligonucleotide-Based Technologies & Therapeutics

Aptamer

TargetProtein

SenseStrand

AntisenseStrand

AntisenseStrand

Antisense Technology Reduces Disease Causing Protein Levels by Targeting mRNA

Gene mRNA

Transcription

Translation

DISEASE

Traditional Small Molecule DrugsInhibitors or Agonists of proteins

BiologicsInhibitors or Mimics of proteins

DISEASE

Disease-Causing Protein

DISEASEX XTranslation

Disease-Causing Protein

Antisense Oligonucleotide

Inhibition of RNA function (no production of disease

causing protein)

Isis Pharmaceuticals Confidential

RNaseH1 and siRNA Antisense Mechanisms

siRNA Mechanism RNase H1 Mechanism

Antisense Strand

mRNA-Antisense Duplex

RNase H1

DNA

mRNA

Nucleus

Cytoplasm

Cell Membrane

Cell Membrane

CytoplasmNucleus

Antisense Strand

RNase H like nuclease

DNA

mRNA

RISCSense Strand

siRNA Duplex

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Recent major publications with antisense drugsDec 2015-July 2015

TargetingAPOC3 in the FamilialChylomicronemia Syndrome

Daniel Gaudet, M.D., Ph.D., Diane Brisson, Ph.D., Karine Tremblay, Ph.D.,Veronica J.Alexander, Ph.D., Walter Singleton, M.D., Steven G. Hughes, M.B., B.S.,

Richard S. Geary, Ph.D., Brenda F. Baker, Ph.D.,Mark J.Graham, M.S., Rosanne M. Crooke, Ph.D.,

and Joseph L. Witztum, M.D.

Factor XI Antisense Oligonucleotide forPrevention of Venous Thrombosis

Harry R. Büller, M.D., Claudette Bethune, Ph.D., Sanjay Bhanot, M.D., Ph.D.,David Gailani, M.D., Brett P. Monia, Ph.D., Gary E. Raskob, Ph.D.,

Annelise Segers, M.D., Peter Verhamme, M.D., and Jeffrey I. Weitz, M.D., forthe FXI-ASO TKA Investigators*

AntisenseInhibitionofApolipoproteinC‐IIIinPatientswithHypertriglyceridemia

Daniel Gaudet, M.D., Ph.D., Veronica J. Alexander, Ph.D., Brenda F. Baker, Ph.D., Diane Brisson, Ph.D., Karine Tremblay, Ph.D., Walter Singleton, M.D.,

Richard S. Geary, Ph.D., Steven G. Hughes, M.B., B.S., Nicholas J. Viney, B.Sc., Mark J. Graham, M.S., Rosanne M. Crooke, Ph.D., Joseph L. Witztum,

M.D., John D. Brunzell, M.D., and John J.P. Kastelein, M.D., Ph.D.

Antisensetherapytargetingapolipoprotein(a):arandomised,double‐blind,placebo‐controlledphase1study

Sotirios Tsimikas, Nicholas J Viney, Steven G Hughes, Walter Singleton, Mark J Graham, Brenda F Baker, Jennifer L Burkey, Qingqing Yang,

Santica M Marcovina, Richard S Geary, Rosanne M Crooke, Joseph L Witztum

IONIS-APO(a)-LRx is Designed to Lower Plasma Lp(a)Generation 2.0+ Antisense Drug

2‘ Methoxyethyl Phosphorothioate Oligonucleotide (2’ MOE Gapmer)

S

S

O O C H3

O O C H3

O B

O

O

B

O

O

B

O

O

B

O

O

OPO

O

OP

S

O

OP

S

O

OP

5'

3'

H

H

Chimera / Gapmer

affinitystability

tolerability

RNase H1Substrate

IONIS-APO(a)-LRx targets a unique splice site of exon 24/25 present in 1 copy of all apo(a) mRNA, corresponding to a Kringle-IV2 repeat

It does not bind to or reduce hepatic expression or plasma levels of plasminogen

T G C T C C G T T G G T G C T T G T T CMOE MOEDeoxyMOE

Deoxy

20

Objectives Evaluate the safety & tolerability of ISIS-APO(a)Rx in healthy volunteers Evaluate effect on Lp(a) levels 2 weeks after the last dose

Exploratory Objectives Change in lipid profile and apolipoprotein B-100 2 weeks after the last dose Change in OxPL/apoB levels 2 weeks after the last dose Impact of apo(a) isoforms on treatment response

Single and Multiple Ascending Dose Study DesignISIS-APO(a)Rx Phase I in Healthy VolunteersRandomized, Blinded, Placebo Controlled, Dose Escalation

21

Baseline Characteristics of Multiple Ascending Dose Groups

22

Placebo(n=6)

100 mg(n=8)

200 mg(n=9)

300 mg(n=8)

Gender (M:F) 6:0 8:0 9:0 8:0Age (yrs) 31 41 40 42BMI (kg/m2) 24.2 27.0 24.1 26.8Lipids & LipoproteinsLp(a) (nmol/L)*† 152±83 92±74 82±67 107±76Total Cholesterol (mg/dL) 194±23.5 199±29.4 196±32.1 200±31.1HDL‐C (mg/dL) 46±6.6 49±7.5 52±14.7 51±13.6ApoB (mg/dL) 89±15 95±19 86±23 89±17LDL‐C (mg/dL) 121±22.3 131±27.2 116±35.5 131±22.7Triglycerides (mg/dL) 137±52.9 96±29.4 151±161.4 94±39.2OxPL‐apoB‐100 (nmol/L)† 11.0±6.1 6.7±4.5 8.8±5.6 9.1±4.9Major apo(a) isoform (#KIV repeats) 21.5±4.5 20.1±3.1 23.0±5.0 20.6±4.0

ITT population, values presented are the mean. * Entry Criterion of Lp(a) ≥ 25 nmol/L (~10 mg/dL) for MAD cohorts

†Excludes 2 subjects who received < 3 doses of Study Drug

Phase 1 ISIS-APO(a)Rx Study Mean Percent Change in Lp(a) Over Time by Treatment Group Multiple-Dose Cohorts (n=29)

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Tsimikas et al, The Lancet 2015

**p<0.01***p<0.001

Phase 1 ISIS-APO(a)Rx Study Mean Percent Change in Lp(a), OxPL-apoB, OxPL-apo(a), Total Cholesterol, LDL-C, apoB, HDL-C, and Triglycerides

24

*p<0.05**p<0.01

***p<0.001

Tsimikas et al, The Lancet 2015

Mean % change in Lp(a), OxPL-apoB and OxPL-apo(a) is independent of baseline Lp(a) levels

Day 36 in the 300mg multiple-dose group 25

Hepatocyte Targeting Antisense via Asialoglycoprotein Receptor (ASGPR) Enhances Drug Delivery to the Liver 10-15x

LICA - ligand conjugated antisense

T. P. Prakash et al . Nucleic Acids Res. 2014 Jul;42(13):8796-807

Summary and Take-Home Message

1. Levels of Lp(a) are associated with increased risk for CVD and have been shown to be a risk factor by genetic studies

2. Individuals with high levels of Lp(a) benefit from treatment with statins but continue to have increased risk compared with individuals with low Lp(a)

3. Several approved and investigational drugs lower Lp(a). CETP inhibitors and niacin have not shown benefit when added to statin therapy

Summary and Take-Home Message (cont'd)

4. Ongoing outcome trials will examine whether high-risk patients with high Lp(a) benefit from PCSK9 inhibitors but will not be able to address directly the question of whether lowering Lp(a) provides additional benefit beyond reducing apoB-containing lipoprotins

5. Novel antisense therapy targeting apo(a) lowers Lp(a) by >80% and could be used to test the hypothesis that lowering Lp(a) in high-risk individuals with high Lp(a) reduces CV events