HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDBile acids inHKASLD the pathogenesis HKASLD and treatment of NASH Wah-Kheong Chan

HKASLDProfessor and ConsultantHKASLD Gastroenterologist and Hepatologist HKASLD HKASLD HKASLD HKASLD E-mail: [email protected] HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

500 600 ml per day HKASLDWater, inorganic electrolytes andHKASLD organic solutes HKASLD

Composition of organic solutes in HKASLD HKASLDbile HKASLD Bile acids 67% Phospholipids 22% HKASLD HKASLDProteins HKASLD4.5% Cholesterol 4% Bilirubin 0.3%

Dawson PA. In: Sleisenger and Fordtran's Gastrointestinal and HKASLD HKASLDLiver Disease. HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDFunction of bile acidsHKASLD HKASLD

Induce bile flow and hepatic secretion of biliary lipids HKASLD(phospholipid and cholesterol).HKASLD HKASLD Play an important role in the digestion of dietary fats and are essential for the intestinal absorption of cholesterol HKASLDand fat-soluble vitamins. HKASLD HKASLD

Dawson PA. In: Sleisenger and Fordtran's Gastrointestinal and HKASLD HKASLDLiver Disease. HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD Enterohepatic circulation of HKASLD HKASLDbile acidsHKASLD

Dawson PA. In: Sleisenger and Fordtran's Gastrointestinal and HKASLD HKASLDLiver Disease. HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD Primary and secondary bile HKASLD HKASLDacids HKASLD

Dawson PA. In: Sleisenger and Fordtran's Gastrointestinal and HKASLD HKASLDLiver Disease. HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDBile acids as signalingHKASLD molecules HKASLD

Regulate their own synthesis HKASLD Regulate metabolic processes,HKASLD such as glucose, lipids, HKASLD and energy homeostasis HKASLD HKASLD HKASLD

HKASLD HKASLDArab JP, et al. HepatologyHKASLD 2017. HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDTarget receptors forHKASLD HKASLD signaling

Members of the superfamily HKASLD (FXR)HKASLD HKASLD Vitamin D receptor HKASLD Pregnane X receptor HKASLD HKASLD Members of the G protein-coupled receptor superfamily Takeda G-protein-coupled receptor 5 (TGR5) Sphingosine-1-phosphate receptor 2 HKASLD HKASLDArab JP, et al. HepatologyHKASLD 2017. HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDFarnesoid X receptorHKASLD (FXR) HKASLD

Expressed in several tissues, including liver, intestine, HKASLDadipose tissue, the vascularHKASLD wall, pancreas and kidney HKASLD HKASLD HKASLD HKASLD

HKASLD HKASLDArab JP, et al. HepatologyHKASLD 2017. HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDRegulation of glucoseHKASLD metabolism HKASLD HKASLD HKASLD HKASLD

FXR-KO mice exhibited decreased Treatment with selective, nonsteroidal FXR HKASLDinsulin sensitivity HKASLDagonist, GW4064, improved insulin resistanceHKASLD and glucose homeostasis in obese ob/ob and diabetic db/db mice Plasma glucose levels were reduced in FXR-KO mice after administration of adenovirus expressing a constitutively active FXR, but not Zhang Y, et al. Proc Natl Acad Sci U S A 2006. HKASLDwhen FXR-KO mice were treated with GW4064HKASLDCariou B, et al. Nutr Metab (London)HKASLD 2011. Masuy C, et al. Cell Mol Life Sci 2015. HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDRegulation of lipidHKASLD metabolism HKASLD HKASLD HKASLD HKASLD

FXR-KO mice exhibited FXR agonist improved lipoprotein profile of db/db HKASLDproatherogenic lipoprotein profile HKASLDand wild-type mice, but not FXR-KO HKASLDmice Sinal CJ, et al. Cell 2000. Zhang Y, et al. Proc Natl Acad Sci U S A 2006. HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD FXR deficiency may improve, rather than worsen glucose homeostasis in some HKASLD HKASLDmouse models of HKASLDobesity.

HKASLD HKASLDTaoka H, et al. World J DiabetesHKASLD 2016. HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDFXR effect on ilealHKASLD enterocytes HKASLD

Production of fibroblast growth factor 15 (FGF15) (FGF19 in HKASLDhumans) HKASLD HKASLD FGF15/19 binds the FGF receptor 4 (FGFR4) Major regulator of bile acid synthesis HKASLD Decreases hepatic lipogenesisHKASLD HKASLD Stimulates mitochondrial fatty acid oxidation

HKASLD HKASLDArab JP, et al. HepatologyHKASLD 2017. HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD Takeda G- protein- HKASLD HKASLDcoupled HKASLD receptor 5 (TGR5) HKASLD HKASLD HKASLD

HKASLDEggink H, et al. Int J Interferon Cytokine MediatorHKASLD Res, 2014. HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD Arab JP, et al. Hepatology 2017. HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDFXR agonists HKASLDNon-steroidal HKASLD GW4064 (GSK) Steroidal Px-102 [Phenox [Intercept Pharmaceuticals] Pharmaceuticals] [Novartis] HKASLD EDP-305 [ENANTA] HKASLD HKASLD Cilofexor [Gilead Sciences] BAR502 [Bar Pharmaceuticals] [Novartis] AGN 242266 [Allergen] EYP001 [ENYO Pharma] HKASLD HKASLD TERN-101 [Lilliy] HKASLD MET409 [Metacrine] WAY-450 [Pfizer]

HKASLDFiorucci et al, Expert Opin Investig DrugsHKASLD 2020 HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDTGR5 agonists HKASLD HKASLD

INT-767( [Intercept Pharamaceuticals]* HKASLD INT-777 [Intercept Pharmaceuticals]HKASLD HKASLD BAR501 [BAR Pharmaceuticals] HKASLD BAR502 [BAR Pharmaceuticals]*HKASLD HKASLD *Denotes a dual TGR5 and FXR agonist

HKASLD HKASLDFiorucci et al, Expert Opin InvestigHKASLDDrugs 2020 HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDObeticholic acid HKASLD(OCA) HKASLD

6-ethylchenodeoxycholic acid HKASLD A synthetic variant of theHKASLD natural bile acid HKASLD Potent activator of the farnesoid X nuclear receptor HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDObeticholic acid HKASLDin patients with HKASLD T2DM and NAFLD

Double-blind, placebo-controlled, proof-of-concept HKASLDstudy HKASLD HKASLD Patients were randomly assigned to groups given placebo (n = 23), 25 mg OCA (n = 20), or 50 mg OCA (n = 21) once daily for 6 weeks HKASLD A 2-stage hyperinsulinemicHKASLD-euglycemic insulin clamp HKASLD was used to measure insulin sensitivity before and after the 6-week treatment period OCA was associated with improved insulin resistance and decreased markers of liver inflammation and fibrosis HKASLD HKASLDMudaliar S et al, GastroenterologyHKASLD 2013. HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDFarnesoid X nuclearHKASLD receptor HKASLD ligand for non-cirrhotic NASH (FLINT)

Multicentre, randomized, double-blinded, placebo- HKASLDcontrolled trial HKASLD HKASLD Biopsy-proven NASH Obeticholic acid 25 mg daily vs. placebo for 72 weeks Pa effcac ce: deceae NAS b 2 HKASLDwithout worsening of fibrosisHKASLD HKASLD Percentage of patients with diabetes mellitus: 53% Percentage of patients with liver fibrosis F3, 22%; F4, 1% HKASLD HKASLD HKASLD Neuschwander-Tetri et al, Lancet 2015. HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLD ObeticholicHKASLD acid Placebo HKASLD 70 61% 60 53% 50 45% 46% 38% 40 35% 35% 31% HKASLD30 HKASLD HKASLD 21% 19% 20 10 0 Primary efficacy Steatosis Lobular Hepatocyte Fibrosis HKASLDoutcome HKASLDinflammation ballooning HKASLD p = 0.0002 p = 0.001 p = 0.006 p = 0.03 p = 0.004

Adverse lipid profile Increased serum insulin level and HOMA-IR HKASLD Pruritus, 23% vs. 6%, p < 0.0001HKASLD HKASLD Neuschwander-Tetri et al, Lancet 2015 HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDMechanism for adverseHKASLD lipid profile HKASLD with obeticholic acid

Increased FGF19 production which acts to suppress HKASLDhepatic bile acid synthesisHKASLD and hepatic demand for HKASLD cholesterol HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDObeticholic acid HKASLDin Japanese HKASLD NASH patients In the completer analysis*, 51% Primary efficacy outcome of patients in the 40 mg group 40 38% achieved the primary efficacy HKASLD35 p across groups = 0.053 HKASLD HKASLD 30 28% outcome compared with 22%

25 22% in the placebo group (p = 20% 20 0.006) 15 No significant difference was HKASLD10 HKASLD HKASLD 5 observed in steatosis, lobular 0 inflammation, hepatocyte Placebo OCA 10 mg OCA 20 mg OCA 40 mg ballooning and fibrosis p = 0.807 p = 0.338 p = 0.050 *45, 44, 44 and 37 patients in the placebo, 10 mg, 20 mg an 40 mg Note: (1) Intention-to-treat analysis OCA groups, respectively HKASLD(2) 50 patients each group HKASLD HKASLD (3) p value compares with placebo Intercept, Oct 28, 2015 HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDRandomized Global PhaseHKASLD 3 Study to Evaluate HKASLD the Impact on NASH With Fibrosis of Obeticholic Acid Treatment (REGENERATE) HKASLD HKASLDPlacebo HKASLD Biopsy- proven Obeticholic acid 10 mg daily NASH, F2-F3 fibrosis Obeticholic acid 25 mg daily HKASLDNAFLD ac ce (NAS) 4 HKASLD HKASLD Cirrhosis excluded

Biopsy Randomized Month 18 Month 48 End-of-study 1:1:1 Biopsy Biopsy HKASLD NASHHKASLD resolution without worsening fibrosis, or HKASLD fibrosis improvement without worsening NASH. HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLD2x HKASLD HKASLD Only 1 in 4 patients p = 0.0002

25 p = 0.04 Intention to treat analysis HKASLD23% HKASLDp = 0.13 HKASLD 20 18% n = 931 p = 0.18

15 12% 15 11% 12% 10 Placebo HKASLD HKASLD10 8% HKASLD Obeticholic acid 10 mg 5 5

Obeticholic acid 25 mg 0 0 HKASLDFibrosis improvement HKASLDNASH resolution HKASLD Younossi et al, EASL 2019 HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDAdverse events HKASLD HKASLD

Placebo (n = 657) Obeticholic acid Obeticholic acid HKASLD HKASLD10 mg (n = 653) 25 mg (n = 658) HKASLD Pruritus* 19% 28% 51% LDL increased 7% 17% 17% Nausea 12% 11% 13% Fatigue 13% 12% 11% HKASLDConstipation 5% HKASLD10% 11% HKASLD Abdominal pain 9% 10% 10% Diarrhea 12% 7% 7% *More patients on obeticholic acid 25 mg stopped treatment due to pruritus, 9% compared with HKASLDpatients on obeticholic acid 10 mg and placebo,HKASLD <1% HKASLD Younossi et al, EASL 2019 HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

FDA adverse Events Reporting System (FAERS), February 2020: Over 4000 side effects linked to the use of OCA in the United States between 2016 and 2019, with 920 cases considered serious side effects including 163 deaths. HKASLD Heah cae fea hdHKASLD f he Ocaliva dosing regimen HKASLDin the drug label, which is based on calculating a Child-Pugh score in PBC patients with suspected liver cirrhosis before treatment to determine their specific cafca ad ag dage. Dg hghe ha eceded he dg abe ca ceae he f HKASLDe deceag, e fae,HKASLD ad ee deah. HKASLD In patients with liver cirrhosis the initial dose of obeticholic acid should not exceed 5 mg once a week.

HKASLD HKASLDFiorucci et al, Expert Opin InvestigHKASLDDrugs 2020 HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDTropifexor (TXR) andHKASLD FLIGHT-FXR HKASLD

Non-bile acid FXR agonist HKASLD HKASLDPlacebo (n = 51) HKASLD Biopsy- proven TXR 140 µg daily (n = 50) NASH, F2-F3 fibrosis

TXR 200 µg daily (n = 51) HKASLDHFF 10% MRI-PDFF HKASLD HKASLD

Biopsy Randomized Week 12 Week 48 End-of-study HKASLD1:1:1 HKASLDMRI-PDFF Biopsy, MRI-PDFF HKASLD Sanyal et al, AASLD 2020 HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDFLIGHT-FXR HKASLD HKASLD Significant decline in ALT and GGT compared with placebo

0 80 -5 Placebo TXR 140 µg TXR 200 µg 68 HKASLD-3.58 daily dailyHKASLD70 HKASLD -10 60 55 -15 50 -20 40 28 -25 30 20 HKASLD-30 HKASLD HKASLD

30% fa edc, fa edc, % 30% 10 -35 -31.25 0 Relative fat reduction, % reduction, fat Relative -40 -39.54 Placebo TXR 140 µg TXR 200 µg -45 daily daily HKASLDp < 0.01 for all groups compared HKASLDwith placebo p = NS HKASLD Sanyal et al, AASLD 2020 HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDFLIGHT-FXR HKASLD HKASLD

p = NS

HKASLD HKASLD30 HKASLD 30 18% 23% 25 25 21% Placebo 20 20 p = NS 15 15 HKASLD HKASLD TXR 140 HKASLDµg daily 10 10 6% 5% 5 5 0% TXR 200 µg daily 0 0 HKASLDFibrosis improvement HKASLDNASH resolution HKASLD Sanyal et al, AASLD 2020 HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDFLIGHT-FXR HKASLD HKASLD

Placebo (n = 51) TXR 140 µg daily (n = TXR 200 µg daily (n = HKASLD HKASLD50) 51) HKASLD At least one AE 90% 98% 96% At least one SAE 12% 10% 6% AE leading to dose 6% 18% 37% reduction or discontinuation HKASLDAE leading to 4% HKASLD10% 18% HKASLD discontinuation Pruritus 22% 52% 69% HKASLD HKASLD HKASLD Sanyal et al, AASLD 2020 HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDAldafermin HKASLD HKASLD

FGF19 analogue Primary endpoint: change in HFF HKASLD HKASLDSecondary endpoints included liver histologyHKASLD Placebo Biopsy-proven NASH, F2-F3 fibrosis Aldafermin 1 mg sc daily

HKASLDHFF 8% MRI-PDFF HKASLD HKASLD

Biopsy, MRI- Randomized Week 6 Week 12 Week 24 End-of-study PDFF MRI-PDFF MRI-PDFF Biopsy, MRI- PDFF HKASLDRosuvastatin 20 mg started at Week 2 ifHKASLD LDL-C rise of 10 mg/dL was HKASLD observed Harrison S et al, AASLD 2020 HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDAldafermin HKASLD HKASLD Rapid and sustained decrease in ALT, AST and PRO- C3 compared with placebo p = 0.004 HKASLD HKASLD70 HKASLD66 60 50 0 0 40 -1 -5 -2 -10 29 HKASLD-3 -15 HKASLD30 HKASLD -4 -2.7 -20 -13 -5 -25 % reduction, 20

-6 -30 30% eae fa -7 -35 10 -8 -40 -9 -7.7 -45 -39 0 HKASLDp = 0.002 HKASLDp = 0.008 Placebo HKASLDAldafermin Sanyal et al, AASLD 2020 Relative fat Relativefat reduction, % Absolute fat reduction, % reduction, fat Absolute HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDAldafermin HKASLD HKASLD

p = 0.015 40 38% 40 40 HKASLD35 35 HKASLD35 HKASLD 30 30 30 24% 25 25 25 22% 20 18% 20 20 Placebo Aldafermin 15 15 15 HKASLD 9% HKASLD HKASLD 10 10 10 5 5 5 0% 0 0 0 Fibrosis improvement NASH resolution without NASH resolution and fibrosis HKASLDwithout worsening NASH worseningHKASLD fibrosis improvement HKASLD Sanyal et al, AASLD 2020 HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDAldafermin HKASLD HKASLD

No increase in gastrointestinal adverse events HKASLD No increase in pruritus (4%HKASLD aldafermin vs. 8% placebo) HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLD HKASLDZhou M et al,HKASLD J Hepatol 2017 HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD Raja A et al, Cell 2019 HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD Raja A et al, Cell 2019 HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD

HKASLDConclusion HKASLD HKASLD

Bile acid signaling plays central roles in the HKASLDdevelopment, progression,HKASLD and regression of the HKASLD metabolic abnormalities seen in NAFLD/NASH. Specific targeting of bile acid-related pathways may be useful for the management of NAFLD/NASH. HKASLD However, some safety concernsHKASLD require longer term HKASLD studies. HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD HKASLD