Discovery and Development of a Novel IV and Oral Orotomide Class Candidate for Systemic Mould Infections Dr Emma Harvey Global Head of Medical Affairs F2G Ltd

Olorofim: Discovery and development of a novel IV and oral orotomide class candidate for systemic mould infections Dr Emma Harvey Global Head of Medical Affairs F2G Ltd

Olorofim_RICAI_December 2019 1 Disclaimer Olorofim is not currently approved for use in any market

Olorofim_RICAI_December 2019 2 Agenda Olorofim … ▪Is the first orotomide antifungal ▪Stops growth quickly; Cell rupture follows ▪Is active in vivo: PK-PD driven by Cmin ▪Target levels readily achieved in man both PO and IV ▪Phase 2 Open-Label study has recruited > 40 patients

Olorofim_RICAI_December 2019 3 Olorofim structure Previously known as F901318

MW = 499

Formula = C28H27FN6O2 > 99% protein bound in all species

F2G, Ltd., data on file Olorofim_RICAI_December 2019 4 Orotomide Mechanism of Action ▪Olorofim is a potent selective inhibitor of fungal dihydroorotate dehydrogenase (DHODH) ▪ DHODH is a key enzyme involved in pyrimidine biosynthesis ▪Humans also have this enzyme ▪ But, > 2000-fold difference in IC50 between human and fungal enzymes ▪Pyrimidine inhibition has profound effects as it interferes with ▪ DNA synthesis and cell cycle regulation ▪ RNA synthesis and protein production ▪ Cell wall synthesis ▪ Phospholipid synthesis

Oliver et al. PNAS 113:12809-14, 2016. Olorofim_RICAI_December 2019 5 DHODH Protein Homology Taxonomy

Note the clustering of (PEZIZOMYCOTA) activity within the (BACTERIAL) Pezizomycota: OLOROFIM DHODH SENSITIVE structurally conserved across these species

OLOROFIM Work in collaboration with Paul Boyer, Univ INTRINSIC RESISTANCE Manchester Olorofim_RICAI_December 2019 6 Aspergillus: In vitro ▪Olorofim MICs are tightly clustered

▪MIC90s are 0.03-0.06 mg/L (CLSI and EUCAST) ▪MICs are of the same order for all Aspergillus spp. tested ▪>2900 isolates from 35 species including: ▪>2300 isolates of 4 most common species1 ▪220 isolates of 16 cryptic species2 ▪No induction of resistance with serial passage ▪Spontaneous resistance seen at low frequency ▪Cross-resistance is not seen ▪MICs of the same order in azole-resistant isolates ▪MICs of the same order in amphotericin-resistant species

1. A. fumigatus, flavus, niger, and terreus 2. A. alliaceus, aureoterreus, calidoustus, carneus, citrinoterreus, fumigatiaffinis, hiratsukae, hortai, insuetus, keveii, lentulus, ochraceus, pseudofischerii, sclerotiorum, tubingensis, and udagawae

Beckmann et al. ICAAC 2015; Fothergill et al. ICAAC 2015; Buil et al.JAC 2017; Rivero- Olorofim_RICAI_December 2019 7 Menéndez et al ECCMID 2017; Oliver et al PNAS 2016; Jorgensen et al. TIMM 2017 In vitro activity against other fungi

▪Scedosporium spp., L. prolificans and numerous other moulds* and endemic dimorphic fungi ▪MICs similar to Aspergillus ▪Fusarium spp ▪Mixed and method-dependent results ▪Further investigative work underway ▪Mucorales, Candida spp., Cryptococcus neoformans ▪Not active (structurally different DHODH enzyme)

*Tested to date: Acremonium persicinum, Acrophialophora fusispora, Rasamsonia spp., Phaeoacremonium spp., Sarocladium kilienses, Scopulariopsis brevicaulis, Microascus spp., Sporothrix schenkii, Trichoderma spp., Ramichloridium (Myrmecridium) schulzeri, Paecilomyces spp., Pleurostomophora richardsiae, Verruconis gallopava, Chaetomium spp., and Penicillium spp. (including P. marneffiii). Wiederhold et al. JAC 2107, Biswas et al. Med Mycol 2018; Alastruey et al. TIMM Olorofim_RICAI_December 2019 8 2017; Oliver et al. PNAS 2016; F2G Ltd, data on file Across the related fungi, the MICs are tightly clustered >2900 Aspergillus isolates >300 Scedosporium isolates >100 Lo Pro isolates

F2G Ltd, data on file Olorofim_RICAI_December 2019 9 Agenda Olorofim … ▪Is the first orotomide antifungal ▪Stops growth quickly; Cell rupture follows ▪Is active in vivo: PK-PD driven by Cmin ▪Target levels readily achieved in man both PO and IV ▪Phase 2 Open-Label study has recruited > 40 patients

Olorofim_RICAI_December 2019 10 Fungicidal: Growth inhibition begins at ~30 minutes and leads to killing ▪ 16-hour-old A. fumigatus hypha Time-lapse video (48h compressed to ~ 15 seconds) ▪ Actively growing ▪ Treated with 0.1 mg/L olorofim ▪ Growth inhibition at ≈ 30 mins ▪ Cell rupture at ≈ 24 hours

Shown here are TEM views of the effect of olorofim at 24h Untreated hyphae 0.1 mg/L olorofim (24h)

Note normal nucleus, cytoplasmic Note absence of cytoplasmic content, and continuous cell wall content, broken/thin cell wall

Olorofim_RICAI_December 2019 du Pre S et al. Antimicrob Agents Chemother 62:e00231-18, 2018. 11 Cell rupture is then seen ▪Cell viability marker (Green = Dead) ▪DiBac: Bis-(1,3-Dibutyl barbituric Acid) Trimethine Oxonol

100

25 % lysed % 0 24h 48h 72h 96h 120h du Pre S et al. Antimicrob Agents Chemother 62:e00231-18, 2018. Olorofim_RICAI_December 2019 12 Effects on conidia as well

Conidia treated for 24h with olorofim Untreated (0.1 µg/mL). Note breaks in cell wall.

A. fumigatus conidia were incubated at 37C in Vogel’s minimal medium. du Pre S et al. Antimicrob Agents Chemother 62:e00231-18, 2018. Olorofim_RICAI_December 2019 13 Agenda Olorofim … ▪Is the first orotomide antifungal ▪Stops growth quickly; Cell rupture follows ▪Is active in vivo: PK-PD driven by Cmin ▪Target levels readily achieved in man both PO and IV ▪Phase 2 Open-Label study has recruited > 40 patients

Olorofim_RICAI_December 2019 14 In vivo activity ▪In vivo activity (mostly murine, some rabbit) shown for ▪ A. fumigatus, A. flavus, A. terreus, A. nidulans, A. tanneri ▪ Scedosporium apiospermum ▪ Lomentospora prolificans ▪ Scedosporium (Pseudallescheria) boydii ▪ Coccidioides immitis ▪In vivo activity has been shown PO & IV ▪ Endpoints: Survival, tissue burden, and GM ▪Works equally well on azole-and amphotericin B-resistant Aspergillus isolates: ▪ Azole-resistant (A. fumigatus, A. tanneri, L. prolificans) ▪ Amphotericin B-resistant (A. terreus, A. tanneri)

Hope et al. mBio 8:1-17, 2017; Seyedmousavi et al. Antimicrob Ag Chemother 63:e00129-19, 2019; J Lackner et al. J Antimicrob Chemo 73:3068-73, 2018; Seyedmousavi et al. Trends in Medical Mycology (abstract), 2019; Wiederhold et al. AAC 2018;62(9):e00999-18. Olorofim_RICAI_December 2019 15 Olorofim activity against A. fumigatus

A. fumigatus (NIH 4215, azole wild-type) Susceptible to OLO, POSA, and VORI Control study, wild- 100 type strain:

80 POSA OLO and POSA are both active. 60 OLO R

40 Reminder: It’s tricky to study voriconazole % survival % in the mouse due its rapid metabolism. 20

Drug Control This model used IV dosing using 0 posaconazole not voriconazole. 0 2 4 6 8 10 Study Day

Neutropenic mouse model, inhalation IA, drug given IV starting 6h after infection through Day 3; Olorofim MIC 0.03 mg/L for both isolates; Posaconazole (POSA) MIC 0.125 mg/L (NIH 4215) and 0.5 mg/L (11628); VORI MIC 0.5 (NIH 4215) and 16 mg/L (11628). Hope et al. mBio 8:1-17,16 2017; Jeans et al. J Infect Dis, 206:442-52, 2012; Simitsopoulou et al. Antimicrob Ag Chemother 52:3301-6, 2008. Olorofim_RICAI_December 2019 Olorofim is effective in vivo vs. azole-resistant A. fumigatus A. fumigatus (11628, G138C mutant) Susceptible to OLO, Resistant to POSA and VORI 100 OLO 80

60 POSA

40 Control 20

Drug 0 0 2 4 6 8 10 Study Day Neutropenic mouse model, inhalation IA, drug given IV starting 6h after infection through Day 3; Olorofim MIC 0.03 mg/L for both isolates; Posaconazole (POSA) MIC 0.125 mg/L (NIH 4215) and 0.5 mg/L (11628); VORI MIC 0.5 (NIH 4215) and 16 mg/L (11628). Hope et al. mBio 8:1-17,17 2017; Jeans et al. J Infect Dis, 206:442-52, 2012; Simitsopoulou et al. Antimicrob Ag Chemother 52:3301-6, 2008. Olorofim_RICAI_December 2019 Olorofim activity vs A. tanneri in CGD mouse model A. tanneri (NIH 1004). Susceptible to OLO, When tested against Resistant to VORI, POSA, and AmB AmB-resistant A. 100 tanneri, OLO remains 80 active but the azole fails OLO

Control 20 Control VORI

Drug 0 0 2 4 6 8 10 CGD= chronic granulomatous disease Study Day Survival curves for mice with oxidative-deficient (CGD) neutrophils. Infection by tail vein injection, drug IP starting 6h after infection through Day 9. MICs for B5213 and NIH 1004 were 0.01 and 0.06 mg/L (OLO), 0.5 and 4 mg/L (VORI), 0.125 and 0.5 mg/L (POSA), and 0.5 and > 16 mg/L 18 (AmB). Seyedmousavi et al. Antimicrob Ag Chemother 63:e00129-19, 2019. Olorofim_RICAI_December 2019 Olorofim activity in vivo vs. amphotericin-resistant A. terreus

100 OLO, iv OLO, po 80 Similar results for olorofim

60 dosed IV and PO

% survival % 20 Ampho Drug 0 Control 0 2 4 6 8 10 Study Day

Neutropenic mouse model, intravenous IA, drug dosed from Day 1 to Day 9; A. terreus with OLO MIC of 0.01 mg/L, amphotericin B 19 MIC of 2 mg/L; Lackner et al. J Antimicrob Chemo 73:3068-73, 2018. Olorofim_RICAI_December 2019 Olorofim activity against Scedosporium spp. and Lomentospora prolificans

100 OLO OLO VORI AMB 75

S. apiospermum 50 S S R 25 Control 0 0 5 10 15 100 O 75

50 S. boydii S S R 25 C % % survival 0 0 5 10 15 100 O 75

L. prolificans 50 S R R 25 C Drug S = sensitive 0 R = Resistant 0 5 Day 10 15 Neutropenic mouse model, intravenous infection, drug dosed from Day 1 to Day 10. Actual MICs were OLO (0.02, 0.01, 0.03 mg/L),20

VORI (0.5, 0.5, 8 mg/L), AMB (8, 8, 8 mg/L); Seyedmousavi et al. Trends in Medical Mycology (abstract), 2019. Olorofim_RICAI_December 2019 Olorofim activity in a murine model of coccidioidomycosis

Survival curves: 100 OLO • Drug given on high 80 days 2-14 • Good initial effect FLU 60 in all 3 arms • But, higher 40 OLO mortality in last

% survival % low week with FLU 20 Control and low dose Drug 0 olorofim (OLO- 0 3 6 9 12 15 18 21 24 27 30 Low) Why? Study Day

Intracranial C. immitis infection on Day 0; Therapy Day 2-14; FLU 25 mg/kg BID, OLO 6.67 mg/kg TID (low), or OLO 13.3 mg/kg TID; 10 21 mice/group. Wiederhold et al. AAC 2018;62(9):e00999-18. Olorofim_RICAI_December 2019 Olorofim activity in a murine model of CNS coccidioidomycosis Brain CFU/g Consistent with early C Flu O-lo O-hi benefit, CFU/g in brain is reduced in Day 9 all 3 groups at Day 9 But…

100 O-hi 80 Flu 60

40 O-lo

% survival % C 20

0 0 3 6 9 12 15 18 21 24 27 30 Study Day

Intracranial C. immitis infection on Day 0; Therapy Day 2-14; FLU 25 mg/kg BID, OLO 6.67 mg/kg TID (low), or OLO 13.3 mg/kg TID; 10 22 mice/group. Wiederhold et al. AAC 2018;62(9):e00999-18. Olorofim_RICAI_December 2019 Olorofim is effective in a murine CNS coccidioidomycosis model Brain CFU/g Day 30 (2 weeks off drug): C Flu O-lo O-hi •FLU: CFU rebound •OLO-low: CFU rebound Day 9 •OLO-hi: CFU cleared Olorofim is fungicidal to Cocci

100 O-hi 80 Flu 60

40 O-lo

% survival % C 20 Day 30 0 0 3 6 9 12 15 18 21 24 27 30 Study Day

Intracranial C. immitis infection on Day 0; Therapy Day 2-14; FLU 25 mg/kg BID, OLO 6.67 mg/kg TID (low), or OLO 13.3 mg/kg TID; 10 23 mice/group. Wiederhold et al. AAC 2018;62(9):e00999-18. Olorofim_RICAI_December 2019 Formal PK-PD ▪Murine & rabbit pulmonary aspergillosis model ▪A. fumigatus & A. flavus, including azole-R isolates ▪Outcome measures: survival, GM, pathology ▪Summary: ▪Time-dependent efficacy – inhibition of growth within an hour; fungicidal within 24 hours ▪Consistent with observed MICs as well as data from other in vivo studies, identical results obtained for azole-resistant and azole-susceptible strains ▪A total drug trough (Cmin) of >0.3 mg/L is our target in man

Hope et al. mBio 8(4):1-17, 2017 Olorofim_RICAI_December 2019 24 Agenda Olorofim … ▪Is the first orotomide antifungal ▪Stops growth quickly; Cell rupture follows ▪Is active in vivo: PK-PD driven by Cmin ▪Target levels readily achieved in man both PO and IV ▪Phase 2 Open-Label study has recruited > 40 patients

Olorofim_RICAI_December 2019 25 PO and IV

▪Linear PK, widely distributed to tissues including lung, liver and brain ▪Total daily doses of 120-180 mg yield plasma Cmin exposures exceeding the PK-PD target ▪Oral bioavailability approaches 100%

F2G, Ltd., data on file Olorofim_RICAI_December 2019 26 Metabolism

▪Cleared by multiple CYPs ▪Doesn’t induce CYPs ▪Weak 3A4 inhibition (less than fluconazole) ▪DDI’s: ▪Can be given in combination with tacrolimus ▪Can be given in combination with novel immunotherapies (ibrutinib, venetoclax)

Olorofim_RICAI_December 2019 27 Agenda Olorofim … ▪Is the first orotomide antifungal ▪Stops growth quickly; Cell rupture follows ▪Is active in vivo: PK-PD driven by Cmin ▪Target levels readily achieved in man both PO and IV ▪Phase 2 Open-Label study has recruited > 40 patients

Olorofim_RICAI_December 2019 28 Phase 2 Open-Label Study (1) ▪Now enrolling ▪ClinicalTrials.gov Identifier: NCT03583164 ▪Key entry criteria ▪Proven IFI or probable IA (EORTC-MSG 2008 criteria) ▪Limited treatment options ▪Example reasons to enroll ▪Lomentospora prolificans or other multi-drug resistant/cross-resistant fungus ▪Lack of response/intolerance with current agents ▪Design ▪Open-Label olorofim for up to 90 days (extensions are possible if longer therapy is deemed useful) ▪Data-Review Committee to adjudicate at 6 and 12 weeks Olorofim_RICAI_December 2019 29 Phase 2 Open-Label Study (2) As of 1st December 2019, 48 patients enrolled ▪M:F 31:17 (64%:36%); Age range (mean) of 19-84 (50) years ▪Heme Malignancy: 19 (40%) and HSCT: 10 (21%) ▪Lung Transplant: 8 (18%) ▪Solid Tumor: 1 (2%), AIDS: 1 (2%), and other conditions: 9 (19%).

Site ▪Lung: 29 (60%) and Sinus: 3 (6%) ▪Bone: 2 (4%), Joint: 3 (6%), and Chest wall: 2 (4%) ▪CNS: 4 (8%) and Disseminated: 5 (10%).

F2G, Ltd., data on file Olorofim_RICAI_December 2019 30 Enrolment by species Species

1 1 2 4

Aspergillus (S) Aspergillus (R) Lomentospora prolificans Scedosporium spp Coccidioides spp Scopulariopsis Fusarium other Olorofim_RICAI_December 2019 31 Phase 2 Open-Label Study (3)

▪Experience to date ▪All patients dosed with oral olorofim to date – including gut GVHD ▪Olorofim has been well tolerated; median therapy duration of 12 weeks, maximum 15 months ▪DDIs have been limited and as predicted: dosed with ibrutinib, tacrolimus, and other challenging agents

▪Complex and slowly resolving infections such as cerebral aspergillosis and osteomyelitis due to L. prolificans have been readily managed with extended dosing

F2G, Ltd., data on file Olorofim_RICAI_December 2019 32 Breakthrough Therapy Designation ▪Olorofim was granted Breakthrough Therapy Designation by FDA in November 2019 ▪Decision made on the basis of preliminary clinical data presented to FDA ▪This potentially provides a pathway to earlier regulatory approval than conventional pathways ▪Further discussions with FDA on-going

Olorofim_RICAI_December 2019 33 Next phase of studies

▪Phase 3 study has been designed and agreed with FDA ▪Planned commencement in late 2020 ▪Study 32 to continue

Olorofim_RICAI_December 2019 34 Summary ▪Olorofim is an antifungal agent with a novel mechanism of action: Selective inhibition of fungal DHODH ▪Lethal to Aspergillus and other filamentous fungi ▪Active against azole- and amphotericin B-resistant Aspergillus ▪Effective in animal models of aspergillosis, scedosporiosis, and coccidioidomycosis ▪PK/PD studies have identified a target for successful therapy using a total plasma Cmin as a PD target ▪Dose proportional PK; Predictable and manageable DDIs ▪Open-label study is enrolling; Extended dosing well tolerated ▪Phase 3 study design agreed

Olorofim_RICAI_December 2019 35 Thank you for your attention Any questions?

Olorofim_RICAI_December 2019 36