ENDOTOXEMIA AND MARKERS OF LIV IVER IN INJURY IN IN NONALCOHOLIC - PowerPoint PPT Presentation

IM IMM-124 124E IM IMPROVES METABOLIC ENDOTOXEMIA AND MARKERS OF LIV IVER IN INJURY IN IN NONALCOHOLIC STEATOHEPATITIS Abdelmalek MF, Freilich BL, Harrison S, Powell EE, Rinella ME, Tobis N, Peres D, Kanellos J, Lalazar G, Sanyal AJ Study Sponsor: Immuron (NCT02316717)

Metabolic endotoxemia: a driver of systemic inflammation in obesity- insulin resistance-type 2 diabetes Ox stress Fat Lipotoxicity Cell death FFA UPR Inflammation Fibrosis INFLAMMATIORY PATHWAYS repair ENDOTOXIN CALORIES BACTERIAL METABOLITES microbiota Bile salts ileum Large bowel Friedman Tetri Rinella Sanyal, Nature Med 2018 Stavros B et al. Molecular Metabolism, 2016 Sharifnia T, et al. Am J Physiol Gastrointest Liver Physiol 2015

IM IMM-124E • Colostrum from cattle vaccinated with pathogenic Enterotoxigenic E. coli (ETEC) (>35% IgG) Pre- • Orally active antibodies bind and neutralize endotoxins Clinical Studies • Reduces motility, adherence to host epithelium and colonization of pathogenic ETEC Without IMM-124E With IMM-124E Decreased Bacteria attach to gut wall Bacterial adherence and and infect colonization Sears et al. Clinical & Vaccine Immunology 2017;24(8) Scanning Electron Micrographs courtesy of Immuron Limited

Hyp ypothesis: Decreasing metabolic ic endotoxemia ia wit ith IM IMM-124E wil ill l reduce the dri rivers of f NASH progression Ox stress Fat Lipotoxicity Cell death FFA UPR Inflammation Fibrosis INFLAMMATIORY PATHWAYS repair ENDOTOXIN CALORIES BACTERIAL METABOLITES • ↓ ALT • ↓ CK18 • ↓ ? Steatosis IMM-124E endotoxin Bile salts Large bowel microbiota ileum

STUDY DESIGN: Prospective dose-ranging phase 2A tria ial 120 patients, 3-arms, Randomized, double blind, Placebo controlled 2-dose, balanced 1:1:1 design Treatment allocation stratified by diabetes status: HBA1C <6.0 versus HBA1C >6.0 and/or diagnosis of Type II diabetes 24 week treatment Placebo (TID) SCREENING ≤ 45 D FOLLOW UP 4 W IMM-124E 600 mg (TID) IMM-124E 1200 mg (TID)

Key In Inclusion Criteria • Age ≥ 18 years • Diagnosis of NASH Histologically proven within 12 months of screening and all of the following criteria met: • NASH activity score (NAS) of 4 or more • Cytologic ballooning score of at least 1 • 10% or more macrovesicular steatosis • Hematoxylin & Eosin (H&E) stained slides and/or paraffin block available for independent assessment • HBA1C of <9.0

Key Exclusion Criteria • Liver disease of other cause • Cirrhosis • BMI <25kg/m 2 • Alcohol use >30g/day • Weight change of ≥ 10% in past 12 months • Other excluded conditions: T1DM, ongoing multi-systemic immune-mediated disease, concurrent or past malignant disease • Concurrent medications including: Immune modulatory agents, antibiotics, or probiotics Change in dose of Vitamin E, Glitazones, Gliptins and GLP1 analogs, Insulin, gemfibrozil or statins prior to determinant biopsy • Cow milk allergy, lactose intolerance

Study Endpoints PRIMARY • Safety and tolerability (clinical) • Hepatic Fat Fraction SECONDARY • Markers of liver injury – ALT, AST, CK-18 • Glucose homeostasis • Serum Bovine Ig – Safety parameter • Establish recommended dose MoA • Lipopolysaccharides (LPS)

Results: S Study Population Patients Screened N = 237 Screen Failures N = 104 Randomized N = 133 Early Termination Full Analysis Set (FAS) N = 21 Non compliance N = 8 Major protocol Deviations Per Protocol (PP) = 102 N = 2

Results: baseline characteristics Placebo IMM-124E 600 mg IMM-124E 1200 mg P value (n=44) (n=43) (n=46) Age (yrs) 49.4 52.5 50.9 0.579 Females (%) 45.5 53.5 58.7 0.410 Caucasian (%) 76.3 72.4 88.6 0.236 T2 DM (%) 38.6 41.9 39.1 0.987 BMI (kg/m 2 ) 34.7 33.8 34.2 0.786 AST (IU/l) 47.8 48.0 46.7 0.968 ALT (IU/l) 70.9 79.9 67.3 0.422 Alk Phos (IU/l) 83.7 88.5 79.9 0.536 Bilirubin (mg/dl) 0.62 0.63 0.68 0.798 HbA1C (%) 7.8 7.3 6.1 0.382 MRI-PDFF (%) 18.1 20.2 19.6 0.559 *Group mean values

Results: baseline histology Placebo IMM-124E IMM-124E P value (n=44) 600 mg (n=43) 1200 mg (n=46) steatosis 2.24 2.24 2.14 0.825 Lobular inflammation 1.71 1.59 1.66 0.647 Ballooning 1.39 1.45 1.5 0.598 Fibrosis 1.66 1.72 1.69 0.952 NAS 5.34 5.28 5.31 0.968 Individual parameters scored by NASH CRN scoring system- Kleiner et al 2005

Primary ry outcome: Serious Adverse Events Placebo IMM-124E IMM-124E (n=44) 600 mg (n=43) 1200 mg (n=46) Any 3 1 2 Chest pain 0 0 1 Motor vehicle accident 1 0 0 Elevated CPK 1 0 0 Transitional cell CA 0 1 0 Anxiety attacks 0 0 1 Psychiatric hospitalization 1 0 0 Rx stopped due to AE 0 1 1 Grade 3-4 1 1 2 Grade 5 (Death) 1 0 0 * p = NS * Serious adverse events defined per CTCAE (5.0) criteria

Primary ry outcome: MRI-PDFF No si signif ificant changes No Significant Changes n o s ig n if ic a n t c h a n g e s 0 Placebo (N=38) % c h a n g e f r o m b a s e l i n e p la c e b o i % Change from baseline IMM-124E 600mg (N=29) I m m - 1 2 4 ( 6 0 0 m g / d a y ) IMM-124E 1200mg (N=39) I m m 1 2 4 ( 1 2 0 0 m g / d a y ) - 1 - 2 - 3 p l a c e b o i I m m - 1 2 4 ( 6 0 0 m g / d a y ) I m m 1 2 4 ( 1 2 0 0 m g / d a y ) s t u d y g r o u p s

Secondary ry outcome: ALT Proportion with ≥ 30% decrease in ALT (Baseline ALT ≥50) 10 % of Subjects with >30% decrease P< 0.05 40 Change in ALT (UL) from Day 0 5 30 0 -5 % 20 -10 -15 10 -20 0 28 56 84 112 140 168 196 0 Study Day o ) ) g g b m m e c g g o 0 0 a 0 0 l 1200mg 600mg Placebo p 6 2 e ( 1 4 ( o 2 4 e 1 2 1 Least Sq Means ± SE m m o m m I I study groups * Sites < 3 subjects excluded

Markers of f liver injury ry: IM IMM-124E improved AST P<0.05 5 Change in AST (UL) from Day 0 0 -5 -10 0 28 56 84 112 140 168 196 Study Day g g o 1200mg 600mg Placebo e MM on Change o Least Sq Means ± SE o *Sites < 3 subjects excluded

Baseline to End of Treatment changes in CK 18 18 Proportion with ≥ 15% decrease in CK-18 P<0.05 p < 0 . 0 5 % of subjects with ≥15% decrease m Day 0 Change in Cytokeratin-18 (pg/mL) from Da... 750 4 0 500 3 0 250 0 2 0 % -250 1 0 -500 0 -750 I m m 1 2 4 ( 6 0 0 m g ) I m m 1 2 4 ( 1 2 0 0 m g ) p l a c e b o 0 28 56 84 112 140 168 Study Day S M 1200mg 600mg Placebo iffe g g o MM on Change Least Sq Means ± SE e o o s t u d y g r o u p s * Sites < 3 subjects excluded

IM IMM-124E does not impact insulin resistance (H (HOMA-IR) placebo IMM-124E IMM-124E 600 mg 1200 mg Mean Baseline 11.78 9.68 9.51 SD Baseline 9.84 6.76 8.04 Mean W24 10.84 11.37 9.89 SD W24 8.68 12.26 7.13 P value vs. Placebo 0.236 0.491

Mechanism of f action related endpoints : : IMM-124 IM 124E (1200 mg) decreased endotoxemia p = 0.03 p = 0 . 0 7 b y o r d in a l r e g r e s s io n p < 0 . 0 2 1 0 0 1 0 0 > 1 5 % i n c r e a s e 8 0 8 0 w it h in 1 5 % o f b a s e lin e > 1 5 % d e c r e a s e 6 0 6 0 % % 4 0 4 0 2 0 2 0 0 0 p l a c e b o A c t i v e d r u g ) ) o g g b m m e c 0 0 s t u d y g r o u p s a 0 0 l p 2 6 ( 1 ( 4 2 3 1 2 1 m m m m I I * PP population s t u d y g r o u p s * Sites < 3 subjects excluded * LPS < 250 (ng/ml) excluded

LPS sensitivity analysis

Summary ry • IMM-124E was well tolerated and had no discernable toxicity • The systemic exposure to bovine IgG was minimal to none • IMM-124E did not improve hepatic steatosis • IMM-124E produced a dose-dependent improvement in endotoxemia and markers of liver injury (AST, ALT, CK 18)

Conclusions • The study provides proof of concept that metabolic endotoxemia can be improved with IMM-124E. • These provide a rationale to evaluate this compound in even higher doses in conditions where endotoxemia may be relevant e.g. alcohol-induced liver injury and cirrhosis.

Acknowledgments • Manal F. • Stephen Harrison • Mary E. Rinella Abdelmalek • Stephen H. • Bradley Freilich • Cynthia Guy Caldwell • Giuseppe Morelli • John Rawls • Amanda Wieland • Mitchel • Lawrence David • Kris Kowdley Shiffrman • Mohammad Shadab • Rohit Loomba • Robert Stuart Siddiqui • Angelo Humberto • Siddarth Sood • John M. Vierling Paredes • Jacob George • Amanda Nicoll • Arthur J. • Martin David McCullough • J. Scott Overcash Weltman • Khoury Tawfik • Sandra S. Win • Elizabeth Powell • Oren Shibolet