Professor of Medicine University of California San Diego May 24, - PowerPoint PPT Presentation

Lp(a): Phase 2 Data and NHLBI Recommendations “The imminent danger of Lp(a): Time to Face the Challenge” EAS satellite meeting Maastricht, The Netherlands Sotirios Tsimikas, MD Director of Vascular Medicine Professor of Medicine University of California San Diego May 24, 2019 1

Faculty Disclosure Declaration of financial interests For the last 3 years and the subsequent 12 months: I I have received a research grant(s)/ in kind support A From current sponsor(s) NO. B From any institution NO II I have been a speaker or participant in accredited CME/CPD A From current sponsor(s) NO B From any institution NO III I have been a consultant/strategic advisor etc A For current sponsor(s) NO B For any institution (Boston Heart Dx) YES IV I am a holder of (a) patent/shares/stock ownerships A Related to presentation NO B Not related to presentation (UCSD) YES

Disclosures Co-inventor and receives royalties from patents owned by the University of California San Diego on oxidation-specific antibodies Dual appointment at UCSD and Ionis Pharmaceuticals Co-Founder Oxitope, Inc and Kleanthi Diagnostics 3

Association of Lp(a) with CVD risk in Patients on Statins from 7 Landmark Trials • 29 069 patients8064 [28%] women; 5751 events, 95,576 person-years at risk • AFCAPS, CARDS, 4D, JUPITER, LIPID, MIRACL, and 4S trials. • Comparison of groups with lipoprotein(a) levels of <15 mg/dL, 15 to <30 mg/dL, 30 to <50 mg/dL, and ≥50 mg/dL. • Multivariable adjustment included age, sex, previous CVD, diabetes, smoking, systolic blood pressure, LDL cholesterol corrected for lipoprotein(a) cholesterol, and HDL cholesterol. • Associations were independent of established risk factors. • In an interaction analysis, the association of high lipoprotein(a) with CVD risk was stronger in patients allocated a statin than in patients allocated placebo Willeit et al. Lancet 2018;392:1311-20 4

Predictive value of on-statin vs. on-placebo Lp(a) with CVD risk from 7 Landmark Trials In an interaction analysis, the association of high lipoprotein(a) with CVD risk was stronger in patients allocated a statin than in patients allocated placebo Willeit et al. Lancet 2018;392:1311-20 5

Predictive value of on-statin vs. on-placebo Lp(a) with CVD risk from 7 Landmark Trials In an interaction analysis, the association of high lipoprotein(a) with CVD risk was stronger in patients allocated a statin than in patients allocated placebo “When LDL -attributable risk is reduced with statin treatment, lipoprotein(a)- associated risk becomes an even stronger predictor of residual risk. This observation is especially evident at lipoprotein(a) concentrations exceeding 50 mg/dL.” Willeit et al. Lancet 2018;392:1311-20 6

Antisense Oligonucleotides Targeting Lp(a) Antisense Oligonucleotide Tsimikas JACC 2017;69:692-711 7

Distinct Chemical Classes of RNA-Based Technologies & Therapeutics Antisense Strand Antisense DNA Single-Strand Phosphorothioate (PS) 2’ - MOE, 2’ -OMe, cEt, LNA Multiple Mechanisms Antisense Strand siRNA RNA Sense Double-strand Phosphodiester Strand RISC Mechanism 2’ - OMe, 2’ -F Aliphatic substituents Target Protein Aptamer Aptamer DNA or RNA Structured Mixed modifications Pegylation (REG1 anticoagulation system) 8

The Antisense Drug-Receptor Interaction 9 Antisense RNA Target Oligonucleotide ~15-20 base pairs required for specificity and binding Natural DNA and RNA do not make good drugs due to insufficient stability and distribution in animals This can be addressed with appropriate chemical modification 9

RNaseH1 and siRNA Antisense Mechanisms 10 ◼ siRNA Mechanism ◼ RNase H1 Mechanism siRNA Duplex Nucleus Cell Cytoplasm Membrane RNase H1 RISC Sense Strand RNase H like Antisense Cell nuclease Strand Membrane mRNA mRNA-Antisense Duplex mRNA DNA Antisense Strand DNA Nucleus Cytoplasm Isis Pharmaceuticals Confidential 10

Examples of Chemical Modifications Used in RNA Therapeutic Agents 11 2ʹ - O -methoxyethyl (MOE) B O Me O O O O P -X O B O Me O O O O P -X O B O Me O O O O P -X O B O Me O O O O P -X O B O X = S, O Me O O O O P -X O 11

Significant Advances in Medicinal Chemistry of Antisense Improve Potency and Tolerability LIC LIC LIC Gen 2.5 LICA Gen 2/2+ 1 st Gen A A A GalNac Design MOE Gapmer Design cEt Gapmer Design P-S 1X ↑10X ↑10X ↑10X =1000X (600-1200/wk) 100-300/wk 10-40/wk 10-40/wk 1-3/wk Potency Side effect profile 12

Genetic architecture of the LPA gene Schmidt et al J Lipid Res 2016;57:1339-59 13

IONIS-APO(a) Rx Targets a unique splice site of Kringle-IV 2 exon 24/25 junction present in 1 copy of all apo(a) mRNA 14 Graham et al J Lipid Res 2016;57:340-51 14

IONIS-APO(a) Rx ASO to Lower Plasma Lp(a) Targets a unique splice site of exon 24/25 present in 1 copy of all apo(a) mRNA, corresponding to a Kringle-IV 2 repeat 2‘ Methoxyethyl Phosphorothioate Oligonucleotide (2’ MOE Gapmer) 15 5' Chimera / Gapmer O B O RNase H1 Substrate O C H3 O O O MOE Deoxy MOE MOE P T G G T C C T T G T T C T G C T C C G T S O B O affinity O C H3 O stability O O tolerability P S O B It does not bind to or reduce hepatic O expression or plasma levels of O H plasminogen O P O B S Deoxy O O H O P O S 3' 15

Screening Process for ASOs 16 DRC (Multiple Rounds) In Vitro Select Lead Sites For Microwalk 2280 ASOs Microwalk DRCs (Multiple Rounds) Rodent PK/Tox Transgenic Mouse In Vivo 38 ASOs 6 ASOs Monkey Study (Tolerability) IND Toxicology/PK 1 ASO 16

Pre-Clinical Proof-of-Concept Studies with ASO Therapy for Lp(a) Reduction in Lp(a) levels with ASO to apoB and apo(a) Merki E et al Circulation 2008;118:743 – 53 Merki et al. JACC 2011;57:1611 – 2 17

Relationship of Plasma ISIS-APO(a) Rx Trough Concentrations and Mean Percent Change in Lp(a), OxPL-apoB and OxPL-apo(a) - 300 mg 18 Terminal elimination half- life of ASO = ~23 days Tsimikas et al Lancet 2015;386:1472-1483 18

IONIS-APO(a) Rx Phase 2 trial- Effect on Lp(a) and OxPL Patients with Lp(a) >50 mg/dL Lp(a) OxPL-apoB OxPL-apo(a) Cohort A (50-175 mg/dL) Cohort B (>175 mg/dL) Placebo Viney et al Lancet 2016;388:2239-53 19

Reduction in Lp(a), OxPL-apoB and OxPL-apo(a) is strongly associated with reduced transendothelial monocyte migration First In vivo demonstration of anti-inflammatory effect of Lp(a)-OxPL lowering Placebo Transendothelial monocyte migration Cohort A (50-175 mg/dL) Cohort B (>175 mg/dL) With van Capelleveen and Stroes Viney et al Lancet 2016;388:2239-53 20

Additional Net Reduction of Atherogenic LDL- ApoB-100 with ASO to Apo(a) Traditional Lipid Profile Corrected Lipid Profile for Lp(a)-C Corrected Lipid Profile TC = LDL-C + Lp(a)-C + VLDL-C + HDL-C Post IONIS-Apo(a) Rx TC = LDL-C + VLDL-C+ HDL- C HDL-C HDL-C 51 mg/dL 51 mg/dL HDL-C 48 mg/dL VLDL-C VLDL-C Total Cholesterol Total Cholesterol Total Cholesterol 26 mg/dL 26 mg/dL 188 mg/dL 188 mg/dL 162 mg/dL VLDL-C 25 mg/dL ApoB-100 Lp(a)-C 95 mg/dL ApoB-100 95 mg/dL Lp(a)-C 56 mg/dL 17 mg/dL ApoB-100 79 mg/dL “LDL - C” 112 mg/dL LDL-Ccorr LDL-Ccorr 72 mg/dL 56 mg/dL Viney et al J Clin Lipidol 2018;12:702-10 21

Hepatocyte Targeting Antisense via Asialoglycoprotein Receptor Enhances Drug Delivery to the Liver 10-15x LICA - ligand conjugated antisense Prakash et al Nucleic Acids Res 2014;42:8796-807 22

Dose-Dependent Effect of Optimized ASO to Apo(a) in Reducing Plasma Lp(a) IONIS-APO(a)-L Rx has ~30x Improved Potency vs. IONIS-APO(a) Rx in Humans ED 50 4 mg vs 122 mg, 30-fold more potent Viney et al Lancet 2016;388:2239-53 23

IONIS-APO(a)-L Rx Produced Dose-dependent, Significant Reductions in Lp(a) in Phase 1 Study in Subjects with Lp(a) >30 mg/dL Up to 97% Reduction in Lp(a), Up to 99% Reduction in Lp(a), with Mean Reduction of 85% with Mean Reduction of 92% Single Ascending Dose Multiple Ascending Dose Mean % Change From Baseline (+/- SEM) Mean % Change from Baseline (+/- SEM) Lp(a) (nmol/L) Lp(a) (nmol/L) Study Day Study Day Placebo 10 mg 20 mg 40 mg 80 mg 120 mg Placebo 10 mg 20 mg 40 mg Mean Lp(a) reductions: 10 mg = ↓ 68% 20 mg = ↓ 80% 40 mg = ↓ 92% Viney et al, Lancet 2016;388:2239-53 24

Safety and efficacy of AKCEA-APO(a)-L Rx to lower lipoprotein(a) levels in patients with established cardiovascular disease: A phase 2 dose-ranging trial Sotirios Tsimikas, Ewa Karwatowska-Prokopczuk, Ioanna Gouni-Berthold, Jean-Claude Tardif, Seth J. Baum, Elizabeth Steinhagen-Thiessen, Michael D. Shapiro, Erik S. Stroes, Patrick M. Moriarty, Børge G. Nordestgaard, Jonathan Guerriero, Nicholas J. Viney, Louis O'Dea, Joseph L. Witztum on behalf of the AKCEA-APO(a)-L Rx Study Investigators University of California San Diego (ST, JLW); Akcea Therapeutics (E K- P, JG, LO’D) , University of Cologne (IG-B); Montreal Heart Institute, (J-CT); Excel Medical Clinical Trials, (SJB); Charité-Universitätsmedizin Berlin and University Medicine Greifswald (E S-T); Oregon Health & Science University (MDS); Academic Medical Center (ESS); University of Kansas Medical Center, (P.M.M.); Herlev and Gentofte Hospital, Copenhagen University Hospital and University of Copenhagen (BGN); Ionis Pharmaceuticals, Inc. (NJV, ST) 25