1
ALN-AS1Investigational RNAi Therapeutic for the Treatment of
Acute Hepatic Porphyrias
Tuesday, September 13, 2016
2
Agenda
Welcome
• Josh Brodsky, Associate Director, Investor Relations & Corporate Communications
Introduction
• John Maraganore, Ph.D., Chief Executive Officer
Overview of the Acute Porphyrias
• Herbert L. Bonkovsky, M.D., Professor of Medicine, Wake Forest University
School of Medicine
AIP Patient Perspective
• Ariel Lager, patient living with Acute Intermittent Porphyria
Q&A Session
• With Dr. Bonkovsky and Ms. Lager
ALN-AS1 Program
• Bill Querbes, Ph.D., Associate Director, Research
Q&A Session
3
Reminders
Event will run for approximately 75 minutes
Q&A Sessions at end of presentation
• Submit questions at bottom of webcast screen
• Questions may be submitted at any time
Replay, slides and audio available at www.alnylam.com/roundtables
4
Alnylam Forward Looking Statements
This presentation contains forward-looking statements, within the meaning of Section 27A of the Securities
Act of 1933 and Section 21E of the Securities Exchange Act of 1934. There are a number of important
factors that could cause actual results to differ materially from the results anticipated by these forward-
looking statements. These important factors include our ability to discover and develop novel drug
candidates and delivery approaches and successfully demonstrate the efficacy and safety of our product
candidates; pre-clinical and clinical results for our product candidates; actions or advice of regulatory
agencies; delays, interruptions or failures in the manufacture and supply of our product candidates; our
ability to obtain, maintain and protect intellectual property, enforce our intellectual property rights and defend
our patent portfolio; our ability to obtain and maintain regulatory approval, pricing and reimbursement for
products; our progress in establishing a commercial and ex-United States infrastructure; competition from
others using similar technology and developing products for similar uses; our ability to manage our growth
and operating expenses, obtain additional funding to support our business activities and establish and
maintain business alliances; the outcome of litigation; and the risk of government investigations; as well as
those risks more fully discussed in our most recent quarterly report on Form 10-Q under the caption “Risk
Factors.” If one or more of these factors materialize, or if any underlying assumptions prove incorrect, our
actual results, performance or achievements may vary materially from any future results, performance or
achievements expressed or implied by these forward-looking statements. All forward-looking statements
speak only as of the date of this presentation and, except as required by law, we undertake no obligation to
update such statements.
5
Agenda
Welcome
• Josh Brodsky, Associate Director, Investor Relations & Corporate Communications
Introduction
• John Maraganore, Ph.D., Chief Executive Officer
Overview of the Acute Porphyrias
• Herbert L. Bonkovsky, M.D., Professor of Medicine, Wake Forest University
School of Medicine
AIP Patient Perspective
• Ariel Lager, patient living with Acute Intermittent Porphyria
Q&A Session
• With Dr. Bonkovsky and Ms. Lager
ALN-AS1 Program
• Bill Querbes, Ph.D., Associate Director, Research
Q&A Session
6
RNAi TherapeuticsNew Class of Innovative Medicines
Harness natural pathway
Catalytic mechanism
Silence any gene in genome
Upstream of today’s medicines
Clinically proven approach
7
Alnylam Strategic Therapeutic Areas (STArs)
Investigational pipeline focused in 3 STArs
Genetic Medicines
Cardio-Metabolic Diseases
Hepatic Infectious Diseases
RNAi therapeutics for rare diseases
RNAi therapeutics for dyslipidemia, NASH,
type 2 diabetes, hypertension, and other
major diseases
RNAi therapeutics for major liver infections
beginning with hepatitis B & D
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Agenda
Welcome
• Josh Brodsky, Associate Director, Investor Relations & Corporate Communications
Introduction
• John Maraganore, Ph.D., Chief Executive Officer
Overview of the Acute Porphyrias
• Herbert L. Bonkovsky, M.D., Professor of Medicine, Wake Forest University
School of Medicine
AIP Patient Perspective
• Ariel Lager, patient living with Acute Intermittent Porphyria
Q&A Session
• With Dr. Bonkovsky and Ms. Lager
ALN-AS1 Program
• Bill Querbes, Ph.D., Associate Director, Research
Q&A Session
Copyright H Bonkovsky 11
Acute Porphyria 101
Herbert L. Bonkovsky, M.D.Professor of Medicine & Molecular Medicine and
Translational Science,Chief of Hepatology & Metabolic Disorders
Wake Forest Univ School of MedicineWinston-Salem, NC
Prof of MedicineUniv of CT Health Center, Farmington
and Univ of NC, Chapel [email protected]
Porphyrias- Definition
• Disorders of normal porphyrin and heme synthesis
• Mostly inherited—but with effects of drugs, nutrition, alcohol, other genetic variation
• Major clinical features: acute neurovisceral attacks or cutaneous photosensitivity
• Symptoms due to effects of ALA or porphyrins
• Most common are AIP, PCT, EPP12
Diseases Associated with Gene Mutations and/or
Deficiencies in Enzymes in the Heme Biosynthesis Pathway
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Copyright H Bonkovsky 14
Classification of PorphyriasAccording to major site of overproduction
• Hepatic porphyrias– Acute or inducible porphyrias – ALADP, AIP, HCP, VP
– Chronic hepatic porphyrias – PCT, HEP
• Erythropoietic porphyrias– Congenital erythropoietic porphyria - CEP
– Erythropoietic protoporphyria - EPP
Copyright H Bonkovsky 15
Classification of PorphyriasAccording to major clinical features
• Acute Porphyrias– Acute or inducible porphyrias – ALADP, AIP, HCP, VP– Major features: attacks of neurovisceral pain, dysfct
• Cutaneous porphyrias– Porphyria cutanea tarda—most common—blisters,
vesicles, chronic lesions slow to heal– Congenital erythropoietic porphyria – severe
blisters; early onset– Erythropoietic protoporphyria – acute burning,
itching, pain—no blisters, vesicles
Copyright H Bonkovsky 18
Selected Features of the 4 Acute Porphyrias, Genes, Enzymes
Type Inherita
nce
Defic
Enz
Subcell
locatn
Enz
Activity
[% Nl]
Known
mutns
[n]
Gene
locus
OMIM #
AIP Autos
domin
PBGD
[HMBS]
Cytosol ~50 ~300 11q23.3 +17600
HCP Autos
domin
Coprog
oxidase
Mito ~50 ~50 3q12 +121300
VP Autos
domin
Protog
oxidase
Mito ~50 ~130 1q22 #176200
ALA-D
defic
Autos
recess
ALA-D
[PBG
Synth]
Cytosol ~5 ~8 9q34 +125270
Copyright H Bonkovsky 19
Acute Intermittent PorphyriaEstimated Prevalence of Disease
• Depends upon country and region: founder effects
– Sweden 8-10/100,000
– Finland 2-3 /100,000
– UK & W Europe 2-5/ 100,000
– USA 2-5/100,000
Prevalence of genetic defects much higher, [~65/100,000] implying incomplete penetrance
Copyright H Bonkovsky 20
Acute PorphyriasMajor Clinical Features
• Due to dysfunction or death of neurons
• Overlapping clinical syndromes
– Acute attacks – pain crises, autonomic disease
– Peripheral sensory-motor neuropathy
– Progression to trunkal, CN, global CNS dysfunction
• Subacute or chronic pain and paresthesias
• (Seizures)
Copyright H Bonkovsky 23
Acute PorphyriasPrecipitating or Aggravating Factors
• Drugs and chemicalsAlcohol HydantoinsEstrogens BarbituratesSulfonamides ProgestagensOther inducers of hepatic cytochrome(s) P-450 + ALA synthase-1
• Luteal phase of menstrual cycle• Pregnancy and post-partum period• Fasting / starvation /s/p gastric bypass• Stress / exhaustion• Infection• Surgery / anesthesia
Copyright H Bonkovsky 24
Acute PorphyriasLaboratory Features during Attacks
• CBC, Routine liver chems usually normal• WBC may be normal, low, or high• NC/NC anemia may occur• Low serum Na, Mg common• Glucose tolerance often impaired• Serum cholesterol, LDL, & serum hormone binding
proteins often increased– TBG– Sex steroid BP’s– Corticoid BP’s
• Urine ALA, PBG, uroporphyrin increased• Blood volume often decreased
Copyright H Bonkovsky 25
Early Diagnosis of Acute Porphyria
• Consider in all adults with unexplained symptoms, especially women 18-45 y; recurrent abdominal pain; muscle weakness; hyponatremia; dark or reddish urine
• Establish diagnosis rapidly by qual test for PBG in a single-void urine [Hoesch, Watson-Schwartz,Trace PBG kit, Thermo Scientific—no longer available—unmet need]
Copyright H Bonkovsky 26
Effect of Light and Air on Urine of
Some Patients with Biochemically Active AIP
Urine just passed Urine left on window sill 18 h
Copyright H Bonkovsky 27
Pos Hoesch Test—Qual Test for PBG
1= Ehrlich’s reagent 2--1 + drops of urine 2—after mixing
Copyright H Bonkovsky 28
Acute PorphyriasManagement of Acute Attacks
• Primum nil nocere: 1st do no harm– Avoid offending drugs, chemicals.
• Maintain nutrition, fluids
– Watch for hypo-natremia, -magnesemia & treat as necessary
– At least 300 g/d dextrose or similar
• Close watch for CNS involvement
– Progressive weakness
• For pain - meperidine, morphine, methadone +thorazine
• For hypertension – propranolol; lisinopril
Effect of IV Heme in first patient with AIP treated with heme
Bonkovsky et al. PNAS 1971:68:2725-2729
Rapid Down-Regulation of Plasma
ALA and PBG by IV Heme
Heme
0
50
100
150
0 2 4 6 16 18 20 22
DAYS
AL
A (
µg
/dl)
0
200
400
600
PB
G (
µg
/dl)
ALA (µg/dl)
PBG (µg/dl)
Heme
Heme
29
Copyright H Bonkovsky 30
Acute PorphyriasHeme Therapy
• Adverse effects
– Obliterative thrombophlebitis
– Lowering of platelet count
– Inactivation of soluble clotting factors
• Adverse effects minimized by heme-albumin
• Some patients require weekly prophylactic infusions
• Secondary iron overload; headaches; myalgias; tachyphylaxis are problems
• Unmet need—alternative, additional therapies—RNAi has shown great promise
Am J Gastroent 1991; 86:1050Ann Int Med 2005; 142:439
Ann Int Med 2006; 144:537
Copyright H Bonkovsky 31
Acute PorphyriasProphylaxis – Prevention of Attacks
• Avoid porphyrogenic drugs, chemicalsAlcoholic beverages BarbituratesEstrogens HydantoinsSulfa drugs ProgestagensOral contraceptives CYP inducers
• Avoid prolonged fasting, low carbohydrate or protein intake.
• Prompt, appropriate treatment of intercurrent illness.
• LHRH analogues – for women with frequent cyclical attacks related to menstrual cycle.
• Periodic infusions of heme—weekly, monthly, etc
Copyright H Bonkovsky 32
AIP Increases Risk of Cirrhosis and Hepatocellular CarcinomaMarkedly Increased Risk of Development of HCC in Acute
PorphyriasData from France, 7 yr follow-up
Screen all patients with AIP over 40 y for cirrhosis & HCCNEJM 1998; 338:1853
Variable Men Women Total
No. of patients 303 347 650
No. of patient – years 1963 2246 4208
HCC
No. of cases (95% CI) 3 (0.6-8.8) 4 (1.1-10.2) 7 (2.8-14.4)
Crude Incidence Rate 1.5% 1.8% 1.7%
Expected No. of Cases 0.16 0.04 0.20
Odds Ratio (95%) CI 19 (4-55) 110 (30-281) 36 (14-74)
Soonawalla et al., Lancet 363: 705-706, 2004
19-year-old woman with
recurrent acute neurologic
attacks had an orthotopic liver
transplant.
Pre-LT:
37 Attacks over 29 Mos
Post-LT:
None for > 8 Years
PBG/Creatinine
Hr after Liver Transplant
µm
ol/
mm
ol
Cre
ati
nin
e
Urinary Excretion of ALA &
PBG after Liver Transplant
ALA/Creatinine
33
Liver Transplant as a Cure for AcuteIntermittent Porphyria
Copyright H Bonkovsky
Liver Transplantation for Acute Porphyria
• Performed mainly in Europe
• 10 cases in UK, 2000-2010. 5 with severe neurol features. None with cirrhosis or HCC. 7/10 had mod-severe hepatic siderosis due to chronic heme Rx
• All had complete clin and biochemresolution
• Rate of devel of hepatic artery thrombosis was high—4/10 [40%] vs ~ 3%
Liver Transpl 2011: 18:195
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Summary
• Acute hepatic porphyrias—worldwide, panethnicproblem
• Low penetrance, but often devastating for the minority of patients, mostly women, with recurrent and severe attacks
• Induction of hepatic ALAS1 is key feature in pathogenesis
• RNAi therapeutic targeting of ALAS1 has been demonstrated
• New therapy—especially self-administration early in attacks or better prophylactic option for patients with recurrent attacks—major unmet needs
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R. Desnick, PhD, MD Mount Sinai School of Medicine, NYC, NY
212-659-8779; [email protected]
K. Anderson, MD U of Texas Medical Branch, Galveston
409-772-4661;[email protected]
M. Bissell, MD U of California, San Francisco (UCSF)
415-476-8405; [email protected]
J. Bloomer, MD U. of Alabama, Birmingham (UAB)
205-996-9543; [email protected]
H. Bonkovsky, MD Wake Forest Univ, Winston-Salem, NC
336-713-1442; [email protected]
J. Phillips, PhD U. of Utah, Salt Lake City
801-585-3229; [email protected]
D. Lyon Howe American Porphyria Foundation
866-APF-3635. http://www.porphyriafoundation.com
http://rarediseasesnetwork.epi.usf.edu/porphyrias/
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39
Agenda
Welcome
• Josh Brodsky, Associate Director, Investor Relations & Corporate Communications
Introduction
• John Maraganore, Ph.D., Chief Executive Officer
Overview of the Acute Porphyrias
• Herbert L. Bonkovsky, M.D., Professor of Medicine, Wake Forest University
School of Medicine
AIP Patient Perspective
• Ariel Lager, patient living with Acute Intermittent Porphyria
Q&A Session
• With Dr. Bonkovsky and Ms. Lager
ALN-AS1 Program
• Bill Querbes, Ph.D., Associate Director, Research
Q&A Session
AIP is a struggle: moment-to-moment and long-term
• About me
• My diagnosis
• After surgery
• Searching for answers
• Connecting with the APF
• Coming to terms
• Treatments
• Symptom management
• Hospitalization
• Limitations of current treatment options/gene therapy
• Managing my care (beyond attacks)
• Daily (chronic symptoms)
• Weekly (infusions)
• Monthly (hormone suppression)
• Yearly (liver scans, port maintenance and repair)
• Long-term health implications
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• Attacks
• Life-threatening
• Debilitating
• Frightening
• Long-term Damage
• Nerve-damage
• Hormonal (bone density, cardiac risk)
• Weight fluctuation
• Pain/pain medication
• Systemic (iron, inflammation)
• Quality of Life
• Lost work
• Impact to family
• Unpredictability
• If I was healthy…
AIP is a struggle: moment-to-moment and long-term 42
43
Agenda
Welcome
• Josh Brodsky, Associate Director, Investor Relations & Corporate Communications
Introduction
• John Maraganore, Ph.D., Chief Executive Officer
Overview of the Acute Porphyrias
• Herbert L. Bonkovsky, M.D., Professor of Medicine, Wake Forest University
School of Medicine
AIP Patient Perspective
• Ariel Lager, patient living with Acute Intermittent Porphyria
Q&A Session
• With Dr. Bonkovsky and Ms. Lager
ALN-AS1 Program
• Bill Querbes, Ph.D., Associate Director, Research
Q&A Session
44
Agenda
Welcome
• Josh Brodsky, Associate Director, Investor Relations & Corporate Communications
Introduction
• John Maraganore, Ph.D., Chief Executive Officer
Overview of the Acute Porphyrias
• Herbert L. Bonkovsky, M.D., Professor of Medicine, Wake Forest University
School of Medicine
AIP Patient Perspective
• Ariel Lager, patient living with Acute Intermittent Porphyria
Q&A Session
• With Dr. Bonkovsky and Ms. Lager
ALN-AS1 Program
• Bill Querbes, Ph.D., Associate Director, Research
Q&A Session
45
ALN-AS1 Therapeutic Hypothesis
Brennan et al. Nature 1979, Hermes-Lima et al. Biochem Biophys Acta 1991, Dar et al., Hepatobiliary Pancreat Dis
Int.; 9:93-6 (2010), Dowman et al., Ann Intern Med; 154:571-2 (2011)
Targeting Liver ALAS1 to Lower Heme Intermediate Production
ALN-AS1
Targeting ALA Synthetase (ALAS1)
• ALAS1 is upregulated in patients due to
various attack triggers (e.g. drugs, fasting,
hormones) causing accumulation of ALA and
PBG upstream of enzyme defect
• ALN-AS1 utilizes GalNAc conjugate
technology with ESC chemistry
• Goal is to reduce ALAS1 levels and prevent
build up of toxic intermediates
• Potential to treat all acute hepatic porphyrias
including AIP, VP and HCP
Triggers
46
RNAi Therapeutic Targeting ALAS1Potential Use for Prophylaxis and Acute Treatment
ALAS1
mRNA
ALN-AS1Acute Attack Setting (Treatment)
Rapid
Suppression
Release of pathway
bottleneck
Quick reduction in
ALA/PBG
Rapid improvement in
clinical symptoms
Days Days
Months
ALAS1
mRNA
Months
ALN-AS1
Recurrent Attack Setting (Prophylaxis)
Blunted
Up-regulation
Mild chronic prophylactic
suppression will blunt
recurrent ALAS1
upregulation
Reduction in attacks,
heme use, and
hospitalizations
47
Importance of Liver ALAS1 and ALA/PBG in
Driving AHP Attacks
Evidence
• ALA/PBG are elevated during attack and
decrease to baseline with heme concurrent
with symptomatic improvement1
◦ Heme downregulates ALAS1 through feedback
• Liver and domino transplant2,3
◦ Elevated ALA/PBG and attacks disappear in AIP
patients and are induced in recipients of AIP
livers
• Rare HCC tumors that cause increased
ALA/PBG and AIP like symptoms4
◦ Cured by hepatoma excision
• Lead poisoning induces ALA increase and AIP
like symptoms by inhibiting second step in
pathway (ALAD)5
1Sardh et al. E J of Int Med; 20:201-7 (2009)2Dar et al., Hepatobiliary Pancreat Dis Int.; 9:93-6 (2010)3Dowman et al., Ann Intern Med; 154:571-2 (2011)4Ochiai et al. Brit J Derm; 136:129-131 (1997)5Friedman et al. NEJM; 370:1542-50 (2014)
Ref. 1
Ref. 3
48
ALN-AS1 Phase 1 Study: AIP patient populations
Asymptomatic High Excreters (ASHE)
• Persistently elevated ALA/PBG
• More clinically relevant than healthy volunteers
• Ability to measure key biomarkers
• Medically stable patient population for initial safety evaluation (studied in
prior enzyme replacement trial)
Recurrent attack patients
• Highest unmet medical need
• Evaluate safety and dose regimen in small subset of patients
Sardh et al. Clin Pharmacokinet;46(4):335-49.
49
ALN-AS1 Phase 1 Study: Design and Objectives
Parts A and B (SAD/MAD) in ASHE patients
Study Design• Randomized, single-blind, placebo-controlled single and multiple ascending dose study in ASHE patients Primary Objective• Safety and tolerability of ALN-AS1Secondary Objectives• Characterize ALN-AS1 pharmacokinetics (PK) and pharmacodynamics (PD), i.e. ALA and PBG loweringExploratory Objectives• Characterize circulating ALAS1 mRNA from the liver in urine and serum using a circulating RNA detection
(cERD) assay
Study Design
• Placebo-controlled multiple dose study in recurrent attacks patients
Primary Objective
• Safety and tolerability of ALN-AS1
Secondary Objectives
• Characterize ALN-AS1 PK and PD
Exploratory Objectives
• Clinical activity of ALN-AS1 on attack characteristics and treatment, and patient quality of life
• Characterize circulating ALAS1 mRNA from the liver in urine and serum
Part C (MD) in recurrent attack patients
50
*Attack definition: intense abdominal or back pain requiring hospitalization, heme use or treatment consisting of increased carbohydrate
intake or pain medication
ALN-AS1 Phase 1 Study: Key Eligibility Criteria
Part A and B Inclusion
• Male or female, ages 18-65 years
• Acute intermittent porphyria (AIP), with genetic diagnosis of HMBS mutation
• Urine PBG > 4 mmol/mol creatinine at screening
Part A and B Exclusion
• Attack* within 6 months of screening
• Heme use in past 6 months
• Subjects with new prescription medication regimen within 3 months of screen
Part C Only Inclusion
• Experienced at least 2 porphyria attacks in past 6 months or on heme prophylaxis to
prevent attacks
• If on heme prophylaxis, willing to stop during study
51
ALN-AS1 Phase 1 Study Progress
0.10 mg/kg x 1 SC, N=4
Part A: Single-Ascending Dose (SAD) │ Randomized 3:1, Single-blind, Placebo-controlled in ASHE
0.035 mg/kg x 1 SC, N=4
0.35 mg/kg x 1 SC, N=4
1.0 mg/kg x 1 SC, N=4
Run-in Observation
(1 to 6 months)
Part C: Multiple-Dose (MD) │ Randomized 3:1, Double-blind, Placebo-controlled in AIP patients with recurrent attacks
Cohort 3 N=4
1.0mg/kg, qMx2 SC, N=4
Part B: Multiple-Ascending Dose (MAD) │ Randomized 3:1, Single blind, Placebo-controlled in ASHE
0.35 mg/kg, qMx2 SC, N=4
*The 0.035 mg/kg SAD cohort was dosed after the
0.10 and 0.35 mg/kg cohorts
Cohort 1 N=4
Cohort 2 N=4
2.5 mg/kg x 1 SC, N=4
ongoing
52
ALN-AS1 Phase 1 Study Part A and Part B Demographics and Baseline Disease Characteristics
Part A and B
Characteristic Result
Number of Patients N=23* (ALN-AS1:Placebo=21:7)
Median Age (range) 47 years (30-64)
Gender 18 Females, 5 Males
Race n 22 White/Caucasian
1 Asian
Genotype (n) 8 different mutations identified**:• HMBS_593G>A (13)
• HMBS_87+1G>A (4)
• HMBS_499-1G>A (1)
• HMBS_517C>T (1)
• HMBS_647G>A (1)
• HMBS_847_848delTG (1)
• 673C>T variant exon 11(1)
• Exon 3 shift IVS3+1G>T(1)
Mean baseline ALA (range) 11.0 mmol/mol Cr (2.9-24.6) ^
Mean baseline PBG (range) 22.0 mmol/mol Cr (4.5-50.5) ^
^Upper Limit of Normal: ALA <3.9 or 3.8 mmol/mol Cr; PBG < 1.6 or 1.5
mmol/mol Cr depending on site
Biorad assay performed at Porphyria Centers in Sweden and UK
*5 subjects had >1 treatment assignment: 2 subjects repeated Part A; 3 subjects enrolled in Part A and Part B
** 3 mutations added to database post data cut and W198X collapsed into HMBS_593G>A
Data in database as of 28 Jun 2016
Sardh et al., SSIEM, September 2016
53
Part A (SAD) and Part B (MAD) Safety and Tolerability
ALN-AS1 was generally well-tolerated in Parts A and B of Study ALN-AS1-001
No drug-related SAEs or discontinuations due to AEs• Two SAD subjects (0.035 and 0.10 mg/kg dose groups) were hospitalized for SAE of “abdominal pain”. Both
events were assessed as unlikely related to ALN-AS1 by the investigators
• One MAD* subject (1 mg/kg dose group) experienced a miscarriage 7 weeks post-conception (90 days post-ALN-AS1) during the extended follow-up period which was assessed as unlikely related by the investigator
SAD: Total of 49 AEs reported (10 AEs in 5 PBO subjects; 39 AEs in 11 ALN-AS1 subjects)• All AEs were mild or moderate in severity with the exception of one severe AE of abdominal pain (same subject
noted above with SAE at 0.10 mg/kg dose).
• AEs reported in 2 subjects were abdominal pain, diarrhea, and hypoesthesia
• 8 related or possibly related AEs were reported in 5 subjects ◦ Diarrhea, dyspepsia, hematochezia, hypoesthesia, injection site erythema, injection site pain, decreased GFR and elevated Cr
• Injection site reactions (erythema and pain) were seen in 2 subjects–both mild and transient
MAD: Total of 29 AEs reported (4 AEs in 1 PBO subject; 25 AEs in 6 ALN-AS1 subjects)• All reported AEs were mild or moderate in severity
• AEs reported in 2 subjects were nasopharyngitis and rash
• 8 related or possibly related AEs were reported in 3 subjects◦ Pruritus only (1 subject), rash only (1 subject) and pruritus and rash (1 subject)
• No injection site reactions were reported
No clinically significant changes in vital signs, EKG, clinical laboratory or physical examination
ALN-AS1 Phase 1 Study Interim Results
*All safety data in database as of 28 Jun 2016 with the exception of the MAD SAE which was as of 03 Sept 2016
Sardh et al., SSIEM, September 2016
54
Circulating Extracellular RNA Detection (cERD) Method for Circulating ALAS1 mRNA Detection
Monitoring RNAi Activity in Liver mRNA or 5’RACE product in tissue
Circulating secreted protein target
Detection of Circulating ALAS1 mRNA Exosomes are shed into bodily fluids from many
different cell types and contain mRNA and miRNAderived from tissue of origin
Exosomes can be used to monitor ALAS1 mRNA after ALN-AS1 dosing in serum/urine without a biopsy
0
20
40
60
80
100
120
PBS 1.25 2.5 5.0
ALAS-GalNAc
(mg/kg)N
orm
ali
ze
d
AL
AS
-1
by cERD
by liver biopsy
AS1 Transcript
QDx5, EOD, d15 (not DC)
Sehgal et al. RNA 2012, Chan et al. MTNA 2015
55
ALN-AS1 Phase 1 Study Interim ResultsSAD Pharmacodynamic Data: Serum ALAS1 mRNA by cERD
ALAS1 mRNA induced approximately 3-fold in ASHE compared to normal healthy volunteers
Rapid, dose-dependent, and durable ALAS1 mRNA lowering after single dose
• 64 ± 1% mean (SEM) maximal reduction in 2.5 mg/kg dose group
• Remaining ALAS1 mRNA levels after highest dose similar to levels in normal healthy individuals
P<0.0001
Me
an
[+
/-S
EM
] A
LA
S1
mR
NA
Lo
we
rin
g
Re
lati
ve
to
Ba
se
lin
e (
%)
80
70
60
50
40
30
20
10
0
-10
-20
-30
Days since first dose
0 5 10 15 20 25 30 35 40 45
90
100
Normal healthy individualSAD Placebo (N=5) 0.035 mg/kg ALN-AS1 (N=3) 0.10 mg/kg ALN-AS1 (N=3)
0.35 mg/kg ALN-AS1 (N=3) 1.0 mg/kg ALN-AS1 (N=3) 2.5 mg/kg ALN-AS1 (N=3)
Data in database as of 28 Jun 2016
Sardh et al., SSIEM, September 2016
56
ALN-AS1 Phase 1 Study Interim ResultsSAD Pharmacodynamic Data: Urinary ALA and PBG
Rapid, dose-dependent, and durable ALA and PBG lowering after single dose • Mean (SEM) maximal reduction in 2.5 mg/kg group: 86± 2% (ALA) and 95± 0.4% (PBG)
• Prolonged ALA and PBG lowering with single dose supporting monthly or quarterly dosing
• Normalization of absolute ALA/PBG levels achieved at higher doses
Excluding subject 201-0002, Day 0: 0-6 hour ALA measurement
Month
ALA
10
Me
an
[+
/-S
EM
] A
LA
Lo
we
rin
g
Re
lati
ve
to
Ba
se
lin
e (
%)
100
80
60
40
20
0
-20
-40
0 1 2 3 4 5 6 7 8 9
Dose
(mg/kg)
ALA
Placebo 0/5
0.035 1/3
0.10 3/3
0.35 2/3
1.0 3/3
2.5 3/3
ALA Assay URL: < 3.9 or 3.8 mmol/mol Cr at sites 101 or 201
PBG Assay URL: < 1.6 or 1.5 mmol/mol Cr at sites 101 or 201
SAD Placebo (N=5)0.035 mg/kg ALN-AS1 (N=3)0.10 mg/kg ALN-AS1 (N=3)
0.35 mg/kg ALN-AS1 (N=3)
1.0 mg/kg ALN-AS1 (N=3)2.5 mg/kg ALN-AS1 (N=3)
Data in database as of 28 Jun 2016
Sardh et al., SSIEM, September 2016
PBG
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
Me
an
[+
/-S
EM
] P
BG
Lo
we
rin
g
Re
lati
ve
to
Ba
se
lin
e (
%)
100
80
60
40
20
-20
-40
-60
Month
0 1 2 3 4 5 6 7 8 9 10
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
0
Dose
(mg/kg)
PBG
Placebo 0/5
0.035 0/3
0.10 1/3
0.35 0/3
1.0 1/3
2.5 2/3
57
ALN-AS1 Phase 1 Study Interim Results
SAD: Changes in Serum ALAS1 mRNA and Urinary ALA/PBG Highly
Correlated
R2 = 0.79,
p<0.001
ALAS1 mRNA vs ALA
ALAS1 mRNA Lowering
Relative to Baseline (%)
SAD Placebo
0.035 mg/kg ALN-AS1
0.10 mg/kg ALN-AS1
0.35 mg/kg ALN-AS1
1.0 mg/kg ALN-AS1
2.5 mg/kg ALN-AS1
Regression Line
Uri
na
ry A
LA
Lo
we
rin
g
Re
lati
ve
to
Ba
se
lin
e (
%)
100
90
80
70
60
50
40
30
20
10
0
-10
-20
-30
-40
-50
-60
R2 = 0.87,
p<0.001
ALAS1 mRNA vs PBG
ALAS1 mRNA Lowering
Relative to Baseline (%)
70 60 50 40 30 20 10 0 -10 -20 -30 -40
Uri
na
ry P
BG
Lo
we
rin
g
Re
lati
ve
to
Ba
se
lin
e (
%)
100
90
80
70
60
50
40
30
20
10
0
-10
-20
-30
-40
-50
SAD Placebo
0.035 mg/kg ALN-AS1
0.10 mg/kg ALN-AS1
0.35 mg/kg ALN-AS1
1.0 mg/kg ALN-AS1
2.5 mg/kg ALN-AS1
Regression Line
100 90 8070 60 50 40 30 20 10 0 -10 -20 -30 -40100 90 80
Data in database as of 28 Jun 2016
Sardh et al., SSIEM, September 2016
58
ALN-AS1 Phase 1 Study Interim Results
Rapid, dose-dependent, and durable ALAS1 mRNA lowering• 54 ± 2% mean (SEM) maximal reduction relative to baseline in 1.0 mg/kg dose group
• ALAS1 mRNA reduction seen with 2 doses similar to single dose
Normal healthy volunteer
Me
an
[+
/-S
EM
] A
LA
S1
mR
NA
Lo
we
rin
g
Re
lati
ve
to
Ba
se
lin
e (
%)
80
70
60
50
40
30
20
10
0
-10
-20
-30
-40
-50
Days since first dose
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70
Dose Group MAD Placebo (N=2) 0.35 mg/kg ALN-AS1 (N=3) 1.0 mg/kg ALN-AS1 (N=3)
MAD Pharmacodynamic Data: Serum ALAS1 mRNA by cERD
Data in database as of 28 Jun 2016
Sardh et al., SSIEM, September 2016
59
ALA
Rapid, dose-dependent, and durable ALA and PBG lowering after multiple doses• Mean (SEM) maximal reduction in 1 mg/kg group: 84 ± 2% (ALA) and 89 ± 5% (PBG)
• Multiple doses without additive effect in either dose group
• Normalization of absolute ALA/PBG levels achieved at higher doses
PBG
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
Me
an
[+
/-S
EM
] A
LA
Lo
we
rin
g
Re
lati
ve
to
Ba
se
lin
e (
%)
100
80
60
40
20
0
-20
-40
-60
Months
0 1 2 3 4 5 6 7 8 9 10
Months
Me
an
[+
/-S
EM
] P
BG
Lo
we
rin
g
Re
lati
ve
to
Ba
se
lin
e (
%)
100
80
60
40
20
0
-20
-40
-60
0 1 2 3 4 5 6 7 8 9 10
MAD Placebo (N=2)
0.35 mg/kg ALN-AS1 (N=3)
1.0 mg/kg ALN-AS1 (N=3)
MAD Placebo (N=2)
0.35 mg/kg ALN-AS1 (N=3)
1.0 mg/kg ALN-AS1 (N=3)
Dose
(mg/kg)
ALA
Placebo 1 /2
0.35 1/3
1.0 3/3
Dose
(mg/kg)
PBG
Placebo 0/2
0.35 0/2
1.0 2/3
ALA Assay URL: < 3.9 or 3.8 mmol/mol Cr at sites 101 or 201
PBG Assay URL: < 1.6 or 1.5 mmol/mol Cr at sites 101 or 201
ALN-AS1 Phase 1 Study Interim ResultsMAD Pharmacodynamic Data: Urinary ALA and PBG
Data in database as of 28 Jun 2016
Sardh et al., SSIEM, September 2016
60
ALN-AS1 Phase 1 Study Interim Results Summary
ALN-AS1 generally well tolerated with single or multiple (2) doses
• SAEs deemed unlikely related to study drug and no discontinuations due to AEs
• No dose-dependent AEs or clinically significant changes in vital signs, EKG, clinical laboratory or
physical examination
Non-invasive cERD assay to quantify liver ALAS1 mRNA expression demonstrated
• ASHE have 3-fold ALAS1 mRNA induction compared to normal healthy individuals
• Rapid, dose-dependent, and durable ALAS1 mRNA lowering with single and multiple doses of ALN-
AS1; highly correlated with changes in ALA and PBG
◦ 64% with a single 2.5 mg/kg dose and 54% with multiple 1.0 mg/kg doses
Rapid, dose-dependent, and durable lowering of urinary ALA and PBG with single and multiple
doses of ALN-AS1
• 86% and 95%, respectively, with a single 2.5 mg/kg dose
• 84% and 89%, respectively with multiple 1.0 mg/kg doses
Next Steps
• Part A/B, (SAD/MAD) continue to monitor ALA, PBG and ALAS1 recovery
• Part C, MD portion in recurrent attack patients ongoing in Sweden, UK and US
◦ Plan to report initial porphyria biomarker data from Part C in late 2016
◦ Potential clinical efficacy data on frequency and severity of recurrent attacks expected in 2017
• Plan to initiate Phase 3 trial in 2017
Data in database as of 28 Jun 2016
Sardh et al., SSIEM, September 2016
61
Study Design Overview
Design
• Observational, prospective natural
history study
Key Eligibility Criteria
• Males or Females ≥ 18 years old
• Diagnosis of AHP including AIP, VP, or
HCP by specialist
• Recurrent attacks
◦ 3+ attacks* within 12 months of screen
if not on heme prophylaxis
◦ Using heme or GnRH analogs
prophylactically
Notify Clinic if Attack and Complete:
• Attack Inventory Form
• Blood/urine samples
Study Schedule
6 months(option to extend to 1 year)
Screening Visit Telephone calls (Q 2 mos) Final Visit
• Questionnaires
• Blood/urine samples
• Questionnaires
• Blood/urine samples
• Questionnaires
• Blood/urine samples
62
Objectives and Status
Key Objectives
• Characterizing signs and symptoms of attacks
• Determining attack rates and treatment practices
• Obtaining medical history and medication usage details
• Exploration of Biomarkers
• Capture Quality of life (QoL) data
• Understanding healthcare utilization
Final Population
• Completed enrollment with112 AHP patients
◦ 44% US, 56% EU
Next Steps
• Presentation of 6 month data from all patients to be presented in Q4
◦ AASLD in Boston, Nov 11-15
• Data will help inform design of the pivotal study in 2017
63
Agenda
Welcome
• Josh Brodsky, Associate Director, Investor Relations & Corporate Communications
Introduction
• John Maraganore, Ph.D., Chief Executive Officer
Overview of the Acute Porphyrias
• Herbert L. Bonkovsky, M.D., Professor of Medicine, Wake Forest University
School of Medicine
AIP Patient Perspective
• Ariel Lager, patient living with Acute Intermittent Porphyria
Q&A Session
• With Dr. Bonkovsky and Ms. Lager
ALN-AS1 Program
• Bill Querbes, Ph.D., Associate Director, Research
Q&A Session
64
Upcoming RNAi Roundtables
ALN-GO1 for the treatment of Primary Hyperoxaluria Type 1 (PH1)
Tuesday, September 27, 10:00 a.m. – 11:00 a.m. ET
• Barry Greene, President and Chief Operating Officer
• David Erbe, Ph.D., Director, Research
• Guest Speaker: Sally-Anne Hulton, M.D., FRCPCH, MRCP, FCP, MBBCh, Consultant Paediatric
Nephrologist and Clinical Lead, Birmingham Children’s Hospital NHS Trust
• Guest Speaker: Jennifer Lawrence, M.D. (mother of George Tidmore, a PH1 patient)
ALN-HBV for the treatment of Hepatitis B Virus (HBV) Infection
Tuesday, October 11, 9:00 a.m. – 10:00 a.m. ET
• Barry Greene, President and Chief Operating Officer
• Laura Sepp-Lorenzino, Ph.D., Vice President, Entrepreneur-in-Residence
• Guest Speaker: Heiner Wedemeyer, M.D., Managing Senior Physician and Assistant Professor in the
Department of Gastroenterology, Hepatology and Endocrinology at Hannover Medical School
For more information, please visit www.alnylam.com/roundtables