NYSE MKT: SYN Microbiome Analyst & Investor Meeting New York - PowerPoint PPT Presentation

Primary Outcome (4 weeks after Tx) Efficacy Efficacy Odds Odds Outcome Outcome Study Study Ratio Ratio (95% CI) (95% CI) p -value p -value TARGET 1 TARGET 1 1.53 1.53 (1.10,2.12) (1.10,2.12) 0.0125 0.0125 SGA-IBS SGA-IBS Primary TARGET 2 TARGET 2 1.45 1.45 (1.05,2.01) (1.05,2.01) 0.0263 0.0263 Weekly Weekly Combined Combined 1.49 1.49 (1.18,1.88) (1.18,1.88) 0.0008 0.0008 Key TARGET 1 TARGET 1 1.62 1.62 (1.16,2.27) (1.16,2.27) 0.0045 0.0045 IBS Bloating IBS Bloating TARGET 2 TARGET 2 1.49 1.49 (1.08,2.06) (1.08,2.06) 0.0167 0.0167 Secondary Weekly Weekly Combined Combined 1.56 1.56 (1.23,1.96) (1.23,1.96) 0.0002 0.0002 Other TARGET 1 TARGET 1 1.76 1.76 (1.26,2.47) (1.26,2.47) 0.0009 0.0009 SGA-IBS Daily SGA-IBS Daily TARGET 2 TARGET 2 1.59 1.59 (1.13,2.24) (1.13,2.24) 0.0072 0.0072 Secondary Combined Combined 1.61 1.61 (1.28,2.04) (1.28,2.04) <0.0001 <0.0001 TARGET 1 TARGET 1 1.41 1.41 (1.01,1.97) (1.01,1.97) 0.0486 0.0486 IBS Bloating IBS Bloating TARGET 2 TARGET 2 1.76 1.76 (1.26,2.44) (1.26,2.44) 0.0008 0.0008 Daily Daily Combined Combined 1.52 1.52 (1.21,1.92) (1.21,1.92) 0.0004 0.0004 TARGET 1 TARGET 1 1.45 1.45 (1.05,2.02) (1.05,2.02) 0.0255 0.0255 IBS Ab Pain IBS Ab Pain TARGET 2 TARGET 2 1.46 1.46 (1.05,2.03) (1.05,2.03) 0.0232 0.0232 Daily Daily Combined Combined 1.42 1.42 (1.13,1.78) (1.13,1.78) 0.0028 0.0028 TARGET 1 TARGET 1 1.40 1.40 (1.02,1.92) (1.02,1.92) 0.0401 0.0401 FDA Ab Pain & Stool Ab Pain & Stool TARGET 2 TARGET 2 1.55 1.55 (1.12,2.13) (1.12,2.13) 0.0077 0.0077 Daily (FDA) Daily (FDA) Proposed Combined Combined 1.47 1.47 (1.17,1.84) (1.17,1.84) 0.0009 0.0009 TARGET 1 TARGET 1 1.48 1.48 (1.08,2.03) (1.08,2.03) 0.0157 0.0157 Ab Pain Daily Ab Pain Daily TARGET 2 TARGET 2 1.46 1.46 (1.06,2.00) (1.06,2.00) 0.0194 0.0194 (FDA) (FDA) Combined Combined 1.46 1.46 (1.17,1.83) (1.17,1.83) 0.0009 0.0009 TARGET 1 TARGET 1 1.80 1.80 (1.25,2.59) (1.25,2.59) 0.0015 0.0015 Stool Consist. Stool Consist. TARGET 2 TARGET 2 1.57 1.57 (1.12,2.21) (1.12,2.21) 0.0096 0.0096 Daily (FDA) Daily (FDA) Combined Combined 1.67 1.67 (1.31,2.14) (1.31,2.14) <0.0001 <0.0001 0.0 0.5 1.0 1.5 2.0 2.5 Odds Ratio and 95% CI Favors Placebo Favors Rifaximin Pimentel, et al NEJM, 2011

Durability of Response (3 months) Efficacy Efficacy Odds Odds Study Study (95% CI) (95% CI) p -value p -value Outcome Outcome Ratio Ratio TARGET 1 TARGET 1 1.35 1.35 (1.00, 1.82) (1.00, 1.82) 0.0477 0.0477 SGA-IBS SGA-IBS Primary TARGET 2 TARGET 2 1.52 1.52 (1.13, 2.03) (1.13, 2.03) 0.0053 0.0053 Weekly Weekly Combined Combined 1.44 1.44 (1.17, 1.77) (1.17, 1.77) 0.0007 0.0007 TARGET 1 TARGET 1 1.28 1.28 (0.95, 1.73) (0.95, 1.73) 0.1042 0.1042 Key IBS Bloating IBS Bloating TARGET 2 TARGET 2 1.56 1.56 (1.16, 2.09) (1.16, 2.09) 0.0031 0.0031 Secondary Weekly Weekly Combined Combined 1.42 1.42 (1.15, 1.75) (1.15, 1.75) 0.0011 0.0011 TARGET 1 TARGET 1 1.60 1.60 (1.18, 2.18) (1.18, 2.18) 0.0025 0.0025 Other SGA-IBS Daily SGA-IBS Daily TARGET 2 TARGET 2 1.47 1.47 (1.09, 1.99) (1.09, 1.99) 0.0127 0.0127 Secondary Combined Combined 1.48 1.48 (1.20, 1.83) (1.20, 1.83) 0.0003 0.0003 TARGET 1 TARGET 1 1.50 1.50 (1.10, 2.04) (1.10, 2.04) 0.0103 0.0103 IBS Bloating IBS Bloating TARGET 2 TARGET 2 1.67 1.67 (1.24, 2.25) (1.24, 2.25) 0.0008 0.0008 Daily Daily Combined Combined 1.53 1.53 (1.24, 1.89) (1.24, 1.89) <0.0001 <0.0001 TARGET 1 TARGET 1 1.35 1.35 (1.00, 1.83) (1.00, 1.83) 0.0495 0.0495 IBS Ab Pain IBS Ab Pain TARGET 2 TARGET 2 1.35 1.35 (1.01, 1.81) (1.01, 1.81) 0.0435 0.0435 Daily Daily Combined Combined 1.31 1.31 (1.06, 1.61) (1.06, 1.61) 0.0118 0.0118 TARGET 1 TARGET 1 1.36 1.36 (1.01, 1.83) (1.01, 1.83) 0.0396 0.0396 Ab Pain & Stool Ab Pain & Stool FDA TARGET 2 TARGET 2 1.44 1.44 (1.08, 1.92) (1.08, 1.92) 0.0141 0.0141 Daily (FDA) Daily (FDA) Proposed Combined Combined 1.40 1.40 (1.14, 1.72) (1.14, 1.72) 0.0014 0.0014 TARGET 1 TARGET 1 1.31 1.31 (0.98, 1.75) (0.98, 1.75) 0.0725 0.0725 Ab Pain Daily Ab Pain Daily TARGET 2 TARGET 2 1.37 1.37 (1.03, 1.83) (1.03, 1.83) 0.0298 0.0298 (FDA) (FDA) Combined Combined 1.33 1.33 (1.09, 1.64) (1.09, 1.64) 0.0058 0.0058 TARGET 1 TARGET 1 1.70 1.70 (1.24, 2.33) (1.24, 2.33) 0.0009 0.0009 Stool Consist. Stool Consist. TARGET 2 TARGET 2 1.48 1.48 (1.09, 2.00) (1.09, 2.00) 0.0114 0.0114 Daily (FDA) Daily (FDA) Combined Combined 1.58 1.58 (1.27, 1.97) (1.27, 1.97) <0.0001 <0.0001 0.0 0.5 1.0 1.5 2.0 2.5 Odds Ratio and 95% CI Favors Placebo Favors Rifaximin Pimentel, et al NEJM, 2011

D-IBS M-IBS C-IBS Constipation-IBS

SSRI – Meta-analysis Treatment Control Study (Year, Drug, Dose) n/N n/N RR (Random) 95% CI Kuiken (2003, fluoxetine 20 qd) 9/19 12/21 Tabas (2004, paroxetine 10-40 qd) 25/44 36/46 Vahedi (2005, fluoxetine 20 qd) 6/22 19/22 Tack (2006, citalopram 20-40 qd) 5/11 11/12 Talley (2008, citalopram 40 qd) 5/17 5/16 Subtotal (95% CI) 113 117 10 0.1 0.2 0.5 1 2 5 Favors Treatment Favors Control *Significant heterogeneity among studies may limit conclusions. RR=0.62 Study duration ranged from 6 weeks to 12 weeks. (95% CI=0.45-0.87) Ford AC, et al. Gut . 2009;58:367-378. NNT=3.5 26

Lubiprostone for IBS-C: Data From Two Phase 3 Trials 50 • 12-week treatment period • Overall responder: Monthly Overall Responders (%) responder for at least 2 of 3 months 25 * P =.001 • Monthly responder: At least 17.9 moderate relief for 4/4 weeks 10.1 or significant relief for 2/4 weeks 0 Lubiprostone 8 µg Placebo BID N=780 N=387 Drossman DA et al. Aliment Pharmacol Ther . 2009;29:329-341.

Lubiprostone: Adverse Effects Lubiprostone Placebo 8 mcg twice daily N=387 N=779 1% 1% Serious Adverse Events 21% 22% Treatment-related Adeverse Events Nausea 4% 8% Diarrhea 4% 6% 5% 4% Abdominal Pain Cardiovascular-related events 0% <1% (Mild tachycardia reported in 1 patient) 6% 5% Discontinuation due to adverse events Drossman DA et al. Aliment Pharmacol Ther. 2009;29:329-341.

Linaclotide Phase 3 Studies in IBS-C: EMA Analysis ≥6/12 weeks considerable or complete relief of IBS symptoms 70 12-Week responder 12-Week responder 12-Week responder 60 Δ = 15.6% Δ = 21.1% Δ = 19.1% % Responders 50 * 36.7 40 * * 33.8 33.2 30 18.2 20 15.6 14.1 10 0 N =395 N =405 N =403 N =401 N =403 N =401 Trial 31 Trial 302 * P <.0001 Quigley EMM et al. Aliment Pharmacol Ther 2013;37:49.

Linaclotide in IBS-C Phase 3 Trial: Safety Weeks 1 – 12 Weeks 1 – 26 Placebo Lin 290 mcg Placebo Lin 290 mcg n=403 n=402 n=403 n=402 Any TEAE 187 (46%) 212 (53%) 228 (57%) 263 (65%) 7 (2%) 71 (18%) 10 (2%) 79 (20%) Diarrhea Nausea 17 (4%) 17 (4%) 24 (6%) 23 (6%) URI 13 (3%) 14 (3%) 22 (5%) 22 (5%) 14 (3%) 15 (4%) 16 (4%) 18 (4%) Abdominal pain Flatulence 7 (2%) 13 (3%) 9 (2%) 15 (4%) 4 (1%) 8 (2%) 9 (2%) 15 (4%) Gastroenteritis viral Headache 8 (2%) 13 (3%) 11 (3%) 13 (3%) TEAE=treatment-emergent adverse event Chey WD et al. Am J Gastroenterol 2012;107:1702

Disadvantages of Current C-IBS therapies • Built on the concept of laxative/accelerants • Side effects are often diarrhea • No biomarker to predict side effects/response • Not based on a mechanism known to be important in the pathophysiology of IBS

Functional Net Value – Diarrhea IBS Shah, et al. Aliment Pharm Ther 2014

Functional Net Value – Constipation IBS Shah, et al. Aliment Pharm Ther 2014

IBS and Microbiome

2000 • American J Gastroenterol 2000 Dec;95(12):3503-6. Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome.

Number of Cells Bacterial Cells 100x more Bacterial cells Human Cells

Kingdoms of Life Eukaryotes Bacteria Archaea Example: Example: Example: Plants and Salmonella, Methanogens animals E. coli

SIBO- What is it? Small Bowel ~ 0 cfu/mL Duodenum Colon 10 11 cfu/mL 10 1 cfu/mL Jejunum Cecum 10 2 cfu/mL Ileum 10 3 cfu/mL

Different Approaches to SIBO Type of Test Specific Test Breath testing Lactulose Breath Test 13C Xylose Breath Test Glucose Breath Test Sucrose Breath Test Sorbitol Breath Test Culture Small bowel aspirate and culture Empiric Approach Test, treat and re-evaluate

D-IBS M-IBS C-IBS Non-Constipation-IBS

Breath Testing is abnormal in IBS Forest plot of all age-sex matched studies Type of % % Author Breath Test OR (95% CI) Weight OR (95% CI) Weight Grover sucrose 2.29 (0.89, 5.87) 18.65 2.29 (0.89, 5.87) 18.65 Lupascu glucose 10.89 (3.52, 33.71) 16.82 10.89 (3.52, 33.71) 16.82 Pimentel lactulose 20.67 (5.29, 80.69) 14.68 20.67 (5.29, 80.69) 14.68 Parodi glucose 4.30 (1.24, 14.98) 15.71 4.30 (1.24, 14.98) 15.71 Scarpellini lactulose 24.27 (7.35, 80.15) 16.20 24.27 (7.35, 80.15) 16.20 Collin lactulose 18.04 (6.55, 49.71) 17.94 18.04 (6.55, 49.71) 17.94 Overall (I-squared = 67.9%, p = 0.008) 9.64 (4.26, 21.82) 100.00 9.64 (4.26, 21.82) 100.00 NOTE: Weights are from random effects analysis .1 .2 .5 1 1 2 5 10 20 Shah, et al Dig Dis Sci, 2010

Small Bowel Culture in IBS P<0.001 P<0.05 50 43% 45 Percent of Subjects 40 35 30 24% Control 25 20 IBS 12% 15 10 4% 5 0 >10,000 coliforms >5,000 coliforms N=165 IBS, 26 controls Posserud, et al, Gut, 2007;56:802-8.

SIBO and IBS 70 60% 60 P=0.004 Percent of Subjects 50 Non- D-IBS 40 27.3% 30 D-IBS 20 10 0 N=77 non-D-IBS, N=35 D-IBS Pyleris, et al. DDS, 2012

Agilent Plots of Normal and IBS IBS Healthy Control Pyleris, et al. DDW, 2014

Sequencing Results- Normal small bowel Normal Subjects Pyleris, et al. DDW, 2014

Sequencing Results- IBS small bowel IBS Subjects Pyleris, et al. DDW, 2014

D-IBS M-IBS C-IBS Constipation-IBS

Complexities of Gas Production Methane Hydrogen 70 60 Parts Per Million H 2 50 40 30 Methane 20 10 Producers 0 0 15 30 45 60 75 90 105 120 135 150 165 180 4H 2 →1CH 4 Hydrogen Time (Minutes) Producers 70 60 70 Parts Per Million 50 60 40 Parts Per Million 50 30 H 2 40 20 10 30 H 2 S 0 20 0 15 30 45 60 75 90 105 120 135 150 165 180 10 Time (Minutes) Producers 0 0 15 30 45 60 75 90 105 120 135 150 165 180 5H 2 →1H 2 S Time (Minutes)

Methane in C-IBS X 2 =16.6, p<0.001 100 90 80 % of patients 70 60 50 Constipation 40 Diarrhea 30 20 10 0 H2 CH4 and H2 CH4 Pimentel, et al. Dig Dis Sci, 2003.

Methane Slows Intestinal Transit 80 n=5, p<0.0001 60 % Marker Recovery 40 20 69% mean slowing of transit with CH 4 0 Room Air Methane Pimentel, et al. Am J Physiol, 2006.

Methane- Important in C-IBS Meta-analysis of studies % % Author Year OR (95% CI) Weight OR (95% CI) Weight Peled 1987 0.83 (0.20, 3.56) 8.43 0.83 (0.20, 3.56) 8.43 Fiedorek 1990 4.32 (1.60, 11.68) 12.03 4.32 (1.60, 11.68) 12.03 Pimentel 2003 5.58 (2.22, 14.03) 12.68 5.58 (2.22, 14.03) 12.68 Pimentel 2003 44.23 (2.48, 788.51) 3.18 44.23 (2.48, 788.51) 3.18 Majewski 2007 1.81 (0.70, 4.67) 12.46 1.81 (0.70, 4.67) 12.46 Bratten 2008 2.22 (1.14, 4.33) 15.14 2.22 (1.14, 4.33) 15.14 Parodi 2009 1.89 (0.79, 4.51) 13.17 1.89 (0.79, 4.51) 13.17 Hwang 2009 47.67 (8.73, 260.41) 6.99 47.67 (8.73, 260.41) 6.99 Attaluri 2009 3.70 (2.06, 6.66) 15.92 3.70 (2.06, 6.66) 15.92 Overall (I-squared = 64.6%, p = 0.004) 3.51 (2.00, 6.16) 100.00 3.51 (2.00, 6.16) 100.00 NOTE: Weights are from random effects analysis .1 .2 .5 1 1 2 5 10 20 Kunkel, et al. Dig Dis Sci, 2011.

Methanobrevibacter smithii -M. smithii is the predominant human methanogen -There are no drug development plans around the organism -This organism is important in health and disease

Methane Factor Analysis • Constipation • lack of milk intolerance • lack of weight loss • small bowel movements • straining

After treatment constipation level by group 60 50 P=0.01 VAS score 40 30 20 10 0 Neo+plac Neo+rifax Pimentel, et al. Dig Dis Sci, 2014.

After treatment bloating level by group 70 60 P<0.01 VAS score 50 40 30 20 10 0 Neo+plac Neo+rifax Pimentel, et al. Dig Dis Sci, 2013.

Weekly Constipation VAS VAS Constipation Severity 80 *P=0.01 70 ¶P<0.01 60 +P=0.14 50 Neo+plac 40 Neo+rifax + 30 ¶ * 20 ¶ ¶ 10 0 Pre Tx Post Tx 1 2 3 4 Pimentel, et al. ACG, 2013.

Weekly Bloating VAS 80 *P<0.05 70 VAS Bloating Severity ¶P=NS 60 50 Neo+plac 40 ¶ * Neo+rifax 30 ¶ * * 20 10 0 Pre Tx Post Tx 1 2 3 4 Pimentel, et al. Dig Dis Sci, 2014.

Weekly Abdominal Pain VAS VAS Abdominal Pain Severity 50 45 40 35 30 Neo+plac 25 Neo+rifax 20 15 10 5 0 Pre Tx Post Tx 1 2 3 4 Pimentel, et al. ACG, 2013.

Final visit constipation severity based on methane >3ppm 80 Analysis of the Neomycin + Rifaximin Group 70 VAS score P=0.04 60 50 40 30 20 10 0 Methane >3ppm Methane <3ppm Pimentel, et al. Dig Dis Sci, 2014.

Genetics Environmental Cultural GI MICROBES OBESITY DIABETES Social Psychological Psychiatric Meds

Methanogen Model- Syntropic Effect Methanobrevibacter smithii Indigestible Indigestible Substrate Substrate H 2 H 2 CH 4 H 2 H 2 Intoxicates self H 2 Digestible Digestible Energy Substrates Energy Substrates for Host for Host = Syntroph = Methanogen

Methane Slows Transit 80 n=5, p<0.0001 60 % Marker Recovery 40 20 69% mean slowing of transit with CH 4 0 Room Air Methane Pimentel, et al. Am J Physiol, 2006.

Methane in Obese Patients N=58 No Methane Positive P-value on Breath Methane on (n=46) breath (n=12) Age (yrs) 41.8+1.4 41.9 + 1.6 41.6 + 3.3 0.933 Height (in) 66.7 + 0.6 66.5 + 0.7 67.7 +1.4 0.373 Weight (lbs) 255 + 8.0 242.3 + 7.1 299.0 + 22.7 0.002 46 44 42 P= 0.001 BMI 40 38 36 34 All No Positive Subjects Methane Methane Mathur et al, Gastro and Hep , 2012

Methane in Non-obese Patients Multivariate analysis controlling for age, sex , diabetes, anti depressant and other confounding 40 (P<0.001) 38 36 N=792 34 BMI 32 30 28 26 24 22 20 Normal Breath test Positive Hydrogen Methane Only Methane and Breath Test Hydrogen Positive Mathur et al. JCEM 98:E698-702, 2013

Examine the metabolic parameters before and after antibiotic treatment in obese pre-diabetic subjects with methane positive breath tests. To determine whether using an antibiotic to eradicate M. smithii (as measured by breath methane) results in improvement in metabolic profile 11 pre-diabetic (9F, 2M), obese (35.2 + 7.7 kg/m 2 ) methane positive subjects aged 47 + 9 years (funded by the ADA) Mathur R et al, ADA 2014

Mathur R et al, ADA 2014

Mathur R et al, ADA 2014

Insulin Sensitivity (SI) estimated using Modified Model for OGTT analysis: P = 0.03 Mathur R et al, ADA 2014

M. Smithii and Obesity in Rat model 330 320 Weight (g) 310 300 290 280 270 0 1 2 3 Number of segments with no M. smithii Mathur R et al, Obesity, 2013

SYN-010: Most Effective CH 4 Inhibitor In Vitro Figure 1: Effect of marketed statins on CH 4 production in stool from IBS-C patients 120 ΔCH 4 0-270 min Normalized to Control 100 80 60 40 20 0 -20 *5 mg statin/g wet stool. Data are change in CH 4 (ppm) from -40 baseline to 270 min; normalized to control (100) -60 -80 Control Statin 1 Statin 2 Statin 3 Statin 4 Statin 5 70 NYSE MKT: SYN

SYN-010 Clinical Validation Figure 3: Reduction of breath CH 4 in an IBS-C patient by Statin 1 but not Statin 2 140 Statin 2: No Statin : CH 4 returns No effect 120 Breath CH 4 (ppm) 100 80 60 Statin 1 Form 1 40 Modest efficacy Statin 1 Form 1 + Form 2 20 No bloating CH 4 = 0 ppm 1 BM per day 0 No Statin Statin 2 Statin 1 Statin 1 No Statin Statin 1 Statin 1 Form 1 Form 1 Form 2 Form 1 + Form 2

Lovastatin: Effect on M. smithii and constipation Morales, et al DDW 2015

High fat diet leads to Constipation 100 % Stool Wet Weight P<0.01 80 60 40 Baseline 7 Weeks HF Morales, et al DDW 2015

SYN-010 is NOT Microbicidal Figure 2: Effect of Statin 1 on levels of M. smithii and total bacteria in the rat GI tract after 10 days oral gavage dosing M. smithii Total bacteria 3.5E+06 7.0E+07 Placebo Placebo Statin 1 (1 mg/kg) 3.0E+06 6.0E+07 Statin 1 (1 mg/kg) M. smithii (cfu/g tissue) Total Bacteria (cfu/g tissue) 2.5E+06 5.0E+07 2.0E+06 4.0E+07 1.5E+06 3.0E+07 1.0E+06 2.0E+07 5.0E+05 1.0E+07 0.0E+00 0.0E+00 Duodenum Jejunum Ileum Left Colon Duodenum Jejunum Ileum Left Colon Rat tissue Rat tissue

70 Water 65 % Stool Wet Weight Lovastatin Lactone 60 55 Lovastatin Hydroxy Acid 50 45 40 Day 0 Day 14 Day 61 Day 70 Day 10 Gavage Morales, et al DDW 2015

Conclusions for Methane • Methane is a biomarker for constipation and C-IBS • The degree of methane production is proportional to constipation severity in C-IBS • Methane infusion in the gut slows transit • Methane reduction is linked to improved constipation

Conclusions for M. smithii • M. smithii is the primary methanogen in humans • M. smithii is distributed throughout the gut in humans and rodents • M. smithii colonization is linked to greater methane production • Degree of M. smithii colonization is linked to greater constipation in C-IBS

Conclusions for Statins in Microbiome directed therapy of methanogens • A key statin strategy inhibits the methanogenesis pathway • Not all statins are the same • The key statin strategy appears most effective at inhibiting methane production in vitro and in humans • Lovastatin improves stool wet weight.

Projected Number of IBS-C Patients in the US to 2023 USA 2015 2017 2019 2020 2023 Prevalence of IBS 17,495,748 17,762,842 18,024,741 18,283,624 18,569,127 IBS-C Cases 20% incidence 3,499,150 3,552,568 3,604,948 3,656,725 3,713,825 Diagnosed IBS-C Cases 1,049,745 1,065,771 1,081,484 1,097,017 1,114,148 IBS-C Cases on therapy 734,821 746,039 757,039 767,912 779,903 • 30% of patients with IBS have a proper IBS diagnoses • Opportunity to increase disease state awareness and treatment options. • 70% of IBS diagnosed patients in US are on pharmacotherapy • IBS-C makes up 20% of the IBS overall prevent cases • Projected growth rate of the P\prevalence of IBS from 2015 to 2023 is est. 6-7% Prevalent Cases from: GlobalData PharmaPoint, Irritable Bowel Syndrome – Global Drug Forecast and Market Analysis to 2023

The IBS Market has Significant Unmet Needs New products with improved efficacy Products that effectively address IBS symptoms, such as abdominal pain and bloating Improved diagnosis of IBS/definitive test or biomarker • IBS patients are underserved with current therapies that show only modest efficacy or are associated with negative safety profiles • Diagnosis and drug-treatment rates for IBS remain low across the major markets • The prescription IBS market is poised for significant growth through 2021, given these unmet needs Source: GlobalData PharmaPoint, IBS Global Drug Forecast & Market Analysis 2014 80

SYN-010 for IBS-C Clinical development plan • Phase 2 study start expected 2Q ‘15 • 1 st study: Demonstrate reduction of breath methane in IBS-C patients using SYN-010 ̶ 60 subjects, all diagnosed IBS-C, breath methane > 10ppm ̶ 2 doses of SYN-010 daily vs placebo, 4 weeks of treatment ̶ Endpoints  Primary: Reduction of breath methane after 4 weeks of therapy  Secondary 1: Improvement in number of complete spontaneous bowel movements per week (required per FDA guidance)  Secondary 2: Improvement in abdominal pain and bloating per standard scales (required per FDA guidance) 81

SYN-010 for IBS-C Clinical development plan • 2 nd study: Demonstrate maintenance of reduction of breath methane in same IBS-C patients using SYN-010 ̶ 60 subjects from the previous study (rollover) ̶ Open label, higher dose of SYN-010 daily, 8 weeks of treatment ̶ Endpoints  Primary: Maintenance of breath methane reduction after 8 weeks of therapy  Analysis of improvement after 8 weeks for subjects who were on placebo or low-dose therapy in the first study  Secondary: CSBMs & abdominal pain per FDA guidance  Results expected Q4 ‘15 82

SYN-010 for IBS-C Clinical development plan: Phase 3  Pursue Phase 3 clinical trial(s) (2016) following discussions with FDA  Objectives: standard IBS-C by-guidance FDA endpoints (CSBMs and abdominal pain and bloating)  Patients: all patients with diagnosed IBS-C regardless of breath methane status  Breath methane to be utilized as a mechanistic secondary endpoint, but not as a screen for patients  Expected: Single large Phase 2b/3 (dose-ranging and final formulation), 12 weeks of therapy daily  Rationale: no safety issues (lovastatin safety profile is well-defined)  505(b)2 NDA pathway  Given standardized endpoints, one large, adequately-powered study should be sufficient for registration 83

Irritable Bowel Syndrome with Constipation (IBS-C) SYN-010 Animated Video Microbiome Analyst & Investor Meeting New York City

Irritable Bowel Syndrome with Constipation (IBS-C) Q&A Session Microbiome Analyst & Investor Meeting New York City

C. difficile Professor Mark H. Wilcox, M.D., FRCPath Microbiome Analyst & Investor Meeting New York City

Professor Mark H. Wilcox, M.D., FRCPath C. difficile Keynote Speaker • Consultant / Head of Microbiology, Leeds Teaching Hospitals NHS Trust • Professor of Medical Microbiology, University of Leeds • Lead on C. difficile Infection, Public Health England • Chairman of Synthetic Biologics’ C. difficile Clinical Advisory Board 87

C. difficile INFECTION (CDI) CLINICAL IMPACT & NOVEL WAY TO PREVENT PROFESSOR MARK WILCOX, MD Chair of Clinical Advisory Board, Synthetic Biologics, Inc. Leeds Teaching Hospitals, University of Leeds, & Public Health England, UK

Preventing C. difficile Is Now a National Priority! National Action Plan for Combating Antibiotic Resistance Issued By the White House in March 2015 2015 2020 • Goal is to reduce the incidence of overall C. difficile infection by 50% compared to rates in 2011 • Implementation of plan and tracking of outcomes will accomplished by several government agencies Source: https://www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf 90

̶ ̶ ̶ ̶ ̶ ̶ C. difficile infections • CDI is currently the most prevalent hospital-acquired infection in the U.S., according to the CDC Surpassed Methicillin-resistant Staphylococcus aureus (MRSA) • CDI has been identified as an “urgent public health threat” by the CDC, FDA and EU health authorities • CDI in the U.S.: 1.1 million patients infected with C. difficile annually 1 Patients with C. difficile hospitalized approximately 4-7 extra days 2 Up to ~25% of CDI patients have a recurrence within 1-3 months 3-5 $8.2 billion in costs associated with C. difficile -related stays in hospital 6 >30,000 C. difficile -related deaths annually 7 1 This information is an estimate derived from the use of information under license from the following IMS Health Incorporated information service: CDM Hospital database for full year 2012. IMS expressly reserves all rights, including rights of copying, distribution and republication. 2 (APIC) National Prevalence Study of Clostridium difficile in U.S. Healthcare Facilities. November 11, 2008. 3 Louie TJ, et al. N Engl J Med 2011;364:422 – 31. 4 Cornely OA, et al. Lancet Infect Dis 2012;12:281 – 9. 5 Vardakas KZ, et al. Int J Antimicrob Agents 2012;40:1 – 8. 6 Agency for Healthcare Research and Quality. Healthcare and Cost Utilization Project. Statistical Brief #124. Clostridium difficile Infections (CDI) in Hospital Stays, 2009. January 2012. 7 U.S. Department of Health & Human Services. Agency for Healthcare Research and Quality. January 25, 2012.

• Largest CDI epidemiology study ever conducted • 20 countries across Europe ~500 hospitals EUropean, multi-centre, prospective bi-annual point prevalence study of CLostridium difficile Infection in hospitalised patients with Diarrhoea Study initiated and financially supported by Astellas Pharma Europe Ltd

EUCLID key findings - Conclusions Rates of CDI in EUCLID were 70% higher than seen in 2008 1,2 An estimated 39,000+ cases of CDI are missed every year in Europe – over 80 cases per hospital per year 1 1. Davies KA, et al. Lancet Infect Dis 2014;14:1208-19. 2. Bauer MP, et al. Lancet 2011;377:63 – 73.

Who is most at risk? Recent antibiotic use Elderly Chronic illness ECDC, European Centre for Disease Prevention and Control Bauer MP, et al. Lancet 2011; 377:63 – 73

CDI ?pneumonia pvd 75 yrs old

Length of hospital stay in patients with CDI by country 50 45 40 37 Length of stay (days) 35 30 27 25 21 20 18 17 17 16 15 15 12 10 5 0 EU, European Union Country Wiegand PN, et al. J Hosp Infect 2012;81:1 – 14.

30-day mortality in patients with healthcare facility-acquired CDI 45 40 35 30-day mortality (%) 30% 30 25 22% 20% 20 16% 16% 15% 14% 15 14% 9% 10 7% 5 3% 0 Country Wiegand PN, et al. J Hosp Infect 2012;81:1 – 14.

Strain ribotype and age-related risk of CDI mortality CD 027 infection associated with n=1,008 CDI cases 2.5 to 3.5-fold increased death rate p=0.005 NAP1/027 18 p=NS Non-NAP1 CDI-related death (%) 16 14 p=0.02 12 p=0.07 10 8 6 p=NS p=NS 4 p=NS 2 0 18 – 39 40 – 49 50 – 59 60 – 69 70 – 79 80 – 89 90+ Age (years) CD, Clostridium difficile ; NS, not significant Miller M, et al. Clin Infect Dis 2010;50:194 – 201.

CDI case costs 1 60,000 Ananthakrishnan (IBD patients) 1 Dubberke (primary admission) 50,000 1 Dubberke (inpatient over 180 days) 40,000 1 Kyne (inpatients only) 1 Lawrence (ICU stay only) 30,000 1 Lawrence (hospital-wide) 20,000 1 O´Brien (secondary diagnosis) 2 10,000 Vonberg (hospital-wide) 1 Zerey (surgical inpatients) 0 Case cost* *Data from the last 10 years; (2008 € equivalent) IBD, inflammatory bowel disease; ICU, intensive care unit 1. Adapted from Ghantoji SS, et al. J Hosp Infect 2010;74:309 – 18; 2. Vonberg R-P, et al. J Hosp Infect 2008;70:15 – 20.