Emerging targets in HDL modification: Relevant data from development

programs

Prof. John KasteleinAcademic Medical Centre

Amsterdam, The Netherlands

2

Novel Approaches to Modify Lipids and Lipoproteins

Low Density Lipoprotein

High Density Lipoprotein

Triglyceride Rich Lipoproteins

Inflammation

Lipoprotein a

3

New Approaches for Raising HDL

What is in development?

• Cholesterol Ester Transfer Protein (CETP) inhibitors• ER-Niacin / Laropiprant combination• ApoA1 based strategies• LCAT replacement strategies• ABCA1 agonists

4

The Verdict is Still Out on CETP Inhibition as a Mechanism

5

New Approaches for Raising HDL

What is in development?

• Cholesterol Ester Transfer Protein (CETP) inhibitors• ER-Niacin / Laropiprant combination• ApoA1 based strategies• LCAT replacement strategies• ABCA1 agonists

6

Nicotinic AcidTreatment of Dyslipidemia and Atherosclerosis

First used as lipid-altering agent in 1955 Well understood safety profile

Broad spectrum of lipid effects* ↓LDL-C (15%–25%) ↑HDL-C (20%–35%) ↓TG (20%–40%) ↓Apo B, non-HDL-C, Lp(a)

Cardiovascular (CV) benefits ↓ CV events (Coronary Drug Project) ↓ Plaque progression (angiographic and IMT studies)

Niacin added to a statin may address residual CV risk

7

Most Patients on ER Niacin TherapyDo Not Reach a 2-g Dose

0

20

40

60

80

100

4 weeks N = 14,386

8 weeksn = 6,349

12 weeks n = 5,277

24 weeks n = 5,402

1 year n = 2,104

Use

rs, %

> 1500 mg

1001–1500 mg

751–1000 mg

501–750 mg

 500 mg

8

Effectiveness of 2 g vs 1 gof ER Niacin

Lipid-modifying efficacy generally seen with at least 1 g/day

Use of 2 g versus 1 g provides: About twice the LDL-C reduction About twice the HDL-C elevation Several times the reduction of TG

LDL-C HDL-C TG

1 g/day –9 +15 –11

2 g/day –17 +26 –35

NIASPAN™ US Prescribing information.

Mean % change from baseline

9

Niacin Flushing Pathway: Two Separate Steps and Sites of Action

Illustrations are artistic renditions.PGD2=prostaglandin D2; PLA2=phospholipase A2; DP1=prostaglandin D2 receptor 1.Benyó Z et al. Mol Pharmacol. 2006;70:1844–1849; Morrow JD et al. J Invest Dermatol. 1992;98:812–815; Cheng K et al. Proc Natl Acad Sci USA. 2006;103:6682–6687.

1. Epidermal Langerhans Cells• Niacin binds • PGD2 is produced and

released

2. Dermal Blood Vessels• PGD2 binds to DP1• Vasodilation results

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An Overview of the Niacin-Induced Flushing Pathway

Niacin

Niacin Receptor

(+)

Arachidonic Acid

Phospholipids

PGG2

PGH2

PGF2α

PGI2PGE2

TXA2

PLA2

PGD Synthase

Arachidonic Acid Pathway

Epidermal Langerhans Cells Dermal Blood Vessel

PGD2

DP1

PG=prostaglandin; PLA2=phospholipase A2; TXA2=thromboxane A2.Dashed arrows are normal parts of the arachidonic acid pathway that may or may not occur in Langerhans cells. Maciejewski-Lenoir D et al. J Invest Dermatol. 2006;126:2637–2646; Narumiya S et al. Physiol Rev. 1999;79:1193–1226; Cheng K et al. Proc Natl Acad Sci USA. 2006;103:6682–6687; Morrow JD et al. Prostaglandins. 1989;38:263–274.

Prostaglandin D2 Receptor 1 (DP1) Pathway

PGD2

Vasodilationand Flushing

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Lipid/Flushing Study: Lower Incidence of Moderate or Greater Flushing vs ER Niacin

Percentage of patients with moderateor greater flushing symptoms

across weeks 1–24

Average number of days per weekwith moderate or greater flushing

symptoms across weeks 1–24

Weeks on Treatment

Num

ber o

f Day

s pe

r Wee

k

dose advancement

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 250

1

2

% P

atie

nts

Weeks on Treatment

dose advancement

0 1 2 3 4 5 6 7 8 9 10 11 12 1314 1516 1718 1920 2122 2324250

10

20

30

40

50

60

ER niacin (n = 508) ER niacin/laropiprant (n = 763) O Placebo (n = 268)

12

-25-20-15-10

-505

10152025

Placebo ER Niacin 2g ER Niacin/Laropiprant 2g

ER Niacin/Laropiprant Lipid Efficacy (Weeks 12-24)M

ean

% c

hang

e fro

m B

asel

ine

HDL-CLDL-C TG(median)

-1.2

19.818.8

-0.5

-18.1 -18.9

3.6

-21.2 -21.7

*

* *

* p<0.001 vs. Placebo

Maccubbin et al. J Clin Lipidol 2007; 1: 323

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Factorial Study: Lipid Efficacy

ER niacin/laropiprant (n = 160) Simvastatin (all doses pooled; n = 565) ER niacin/laropiprant + simvastatin

(all doses pooled; n = 520)

Primary end point

TG-33.3

-21.6

-14.7

0 4 8 12

% C

hang

e

-40

-30

-20

-10

0

Weeks on Treatment

HDL-C 27.5

23.4

0 4 8 12

% C

hang

e

0

10

20

30

Weeks on Treatment

6.0

LDL-C

-17.0

-37.0

-47.9

0 4 8 12

% C

hang

e

-60

-50

-40

-30

-20

-10

0

Weeks on Treatment

14

ER niacin/laropiprant 2 g/40mg

Placebo

Patient Population Subjects Primary End PointAge 50-80• History of MI or cerebrovascular

atherosclerotic disease or PAD or diabetes mellitus with any of the above or with other evidence of symptomatic CHD

25,000 UK

(n=8500), Scandinavia (n=6000) and China (n=10500)

Major vascular events (non-fatal MI or coronary death, non-fatal or fatal stroke or revascularisation)

All patients receive either simvastatin 40mg or ezetimibe/simvastatin 10/40 mg

HPS2-THRIVE (Heart Protection Study 2 – Treating HDL to Reduce Vascular Events)

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New Approaches for Raising HDL

What is in development?

• Cholesterol Ester Transfer Protein (CETP) inhibitors• ER-Niacin / Laropiprant combination• ApoA1 based strategies• LCAT replacement strategies• ABCA1 agonists

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Where to Intervene inHDL-C Metabolism?

Hovingh et al. Current Opinion in Lipidology 2005

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ApoA1 Based Therapies

ApoA1 Mimetics, such as APL-180 Novartis

Full-length ApoA1, such as ApoA1 Cerenis Therapeutics

Pre-Beta HDL, as generated by delipidation, HDL Therapeutics Inc.

Reconstituted HDL, CSL Ltd.

ApoA1 Milano, The Medicines Company

Trimeric ApoA1, Borean Pharma and now Roche

RVX-208, as developed by Resverlogix

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ApoA-I is made in the Liver and Small Intestines.

Liver

SmallIntestines

19

RVX-208 is an orally active, novel, and synthetic small molecule (<400 kDa) that shares similarities with the

Quinazoline family of compounds.

IT IS NOT RESVERATROL NOR A DERIVATIVE!

RVX-208

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RVX-208 increases ApoA-I production, thus triggering HDL synthesis, especially pre-beta HDL known for its potent

cholesterol efflux activity. ApoA-

I

ApoA-IPool

a-HDL3

pre-bHDL

a-HDL2

RVX-208

Enhanced R.C.T.

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Schematic of Phase 1a Protocol

Cohorts 1- 6 (42 treated and 14 placebo)

Cohort 7 (12 treated and 4 placebo)

Cohorts 8 - 9 (12 treated and 4 placebo)

Cohort 10 (6 treated and 2 placebo)

Single dose of RVX-208 (1-20 mg/kg), fasted

Single dose of RVX-208 (4 mg/kg), fed

Multiple doses x 7 days of RVX-208 (4 or 1 mg/kg), b.i.d., fasted

Single dose x 7 days of RVX-208 (3 mg/kg), q.d., fasted

A

B

C

D

80 S

ubje

cts

This color denotes multiple day dosing of RVX-208

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Efficacy of RVX-208 in HumansPhase 1b/2a ApoA-I, % Change vs. Placebo

All Subjects Low HDL Normal HDL

DAY 8 Day 28 Day 8 Day 28 Day 8 Day 28

1mg/kg 5.11** 6.48* 5.7* 7.8* 4.53 5.2

3mg/kg 7.96*** 10.31*** 6.5** 10.6** 9.3*** 10.0*

* p<0.05, ** p<0.01, *** p<0.001

232323

RVX208 α1-HDL Comparison vs. High Dose Statins α1-HDL Strongest Predictor from Framingham Offspring Study

** p<0.008

0

10

20

30

40

50

60

70

Crestor 40mg Lipitor 80mg RVX208 1mg/kg RVX208 1mg/kgA

ll Su

bjec

ts

Low

HD

L Su

bjec

ts**

**

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Cerenis HDL (CER-001)Homogeneous Drug Product

Traditional rHDL complexes

Proprietary charged CerenisrHDL complexes

Validated, scaleable GMP process for producing proprietary charged lipoprotein complexes

HDL

HDL

GMP run

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CER-001-CLIN-001 : 15 mg/kgLCAT Activation

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CER-001 Mobilizes Cholesterol in Rabbits: Comparison with ETC-216

CER-001 is at least 10 to 20 time more potent to mobilize cholesterol than ETC-216

* ETC-216 data were extracted from Marchesi M. et al (2004) J Pharmacol Exp Ther, 311(3): p. 1023-31

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CHI SQUARE Study Design

4 Treatment Groups Placebo Low dose CER-001 Mid dose CER-001 High dose CER-001

6 doses per subject

125 subjects enrolled per group Estimated 75 - 80% completion rate

==> ~98 subjects w/ follow-up IVUS per group

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N = 126 Placebo

N = 126 Low dose

N = 126 Mid dose

N = 126 High dose

Observation Period2 to 5 weeks

504

Subj

ects

Ran

dom

ized

50 SitesCanada, US, France,

Netherlands

Core IVUS LabMontreal Heart

Up to 1000 SubjectsScreened w/

Baseline IVUS following

Acute ACS Event

Screen Period2 weeks

IVUS VisitScreening

Follow-Up IVUS Visit

Infusion Visits InterimVisit

Therapy Period5 weeks

Long Term Follow-up6 months

Follow-UpVisit

CHI-SQUARE Study Design

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CER-001-CLIN-001Overall Conclusions

Administration of a single intravenous infusion of CER-001 at doses up to 45 mg/kg over 1 or 2 hours has been safe and well-tolerated

CER-001 exhibits the desired effect of cholesterol mobilization and is significantly more effective than earlier complexes

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Step 1Collected~1 litre

of plasma

Step 2Plasma enrichedthrough process

Step 3Re-infused preβenriched plasma

• Used patients own HDL• Cholesterol removed from

αHDL to yield preβ-HDL• Preβ enriched plasma is

re-infused into patient

IVUS clinical trial using selective delipidated HDL

Walksman R, et al. J Am Coll Cardiol 2010; 55 : 2727-35.

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Treatment arm (N=14)

Control arm (N=14)

1:1 randomization

(N=28)

Day 0 1 2 3 4 5 6 7 8

Week

IVUS IVUS

Treatment or control plasma infusion

IVUS Clinical Trial Using Selective Delipidated HDL

Walksman R, et al. J Am Coll Cardiol 2010; 55 : 2727-35.

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-14Change in total

atheroma volumeChange in 10mm most

diseased segment

4

2

0

-2

-4

-6

-8

-10

-12-12.18

-6.24

-1.73

2.8C

hang

e in

ath

erom

a vo

lum

e (m

m3 )

Preβ-HDL infusion

Control infusion

Results of the IVUS Clinical Trial Using Selective Delipidated HDL

Waksman R, et al. J Am Coll Cardiol 2010; 55 : 2727-35.

33

Conclusion

Therapies that raise levels of ApoA-I and pre-beta HDL carry a strong promise for the future of

cardiovascular disease prevention

34

New Approaches for Raising HDL

What is in development?

• Cholesterol Ester Transfer Protein (CETP) inhibitors• ER-Niacin / Laropiprant combination• ApoA1 based strategies• LCAT replacement strategies• ABCA1 agonists

35

LDL

Peripheral tissues

SR-BI

LDL-RCETP

mature HDL(large, α-HDL)

nascent HDL (small, preβ-HDL)

LCAT

Kidney

Liver

Small HDL Clearance

LCAT Product Gradient Drives Reverse Cholesterol Transport

36

>75 gene mutations have been described resulting in two phenotypes>200 cases reported worldwide Familial LCAT Deficiency (FLD)• Complete absence of LCAT activity in

plasma

• Corneal opacities, anemia, proteinuria, renal failure

• Glomerulosclerosis a major cause of morbidity and mortality

Fish Eye Disease (FED)• Partial deficiency of LCAT activity in plasma

• Corneal opacities

Current TreatmentsDietary fat restrictionACE inhibitor, ARB’sDialysisKidney transplantationCorneal transplantation

LCAT Deficiency in Humans

37

LDL

Peripheral tissues

SR-BI

LDL-RCETP

mature HDL(α-HDL)

nascent HDL (Preβ-HDL)

LCAT

Lp-X Kidney

Liver

Decreased

Increased

Impaired RCT in Familial LCAT Deficiency

38

Conclusion

In the next five years, we will prove or disprove that additional LDL lowering with other agents

than statins is effective

and

we will show or not show that the HDL hypothesis is true.