Erik StroesAMC

Antisense and Antibodies

as ‘Game changers’

in refractory dyslipidemia

There is a significant residual CVD riskat least partially modifiable

Packard et al. Vascul Pharmacol 2015;71:37–39.

Non-modifiable riskage, sex, genetics

Pla

que

ruptu

reA

sym

pto

matic p

hase

Clinical event horizon

Non-modifiable risk

age, sex, genetics

Age

Primordial

prevention

of atherogenesis

40 8050 60 70

Total

modifiable risk

Residual

modifiable risk

Gain in event free years

Statin Combination therapy

Probability of a

clinical event

without

prevention

with first-line

statins

combination

therapy

with optimal

risk factors

Postponement of coronary event

Lipid disorders are major risk factorsfor atherosclerotic CVD

LDL-C: primary risk factor in CHD and causative for development of coronary

atherosclerosis6

1. World Heart Federation. Cardiovascular disease risk factors.

2. Dekker et al. Circulation 2005;112:666–673. 3. Bhatt et al. JAMA 2010;304:1350–1357.

4. Lagrand et al. Circulation 1999;100:96–102. 5. Go et al. N Engl J Med 2004;351:1296–1305.

6. Grundy et al. J Am Coll Cardiol 1999;34:1348–1359.

Increased

CV risk

Prior CV

event/manifest

atherosclerosis3

Smoking, physical

inactivity1

Hypertension1

Age, ethnicity, gender,

family history/genetic

variations1

Obesity1

Type 2 diabetes1

High CRP,4 chronic

kidney disease5

Metabolic syndrome2

Lipid disorders1

(LDL↑, HDL↓, TG↑)

Major lipid targets for CVD preventionGenetic test of LDL and HDL hypothesis

Do people with more LDL-raising alleles have higher MI risk?

YES 113%

P=10-10

Change in MI risk

Do people with more HDL-raising alleles have lower MI risk?

NO No effect

P=0.63

Change in MI risk

Voight et al. Lancet. 2012; 380:572-580

Mutations in major LPL-pathway genes affect [TG] and risk for CVD-risk

Triglycerides

Cholesterol

‘Remnant’

cholesterol

Lipoprotein Pathways for CVD-risk

Epidemiology Genetics Therapy

HDL-

raising

therapy

Common variants:

no effect on MI

Rare variants:

no effect on MI Failed

Plasma Level

TG

MI R

isk

Plasma Level

HDL

MI R

isk

LDLR

PCSK9

NPC1L1

Statins

PCSK9 Abs

Ezetimibe

Common variants:

Yes

Rare variants:

LPL, APOC3,

APOA5, ANGPTL4

?

Plasma Level

LDL

There are multiple reasons why ‘Lipid’ targets are not achieved

• Absence of effective therapy1,2

– Triglyceride-rich remnants, Lipoprotein(a)

• Lack of potency1

– 81% of patients with Familial Hypercholesterolemia do not reach target

LDL-C despite maximal lipid-lowering therapy

• Low tolerance to available therapy3

– 7-15% of statin users experience muscle complaints,

whereas ~2% discontinues statins due to muscle-related complaints

1. Béliard et al. Atherosclerosis 2014;234:136–141.

2. NCEP Expert Panel. Circulation 2002;106:3143–3421.

3. Cohen et al. J Clin Lipidol 2012;6:208–215.

4. Kuklina et al. MMWR Morb Mortal Wkly Rep 2011;60:109–114.

What is a game-changerfor refractory dyslipidemia ?

Definition:

Something that affects an area very much:

- having a powerfull effect

- unfailing

Candidate game-changersCompound Target

I] PCSK9- antibodies LDLc reduction

II] Apo(a)-antisense Lp(a) reduction

III] ApoCIII-antisense TG/TRL reduction

LDLR

PCSK9

3. C-terminus2. Prodomain1. Catalytic domain

I] PCSK9

• A serine proprotein convertase1

• Expressed in hepatocytes,

kidney mesenchymal cells,

intestinal ileum and colon

epithelia, CNS2

• Regulates hepatic LDLRs, which

bind and internalise LDL

particles2

1. Abifadel et al. Hum Mutat 2009;30:520–529.

2. Seidah et al. Proc Natl Acad Sci USA 2003;100:928–933.

3. Horton et al. J Lipid Res 2009;50:S172–S177.

1

2

3

Plasma LDL-C is controlled by hepatic low density lipoprotein receptor (LDLR) levels

Brown et al. Proc Natl Acad Sci USA 1979;76:3330–3337.

Recycling of LDL-R

Increased LDL-R surface concentration

LDL particles

LDL-R

PCSK9 reduces LDLR recycling, thereby increasing plasma LDL-C

Horton et al. J Lipid Res 2009;50:S172–S177.

LDL particles

LDL-R

PCSK9 secretion

PCSK9 routes LDL-R for lysosomal degradation

LDL-R recycling blocked

Genetic variants of PCSK9 demonstrate its importance in regulating LDL levels

1. Abifadel et al. Hum Mutat 2009;30:520–529. 2. Dadu et al. Nat Rev Cardiol 2014;11:563–575.

3. Benn et al. J Am Coll Cardiol 2010;55:2833–2842.

PCSK9 gain of function (GOF) = Fewer LDLRs1 (rare2)

GOF variant Population Characteristics

D374Y British, Norwegian families, 1 Utah familyPremature CHD, tendon xanthomas, severe hypercholesterolaemia

S127R French, South African, Norwegian patients Tendon xanthomas; CHD, early MI, stroke

D129G New Zealand familyBrother died at 31 from MI; strong family history of CVD

PCSK9 loss of function (LOF) = More LDLRs3 (more common2)

LOF variant Population LDL-C CHD risk

R46L ARIC, DHS ↓ 15% ↓ 47%

Y142X or C679X ARIC, DHS ↓ 28%–40% ↓ 88%

R46L CGPS ↓ 11% ↓ 46%

Loss-of-function variants in PCSK9, with lifetime low LDL-C, are associated with a lower risk of CV events

Serum

LDL-C

Genetic

PCSK9 LDL-R

Yes

12

No

8

4CH

D(%

)

0

CHD

88%

P=0.008

Plasma LDL-C in black subjects (mg/dL)

Cohen et al. N Engl J Med 2006;354;1264–1272.

30

20

10

(N=85)

50th percentile with no nonsense mutation

Fre

quency (

%)

0

50 100 300150 200 250

Nonsense mutation

Nonsense mutation

Antibody-based therapeutics have a long history

www.nobelprize.org/nobel_prizes/medicine/laureates/1901/behring-article.html. Accessed 10 Jan 2016.

www.nobelprize.org/nobel_prizes/medicine/laureates/1908/ehrlich-bio.html. Accessed 10 Jan 2016.

Zhou et al. Annu Rev Pharmacol Toxicol 2011;51:359–372.

www.nobelprize.org/nobel_prizes/medicine/laureates/1972/. Accessed 10 Jan 2016.

Caravella et al. Curr Comput Aided Drug Des 2010;6:128-138.

www.nobelprize.org/nobel_prizes/medicine/laureates/1984/. Accessed 10 Jan 2016.

Ecker et al. MAbs 2015;7:9–14.

1890 1901 1962 1984 19861908

Serum therapy used as treatment against diphtheria and tetanus

• Side-chain theory predicted substances todaycalled antibodies

• First idea of a "magic bullet"

Discovery of antibody chemical structure

Development of hybridoma technology

Production of first monoclonal antibody

César Milstein

Emil Adolf von Behring

Gerald Edelman

Rodney Porter

Paul Ehrlich

Georges Köhler

>40 Ab-based

therapies

approved

in the EU

>300 in

development

1972 1975

Nobel

prizes

Discovery

milestones

2015

Fully human antibodies are less immunogenic than those containing elements of mouse antibodies

Weiner. J Immunother 2006;29:1–9.

Yang et al. Crit Rev Oncol Hematol 2001;38:17–23.

WHO INN (International Nonproprietary Names) Working Document 05.179

Mouse

(0% human)

Fully human

(100% human)

Humanised

(> 90% human)

Chimeric

(65% human)

-umab-zumab-ximab-omabGeneric suffix

LowHigh Potential for immunogenicity

Examples: Infliximab Bococizumab Evolocumab

Alirocumab

Evolocumab reduces LDL-C by ≥ 60%by 1 injection per 2-4 weeks

1. Robinson et al. JAMA 2014;311:1870–1882. 2. Raal et al. Lancet 2015;385:331–340

% c

ha

ng

e in

LD

L-C

fro

m b

ase

line

at

me

an

of W

ee

ks 1

0 a

nd

12

Evolocumab 140mg Q2W Placebo Q2W

Primary hypercholesterolaemia or

mixed dyslipidaemiaHeFH

High-intensity statin1

(atorvastatin 80mg)

Statin +

ezetimibe2

Moderate-intensity

statin1

(simvastatin 40mg)

Raal et al. Lancet 2015;385:331–340.

Evolocumab significantly reduces LDL-C in patients with heterozygous FH

Placebo Q2W (n=54) Evolocumab 140 mg Q2W (n=110)

Study week

Mean

% c

han

ge i

n L

DL

-C f

rom

bas

elin

e

10 8 12

20

0

-20

-40

-60

-80

Baseline 2

60% vs placebo

-1%

- 61%

Stroes et al. J Am Coll Cardiol 2014;63:2541–2548.

Evolocumab significantly reduces LDL-C in patients unable to tolerate statins

–56%

–19%

Ezetimibe QD + placebo Q2W (n=51)

Evolocumab 140 mg Q2W + placebo oral QD (n=103)

0

–20

–40

–60

–80

BL Day 1 2 4 6

Mean

% c

han

ge in

LD

L-C

fro

m b

as

eli

ne

8 10 12

Study week

37% vs ezetimibe

ODYSSEY LONG TERM Study Design

ClinicalTrials.gov identifier: NCT01507831.

86% (2011/2341) completed 52 weeks (both treatment arms)26.1% (405/1553 alirocumab) and 25.6% (202/788 placebo) had completed 78 weeks by time of this analysisMean treatment duration: 65 weeks (both treatment arms)

HeFH or High CV-risk patients

On max-tolerated statin other lipid-lowering

therapy

LDL-C ≥1.81 mmol/L [70 mg/dL]

Double-blind treatment (18 months)

n=1553

n=788

R

Follow-up(8 weeks)

Alirocumab 150 mg Q2W SC(single 1-mL injection using prefilled syringe for self-administration)

Placebo Q2W SC

Assessments

W0

W4

W8

W12

W16

W24

W36

W52

Primaryefficacy endpoint

Pre-specified analysisEfficacy: All Patients To W52Safety: Baseline-W78 (all patients at least W52)

W64 W78

Robinson J, Stroes E, et N Engl J Med 2015

Week

39

53

67

81

95

109

123

137

151

1

1,5

2

2,5

3

3,5

4

0 4 8 12 16 20 24 28 32 36 40 44 48 52

3.1 mmol/L

118.9 mg/dL

1.3 mmol/L

48.3 mg/dL

3.2 mmol/L

123.0 mg/dL

1.4 mmol/L

53.1 mg/dL

mg/

dL

Placebo

Alirocumab

LD

L-C

, L

S m

ean

(S

E),

mm

ol/

L

Achieved LDL-C Over Time All patients on background of maximally-tolerated statin ±other lipid-lowering therapy

Intent-to-treat (ITT) analysis

ODDYSSEY Outcomes: Long term LDL-C reduction with alirocumab 150 mg Q2W

Robinson J, Stroes E, et al N Engl J Med 2015

Substantial proportion of patients achieveLDL-C < 1.8mmol/L

1. Robinson et al. JAMA 2014;311:1870–1882. 2. Raal et al. Lancet 2015;385:331–340.

3. Stroes et al. J Am Coll Cardiol 2014;63:2541–2548.

High-risk patients on

high-intensity statin1

Placebo Q2W Ezetimibe + placebo Q2W Evolocumab 140mg Q2W

Perc

ent

of

subje

cts

achie

vin

g

LD

L-C

<70m

g/d

L (

1.8

mm

ol/L)

(95%

CI)

Patients with

HeFH2

Statin-intolerant

patients3

1

2

3

4

3.3

1.7

2.3

0.9

Placebo Alirocumab SOC EvolocumabODYSSEY LONG-TERM OSLER 1 & 2

CV

D E

ven

t ra

te (

%)

HR 0.52(95% CI 0.31-0.91)

HR 0.47(95% CI 0.28-0.78)

CVD events from ODYSSEY LONG TERM and OSLER Trials

Robinson JG et al. NEJM 2015; 372:1489-99

Sabatine MS et al. N Engl J Med 2015;372:1500-1509

No increases in adverse events at very low LDL-C

• Evolocumab-treated subjects in OSLER programme were

stratified by minimum achieved LDL-C

Adverse events (AEs), %LDL-C

<25 mg/dL(N=773)

LDL-C25 to <40 mg/dL

(N=759)

LDL-C<40 mg/dL(N=1532)

LDL-C ≥40 mg/dL(N=1426)

Any AE 70.0 68.1 69.1 70.1

Serious AEs 7.6 6.9 7.2 7.8

Muscle-related AE 4.9 7.1 6.0 6.9

CK >5 x ULN 0.4 0.9 0.7 0.5

ALT or AST >3 x ULN 0.9 0.8 0.8 1.3

Neurocognitive AE 0.5 1.2 0.8 1.0

Sabatine et al. N Engl J Med 2015;372:1500–1509 Supplementary Appendix.

ODYSSEY Outcomes: Summary of Adverse Events (AEs) by achieved LDL-C: number of patients (%)

Alirocumab

(N=1550)

Alirocumab with 2

consecutive LDL-C <25

mg/dL (N=575)

Placebo

(N=788)

Any AE 1255 (81.0%) 435 (75.7) 650 (82.5%)

Serious AE 290 (18.7%) 98 (17.0) 154 (19.5%)

AE leading to death 8 (0.5%) 4 (0.7%) 10 (1.3%)

AE leading to study drug

discontinuation111 (7.2%) 26 (4.5%) 46 (5.8%)

Robinson JG et al. N Engl J Med 2015;372:1489-1499

Evolocumab Alirocumab Bococizumab

Sponsor Amgen Sanofi / Regeneron Pfizer

Trial FOURIER ODYSSEY Outcomes SPIRE I SPIRE II

Sample size 27,500 18,000 17,000 9,000

Patients MI, stroke or PAD 4-52 wks post-ACS High risk of CV event

Statin Atorva ≥20 mg or equiv Evid-based med Rx Lipid-lowering Rx

LDL-C

mg/dL(mmol/L)≥70 (≥1.8) ≥70 (≥1.8)

70-99 (1.8-

2.6)≥100 (≥2.6)

PCSK9i Dosing Q2W or Q4W Q2W Q2W

Endpoint 1: CV death, MI, stroke,

revasc or hosp for UA,

Key 2: CV death, MI, or

stroke

CHD death, MI,

ischemic stroke, or hosp

for UA

CV death, MI, stroke, or

urgent revasc

Recruitment Status Completed June 2015 Projected for Dec 2015 ?

Completion ? /2016 ? /2017 ? /2017

PCSK9 Inhibitor CVD Outcomes Trials

What is a game-changerfor refractory dyslipidemia ?

Candidate game-changersCompound Target

I] PCSK9- antibodies LDLc reduction

II] Apo(a)-antisense Lp(a) reduction

III] ApoCIII-antisense TG/TRL reduction

II] Targeting Apo(a) to Reduce Lp(a)

• Apo(a) is liver-derived protein

linked to an LDL

• Lp(a) is a genetically

determined

• Various apo(a) isoforms with

10 to > 50 kringle IV repeats

Schematic of Lp(a) (Koschinsky & Marcovina (2004) Curr Opin Lipol. 15:167-174)

Apo(a) + LDL = Lp(a)

Consistent Evidence Demonstrates High Lp(a) as Key Driver of CVD

• Linear relationship between Lp(a) levels and CVD-risk

– Modest increases in Lp(a) CVD-risk increase

– Very high Lp(a) > 2-fold CVD risk increase

OxPL-apoB predicts CVD and stroke risk

Tsimikas S, J Am Coll Cardiol 2012

Potent & selective Lp(a) reduction byapo(a) antisense once a week

LICA Technology

• LICA increases tissue-specific delivery and efficacy– ligand technology utilizing N-Acetylgalactosamine (GalNAc),

a highly efficient ligand for the asialoglycoprotein receptor (ASGPR)

– Much lower ASO drug exposure leads to better tolerability

• Hepatocyte oligonucleotide concentration at 30 mg

• Total liver exposure > 10-fold lower

What is a game-changerfor refractory dyslipidemia ?

Candidate game-changersCompound Target

I] PCSK9- antibodies LDLc reduction

II] Apo(a)-antisense Lp(a) reduction

III] ApoCIII-antisense TG/TRL reduction

III] Apolipoprotein C-III

• 8.8 kD – 79 amino-acids

• Synthesized in

– Predominantly in liver

– Intestine

• Carried by lipoproteins:

– Large VLDL 60-90%

– Small VLDL 40-70%

– LDL 5-15%

• Role:– Inhibits lipoprotein lipase

– Inhibits hepatic lipase

– Inhibits hepatic uptake of TG-rich

particles

ApoC-III in a complex with an SDS micelle as derived by NMR

V. Alexander et al. J Am Coll Cardiol 2012; M. Wyler von Ballmoos et al. J Clin Lipidol 2015

Apo-CIII antisense potently reduces ApoC-III (Mean % Change)

Gaudet et al. NEJM 2015

Apo-CIII antisense potently reduces TG levels(Mean % Change)

Gaudet et al. NEJM 2015

Apo-CIII antisense also reduces TG levelsin patients with LPL-deficiency

Gaudet et al. NEJM 2014

ApoCIII-as increases hepatic TRL removalin LPL deficient patients

Gaudet, N Engl J Med 2014

Conclusionsin refractory dyslipidemia by antibodies/antisense

• Revolution for potency and efficacy• Even in FH > 70% on LDLc target• Even Lp(a)<100g/l in extreme Lp(a) patients• Even TG < 5 mmol/l in LPL-deficiency patients

• Revolution for therapy adherance• Sc injection once every 2 – 4 (12) weeks• Very few side effects with ab and LICA-as

• Refractory dyslipidemias likely to be wiped out in 2019 (?)

• Real game-changersif prices are realistic!