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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
2
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
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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)
*Data transfer: 3/2/2016
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%
*Data transfer: 03/02/2016
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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ALN-CC5 Phase 1/2: Part B – MAD*
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 (%
)
Days since first visit
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
*Data transfer: 03/02/2016
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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ALN-CC5 Phase 1/2: Part B – MAD*
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 (%
)
Days since first visit
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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ALN-CC5 Phase 1/2: Part B – MAD*
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
Days since first visit
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